med surg exam 2
A patient is diagnosed with type 1 diabetes. What clinical characteristics does the nurse expect to see in this patient? Select all that apply.
Ketosis-prone Little endogenous insulin Younger than 30 years of age
Which statement by a client undergoing external radiation therapy indicates the need for further teaching?
"I'm worried I'll expose my family members to radiation." Internal radiation, not external radiation, poses a risk to the client's family
A client newly diagnosed with diabetes mellitus asks why he needs ketone testing when the disease affects his blood glucose levels. How should the nurse respond?
"Ketones will tell us if your body is using other tissues for energy."
A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching?
"I floss my teeth every morning."
While administering cisplatin to a client, the nurse assesses swelling at the insertion site. What is the nurse's first action?
Discontinue the intravenous medication.
A side-effect of chemotherapy is renal damage. To prevent this, the nurse should:
Encourage fluid intake, if possible, to dilute the urine
Which of the following would be inconsistent as a common side effect of chemotherapy?
Weight gain
2. The nurse is reviewing the causes for the development of type 1 diabetes mellitus with a patient who is newly diagnosed with the disorder. What major factor in the development of this disease should the nurse include? a. Obesity b. A high-fat diet c. An autoimmune response d. A diet high in concentrated carbohydrate
c. An autoimmune response
9. The nurse is caring for a patient with diabetes. For which symptom should the nurse be the most concerned? a. Fatigue b. Heartburn c. Diaphoresis d. Muscle cramps
c. Diaphoresis for hypoglycemia
A nurse is performing a home visit for a client who received chemotherapy within the past 24 hours. The nurse observes a small child playing in the bathroom, where the toilet lid has been left up. Based on these observations, the nurse modifies the client's teaching plan to include:
chemotherapy exposure and risk factors.
A patient is recovering after a bronchoscopy. Which action is a priority for this patient? a. Encourage oral fluids. b. Check for swallow and gag reflexes. c. Monitor the patient for return to consciousness. d. Order a meal because the patient has been NPO for 8 hours.
b. Check for swallow and gag reflexes.
21. A patient at home with type 1 diabetes has a glucose level of 324 mg/dL. It is usually less than 150 mg/dL. What should the patient do first? a. Call the physician. b. Have a glass of orange juice. c. Check the urine for ketones and drink water. d. Exercise and recheck glucose level in 2 hours.
c. Check the urine for ketones and drink water.
A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The health care provider has ordered a visualization of the small intestine via a capsule endoscopy. What will the nurse include in the client education about this procedure?
"You will need to swallow a capsule."
The nurse is preparing to assess a client whose chart documents that the client experienced extravasation when receiving the vesicant vincristine during the previous shift. The documentation also notes that an antidote was administered immediately. The nurse prepares to assess for which conditions? Select all that apply.
- Tissue necrosis - Sloughing tissue - Effectiveness of the antidote
A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of 800 mg/dl. Which solution is the most appropriate at the beginning of therapy?
100 units of regular insulin in normal saline solution
What is the duration of regular insulin?
4 to 6 hours The duration of regular insulin is 4 to 6 hours; 3 to 5 hours is the duration for rapid-acting insulin such as Novolog. The duration of NPH insulin is 12 to 16 hours. The duration of Lantus insulin is 24 hours.
A client is receiving insulin lispro at 7:30 AM. The nurse ensures that the client has breakfast by which time?
7:45 AM Insulin lispro has an onset of 5 to 15 minutes. Therefore, the nurse would need to ensure that the client has his breakfast by 7:45 AM at the latest. Otherwise, the client may experience hypoglycemia
A nurse is caring for a diabetic patient with a diagnosis of nephropathy. What would the nurse expect the urinalysis report to indicate?
Albumin is one of the most important blood proteins that leak into the urine
The nurse is performing a focused abdominal assessment of a client with a history of bowel obstruction. The nurse has positioned the client appropriately and inspected the client's abdomen carefully. What action should the nurse perform next?
Auscultate the client's abdomen
When assisting with preparing a client scheduled for a barium swallow, which of the following would be appropriate to include?
Avoid smoking for at least 12 to 24 hours before the procedure.
The nurse is providing client teaching for a client undergoing chemotherapy. What dietary modifications should the nurse advise?
Avoid spicy and fatty foods.
The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action?
Extravasation o prevent tissue necrosis to blood vessels, skin, muscles, and nerves
You are the nurse caring for a client with cancer. The client complains of pain and nausea. When assessed, you note that the client appears fearful. What other factor must you consider when a client with cancer indicates signs of pain, nausea, and fear?
Fatigue
The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take?
Flush with 10 mL of water.
When the nurse inspects the feet of a diabetic, a tack is found sticking in the sole of one foot. The client denies feeling anything unusual in the foot. Which is the best rationale for this finding?
High blood sugar decreases blood circulation to nerves.
Which combination of adverse effects should a nurse monitor for when administering IV insulin to a client with diabetic ketoacidosis?
Hypokalemia and hypoglycemia
The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon return to the nursing unit, what does the nurse identify as the client goal?
Increase the amount of fluids
The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? Use all options.
Inspection Auscultation Percussion Palpation
What disadvantages of chemotherapy should the patient be informed about prior to starting the regimen?
It targets normal body cells as well as cancer cells.
The nurse working on a bone marrow unit knows that it is a priority to monitor which of the following in a client who has just undergone a stem cell transplant?
Monitor the client closely to prevent infection these clients have no physiologic means to fight infection, which makes them very prone to infection
The nurse working on a bone marrow unit knows that it is a priority to monitor which of the following in a client who has just undergone a stem cell transplant?
Monitor the client closely to prevent infection.
A nurse assesses an oncology client with stomatitis during a chemotherapy session. Which nursing intervention would most likely decrease the pain associated with stomatitis?
Provide a solution of viscous lidocaine for use as mouth rinse commercial mouth wash contains alcohol
Laboratory studies indicate a client's blood glucose level is 185 mg/dl. Two hours have passed since the client ate breakfast. Which test would yield the most conclusive diagnostic information about the client's glucose use?
Serum glycosylated hemoglobin (Hb A1c)
The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample?
Take deep breaths and cough forcefully.
Which of the following factors would a nurse identify as a most likely cause of diabetic ketoacidosis (DKA) in a client with diabetes?
The client has eaten and has not taken or received insulin.
A nurse is preparing to administer two types of insulin to a client with diabetes mellitus. What is the correct procedure for preparing this medication?
The short-acting insulin is withdrawn before the intermediate-acting insulin.
A 36-year-old man is receiving three different chemotherapeutic agents for Hodgkin's disease. The nurse explains to the client that the three drugs are given over an extended period because:
The three drugs have a synergistic effect and act on the cancer cells with different mechanisms.
he physician is attending to a 72-year-old client with a malignant brain tumor. The physician recommends immediate radiation therapy. What is a reason for the physician's recommendation
To prevent the formation of new cancer cells
A client received chemotherapy 24 hours ago. Which precautions are necessary when caring for the client?
Wear personal protective equipment when handling blood, body fluids, and feces
A patient with diabetes has peripheral neuropathy. What should the nurse do to prevent related complications? a. Wash, dry, and inspect feet daily. b. Use a lubricating lotion on feet daily. c. Avoid wearing shoes as much as possible. d. Soak feet in soap and water for 20 minutes daily.
a. Wash, dry, and inspect feet daily.
7. The nurse is reinforcing teaching for a patient who is on four injections of regular insulin daily. About how many hours after each injection of insulin should the nurse teach the patient to be alert for symptoms of hypoglycemia? a. 1/2 hour b. 3 hours c. 8 hours d. 12 hours
b. 3 hours
The nurse prepares a client for a barium enema. The nurse should place the client on which diet prior to the procedure?
clear liquids day before The nurse should place the client on clear liquids the evening before the procedure, a low-residue diet 1 to 2 days before the test, and NPO at midnight in preparation for the barium enema.
After providing chest physiotherapy, the nurse notes the patient has loose secretions and a slight rattle with expiration. Which action should the nurse take first? a. Administer an expectorant. b. Suction the patients airway. c. Keep the patient on bedrest for 4 hours. d. Encourage the patient to cough and deep breathe.
d. Encourage the patient to cough and deep breathe.
The nurse teaches an unlicensed caregiver about bathing clients who are receiving tube feedings. The most significant complication related to continuous tube feedings is the
potential risk for aspiration.
1. A patient is experiencing rapid deep breathing, fruity odor, lethargy, and weight loss. Laboratory results include a blood glucose of 720 mg/dL. Which symptom should indicate to the nurse that the patient has type 1 diabetes mellitus? a. Thirst b. Hunger c. Lethargy d. Fruity odor
d. Fruity odor
Which information noted by the nurse reviewing the laboratory results of a patient who is receiving chemotherapy is most important to report to the health care provider? a. Hematocrit of 30% b. Platelets of 95,000/l c. Hemoglobin of 10 g/L d. WBC count of 1700/l
d. WBC count of 1700/l
The nurse reminds the 40-year-old female patient that the American Cancer Society (ACS) recommendations for early detection of cancer include that she should: a. get a Pap smear every year. b. get an annual fecal occult blood exam. c. plan a sigmoidoscopy every 5 years. d. have a mammogram done every year.
d. have a mammogram done every year.
Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"?
"Test your blood glucose every 4 hours."
A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse?
Notify the surgeon about the tube's removal.
A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia?
Sweating, tremors, and tachycardia
18. The nurse is caring for a patient who has not been diagnosed with diabetes. Which serum glucose result should the nurse expect on routine laboratory work? a. 45 mg/dL b. 88 mg/dL c. 115 mg/dL d. 270 mg/dL
b. 88 mg/dL normal plasma glucose level is less than 100 mg/dL.
A chemotherapeutic agent known to cause alopecia is prescribed for a patient. To maintain the patients self-esteem, the nurse plans to a. suggest that the patient limit social contacts until regrowth of the hair occurs. b. encourage the patient to purchase a wig or hat and wear it once hair loss begins. c. have the patient wash the hair gently with a mild shampoo to minimize hair loss. d. inform the patient that the hair will grow back once the chemotherapy is complete.
b. encourage the patient to purchase a wig or hat and wear it once hair loss begins.
A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. An important nursing intervention for the patient is to a. teach about the importance of nutrition during treatment. b. have the patient eat large meals when nausea is not present. c. offer dry crackers and carbonated fluids during chemotherapy. d. administer prescribed antiemetics 1 hour before the treatments.
d. administer prescribed antiemetics 1 hour before the treatments.
A patient receiving head and neck radiation has ulcerations over the oral mucosa and tongue and thick, ropey saliva. The nurse will teach the patient to a. remove food debris from the teeth and oral mucosa with a stiff toothbrush. b. use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. c. gargle and rinse the mouth several times a day with an antiseptic mouthwash. d. rinse the mouth before and after each meal and at bedtime with a saline solution.
d. rinse the mouth before and after each meal and at bedtime with a saline solution.
