practice test 1
A client who had a cholecystectomy with a biliary drainage tube in place. What color of the drainage is expected? a) dark yellow-orange b) green c) clear d) pinkish red
a) dark yellow-orange
The nurse is evaluating how a client with hepatitis A understands the discharge teaching given. Which client statements indicate that further teaching is needed? Select all that apply. a) "I should wear a mask when visitors come." b) "My family and I do not need to take any special precautions as long as I take my medication." c) "My family members should receive the hepatitis A vaccine to prevent them from getting the disease." d) "I can have an occasional glass of wine with my meal as I recover." e) "My spouse and I can have intercourse and kiss." f) "My bath towels shouldn't be used by any other family members."
a) "I should wear a mask when visitors come." b) "My family and I do not need to take any special precautions as long as I take my medication." d) "I can have an occasional glass of wine with my meal as I recover." e) "My spouse and I can have intercourse and kiss."
A nurse is following the progress of a client being treated for hypothyroidism. Which findings indicate that thyroid replacement therapy has been inadequate? Select all that apply. a) Low body temperature. b) Nervousness. c) ECG changes. d) Bradycardia. e) Tachycardia. f) Dry mouth.
a) Low body temperature. c) ECG changes. d) Bradycardia.
During an initial shift assessment, a nurse finds a diabetic client who is lethargic and who has rapid, deep respirations. Which of the following actions should the nurse take? a) Administer a saline bolus as needed b) Contact the healthcare provider c) Administer IV glucagon bolus as needed d) Start oxygen at 2 L/min as needed
a) Administer a saline bolus as needed -The rapid, deep (Kussmaul) respirations are compensatory and indicate metabolic acidosis. -There is an immediate need for correction of the acidosis with a saline bolus to prevent hypovolemia. -This will be followed by assessment of glucose level and insulin administration to allow the glucose to reenter the cells.
A hospitalized adolescent with type 1 diabetes mellitus is weak and nauseated with poor skin turgor. The nurse notes a fruity odor to the client's breath. The client uses insulin lispro. The last meal was lunch, 2 hours ago. Place the nursing actions in the order in which the nurse should perform them. All options must be used. 1.Administer insulin lispro. 2.Notify the health care provider (HCP). 3.Obtain a fingerstick test for blood glucose. 4.Start an IV infusion with normal saline solution.
3, 2, 4, 1
Three days after a cholecystectomy, a client states, "I feel like my stomach is going to burst." The client is taking a regular diet. After determining that vital signs are stable, in which order of priority from first to last does the nurse assist the client? All options must be used. 1.Encourage ambulation. 2.Offer 120 mL of hot liquids. 3.Auscultate for bowel sounds. 4.Position the client on right side.
3,2,4,1
A client is admitted from the emergency department after falling down a flight of stairs at home. The client's vital signs are stable, and the history states that the client had a gastric stapling 2 years ago. The client jokes about being clumsy lately and tripping over things. The nurse should gather additional information by asking the client which questions? Select all that apply. a) "How much vitamin B12 are you getting?" b) "Are you getting sufficient iron in your diet?" c) "Do you feel safe at home?" d) "Are you feeling depressed?" e) "Are you experiencing numbness in your extremities?"
a) "How much vitamin B12 are you getting?" c) "Do you feel safe at home?" d) "Are you feeling depressed?" e) "Are you experiencing numbness in your extremities?" -The nurse should ask the client about symptoms related to pernicious anemia because the client had gastric stapling 2 years ago and shows no history of taking supplemental vitamin B12. -Numbness and tingling relate to a loss of intrinsic factor from the gastric stapling. -Intrinsic factor is necessary for absorption of vitamin B12. -Other signs and symptoms of pernicious anemia include cognitive problems and depression. -The nurse also should ask about the client's support at home in case the fall was not an accident.
After teaching a client about collecting a stool sample for occult testing, which client statement indicates effective teaching? Select all that apply. a) "I will take the sample from different areas of the stool that I have passed." b) "I need to eat foods low in fiber a few days before collecting the sample." c) "I will avoid eating meat for 1 to 3 days before getting a stool sample." d) "I need to send the stool sample to the lab in a covered container right away." e) "I can continue to take all of my regular medications at home."
a) "I will take the sample from different areas of the stool that I have passed." c) "I will avoid eating meat for 1 to 3 days before getting a stool sample." -When a client collects stool for occult blood, the nurse should instruct the client to avoid eating meat, especially red meat, for 1 to 3 days before the sample collection because meat eliminated in the stool can lead to false-positive results. -Eating foods high in fiber a few days before sample collection may be recommended because doing so improves the chances of finding occult blood if a lesion is present. -The client should take stool samples from different sites of the stool for a better sample. -The stool sample should be covered to protect everyone from body secretions. -The specimen does not have to be sent to the laboratory immediately. -Some medications, herbs, foods, and activities can lead to false results of the occult testing. For example, iron pills, turnips, and horseradish lead to false-positive results. Vitamin C leads to false-negative results. -Some anti-inflammatory drugs and aspirin should be avoided due to antiplatelet properties that increase the risk of gastrointestinal bleeding.
A client visiting the clinic is scheduled for an outpatient thyroid scan in 2 weeks. Which instructions should the nurse include to ensure that this client is prepared for the test? Select all that apply. a) Do not take prescribed thyroid medication until the results of the scan are known. b) Stop using iodized salt or iodized salt substitutes 1 week before the scan. c) Maintain bed rest for 24 hours after the scan. d) Stop eating seafood 1 week before the scan. e) Do not consume any food or fluids after midnight on the night before the scan. f) Do not take any prescribed thyroid medication on the day of the scan.
a) Do not take prescribed thyroid medication until the results of the scan are known. b) Stop using iodized salt or iodized salt substitutes 1 week before the scan. d) Stop eating seafood 1 week before the scan.
A client with ulcerative colitis is to take sulfasalazine. Which instruction should the nurse provide for the client about taking this medication at home? Select all that apply. a) Drink enough fluids to maintain a urine output of at least 1,200 to 1,500 mL/day. b) Stop taking the medication if the urine turns orange-yellow. c) If a dose is missed, skip and continue with the next dose. d) Discontinue therapy if symptoms of acute intolerance develop, and notify the health care provider (HCP). e) Avoid activities that require alertness.
a) Drink enough fluids to maintain a urine output of at least 1,200 to 1,500 mL/day. d) Discontinue therapy if symptoms of acute intolerance develop, and notify the health care provider (HCP). e) Avoid activities that require alertness.
A client with a diagnosis of severe ulcerative colitis is admitted to the hospital. The nurse would assess for which of the following? a) Extreme muscle weakness and tachycardia b) Skin rash and diplopia c) Nausea, vomiting, and leg and stomach cramps d) Development of tetany with muscle spasms
a) Extreme muscle weakness and tachycardia
A client with diverticulitis has developed peritonitis following diverticular rupture. When assessing the client, what should the nurse do? Select all that apply. a) Percuss the liver to note lack of dullness. b) Auscultate bowel sounds to note frequency. c) Monitor the vital signs for fever. d) Percuss the abdomen to note tympany. e) Assess presence of excessive thirst.
a) Percuss the liver to note lack of dullness. b) Auscultate bowel sounds to note frequency. c) Monitor the vital signs for fever. d) Percuss the abdomen to note tympany. -Percussion will show resonance and tympany indicating paralytic ileus. -Lack of liver dullness may indicate free air in the abdomen. -The client with peritonitis will have fever, tachypnea, and tachycardia. -The abdomen becomes rigid with rebound tenderness and there will be absent bowel sounds. -The client will not demonstrate excessive thirst but may have anorexia, nausea, and vomiting as peristalsis decreases.
A client with long-standing type 1 diabetes is admitted to the hospital with unstable angina pectoris and a hemoglobin A1C of 10%. After evaluating the client's diabetic management regimen the nurse should do what? Select all that apply. a) Prepare to schedule a trans-esophageal echo (TEE). b) Consult the diabetic educator. c) Expect to give large doses of oral sulfonylureas. d) Connect to continuous cardiac monitoring and prepare to cardiovert. e) Obtain a blood sample for a troponin level.
a) Prepare to schedule a trans-esophageal echo (TEE). b) Consult the diabetic educator. e) Obtain a blood sample for a troponin level.
A nurse is developing a care plan for a client with hepatic encephalopathy. Which are goals for the care for this client? Select all that apply. a) Provide food and fluids high in carbohydrate. b) Prevent constipation. c) Administer lactulose to reduce blood ammonia levels. d) Monitor coordination while walking. e) Check the pupil reaction. f) Encourage physical activity.
a) Provide food and fluids high in carbohydrate. b) Prevent constipation. c) Administer lactulose to reduce blood ammonia levels. d) Monitor coordination while walking. e) Check the pupil reaction. -Constipation leads to increased ammonia production. -Lactulose is a hyperosmotic laxative that reduces blood ammonia by acidifying the colon contents, which retards diffusion of nonionic ammonia from the colon to the blood while promoting its migration from the blood to the colon. -Hepatic encephalopathy is considered a toxic or metabolic condition that causes cerebral edema; it affects a person's coordination and pupil reaction to light and accommodation. -Food and fluids high in carbohydrates should be given because the liver is not synthesizing and storing glucose. -Because exercise produces ammonia as a byproduct of metabolism, physical activity should be limited, not encouraged.
A client with a peptic ulcer reports epigastric pain that frequently awakens her during the night. The nurse should instruct the client to do which activities? Select all that apply. a) Take all medications on time as ordered. b) Stay away from crowded areas. c) Eat small, frequent meals throughout the day. d) Obtain adequate rest to reduce stimulation. e) Sit up for 1 hour when awakened at night.
a) Take all medications on time as ordered. c) Eat small, frequent meals throughout the day. d) Obtain adequate rest to reduce stimulation. e) Sit up for 1 hour when awakened at night.
A 56-year-old female client is being discharged after having a thyroidectomy. Which discharge instructions are appropriate for this client? Select all that apply. a) Take thyroid replacement medication, as ordered. b) Report any signs and symptoms of hypoglycemia. c) Recognize the signs of dehydration. d) Carry injectable dexamethasone at all times. e) Watch for changes in body functioning, such as lethargy, restlessness, sensitivity to cold, and dry skin. Report them to the physician. f) Avoid over-the-counter medications.
a) Take thyroid replacement medication, as ordered. e) Watch for changes in body functioning, such as lethargy, restlessness, sensitivity to cold, and dry skin. Report them to the physician.
A 22-year-old female client has lactose intolerance. After teaching her about foods that will help her maintain adequate calcium intake, which client responses identifying foods to eat or drink indicates to the nurse that the client understands the teaching plan? Select all that apply. a) broccoli b) canned sardines c) ice cream d) soy milk e) almonds
a) broccoli b) canned sardines d) soy milk e) almonds
A 34-year-old female is diagnosed with hypothyroidism. What should the nurse assess the client for? Select all that apply. a) constipation b) fine, thin hair with hair loss c) rapid pulse d) menorrhagia e) decreased energy and fatigue f) weight gain of 10 lb (4.5 kg)
a) constipation d) menorrhagia e) decreased energy and fatigue f) weight gain of 10 lb (4.5 kg) -Clients with hypothyroidism exhibit symptoms indicating a lack of thyroid hormone. -Bradycardia, decreased energy and lethargy, memory problems, weight gain, coarse hair, constipation, and menorrhagia are common signs and symptoms of hypothyroidism.
The nurse should assess the client who is being admitted to the hospital with upper GI bleeding for which finding? Select all that apply. a) decreased urine output b) tachycardia c) thirst d) widening pulse pressure e) rapid respirations f) dry, flushed skin
a) decreased urine output b) tachycardia c) thirst e) rapid respirations The client who is experiencing upper GI bleeding is at risk for developing hypovolemic shock from blood loss. Therefore, the signs and symptoms the nurse should expect to find are those related to hypovolemia, including decreased urine output, tachycardia, rapid respirations, and thirst. The client's skin would be cool and clammy, not dry and flushed. The client would also be likely to develop hypotension, which would lead to a narrowing pulse pressure, not a widening pulse pressure.
What diet should be implemented for a client who is in the early stages of cirrhosis? a) high-calorie, high-carbohydrate b) high-carbohydrate, low-sodium c) high-protein, low-fat d) low-fat, low-protein
a) high-calorie, high-carbohydrate
Which finding should the nurse report to the client's health care provider (HCP) for a client with unstable type 1 diabetes mellitus? Select all that apply. a) high-density lipoprotein (HDL), 30 mg/dL (1.7 mmol/L) b) systolic blood pressure, 145 mm Hg c) diastolic blood pressure, 87 mm Hg d) urine ketones, negative e) glycosylated hemoglobin (HbA1c), 10.2% (0.1) f) triglycerides, 425 mg/dL (23.6 mmol/L)
a) high-density lipoprotein (HDL), 30 mg/dL (1.7 mmol/L) b) systolic blood pressure, 145 mm Hg c) diastolic blood pressure, 87 mm Hg e) glycosylated hemoglobin (HbA1c), 10.2% (0.1) f) triglycerides, 425 mg/dL (23.6 mmol/L) -Heart disease is the leading cause of mortality in clients with diabetes. -The goal blood pressure for diabetics is less than 130/80 mm Hg. -The goal of HbA1c is less than 7% (0.07); -HDL less than 40 mg/dL (2.2 mmol/L) and triglycerides greater than 150 mg/dL (8.3 mmol/L) are risk factors for heart disease. -The urine ketones are negative, but this is a late sign of complications when there is a profound insulin deficiency.
The nurse is giving preoperative instructions to a client who will have a reversal of a colostomy. The nurse should prepare the client to expect which nursing actions during the immediate postoperative period? Select all that apply. a) nasogastric (NG) tube attached to low intermittent suction b) calculation of intake and output every 8 hours c) administration of IV fluids d) daily measurement of abdominal girth e) assessment of vital signs every 6 hours
a) nasogastric (NG) tube attached to low intermittent suction b) calculation of intake and output every 8 hours c) administration of IV fluids
A client with diabetes who takes insulin has a blood glucose level of 40 mg/dL (2.22 mmol/L). What should the nurse offer the client to begin to raise the blood glucose level? Select all that apply. a) one slice of bread b) one-quarter cup (60 mL) of tuna c) one-half cup (120 mL) of orange juice d) one cup (240 mL) of milk e) one-half cup (120 mL) of regular soda f) one tablespoon (15 mL) of peanut butter
a) one slice of bread c) one-half cup (120 mL) of orange juice d) one cup (240 mL) of milk e) one-half cup (120 mL) of regular soda -To treat a low blood glucose level, the nurse should provide the client with approximately 15 g of carbohydrate and monitor the blood glucose level within 15 minutes. -Meat or fish, such as tuna, do not contain carbohydrate.
A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for which signs and symptoms? Select all that apply. a) rapid onset of dehydration b) projectile vomiting c) significant abdominal distention d) increased bowel sounds e) copious diarrhea
a) rapid onset of dehydration b)projectile vomiting d)increased bowel sounds -Signs and symptoms of intestinal obstructions in the small intestine may include projectile vomiting and rapidly developing dehydration and electrolyte imbalances. -The client will also have increased bowel sounds, usually high-pitched and tinkling. -The client would not normally have diarrhea and would have minimal abdominal distention. -Pain is intermittent, being relieved by vomiting. - Intestinal obstructions in the large intestine usually evolve slowly, produce persistent pain, and vomiting is less common. -Clients with a large-intestine obstruction may develop obstipation and significant abdominal distention.
A 58-year-old homeless person is brought to the emergency department by the police after being found unconscious on the street. Following examination and evaluation of laboratory test results, a diagnosis of diabetic ketoacidosis is confirmed. Which information is most crucial to document on the client's medical record? Select all that apply. a) skin condition and presence of any rashes, lesions, or ulcers b) size of pupils and reaction of pupils to light c) response to verbal and painful stimuli d) length of time the client has had diabetes e) hourly urine output f) blood pressure
a) skin condition and presence of any rashes, lesions, or ulcers b) size of pupils and reaction of pupils to light c) response to verbal and painful stimuli e) hourly urine output f) blood pressure
A client with insulin-dependent diabetes develops a seizure disorder and has been prescribed phenytoin. Which information should the nurse include in the teaching plan? The client should: (Select all that apply.) a) use a soft toothbrush and floss the teeth daily. b) report changes in blood glucose levels to the health care provider. c) increase the daily calorie allotment by 200 calories. d) substitute various brands of phenytoin as long as the dosage is the same. e) take potassium supplements to prevent hypokalemia.
a) use a soft toothbrush and floss the teeth daily. b) report changes in blood glucose levels to the health care provider.
When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms should the nurse assess? Select all that apply. a) vomiting b) relief of epigastric pain after eating c) epigastric pain at night d) melena e) weight loss
a) vomiting d) melena e) weight loss -Vomiting and weight loss are common with gastric ulcers. - The client may also have blood in the stools (melena) from gastric bleeding. -Clients with a gastric ulcer are most likely to have a burning epigastric pain that occurs about 1 hour after eating. -Eating frequently aggravates the pain. -Clients with duodenal ulcers are more likely to have pain that occurs during the night and is frequently relieved by eating.
Which dietary instruction would be appropriate for the nurse to give a client who is recovering from acute pancreatitis? a) Decrease sodium in the diet. b) Avoid crash dieting. c) Restrict carbohydrate intake. d) Eat six small meals a day.
b) Avoid crash dieting. Crash dieting or bingeing may cause an acute attack of pancreatitis and should be avoided. Carbohydrate intake should be increased because carbohydrates are less stimulating to the pancreas. There is no need to maintain a dietary pattern of six meals a day; the client can eat whenever desired. There is no need to place the client on a sodium-restricted diet because pancreatitis does not promote fluid retention.
A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. What should the nurse do? Select all that apply. a) Use a higher volume of formula because the formula may be too hypotonic. b) Change the feeding apparatus every 24 hours. c) Use a diluted formula, gradually increasing the volume and concentration. d) Anticipate changing to a lactose-free formula. e) Slow the administration rate.
b) Change the feeding apparatus every 24 hours. c) Use a diluted formula, gradually increasing the volume and concentration. d) Anticipate changing to a lactose-free formula. e) Slow the administration rate. -Although about 50% of diarrhea in clients receiving tube feedings is caused by sorbitol-containing medications, the nurse should assess for other possible causes. -Diarrhea can occur as a result of bacterial contamination if fresh formula is not used or stored in a refrigerator, or if the feeding apparatus is not changed at least every 24 hours. -Lactose intolerance, rapid formula administration, low serum albumin level, and hypertonic solutions may also cause diarrhea.
Which are the important considerations by the nurse before administering feedings to a client through a nasogastric tube? Select all that apply. a) Position the client in the supine position to prevent aspiration. b) Measure the pH of the aspirated fluid. c) Determine placement of the tube by aspiration of gastric contents. d) Flush the tube with 50 mL of water before the feeding to prevent obstruction of the tube. e) Ensure that anchoring tape is intact.
b) Measure the pH of the aspirated fluid. c) Determine placement of the tube by aspiration of gastric contents. -The most important consideration prior to initiating a tube feeding involves checking placement of the feeding tube. -A more definitive placement check after insertion is to measure the pH of the fluid. -Gastric aspirate should be acidic. -The client should be in high Fowler's position to prevent aspiration, and flushing should be done after the feeding, not before
A client diagnosed with hypothyroidism (myxedema) is receiving levothyroxine. Which assessment findings would require a nursing intervention? Select all that apply. a) Dysuria b) Mild chest pain c) Heart rate of 132 beats/min d) Adventitious breath sounds e) Dysrhythmias
b) Mild chest pain c) Heart rate of 132 beats/min e) Dysrhythmias
A physician orders laboratory tests to confirm hyperthyroidism in a client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis? a) A decreased TSH level b) No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test c) An increase in the TSH level after 30 minutes during the TSH stimulation test d) Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay
b) No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test -In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. -A decreased TSH level indicates a pituitary deficiency of this hormone. -Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. -A below-normal T4 level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs.
A client comes to the emergency department with suspected cholecystitis. Which data collection findings are characteristic of this diagnosis? Select all that apply. a) Urticaria b) Transient epigastric pain radiating to the back and right shoulder c) Nausea d) Flatulence e) Burning in the chest after eating fried foods
b) Transient epigastric pain radiating to the back and right shoulder c) Nausea d) Flatulence e) Burning in the chest after eating fried foods
The nurse should review the glucose level of which clients who are going to surgery today? Select all that apply. a) a client with a family history of diabetes receiving dextrose 5% in lactated Ringer's solution (DLR) IV fluids b) a client with diabetes mellitus controlled by diet c) a client receiving corticosteroids for the past 3 months d) a client who consumes a high carbohydrate diet e) a client with a high stress response to surgery
b) a client with diabetes mellitus controlled by diet c) a client receiving corticosteroids for the past 3 months e) a client with a high stress response to surgery
A client with peptic ulcer disease reports being nauseated most of the day and is now feeling light-headed and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? Select all that apply. a) initiating oxygen therapy b) monitoring the client's vital signs c) reassessing the client in an hour d) administering an antacid hourly until nausea subsides e) notifying the health care provider (HCP) of the client's symptoms
b) monitoring the client's vital signs e) notifying the health care provider (HCP) of the client's symptoms -The symptoms of nausea and dizziness in a client with peptic ulcer disease may be indicative of hemorrhage and should not be ignored. -To administer an antacid hourly or to wait 1 hour to reassess the client would be inappropriate; prompt intervention is essential in a client who is potentially experiencing a gastrointestinal hemorrhage.
A client with type 1 diabetes has been on a regimen of multiple daily injection therapy. He's being converted to continuous subcutaneous insulin therapy. While teaching the client about continuous subcutaneous insulin therapy, the nurse should tell him that the regimen includes the use of: a) intermediate- and long-acting insulins. b) rapid-acting insulin only. c) short- and long-acting insulins. d) short- and intermediate-acting insulins.
b) rapid-acting insulin only.
A client is scheduled to undergo an upper gastrointestinal (GI) series. The nurse should give the client which instructions in preparation for the test? Select all that apply. a) "It is okay for you to smoke before the test." b) "You will need to take a stool softener before the test to promote evacuation of the barium." c) "Do not eat or drink for 8 hours before the test." d) "You will experience mild stomach pain during the test." e) Do not eat or drink for 8 hours before the test
c) "Do not eat or drink for 8 hours before the test." e) Do not eat or drink for 8 hours before the test
The nurse is teaching the family and a client newly diagnosed with type 1 diabetes how diet and exercise affect insulin requirements. Which statement made by the client indicates understanding of the teaching? a) "An exercise regimen may cause me to eliminate my bedtime snack." b) "Exercise will decrease my insulin need and decrease my food requirements." c) "I can remove my insulin pump when exercising." d) "I will need more insulin and food when exercising."
c) "I can remove my insulin pump when exercising." The nurse should advise the client that exercise will lower blood sugar and a snack should be eaten prior to exercise. It is recommended that the insulin pump be remove during exercise because it can become dislodged.
Which information should the nurse include when developing a teaching plan for a client newly diagnosed with type 2 diabetes mellitus? Select all that apply. a) Exercise increases insulin resistance. b) Supplemental insulin is mandatory for controlling the disease. c) A major risk factor for complications is obesity and central abdominal obesity. d) The primary nutritional source requiring monitoring in the diet is carbohydrates. e) Annual eye and foot examinations are recommended by the American and Canadian Diabetes Associations.
c) A major risk factor for complications is obesity and central abdominal obesity. e) Annual eye and foot examinations are recommended by the American and Canadian Diabetes Associations.
A client is diagnosed with diabetes mellitus. Which assessment findings best support a nursing diagnosis of ineffective coping related to diabetes mellitus? Select all that apply. a) Failure to purchase diabetic test strips for glucose monitor b) Recent weight gain of 20 lb. (9.1 kg) c) Changes the subject whenever diabetes is mentioned d) Skipping insulin doses during illness e) Refuses to attend diabetic support meetings
c) Changes the subject whenever diabetes is mentioned e) Refuses to attend diabetic support meetings -Ineffective coping includes denial or lack of acceptance of the disease.
The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable for the last 24 hours, but the client now has a temperature of 101.1 F (38.4 C), a heart rate of 116 beats/min, and a respiratory rate of 26 breaths/min. Using SBAR communication, which of the following recommendations should the nurse make when calling the physician? Select all that apply. a) Start broad-spectrum IV antibiotics 4 hours after blood cultures are drawn. b) Continue to check vital signs every 4 hours. c) Draw stat blood cultures x 2. d) Draw CBC, CRP, ESR, UA with culture and sensitivity if indicated. e) Assist with a CT scan of the abdomen. f) Ensure patent IV access for fluid bolus.
c) Draw stat blood cultures x 2. d) Draw CBC, CRP, ESR, UA with culture and sensitivity f) Ensure patent IV access for fluid bolus.
Cimetidine may also be used to treat hiatal hernia. The nurse should understand that this drug is used to prevent which of the following? a) Dysphagia. b) Esophageal reflux. c) Esophagitis. d) Ulcer formation.
c) Esophagitis. Cimetidine is a histamine receptor antagonist that decreases the quantity of gastric secretions. It may be used in hiatal hernia therapy to prevent or treat the esophagitis and heartburn associated with reflux.
When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which nursing interventions would be most appropriate for this client? Select all that apply. a) Maintain the client on a high-calorie, high-protein diet. b) Administer morphine sulfate for pain as needed. c) Obtain daily weights. d) Monitor the client's respiratory status. e) Place the client in a side-lying position.
c) Obtain daily weights. d) Monitor the client's respiratory status. e) Place the client in a side-lying position. -The client with acute pancreatitis usually experiences acute abdominal pain. -Placing the client in a side-lying position relieves the tension on the abdominal area and promotes comfort. -A semi-Fowler's position is also appropriate. -The nurse should also monitor the client's respiratory status because clients with pancreatitis are prone to develop respiratory complications. -Daily weights are obtained to monitor the client's nutritional and fluid volume status. -While the client will likely need opioid analgesics to treat the pain, morphine sulfate is not appropriate as it stimulates spasm of the sphincter of Oddi, thus increasing the client's discomfort. -When the diet is reintroduced, it is a high-carbohydrate, low-fat, bland diet.
A nurse is caring for a client with symptoms of epigastric pain. When teaching the action of gastric contents related to functioning of the body, which actions occur in the stomach? Select all that apply. a) Vitamin B6 absorption b) Emulsifying fats c) Vitamin B12 absorption d) Activating the enzyme pepsin e) Breaking down food fibers f) Killing microorganisms
c) Vitamin B12 absorption d) Activating the enzyme pepsin e) Breaking down food fibers f) Killing microorganisms
The nurse is obtaining a health history from a client with diabetes mellitus who has been taking insulin for 20 years. Currently the client reports having periods of hypoglycemia followed by periods of hyperglycemia. The nurse should specifically ask if the client is: a) initiating the use of the insulin pump. b) adjusting insulin according to blood glucose levels. c) injecting insulin at a site of lipodystrophy. d) eating snacks between meals.
c) injecting insulin at a site of lipodystrophy.
A client with acute pancreatitis is put on nothing-by-mouth status, with the intent of not stimulating the pancreas. The client is prescribed an IV infusion of dextrose 5% in half-normal saline solution at 120 mL/h. After 3 days of this regimen, the nurse should observe the client for which adverse metabolic condition? a) lactic acidosis b) hyperglycemia c) ketosis d) metabolic syndrome
c) ketosis Ketosis is an adaptation to prolonged fasting or carbohydrate deprivation. The body takes partially broken-down fat fragments and combines them into ketone bodies, which the brain can then use for energy. Hypoglycemia is more likely to occur than hyperglycemia, although glucagon assists in preventing this. Metabolic syndrome refers to syndrome X, which includes an abnormal lipid profile and a tendency to gain weight in the abdomen. Lactic acidosis is a metabolic reaction that occurs when oxygen is reduced or not present.
Which statement indicates that the client with hepatitis B has understood the nurse's discharge teaching? a) "Because hepatitis B is a chronic disease, I know I will always be jaundiced." b) "I must avoid sexual intercourse." c) "I should be able to resume normal activity in a week or two." d) "I will not drink alcohol for at least 1 year."
d) "I will not drink alcohol for at least 1 year." It is important that the client understand that alcohol should be avoided for at least 1 year after an episode of hepatitis. Sexual intercourse does not need to be avoided, but the client should be instructed to use condoms until the hepatitis B surface antigen measurement is negative. The client will need to restrict activity until liver function test results are normal; this will not occur within 1 to 2 weeks. Jaundice will subside as the client recovers; it is not a permanent condition.
What information will the nurse include in the preoperative education for a client scheduled for thyroid lobectomy? a) Medications for thyroid replacement b) Symptoms of hypercalcemia c) Instructions for tracheostomy care d) Daily neck exercises
d) Daily neck exercises
A client's stools are light gray in color. For what finding should the nurse assess the client? Select all that apply. a) peptic ulcer disease b) pain at McBurney's point c) respiratory distress d) intolerance to fatty foods e) fever f) jaundice
d) intolerance to fatty foods e) fever f) jaundice
A nurse is teaching a client about insulin therapy. The nurse knows the client needs additional teaching when she states that insulin may interact with: a) hormonal contraceptives. b) hydrochlorothiazide (Hydro DIURIL). c) aspirin. d) metoprolol.
d) metoprolol. Although metoprolol may mask the signs of hypoglycemia, it doesn't interact with insulin. Therefore, the client requires additional teaching. Thiazide diuretics such as hydrochlorothiazide, aspirin, and hormonal contraceptives all interact with insulin.
