passpoint medsurg

A nurse obtained a client's fasting blood sugar (FBS) at 0700, which was 144 mg/dL (8 mmol/L). The client has an order for regular insulin 8 units every morning. What should the nurse do next?

Administer the insulin as ordered. he nurse knows that a normal fasting blood sugar is between 72 and 108 mg/dL (4 and 6 mmol/L). The result of 144 mg/dL indicates that the client requires insulin to lower the blood glucose level.

To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina. Which observation by the nurse indicates a radiation hazard?

The client receives a complete bed bath each morning. the client shouldn't receive a complete bed bath while the applicator is in place. In fact, she shouldn't be bathed below the waist because doing so puts the nurse at risk for radiation exposure.

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?

using a "picture board" for the client to point to pictures Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say.

The nurse is caring for a client with a burn injury who is experiencing hypersecretion of gastric acid. The nurse should monitor for development of what complication?

gastrointestinal ulceration Gastrointestinal ulceration, also known as Curling's ulcer, occurs in about half of clients suffering from severe burns.

An anxious client who suffered an acute myocardial infarction is transferred from the coronary care unit to the telemetry unit. The client asks the charge nurse if they can have the same nurse care for them every day. How should the charge nurse respond?

"We will try to assign you the same nurse as often as possible." The charge nurse should try to accommodate the client's wishes by assigning a familiar nurse whenever possible.

The nurse is assessing a client's motor response after brain surgery. The nurse pinches the client's skin to elicit a response and observes the client's arms and legs moving straight out and the feet and toes bend downward. How should the nurse document this response?

extension posturing The client is exhibiting extension posturing indicating severe brain stem or midbrain damage which may be a sign of irreversible damage.

The nurse is working the night shift and needs to collect urine from four clients for routine urinalysis. Which client collection can be delegated to the unlicensed assistive personnel (UAP)?

the client ordered a voided urine The UAP can collect a urine sample from a client who voids the specimen since no additional education is needed.

A nurse is educating a client recently diagnosed with early glaucoma. Which client statement indicates further teaching is necessary?

"I will take my latanoprost eye drops as soon as I start to feel pain." Treatments for glaucoma include medicated eye drops that help drain fluid in the eye, thereby decreasing the intraocular pressure. Latanoprost is a prostaglandin agonist that should be administered daily. This medication is ineffective if the client takes it only when feeling pain.

A client is admitted for a transurethral resection of the prostate (TURP). Preoperative teaching will include which information?

"You will return from surgery with a catheter in your bladder and fluid flowing into and out of it continuously." A continuous bladder irrigation system is present for a prescribed period of time after a TURP in order to dilute the bleeding and prevent clots from blocking the urinary tract.

Before surgery to repair an aortic aneurysm, the client's pulse pressure begins to widen, suggesting increased aortic valvular insufficiency. If the branches of the aortic arch are involved, the nurse should assess the client for:

loss of consciousness If the aortic arch is involved, there will be a decrease in the blood flow to the cerebrum. Therefore, loss of consciousness will be observed. A sudden loss of consciousness is a primary symptom of rupture and no blood flow to the brain.

A nurse notes the following laboratory values for a client receiving chemotherapy: white blood cell count 6000/µL, red blood cell count (RBC) 3.7 million cells/cm3, hematocrit 35%, platelet count 80,000 mm3. Which order would the nurse question?

rectal temperatures every 4 hours The platelet count indicated that the client is a risk for bleeding. The low RBC can cause fatigue, so the activity order is appropriate.

Which client is at highest risk for colorectal cancer?

the client who has been treated for Crohn's disease for 20 years Clients over age 50 who have a history of inflammatory bowel disease are at risk for colon cancer. The client who smokes is at high risk for lung cancer.