HIM FINAL
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\*A nurse is teaching a client with diabetes mellitus who asks, Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL? How should the nurse respond?
a. Glucose is the only fuel used by the body to produce the energy that it needs.
b. Your brain needs a constant supply of glucose because it cannot store it.
c. Without a minimum level of glucose, your body does not make red blood cells.
d. Glucose in the blood prevents the formation of lactic acid and preventsacidosis.
a. Glucose is the only fuel used by the body to produce the energy that it needs.
b. Your brain needs a constant supply of glucose because it cannot store it.
c. Without a minimum level of glucose, your body does not make red blood cells.
d. Glucose in the blood prevents the formation of lactic acid and preventsacidosis.
b. Your brain needs a constant supply of glucose because it cannot store it.
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A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the client's polyuria?
a. Serum sodium: 163 mEq/L
b. Serum creatinine: 1.6 mg/dL
c. Presence of urine ketone bodies
d. Serum osmolarity: 375mOsm/kg
a. Serum sodium: 163 mEq/L
b. Serum creatinine: 1.6 mg/dL
c. Presence of urine ketone bodies
d. Serum osmolarity: 375mOsm/kg
d. Serum osmolarity: 375mOsm/kg
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\*After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations?
a. At my age, I should continue seeing the ophthalmologist as I usually do.
b. I will see the eye doctor when I have a vision problem and yearly after age
c. My vision will change quickly. I should see the ophthalmologist twice a year.
d. Diabetes can cause blindness, so I should see the ophthalmologist yearly.
a. At my age, I should continue seeing the ophthalmologist as I usually do.
b. I will see the eye doctor when I have a vision problem and yearly after age
c. My vision will change quickly. I should see the ophthalmologist twice a year.
d. Diabetes can cause blindness, so I should see the ophthalmologist yearly.
d. Diabetes can cause blindness, so I should see the ophthalmologist yearly.
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\*A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first?
a. Document the finding in the clients chart.
b. Assess tactile sensation in the clients hands.
c. Examine the clients feet for signs of injury.
d. Notify the health care provider.
a. Document the finding in the clients chart.
b. Assess tactile sensation in the clients hands.
c. Examine the clients feet for signs of injury.
d. Notify the health care provider.
c. Examine the clients feet for signs of injury.
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\*A nurse cares for a client who has a family history of diabetes mellitus. The client states, My father has type 1 diabetes mellitus. Will I develop this disease as well? How should the nurse respond?
a. Your risk of diabetes is higher than the general population, but it may not occur.
b. No genetic risk is associated with the development of type 1 diabetes mellitus.
c. The risk for becoming a diabetic is 50% because of how it is inherited.
d. Female children do not inherit diabetes mellitus, but male children will.
a. Your risk of diabetes is higher than the general population, but it may not occur.
b. No genetic risk is associated with the development of type 1 diabetes mellitus.
c. The risk for becoming a diabetic is 50% because of how it is inherited.
d. Female children do not inherit diabetes mellitus, but male children will.
a. Your risk of diabetes is higher than the general population, but it may not occur.
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\*A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications?
a. Maintain tight glycemic control and prevent hyperglycemia.
b. Restrict your fluid intake to no more than 2 liters a day.
c. Prevent hypoglycemia by eating a bedtime snack.
d. Limit your intake of protein to prevent ketoacidosis.
a. Maintain tight glycemic control and prevent hyperglycemia.
b. Restrict your fluid intake to no more than 2 liters a day.
c. Prevent hypoglycemia by eating a bedtime snack.
d. Limit your intake of protein to prevent ketoacidosis.
a. Maintain tight glycemic control and prevent hyperglycemia.
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\*A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk?
a. A 29-year-old Caucasian
b. A 32-year-old African- American
c. A 44-year-old Asian
d. A 48-year-old American Indian
a. A 29-year-old Caucasian
b. A 32-year-old African- American
c. A 44-year-old Asian
d. A 48-year-old American Indian
d. A 48-year-old American Indian
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\*A nurse teaches a client about self-monitoring of blood glucose levels. Which statement should the nurse include in this client's teaching to prevent bloodborne infections?
a. Wash your hands after completing each test.
b. Do not share your monitoring equipment.
c. Blot excess blood from the strip with a cotton ball.
d. Use gloves when monitoring your blood glucose.
a. Wash your hands after completing each test.
b. Do not share your monitoring equipment.
c. Blot excess blood from the strip with a cotton ball.
d. Use gloves when monitoring your blood glucose.
b. Do not share your monitoring equipment.
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A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement should the nurse include in this client's teaching?
a. Change positions slowly when you get out of bed.
b. Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs).
c. If you miss a dose of this drug, you can double the next dose.
d. Discontinue the medication if you develop a urinary infection.
a. Change positions slowly when you get out of bed.
b. Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs).
c. If you miss a dose of this drug, you can double the next dose.
d. Discontinue the medication if you develop a urinary infection.
b. Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs).
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\*A nurse cares for a client with diabetes mellitus who asks, Why do I need to administer more than one injection of insulin each day? How should the nurse respond?
a. You need to start with multiple injections until you become more proficient at self-injection.
b. A single dose of insulin each day would not match your blood insulin levels and your food intake patterns.
c. A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates.
d. A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock.
a. You need to start with multiple injections until you become more proficient at self-injection.
b. A single dose of insulin each day would not match your blood insulin levels and your food intake patterns.
c. A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates.
d. A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock.
b. A single dose of insulin each day would not match your blood insulin levels and your food intake patterns.
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\*After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
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a. The lower abdomen is the best location because it is closest to the pancreas
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b. I can reach my thigh the best, so I will use the different areas of my thighs.
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c. By rotating the sites in one area, my chance of having a reaction is decreased.
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d. Changing injection sites from the thigh to the arm will change absorption rates.
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a. The lower abdomen is the best location because it is closest to the pancreas
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b. I can reach my thigh the best, so I will use the different areas of my thighs.
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c. By rotating the sites in one area, my chance of having a reaction is decreased.
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d. Changing injection sites from the thigh to the arm will change absorption rates.
a. The lower abdomen is the best location because it is closest to the pancreas
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\*A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first?
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a. Administer 1 mg of intramuscular glucagon.
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b. Encourage the client to drink orange juice.
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c. Insert a new intravenous access line.
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d. Administer 25 mL dextrose 50% (D50) IV push.
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a. Administer 1 mg of intramuscular glucagon.
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b. Encourage the client to drink orange juice.
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c. Insert a new intravenous access line.
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d. Administer 25 mL dextrose 50% (D50) IV push.
a. Administer 1 mg of intramuscular glucagon.
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\*A nurse cares for a client with diabetes mellitus who is visually impaired. The client asks, Can I ask my niece to prefill my syringes and then store them for later use when I need them? How should the nurse respond?
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a. Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needlepointing up.
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b. Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light.
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c. Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes.
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d. No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container.
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a. Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needlepointing up.
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b. Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light.
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c. Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes.
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d. No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container.
a. Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needlepointing up.
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\*A nurse teaches a client who is prescribed an insulin pump. Which statement should the nurse include in this client's discharge education?
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a. Test your urine daily for ketones.
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b. Use only buffered insulin in your pump.
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c. Store the insulin in the freezer until you need it.
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d. Change the needle every 3 days.
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a. Test your urine daily for ketones.
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b. Use only buffered insulin in your pump.
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c. Store the insulin in the freezer until you need it.
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d. Change the needle every 3 days.
d. Change the needle every 3 days.
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\*After teaching a client who has diabetes mellitus and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching?
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a. I have so many complications; exercising is not recommended
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b. I will exercise more frequently because I have so many complications.
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c. I used to run for exercise; I will start training for a marathon.
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d. I should look into swimming or water aerobics to get my exercise.
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a. I have so many complications; exercising is not recommended
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b. I will exercise more frequently because I have so many complications.
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c. I used to run for exercise; I will start training for a marathon.
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d. I should look into swimming or water aerobics to get my exercise.
d. I should look into swimming or water aerobics to get my exercise.
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\*An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should the nurse correlate with this condition?
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a. Increased rate and depth of respiration
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b. Extremity tremors followed by seizure activity
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c. Oral temperature of 102 F (38.9 C)
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d. Severe orthostatic hypotension
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a. Increased rate and depth of respiration
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b. Extremity tremors followed by seizure activity
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c. Oral temperature of 102 F (38.9 C)
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d. Severe orthostatic hypotension
a. Increased rate and depth of respiration
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A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client?
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a. pH 7.38, HCO3 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg
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b. pH 7.28, HCO3 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg
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c. pH 7.48, HCO3 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg
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d. pH 7.32, HCO3 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg
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a. pH 7.38, HCO3 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg
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b. pH 7.28, HCO3 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg
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c. pH 7.48, HCO3 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg
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d. pH 7.32, HCO3 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg
b. pH 7.28, HCO3 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg
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\*A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take?
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a. Administration of oxygen via face mask
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b. Intravenous administration of 10% glucose
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c. Implementation of seizure precautions
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d. Administration of intravenous insulin
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a. Administration of oxygen via face mask
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b. Intravenous administration of 10% glucose
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c. Implementation of seizure precautions
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d. Administration of intravenous insulin
d. Administration of intravenous insulin
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\*A nurse cares for a client who has type 1 diabetes mellitus. The client asks, Is it okay for me to have an occasional glass of wine? How should the nurse respond?
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a. Drinking any wine or alcohol will increase your insulin requirements.
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b. Because of poor kidney function, people with diabetes should avoid alcohol.
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c. You should not drink alcohol because it will make you hungry and overeat.
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d. One glass of wine is okay with a meal and is counted as two fat exchanges.
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a. Drinking any wine or alcohol will increase your insulin requirements.
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b. Because of poor kidney function, people with diabetes should avoid alcohol.
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c. You should not drink alcohol because it will make you hungry and overeat.
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d. One glass of wine is okay with a meal and is counted as two fat exchanges.
d. One glass of wine is okay with a meal and is counted as two fat exchanges.
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\*A nurse teaches a client with type 1 diabetes mellitus. Which statement should the nurse include in this client's teaching to decrease the client's insulin needs?
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a. Limit your fluid intake to 2 liters a day.
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b. Animal organ meat is high in insulin.
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c. Limit your carbohydrate intake to 80 grams a Day.
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d. Walk at a moderate pace for 1 mile daily.
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a. Limit your fluid intake to 2 liters a day.
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b. Animal organ meat is high in insulin.
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c. Limit your carbohydrate intake to 80 grams a Day.
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d. Walk at a moderate pace for 1 mile daily.
d. Walk at a moderate pace for 1 mile daily.
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\*A nurse cares for a client who is diagnosed with acute rejection 2 months after receiving a simultaneous pancreas-kidney transplant. The client states, I was doing so well with my new organs, and the thought of having to go back to living on hemodialysis and taking insulin is so depressing. How should the nurse respond?
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a. Following the drug regimen more closely would have prevented this.
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b. One acute rejection episode does not mean that you will lose the new organs.
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c. Dialysis is a viable treatment option for you and may save your life.
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d. Since you are on the national registry, you can receive a second transplantation.
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a. Following the drug regimen more closely would have prevented this.
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b. One acute rejection episode does not mean that you will lose the new organs.
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c. Dialysis is a viable treatment option for you and may save your life.
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d. Since you are on the national registry, you can receive a second transplantation.
b. One acute rejection episode does not mean that you will lose the new organs.
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\*After teaching a client who is recovering from pancreas transplantation, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional education?
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a. If I develop an infection, I should stop taking my corticosteroid.
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b. If I have pain over the transplant site, I will call the surgeon immediately.
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c. I should avoid people who are ill or who have an infection.
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d. I should take my cyclosporine exactly the way I was taught.
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a. If I develop an infection, I should stop taking my corticosteroid.
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b. If I have pain over the transplant site, I will call the surgeon immediately.
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c. I should avoid people who are ill or who have an infection.
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d. I should take my cyclosporine exactly the way I was taught.
a. If I develop an infection, I should stop taking my corticosteroid.
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\*A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the client's breath has a fruity odor. Which action should the nurse take?
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a. Encourage the client to use an incentive Spirometer.
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b. Increase the client's intravenous fluid flow rate.
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c. Consult the provider to test for ketoacidosis.
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d. Perform meticulous pulmonary hygiene care.
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a. Encourage the client to use an incentive Spirometer.
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b. Increase the client's intravenous fluid flow rate.
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c. Consult the provider to test for ketoacidosis.
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d. Perform meticulous pulmonary hygiene care.
c. Consult the provider to test for ketoacidosis.
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\*A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The client's blood glucose level is 160 mg/dL. Which action should the nurse take?
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a. Document the finding in the clients chart.
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b. Administer a bolus of regular insulin IV.
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c. Call the surgeon to cancel the procedure.
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d. Draw blood gasses to assess the metabolic state.
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a. Document the finding in the clients chart.
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b. Administer a bolus of regular insulin IV.
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c. Call the surgeon to cancel the procedure.
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d. Draw blood gasses to assess the metabolic state.
a. Document the finding in the clients chart.
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\*A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement should the nurse include in this client's teaching to prevent injury?
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a. Examine your feet using a mirror every day.
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b. Rotate your insulin injection sites every week.
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c. Check your blood glucose level before each meal.
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d. Use a bath thermometer to test the water temperature.
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a. Examine your feet using a mirror every day.
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b. Rotate your insulin injection sites every week.
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c. Check your blood glucose level before each meal.
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d. Use a bath thermometer to test the water temperature.
d. Use a bath thermometer to test the water temperature.
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\*A nurse assesses a client with diabetes mellitus. Which clinical manifestation should alert the nurse to decreased kidney function in this client?
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a. Urine specific gravity of 1.033
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b. Presence of protein in the urine
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c. Elevated capillary blood glucose level
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d. Presence of ketone bodies in the urine
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a. Urine specific gravity of 1.033
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b. Presence of protein in the urine
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c. Elevated capillary blood glucose level
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d. Presence of ketone bodies in the urine
b. Presence of protein in the urine
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A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the client's diet should the nurse decrease?
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a. Carbohydrates
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b. Proteins
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c. Fats
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d. Total calories
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a. Carbohydrates
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b. Proteins
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c. Fats
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d. Total calories
b. Proteins
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\*A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the client's clinical manifestations have not changed. Which action should the nurse take next?
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a. Administer another half-cup of orange juice.
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b. Administer a half-ampule of dextrose 50% intravenously.
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c. Administer 10 units of regular insulin subcutaneously.
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a. Administer another half-cup of orange juice.
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b. Administer a half-ampule of dextrose 50% intravenously.
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c. Administer 10 units of regular insulin subcutaneously.
a. Administer another half-cup of orange juice.
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A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately?
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a. Serum chloride level of 98 mmol/L
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b. Serum calcium level of 8.8 mg/dL
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c. Serum sodium level of 132 mmol/L
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d. Serum potassium level of 2.5 mmol/L
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a. Serum chloride level of 98 mmol/L
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b. Serum calcium level of 8.8 mg/dL
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c. Serum sodium level of 132 mmol/L
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d. Serum potassium level of 2.5 mmol/L
d. Serum potassium level of 2.5 mmol/L
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\*A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this client's teaching?
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a. When ill, avoid eating or drinking to reduce vomiting and diarrhea.
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b. Monitor your blood glucose levels at least every 4 hours while sick.
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c. If vomiting, do not use insulin or take your oral antidiabetic agent.
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d. Try to continue your prescribed exercise regimen even if you are sick.
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a. When ill, avoid eating or drinking to reduce vomiting and diarrhea.
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b. Monitor your blood glucose levels at least every 4 hours while sick.
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c. If vomiting, do not use insulin or take your oral antidiabetic agent.
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d. Try to continue your prescribed exercise regimen even if you are sick.
b. Monitor your blood glucose levels at least every 4 hours while sick.
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\*A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted?
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a. Serum potassium level has increased.
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b. Blood osmolarity has decreased.
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c. Glasgow Coma Scale score is unchanged.
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d. Urine remains negative for ketone bodies.
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a. Serum potassium level has increased.
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b. Blood osmolarity has decreased.
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c. Glasgow Coma Scale score is unchanged.
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d. Urine remains negative for ketone bodies.
c. Glasgow Coma Scale score is unchanged.
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A nurse cares for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 0700. At which time should the nurse assess the client for potential problems related to the NPH insulin?
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a. 0800
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b. 1600
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c. 2000
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d. 2300
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a. 0800
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b. 1600
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c. 2000
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d. 2300
b. 1600
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\*After teaching a client with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
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a. I need to have an annual appointment even if my glucose levels are in good control.
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b. Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick.
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c. I can still develop complications even though I do not have to take insulin at this time
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d. If I have surgery or get very ill, I may have to receive insulin injections for a short time.
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a. I need to have an annual appointment even if my glucose levels are in good control.
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b. Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick.
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c. I can still develop complications even though I do not have to take insulin at this time
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d. If I have surgery or get very ill, I may have to receive insulin injections for a short time.
b. Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick.
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\*When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, I will never be able to stick myself with a needle. How should the nurse respond?
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a. I can give your injections to you while you are here in the hospital.
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b. Everyone gets used to giving themselves injections. It really does not hurt.
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c. Your disease will not be managed properly if you refuse to administer the shots.
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d. Tell me what it is about the injections that are concerning you.
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a. I can give your injections to you while you are here in the hospital.
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b. Everyone gets used to giving themselves injections. It really does not hurt.
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c. Your disease will not be managed properly if you refuse to administer the shots.
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d. Tell me what it is about the injections that are concerning you.
d. Tell me what it is about the injections that are concerning you.
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\*A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. Which action should the nurse take?
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a. Apply ice to the site to reduce inflammation.
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b. Consult the provider for a new administration route.
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c. Assess the client for other signs of cellulitis.
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d. Instruct the client to rotate sites for insulin injection.
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a. Apply ice to the site to reduce inflammation.
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b. Consult the provider for a new administration route.
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c. Assess the client for other signs of cellulitis.
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d. Instruct the client to rotate sites for insulin injection.
d. Instruct the client to rotate sites for insulin injection.
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\*A nurse reviews the medication list of a client recovering from a computed tomography (CT) scan with IV contrast to rule out small bowel obstruction. Which medication should alert the nurse to contact the provider and withhold the prescribed dose?
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a. Pioglitazone (Actos)
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b. Glimepiride (Amaryl)
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c. Glipizide (Glucotrol)
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d. Metformin
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a. Pioglitazone (Actos)
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b. Glimepiride (Amaryl)
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c. Glipizide (Glucotrol)
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d. Metformin
d. Metformin
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\*After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
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a. I should increase my intake of vegetables with higher amounts of dietary fiber.
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b. My intake of saturated fats should be no more than 10% of my total calorie intake.
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c. I should decrease my intake of protein and eliminate carbohydrates from my diet.
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d. My intake of water is not restricted by my treatment plan or medication regimen.
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a. I should increase my intake of vegetables with higher amounts of dietary fiber.
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b. My intake of saturated fats should be no more than 10% of my total calorie intake.
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c. I should decrease my intake of protein and eliminate carbohydrates from my diet.
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d. My intake of water is not restricted by my treatment plan or medication regimen.
c. I should decrease my intake of protein and eliminate carbohydrates from my diet.
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\*A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen:Fasting blood glucose: 75 mg/dLPostprandial blood glucose: 200 mg/dLHemoglobin A1c level: 5.5%How should the nurse interpret these laboratory findings?
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a. Increased risk for developing ketoacidosis
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b. Good control of blood glucose
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c. Increased risk for developing hyperglycemia
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d. Signs of insulin resistance
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a. Increased risk for developing ketoacidosis
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b. Good control of blood glucose
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c. Increased risk for developing hyperglycemia
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d. Signs of insulin resistance
b. Good control of blood glucose
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\*At 4:45 p.m., a nurse assesses a client with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the client is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below:After reviewing the clients assessment data, which action is appropriate at this time?
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a. Assess the client's oxygen saturation level and administer oxygen.
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b. Reorient the client and apply a cool washcloth to the clientsforehead.
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c. Administer dextrose 50% intravenously and reassess the client.
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d. Provide a glass of orange juice and encourage the client to eat dinner.
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a. Assess the client's oxygen saturation level and administer oxygen.
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b. Reorient the client and apply a cool washcloth to the clientsforehead.
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c. Administer dextrose 50% intravenously and reassess the client.
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d. Provide a glass of orange juice and encourage the client to eat dinner.
c. Administer dextrose 50% intravenously and reassess the client.
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\*A nurse assesses clients at a health fair. Which clients should the nurse counsel to be tested for diabetes? SATA
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a. 56-year-old African-American male
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b. Female with a 30-pound weight gain during pregnancy
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c. Male with a history of pancreatic trauma
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d. 48-year-old woman with a sedentary lifestyle
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e. Male with a body mass index greater than 25 kg/m2
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f. 28-year-old female who gave birth to a baby weighing 9.2 pounds
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a. 56-year-old African-American male
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b. Female with a 30-pound weight gain during pregnancy
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c. Male with a history of pancreatic trauma
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d. 48-year-old woman with a sedentary lifestyle
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e. Male with a body mass index greater than 25 kg/m2
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f. 28-year-old female who gave birth to a baby weighing 9.2 pounds
a. 56-year-old African-American male
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d. 48-year-old woman with a sedentary lifestyle
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e. Male with a body mass index greater than 25 kg/m2
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f. 28-year-old female who gave birth to a baby weighing 9.2 pounds
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d. 48-year-old woman with a sedentary lifestyle
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e. Male with a body mass index greater than 25 kg/m2
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f. 28-year-old female who gave birth to a baby weighing 9.2 pounds
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\*A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? SATA
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a. Deep and fast respirations
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b. Decreased urine output
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c. Tachycardia
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d. Dependent pulmonary crackles
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e. Orthostatic hypotension
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a. Deep and fast respirations
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b. Decreased urine output
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c. Tachycardia
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d. Dependent pulmonary crackles
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e. Orthostatic hypotension
a. Deep and fast respirations
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c. Tachycardia
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e. Orthostatic hypotension
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c. Tachycardia
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e. Orthostatic hypotension
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\*A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in this client's teaching? SATA
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a. Do not walk around barefoot.
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b. Soak your feet in a tub each evening.
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c. Trim toenails straight across with a nail clipper.
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d. Treat any blisters or sores with Epsom salts.e. Wash your feet every other day.
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a. Do not walk around barefoot.
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b. Soak your feet in a tub each evening.
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c. Trim toenails straight across with a nail clipper.
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d. Treat any blisters or sores with Epsom salts.e. Wash your feet every other day.
a. Do not walk around barefoot.
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c. Trim toenails straight across with a nail clipper.
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c. Trim toenails straight across with a nail clipper.
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\*A nurse provides diabetic education at a public health fair. Which disorders should the nurse include as complications of diabetes mellitus? SATA
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a. Stroke
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b. Kidney failure
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c. Blindness
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d. Respiratory failure
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e. Cirrhosis
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a. Stroke
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b. Kidney failure
\
c. Blindness
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d. Respiratory failure
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e. Cirrhosis
a. Stroke
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b. Kidney failure
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c. Blindness
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b. Kidney failure
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c. Blindness
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\*A nurse collaborates with the interdisciplinary team to develop a plan of care for a client who is newly diagnosed with diabetes mellitus.Which team members should the nurse include in this interdisciplinary team meeting? SATA
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a. Registered dietitian
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b. Clinical pharmacist
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c. Occupational therapist
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d. Health care provider
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e. Speech-language pathologist
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a. Registered dietitian
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b. Clinical pharmacist
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c. Occupational therapist
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d. Health care provider
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e. Speech-language pathologist
a. Registered dietitian
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b. Clinical pharmacist
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d. Health care provider
\
b. Clinical pharmacist
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d. Health care provider
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Occurs when gas or air leaks into the subcutaneous layer of the skin. This can indicate an air leak or the need for a dressing change. Notify the doctor if crepitus is felt.
Crepitus
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Air bubbling through the water seal INTERMITTENTLY is normal when the patient coughs or exhales. But if there is continuous air bubbling in the chamber it can indicate an:
Air leak
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If drainage system is damaged in any way insert the patients chest tube into:
A sterile bottle of water, kept below the level of the chest until a new drainage system arrives
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* Emphysema and chronic bronchitis
* Characterized by bronchospasm and dyspnea
* Tissue damage is IRREVERSIBLE and increases in severity until eventually leading to respiratory failure
* Characterized by bronchospasm and dyspnea
* Tissue damage is IRREVERSIBLE and increases in severity until eventually leading to respiratory failure
COPD
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\*A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond?
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a. There are a variety of support groups for people who have COPD.
\
b. I will ask your provider to prescribe you with an antianxiety agent.
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c. Share any thoughts and feelings that cause you to limit social activities.
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d. Friends can be a good support system for clients with chronic disorders.
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a. There are a variety of support groups for people who have COPD.
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b. I will ask your provider to prescribe you with an antianxiety agent.
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c. Share any thoughts and feelings that cause you to limit social activities.
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d. Friends can be a good support system for clients with chronic disorders.
a. There are a variety of support groups for people who have COPD.
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\*A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question should the nurse ask first?
\
a. Do you have a strong support system?
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b. What do you understand about your disease?
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c. Do you experience shortness of breath with basic activities?
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d. What medications are you prescribed to take each day?
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a. Do you have a strong support system?
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b. What do you understand about your disease?
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c. Do you experience shortness of breath with basic activities?
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d. What medications are you prescribed to take each day?
c. Do you experience shortness of breath with basic activities?
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\*A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first?
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a. A 46-year-old with a 30 pack-year history of smoking
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b. A 52-year-old in a tripod position using accessory muscles to breathe
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c. A 68-year-old who has dependent edema and clubbed fingers
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d. A 74-year-old with a chronic cough and thick, tenacious secretions
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a. A 46-year-old with a 30 pack-year history of smoking
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b. A 52-year-old in a tripod position using accessory muscles to breathe
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c. A 68-year-old who has dependent edema and clubbed fingers
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d. A 74-year-old with a chronic cough and thick, tenacious secretions
b. A 52-year-old in a tripod position using accessory muscles to breathe
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\*The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching?
\
a. I plan to wear my oxygen when I exercise and feel short of breath.
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b. I will use my portable oxygen when grilling burgers in the backyard.
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c. I plan to use cotton balls to cushion the oxygen tubing on my ears.
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d. I will only smoke while I am wearing my oxygen via nasal cannula.
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a. I plan to wear my oxygen when I exercise and feel short of breath.
\
b. I will use my portable oxygen when grilling burgers in the backyard.
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c. I plan to use cotton balls to cushion the oxygen tubing on my ears.
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d. I will only smoke while I am wearing my oxygen via nasal cannula.
c. I plan to use cotton balls to cushion the oxygen tubing on my ears.
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A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD):Arterial Blood Gas Results Vital SignspH = 7.32PaCO2 = 62 mm HgPaO2 = 46 mm HgHCO3 = 28 mEq/L Heart rate = 110 beats/minRespiratory rate = 12 breaths/minBlood pressure = 145/65 mm HgOxygen saturation = 76%Which action should the nurse take first?
\
a. Administer a short-acting beta2 agonist inhaler.
\
b. Document the findings as normal for a client with COPD.
\
c. Teach the client diaphragmatic breathing techniques.
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d. Initiate oxygenation therapy to increase saturation to 92%.
\
a. Administer a short-acting beta2 agonist inhaler.
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b. Document the findings as normal for a client with COPD.
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c. Teach the client diaphragmatic breathing techniques.
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d. Initiate oxygenation therapy to increase saturation to 92%.
d. Initiate oxygenation therapy to increase saturation to 92%.
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\*A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this client's teaching? SATA
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a. Avoid drinking fluids just before and during meals.
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b. Rest before meals if you have dyspnea.
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c. Have about six small meals a day.
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d. Eat high-fiber foods to promote gastric emptying.
\
a. Avoid drinking fluids just before and during meals.
\
b. Rest before meals if you have dyspnea.
\
c. Have about six small meals a day.
\
d. Eat high-fiber foods to promote gastric emptying.
a. Avoid drinking fluids just before and during meals.
\
b. Rest before meals if you have dyspnea.
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c. Have about six small meals a day.
\
b. Rest before meals if you have dyspnea.
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c. Have about six small meals a day.
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\*A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the client's activity tolerance? SATA
\
a. What color is your sputum?
\
b. Do you have any difficulty sleeping?
\
c. How long does it take to perform your morning routine?
\
d. Do you walk upstairs every day?e. Have you lost any weight lately?
\
a. What color is your sputum?
\
b. Do you have any difficulty sleeping?
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c. How long does it take to perform your morning routine?
\
d. Do you walk upstairs every day?e. Have you lost any weight lately?
b. Do you have any difficulty sleeping?
\
c. How long does it take to perform your morning routine?
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e. Have you lost any weight lately?
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c. How long does it take to perform your morning routine?
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e. Have you lost any weight lately?
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\*A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions should the nurse include in this client's plan of care? SATA
\
a. Ask the client to drink 2 liters of fluids daily.
\
b. Add humidity to the prescribed oxygen.
\
c. Suction the client every 2 to 3 hours.
\
d. Use a vibrating positive expiratory pressure device.
\
e. Encourage diaphragmatic breathing.
\
a. Ask the client to drink 2 liters of fluids daily.
\
b. Add humidity to the prescribed oxygen.
\
c. Suction the client every 2 to 3 hours.
\
d. Use a vibrating positive expiratory pressure device.
\
e. Encourage diaphragmatic breathing.
a. Ask the client to drink 2 liters of fluids daily.
\
b. Add humidity to the prescribed oxygen.
\
d. Use a vibrating positive expiratory pressure device.
\
b. Add humidity to the prescribed oxygen.
\
d. Use a vibrating positive expiratory pressure device.
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\*While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first?
\
a. Assess for drainage from the site.
\
b. Cover the insertion site with sterile gauze.
\
c. Contact the provider and obtain a suture kit.
\
d. Reinsert the tube using sterile technique.
\
a. Assess for drainage from the site.
\
b. Cover the insertion site with sterile gauze.
\
c. Contact the provider and obtain a suture kit.
\
d. Reinsert the tube using sterile technique.
b. Cover the insertion site with sterile gauze.
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\*A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take?
\
a. Ambulate the client in the hallway to promote deep breathing.
\
b. Auscultate the clients anterior and posterior lung fields.
\
c. Encourage the client to take shallow breaths to help with the pain.
\
d. Administer pain medication and encourage the client to take deep breaths.
\
a. Ambulate the client in the hallway to promote deep breathing.
\
b. Auscultate the clients anterior and posterior lung fields.
\
c. Encourage the client to take shallow breaths to help with the pain.
\
d. Administer pain medication and encourage the client to take deep breaths.
d. Administer pain medication and encourage the client to take deep breaths.
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\*A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax?
\
a. When the insertion site becomes red and warm to the touch
\
b. When the tube drainage decreases and becomes sanguineous
\
c. When the client experiences pain at the insertion site
\
d. When the tube becomes disconnected from the drainage system
\
a. When the insertion site becomes red and warm to the touch
\
b. When the tube drainage decreases and becomes sanguineous
\
c. When the client experiences pain at the insertion site
\
d. When the tube becomes disconnected from the drainage system
d. When the tube becomes disconnected from the drainage system
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\*A nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?
\
a. Strip the tubing to minimize clot formation and ensure patency.
\
b. Secure tubing junctions with clamps to prevent accidental disconnections.
\
c. Connect the chest tube to wall suction at the level prescribed by the provider.
\
d. Keep padded clamps at the bedside for use if the drainage system is interrupted.
\
a. Strip the tubing to minimize clot formation and ensure patency.
\
b. Secure tubing junctions with clamps to prevent accidental disconnections.
\
c. Connect the chest tube to wall suction at the level prescribed by the provider.
\
d. Keep padded clamps at the bedside for use if the drainage system is interrupted.
d. Keep padded clamps at the bedside for use if the drainage system is interrupted.
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\*A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurses immediate intervention? SATA
\
a. Production of pink sputum
\
b. Tracheal deviation
\
c. Pain at insertion sited. Sudden onset of shortness of breath
\
e. Drainage greater than 70 mL/hr
\
f. Disconnection at Y site
\
a. Production of pink sputum
\
b. Tracheal deviation
\
c. Pain at insertion sited. Sudden onset of shortness of breath
\
e. Drainage greater than 70 mL/hr
\
f. Disconnection at Y site
b. Tracheal deviation
\
d. Sudden onset of shortness of breath
\
e. Drainage greater than 70 mL/hr
\
f. Disconnection at Y site
\
d. Sudden onset of shortness of breath
\
e. Drainage greater than 70 mL/hr
\
f. Disconnection at Y site
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A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? SATA
\
a. Production of pink sputum
\
b. Tracheal deviation
\
c. Sudden onset of shortness of breath
\
d. Pain at insertion site
\
e. Drainage of 75 mL/hr
\
a. Production of pink sputum
\
b. Tracheal deviation
\
c. Sudden onset of shortness of breath
\
d. Pain at insertion site
\
e. Drainage of 75 mL/hr
b. Tracheal deviation
\
c. Sudden onset of shortness of breath
\
e. Drainage of 75 mL/hr
\
c. Sudden onset of shortness of breath
\
e. Drainage of 75 mL/hr
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\*An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?
\
a. I get short of breath when I climb stairs.
\
b. I see halos floating around my head
\
c. I have trouble remembering things
\
d. I have lost weight over the past month
\
a. I get short of breath when I climb stairs.
\
b. I see halos floating around my head
\
c. I have trouble remembering things
\
d. I have lost weight over the past month
a. I get short of breath when I climb stairs.
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\*A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond?
\
a. I will consult the provider to prescribe a sleep study to determine the problem.
\
b. You become hypoxic while sleeping; oxygen therapy via nasal cannula will help.
\
c. A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night.
\
d. Use pillows to elevate your head and chest while you are sleeping.
\
a. I will consult the provider to prescribe a sleep study to determine the problem.
\
b. You become hypoxic while sleeping; oxygen therapy via nasal cannula will help.
\
c. A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night.
\
d. Use pillows to elevate your head and chest while you are sleeping.
d. Use pillows to elevate your head and chest while you are sleeping.
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\*A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema?
\
a. I wake up to go to the bathroom at night.
\
b. My shoes fit tighter by the end of the day.
\
c. I seem to be feeling more anxious lately.
\
d. I drink at least eight glasses of water a day.
\
a. I wake up to go to the bathroom at night.
\
b. My shoes fit tighter by the end of the day.
\
c. I seem to be feeling more anxious lately.
\
d. I drink at least eight glasses of water a day.
b. My shoes fit tighter by the end of the day.
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A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. Which action should the nurse take next?
\
a. Administer intravenous diltiazem (Cardizem).
\
b. Assess vital signs and level of consciousness.
\
c. Administer sublingual nitroglycerin.
\
d. Assess capillary refill and temperature.
\
a. Administer intravenous diltiazem (Cardizem).
\
b. Assess vital signs and level of consciousness.
\
c. Administer sublingual nitroglycerin.
\
d. Assess capillary refill and temperature.
b. Assess vital signs and level of consciousness.
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\*A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client's teaching? SATA
\
a. Until your incision is healed, do not submerge your pacemaker. Only take showers.
\
b. Report any pulse rates lower than your pacemaker settings.
\
c. If you feel weak, apply pressure over your generator.
\
d. Have your pacemaker turned off before having magnetic resonance imaging (MRI).
\
e. Do not lift your left arm above the level of your shoulder for 8 weeks.
\
a. Until your incision is healed, do not submerge your pacemaker. Only take showers.
\
b. Report any pulse rates lower than your pacemaker settings.
\
c. If you feel weak, apply pressure over your generator.
\
d. Have your pacemaker turned off before having magnetic resonance imaging (MRI).
\
e. Do not lift your left arm above the level of your shoulder for 8 weeks.
a. Until your incision is healed, do not submerge your pacemaker. Only take showers.
\
b. Report any pulse rates lower than your pacemaker settings.
\
e. Do not lift your left arm above the level of your shoulder for 8 weeks.
\
b. Report any pulse rates lower than your pacemaker settings.
\
e. Do not lift your left arm above the level of your shoulder for 8 weeks.
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- Regular- 60-100 bpm
Normal Sinus Rhythm
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- Rate: 100-250- Dead rhythm- Treatment: CPR, defibrillation, code drugs
Ventricular Tachycardia
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- Dead rhythm- Treatment: CPR, shock, code meds
Ventricular Fibrillation
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* Atrial rate: over 350- Convert back to NSR
* S/S: palpitations, dizziness
* Meds: Cardizem and Coumadin
* S/S: palpitations, dizziness
* Meds: Cardizem and Coumadin
Atrial Fibrillation
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- Irregular- 150 bpm- Electrical cardioversion
Atrial Flutter
74
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- Atrial rate= 60-100- Ventricle rate=40-60- Lethal, medical emergency- External pace
Complete Heart Block (3rd degree):
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\*A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation?
\
a. A 45-year-old who takes an aspirin daily
\
b. A 50-year-old who is post coronary artery bypass graft surgery
\
c. A 78-year-old who had a carotid endarterectomy
\
d. An 80-year-old with chronic obstructive pulmonary disease
\
a. A 45-year-old who takes an aspirin daily
\
b. A 50-year-old who is post coronary artery bypass graft surgery
\
c. A 78-year-old who had a carotid endarterectomy
\
d. An 80-year-old with chronic obstructive pulmonary disease
b. A 50-year-old who is post coronary artery bypass graft surgery
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\*A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition?
\
a. Sinus tachycardia
\
b. Speech alterations
\
c. Fatigue
\
d. Dyspnea with activity
\
a. Sinus tachycardia
\
b. Speech alterations
\
c. Fatigue
\
d. Dyspnea with activity
b. Speech alterations
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A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition?
\
a. Sotalol (Betapace)
\
b. Warfarin (Coumadin)
\
c. Atropine (Sal-Tropine)
\
d. Lidocaine (Xylocaine)
\
a. Sotalol (Betapace)
\
b. Warfarin (Coumadin)
\
c. Atropine (Sal-Tropine)
\
d. Lidocaine (Xylocaine)
b. Warfarin (Coumadin)
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\*A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess?
\
a. Preventricular contractions
\
b. Atrial fibrillation
\
c. Symptomatic bradycardia
\
d. Sinus tachycardia
\
a. Preventricular contractions
\
b. Atrial fibrillation
\
c. Symptomatic bradycardia
\
d. Sinus tachycardia
b. Atrial fibrillation
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\*A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this client's concerns?
\
a. Administer oxygen therapy at 2 liters per nasal cannula.
\
b. Provide the client with a sleeping pill to stimulate rest.
\
c. Schedule periods of exercise and rest during the day.
\
d. Ask unlicensed assistive personnel to help bathe the client.
\
a. Administer oxygen therapy at 2 liters per nasal cannula.
\
b. Provide the client with a sleeping pill to stimulate rest.
\
c. Schedule periods of exercise and rest during the day.
\
d. Ask unlicensed assistive personnel to help bathe the client.
c. Schedule periods of exercise and rest during the day.
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\*A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion?
\
a. Administer intravenous adenosine.
\
b. Turn off oxygen therapy.
\
c. Ensure a tongue blade is available.
\
d. Position the client on the left side.
\
a. Administer intravenous adenosine.
\
b. Turn off oxygen therapy.
\
c. Ensure a tongue blade is available.
\
d. Position the client on the left side.
b. Turn off oxygen therapy.
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A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?
\
a. Mid-sternal chest pain
\
b. Increased urine output
\
c. Mild orthostatic hypotension
\
d. P wave touching the T wave
\
a. Mid-sternal chest pain
\
b. Increased urine output
\
c. Mild orthostatic hypotension
\
d. P wave touching the T wave
a. Mid-sternal chest pain
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\*A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below:Which action should the nurse take first?
\
a. Assess airway, breathing, and level of consciousness.
\
b. Administer an amiodarone bolus followed by a drip.
\
c. Cardiovert the client with a biphasic defibrillator.
\
d. Begin cardiopulmonary resuscitation (CPR).
\
a. Assess airway, breathing, and level of consciousness.
\
b. Administer an amiodarone bolus followed by a drip.
\
c. Cardiovert the client with a biphasic defibrillator.
\
d. Begin cardiopulmonary resuscitation (CPR).
a. Assess airway, breathing, and level of consciousness.
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A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client?
\
a. Make sure the defibrillator is set to synchronous mode.
\
b. Administer 1 mg of intravenous epinephrine.
\
c. Test the equipment by delivering a smaller shock at 100 joules.
\
d. Ensure that everyone is clear of contact with the client and the bed.
\
a. Make sure the defibrillator is set to synchronous mode.
\
b. Administer 1 mg of intravenous epinephrine.
\
c. Test the equipment by delivering a smaller shock at 100 joules.
\
d. Ensure that everyone is clear of contact with the client and the bed.
d. Ensure that everyone is clear of contact with the client and the bed.
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\*After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching?
\
a. I should wear a snug-fitting shirt over the ICD.
\
b. I will avoid sources of strong electromagnetic fields.
\
c. I should participate in a strenuous exercise program.
\
d. Now I can discontinue my antidysrhythmic medication.
\
a. I should wear a snug-fitting shirt over the ICD.
\
b. I will avoid sources of strong electromagnetic fields.
\
c. I should participate in a strenuous exercise program.
\
d. Now I can discontinue my antidysrhythmic medication.
b. I will avoid sources of strong electromagnetic fields.
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The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below:After calling for assistance and a defibrillator, which action should the nurse take next?
\
a. Perform a pericardial thump.
\
b. Initiate cardiopulmonary resuscitation (CPR).
\
c. Start an 18-gauge intravenous line.
\
d. Ask the clients family about code status.
\
a. Perform a pericardial thump.
\
b. Initiate cardiopulmonary resuscitation (CPR).
\
c. Start an 18-gauge intravenous line.
\
d. Ask the clients family about code status.
b. Initiate cardiopulmonary resuscitation (CPR).
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\*A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next?
\
a. Pulmonary auscultation
\
b. Pulse strength and amplitude
\
c. Level of consciousness
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d. Mobility and gait stability
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a. Pulmonary auscultation
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b. Pulse strength and amplitude
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c. Level of consciousness
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d. Mobility and gait stability
c. Level of consciousness
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\*A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse use?
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a. Standard Precautions
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b. Bleeding precautions
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c. Reverse isolation
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d. Contact isolation
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a. Standard Precautions
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b. Bleeding precautions
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c. Reverse isolation
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d. Contact isolation
a. Standard Precautions
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\*After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching?
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a. Ill be able to carry heavy loads after 6 months of rest.
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b. I will have my teeth cleaned by my dentist in 2 weeks.
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c. I must avoid eating foods high in vitamin K, like spinach.
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d. I must use an electric razor instead of a straight razor to shave.
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a. Ill be able to carry heavy loads after 6 months of rest.
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b. I will have my teeth cleaned by my dentist in 2 weeks.
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c. I must avoid eating foods high in vitamin K, like spinach.
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d. I must use an electric razor instead of a straight razor to shave.
b. I will have my teeth cleaned by my dentist in 2 weeks.
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\*A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? SATA
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a. Weight gain
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b. Night sweats
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c. Cardiac murmur
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d. Abdominal bloating
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e. Oslers nodes
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a. Weight gain
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b. Night sweats
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c. Cardiac murmur
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d. Abdominal bloating
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e. Oslers nodes
b. Night sweats
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c. Cardiac murmur
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e. Oslers nodes
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c. Cardiac murmur
\
e. Oslers nodes
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* Inflammatory disease of small intestine, colon, or both
* Skip lesions
* Fistula formation
* Steatorrhea
* Labs for anemia
* TPN
* Signs of infections, skin care\*
* Skip lesions
* Fistula formation
* Steatorrhea
* Labs for anemia
* TPN
* Signs of infections, skin care\*
Crohn's disease
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\*A nurse assesses a client who is hospitalized with an exacerbation of Crohn's disease. Which clinical manifestation should the nurse expect to find?
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a. Positive Murphys sign with rebound tenderness to palpitation
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b. Dull, hypoactive bowel sounds in the lower abdominal quadrants
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c. High-pitched, rushing bowel sounds in the right lower quadrant
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d. Reports of abdominal cramping that is worse at night
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a. Positive Murphys sign with rebound tenderness to palpitation
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b. Dull, hypoactive bowel sounds in the lower abdominal quadrants
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c. High-pitched, rushing bowel sounds in the right lower quadrant
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d. Reports of abdominal cramping that is worse at night
c. High-pitched, rushing bowel sounds in the right lower quadrant
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A nurse reviews the chart of a client who has Crohn's disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions?
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a. Serum potassium of 2.6 mEq/L
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b. Client ate 20% of breakfast meal
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c. White blood cell count of 8200/mm3
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d. Clients weight decreased by 3 pounds
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a. Serum potassium of 2.6 mEq/L
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b. Client ate 20% of breakfast meal
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c. White blood cell count of 8200/mm3
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d. Clients weight decreased by 3 pounds
a. Serum potassium of 2.6 mEq/L
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- Has a regular pattern, rest and medicine usually help
Stable angina
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- Most dangerous, does not follow a pattern and can happen without physical exertion
Unstable angina
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- Intermittent chest pain that occurs between midnight and the morning while you're asleep or resting
Variant angina
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- Chest pain occurs while resting or sleeping
Nocturnal angina
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* Chest pain resulting from insufficient blood flow to heart in which treatment with medication and heart surgery is insufficient or no longer effective
Intractable angina
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- Syndrome of ischemic chest pain occurring either at rest or during minimal activity 24 hours or more following an acute myocardial infarction
Post-infarction angina
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\*A nurse plans care for a client with Crohn's disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this client's plan of care?
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a. Low-fiber diet
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b. Skin protection
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c. Antibiotic administration
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d. Intravenous glucocorticoids
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a. Low-fiber diet
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b. Skin protection
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c. Antibiotic administration
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d. Intravenous glucocorticoids
b. Skin protection
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* Autoimmune abnormal response to normal flora in the bowel
* Hemorrhage
* Access formation
* Malabsorption/Dehydration
* Toxic mega colon
* Non mechanical bowel obstruction
* High protein, low fiber diet
* Monitor K+
* B12 supplementation
* Hemorrhage
* Access formation
* Malabsorption/Dehydration
* Toxic mega colon
* Non mechanical bowel obstruction
* High protein, low fiber diet
* Monitor K+
* B12 supplementation
Ulcerative Colitis