NUR ATI 3262-1 thru 3262-6/Finals Exam1-3/Kahoot/Fluid and electrolyte and ABG

Six days after kidney transplant from a deceased donor, a patient develops a temperature of 101.2º F (38.5º C), tenderness at the transplant site, and oliguria. The nurse recognizes that these findings indicate: A. Acute rejection, which is not uncommon and is usually reversible. B. Hyperacute rejection, which will necessitate removal of the transplanted kidney. C. An infection of the kidney, which can be treated with IV antibiotics. D. The onset of chronic rejection of the kidney with eventual failure of the kidney.

A. Acute rejection, which is not uncommon and is usually reversible. Rational: Signs of acute kidney rejection include pain at the site of the transplant, flulike symptoms, fever, weight changes, swelling, changes in heart rate, and reduction in urine output

Which of the following treatment goals is for the client with status asthmaticus? A. Avoiding intubation B. Improving exercise tolerance C. Determining the cause of attack D. Reducing secretions

A. Avoiding intubation

One of the most important pulmonary treatments in cystic fibrosis is? A. Chest physiotherapy B. Oral enzymes C. Inhaled beta agonists D. Inhaled corticosteroids

A. Chest physiotherapy

A nurse is administering 1L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? A. Decrease in heart rate B. Increase in hematocrit C. Increase in respiratory rate D. Decrease in capillary refill time

A. Decrease in heart rate Rational: Fluid-volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to expected range.

A nurse in an emergency department is preparing to administer theophylline by continuous intravenous (IV) infusion to a client who is an experiencing an asthma attack. Which of the following actions should the nurse take? A. Infuse the medication with an IV pump. B. Cover the IV container with dark paper. C. Administer a test dose first. D. Infuse the medication at 35 mg/min.

A. Infuse the medication with an IV pump. Rational: Theophylline should be administered slowly on an infusion pump. Rapid administration may cause hypotension and death.

RN plan the care of a client with COPD, knowing that the client is most likely to experience what type acid base imbalance? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

A. Respiratory acidosis

A nurse is caring for a client who has a blood serum sodium level 133 mEq/L and serum potassium level 3.4 mEq/L. The nurse should recognize that which of the following treatments can result in these laboratory findings? A. Three tap water enemas B. 0.9% sodium chloride solution IV at 50 mL/hr C. 5% dextrose in water solution with 20 mEq of K+ IV at 80 mL/hr D. Antibiotic therapy

A. Three tap water enemas Rational: Three tap water enemas can result in a decrease in serum sodium and potassium. Tap water is hypotonic, and gastrointestinal losses are isotonic. This creates an imbalance and solute dilution.

Most patients with hypertension are asymptomatic. A. True B. False

A. True

NPH (Intermediate acting insulin) can be mixed with rapid and short acting insulin A. True B. False

A. True

A nurse manager is discussing the nurse practice act with staff. Which of the following should the nurse manager identify as the most important function of this act? A. Defines the requirement for licensure B. Defines nursing practice to protect the public C. Defines where the RN can practice D. Defines the power of the state board of nursing

B. Defines nursing practice to protect the public Rationale: The most important function of the nurse practice act is to define nursing practice to protect public safety.

A nurse is assessing a client who has chronic bronchitis. Which of the following percussion sounds should the nurse expect? A. Dullness B. Resonance C. Tympany D. Flatness

B. Resonance Rational: Resonance characterizes chronic bronchitis. It is a loud, low-pitched sound of long duration.

A nurse is teaching a client about strategies to manage gastroesophageal reflux disease (GERD). Which of the following statements should the nurse include? A. "Sleep on your left side." B. "Drink milk to soothe your stomach." C. "Eat four small meals each day." D. "Wait to go to bed for 1 hr after eating."

C. "Eat four small meals each day." Rational: The client should avoid eating large meals because of the pressure it places on the stomach. Instead, he should eat four to six small meals per day.

A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention? A. Daily weight B. Sodium level C. Tissue turgor D. Intake and output

A. Daily weight Rational: Obtaining a client's daily weight and comparing it to previous weights is a reliable method for measuring a client's fluid volume over time.

A nurse is admitting an older adult client who reports a weight gain of 2.3kg (5lb) in 48 hr. Which of the following manifestations of fluid volume excess should the nurse expect? (select all that apply) A. Dyspnea B. Edema C. Bradycardia D. Hypertension E. Weakness

A. Dyspnea B. Edema D. Hypertension E. Weakness

A nurse is screening a client for hypertension, the nurse should identify that which of the following actions by the client increase the risk for hypertension? (select all that apply) A. Eating popcorn at the movie theatre B. Walking 1 mile daily at 12 min/mile pace C. Drinking 8 0z nonfat milk daily D. Consuming 36oz beer daily E. Getting a massage once a week

A. Eating popcorn at the movie theatre Rational: Popcorn at a movie theater contains a large quantity of sodium and fat, which increases the risk for hypertension. D. Consuming 36oz beer daily Rational: Consuming more than 24 oz beer per day for a male client increases the risk for hypertension.

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as cause of constipation? (select all that apply) A. Excessive laxative use B. Ignoring the urge to defecate C. Inadequate fluid intake D. Increased fiber in the diet E. Increased activity

A. Excessive laxative use Rational: Chronic use of laxatives causes the large intestine to lose muscle tone and become less responsive to stimulation by laxatives. B. Ignoring the urge to defecate Rational: Anything that prevents the client from responding to the urge to defecate and disrupts regular habits can cause alterations in bowel habits, such as constipation. C. Inadequate fluid intake Rational: Reduced fluid intake slows the passage of food through the intestine and can result in hardening of stool.

A nurse is planning care for a client who is to start receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include in the plan of care? A. Use a 1.2 micron filter when infusing TPN with fat emulsions added. B. Allow 18 hr for the lipids to infuse when not mixed with the TPN solution. C. Change the TPN solution after 36 hr. D. Change the TPN tubing every 48 hr.

A. Use a 1.2 micron filter when infusing TPN with fat emulsions added. Rational: The nurse should use a 1.2 micron filter when infusing TPN with fat emulsion added to filter out any precipitate that is too large to pass through the filter.

A nurse is teaching a client who has chronic kidney failure about planning a low-protein diet. The client states, "Why do I have to be concerned about protein?" Which of the following responses should the nurse make? A. "A low-protein diet will increase the nitrogenous waste in the blood" B. "A low-protein diet reduces the risk for uremia" C. "A low-protein diet reduces the risk for edema" D. "A low-protein diet will reduce the risk for hyperkalemia"

B. "A low-protein diet reduces the risk for uremia" Rational: Urea is a waste product of protein breakdown and can accumulate in clients who have kidney failure, causing uremia

A nurse is teaching a client who has diabetes about which dietary source should provide the greatest percentage of calories. Which of the following client statements indicates an understanding of the teaching? A. "Most of my calories each day should be from fats." B. "I should eat more calories from complex carbohydrates than anything else." C. "Simple sugars are needed more than other calorie sources." D. "Protein should be my main source of calories."

B. "I should eat more calories from complex carbohydrates than anything else." Rational: The client who has diabetes should consume the majority of calories from complex carbohydrates, such as whole grains, fruits, and vegetables.

A nurse is teaching about disease management for a client who has type 1 diabetes mellitus. Which statement made by the client indicates an understanding of the teaching? A. "A weight reduction program will make me hypoglycemic" B. "I am taking my blood sugar reading after meal" C. "I give the insulin injections in my abdominal area." D. "Insulin allows me to eat ice cream at bedtime"

C. "I give the insulin injections in my abdominal area."

A nurse is evaluating teaching with a client who is receiving continuous subcutaneous insulin via an external insulin pump. which of the following statements by the client indicates a need for further teaching? A. "I will change the needle every 3 days" B. If i skip lunch, I will skip my mealtime dose of insulin C. "I will use insulin glargine in my insulin pump." D. "I should store all unread insulin in the refrigerator"

C. "I will use insulin glargine in my insulin pump." Rational: The client should use a short-acting insulin in the pump. The pump is designed to administer rapid-acting or short acting insulin 24 hours a da. Glargine is classified as a long-acting insulin and is administered at the same time each day to maintain stable blood glucose concentration for a 24 hours period.

A nurse is performing a monofilament sensory assessment of a client who has diabetes mellitus. when performing this assessment, for which of the following complications is the nurse monitoring? A. Nephropathy B. Neuropathy C. Retinopathy D. Radiculopathy

B. Neuropathy Rational: Neuropathy is a loss of sensation in the feet, which is a complication that occurs as a result of long term hyperglycemia which affects the microvasculature and causes demyelinization of the nerves. Peripheral neuropathy is assessed by lightly touching a monofilament to different areas of the client's feet to assess the client's ability to feel light toughing. An inability to feel light touching is indicative of peripheral neuropathy, which places the client at risk for injury and infection.

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select all that apply) A. Keep the client's room dark at night B. Teach the client to use the call light C. Keep the client's bed in the lowest position D. Place a fall-risk identification band on the client's wrist E. Assess the client every 4 hr

B. Teach the client to use the call light Rational: Clients need an easy, accessible way to summon assistance, especially those who are at risk for falls C. Keep the client's bed in the lowest position Rational: With the bed in the lowest position and the wheels locked, the client is less likely to fall when getting out of bed. D. Place a fall-risk identification band on the client's wrist Rational: Fall-risk bands, usually yellow, help staff identify clients at risk and take precautions to prevent falls.

A nurse is giving a presentation at a community center about chronic bronchitis. which of the following information should the nurse include as effective for preventing this disorder? A. Maintenance of ideal weight B. Annual influenza immunization C. Smoking cessation D. Regular moderate exercise

C. Smoking cessation Rational: Smoking is a major cause of chronic bronchitis; therefore, smoking cessation is an effective preventive strategy.

A nurse is developing a teaching plan for a client who has a new diagnosis of type 2 diabetes mellitus. What action should the nurse plan to take first? A. Evaluate the effectiveness of the client's admission teaching plan B. Give the client access to a video about diabetes C. Establish short-term realistic goals for the client D. Determine what the client knows about managing diabetes.

D. Determine what the client knows about managing diabetes. Rationale: The first action the nurse should take using the nursing process is to assess data from the client. The nurse should find out what the client knows before proceeding with the plan.

A nurse is providing teaching to a client who has gastroesophageal reflux disease and a new prescription for omeprazole. which of the following instructions should the nurse provide? A. Take NSAIDs if headaches occur. B. Decrease intake of vitamin D. C. Expect muscle cramps for several weeks. D. Report diarrhea to the provider.

D. Report diarrhea to the provider. Rational: Omeprazole is associated with an increased risk of C. difficile infection. The nurse should instruct the client to contact the provider if diarrhea occurs.

How is cystic fibrosis diagnosed? A. Echocardiogram B. Complete blood count C. Chest x-ray D. Sweat test

D. Sweat test

You develop a care plan to reduce infection for your patient that received a kidney transplant. A goal for this patient is to A. Resume the patient's job within 2-3 weeks B. Remain afebrile and have negative cultures C. Discontinue cyclosporine as quickly as possible D. Resume normal fluid intake in 2-3 days

B. Remain afebrile and have negative cultures

A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. "I can concentrate best in the morning." B. "You will have to talk to my wife about this." C. "I'm wondering why I need to learn this." D. "It is difficult to read the instructions because my glasses are at home."

A. "I can concentrate best in the morning." Rational: He is ready to learn and gives information on when it would be best to learn the information

A nurse is providing discharge teaching for a client who has a prescription for furosemide 40 mg PO daily. The nurse should instruct the client to take this medication at which of the following times of day? A. Morning B. Immediately after lunch C. Immediately before dinner D. Bedtime

A. Morning Rational: The client should take furosemide, a diuretic, in the morning so that the peak action and duration ofthe medication occurs during waking hours.

A patient with chronic kidney disease has a low erythropoietin level. What is this patient most at risk for? A. Emnolism B. Hyperkalemia C. Anemia D. Hyperphosphatemia

C. Anemia

When administering pancrelipase to child with cystic fibrosis. the RN knows they should be given A. After each bowel movement and after postural drainage B. With meals and snacks C. On awakening, following meals, and at bedtime D. Every three hours while awake

B. With meals and snacks

A nurse is assessing a client who is 2 days postoperative and auscultation bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications? A. Atelectasis B. Pneumonia C. Pulmonary embolism D. Arterial thrombus

A. Atelectasis Rational: Atelectasis is an incomplete alveolar expansion or collapse. Breath sounds are dull or absent over areas of alveolar collapse.

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis? A. Oral mucosa B. Conjunctivae C. Ear lobes D. Soles of the feet

A. Oral mucosa Rational: According to evidence-based practice, the nurse should first monitor the client's tongue and lips for manifestations of central cyanosis because cyanosis is most evident in areas with minimal pigmentation.

A nurse is teaching a client about the uses of aloe vera. which of the following information should the nurse include in the teaching? A. "Aloe vera can cause drowsiness when taken with an antidepressant." B. "Aloe vera can act as a laxative." C. "Aloe vera can help decrease moderate blood pressure." D. "Aloe vera can be taken to prevent migraine headaches."

B. "Aloe vera can act as a laxative." Rational: Aloe vera has a laxative effect when taken orally.

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include? A. "Examine your feet carefully everyday" B. "Wear compression stocking daily" C. "Have an eye examination once per day" D. "Maintain stable blood glucose levels."

D. "Maintain stable blood glucose levels."

Which information is most important to communicate to the physician 2 hours after a kidney transplant? A. BUN and creatinine are elevated B. UO is 900-1100 mL/hr C. The patient has 8/10 incisional pain D. Central venous pressure decreased

D. Central venous pressure decreased Rational: The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant.

A nurse is providing teaching to a client who has renal failure and an elevated phosphorus level. The provider instructed the client to take aluminum hydroxide 300 mg PO three times daily. For which of the following adverse effects should the nurse inform the client? A. Muscle spasms B. Headache C. Metallic taste D. Constipation

D. Constipation

What is a common side effect of Losartan and this class of medication? A. Bradycardia B. Dry cough C. Increased urination D. Lower extremity edema E. Hyperkalemia

E. Hyperkalemia Rational: ARBs cause hyperkalemia

A client is prescribed potassium phosphate (K phos) IV 1 g over 6 hr. The medication is available from the pharmacy as 1g/250 mL D5W. The nurse should set the IV pump to run at how many mL/hr? __________ mL

42 mL

A nurse is caring for a client who is to receive liquid medications via a gastrostomy tube. the client is prescribed phenytoin 250 mg. the amount available is phenytoin oral solution 25 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trialing zero.) __________ mL

50 mL

A client who has Type 2 diabetes mellitus asks the nurse, "Why did I develop diabetes?" Which of the following responses should the nurse make? A. "Your body has insulin resistance and decrease insulin secretion" B. "Your kidneys are not able reabsorb water which leads to Type 2 diabetes mellitus" C. "Your body is destroying the cells that secretes insulin" D. "An infection in your pancreas destroyed the cells that make insulin"

A. "Your body has insulin resistance and decrease insulin secretion" Rational: A client genetically susceptible can develop Type 2 diabetes mellitus when obesity and physical inactivity lead to insulin resistance at cells as well as decreased secretion of insulin by pancreatic beta-cells.

Emergency treatment of a client in status asthmaticus includes which of the following medications? A. Inhaled beta-adrenergic agents B. IV bet-adrenergic agents C. Inhaled corticosteroids D. Oral corticosteroids

A. Inhaled beta-adrenergic agents

A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance? A. Diabetic ketoacidosis B. Heart failure C. Cushing's syndrome D. Thyroidectomy

A. Diabetic ketoacidosis Rational: Hyperkalemia, an increase in serum potassium, is a laboratory finding associated with diabetic ketoacidosis.

A nurse is providing teaching to a client who has hypertension and a new prescription for captopril. Which of the following instructions should the nurse provide? A. Do not use salt substitutes while taking this medication B. Take the medication with food C. Count your pulse rate before taking the medication D. Expect to gain weight while taking this medication

A. Do not use salt substitutes while taking this medication Rational: Captopril, an ACE inhibitor, can cause hyperkalemia due to potassium retention by the kidney. The client should avoid salt substitutes, as most of them are high in potassium.

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (select all that apply) A. Dyspnea B. Bradycardia C. Barrel chest D. Clubbing of the fingers E. Deep respirations

A. Dyspnea Rational: Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues. C. Barrel chest Rational: Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients. D. Clubbing of the fingers Rational: Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge, and the nails become extremely curved from front to back.

An LPN/LVN is assigned to administer rapid-acting insulin, lispro, to a patient with type 1 diabetes. What essential information would the RN be sure to tell the LPN/LVN? A. Give this insulin when the food tray has been delivered and the patient is ready to eat. B. Only give this insulin for fingerstick glucose reading is above 200 mg/dL (11.1 mmol/L). C. This insulin mimics the basal glucose control of the pancreas. D. Rapid-acting insulin is the only insulin that can be given subcutaneously or IV.

A. Give this insulin when the food tray has been delivered and the patient is ready to eat. Rational: The onset of action for rapid-acting insulin is within minutes, so it should be given only when the patient has food and is ready to eat. Because of this, rapid-acting insulin is sometimes called "see food" insulin. Options 2, 3, and 4 are incorrect with regard to rapid-acting insulin. Option 2 is incorrect with regard to all forms of insulin. Long-acting insulins mimic the action of the pancreas. Regular insulin is the only insulin that can be given IV

A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select? A. Median vein in the forearm B. Antecubital vein C. Dorsal metacarpal vein D. Radial vein in the wrist

A. Median vein in the forearm Rational: The nurse should use the median vein in the forearm because it is distal to other potential venipuncture sites, and it avoids areas of flexion. The bones in the forearms provide natural splinting and protection for IV insertion sites in the forearm and allow more freedom of movement for the client.

A nurse is teaching an adult client about diphenhydramine. The nurse should explain to the client that which of the following is an adverse effect of this medication? A. Sedation B. Constipation C. Hypertension D. Bradycardia.

A. Sedation Rational: Diphenhydramine can cause sedation. It is used to treat rhinitis, allergies, and insomnia.

A nurse is assessing a client who is dehydrated. Which of the following findings should the nurse expect? A. Tachycardia B. Moist skin C. Increased urinary output D. Distended neck veins

A. Tachycardia

A nurse is providing teaching about dietary recommendations to a client who has iron-deficiency anemia. Which of the following dietary recommendations should the nurse include as a food that enhances iron absorption when consumed with nonheme iron? A. Tomato juice B. Tea C. Milk D. Dried beans

A. Tomato juice Rational: Food sources rich in Vitamin C enhance nonhdme iron absorption. Tomato products contain vitamin C; therefore, tomato juice is appropriate to include as a food that that enhances iron absorption when consumed with nonheme iron.

A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client. The nurse should follow the following sequence of events. 1. Inspect vials for contaminants 2. Roll NPH vial between palms of hands 3. Inject air into the NPH insulin vial 4. Inject air into regular insulin vial 5. Withdraw short acting into syringe 6. Add intermediate insulin to syringe A. True B. False

A. True

COPD is reversible? A. True B. False

B. False

A nurse is developing a plan of care for a client who is to begin receiving peritoneal dialysis. What intervention should the nurse implement to ensure proper dialysate exchange? A. Warm the dialysate solution prior to instillation. B. Place the drainage bag above the level of the client's abdomen C. Maintain the client in a lateral position dialysis D. Monitor vital signs every 2 hr during the procedure

A. Warm the dialysate solution prior to instillation. Rationale: Pain during inflow of the dialysate is a common adverse effect when client begin peritoneal dialysis. Warming the solution decreases discomfort.

A nurse is caring for a client who has an NG tube set to low intermittent suction. The nurse irrigates the NG tube twice with 30 mL of normal saline solution during his shift. At the end of the shift, the NG canister contains 475 mL. What amount of NG drainage should the nurse record? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) _________ mL

415 mL

Which of the following pathophysiological mechanisms that occurs in the lung parenchyma allows pneumonia to develop? A. Atelectasis B. Effusion C. Bronchiectasis D. Inflammation

D. Inflammation

A nurse on a medical-surgical unit is caring for a group of clients. The nurse demonstrates respect when he makes which of the following statements? A. "Now that you are in the hospital you will need to follow hospital rules" B. "I hear people of your culture prefer kosher food" C. I will tell the provider to speak with your husband about your condition." D. "Do you want your family to be present during your session with the speech therapist?"

"Do you want your family to be present during your session with the speech therapist?" Rationale: This statement by the nurse indicates that she is checking with the client about his wishes. This behavior demonstrates respect for the client.

A nurse is calculating the output of a client at the end of the shift. The nurse notes the following: client voided 400mL at 1100 and 350mL at 1430. The closed chest drainage system was previously marked at 155mL and is now at 175mL. The NG tube has 575mL in drainage container, and 25mL is emptied out of the Jackson-Pratt drainage tube. How many mL should the nurse record in the medical record as the client's output? ____________ mL

1370 mL

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen. Which of the following instructions should the nurse include in the teaching? A. "Do not adjust the oxygen flow rate." B. "Check your oxygen equipment once each week." C. "Store unused oxygen tanks horizontally." D. "Use wool blankets on your bed."

A. "Do not adjust the oxygen flow rate." Rational: The nurse should instruct the client not to adjust the oxygen flow rate to ensure that the client receives the prescribed rate.

​A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching? A. "Eating yogurt can help decrease the amount of gas that I have." B. "I should eliminate pasta from my diet so that I don't have as many loose stools." C. "My largest meal of the day should be in the evening." D. "Carbonated beverages can help control odor."

A. "Eating yogurt can help decrease the amount of gas that I have." Rational: The client who has a colostomy can include yogurt into his diet to help reduce odors and intestinal gas.

A nurse is teaching a client who has a new prescription for cimetidine to treat peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply) A. "I can take this medication with or without food." B. "I will take this medication in the morning." C. "I should expect my stools to turn black." D. "I will take this medication with an antacid." E. "I will take this medication when I need it for pain." F. "I will eat five small meals each day."

A. "I can take this medication with or without food." Rational: Food slows the rate of absorption of cimetidine, but beneficial effects will be prolonged. Cimetidine can be taken with meals, after meals, or at bedtime. F. "I will eat five small meals each day." Rational: The client should eat 5 to 6 small meals each day to enhance the therapeutic effects of cimetidine.

A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching? A. "I may eat 10 ounces of lean protein each day." B. "Fresh fruits make a good snack option." C. "I will replace table salt with dried herbs." D. "I may thicken gravies with cornstarch as I cook."

A. "I may eat 10 ounces of lean protein each day." Rational: Lean meats should be limited to 5 to 6 oz per day. This statement by a client requires additional teaching.

A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux(GERD). Which of the following statements by the parent indicates an understanding of the teaching? A. "I will keep my baby in an upright position after feedings." B. "My baby's formula can be thickened with oatmeal." C. "I will have to feed my baby formula rather than breast milk." D. "I should position my baby side-lying during sleep."

A. "I will keep my baby in an upright position after feedings." Rational: The infant should be maintained in an upright position for 1 hr after feedings.

A nurse is providing discharge teaching to a client who will be receiving total parenteral nutrition (TPN) at home. Which of the following instructions should the nurse include? (Select all that apply) A. "Keep the TPN refrigerated when not in use." B. "Infuse 10 percent dextrose and water if the solution runs out." C. "Shake the TPN bag with fat emulsion if precipitate is present." D. "Stop using TPN once weight gain is achieved." E. "Maintain TPN infusion rate when behind schedule."

A. "Keep the TPN refrigerated when not in use." Rational: TPN should be stored in the refrigerator to maintain the integrity of the substances. These ingredients provide nutritional support and daily requirements to clients who cannot eat food by mouth or achieve nutrition from a diet for more than a week. TPN is required by clients who have pancreatitis, ulcerative colitis, Crohn's disease, burn injury, cancer, AIDS, and starvation. B. "Infuse 10 percent dextrose and water if the solution runs out." Rational: The nurse should infuse 10% dextrose and water at the same rate if the next TPN is not available to maintain blood glucose levels and prevent hypoglycemia. E. "Maintain TPN infusion rate when behind schedule." Rational: The rate of TPN infusion should not be changed without the guidance of the provider. TPN is a hypertonic solution and should be slowly decreased in rate with a strategic plan to discontinue therapy over time. An increase or decrease in TPN infusion rate can impact the client's glucose level and cause the complication of hyperglycemia or hypoglycemia.

A nurse is talking with an older client who is contemplating retirement. The client states "I keep thinking about how much I enjoy you job. I'm not sure I want to retire," which of the following responses should the nurse make? A. "Let's talk about how the change in your job status will affect you" B. "You would have so much more time to spend with family" C. "why wouldn't you want to retire and relax?" D. "You should consider getting a part-time job or doing volunteer work"

A. "Let's talk about how the change in your job status will affect you" Rational: This response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement

A nurse is caring for an older adult client who asks why she has developed greater difficulty sleeping s she ages. Which of the following responses should the nurse provide? A. "The body rhythms that control sleep-wake cycle weaken a bit with aging" B. "It's normal to fall asleep easily but wake up later" C. "Perhaps you are spending more of your sleep time in deep sleep" D. "Maybe you need less sleep now than when you were younger"

A. "The body rhythms that control sleep-wake cycle weaken a bit with aging" Rational: Older adults trend to tend longer to fall asleep and wake up more often during the night than those at younger ages. Additionally, older adults tend to maintain earlier bedtimes and earlier awakening times than they did at younger ages.

A nurse is caring for a client who will have blood sampling for a serum creatinine level and asks what this test shows. Which of the following responses should the nurse make? A. "This test will tell your doctor how your kidneys are functioning." B. "You'll have to ask your doctor." C. "This test will tell if you have severe renal impairment or a disease." D. "We'll find out if any medications, such as steroids, are interfering with your kidney function."

A. "This test will tell your doctor how your kidneys are functioning."

The RN is orienting a new graduate nurse who is providing diabetes education for a patient about insulin injection. For which teaching statement by the new nurse must the RN intervene? A. "To prevent lipohypertrophy, be sure to rotate injection sites from the abdomen to the thighs." B. "To correctly inject the insulin, lightly grasp a fold of skin and inject at a 90-degree angle." C. "Always draw your regular insulin into the syringe first before your NPH (neutral protamine Hagedorn) insulin." D. "Avoid injecting the insulin into scarred sites because those areas slow the absorption rate of insulin."

A. "To prevent lipohypertrophy, be sure to rotate injection sites from the abdomen to the thighs." Rational: Although it is important to rotate injection sites for insulin, it is preferred that the injection sites be rotated within one anatomic site (e.g., the abdomen) to prevent day-to-day changes in the absorption rate of the insulin. All of the other teaching points are appropriate

The nurse is teaching a client who has a new diagnosis of urge incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. "Your provider might prescribe anticholinergic medications." B. "You should limit fluids in the evening." C. "You should restrict your intake of caffeine." D. "You might require intermittent urinary catheterization." E. "You might require an anterior vaginal repair."

A. "Your provider might prescribe anticholinergic medications." Rational: Anticholinergic medications suppress bladder contractions and increase bladder capacity. B. "You should limit fluids in the evening." Rational: Limiting fluid intake in the evening prior to bedtime helps prevent an overload of fluid in the bladder during hours of sleep. C. "You should restrict your intake of caffeine." Rational: The restriction of caffeine is effective in the treatment of urge incontinence because caffeine is a bladder irritant.

A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times? A. 0745 B. 0720 C. 0730 D. 0815

A. 0745 Rational: Regular insulin should be given 20 to 30 minutes before eating because the onset of action is 30 minutes. There are circumstances when this lag time guide can be adjusted.

A nurse is caring for client who is receiving oxygen at 2 L/min via a nasal cannula. The Nurse recognizes the client is receiving which of the following inspired oxygen concentration? A. 28% B. 36% C. 50% D. 70%

A. 28% Rational: The nurse should recognize that a flow rate of 2 L/min via nasal cannula delivers an oxygen concentration of about 28%.

A nurse working for a home health agency is teaching a client who has diabetes mellitus about disease management. Which of the following glycosylated hemoglobin (HbA1c) values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels? A. 6.3% B. 7.8% C. 8.5% D. 10%

A. 6.3% Rational: The client who has diabetes mellitus needs to manage activity and diet while monitoring blood glucose levels. High levels of blood glucose cause damage to the macro and microcirculation, affecting such things as eyesight and kidney function. The goal for a client who has diabetes mellitus is to keep the HbA1c values at 6.5% or less.

A nurse is reviewing the medical records of 4 patients who have an acid-base imbalance. The nurse should recognize that which of the following patients is at risk for metabolic acidosis? A. A client who has diarrhea B. A client who is vomiting C. A client who is taking a thiazide diuretic D. A client who has salicylate intoxication

A. A client who has diarrhea Rational: Diarrhea can cause metabolic acidosis due to the loss of bicarbonate.

A nurse is caring for a client who has a sodium level of 125mEq/L. Which of the following findings should the nurse expect? A. Abdominal cramping B. Numbness of the extremities C. Bradycardia D. Positive Chvostek's sign

A. Abdominal cramping Rational: The client has hyponatremia, a low sodium level. Manifestations include abdominal cramping, weakness, headache, and nausea.

A nurse is caring for an adolescent who is experiencing status asthmaticus. Which of the following actions should the nurse take? A. Administer a short-acting B2-agonist (SABA) B. Obtain a peak flow reading C. Administer an inhaled glucocorticoid D. Determine the cause of the acute exacerbation

A. Administer a short-acting B2-agonist (SABA) Rational: When using the urgent versus non-urgent approach to client care, the nurse should determine that the priority action is to administer a nebulized high-dose SABA to relieve bronchoconstriction and improve ventilation.

An elderly client pneumonia may appear with which of the following symptoms first? A. Altered mental status and dehydration B. Fever and chills C. Hemoptysis and dyspnea D. Pleuritic chest pain and cough

A. Altered mental status and dehydration

A nurse on a medical unit is planning care for several clients. Which of the following clients should benefit most from the nurse acting as an advocate? A. An older adult client who has no family and is uncertain about moving to assisted living B. A client who has been educated on treatment options and chooses alternative treatments C. A client who has previously undergone a procedure that is to be performed for a second time D. A client who makes an informed decision not to participate in chemotherapy treatment

A. An older adult client who has no family and is uncertain about moving to assisted living Rational: The nurse acts as an advocate by ensuring the client has information to make an appropriate decision in selecting needed services. This is an example of a client benefiting most from the nurse acting as an advocate.

A nurse is planning care for a client who is receiving enteral feedings through an NG tube. Which of the following actions should the nurse plan to take first? A. Aspirate the client's stomach contents. B. Hang the feeding bag 30 cm (12 in) above the client. C. Label the feeding bag with the date and time of the start of the feeding. D. Warm the feeding to room temperature.

A. Aspirate the client's stomach contents. Rational: The first action the nurse should take using the nursing process is to assess the residual stomach contents. The nurse should measure the stomach contents to assess whether the feeding is being absorbed by the client. The nurse might delay the tube feeding for a high residual to reduce the risk of aspiration.

The nurse is caring for an older patient with type 1 diabetes and diabetic retinopathy. What is the nurse's priority concern for assessing this patient? A. Assess ability to measure and inject insulin and to monitor blood glucose levels. B. Assess for damage to motor fibers, which can result in muscle weakness. C. Assess which modifiable risk factors can be reduced. D. Assess for albuminuria, which may indicate kidney disease.

A. Assess ability to measure and inject insulin and to monitor blood glucose levels. Rationale: The older patient with diabetic retinopathy also has general age-related vision changes, and the ability to perform self-care may be seriously affected. He or she may have blurred vision, distorted central vision, fluctuating vision, loss of color perception, and mobility problems resulting from loss of depth perception. When a patient has visual changes, it is especially important to assess his or her ability to measure and inject insulin and to monitor blood glucose levels to determine if adaptive devices are needed to assist in self-management. The other options are important but are not specific to diabetic retinopathy.

A nurse is planning care for a client who has Stage 4 chronic kidney disease. Which of the following actions should the nurse include in the plan of care? (Select all that apply) A. Assess for jugular vein distention B. provide frequent mouth rinses C. auscultate for a pleural friction rub D. provide a high-sodium diet E. monitor for dysrhythmias

A. Assess for jugular vein distention Rational: the nurse should assess for jugular vein distention, which can indicate fluid overload and heart failure. B. provide frequent mouth rinses Rational: The nurse should provide frequent mouth rinses due to uremic halitosis caused by urea waste in the blood. C. auscultate for a pleural friction rub Rational: The nurse should auscultate for a pleural friction rub related to respiratory failure and pulmonary edema caused by acid base imbalances and fluid retention E. monitor for dysrhythmias Rational: the nurse should monitor for dysrhythmias related to increased serum potassium caused by Stage 4 chronic kidney disease.

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take? A. Attach a humidifier bottle to the base of the flow meter. B. Remove the nasal cannula while the client eats. C. Secure the oxygen tubing to the bed sheet near the client's head. D. Apply petroleum jelly to the nares as needed to soothe mucous membranes.

A. Attach a humidifier bottle to the base of the flow meter. Rational: Oxygen therapy can dry the mucous membranes. The nurse should attach humidification for a client receiving oxygen greater than 4 L/min via nasal cannula.

A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care? A. Auscultate breath sounds at least every 2 hr. B. Perform range-of-motion (ROM) exercises at least two to three times daily. C. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day. D. Apply antiembolic stockings.

A. Auscultate breath sounds at least every 2 hr. Rational: The priority action the nurse should contribute to the plan of care when using the airway, breathing, circulation approach to client care is auscultating breath sounds to determine the client's need for suctioning. With inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea.

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure which of the following nursing actions should the nurse complete first? A. Auscultate lung fields. B. Assess pulse and respirations. C. Assess characteristics of her sputum. D. Instruct to slowly exhale with pursed lips.

A. Auscultate lung fields. Rational: The first action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to auscultate lung fields to provide knowledge of which lung areas are most affected and would be the focus of the procedure.

A nurse is caring for a client who has heart failure and a history of asthma the nurse reviews the providers orders and recognizes that clarification is needed for which of the following medications? A. Carvedilol B. Fluticasone C. Captopril D. Isosorbide dinitrate

A. Carvedilol Rational: Medications that block beta-2 receptors, such as carvedilol, are contraindicated in clients with asthma.

A nurse is planning post-procedure care for a client who received hemodialysis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Check BUN and serum creatinine. B. Administer medications the nurse withheld prior to dialysis. C. Observe for signs of hypovolemia. D. Assess the access site for bleeding. E. Evaluate blood pressure on the arm with AV access.

A. Check BUN and serum creatinine. Rational: The nurse should check the BUN and serum creatinine to determine the presence and degree of uremia or waste products that remain following dialysis. B. Administer medications the nurse withheld prior to dialysis. Rational: The nurse should withhold medications the treatment can partially dialyze. After the treatment, the nurse should administer the medications. C. Observe for signs of hypovolemia. Rational: A client who is post‐dialysis is at risk for hypovolemia due to a rapid decease in fluid volume. D. Assess the access site for bleeding. Rational: The nurse should assess the access site for bleeding because the client receives heparin during the procedure to prevent clotting of blood. E. Evaluate blood pressure on the arm with AV access. Rational: The nurse should never measure blood pressure on the extremity that has the AV access site because it can cause collapse of the AV fistula or graft.

A nurse is admitting a client who reports nausea, vomiting and weakness. The client has dry oral mucous membranes and a BP 102/64. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? (select all) A. Decreased skin turgor B. Concentrated urine C. Bradycardia D. Low grade fever E. Tachypnea

A. Decreased skin turgor B. Concentrated urine D. Low grade fever E. Tachypnea

A nurse is providing teaching to a client who has hypertension and a new prescription for captopril. Which of the following instructions should the nurse provide? A. Do not use salt substitutes while taking this medication. B. Take the medication with food. C. Count your pulse rate before taking the medication. D. Expect to gain weight while taking this medication.

A. Do not use salt substitutes while taking this medication. Rational: Captopril, an ACE inhibitor, can cause hyperkalemia due to potassium retention by the kidney. The client should avoid salt substitutes, as most of them are high in potassium.

A 71-year-old woman is at the clinic for a follow-up appointment after being diagnosed. with type 2 diabetes mellitus 3 months ago. HbA1c 7 %. At that time, she was given metformin 1000 mg PO twice a day, and she was instructed to check her blood glucose levels in the morning before breakfast, before lunch and dinner, and at bedtime. Seh also received general education about self-care for diabetes. Yesterday she had fasting lab work drawn. The nurse is reviewing the education that was done at her initial appointment and answering any questions the patient has. The following assessment indicates that the intervention was ineffective (did not help to meet expected outcomes). (Select all that apply) A. Fasting blood glucose level results 132 mg/dL B. Patient states that she will eat a candy bar if her blood glucose is less than 70 mg/dL C. Patient reports decrease tingling in her feet D. Patient states she applies lanolin to her feet and between her toes after washing them daily.

A. Fasting blood glucose level results 132 mg/dL Rational: Not effective because this fasting blood glucose level is high. Normal fasting glucose level is 60-99 mg/dL D. Patient states she applies lanolin to her feet and between her toes after washing them daily. Rational: Intervention not effective. Lotions or anything with moisture should not be applied between toes after washing them. Moisture encourages bacteria or fungus which can cause infection.

A nurse on the day shift is preparing to change a client's total parenteral nutrition (TPN) solution, but the new TPN solution has not arrived from the pharmacy. The client receives additional IV fat emulsion during the night shift. Which of the following actions should the nurse take? A. Hang dextrose 10% in water (D10W) until the TPN solution is delivered. B. Saline lock the IV catheter after discontinuing the TPN solution. C. Hang the IV fat emulsion solution. D. Call the provider for new TPN orders.

A. Hang dextrose 10% in water (D10W) until the TPN solution is delivered. Rational: The nurse should hang D10W if the TPN runs out or is not available to hang. D10W is a hypertonic solution that will maintain glucose level and prevent rebound hypoglycemia.

What are the most common symptoms of hypertension? A. Headache B. Blurry vision C. Tinnitus D. Lightheadedness E. Chest pain F. Dizziness

A. Headache B. Blurry vision E. Chest pain F. Dizziness

A nurse working on a medical-surgical unit is discussing the roles of the interprofessional team with the charge nurse. Which of the following observations by the nurse indicates the essential skills of the interprofessional team? A. I can see that various health care professionals are able to share their thoughts regarding planning client care. B. I can see that various health care professional are working independently when planning care for clients. C. I can see that various health care professionals are using personal experience to plan client care. D. I can see that various health care professional are using the clients experience to plan client care.

A. I can see that various health care professionals are able to share their thoughts regarding planning client care. Rationale: Collaboration is an essential skill of an interprofessional team. It includes sharing thoughts and keeping an open mind.

A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following physiological changes? (Select all that apply) A. Increased pain threshold B. Decreased skin elasticity C. Decreased gastric motility D. Increased cardiac output E. Increased metabolic rate

A. Increased pain threshold Rational: Older adults can have an increase in sensation of pain, temperature, and touch B. Decreased skin elasticity Rational: Older adults cab have a decrease in skin elasticity that can increase the risk for skin breakdown and injury C. Decreased gastric motility Rational: Older adults can have an increase in gastric pH, a decrease in gastric blood flow, and a decrease in gastric motility, which can alter oral medication adsorption

A nurse is teaching a client who has asthma how to use a metered-dose inhaler (MDI). The nurse identifies the sequence of steps the client should follow. A. Inhale deeply and then exhale completely B. Place lips firmly around mouthpiece C. Breathe in deeply over 2-3 seconds while pushing down on the canister D. Hold breath for 10 seconds E. Exhale slowly through pursed lips F. Wait 60 seconds between each puff

A. Inhale deeply and then exhale completely B. Place lips firmly around mouthpiece C. Breathe in deeply over 2-3 seconds while pushing down on the canister D. Hold breath for 10 seconds E. Exhale slowly through pursed lips F. Wait 60 seconds between each puff Rational: Inhaling deeply and then exhaling completely is the first step. Next, the client should place her lips firmly around the mouthpiece to direct the spray to the airways, then breathe in deeply over 2 to 3 seconds while pushing down on the canister. This slow, deep inhalation directs the medication down into the lower respiratory tract. Holding her breath for 10 seconds is next; it allows time for absorption of the medication. Then, pursed-lip breathing keeps the small airways open during slow exhalation. And finally, waiting 60 seconds between puffs allows for deeper penetration of the medication into the respiratory tract.

A nurse is assessing a client to identify risk factors for disease. which of the following findings is a risk for metabolic syndrome? A. Large waist size B. hypoglycemia C. Hyperglycemia D. Hypertension E. History of asthma F. Hypotension

A. Large waist size

A patient with CKD4 asks what type of diet should I follow. You explain that the patient should follow A. Low protein, low sodium, low potassium, low phosphate B. High protein, low sodium, low potassium, high phosphate C. High phosphate, high sodium, low protein, high potassium D. Low protein, high sodium, high potassium, high phosphate

A. Low protein, low sodium, low potassium, low phosphate

Afrezza inhaled insulin was approved by food and drug administration (FDA). it is new, quicker acting inhalable insulin with a different and safer pharmacokinetic profile in comparison to previous failed inhaled form of insulin. The following in true (select all that apply) A. May cause bronchospasm in patients with asthma and COPD B. It is used in combination with long acting insulin in Type 1 diabetes C. Not recommended for treatment of Diabetic Ketoacidosis (DKA) or in patient who smoke D. It is a substitute for long acting insulin E. It is not a substitute for long acting insulin

A. May cause bronchospasm in patients with asthma and COPD B. It is used in combination with long acting insulin in Type 1 diabetes C. Not recommended for treatment of Diabetic Ketoacidosis (DKA) or in patient who smoke E. It is not a substitute for long acting insulin

A nurse is planning care for a client who will undergo peritoneal dialysis. Which of the following actions should the nurse take? (Select all that apply.) A. Monitor serum glucose levels. B. Report cloudy dialysate return. C. Warm the dialysate in a microwave oven. D. Assess for shortness of breath. E. Check the access site dressing for wetness. F. Maintain medical asepsis when accessing the catheter insertion site.

A. Monitor serum glucose levels. Rational: The nurse should monitor serum glucose levels because the dialysate solution contains glucose. B. Report cloudy dialysate return. Rational: The nurse should monitor for cloudy dialysate return, which indicates an infection. Clear, light‐yellow solution is typical during the out-flow process. C. Warm the dialysate in a microwave oven. Rational: The nurse should avoid warming the dialysate in a microwave oven, which causes uneven heating of the solution. D. Assess for shortness of breath. Rational: The nurse should assess for shortness of breath, which can indicate inability to tolerate a large volume of dialysate. E. Check the access site dressing for wetness. Rational: The nurse should check the access site dressing for wetness and look for kinking, pulling, clamping, or twisting of the tubing, which can increase the risk for exit‐site infections. F. Maintain medical asepsis when accessing the catheter insertion site. Rational: The nurse should maintain surgical, not medical, asepsis when accessing the catheter insertion site to prevent infection from contamination.

A nurse manager hires a nurse whose personal reference reports that the nurse plagiarized during nursing school. Based on the information from the reference, which of the following actions should the nurse manager take? A. Monitor the nurse's documentation during times of high client acuity. B. Caution other staff nurses about the potential for the nurse's misconduct C. Inform the risk manager of the situation D. Discussion the consequences of plagiarism during staff meeting

A. Monitor the nurse's documentation during times of high client acuity. Rationale: A nurse who plagiarized during nursing school may not have a sound knowledge base, and during times of high client acuity, the nurse may resort to inaccurate documentation to conceal deficits in client care. The nurse manager should monitor the nurse's documentation to ensure client safety.

Case Study: R.H. is a 62-year-old woman who comes to the clinic for a routine physical exam. She works as a banking executive and gets little exercise. She says she is "just tired". She has gained 18 pounds over the past year and eats a high-fat diet. Her BP is 162/98, HR 92, and RR is 20, and O2 sat is 92% on room air. R.H. complains of some weakness in her right foot that began about a month ago and also says that it feels a little numb. A sensory examination reveals diminished sensations of light touch, proprioception (6th sense/sense of body position), and vibration in both feet. R.H. complains of increased thirst and frequent nighttime urination. She denies any other weakness, numbness, or changes in vision. A physical examination reveals an erythematous scaling rash in both inguinal areas and axillae. RH states the rash has been there on and off for several years and is worse in the warm weather. What risk factor for diabetes does R.H. have? A. Obesity B. Aging C. Hypertension D. Sedentary lifestyle E. Hypotension F. Low fat diet

A. Obesity B. Aging C. Hypertension D. Sedentary lifestyle

A 71-year-old woman is at the clinic for a follow-up appointment after being diagnosed. with type 2 diabetes mellitus 3 months ago. HbA1c 7 %. At that time, she was given metformin 1000 mg PO twice a day, and she was instructed to check her blood glucose levels in the morning before breakfast, before lunch and dinner, and at bedtime. Seh also received general education about self-care for diabetes. Yesterday she had fasting lab work drawn. The nurse is reviewing the education that was done at her initial appointment and answering any questions the patient has. The following assessment indicates that the intervention was effective (helped to meet expected outcomes). (Select all that apply) A. Patient states she checks her feet daily B. Patient reports decrease tingling in her feet C. Causal blood glucose level (drawn this morning 3 hours after breakfast): 220 mg/dL D. Hemoglobin A1C level results: 6.8% E. Patient states she applies lanolin to her feet and between her toes after washing them daily.

A. Patient states she checks her feet daily Rational: Intervention effective because patient is demonstrating that the teaching was successful. Diabetes should check their feet daily to monitor for signs of sores, pressure ulcers etc. B. Patient reports decrease tingling in her feet Rational: Intervention effective because this shows that her neuropathy has improved

Case Study: R.H. is a 62-year-old woman who comes to the clinic for a routine physical exam. She works as a banking executive and gets little exercise. She says she is "just tired". She has gained 18 pounds over the past year and eats a high-fat diet. Her BP is 162/98, HR 92, and RR is 20, and O2 sat is 92% on room air. R.H. complains of some weakness in her right foot that began about a month ago and also says that it feels a little numb. A sensory examination reveals diminished sensations of light touch, proprioception (6th sense/sense of body position), and vibration in both feet. R.H. complains of increased thirst and frequent nighttime urination. She denies any other weakness, numbness, or changes in vision. A physical examination reveals an erythematous scaling rash in both inguinal areas and axillae. RH states the rash has been there on and off for several years and is worse in the warm weather. Which clinical manifestations of diabetes is R.H. displaying (select all that apply) A. Polyuria B. Weakness C. Fatigue D. Loss of appetite E. Polydypsia

A. Polyuria B. Weakness C. Fatigue E. Polydypsia

A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding? A. Potassium 2.9 mEq/L B. Phosphorous 4.5 mEq/L C. Sodium 145 mEq/L D. Calcium 8.2 mg/dL

A. Potassium 2.9 mEq/L Rational: Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is the client's potassium level. The client's level is below the expected reference range of 3.5 to 5.0 mEq/L. Hypokalemia can be a life-threatening condition if left untreated. Potassium is the primary electrolyte vital for cell metabolism and cardiac and neuromuscular function.

A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications? A. Propranolol B. Theophylline C. Montelukast D. Prednisone

A. Propranolol Rational: Medications that block beta-2 receptors, such as propanolol, are contraindicated in clients with asthma.

A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD).The nurse should instruct the client to limit which of the following nutrients? (Select all that apply.) A. Protein B. Calcium C. Calories D. Phosphorous E. Sodium

A. Protein Rational: A client who has CKD should restrict protein intake to prevent uremia that can develop as a result of the kidneys' inability to remove the waste products of protein. D. Phosphorous Rational: A client who has CKD is at risk for hyperphosphatemia due to a reduction in excretion of phosphorous by the kidneys E. Sodium Rational: A client who has CKD is at risk for hypernatremia, edema, and hypertension due to sodium retention

A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. What types of food should the nurse instruct the client to avoid? (Select all that apply) A. Raisins B. Asparagus C. Tomato D. Green beans E. Banana

A. Raisins C. Tomato E. Banana

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mRq/L. The nurse should recognize that these findings indicate of which of the following acid base balances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A. Respiratory acidosis Rational: A number of conditions can lead to respiratory acidosis, including COPD and pneumonia. In the presence of respiratory acidosis, the client's blood gas values meet the following criteria: a pH less than 7.35, a PaCO2 greater than greater 45 mg/Hg, and a HCO3 that is normal or slightly elevated (22 to 26 mEq/mL).

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L A. Respiratory acidosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory alkalosis

A. Respiratory acidosis Rational: Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory function. It can be the result of respiratory depression, seen with anesthesia or opioid administration; inadequate chest expansion, due to a weakness of the respiratory muscles or constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction, or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (O2 and CO2), resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 - 7.45) and a CO2 level that is higher than the normal reference range (35 - 45 mm Hg).

A nurse is caring for a patient who is postop and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the patient as being at risk for developing initially? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A. Respiratory acidosis Rational: Respiratory acidosis represents an increase in the acid component, carbon dioxide, due to inadequate excretion of it, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. A major cause of this imbalance is hypoventilation from anesthetics or opioids.

A nurse is providing discharge teaching to a client who has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching? A. Shake the inhaler for 3 to 5 seconds. B. Rinse the mouth with mouthwash after inhaling the medication. C. Wait 2 min between inhalations. D. Press down twice on the MDI canister.

A. Shake the inhaler for 3 to 5 seconds. Rational: After fully inserting the canister into the inhaler, the client should shake it vigorously for 3 to 5 seconds to make sure he mixes the medication thoroughly.

The RN is caring for a patient with diabetes admitted with hypoglycemia that occurred at home. Which teaching points for treatment of hypoglycemia at home would the nurse include in a teaching plan for the patient and family before discharge? (Select all that apply) A. Signs and symptoms of hypoglycemia include hunger, irritability, weakness, headache, and blood glucose less than 60 mg/dL (3.3 mmol/L). B. Treat hypoglycemia with 4 to 8 g of carbohydrate such as glucose tablets or ¼ cup (60 mL) of fruit juice. C. Retest blood glucose in 30 minutes. D. Repeat the carbohydrate treatment if the symptoms do not resolve. E. Eat a small snack of carbohydrate and protein if the next meal is more than an hour away. F. If the patient has severe hypoglycemia, does not respond to treatment, and is unconscious, transport to the emergency department (ED)

A. Signs and symptoms of hypoglycemia include hunger, irritability, weakness, headache, and blood glucose less than 60 mg/dL (3.3 mmol/L). D. Repeat the carbohydrate treatment if the symptoms do not resolve. E. Eat a small snack of carbohydrate and protein if the next meal is more than an hour away. F. If the patient has severe hypoglycemia, does not respond to treatment, and is unconscious, transport to the emergency department (ED) Rationale: The manifestations listed in option 1 are correct. The symptoms should be treated with carbohydrate, but 10 to 15 g (not 4 to 8 g). Glucose should be retested at 15 minutes; 30 minutes is too long to wait. Options 4 and 5 are correct. When a patient has severe hypoglycemia, does not respond to administration of glucagon, and remains unconscious, he or she should be transported to the ED and the health care provider notified.

A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory bowel disease and is to start a low-lactose diet. Which of the following foods is the best choice for the client? A. Soy milk B. Cheddar cheese C. Low-fat yogurt D. Cottage cheese

A. Soy milk Rational: Soy milk is the best choice for this client because soy milk is lactose-free.

A nurse is teaching a client who has asthma about how to use an a butyryl inhaler. Which of the following actions should the client indicates as an understanding of teaching? A. The client holds his breath for 10 seconds after inhaling the medication. B. The client takes a quick inhalation while releasing the medication from the inhaler. C. The client exhales as the medication is released from the inhaler. D. The client waits 10 min between inhalations.

A. The client holds his breath for 10 seconds after inhaling the medication. Rational: The medication should be retained in the lungs for a minimum of 10 seconds so the maximum amount of the dosage can be delivered properly to the airways. To use the inhaler, the client exhales normally just prior to releasing the medication, inhales deeply as the medication is released, then holds the medication in the lungs for approximately 10 seconds prior to exhaling.

A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should be base her actions on which of the following information? (select all that applies) A. The student should use his quick-relief inhaler. B. The student's asthma is not well controlled. C. The student's peak flow is 50% to 80% of his best peak flow. D. The student needs to go to the hospital. E. The nurse should obtain a second expiratory flow rate.

A. The student should use his quick-relief inhaler. Rational: The student should use his quick-relief inhaler is correct. A student in the yellow zone should use a quick-relief inhaler such as albuterol to reverse airway obstruction. B. The student's asthma is not well controlled. Rational: The student's asthma is not well controlled is correct. The yellow zone indicates that the student's asthma is not well controlled. The desired range is the green zone which is represents 80 % of the client's personal best. C. The student's peak flow is 50% to 80% of his best peak flow. Rational: The student's peak flow is 50% to 80 % of his best peak flow is correct. This is the range for a client who is in the yellow zone. E. The nurse should obtain a second expiratory flow rate. Rational: The nurse should obtain a second expiratory flow rate is correct. The second peak flow rate should be obtained after the student uses his quick-relief inhaler.

A nurse is presenting an in-service about the use of postural drainage for infants who have cystic fibrosis. Which of the following positions should the nurse identify as being contraindicated for the infant? A. Trendelenburg B. Sitting on a nurse's lap leaning forward C. Supine D. Sitting on a nurse's lap leaning backward

A. Trendelenburg Rational: Infants who have cystic fibrosis are placed in various positions to allow gravity to facilitate the removal of tenacious secretions. The nurse should identify the Trendelenburg position (head lower than body) as being contraindicated for the infant because infants do not have autonomic regulation of blood flow to the head. This position is also contraindicated for children who have head injuries.

No laboratory test exist to diagnose hypertension. However, several laboratory test can identify the cause of secondary hypertension and target organ. A. True B. False

A. True

Older adults with altered renal impairment may need a lower dose and or decreased frequency of administration of a drug excreted by the kidney. A. True B. False

A. True

A nurse is caring for a client who has a new diagnosis of essential hypertension. The nurse should monitor the client for which of the following findings that is consistent with this diagnosis? A. Vertigo B. Uremia C. Blurred vision D. Dyspnea

A. Vertigo Rational: The nurse should monitor the client for findings such as vertigo, headache, facial flushing, and fainting. These manifestations are consistent with a new diagnosis of essential hypertension

A nurse is assessing a female client who is at risk for developing type 2 diabetes mellitus. The nurse should identify that which of the following manifestations increases the client's risk for developing type 2 diabetes? A. blood pressure 138/98 mm Hg B. Triglyceride level 100 mg/dL C. Abdominal girth 32 inches D. Fasting blood glucose 98 mg/dL

A. blood pressure 138/98 mm Hg Rational: A female client who has a blood pressure greater than 130 mm Hg systolic and 85 mm Hg diastolic is at risk for type 2 diabetes

A nurse is reviewing the health history of a client who has diabetes mellitus type 2. Which of the following are risk factors for hyperglycemia-hyperosmolar state (HHS)? (Select all that apply.) A. evidence of recent myocardial infarction B. BUN 35 mg/dL C. takes a calcium channel blocker D. age 77 years E. daily insulin injections

A. evidence of recent myocardial infarction B. BUN 35 mg/dL C. takes a calcium channel blocker D. age 77 years

a nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? A. potassium 5.4 mEq/L B. Creatinine 0.8 mg/dL C. Sodium 143 mEq/L D. BUN 15 mg/dL

A. potassium 5.4 mEq/L

An ESRD patient receiving hemodialysis is considering asking a relative to donate a kidney for transplantation. In assisting the patient to make a decision about treatment, the nurse informs the patient that; A. successful transplantation usually provides better quality of life than that offered by dialysis B. if rejection of the transplanted kidney occurs, no further treatment for the renal failure is available C. hemodialysis replaces the normal functions of the kidneys, and patients do not have to live with the continual fear of rejection D. the immunosuppressive therapy following transplantation makes the person ineligible to receive other forms of treatment if the kidney fails

A. successful transplantation usually provides better quality of life than that offered by dialysis Rationale: Kidney transplantation is extremely successful, with 1-year graft survival rates of about 90% for deceased donor organs and 95% for live donor organs. An advantage of kidney transplantation over dialysis is that it reverses many of the pathophysiologic changes associated with renal failure when normal kidney function is restored. It also eliminates the dependence on dialysis and the need for the accompanying dietary and lifestyle restrictions. Transplantation is less expensive than dialysis after the first year.

A patient with newly diagnosed diabetes has peripheral neuropathy. Which key points should the nurse include in the teaching plan for this patient? Select all that apply. A."Clean and inspect your feet every day." B. "Be sure that your shoes fit properly." C. "Nylon socks are best to prevent friction on your toes from shoes." D. "Only a podiatrist should trim your toenails." E. "Report any non-healing skin breaks to your health care provider (HCP)." F. "Use a thermometer to check the temperature of water before taking a bath."

A."Clean and inspect your feet every day." B. "Be sure that your shoes fit properly." E. "Report any non-healing skin breaks to your health care provider (HCP)." F. "Use a thermometer to check the temperature of water before taking a bath." Rational: Sensory alterations are the major cause of foot complications in patient with diabetes, and patients should be taught to examine their feet on a daily basis. Properly fitted shoes protect the patient from foot complications. Broken skin increases the risk of infection. Cotton socks are recommended to absorb moisture. Using a bath thermometer can prevent burn injuries. Patients, family, or HCPs may trim toenails.

A nurse is teaching a middle-age client about hypertension. Which of the following information should the nurse include in the teaching? A. "Reaching you goal blood pressure will occur within 2 months." B. "Diuretics are the first type of medication to control hypertension." C. "Limit your alcohol consumption to three drinks a day." D. "Plan to lower saturated fats to 10% of your daily calorie intake."

B. "Diuretics are the first type of medication to control hypertension." Rational: The nurse should include in the teaching that diuretic medication is the first type of medication to control hypertension, by decreasing blood volume and lowering blood pressure

A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make? A. "Irregular bowel movements are an indication of poor intestinal health." B. "Excessive laxative use may cause an electrolyte imbalance." C. "Chronic use of laxatives can lead to a tear in the rectal mucosa." D. "Decrease your intake of foods high in fiber."

B. "Excessive laxative use may cause an electrolyte imbalance." Rational: Bisacodyl is a stimulant laxative that acts by stimulating intestinal motility and increasing the amount of water and electrolytes within the intestines; therefore, chronic use of laxatives can lead to fluid and electrolyte imbalance.

A nurse is caring for a client who reports taking bisacodyl (Ducolax) to promote a daily bowel movement. Which of the following should be the nurse's priority? A. "What do your bowel movements look like?" B. "How long have you been taking the bisacodyl?" C. "Do you take the bisacodyl with a glass of milk?" D. "How often do you have a bowel movement?"

B. "How long have you been taking the bisacodyl?" Rational: The greatest risk to this client is injury from dependency on laxatives, as bowel tone can be lost; therefore, the priority question the nurse should ask the client is how long he has been using bisacodyl.

A nurse is providing teaching to a client with gastroesophageal reflux. Which of the following statements by the client indicates a need for further teaching? A. "I should elevate the head of my bed while sleeping." B. "I drink no more than 4 cups of coffee a day." C. "I take my time when I am eating." D. "I avoid foods and drinks made with chocolate."

B. "I drink no more than 4 cups of coffee a day." Rational: The client should not consume regular or decaffeinated beverages; therefore, this statement by the client indicates a need for further teaching.

A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching? A. "I will empty my pouch when it becomes 1/3 full." B. "I will be certain to take enteric-coated medications." C. "I will change my entire pouch system at least weekly." D. "I will use caution when eating high fiber foods."

B. "I will be certain to take enteric-coated medications." Rational: This is not an appropriate statement and indicates a need for additional teaching. Enteric-coated medications should be avoided to reduce the risk of blockage caused by the coating.

A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching? A. "If my breathing begins to feel tight, I will use the cromolyn immediately." B. "I will be sure to take the albuterol before taking the cromolyn." C. "I will use both medications immediately after exercising." D. "I will administer the medications 10 minutes apart."

B. "I will be sure to take the albuterol before taking the cromolyn." Rational: The client should always use the bronchodilator (albuterol) prior to using the leukotriene modifier (cromolyn). Using the bronchodilator first allows the airways to be opened, ensuring that the maximum dose of medication will get to the client's lungs.

A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following client statements indicates an understanding of the teaching? (Select all that apply) A. "I will lie down for one half hour after meals." B. "I will consume less caffeine and fewer spicy foods." C. "I will sleep with the head of my bed elevated." D. "I will try not to gain weight." E. "I will drink less fluid."

B. "I will consume less caffeine and fewer spicy foods." C. "I will sleep with the head of my bed elevated." D. "I will try not to gain weight." Rational: "I will lie down for one half hour after meals" is incorrect. A client who has a hiatal hernia should remain upright for several hours after meals."I will consume less caffeine and fewer spicy foods" is correct. Foods and beverages that are spicy or contain caffeine can exacerbate the manifestations of a hiatal hernia."I will sleep with the head of my bed elevated" is correct. The client should raise the head of the bed on blocks to avoid lying flat when sleeping."I will try not to gain weight" is correct. Obesity raises intra-abdominal pressure, which worsens the hernia."I will drink less fluid" is incorrect. Although the client should avoid fluids containing caffeine and alcohol, there is no indication for clients who have a hiatal hernia to decrease overall fluid intake.

A nurse is instructing a client who has GERD about positions that can help minimize the effects of reflux during sleep. Which statement indicates to the nurse that the client understands the instructions? A. "I will lie on my left side to sleep at night." B. "I will lie on my right side to sleep at night." C. "I will sleep on my back with my head flat." D. "I will sleep on my stomach with my head flat."

B. "I will lie on my right side to sleep at night." Rational: Sleeping in a right side-lying position helps reduce the manifestations of nighttime reflux. The client can also elevate the head of the bed about 10.2 cm (4 in) to 30.5 cm (12 in) on blocks.

A nurse is teaching a client who has acute kidney disease about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding of the teaching? A. "I should consume most of the fluid during the evening." B. "I will make a list of my favorite beverages." C. "I will put beverages in large containers to give the appearance of drinking a lot." D. "I will not add ice cream to the amount of fluid intake."

B. "I will make a list of my favorite beverages." Rational: The nurse should work with the client to develop a schedule for fluid restrictions, and should attempt to include the client's favorite beverages when possible to promote satisfaction.

A nurse is providing teaching fora client who has a new diagnosis of hypertension and a new prescription for spironolactone25 mg/day. Which of the following statements by the client indicates an understanding of the teaching? A. "I should eat a lot of fruits and vegetables, especially bananas and potatoes." B. "I will report any changes in heart rate to my provider." C."I should replace the salt shaker on my table with a salt substitute." D."I will decrease the dose of this medication when I no longer have headaches and facial redness."

B. "I will report any changes in heart rate to my provider." Rational: The nurse should teach the client to monitor her heart rate and report any changes to her provider.

A nurse is providing teaching to a client who has CKD. Which of the following statements by the client indicates an understanding of the teaching? A. "I will rest for at least 30 minutes before eating." B. "I will take my bronchodilators after meals." C. "I will eat five or six small meals each day." D. "I will choose foods that are not gas-forming."

B. "I will take my bronchodilators after meals." Rational: bronchodilators should be taken before meals, not after, in order to reduce shortness of breath. This statement by the client indicates a need for further teaching.

A nurse is teaching a client who has chronic kidney disease and is to start using fluticasone by MDI twice daily. Which of the following instructions should the nurse include? A. "Check your heart rate before each dose." B. "Inspect your mouth for lesions daily." C. "Use this medication to relieve an acute attack." D. "Skip the morning dose if you do not have any symptoms."

B. "Inspect your mouth for lesions daily." Rational: The nurse should instruct the client to inspect her mouth daily. Fluticasone is a corticosteroid, which reduces the client's immunity and increases the risk for infection, such as Candida albicans.

A nurse is providing dietary teaching for a client who has chronic obstructive pulmonary disease. Which of the following instructions should the nurse include? A. "Eat 3 large meals each day" B. "Limit water intake with meals" C. "Reduce protein intake" D. "Use a bronchodilator 1 hour before eating"

B. "Limit water intake with meals" Rational: The nurse should instruct the client to limit low nutrient liquids during meals to prevent early satiety and increase intake of nutrient dense foods.

A nurse is teaching a client who is taking metformin XR for type 2 diabetes mellitus. Which of the following instructions should the nurse include in the teaching? A. "This medication may cause an increase in perspiration" B. "Take the medication with a meal." C. "You may crush or chew the medication" D. "This medication may turn your urine orange"

B. "Take the medication with a meal."

A nurse is teaching the parents of a child who is to start using a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching. A. "The spacer increases the amount of medication delivered to the oropharynx" B. "The spacer increases the amount of medication delivered to the lungs" C. "Inhale rapidly using the spacer with the MDI" D. "Cover exhalation slots of the spacer with lips when inhaling"

B. "The spacer increases the amount of medication delivered to the lungs" Rational: The client uses a spacer to increase the amount of medication that reaches the lungs

While the RN is performing an admission assessment on a patient with type 2 diabetes, the patient states that he routinely drinks 3 beers a day. What is the nurse's priority follow-up question at this time? A. "Do you have any days when you do not drink?" B. "When during the day do you drink your beers?" C. "Do you drink any other forms of alcohol?" D. "Have you ever had a lipid profile completed?"

B. "When during the day do you drink your beers?" Rationale: Alcohol has the potential for causing alcohol-induced hypoglycemia. It is important to know when the patient drinks alcohol and to teach the patient to ingest it shortly after meals to prevent this complication. The other questions are important but not urgent. The lipid profile question is important because alcohol can raise plasma triglycerides but is not as urgent as the potential for hypoglycemia.

A nurse is providing teaching for a client who has hypertension and a prescription change from metoprolol to metoprolol/hydrochlorothiazide. Which of the following statements by the clients indicates an understanding of the teaching? A. "Now I will not have to diet to lose weight." B. "With the new medication, I should experience fewer side effects." C. "I will not have to do anything different because it is the same medication." D. "The extra letters after the name of medication means it is a stronger dose."

B. "With the new medication, I should experience fewer side effects." Rational: The client has stated an understanding of the purpose of the addition of the hydrochlorothiazide (HCTZ) to the metoprolol dosage. When used in combination with thiazide diuretics, a lower dose of the beta-blocker can be used. The benefit is there are fewer side effects when beta-blockers (and other antihypertensives) are used in lower dosages.

a nurse is providing teaching for a client who has hypertension and a prescription change from metoprolol to metoprolol/hydrochlorothiazide. which of the following statements by the client indicates an understanding of the teaching? A. "Now I will not have to diet to lose weight." B. "With the new medication, I should experience fewer side effects." C. "I will not have to do anything different because it is the same medication." D. "The extra letters after the name of medication means it is a stronger dose."

B. "With the new medication, I should experience fewer side effects." Rational: The client has stated an understanding of the purpose of the addition of the hydrochlorothiazide (HCTZ) to the metoprolol dosage. When used in combination with thiazide diuretics, a lower dose of the beta-blocker can be used. The benefit is there are fewer side effects when beta-blockers (and other antihypertensives) are used in lower dosages.

A nurse is discussing with a nursing student how to accurately measure blood pressure . Which of the following points does the nurse emphasize ? A. A cuff that is too small will give false low blood pressure B. A cuff that is too small will give a false high blood pressure C. A cuff that is too large will give a false high blood pressure D. Blood pressure cuff placement is more important than the appropriate size

B. A cuff that is too small will give a false high blood pressure Rational: Using a cuff that is too small will give a false high blood pressure measurement , while using a cuff that is too large results in a false low blood pressure measurement

A client is hospitalized with acute exacerbation of COPD. Which of the nurse expect to see an assessment? A. Increased oxygen saturation with exercise B. A hyperinflated chest on x-ray C. Hypocapnia D. A widened diaphragm noted on the chest x-ray

B. A hyperinflated chest on x-ray

A nurse is preparing to administer a morning dose of Aspart insulin (NovoLog) to a client who has type 1 diabetes mellitus. Which of the following is an appropriate action by the nurse? A. Check the client's blood glucose immediately after breakfast. B. Administer the insulin when breakfast arrives. C. Hold breakfast for 1 hr after insulin administration. D. Clarify the prescription because insulin should not be administered at this time.

B. Administer the insulin when breakfast arrives. Rational: Administer Aspart insulin when breakfast arrives to avoid a hypoglycemic episode. Aspart insulin is rapid-acting, and should be administered 5 to 10 min before breakfast.

A nurse is administering sulfasalazine to a client who has a gastric ulcer. Which of the following actions should the nurse take? A. Instruct the client to chew the sucralfate for fasting absorption. B. Administer the medication without food or fluids. C. Limit the client's fluids while on sucralfate therapy. D. Administer sucralfate with an antacid.

B. Administer the medication without food or fluids. Rational: The nurse should administer the medication to the client on an empty stomach for best absorption.

A nurse is facing charges of professional negligence. Which of the following professional nursing organizations provides resources to demonstrate whether she met the standard of practice? A. American Nurses Credentialing Center (ANCC) B. American Nurses Association (ANA) C. American Nurse Foundation (ANF) d. National League for Nursing (NLN)

B. American Nurses Association (ANA) Rationale: The ANA's Scope and Standards of Practice informs decision-making, guides practice, and influences quality of client care.

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client tells the nurse she has been having difficulty breathing. Which of the following nursing actions is the priority at this time? A. Increase the oxygen flow to 3 L/min. B. Assess the client's respiratory status. C. Call emergency services for the client. D. Have the client cough and expectorate secretions.

B. Assess the client's respiratory status. Rational: The first action the nurse should take using the nursing process is to collect data from the client. The nurse should immediately assess the client's respiratory status before determining the appropriate interventions.

a nurse is administering IV fluids to a client. when monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? A. Monitor blood pressure readings B. Auscultate lung sounds C. Measure urine output D. Monitor electrolyte levels

B. Auscultate lung sounds Rational: he priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath.

Which finding is the best indication that a client with ineffective clearance needs suctioning? A. Oxygen saturation B. Breath sounds C. Respiratory rate Arterial blood gasses

B. Breath sounds

A nurse notices an assistive personnel (AP) preparing to deliver a food tray to a client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take? A. Allow the AP to deliver the food tray to the client. B. Call the dietary department and ask for a kosher tray. C. Replace the nonfat milk with apple juice. D. Explain to the client that he needs the protein in the milk and the beef.

B. Call the dietary department and ask for a kosher tray. Rational: This action shows cultural sensitivity and respect for the client's cultural and spiritual beliefs. Clients who practice the Orthodox Jewish faith do not eat meat and dairy together.

A nurse is providing discharge teaching's to a client who has a new prescription for home oxygen therapy via nasal cannula. Which of the following should the nurse include in the teaching? (Select all that apply) A. Verify the oxygen flow rate every other day. B. Check the cannula position on a regular basis. C. Check the tops of the ears for skin breakdown. D. Post "no smoking" signs in a prominent location in the home. E. Apply petroleum ointment to nares if they become dry and irritated.

B. Check the cannula position on a regular basis. Rational: The position of the nasal cannula should be verified every 8 hours or more often if needed. C. Check the tops of the ears for skin breakdown. Rational: The tops of the ears, the nares and the nasal mucous membranes should be assessed regularly for skin breakdown. D. Post "no smoking" signs in a prominent location in the home. Rational: The family is instructed to post "no smoking" signs in a prominent location in the home because oxygen increases the risk of fire injuries.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? A. Replace the catheter every 3 days. B. Check the catheter tubing for kinks or twisting. C. Irrigate the catheter once each shift. D. Clean the perineal area with an antiseptic solution daily.

B. Check the catheter tubing for kinks or twisting. Rational: The nurse should check the catheter for twisting or kinks in the tubing. These obstructions can affect the flow of urine causing pooling in the tubing that could backflow into the bladder.

A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid? A. Nonfat milk B. Chocolate C. Apples D. Oatmeal

B. Chocolate Rational: The client should avoid foods that reduce pressure on the lower esophageal sphincter. These include fatty and fried foods, chocolate, caffeine, alcohol, and carbonated drinks.

The term "blue bloater" refers to which of the following conditions? A. Adult respiratory distress syndrome (ARDs) B. Chronic obstructive pulmonary disease C. Asthma D. Emphysema

B. Chronic obstructive pulmonary disease

A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for? A. Elevated sodium level B. Decreased potassium level C. Elevated magnesium level D. Decreased calcium level

B. Decreased potassium level Rational: Hypokalemia is an electrolyte imbalance in which the serum potassium level is less than 3.5 mEq/L. Hypokalemia may be the result of diuretic use, diarrhea, vomiting, and prolonged nasogastric suctioning.

A nurse is preparing to initiate a continuous enteral feeding through an open system to a client. Which of the following actions should the nurse take? A. Reconstitute the formula with tap water. B. Discard unused formula after 8 hr. C. Administer 200 mL of formula during the initial infusion. D. Give the initial feeding over 15 min.

B. Discard unused formula after 8 hr. Rational: The nurse should discard unused formula 8 to 12 hr after reconstitution to reduce the risk for bacterial growth.

A nurse is preparing to measure a client's oxygen saturation and notes edema of the client's hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations? A. Finger B. Earlobe C. Toe D. Skin fold

B. Earlobe Rational: The earlobe is rarely edematous, is the least affected by decreased blood flow, and has greater accuracy when measuring oxygen saturation.

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. determine the correct order of steps for this procedure. 1. Inject 5 units of air into the bottle of regular insulin 2. Inject 10 units of air into the bottle of NPH insulin 3. Withdraw the correct dose of regular insulin from the bottle 4. Withdraw the correct dose of NPH insulin from the bottle A. True B. False

B. False

Insulin is given to someone experiencing symptoms of diaphoresis, sweating, and tremors A. True B. False

B. False

Long-acting insulin can only be mixed with short-acting insulin. A. True B. False

B. False

A nurse is assessing a client who has diabetic ketoacidosis and ketones in the urine. The nurse should expect which of the following finding. (Select all that apply) A. Weight gain B. Fruity odor of breath C. Abdominal pain D. Kussmaul respirations E. Metabolic acidosis

B. Fruity odor of breath Rational: manifestation of elevated ketones C. Abdominal pain Rational: manifestation of elevated ketones & acidosis D. Kussmaul respirations Rational: hyperventilation = respiratory system trying to correct metabolic acidosis E. Metabolic acidosis Rational: caused by glucose, protein, & fat breakdown, which produces ketones

A nurse is caring a client who has heart failure and potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as the cause of the client's low potassium level? A. Spironolactone B. Furosemide C. Nitroglycerin D. Metoprolol

B. Furosemide Rational: Furosemide is a loop (high ceiling) diuretic that inhibits the reabsorption of sodium and chloride and results in diuresis, which decreases potassium through excretion in the distal nephrons. Hypokalemia is an adverse effect of furosemide

A nurse is reviewing client laboratory data. The nurse should recognize that which of the following findings is expected for a client who has Stage 4 chronic kidney disease? A. BUN 15 mg/dL B. GFR 20 mL/min C. serum creatinine 1.1 mg/dL D. serum potassium 5.0 mEq/L

B. GFR 20 mL/min Rational: The GFR is severely decreased to approximately 20 mL/min, which is indicative of stage 4 chronic kidney disease

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate? A. Cane B. Gait belt C. Four-wheel walker D. Jacket harness

B. Gait belt Rational: The nurse should use a gait belt to help support the client during ambulation. A gait belt helps keep the client's center of gravity stable and helps maintain balance and prevent falls.

A nurse is caring for a client immediately following hemodialysis treatment. For which of the following manifestations will the nurse administer a PRN dose of phenytoin? A. Decreased blood pressure, rapid pulse B. Headache, restlessness C. Pain and tingling at the access site D. Muscle cramps, chest heaviness

B. Headache, restlessness Rational: Headache and restlessness are manifestations of disequilibrium syndrome, which occurs during or after hemodialysis due to the rapid shift of fluids, pH, and osmolarity between fluid and blood that occurs.. This condition can cause cerebral edema leading to seizures and coma, and a PRN dose of the anticonvulsant phenytoin should be administered.

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this condition? A. History of bulimia B. History of NSAID use C. Drinks green tea D. Has a glass of wine with dinner each day

B. History of NSAID use Rational: The nurse should recognize that long-term use of NSAIDs is a risk factor for peptic ulcer disease. NSAIDs break down the mucosal barrier and cause production of prostaglandins to decrease, which results in local gastric mucosal injury.

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client? A. Respiratory alkalosis B. Increased anteroposterior diameter of the chest C. Oxygen saturation level 96% D. Petechiae on chest

B. Increased anteroposterior diameter of the chest Rational: The nurse should anticipate an increased anteroposterior diameter of the chest (barrel chest) because of chronic hyperinflation of the lungs.

A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration? A. Place her hands on the sides of her rib cage B. Inhale slowly and evenly through her nose C. Hold her breath for at least 10 seconds D. Exhale forcefully through the nose

B. Inhale slowly and evenly through her nose Rational: The nurse should inhale slowly and evenly through her nose until chest expansion is maximized.

Which of the following findings would help confirm a diagnosis of asthma in a client of having the disorder? A. Circumoral cyanosis B. Inspiratory and expiratory wheezing C. Increased forced expiratory volume D. Normal breath sounds

B. Inspiratory and expiratory wheezing

A nurse is collaborating on care for a client who has COPD. Which of the following tasks should the nurse recommend be referred to an occupational therapist for assistance? A. Instructing how to measure oxygen saturation B. Instructing how to use kitchen tools to prepare a meal C. Instruction how to plan a diet based on individual caloric needs D. Instructing how to perform pursed-lip breathing

B. Instructing how to use kitchen tools to prepare a meal Rational: As a member of the interdisciplinary team, the occupational therapist works with the client to develop fine motor skills and coordination, such as improving hand strength and hand movements. The occupational therapist focuses on self-management of ADLs, such as skills needed for eating, hygiene, and dressing. Occupational therapists also can teach clients to perform other independent living skills, such as cooking and shopping.

​A nurse is pursuing chemotherapy certification. Which of the following is an advantage of receiving certification? A. Gaining self-satisfaction in learning about chemotherapy administration B. Maintaining knowledge of current practice in chemotherapy administration C. There is no advantage in obtaining certification D. Providing formal instruction to peers about chemotherapy administration

B. Maintaining knowledge of current practice in chemotherapy administration Rationale: By becoming certified in chemotherapy administration, the nurse meets her quest for lifelong learning by maintaining knowledge of current practice.

A nurse on a medical-surgical unit is caring for a group of clients. The nurse demonstrates autonomy when he performs which of the following actions? A. Administers a scheduled PO dose of levothyroxine (Synthroid) before breakfast B. Measures the calf circumference of a client who reports unrelieved leg pain. C. Assist the patient to the supine position for BP measurements D. Obtains a client signature for informed consent.

B. Measures the calf circumference of a client who reports unrelieved leg pain Rationale: The nurse measures the calf circumference of a client who reports unrelieved leg pain based on his nursing knowledge. Therefore, this is an autonomous action by the nurse.

A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care? A. Monitor the client's intake and output every 6 hr. B. Offer the client 240 mL (8 oz) of oral fluids every 4 hr. C. Check the client's IV infusion every 8 hr. D. Administer furosemide to the client.

B. Offer the client 240 mL (8 oz) of oral fluids every 4 hr. Rational: The nurse should offer 60 to 120 mL (2 to 4 oz) of fluids every 1 to 2 hr to manage the dehydration as well as prevent further dehydration.

A nurse is reviewing the medication list for a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize which of the following medications can cause glucose intolerance? A. Dextromethorphan B. Prednisone C. Atorvastatin D. Crimidine

B. Prednisone Rational: Corticosteroids such as prednisone can cause glucose intolerance and hyperglycemia. The client might require increased dosage of a hypoglycemic medication.

The nurse receive report on 2 patients with diabetes. which patient should the nurse assess immediately? A. Numbness and tingling in both feet B. Profuse perspiration C. Fingerstick glucose reading of 185 mg/dL (10.3 mmol/L) D. A sore on the left great toe

B. Profuse perspiration Rational: Profuse perspiration is a symptom of hypoglycemia, a complication of diabetes that requires urgent treatment. A glucose level of 185 mg/dL (10.3 mmol/L) will need coverage with sliding-scale insulin, but this is not urgent. Numbness and tingling, as well as bunions, are related to the chronic nature of diabetes and are not urgent problems.

A patient undergoes peritoneal dialysis exchanges several times each day. What should the nurse plan to increase in the patient's diet? A. Fat B. Protein C. Calories D. Carbohydrates

B. Protein Rational: Dietary protein guidelines for peritoneal dialysis (PD) differ from those for hemodialysis because of protein loss in the dialysate. During PD, protein intake must be high enough to compensate for the losses, so that the nitrogen balance is maintained. Recommended protein intake is at least 1.2 g/kg of ideal body weight per day, and it increases according to the individual needs of the patient

A nurse is caring for a client who has blood glucose 52 mg/dL. The client is lethargic but arousable. Which of the following actions should the nurse perform first? A. Provide a carbohydrate and protein food B. Provide 15g of simple carbohydrate C. Report findings to the provider D. Recheck blood glucose in 15 min

B. Provide 15g of simple carbohydrate Rational: The greatest risk to the client is injury from hypoglycemia; therefore, the priority action to take is to administer 15 to 20 g of a rapidly absorbed carbohydrate (grape juice)

A nurse is caring for a client who requires total parenteral nutrition (TPN). Which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly A. Turn the client on his left side. B. Sit the client upright. C. Prepare to add insulin to the TPN infusion. D. Stop the TPN infusion.

B. Sit the client upright. Rational: Fluid overload can cause dyspnea. The nurse should slow the infusion rate and sit the client upright to help prevent or treat dyspnea. The nurse should also administer oxygen if necessary.

Your patient is using a Budesonide inhaler. You should connect _______________ to decrease ___________________ A. Peak flow meter; Pneumonia B. Spacer; thrush C. Incentive spirometer; thrust D. Peak flow meter; mount sores

B. Spacer; thrush

A nurse is providing teaching to a client who has hypertension and a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse provide? A. Weigh weekly to monitor therapeutic effect B. Take the medication early in the day C. Muscle pain is an expected adverse effect D. Take the medication on an empty stomach

B. Take the medication early in the day Rational: The nurse instruct the client to take hydrochlorothiazide early in the day to avoid nocturia

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take?(select all that apply) A. Keep the client's room dark at night. B. Teach the client to use the call light. C. Keep the client's bed in the lowest position. D. Place a fall-risk identification band on the client's wrist. E. Assess the client every 4 hr.

B. Teach the client to use the call light. Rational: Clients need an easy, accessible way to summon assistance, especially those who are at risk for falls. C. Keep the client's bed in the lowest position. Rational: With the bed in the lowest position and the wheels locked, the client is less likely to fall when getting out of bed. D. Place a fall-risk identification band on the client's wrist. Rational: Fall-risk bands, usually yellow, help staff identify clients at risk and take precautions to prevent falls.

A nurse is preparing a teaching plan for a client who has chronic constipation secondary to irregular bowel habits. Which of the following should the nurse plan to include in the teaching? A. The client should drink two to three 8 oz glasses of water each day. B. The client should follow a high-fiber diet to establish bowel regularity. C. The client should try to take in all of the required dietary fiber with the morning meal. D. The client should be taught that the goal of therapy is to have a bowel movement daily.

B. The client should follow a high-fiber diet to establish bowel regularity. Rational: The client who has chronic constipation should consume a diet with high-fiber food sources, including bran and complex carbohydrates.

A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make? (select all that apply) A. The medication will stimulate flow of mucus. B. The medication will prevent wheezing. C. The medication will open the airways. D. The medication will reduce inflammation. E. The medication will decrease coughing episodes.

B. The medication will prevent wheezing. Rational: Albuterol is used to prevent or treat wheezing. C. The medication will open the airways. Rational: Albuterol promotes bronchodilation. The primary purpose is to provide rapid relief of bronchoconstriction, thus opening the airway and improving oxygenation. E. The medication will decrease coughing episodes. Rational: Coughing is often an early indicator of bronchospasm. Albuterol provides a rapid response to relax smooth muscle and reduce bronchoconstriction, which will decrease coughing.

A nurse is monitoring a client who is receiving packed RBCs. The nurse identifies which of the following as an expected finding? A. The drip chamber with filter is filled completely with blood. B. The packed RBCs are connected by Y tubing to normal saline. C. The blood has been infusing steadily for 5 hr with no client symptoms. D. A medication is being administered IV through the injection site closest to the client.

B. The packed RBCs are connected by Y tubing to normal saline. Rational: The only intravenous fluid that can be used in the blood administration tubing is normal saline. It is used to prime the tube, and when the infusion is complete, it should also be used to clear the line. Y tubing allows for normal saline to infuse through one branch of the Y and packed RBCs through the other.

A nurse is making a home visit to see a client who has Alzheimer's disease and their client's partner. Which observation indicates to the nurse that the partner is experiencing caregiver role strain? A. The partner redirects the client when the client is frustrated B. The partner has lost 20 Ib in the past 2 months C. The partner has hired a house cleaner D. The partner has placed locks at the top of the doors leading to the outside

B. The partner has lost 20 Ib in the past 2 months Rational: A large weigh loss by caregiver is an indication of caregiver role strain.

A nurse is delegating client care to an assistive personnel (AP) and instructs the AP to provide morning care to a client who has left-sided weakness. Which of the following rights should the AP clarify with the nurse? A. The right person B. The right direction C. The right time D. The right direction

B. The right direction Rationale: The AP should clarify the directions for performing morning care. The nurse should provide specific instructions for the AP to follow.

"An 18-year-old female client, 5'4'' tall, weighing 113 kg, comes to theclinic for a non-healing wound on her lower leg, which she has had for two weeks. Which disease process should the nurse suspect the client is developing?" A. Type 1 diabetes B. Type 2 diabetes C. Gestational diabetes D. Acanthosis nigricans"

B. Type 2 diabetes Rational: Type 2 diabetes is a disorder usually occurring around the age of 40, but it is now being detected in children and young adults as a result of obesity and sedentary lifestyles. Non-healing wounds are a hallmark sign of type 2 diabetes.

To prevent the most common serious complication of peritoneal dialysis, what is important for the nurse to do? A. Infuse the dialysate slowly. B. Use strict aseptic technique in the dialysis procedures. C. Wash hands and maintain a clean working field D. Titrate the dialysate per order

B. Use strict aseptic technique in the dialysis procedures. Rational: Peritonitis is a common complication of peritoneal dialysis (PD) and may require catheter removal and termination of dialysis. Infection occurs from contamination of the dialysate or tubing or from progression of exit-site or tunnel infections and strict sterile technique must be used by health professionals as well as the patient to prevent contamination. Too-rapid infusion may cause shoulder pain and pain may be caused if the catheter tip touches the bowel. Difficulty breathing, atelectasis, and pneumonia may occur from pressure of the fluid on the diaphragm, which may be prevented by elevating the head of the bed and promoting repositioning and deep breathing.

A nurse is preparing to obtain a daily weight from a client who has chronic kidney disease. Which of the following actions should the nurse implement? A. Obtain the weight each day at a time convenient for the client B. Weight the client after he (the client) has voided C. Use any available scale to weight the client D. Balance the scale at minus two before weight the client

B. Weight the client after he (the client) has voided

A nurse is reviewing laboratory reports of client who has HHS. Which of the following findings should the nurse expect? A. blood pH 7.2 B. blood osmolarity 350 mOsm/L C. blood potassium 3.8 mg/dL D. blood creatinine 0.8 mg/dL

B. blood osmolarity 350 mOsm/L

A nurse is assessing a client who has diabetic ketoacidosis and ketones in the urine. The nurse should expect which of the following findings? (Select all that apply.) A. weight gain B. fruity odor of breath C. abdominal pain D. Kussmaul respirations E. metabolic acidosis

B. fruity odor of breath C. abdominal pain D. Kussmaul respirations E. metabolic acidosis

A nurse is reviewing the BUN and creatinine levels of an older adult client who has chronic kidney disease. The nurse should expect what lab finding? A. BUN 23 mg/dL and creatinine B. BUN 45 mg/dL and creatinine 8 mg/dL. C. BUN 10mg.dL and creatinine 0.3 mg/dL D. BUN 8 mg/dL and creatinine 0.7 mg/dL

BUN 45 mg/dL and creatinine 8 mg/dL. Rationale: An elevation of both BUN and creatinine is an expected finding of chronic kidney disease.

A nurse is teaching a client who has a new prescription for esomeprazole to manage his GERD. Which of the following statements by the client indicates an understanding of the teaching? A. "I won't pass gas as often now that I am taking this medication." B. "I will take this medication each morning with my breakfast." C. "I have an increased risk of getting pneumonia while taking this medication." D. "I will need to take a daily stool softener while taking this medication."

C. "I have an increased risk of getting pneumonia while taking this medication." Rational: The client taking esomeprazole is at a greater risk for developing pneumonia due to an elevation of gastric pH, especially during the first few days of treatment. The nurse should instruct the client about manifestations of a respiratory infection and to report these findings to the provider if they occur.

A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching? A. "I will inhale slowly through pursed lips to help me breathe better." B. "I will avoid getting a flu shot." C. "I will follow a daily diet high in calories and protein." D. "I will lie on my stomach to practice abdominal breathing every day."

C. "I will follow a daily diet high in calories and protein." Rational: Clients who have emphysema have greater-than-usual nutritional requirements for calories and protein and often need nutritional supplements between meals.

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. "HIPAA established regulations of individual identifiable health information in verbal. electronic, or written form" B. "HIPAA is a federal law, not a state law" C. "Information about a client can be disclosed to family members at any time." D. "A client's address would be an example of personally identifiable information"

C. "Information about a client can be disclosed to family members at any time." Rational: This statement reflects a need for further teaching. Privacy relates to the client's rights over the use and disclosure of his own personal health information.

A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which of the following statements indicates that the mother understands the teaching? A. "My child will take the enzymes to improve her metabolism." B. "My child will take the enzymes following meals." C. "My child will take the enzymes to help digest the fat in foods." D. "My child will take the enzymes 2 hours before meals."

C. "My child will take the enzymes to help digest the fat in foods." Rational: Pancreatic enzymes help the body to digest fat in foods.

A nurse is a client who is taking metformin XR for type 2 DM. Which of the following instructions should the nurse include in the teaching? A. "You may crush or crew the medication" B. "This medication may cause an increase in perspiration" C. "Take the medication with a meal" D. "This medication may turn your urine orange"

C. "Take the medication with a meal." Rational: This will help the client avoid HYPOglycemia and GI upset and to provide the most absorption of the medication.

A nurse is teaching a client about self-administered peritoneal dialysis. Which of the following statements by the client indicates a need for further teaching? A. "The fluid from my abdomen will be clear or slightly yellow." B. "The catheter can become infected even with sterile precautions." C. "The microwave in my kitchen can warm the solution before I use it." D. "The volume of the output solution should be greater than the input solution."

C. "The microwave in my kitchen can warm the solution before I use it."

A nurse is caring for a client who has fallen while getting out of bed and states "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record? A. "An incident report was completed" B. "There were no injuries sustained" C. "The provider was notified" D. "An incident report was forwarded to risk management"

C. "The provider was notified" Rational: Nursing interventions that support factual information should be documented in the health record

A nurse is teaching a client about glycosylated hemoglobin (HbA1c) testing. Which of the following statements should the nurse identify as an indication that the client understands the information about this test? A. "A level of 8-10 percent suggests adequate blood glucose control" B. "I will use my hemoglobin A1c level to adjust my daily insulin doses" C. "This test's result is a good indicator of my average blood glucose levels." D. "I need to fast after midnight the night before the test"

C. "This test's result is a good indicator of my average blood glucose levels." Rational: HbA1c reflects the client's glucose levels over a 120-day period, which is the life span of RBCs.

A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus about self administration of insulin. which of the following instructions should the nurse include? A. "Use each syringe up to six times" B. "Pull back on the plunger after injecting the insulin" C. "store the current bottle of insulin at room temperature" D. "Massage the injection site after removing the needle"

C. "store the current bottle of insulin at room temperature" Rational: The nurse should instruct the client to keep the bottle of insulin she is currently using a room temperature to minimize painful injections. The client should refrigerate unused bottles of insulin to protect the quality of the medication

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? A. Lactated Ringer's B. Dextrose 5% in 0.9% sodium chloride C. 0.45% sodium chloride D. Dextrose 10% in water

C. 0.45% sodium chloride Rational: A client who has an elevated sodium level and is NPO requires a hypotonic IV solution, such as 0.45% sodium chloride or 0.225% sodium chloride.

Cystic fibrosis is caused by? A. A defective gene that causes abnormalities in the brain B. It is not known what the cause is C. A defective gene that leads to the making of an abnormal protein D. A diet too high in salt

C. A defective gene that leads to the making of an abnormal protein

A nurse is caring for a client who reports recurrent flank pain, nausea, and vomiting for 24 hr. Which of the following actions is the nurse's priority? A. Monitor intake and output. B. Strain the urine. C. Administer pain medication. D. Administer an antiemetic.

C. Administer pain medication. Rational: Using Maslow's hierarchy of needs, the nurse's priority is to meet the client's physiological need for comfort. Therefore, the first action the nurse should take is to administer pain medication to relieve the client's flank pain.

A client with type 1 diabetes mellitus has a finger stick glucose level of 258 mg/dL at bedtime. A prescription for sliding scale insulin exists. What should the nurse do? A. Encourage fluids B. Give 1/2 cup of orange juice C. Administer the insulin as ordered D. Call the physician

C. Administer the insulin as ordered

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? A. Nausea B. Dysphagia C. Agitation D. Hypotension

C. Agitation Rational: The nurse should expect the client to display dyspnea, not dysphagia, during an asthma attack

A nurse is caring for a client who develops disequilibrium syndrome after receiving hemodialysis. Which of the following actions should the nurse take? A. Administer an opioid medication. B. Monitor for hypertension. C. Assess level of consciousness. D. Increase the dialysis exchange rate.

C. Assess level of consciousness. Rational: The nurse should assess the client's level of consciousness. A change in urea levels can cause increased intracranial pressure. Subsequently, the client's level of consciousness decreases.

A community health nurse is conducting an educational program on various environmental pollutants. The nurse should emphasize that clients who have which of the following disorders are especially vulnerable to ozone effects? A. Osteoarthritis B. Basal cell carcinoma C. Asthma D. Hypothyroidism

C. Asthma Rational: The ozone exerts its primary adverse effects on the respiratory system, reducing lung function and increasing the risk of respiratory infection. Clients who have respiratory disorders, such as asthma and COPD, are especially vulnerable.

An acute asthma attack with inspiratory and expiratory wheezes and a decreased expiratory volume should be treated with? A. Beta-adrenergic blockers B. Inhaled steroids C. Bronchodilators D. Oral steroids

C. Bronchodilators

Which information is most important to communicate to the MD 2 hours after a kidney transplant? A. The patient has 8/10 incisional pain B. Urine output is 900-1000ml C. Central venous pressure decreased D. BUN and creatinine elevated

C. Central venous pressure decreased

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations? A. Kussmaul respirations B. Apneustic respirations C. Cheyne-Stokes respirations D. Stridor

C. Cheyne-Stokes respirations Rational: Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR are common respiratory alterations seen in clients who are unconscious, comatose, or moribund (approaching death).

The nurse is assessing a patient who has dark skin for cyanosis. Which of the following sites should the nurse examine to identify cyanosis in this client? A. Pinnae of the ears B. Dorsal surface of the hand C. Conjunctivae D. Dorsal surface of the foot

C. Conjunctivae Rational: To assess skin color changes in clients who have dark skin, the nurse should examine body areas with minimal pigmentation, such as the sclerae, soles of the feet, conjunctivae, and mucous membranes.

A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following? A. Delivers a constant rate of a specific concentration of oxygen B. Delivers a high concentration of oxygen C. Delivers a low concentration of oxygen D. Restricts the client's ability to eat, speak, or drink

C. Delivers a low concentration of oxygen Rational: A nasal cannula delivers a relatively low concentration of oxygen (24% to 44%).

A nurse is teaching a client who has type 1 diabetes mellitus about exercise. Which of the following instructions should the nurse include? A. Perform vigorous exercise when blood glucose is less than 100 mg/dL B. Examine your feet weekly C. Do not exercise if ketones are present in your urine. D. Avoid eating 2 hr before exercise

C. Do not exercise if ketones are present in your urine.

A nurse is preparing to administer the morning doses of glargine (Lantus) insulin and regular (Humulin R)insulin to a client who has a blood glucose of 278 mg/dL. Which of the following is an appropriate nursing action? A. Draw up the regular insulin and then the glargine insulin in the same syringe. B. Draw up the glargine insulin then the regular insulin in the same syringe. C. Draw up and administer regular and glargine insulin in separate syringes. D. Administer the regular insulin, wait 1 hr, and then administer the glargine insulin.

C. Draw up and administer regular and glargine insulin in separate syringes. Rational: Administer each insulin as a separate injection. These insulins are not compatible and should not be drawn up in the same syringe.

Which of the following can trigger an asthma attack? A. Sulfites, smoke, caffeine B. Cold weather, caffeine, beta agonist C. GERD, cold weather, cockroaches D. GERD, sulfites, beta agonist

C. GERD, cold weather, cockroaches

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions? A. Asthma B. Aortic valve regurgitation C. Heart failure D. Aortic stenosis

C. Heart failure Rational: Fatigue and tachycardia are early manifestations of heart failure. Other manifestations include dyspnea and weak peripheral pulses.

Teaching for a client with chronic obstructive disease (COPD) should include which of the following topics? A. How to have his wife learn to listen to his lungs with a stethoscope B. How to treat respiratory infections without going to the physician C. How to recognize the signs pf an impending respiratory D. How to increase his oxygen therapy

C. How to recognize the signs pf an impending respiratory

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching? A. Bear down hard when defecating. B. Drink four to five glasses of water daily. C. Increase dietary intake of raw vegetables. D. Limit activity.

C. Increase dietary intake of raw vegetables. Rational: The client should increase dietary intake of raw vegetables to help provide fiber in the diet, which will increase stool bulk and move the stool through the colon to prevent constipation.

A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings? A. Decreased urine specific gravity B. Decreased Hgb C. Increased BUN D. Increased urine ketones

C. Increased BUN Rational: Increased BUN is an expected finding of fluid volume deficit due to the hemoconcentration of substances in the blood from excessive water loss.

A nurse is preparing to administer lispro insulin to a client who has type one diabetes mellitus. which of the following actions should the nurse take? A. Assess for hypoglycemia 4 hr after the insulin injection B. Monitor for polyuria C. Inject the insulin 15 min before a meal D. Administer with short-acting insulin

C. Inject the insulin 15 min before a meal Rational: The nurse administer lispro insulin 15 min before a meal, because lispro is a rapid-acting insulin that has an onset within 15 to 30 min. The client may develop hypoglycemia quickly if they do not eat.

A nurse is caring for a client in a long-term care facility who has become weak, confused, and dizzy when standing. The client's temp is 100.9 degrees F, pulse 92/min, RR 20/min , and BP 108/60. Which of the following actions should the nurse take? A. Encourage the client to ambulate to promote oxygenation B. Initiate fluid restriction to limit intake C. Monitor for orthostatic hypotension D. Check for peripheral edema

C. Monitor for orthostatic hypotension

A nurse is caring for a client who has asthma and developed viral pharyngitis. Which of the following finding should the nurse expect ? A. Petechiae on the chest and the abdomen B. WBC 16,000/mm3 C. Negative throat culture D. Severe hyperemia of pharyngeal mucosa

C. Negative throat culture Rational: A client who has viral pharyngitis will have a negative throat culture. A client who has bacterial pharyngitis usually has a throat culture positive for beta-hemolytic streptococcus.

A nurse is caring for a client who is admitted to the emergency department with a blood pressure of 266/147 mm Hg. The client reports a headache and double vision. The client states that she ran out of her diltiazem 3 days ago, and is unable to purchase more. Which of the following actions should the nurse take first? A. Administer acetaminophen for headache. B. Provide teaching regarding the importance of not abruptly stopping an antihypertensive. C. Obtain IV access and prepare to administer an IV antihypertensive. D. Call social services for a referral for financial assistance in obtaining prescribed medication.

C. Obtain IV access and prepare to administer an IV antihypertensive. Rational: The greatest risk to the client is injury due to a blood pressure of 266/147 mm Hg, which can be life-threatening and should be lowered as soon as possible. ObtainingIV access will permit administration of an IV hypertensive,which will act more rapidly than by the oral route.

A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection? A. Temperature 36.1° C (97.0° F) B. Insomnia C. Oliguria D. Weight loss

C. Oliguria Rationale: The nurse should identify little to no urine output as possible manifestations of kidney rejection.

A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence? A. Stress incontinence B. Urge incontinence C. Overflow incontinence D. Reflex incontinence

C. Overflow incontinence Rational: These findings are associated with overflow incontinence, which occurs when the pressure of urine in an overfull bladder overcomes sphincter control.

A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft? A. Measure the client's blood pressure to ensure it is higher in the left arm than the right. B. Check the brachial and radial pulses of the left arm simultaneously. C. Palpate the site for a bruit. D. Auscultate the antecubital fossa using a Doppler stethoscope

C. Palpate the site for a bruit. Rationale: The nurse should palpate the AV graft site for a thrill and auscultate for the presence of a bruit every 4 hr to assess for blood flow.

A nurse is providing teaching to a client with a colostomy about appropriate food choices. Which of the following foods should the nurse include in the teaching? A. Eggs B. Dried peas C. Pasta D. Dried fruits

C. Pasta Rational: Pasta may thicken stool and is an appropriate food choice for a client with a colostomy.

A nurse is teaching foot care to a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Remove calluses using over-the-counter remedies. B. Apply lotion between toes. C. Perform nail care after bathing. D. Trim toenails straight across. E. Wear closed-toe shoes.

C. Perform nail care after bathing. Rational: Perform nail care after bathing, when toenails are soft and easier to trim. D. Trim toenails straight across. Rational: Trim toenails straight across to prevent injury to soft tissue of the toes. E. Wear closed-toe shoes. Rational: Wear closed-toe shoes to prevent injury to soft tissue of the toes and feet.

A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge? A. Attending a class given about tracheostomy care B. Verbalizing all steps in the procedure C. Performing the procedure independently D. Asking appropriate questions about suctioning

C. Performing the procedure independently Rational: The nurse should recognize that the client is ready for discharge when the spouse demonstrates an ability to perform the procedure that will need to be performed independently at home.

A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take? A. Perform suctioning for up to four passes. B. Apply suction to the catheter when advancing it into the trachea. C. Preoxygenate the client with 100% oxygen for up to 3 min. D. Limit each suction pass to 25 seconds.

C. Preoxygenate the client with 100% oxygen for up to 3 min. Rational: To prevent hypoxemia, the nurse should preoxygenate the client with 100% oxygen for 30 seconds to 3 min prior to suctioning.

A nurse caring for a client who is vomiting. Which of the following actions should the nurse take first? A. Provide the client with an emesis basin. B. Notify housekeeping. C. Prevent the client from aspirating. D. Administer an antiemetic to the client.

C. Prevent the client from aspirating. Rational: When using the airway, breathing, circulation approach to client care, the nurse determines the priority action is to prevent the client from aspiration by turning the client to his side and suctioning his airway.

A nurse is caring for a client who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider? A. Report of discomfort during dialysate B. Blood-tinged dialysate C. Purulent dialysate outflow D. Dialysate leakage during inflow

C. Purulent dialysate outflow

A nurse is reviewing the medical record for a client who is to begin therapy for DKA. Which of the following prescriptions should the nurse expect? A. Administer an IV infusion of regular insulin at 0.3 unit/kg/hr B. Administer a slow IV infusion of 3% sodium chloride C. Rapidly administer an IV infusion of 0.9% sodium chloride. D. Add glucose to the IV infusion when blood glucose is 350 mg/dL

C. Rapidly administer an IV infusion of 0.9% sodium chloride. Rational: 0.9% sodium chloride is isotonic, will help maintain blood volume & perfusion to vital organs.Elevated sodium level use 0.45% sodium chlorideAdminister IV infusion of regular insulin at 0.1 unit/kg/hr to gradually lower blood glucose to prevent cerebral edema3% sodium chloride is given to someone w/ hypOnatremia Add glucose to IV infusion when blood glucose is 250 mg/dL not 350 mg/dL to prevent hypoglycemia & prevent edema

A nurse is developing a plan of care for a client who practices Islam. Which of the following actions should the nurse include in the plan? A. Serve foods that have a hot/cold balance. B. Serve milk products separately from meals. C. Request a meal tray without pork. D. Remove tea and coffee from meal trays.

C. Request a meal tray without pork. Rational: Clients who practice Islam do not eat pork. Clients who practice the Hindu, Seventh-Day Adventist, Mormon, and Jewish faiths abstain from pork as well.

A nurse is assessing a client who has peritonitis. Which of the following should the nurse expect? A. Frequent bowel movement B. Hyperactive bowel sounds C. Rigid abdomen D. Increased urinary output

C. Rigid abdomen

A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer? A. Lactulose B. Sevelamer C. Sodium polystyrene D. Darbepoetin alfa

C. Sodium polystyrene Rational: Sodium polystyrene is used for the treatment of hyperkalemia., It removes excess potassium by ion exchange through the bowel. The client's serum potassium level of 6.8 mEq/L is significantly above the reference range of 3.5 - 5.0 mEq/L..

A nurse manager is discussing integrity with the nurses on the unit. Which of the following promotes professional integrity? A. Rotating unit assignments B. Monthly staff social gatherings C. Streamlined error-reporting system D. Celebrate birthdays

C. Streamlined error-reporting system Rationale: A streamlined error-reporting system promotes workplace integrity by operating in accordance with the American Nurses Association's Code of Ethics.

A patient received a nebulizer of Albuterol. What is side an effect of this medication? A. Bradycardia B. Drowsiness C. Tachycardia D. Hypothermia

C. Tachycardia

A nurse in an urgent care clinic is obtaining a history from a client who has type 2 diabetes mellitus and a recent diagnosis of hypertension. This is the second time in 2 weeks that the client experienced hypoglycemia. Which of the following client data should the nurse report to the provider? A. Takes psyllium daily as a fiber laxative B. Drinks skim milk daily as a bedtime snack C. Takes metoprolol daily after meals D. Drinks grapefruit juice daily with breakfast

C. Takes metoprolol daily after meals Rational: Metoprolol can mask the effects of hypoglycemia in clients who have diabetes mellitus.

A nurse is assessing a client for Chvostek's sign. Which of the following techniques should the nurse use to perform this test? A. Apply a blood pressure cuff to the client's arm. B. Place the stethoscope bell over the client's carotid artery. C. Tap lightly on the client's cheek. D. Ask the client to lower her chin to her chest.

C. Tap lightly on the client's cheek. Rational: The nurse taps the client's cheek over the facial nerve just below and anterior to the ear to elicit Chvostek's sign. A positive response is indicated when the client exhibits facial twitching on this side of her face.

A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? A. The client will increase calories intake by 200 cal per day B. The client will list foods that are high in calcium, which should be avoided. C. The client will walk for 30 min 5 days a week. D. The client will replace cigarettes with smokeless tobacco products.

C. The client will walk for 30 min 5 days a week. Rational: Smokeless tobacco delivers a higher concentration of nicotine and places the clint at risk for cancer. The nurse should discuss nicotine replacement and acupuncture as measures to stop smoking tobacco products.

During the change of shift report, the nurse obtains this information about a hypertensive patient who received the first dose of propranolol (Inderal) during the previous shift. Which information indicates that the patient needs intervention. A. The patients most recent BP reading is 156/94 mm Hg. B. The patients pulse has dropped from 64 to 58 beats/minute. C. The patient has developed wheezes throughout the lung fields. D. The patient complains that the fingers and toes feel quite cold

C. The patient has developed wheezes throughout the lung fields. Rational: The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of the noncardioselective b-blockers) is occurring. The nurse should immediately obtain an O2 saturation measurement, apply supplemental O2, and notify the health care provider. The mild decrease in heart rate and complaint of cold fingers and toes are associated with b-receptor blockade but do not require any change in therapy. The BP reading may indicate that a change in medication type or dose may be indicated. However, this is not as urgently needed as addressing the bronchospasm.

A nurse is caring for client who just returned from the PACU with an IV fluid infusion and an NG tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess? A. The coping ability of the client B. The client's bowel sounds 24 to 48 C. The surgical dressing D. The patency of the NG tube

C. The surgical dressing Rational: When using the airway, breathing, circulation approach to client care, the nurse determines that the assessment priority is monitoring the surgical dressing. Hemorrhage is a major complication postoperatively, so the nurse should assess for early indications of bleeding, such as visible blood stains on the surgical dressing. Covert manifestations of bleeding include rapid, thready pulse, tachycardia, and decreased urine output.

Case Study: R.H. is a 62-year-old woman who comes to the clinic for a routine physical exam. She works as a banking executive and gets little exercise. She says she is "just tired". She has gained 18 pounds over the past year and eats a high-fat diet. Her BP is 162/98, HR 92, and RR is 20, and O2 sat is 92% on room air. R.H. complains of some weakness in her right foot that began about a month ago and also says that it feels a little numb. A sensory examination reveals diminished sensations of light touch, proprioception (6th sense/sense of body position), and vibration in both feet. R.H. complains of increased thirst and frequent nighttime urination. She denies any other weakness, numbness, or changes in vision. A physical examination reveals an erythematous scaling rash in both inguinal areas and axillae. RH states the rash has been there on and off for several years and is worse in the warm weather. Which type of diabetes is R.H. at highest risk for developing? A. Gestational diabetes B. Juvenile diabtes C. Type 2 diabetes D. Type 1 diabetes

C. Type 2 diabetes

A nurse is teaching a client who has acute kidney injury about the oliguric phase. Which of the following information should the nurse include in the teaching? A. Renal function is reestablished. B. BUN and creatinine levels decrease. C. Urine output is less than 400 mL per 24 hr. D. The glomerular filtration rate (GFR) recovers.

C. Urine output is less than 400 mL per 24 hr. Rational: Inadequate urinary output is associated with the oliguric phase of acute kidney injury. The minimum amount of urine needed to rid the body of metabolic waste products is 400 mL. Therefore, a client who is producing less than 400 mL of output in 24 hr is manifesting acute kidney injury.

A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment? A. Sodium 165 mEq/L B. Potassium 5.2 mEq/L C. Urine specific gravity 1.020 D. Hct 62%.

C. Urine specific gravity 1.020 Rational: In cases of dehydration or fluid volume deficit, the kidney reabsorbs all available water, making the urine more concentrated and increasing the urine specific gravity. A level of 1.020 is within the expected reference range of 1.005 to 1.030, which indicates that the treatment is effective.

A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effect should the nurse instruct the client to report to the provider. A. Sedation B. Increased appetite C. White coating in the mouth D. Dry oral mucous membranes

C. White coating in the mouth Rational: Fluticasone/salmeterol is an inhaled glucocorticoid and long acting beta2 adrenergic agonist combination inhalation medication that is used for daily management of asthma. It is not a rescue medication. An adverse effect of the medication is oropharyngeal candidiasis. The nurse should instruct the client to gargle after each use, use a spacer to reduce the amount of drug in the mouth and throat, and report any white patches inside the mouth or on the tongue to the provider.

A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hours-which of the following actions should the nurse take first? A. Document the client's IV intake in the medical record B. reposition the client C. check the IV tubing for obstruction D. Request a new IV fluid prescription

C. check the IV tubing for obstruction

A nurse is reviewing the medical record for client who is to begin therapy for DKA. Which of the following prescriptions should the nurse expect? A. administer an IV infusion of regular insulin at 0.3 unit/kg/hr B. administer a slow IV infusion of 3% sodium chloride C. rapidly administer an IV infusion of 0.9% sodium chloride D. add glucose to the IV infusion when blood glucose is 350 mg/dL

C. rapidly administer an IV infusion of 0.9% sodium chloride

A nurse is teaching a client who has chronic kidney disease about the process of continuous ambulatory peritoneal dialysis. What information should the nurse include in the teaching? A. CAPD requires a rigid schedule of exchange times B. CAPD requires the client to follow fewer dietary and fluid restrictions than hemodialysis requires. c. CAPD filters the client blood through an artificial device called a dialyzer

CAPD requires the client to follow fewer dietary and fluid restrictions than hemodialysis requires. Rationale: CAPD's advantages include fewer dietary and fluid restrictions as compared to hemodialysis.

A nurse is planning on teaching a client who is scheduled for an intravenous pyelogram (IVP). Which of the following statements should the nurse include in the teaching? A. "The procedure will be cancelled if the urinalysis indicates the presence of red blood cells." B. "High frequency sound waves will be used to identify renal system structures." C. "You will be able to resume your regular diet as soon as the test is complete." D. "After the procedure you will be encouraged to drink plenty of fluids."

D. "After the procedure you will be encouraged to drink plenty of fluids." Rational: The nurse should encourage fluid intake after the procedure to help promote elimination of the dye used during the procedure.

A nurse is teaching a client about strategies to manage gastroesophageal reflux disease (GERD). Which of the following statements should the nurse include? A. "Elevate the head of your bed by 18 inches." B. "Avoid snacking between meals." C. "Limit foods that are high in fiber." D. "Avoid eating 2 to 3 hours before bedtime."

D. "Avoid eating 2 to 3 hours before bedtime." Rational: The nurse should instruct the client to avoid eating or drinking 2 to 3 hr prior to lying down.

A nurse is providing education to a school-age child who has a new diagnosis of asthma. Which of the following statements should the nurse include in the teaching? A. "Take cromolyn sodium at the first sign of breathing difficulty." B. "You should stop playing basketball, but you can swim instead." C. "Use the peak expiratory flow meter once per week." D. "Avoid triggers that cause an attack."

D. "Avoid triggers that cause an attack." Rational: The nurse should emphasize that the ability to prevent asthma attacks can be improved by avoiding allergens that the child is sensitive to. Triggers can include animals, dust, certain foods, pollen, and grass. Clients who have asthma manifestations throughout the year should receive allergy testing to determine specific triggers.

The nurse is discharging a client from the hospital who has a new prescription for furosemide (Lasix). Which of the following client statements indicates an understanding of this medication? A. "I should eat a diet low in potassium while taking this medication." B. "I should limit my fluid intake while taking this medication." C. "My blood pressure will increase while I am taking this medication." D. "I need to limit my sun exposure and wear sunscreen while on this medication."

D. "I need to limit my sun exposure and wear sunscreen while on this medication." Rational: Limiting sun exposure and wearing sunscreen are appropriate while taking furosemide due to the adverse effect of photosensitivity.

A nurse is teaching about self-monitoring to a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? A. "I will notify my provider if pre-meal glucose is 120 mg/dL" B. "I will check my urine once a day for ketones" C. "I will check blood glucose every 5 minutes when lightheaded" D. "I will check my blood glucose every 4 hours when I am sick."

D. "I will check my blood glucose every 4 hours when I am sick." Rational: The client should follow specific guideline when sick. The nurse should instruct the client to monitor blood glucose every 3 to 4 hr and continue to take insulin or oral antidiabetic agents. The client should consume 4 oz sugar-free, noncaffeinated liquid every 30 min to prevent dehydration and meet carbohydrate needs through soft food if possible. If not, the client should consume liquids equal to usual carbohydrate content. The nurse should also instruct the client to test urine for ketones and report to provider if they are abnormal (the level should be negative to small)

A nurse is providing discharge teaching for a client who has gastroesophageal reflux disease (GERD). Which of the following statements by the client indicates an understanding of the teaching? A. "The type of foods I eat does not affect this condition." B. "I will sleep on my left side." C. "I will eat a snack just before going to bed." D. "I will sleep with the head of my bed elevated."

D. "I will sleep with the head of my bed elevated." Rational: The client should sleep with the head of the bed elevated by 6 to 12 inches to prevent reflux at night.

A nurse is teaching a client who has a new prescription for sulfasalazine. Which of the following statements by the client indicates an understanding of the teaching? A. "I will take this medication as needed to reduce pain." B. "I will reduce my fluid intake with this medication." C. "I will take this medication with an antacid." D. "I will take this medication 1 hour before meals and at bedtime."

D. "I will take this medication 1 hour before meals and at bedtime." Rational: The client should take sucralfate on an empty stomach, 1 hr before each meal and at bedtime to create a protective coating over the ulcer.

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching? A. "I will be able to tell how much oxygen I'm getting by looking at the flowmeter." B. "I should call my doctor if I find it harder to concentrate." C. "I will make sure my visitors smoke outside." D. "I will wear synthetic clothing and woolen socks when using my oxygen."

D. "I will wear synthetic clothing and woolen socks when using my oxygen." Rational: Woolen and synthetic materials can generate static electricity. Because oxygen is a flammable gas, the client should wear cotton clothing and use cotton bedding and blankets.

A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching? A. "It might help if I tried sleeping only on my back." B. "I'll sleep better if I take a sleeping pill at night." C. "I'll get a humidifier to run at my bedside at night." D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."

D. "If I could lose about 50 pounds, I might stop having so many apneic episodes." Rational: Sleep apnea is a disorder in which breathing stops during sleep for at least 10 seconds at least five times per hour. Excessive weight is one of the three major risk factors associated with sleep apnea and is the only one the client can modify (gender and age are the other two). Weight loss and maintenance are the primary interventions for the treatment of sleep apnea.

A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching? A. "You can expect fecal output within 24 hours." B. "You will need to increase your dietary intake of raw vegetables." C. "You can expect the stoma to be purplish in color for the first week." D. "You may experience a small amount of bleeding around the stoma."

D. "You may experience a small amount of bleeding around the stoma." Rational: A small amount of bleeding around the stoma and its stem can occur. However, the client should report an increase in bleeding to the surgeon.

A nurse is providing teaching to a client about completing a creatinine clearance test. Which of the following instructions should the nurse include in the teaching? A. "You will need to collect all of your urine for the next 12 hours." B. "You will need to store the urine container in a dark location." C. "You will need to start the collection time with your first urine specimen of the day." D. "You will need to avoid rigorous exercise during the test."

D. "You will need to avoid rigorous exercise during the test." Rationale: The nurse should instruct the client to avoid exercising during the testing time because it can cause an increase in the creatinine values.

A nurse is assessing four clients for fluid balance. The nurse should identify that which of thefollowing clients is exhibiting manifestations of dehydration? A. A client who has a urine specific gravity of 1.010. B. A client who has a weight gain of 2.2 kg (2 lb) in 24 hr. C. A client who has a hematocrit of 45% D. A client who has a temperature of 39° C (102° F)

D. A client who has a temperature of 39° C (102° F) Rational: This temperature is greater than the expected reference range of 36° C (96.8° F) to 37° C (98.6° F). An elevated temperature is a manifestation of dehydration.

A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority? A. Initiating oxygen therapy B. Providing immediate rest for the client C. Positioning the client in high-Fowler's D. Administering a nebulized beta-adrenergic

D. Administering a nebulized beta-adrenergic Rational: MY ANSWER The greatest risk to the client's safety is airway obstruction. Beta-adrenergic medications act as bronchodilators. They provide prompt relief of airflow obstruction by relaxing bronchiolar smooth muscle and are the initial priority intervention when a client has an acute asthma exacerbation.

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? A. Creatine kinase B. Troponin C. Total bilirubin D. Albumin

D. Albumin Rational: A low albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time.

A nurse is teaching a client who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the client to use to abort an acute asthma attack? A. Beclomethasone B. Salmeterol C. Formoterol D. Albuterol

D. Albuterol Rational: Albuterol is an inhaled short-acting beta2 agonist (beta2-adrenergic agonist) used as a rescue medication to relieve an acute asthma attack. Albuterol dilates the airways, decreases wheezing, and improves oxygenation.

A nurse in the emergency department is caring for a client who is having an acute asthma attack. Which of the following medications should the nurse expect to administer first? A. Fluticasone B. Budesonide C. Montelukast D. Albuterol

D. Albuterol Rational: Albuterol is considered a "rescue" medication due to its rapid onset of action. Asthma is a chronic inflammatory disorder of the airways. Asthmatic episodes are associated with airflow limitation or reversible obstruction. Albuterol is a beta2 adrenergic agonist used for the treatment of acute exacerbations of asthma by promoting bronchodilation and suppressing histamine release in the lungs. This medication can be given by inhalation, orally, or as a parenteral preparation. The inhaled medication has a more rapid onset of action than the oral form and also reduces the risk for the adverse effects of irritability, tremor, nervousness, and insomnia.

A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms? A. Cromolyn via metered-dose inhaler B. Montelukast orally C. Budesonide via dry-powder inhaler D. Albuterol via jet nebulizer

D. Albuterol via jet nebulizer Rational: The nurse should identify that albuterol is a bronchodilator used as the first medication of choice to stop bronchospasm or constriction in clients who have acute asthma exacerbation.

A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment? A. Breast cancer survivor for 8 years B. Pacemaker C. 65-years of age D. Alcohol use disorder

D. Alcohol use disorder Rationale: The nurse should identify that a substance use disorder is a contraindication for kidney transplant.

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? A. Pigeon B. Funnel C. Kyphotic D. Barrel

D. Barrel Rational: Clients who have COPD use accessory muscles to assist with respiratory effort. The use of those accessory muscles causes the chest wall to eventually increase in anterior-posterior diameter, making it appear barrel shaped.

The nurse teaches a patient with chronic kidney disease about prevention of complications. What should the nurse include in the teaching plan? A. Monitor for proteinuria daily with a urine dipstick. B. Perform self-catheterization every 4 hours to measure urine. C. Take calcium-based phosphate binders on an empty stomach. D. Check weight daily and report a gain of greater than 4 pounds.

D. Check weight daily and report a gain of greater than 4 pounds. Rational: Patients with chronic kidney disease are taught to report weight gain greater than 4 pounds (2 kg). Proteinuria is an expected finding and is not monitored. Calcium-based phosphate binders should be taken with meals because most phosphate is absorbed within 1 hour after eating. Self-catheterization is not indicated and may lead to infection.

A patient has newly-diagnosed type 2 diabetes. Which task should the RN delegate to an experienced unlicensed assistive personnel (UAP)? A. Arranging a consult with the dietitian B. Assessing the patient's insulin injection technique C. Teaching the patient to use a glucometer to monitor glucose at home D. Checking the patient's glucose level before each meal

D. Checking the patient's glucose level before each meal Rationale: The experienced UAP would have been taught to perform tasks such as checking pulse oximetry and glucose checks, and these actions would be part of his or her scope of practice. Arranging for a consult with the dietitian is appropriate for the unit clerk. Teaching and assessing require additional education and should be carried out by licensed nurses.

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as a result of a long-term in adequate oxygenation? A. Restlessness B. Retractions C. Dependent edema D. Clubbing of the fingers

D. Clubbing of the fingers Rational: The nurse should expect the client who has chronic hypoxia or respiratory insufficiency to display clubbing of the fingers and toes. The base of the nail becomes swollen and the ends of the fingers and toes can increase in size.

A nurse is discussing lab values associated w/ the renal system w/ a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the values? A. Potassium levels are increased in clients who have polyuria. B. Specific gravity is decreased in clients who have hypovolemia. C. BUN is decreased in clients who have dehydration. D. Creatinine levels are increased in clients who have acute kidney injury.

D. Creatinine levels are increased in clients who have acute kidney injury. Rational: Increased creatinine levels are associated with renal failure.

A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client? A. Nephrosclerosis B. Uremia C. Diverticulitis D. Cystitis

D. Cystitis Rational: A sudden onset of urinary incontinence or increased confusion can indicate the presence of a urinary tract infection or bacterial cystitis in the older adult client.

A nurse is assessing a client who has chronic kidney disease for fluid volume increase. What provides a reliable measure of fluid retention? A. Sodium level B. Intake and output C. Tissue turger D. Daily weight

D. Daily weight Rationale: Obtaining a client's daily weight and comparing it to previous weights is a reliable method for measuring a client's fluid volume over time

A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect? A. Increased vital capacity B. Moist skin C. Heat intolerance D. Decreased mental status

D. Decreased mental status Rational: Lethargy and depression are manifestation of malnutrition. The brain requires glucose to function. When the body lacks adequate glucose, the body will metabolize tissue such as muscle and fat. The resulting metabolic acidosis can further decrease the client's mental status.

A nurse is providing discharge instructions to a client who has asthma and a new prescription for montelukast. The nurse should instruct the client to report which of the following adverse effects to the provider? A. Blurred vision B. Palpitations C. Constipation D. Depression

D. Depression Rational: Montelukast can cause neuropsychiatric effects such as depression, behavior changes, hallucinations, and suicide ideation. The nurse should instruct the client to report such adverse effects. A change in medication might be prescribed.

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first? A. Review the effects of the pain medication B. Administer the medication C. Reposition the client D. Determine the location of the pain

D. Determine the location of the pain Rational: The first action the nurse should take using the nursing process is to assess the client. By determining the location of the pain medication, repositioning the client, and teaching the client about the effects of the medication

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A. Maintaining a semi-Fowler's position as often as possible B. Administering oxygen via nasal cannula at 2 L/min C. Helping the client select a low-salt diet D. Encouraging the client to drink 2 to 3 L of water daily

D. Encouraging the client to drink 2 to 3 L of water daily Rational: COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration.

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate? A. Collect a urine specimen for culture and sensitivity. b. Continue routine care because the results are within the expected reference range. C. Decrease the IV fluid infusion rate and limit oral fluid intake. D. Evaluate urine for amount and for specific gravity.

D. Evaluate urine for amount and for specific gravity. Rational: These results indicate that the client is dehydrated. Specific gravity and urine output measurements can support the laboratory findings. The higher the specific gravity, the more dehydrated the client.

You suspect kidney transplant rejection when the patient shows which symptoms? A. Diminished urine output and hypotension B. Pain in the incision, general malaise, and hypotension C. Pain in the incision, general malaise, and depression D. Fever, weight gain, and diminished urine output

D. Fever, weight gain, and diminished urine output Rationale: Symptoms of rejection include fever, rapid weight gain, HTN, pain over the graft site, peripheral edema, and diminished urine output.

A nurse is caring for a client who reports having chronic constipation. Which of the following herbal supplements should the nurse recommend? A. Ginseng B. Coenzyme Q-10 C. Cranberry juice D. Flaxseed

D. Flaxseed Rational: The nurse should recommend the client use flaxseed to treat constipation, which is a high-fiber product.

A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect? A. Hypothermia B. Protruding eyeballs C. Elevated blood pressure D. Furrows in the tongue

D. Furrows in the tongue Rational: In older adult clients who have dehydration, the surface of the tongue will be dry with deep furrows.

A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following beverages should the nurse tell the client to avoid while taking this medication? A. Milk B. Orange juice C. Coffee D. Grapefruit juice

D. Grapefruit juice Rational: Grapefruit juice increases blood levels of verapamil, a calcium channel blocker, by inhibiting its metabolism. The excess amount of medication can intensify the medication's hypotensive effects, putting the client at risk for syncope and dizziness.

A nurse in a public clinic is planning a health fair for older adult clients in the community. In teaching medication safety, which of the following foods should the nurse advise the clients to avoid when taking their prescriptions? A. Carbonated beverage B. Milk C. Orange juice D. Grapefruit juice

D. Grapefruit juice Rational: There is a high rate of food-drug interactions between grapefruit juice and many medications frequently taken by older adults, especially lipid-lowering agents. It is thought that one or more of the chemicals (most likely flavonoids) in grapefruit juice alter the activity of specific enzymes (such as CYP3A4 and CYP1A2) in the intestinal tract. These enzymes decrease the rate at which medications enter the systemic circulation. This could allow a larger amount of these drugs to reach the bloodstream, resulting in increased drug levels and possibly toxicity.

A nurse is planning care for a client who has diverticulitis. Which of the following menu selections should the nurse include in the plan? A. Turkey sandwich with celery sticks B. Sliced ham with green salad C. Pork tenderloin with green peas D. Grilled chicken breast with white rice

D. Grilled chicken breast with white rice Rational: Both of these items are low in fiber which is advised during the inflammation of diverticulitis. In the presence of diverticulosis, a high-fiber diet is indicated.

A nurse is teaching a client who has chronic kidney disease and is to begin hemodialysis. Which of the following information should the nurse include in the teaching? A. Hemodialysis restores kidney function. B. Hemodialysis replaces hormonal function of the renal system. C. Hemodialysis allows an unrestricted diet. D. Hemodialysis returns a balance to serum electrolytes.

D. Hemodialysis returns a balance to serum electrolytes. Rational: The nurse should explain to the client that hemodialysis restores electrolyte balance by removing excess sodium, potassium, fluids, and waste products, and also restores acid‐base balance.

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? A. Restrict the client's fluid intake to less than 2 L/day. B. Provide the client with a low-protein diet. C. Have the client use the early-morning hours for exercise and activity. D. Instruct the client to use pursed-lip breathing.

D. Instruct the client to use pursed-lip breathing. Rational: Pursed-lip breathing lengthens the expiratory phase of respiration and also increases the pressure in the airway during exhalation. This action reduces airway resistance and decreases trapped air for clients who have COPD.

A nurse is teaching a client who has chronic kidney disease and a new prescription for epoetin alfa. The nurse should instruct the client to increase the dietary intake of which of the following substance? A. Potassium B. Protein C. Sodium D. Iron

D. Iron Rationale: Epoetin Alfa is a synthetic form of erythropoietin, a substance produced by the kidneys that stimulates the bone marrow to produce red blood cells.

A nurse is caring for a client who is postoperative. Which of the following actions by the nurse demonstrates the professional characteristic of autonomy? A. Verifying the completion of delegated vital signs B. Reviewing the client's laboratory data prior to contacting the provider C. Discussing discharge instructions with the client D. Making a decision about when to administer PRN pain medication

D. Making a decision about when to administer PRN pain medication Rationale: Administering PRN pain medication is an example of autonomy because it requires the nurse to act based on what is known about the client's pain status and needs.

A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effects? A. Hypoglycemia B. Hypertension C. Polyuria D. Oral candidiasis

D. Oral candidiasis Rational: Fluticasone can cause oral candidiasis, or thrush; therefore, the client should rinse her mouth with water.

A nurse is caring for a client who has dementia. the client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first? A. Place the client in bed with two side rails raised B. Apply a vest restraint on the client C. Administer lorazepam the client D. Place a seat alarm in the client's chair

D. Place a seat alarm in the clients chair Rational: When providing client care, the nurse first use the least restrictive intervention. Therefore, the nurse should first place a seat alarm on the client's chair so she can monitor his actions and provide for his safety.

A nurse instructs a client to use the pursed lip method of breathing. What is the purpose of this? A. Promote oxygen intake B. Strengthen the intercoastal muscles C. Strengthen the diaphragm D. Promote carbon dioxide elimination

D. Promote carbon dioxide elimination

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Reposition the client every 3 hr. B. Massage bony prominences to promote circulation. C. Apply cornstarch to keep the skin dry. D. Provide the client with a diet high in protein.

D. Provide the client with a diet high in protein. Rational: Inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown

A nurse is assessing a client who is on long-term omeprazole therapy. Which of the following findings should indicate to the nurse the medication is effective? A. Increased appetite B. Regular bowel movements C. Absence of headache D. Reduced dyspepsia

D. Reduced dyspepsia Rational: Omeprazole, a proton pump inhibitor, reduces gastric acid secretion and treats duodenal and gastric ulcers, prolonged dyspepsia, gastrointestinal reflux disease, and erosive esophagitis.

Which of the following indicates the patient is experiencing an adverse effect of hydrochlorothiazide? A. Blood glucose value of 160 mg/dL B. Electrocardiogram (EGG) tracing demonstrating peaked T waves C. Serum magnesium value of 2.0 mg/dL D. Serum potassium value of 3.0 mEq/L E. Urine output of 90 cc/mL 1 hour after medication administration

D. Serum potassium value of 3.0 mEq/L Rational: A serum potassium value of 3.0 mEq/L is hypokalemic. Normal serum potassium values range from 3.5- 5.2 mEq/L

A nurse is teaching a client about taking an expectorant to treat a cough. The nurse should explain that this type of medication has which of the following actions? A. Reduces inflammation B. Suppresses the urge to cough C. Dries mucous membranes D. Stimulates secretions

D. Stimulates secretions Rational: Expectorants act by increasing secretions to improve a cough's productivity.

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? A. Bradypnea B. Somnolence C. Pallor D. Tachycardia

D. Tachycardia Rational: The nurse should expect the client who has hypoxia to manifest tachycardia.

A nurse is providing discharge instructions to a client who has asthma and is about to start taking theophylline (Theo-24). The nurse should tell the client that this medication might cause which of the following adverse effects? A. Drowsiness B. Constipation C. Oliguria D. Tachycardia

D. Tachycardia Rational: Theophylline can increase cardiac stimulation and cause tachycardia.

A nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include blood glucose of 120 mg/dL, temp of 101 F, pulse of 88 bpm, respiration of 22, and blood pressure of 100/72. Which finding would of most concern to the nurse? A. Pulse B. Respiration C. Blood pressure D. Temperature

D. Temperature Rational: An elevated temperature may indicate infection. Infection is a leading cause of hyperglycemic hyperosmolar nonketotic syndrome or diabetic ketoacidosis. The other findings noted in the question are within normal limits.

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being a risk for fluid volume deficit? A. The client who has been NPO since midnight for endoscopy. B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL. C. The client who has end-stage renal failure and is scheduled for dialysis today. D. The client who has gastroenteritis and is febrile.

D. The client who has gastroenteritis and is febrile. Rational: This client has two risk factors for the development of fluid volume deficit, or dehydration. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. Consequently, this is the client at greatest risk for fluid volume deficit.

A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide? A. Services are centered in long-term care facilities B. The emphasis is on the client's complete recovery from the illness or injury C. This service focuses on teaching the primary caregiver to meet the client's needs D. This service began with the client's admission to the hospital

D. This service began with client's admission to the hospital Rationale: Rehabilitation is a process that assists an ill person or a person with a disability or impairment to achieve the highest possible level of function. The process of rehabilitation begins with the client's admission to a health care facility for treatment

A patient with type 1 diabetes reports feeling dizzy. What should the nurse do first? A. Check the patient's blood pressure. B. Give the patient some orange juice. C. Give the patient's morning dose of insulin. D. Use a glucometer to check the patient's glucose level

D. Use a glucometer to check the patient's glucose level Rational: Before orange juice or insulin is given, the patient's blood glucose level should be checked. Checking blood pressure is a good idea but is not the first action the nurse should take

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds? A. Crackles B. Rhonchi C. Stridor D. Wheezes

D. Wheezes Rational: Wheezes are continuous, high-pitched squeaking sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. Wheezes are often audible without a stethoscope.

A nurse is reviewing guidelines to prevent DKA during periods of illness with a client who has type 1 diabetes mellitus. which of the following instructions should the nurse include in the teaching? A. "Withhold your usual daily dose of insulin" B. "Test your blood glucose level every 8 hours" C. "Drink 240 to 360 milliliters of calorie-free liquids every 8 hours" D. "check your urine for ketones when blood glucose levels are greater than 240 mg/dL"

D. check your urine for ketones when blood glucose levels are greater than 240 mg/dL Rational: The client should check his urine for ketones when blood glucose levels are greater than 240 mg/dL in order to detect DKA. The client should contact the provider if he has moderate or large amounts of ketones in his urine

A nurse is caring for a client who is diabetic and reports a headache, restlessness, fatigue, and hunger. the nurse should identify that the client is likely experiencing which of the following conditions? A. Neuropathy B. Hypokalemia C. Hyperglycemia D. Hypoglycemia

D. hypoglycemia Rational: Hypoglycemia is a complication of diabetes indicating a blood glucose level less than 70 mg/dL. It can occur when excessive insulin or oral hypoglycemia include sweating, tremor, tachycardia, palpitation, headache, fatigue, nervousness, and hunger

A patient complains of leg cramps during hemodialysis. The nurse should A. massage the patient's legs. B. reposition the patient supine. C. give acetaminophen (Tylenol). D. infuse a bolus of normal saline.

D. infuse a bolus of normal saline. Rational: Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps.

A nurse is caring for a client who has acute kidney injury. Which of the following arterial blood gas values would the nurse expect this client to have? A. pH 7.49, HCO3 24, PaCO2 30 B. pH 7.49, HCO3 30, PaCO2 40 C. pH 7.26, HCO3 24, PaCO2 46 D. pH 7.26, HCO3 14, PaCO2 30

D. pH 7.26, HCO3 14, PaCO2 30 Rational: AKI causes metabolic acidosis because the kidneys cannot adequately process and excrete the acidic substances the usual bodily functions produce every day. With metabolic acidosis, the pH is low, the bicarbonate is low, and the PaCO2 is low or in the expected range, as in these results.

Patients with CKD experience an increase of cardiovascular disease related to? A. Genetic predisposition B. Hyperinsulinemia causing dyslipidemia C. Vascular calcifications D. Hypertension E. Increased HDL levels

E. Increased HDL levels

A nurse is monitoring the laboratory values of a client who has diabetes mellitus and is taking insulin. Which of the following results indicates a therapeutic outcome of insulin therapy? A. Random blood glucose of 210 mg/dL B. Fasting blood glucose 96 mg/dL C. Preprandial blood glucose level of 60 mg/dL D. Postprandial blood glucose of 195 mg/dL

Fasting blood glucose 96 mg/dL Rational: This is within the expected reference range for a fasting blood glucose level and indicates that insulin therapy is effective.

A nurse working in an acute care facility is aware of the scope of practice and rules of her professional boundaries. Which of the following is an appropriate action for the nurse to take? A. Obtaining assistance with financial from a client B. Accepting a personal bouquet of flowers and invitation to dinner from the client C. Accepting a $50 gift certification to a local restaurant from a client's family D. Receiving a basket of fruit sent for the unit staff from a client who has been discharged

Receiving a basket of fruit sent for the unit staff from a client who has been discharged Rationale: Receiving a fruit basket sent to the unit staff by a client is within the professional boundaries of the nurse's scope of practice.

A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? A. Repeat auscultation after asking the client to breathe deeply and cough. B. Instruct the client to limit fluid intake to less than 2,000 mL/day. C. Prepare to administer antibiotics. D. Place the client on bed rest in semi-Fowler's position.

Repeat auscultation after asking the client to breathe deeply and cough. Rational: Although crackles often indicate fluid in the alveoli, they can also be the result of positioning or decreased ventilation. They sometimes clear after a deep breath or a cough.