NCLEX RN Practice Questions 17

NCLEX RN Practice Questions 171. What’s the first intervention for a patient experiencing chest pain and an 5p02 of 89%? A. Administer morphine. B. Administer oxygen. C. Administer sublingual nitroglycerin. D. Obtain an electrocardiogram (ECC) 2. Which of the following signs and symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm? A. Abdominal pain. B. Absent pedal pulses. C. Chest pain. D. Lower back pain. 3. In which of the following types of cardiomyopathy does cardiac output remain normal? A. Dilated. B. Hypertrophic. C. Obliterative. D. Restrictive. 4. Which of the following interventions should be your first priority when treating a patient experiencing chest pain while walking? A. Have the patient sit down. B. Get the patient back to bed. C. Obtain an ECG. D. Administer sublingual nitroglycerin. 5. Which of the following positions would best aid breathing for a patient with acute pulmonary edema? A. Lying flat in bed. B. Left side-lying position. C. High Fowler’s position. D. Semi-Fowler’s position. 6. A pregnant woman arrives at the emergency department (ED) with abruptio placentae at 34 weeks’ gestation. She’s at risk for which of the following blood dyscrasias? A. Thrombocytopenia. B. Idiopathic thrombocytopenic purpura (ITP). C. Disseminated intravascular coagulation (DIC). D. Heparin-associated thrombosis and thrombocytopenia (HATT). 7. A 16-year-old patient involved in a motor vehicle accident arrives in the ED unconscious and severely hypotensive. He’s suspected to have several fracture of his pelvis and legs. Which of the following parenteral fluids is the best choice for his current condition? A. Fresh frozen plasma. B. 0.9% sodium chloride solution. C. Lactated Ringer’s solution. D. Packed red blood cells. 8. Corticosteroids are potent suppressors of the body’s inflammatory response. Which of the following conditions or actions do they suppress? A. Cushing syndrome. B. Pain receptors. C. Immune response. D. Neural transmission. 9. A patient infected with human immunodeficiency virus (HIV) begins zidovudine therapy. Which of the following statements best describes this drug’s action? A. It destroys the outer wall of the virus and kills it. B. It interferes with viral replication. C. It stimulates the immune system. D. It promotes excretion of viral antibodies. 10. A 20-year-old patient is being treated for pneumonia. He has a persistent cough and complains of severe pain on coughing. What could you tell him to hel him reduce his discomfort? A. "Hold your cough as much as possible." B. "Place the head of your bed flat to help with coughing." C. "Restrict fluids to help decrease the amount of sputum." D. "Splint your chest wall with a pillow for comfort." 11. A 19-year-old patient comes to the ED with acute asthma. His respiratory rate is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following actions should you take first? A. Take a full medical history. B. Give a bronchodilator by nebulizer. C. Apply a cardiac monitor to the patient. D. Provide emotional support for the patient. 12. A firefighter who was involved in extinguishing a house fire is being treated for smoke inhalation. He develops severe hypoxia 48 hours after the incident requiring intubation and mechanical ventilation. Which of the following conditions has he most likely developed? A. Acute respiratory distress syndrome (ARDS). B. Atelectasis. C. Bronchitis. D. Pneumonia. 13. Which of the following measures best determines that a patient who had a pneumothorax no longer needs a chest tube? A. You see a lot of drainage from the chest tube. B. Arterial blood gas (ABG) levels are normal. C. The chest X-ray continues to show the lung is 35% deflated. D. The water-seal chamber doesn’t fluctuate when no suction is applied. 14. Which of the following nursing interventions should you use to prevent footdrop and contractures in a patient recovering from a subdural hematoma? A. High-top sneakers. B. Low-dose heparin therapy. C. Physical therapy consultation. D. Sequential compressive device. 15. Which of the following signs of increased intracranial pressure (ICP) would appear first after head trauma? A. Bradycardia. B. Large amounts of very dilute urine. C. Restlessness and confusion. D. Widened pulse pressure. 16. When giving intravenous (I.V.) phenytoin, which of the following methods should you use? A. Use an in-line filter. B. Withhold other anticonvulsants. C. Mix the drug with saline solution only. D. Flush the I.V. catheter with dextrose solution. 17. After surgical repair of a hip, which of the following positions is best for the patient’s legs and hips? A. Abduction. B. Adduction. C. Prone. D. Subluxated. 18. Which of the following factors should be the primary focus of nursing management in a patient with acute pancreatitis? A. Nutrition management. B. Fluid and electrolyte balance. C. Management of hypoglycemia. D. Pain control. 19. After a liver biopsy, place the patient in which of the following positions? A. Left side-lying, with the bed flat. B. Right side-lying, with the bed flat. C. Left side-lying, with the bed in semi-Fowler’s position. D. Right side-lying, with the bed in semi-Fowler’s position. 20. Which of the following potentially serious complications could occur with therapy for hypothyroidism? A. Acute hemolytic reaction. B. Angina or cardiac arrhythmia. Placing the head of the bed flat may increase the frequency of his cough and his work of breathing. and restrictive cardiomyopathy all decrease cardiac output.9% sodium chloride is used to increase volume and blood pressure. 0. ITP doesn’t have a definitive cause. 3. No changes. The patient may not need cardiac monitoring because he’s only 19 years old. stabilizes lysosomal membranes. Dilated cardiomyopathy. a 32-year-old patient has a decreased hematocrit level. B Administering supplemental oxygen to the patient is the first priority. Less insulin. More insulin. 13. B The patient having an acute asthma attack needs more oxygen delivered to his lungs and body. The expansion applies pressure in the abdomen.C. 21. Albumin. C. Diabetes mellitus. D. Drainage should be minimal before the chest tube is removed. B. D The chest tube isn’t removed until the patient’s lung has adequately reexpanded and is expected to stay that way. Adequate fluid replacement and vasopressin replacement are objectives of therapy for which of the following disease processes? A. 9. B. and the pain is referred to the lower back. C Abruptio placentae is a cause of DIC because it activates the clotting cascade after hemorrhage. thus blocking the release of more inflammatory materials. Which of the following I. D Lower back pain results from expansion of the aneurysm. . Infection. C. Absent pedal pulses are a sign of no circulation and would occur after a ruptured aneurysm or in peripheral vascular disease. Lying flat and side-lying positions worsen breathing and increase the heart’s workload. 11. Diabetic ketoacidosis. 1. 8. Oral diabetic agents. 10.V. lymphocytes. 4. as a result. D. Sublingual nitroglycerin and morphine are commonly administered after oxygen. One indication of reexpansion is the cessation of fluctuation in the water-seal chamber when suction isn’t applied. On a follow-up visit after having a vaginal hysterectomy. Use a sterile swab to collect drainage from the dressing. D. 23. Abdominal pain is the most common symptom resulting from impaired circulation. fluids is given first? A. The drug doesn’t destroy the viral wall. A Severe hypoxia after smoke inhalation typically is related to ARDS. 12. making it easier for him to clear them. unless he has a medical history of cardiac problems. Administer oxygen to increase SpO2 to greater than 90% to help prevent further cardiac damage. Excessive corticosteroid therapy can lead to Cushing syndrome. Use a sterile swab and wipe the crusty area around the outside of the wound. B Zidovudine inhibits DNA synthesis in HIV. but too much of these crystalloids will dilute the blood and won’t improve oxygen-carrying capacity. C Corticosteroids suppress eosinophils. 5. C. D. D Showing this patient how to splint his chest wall will help decrease discomfort when coughing. Chest pain usually is associated with coronary artery or pulmonary disease. D. 6. B. The chest X-ray should show that the lung is reexpanded. C.9% sodium chloride solution with 2 mEq of potassium per 100 ml. Thrombocytopenia. D5W. and depresses phagocytosis of tissues by white blood cells. C. stimulate the immune system. 24. inhibiting the natural inflammatory process in an infected or injured part of the body. B Cardiac output isn’t affected by hypertrophic cardiomyopathy because the size of the ventricle remains relatively unchanged. Hematoma. Lactated Ringer’s solution. The other choices aren’t typically associated with smoke inhalation. Diabetes insipidus. Nebulized bronchodilators open airways and increase the amount of oxygen delivered. and natural-killer cells. A patient with abruptio placentae wouldn’t get heparin and. 2. Pulmonary embolus (PE). Administer sublingual nitroglycerin as you simultaneously do the ECG. A patient has partial-thickness burns to both legs and portions of his trunk. D In a trauma situation. Which of the following complications does this suggest? A. Lactated Ringer’s solution or 0. B. decreases capillary permeability. wouldn’t be at risk for HATT. the first blood product given is unmatched (0 negative) packed red blood cells. he can be returned to bed. An ABG test isn’t necessary if clinical assessment criteria are met. Increasing fluid intake will help thin his secretions. Fresh frozen plasma often is used to replace clotting factors. thus interfering with viral replication. Which of the following techniques is correct for obtaining a wound culture specimen from a surgical site? A. When the patient’s condition is stabilized. D. obliterative cardiomyopathy. 22. Hypovolemia. This helps resolve inflammation. C High Fowler’s position facilitates breathing by reducing venous return. Thrombocytopenia results from decreased production of platelets. or promote HIV antibody excretion. Thoroughly irrigate the wound before collecting the specimen. 7. Syndrome of inappropriate antidiuretic hormone secretion (SIADH). B. Patients with Type 1 diabetes mellitus may require which of the following changes to their daily routine during periods of infection? A. 25. A The initial priority is to decrease oxygen consumption by sitting the patient down. Holding in his coughs will only increase his pain. Retinopathy. Gently roll a sterile swab from the center of the wound outward to collect drainage. Symptoms of a PE include dyspnea. Terms . B Precipitation of angina or cardiac arrhythmia is a potentially serious complication of hypothyroidism treatment. administer the spironolactone. your priority is to manage hypovolemia and restore electrolyte balance. a delayed complication of abdominal and vaginal hysterectomy. B Rationale: The disease progression can be stopped or reversed by alcohol abstinence. not primary fluid replacement. b. administer the spironolactone. C During periods of infection or illness. Rationale: Spironolactone is a potassiumsparing diuretic and will help to increase the patient's potassium level. C Phenytoin is compatible only with saline solutions. keep the legs and hips abducted to stabilize the prosthesis in the acetabulum. The other positions won’t do this and may cause more bleeding at the site or internally. dextrose causes an insoluble precipitate to form. You needn’t withhold additional anticonvulsants or use an in-line filter. 16. C Rolling a swab from the center outward is the right way to obtain a culture specimen from a wound. vitamin B supplements. d. so specimens from these sites could give inaccurate results. although the health care provider should be notified about the low potassium value. but you can use high-top sneakers independently. long-term. A patient with cirrhosis who is being treated with spironolactone (Aldactone) and furosemide (Lasix) has a serum sodium level of 135 mEq/L (135 mmol/L) and serum potassium 3. Symptoms of hypovolemia include increased hematocrit and hemoglobin values. Irrigating the wound washes away drainage. the nurse should a. but the priority for this patient is to stop the progression of the disease. so potassium would be detrimental. Therefore. d.2 mEq/L (3. B Positioning the patient on his right side with the bed flat will splint the biopsy site and minimize bleeding. Patients are at risk for hyperglycemia. debris. A High-top sneakers are used to prevent footdrop and contractures in patients with neurologic conditions. Definitions C A 32-year-old patient has early alcoholic cirrhosis diagnosed by a liver biopsy. Fluid and electrolyte loss from vomiting is a major concern. An excess of antidiuretic hormone leads to SIADH. c. hemoptysis. Albumin is used as adjunct therapy. and signs of shock. 25. restlessness. Dextrose isn’t given to burn patients during the first 24 hours because it can cause pseudodiabetes. causing the patient to retain fluid. 22. 17. withhold both drugs until talking with the health care provider. Retinopathy typically is a complication of diabetes mellitus. 21. C Lactated Ringer’s solution replaces lost sodium and corrects metabolic acidosis. Acute hemolytic reaction is a complication of blood transfusions. maintenance of a nutritious diet. A A decreased hematocrit level is a sign of hematoma. Pain control and nutrition also are important. The patient is hyperkalemic from the potassium shift from the intracellular space to the plasma. abstinence from alcohol. The nurse does not need to talk with the doctor before giving the spironolactone.2 mmol/L). low-dose corticosteroids.2 mmol/L). C Rationale: Spironolactone is a potassium-sparing diuretic and will help to increase the patient's potassium level. c. patients with Type 1 diabetes may need even more insulin to compensate for increased blood glucose levels. b. When planning patient teaching. Before notifying the health care provider. give both drugs as scheduled.14. Diabetic ketoacidosis is a result of severe insulin insufficiency. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider. Thrombocytopenia doesn’t result from treating hypothyroidism. give both drugs as scheduled. c. withhold both drugs until talking with the health care provider. A After surgical repair of the hip. Before notifying the health care provider.2 mEq/L (3. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider. The patient may void a lot of very dilute urine if his posterior pituitary is damaged. 19. cough. chest pain. 15. administer the furosemide and withhold the spironolactone. 18. the nurse should a. the priority information for the nurse to include is the need for a. The nurse does not need to talk with the doctor before giving the spironolactone. administer the furosemide and withhold the spironolactone. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications. A patient with cirrhosis who is being treated with spironolactone (Aldactone) and furosemide (Lasix) has a serum sodium level of 135 mEq/L (135 mmol/L) and serum potassium 3. B Acute pancreatitis is commonly associated with fluid isolation and accumulation in the bowel secondary to ileus or peripancreatic edema. . d. b. 23. both of which commonly occur following a bur n. and many of the colonizing or infecting microorganisms. A consult with physical therapy is important to prevent footdrop. . not hypoglycemia. B Maintaining adequate fluid and replacing vasopressin are the main objectives in treating diabetes insipidus. The outside of the wound and the dressing may be colonized with microorganisms that haven’t affected the wound. Bradycardia and widened pulse pressure occur later. 20. C The earliest sign of increased ICP is a change in mental status. 24. although the health care provider should be notified about the low potassium value. nausea and vomiting. the nurse should assess the patient's interest in and ability to self-manage the diabetes. resulting in peritonitis. d. D. anxiety. but planning needs to be individualized to each patient. c. Which of the following disorders might the client develop? a. which will help in making other needed changes. "I hate to exercise! Can't I just follow the diet to keep my glucose under control?" The nurse teaches the patient that the major purpose of exercise for diabetics is to a. five to six hard candies such as Lifesavers. which will help with body image. C. assess the patient's perception of what it means to have type 2 diabetes. or 1 tablespoon of sugar. The nurse may also give two to three glucose tablets for a hypoglycemic reaction. Diverticulosis doesn't result from . which will decrease peripheral insulin resistance. the other nursing actions may be appropriate. When developing an education plan. and palpitations and tells the nurse he has type 1 diabetes mellitus. Which of the follow actions should the nurse do first? A. b. increase energy and sense of well-being. or 50 mL of 50% glucose I. Increased energy. A 1200-calorie diet and exercise are prescribed for a patient with newly diagnosed type 2 diabetes. demonstrate how to check glucose using capillary blood glucose monitoring. and abnormal liver function studies. exposure to children recently immunized for hepatitis B A and D assess for exposure to hepatitis. The patient tells the nurse. hepatomegaly. During assessment of the patient. facilitate weight loss. B. the use of all prescription and OTC (over the counter) medications C. Rationale: Exercise is essential to decrease insulin resistance and improve blood glucose control. but they are not the major reason. This could be 4 to 6 oz of fruit juice. discuss the need for the patient to actively participate in diabetes management.V.A 37-year-old forklift operator presents with shakiness. A client has just had surgery for colon cancer. Peritonitis b. and setting a pattern of success are secondary benefits of exercise. treatment of chronic diseases with corticosteriods D. Inject 1 mg of glucagon subcutaneously. Administer 50 mL of 50% glucose I. the nurse's first action should be to a. Correct answer: C Because the client is awake and complaining of symptoms. c. which will decrease peripheral insulin resistance.V. Hepatitis was ruled out this is inappropriate. sweating. the nurse should first give him 15 grams of carbohydrate to treat hypoglycemia. C is incorrect because corticosteroids do not commonly cause liver disease B is correct because overdose of medications can cause liver disease. improve cardiovascular endurance. When a client has worsening symptoms of hypoglycemia or is unconscious. Complete or partial bowel obstruction may occur before bowel resection. Serologic testing is negative for viral causes of hepatitis. b. which is important for diabetics. Peritonitis Bowel spillage could occur during surgery. treatment includes 1 mg of glucagon subcutaneously or intramuscularly. set a successful pattern. Diverticulosis a. A 60 year old patient has an abrupt onset of anorexia. any prior exposure to people with jaundice B. b. After assessing the patient. Give the client four to six glucose tablets. it is most important for the nurse to question the patient regarding A. improved cardiovascular endurance. A 63-year-old patient is newly diagnosed with type 2 diabetes. A Rationale: Before planning education. facilitate weight loss. ask the patient's family to participate in the diabetes education program. d. Give 4 to 6 oz (118 to 177 mL) of orange juice. The nurse would immediately prepare to initiate which of the following anticipated physician's orders? a) endotracheal intubation b) 100 units of NPH insulin c) intravenous infusion of normal saline d) intravenous infusion of sodium bicarbonate c) intravenous infusion of normal saline The primary goal of treatment in hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Correct answer: A An NG tube is no longer routinely inserted to treat pancreatitis. Which of the following recommendations would the nurse make to help the client increase calorie consumption to offset absorption problems? A Eating small meals with two or three snacks may be more helpful in maintaining blood glucose levels than three large meals. His past medical history reveals hyperlipidemia and alcohol abuse. Prevent air from forming in the small and large intestines.3°C). and he has been experiencing severe vomiting for 24 hours. respirations 22 breaths/minute. and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome is made. A client who recently underwent cranial surgery develops syndrome of inappropriate antidiuretic hormone (SIADH). Eat small meals with two or three snacks throughout the day to keep blood glucose levels steady c. the NG tube is inserted to drain fluids and gas and relieve vomiting. not NPH insulin. His blood pressure is 136/76 mm Hg. A client is brought to the emergency room in an unresponsive state. Increase consumption of simple carbohydrates d. Intravenous fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. temperature 99°F (38. The common bile duct connects to the pancreas and the gall bladder. The physician prescribes a nasogastric (NG) tube for the client. would be administered. Complete bowel obstruction surgery or colon cancer. Intubation and mechanical ventilation are not required to treat HHNS. D. Which of the following symptoms should the nurse Correct answer: A Syndrome of inappropriate antidiuretic hormone (SIADH) results in an abnormally . Which of the following is the primary purpose for insertion of the NG tube? A. Eating small meals with two or three snacks may be more helpful in maintaining blood glucose levels than three large meals. B. Regular insulin. b. and a T tube rather than an NG tube would be used to collect bile drainage from the common bile duct. Skip meals to help lose weight A client is admitted to the medical-surgical floor with a diagnosis of acute pancreatitis. but if the client has protracted vomiting. Empty the stomach of fluids and gas to relieve vomiting. Prevent spasms at the sphincter of Oddi. a. C. An NG tube doesn't prevent spasms at the sphincter of Oddi (a valve in the duodenum that controls the flow of digestive enzymes) or prevent air from forming in the small and large intestine. Partial bowel obstruction d. pulse 96 beats/minute. Remove bile from the gallbladder. A client has recently been diagnosed with Type I diabetes and asks the nurse for help formulating a nutrition plan.c. High-sodium diet. Excessive urinary output. the specific gravity increases. and after swimming. seizures. C. check glucose level before. encephalitis. b. The clinic nurse teaches the patient to a. D. Ambulate 100 ft. Fluid loss and dehydration. As the urine becomes more concentrated. c. Give sodium bicarbonate 50 mEq IV push. head trauma. C Rationale: The most urgent patient problem is the hypovolemia associated with DKA. A diabetic patient is admitted with ketoacidosis and the health care provider writes all of the following orders. The other actions can be accomplished after the infusion of normal saline is initiated. BID. and the priority is to infuse IV fluids. Edema and weight gain. A college student who has type 1 diabetes normally walks each evening as part of an exercise regimen. Fluid is restricted to prevent fluid overload rather than replaced. thereby decreasing the fluid that accumulates in the peritoneal space. Restrict fluid to 1000 mL per day. C. A client with cirrhosis of the liver develops ascites. The nurse will plan to teach the patient about mealtime coverage using B Rationale: Rapid or short acting insulin is used for mealtime coverage for patients . Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia. increase the morning dose of neutral protamine Hagedorn (NPH) insulin on days of the swimming class. A high sodium diet would increase fluid retention. Because of fluid retention. It may also be triggered by medications. Infuse 1 liter of normal saline per hour. and after swimming. patients are advised to eat before exercising. Which of the following orders would the nurse expect? A. D. Which order should the nurse implement first? a. The student now plans to take a swimming class every day at 1:00 PM. meningitis. d. Loop diuretics (such as furosemide) are usually ordered. especially with the increased exercise. altered mentation. and coma. three times per day.O. d. Maalox 30 ml P. c. vomiting. A diabetic patient is started on intensive insulin therapy. Administer regular IV insulin 30 U. d. during. urine output is low. and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. B. Because exercise tends to decrease blood glucose. and Maalox® (a bismuth subsalicylate) may interfere with the action of the diuretics. b. delay eating the noon meal until after the swimming class. Physical activities are usually restricted until ascites is relieved. Rationale: The change in exercise will affect blood glucose. Restricting fluids decreases the amount of fluid present in the body. Low urine specific gravity. or brain tumors. Correct answer: A Fluid restriction is a primary treatment for ascites.anticipate? A. during. SIADH is most common with diseases of the hypothalamus but can also occur with heart failure. leading to edema and weight gain. Guillain-Barré syndrome. high release of antidiuretic hormone. Other symptoms include nausea. which causes water retention as serum sodium levels fall. Start an infusion of regular insulin at 50 U/hr. B. check glucose level before. time the morning insulin injection so that the peak occurs while swimming. establishing a stable home environment. A health care provider who has not been immunized for hepatitis B is exposed to the hepatitis B virus (HBV) through a needle stick from an infected patient. d. The client's intake has been very poor. so the best option is for the patient to have lunch at the . The D Rationale: Consistency for mealtimes assists with regulation of blood glucose. d. The infection control nurse informs the individual that treatment for the exposure should include a. usually is caused by absent or markedly decreased amounts of insulin. Insulin resistance has developed. Diabetic ketoacidosis is occurring. hepatitis B immune globulin (HBIG) injection. Hyperglycemic hyperosmolar non-ketotic coma Illness. Diabetic ketoacidosis. fatigue. especially with the frail elderly patient whose appetite is poor. A hospitalized diabetic patient receives 12 U of regular insulin mixed with 34 U of NPH insulin at 7:00 AM. both the hepatitis B vaccine and HBIG injection. which would provide temporary passive immunity and promote active immunity. a. The patient is away from the nursing unit for diagnostic testing at noon. increasing activity level. Finding a home for the patient and identifying the source of the infection would be appropriate activities. A Rationale: The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Although the patient's activity level will be gradually increased. Hyperglycemic hyperosmolar non-ketotic coma daily insulin requirement of 200 units or more. A frail elderly patient with a diagnosis of type 2 diabetes mellitus has been ill with pneumonia. rest is indicated during the acute phase of hepatitis. give 50% dextrose as a bolus. b. b. and hepatomegaly is diagnosed with viral hepatitis and has just been admitted to the hospital. Insulin resistance usually is indicated by a a. c. Antibody testing may also be done. c. jaundice. but this would not provide protection from the exposure. acting insulin. administer glargine (Lantus) insulin. insert a large-bore IV catheter. c. baseline hepatitis B antibody testing now and in 2 months. glargine receiving intensive insulin therapy._____ insulin. A homeless patient with severe anorexia. Regular insulin is administered. What is the most likely problem with this patient? d. can result in dehydration and HHNC. b. D Rationale: The recommended treatment for exposure to hepatitis B in unvaccinated individuals is to receive both HBIG and the hepatitis B vaccine. or detemir will be used as the basal insulin. c. when lunch trays are distributed. In planning care for the patient. Dextrose solutions will increase the patient's blood glucose and would be contraindicated. but they do not have as high a priority as having adequate nutrition. NPH. b. d. the nurse assigns the highest priority to the patient outcome of a. glargine. Hypoglycemia unawareness is developing. identifying the source of exposure to hepatitis. A diagnosis of hyperglycemic hyperosmolar nonketotic coma (HHNC) is made for a patient with type 2 diabetes who is brought to the emergency department in an unresponsive state. The nurse will anticipate the need to C Rationale: HHNC is initially treated with large volumes of IV fluids to correct hypovolemia. maintaining adequate nutrition. There is no indication that the patient requires oxygen. lispro c. not a long- a. and she is admitted to the hospital for observation and management as needed. detemir d. d. an acute metabolic condition. initiate oxygen by nasal cannula. NPH b. active immunization with hepatitis B vaccine. d. A Answer: A . NPH insulin will not peak until mid-afternoon and is safe to take before a morning run." b. Position to a right side-lying position. "Plan to eat breakfast about an hour before your run. c. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items. A newly diagnosed type 1 diabetic patient likes to run 3 miles several mornings a week. Position in a dorsal recumbent position. Administer immune globulin and the HCV vaccine. b. calcium. Which teaching will the nurse implement about exercise for this patient? a. d. A patient hospitalized with possible acute pancreatitis has severe abdominal pain and nausea and vomiting. bilirubin. c. C Rationale: Amylase is elevated early in acute pancreatitis. Teach the patient that the HCV will resolve in 2 to 4 months. A Rationale: Genotyping of HCV has an important role in managing treatment and is done before drug therapy with -interferon or other medications is started. A patient is admitted to the hospital with a diagnosis of primary hyperparathyroidism. d. Running can be done in either the morning or afternoon." c. the patient should postpone the run. c. Instruct the patient on self-administration of -interferon. Which nursing care plan reflects proper care? c. with one pillow under the head b. call the diagnostic testing area and ask that a 5% dextrose IV be started. "Afternoon running is less likely to cause hypoglycemia. Changes in bilirubin. The nurse would expect the diagnosis to be confirmed with laboratory testing that reveals elevated serum a. usual time. calcium." B Rationale: Blood sugar increases after meals. with a pressure dressing over the biopsy site c. and potassium levels are not diagnostic for pancreatitis. "You should not take the morning NPH insulin before you run. Position to a right side-lying position. so this will be the best time to exercise. If the glucose is very elevated. b. B ed rest is only required for several hours. A patient in the outpatient clinic has positive serologic testing for anti-HCV. Waiting to eat until after the procedure is likely to cause hypoglycemia. b. with a pillow under the biopsy site d." d. Neurological checks of lower extremities every hour position with a pillow under the biopsy site reflects proper care. A nurse cares for a client following a liver biopsy.most appropriate action by the nurse is to a. Immune globulin or vaccine is not available for HCV. amylase. Schedule the patient for HCV genotype testing. Answer 1 does not permit the necessary pressure applied to the biopsy site. Administration of an IV solution is unnecessarily invasive for the patient. "You may want to run a little farther if your glucose is very high. request that the patient be returned to the unit to eat lunch if testing will not be completed promptly. There is no reason to do neurological checks. HCV has a high percentage of conversion to the chronic state so the nurse should not teach the patient that the HCV will resolve in 2 to 4 months. with a pillow under the biopsy site Positioning the client in a right side-lying a. save the lunch tray to be provided upon the patient's return to the unit. ensure that the patient drinks a glass of milk or orange juice at noon in the diagnostic testing area. potassium. Which action by the nurse is appropriate? a. Bed rest for 24 hours. clammy skin an pulse of 110 b. level will be elevated. lethargic with hot dry dkin and rapid deep respirations c. the nurse observes the man performing blood sugar analysis. Urine calcium may be elevated. Low serum parathyroid hormone (PTH). nausea and vomiting.nurse checking the patient's lab results would expect which of the following changes in laboratory findings? The parathyroid glands regulate the calcium level in the blood. short of breath. B. and the ABRUPT onset of symptoms suggest toxic hepatitis. and abnormal liver function studies. and check blood sugar qid. D. Which question by the nurse is most appropriate? a. hepatomegaly. headache and polyuria c. "Have you been around anyone with jaundice?" b. diaphoresis and trembling d. "Do you use any prescription or over-thecounter (OTC) drugs?" c. The nurse would be MOST concerned if which of the following was observed? a. and as cells rupture they release organic acids into the blood. A patient newly diagnosed with Type I DM is being seen by the home health nurse. Elevated serum calcium. "Is there any history of IV drug use?" B Rationale: The patient's symptoms. Corticosteroid use does not cause the symptoms listed. the serum calcium A. Low urine calcium. kussmaul respirations and diaphoresis b. In hyperparathyroidism. The best response by the nurse is that a. diaphoresis and trembling indicates hypoglycemia A patient recovering from DKA asks the nurse how acidosis occurs. Exposure to a jaundiced individual and a history of IV drug use are risk factors for VIRAL hepatitis. A patient is admitted with an abrupt onset of jaundice. C. b. a. When the nurse visits the patient at 5 pm. "Are you taking corticosteroids for any reason?" d. 15 units NPH insulin before breakfast. which can be caused by commonly used OTC drugs such as acetaminophen (Tylenol). The nurse would expect the patient to be a. This may cause renal stones. The doctors orders include: 1200 calorie ADA diet. Elevated serum vitamin D. confused with cold. Parathyroid hormone levels may be high or normal but not low. Serologic testing is negative for viral causes of hepatitis. The body will lower the level of vitamin D in an attempt to lower calcium. . alert and cooperative with BP of 130/80 and respirations of 12 d. confused with cold. lack of antibodies for hepatitis. with calcium spilling over from elevated serum levels. with distended neck veins and bounding pulse of 96. The result is 50 mg/dL. The other responses are inaccurate. anorexia and lethargy c. clammy skin an pulse of 110 hypoglycemia A patient received 6 units of REGULAR INSULIN 3 hours ago. insufficient insulin leads to cellular starvation. when an insulin deficit causes D Rationale: Ketoacidosis is caused by the breakdown of fat stores when glucose is not available for intracellular metabolism. 7 mmol/L). The other outcomes are also appropriate but are not as high in priority. d. c.hyperglycemia. A patient who has just been diagnosed with type 2 diabetes is 5 ft 4 in (160 cm) tall and weighs 182 pounds (82 kg). Intensive insulin therapy is not confined to type 2 diabetics and would prevent microvascular changes as well as macrovascular changes. A patient who is admitted with acute hepatic encephalopathy and ascites receives instructions about appropriate diet. . an omelet with cheese and mushrooms and b. pancakes with butter and honey and orange juice. b. The patient will have a diet and exercise plan that results in weight loss. use of low doses of regular insulin. A nursing diagnosis of imbalanced nutrition: more than body requirements is developed. b. Which patient outcome is most important for this patient? a. maintenance of a healthy weight. causing acidic by-products. an insulin deficit promotes metabolism of fat stores. D Rationale: The patient's impaired fasting glucose indicates pre-diabetes and the patient should be counseled about LIFESTYLE CHANGES to prevent the development of type 2 diabetes. d. d. oral hypoglycemic medications. The patient will state the reasons for eliminating simple sugars in the diet. A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dl (6. A previous episode of ketoacidosis is not a contraindication for intensive insulin therapy. The nurse determines that the teaching has been effective when the patient's choice of foods from the menu includes a. c. an insulin pump provides the best glucose control and requires about the same amount of attention as intensive insulin therapy. A patient using a split mixed-dose insulin regimen asks the nurse about the use of intensive insulin therapy to achieve tighter glucose control. excess glucose in the blood is metabolized by the liver into acetone. then proteins are deaminated by the liver. which produces large amounts of acidic ketones. B Rationale: The patient with acute hepatic encephalopathy is placed on a LOW-protein diet to decrease ammonia levels. Intensive insulin therapy and an insulin pump are comparable in glucose control. The patient will choose a diet that distributes calories throughout the day. and the most important patient outcome is the reduction of glucose to near-normal levels. c. b. A Rationale: Patients using intensive insulin therapy must check their glucose level four to six times daily and administer insulin accordingly. The nurse will plan to teach the patient about a. self-monitoring of blood glucose. The patient will have a glycosylated hemoglobin level of less than 7%. intensive insulin therapy requires three or more injections a day in addition to an injection of a basal long-acting insulin. The nurse should teach the patient that a. d. C Rationale: The complications of diabetes are related to elevated blood glucose. studies have shown that intensive insulin therapy is most effective in preventing the macrovascular complications characteristic of type 2 diabetes. The patient with prediabetes does not require insulin or the oral hypoglycemics for glucose control and does not need to self-monitor blood glucose. intensive insulin therapy is indicated only for newly diagnosed type 1 diabetics who have never experienced ketoacidosis. c. which is acidic. controlling bleeding. baked chicken with french-fries. The pancreatic enzymes that precipitate the pancreatitis are not removed by NG suction.milk. b. A Rationale: The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. reduction of pancreatic enzymes. A patient with cancer of the liver has severe ascites. b. assists the patient to lie flat in bed. In planning care for the patient.2 mEq/L (3. A patient with cirrhosis has a massive hemorrhage from esophageal varices. The health care provider is responsible for obtaining informed consent. d. d. The airway is compromised by the bleeding in the esophagus and aspiration easily occurs. pancakes with butter and honey and orange juice. positions the patient on the right side. In addition. Fluid and electrolyte imbalances will be caused by NG suction and require that the patient receive IV fluids to prevent this. albumin level. d. baked beans with ham. asks the patient to empty the bladder. but this is not the major reason for these treatments. The patient's nausea and vomiting may decrease. B Rationale: The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of ascites and edema. c. relieving the patient's anxiety. the nurse a. c. c. b. The patient's most recent laboratory results indicate a serum sodium of 134 mEq/L (134 mmol/L) and a serum potassium of 3. The data indicate that it is most important for the nurse to monitor the patient's a. b. hemoglobin. low-fiber bread. relief from nausea and vomiting. while spironolactone is potassium sparing. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. b. but they are not as high a priority as airway maintenance. maintenance of the airway. administer only the spironolactone The potassium level is dangerously low. d. removal of the precipitating irritants. A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. To prepare the patient for the procedure. reduction of pancreatic enzymes. Rationale: Pancreatic enzymes are released when the patient eats.2 mmol/L). cornbread. control of fluid and electrolyte imbalance. but they are not contributing factors to the patient's current symptoms. C. c. activity level. A patient with cirrhosis is being treated with spironolactone (Aldactone) tid and furosemide (Lasix) bid. NG suction and NPO status decrease the release of these enzymes. and the health care provider plans a paracentesis to relieve the fluid pressure on the diaphragm. The other choices are all higher in protein and would not be as appropriate for this patient. You would hold the Lasix and call the physician. This is a good . and tea. The nurse explains to the patient that the major purpose of this treatment is a. temperature. the patient's ascites indicate that a low-sodium diet is needed and the other choices are all high in sodium. and coffee. d. maintenance of fluid volume. c. potatoes. A patient with cirrhosis has 4+ pitting edema of the feet and legs and massive ascites. c. the nurse gives the highest priority to the goal of a. The other goals would also be important for this patient. B Rationale: Maintaining gas exchange has the highest priority because oxygenation is essential for life. obtains informed consent for the procedure. Lasix is potassium depleting. The other parameters should also be monitored. administer both drugs as ordered C. C Rationale: The blood in the GI tract will be absorbed as protein and may result in an increase in ammonia level since the liver cannot metabolize protein well. "I will eat meals as scheduled. administer only the spironolactone D. A patient with type 1 diabetes has received diet instruction as part of the treatment plan. and potassium levels should also be monitored. even if I am not hungry. chooses a puncture site in the center of the finger pad. as long as I use enough insulin to cover the calories. To detect possible complications of the bleeding episode. limit intake to non-calorie-containing liquids until the glucose is within the usual range. monitor blood glucose every 4 hours and notify the clinic if it continues to rise. Withhold the furosemide and spironolactone NCLEX question that integrates this course with pharmacology. c. b." D Rationale: Most patients with type 1 diabetes need to plan diet choices very carefully." c. the nurse advises the patient to a. B Rationale: Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently." b. b. The prothrombin time." d.Before notifying the physician. a. treat elevations appropriately with insulin. the nurse identifies a need for additional teaching when the patient a. d. The nurse determines a need for additional instruction when the patient says. it is most important for the nurse to monitor a. ammonia levels. potassium levels. says the result of 130 mg indicates good blood sugar control. administer only the furosemide B. bilirubin. but these will not be affected by the bleeding episode. hangs the arm down for a minute before puncturing the site. and call the health care provider if glucose levels continue to be elevated. and alcohol. The other patient actions indicate that teaching has been effective. "I will need a bedtime snack because I take an evening dose of NPH insulin. and fever. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%. use only the lispro insulin until the symptoms of infection are resolved. "I may have an occasional alcoholic drink if I include it in my meal plan. bilirubin levels. b. Discontinuing the glargine will contribute to hyperglycemia and may lead to DKA. d. Decreasing carbohydrate or caloric intake is not appropriate as the patient will need more calories when ill. c. d. A patient with severe cirrhosis has an episode of bleeding esophageal varices. Glycosylated hemoglobins are not used to . A patient with type 1 diabetes who uses glargine (Lantus) and lispro (Humalog) insulin develops a sore throat. to prevent hypoglycemia. A Rationale: The patient is taught to choose a puncture site at the side of the finger pad. c. A patient with type 1 diabetes has been using self-monitoring of blood glucose (SMBG) as part of diabetes management. When the patient calls the clinic to report the symptoms and a blood glucose level of 210 mg/dl. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat. the nurse should A. During evaluation of the patient's technique of SMBG. washes the puncture site using soap and water. "I may eat whatever I want. The other patient statements are correct and indicate good understanding of the diet instruction. cough. protein. prothrombin time. a. in warm water daily. c. Heating pad use should be avoided. The nurse teaches the patient that B Rationale: The patient is taught to avoid high heels and that leather shoes are preferred. The nurse will anticipate that the patient may a. d. the nurse will tell the patient that a. Which information obtained by the nurse when admitting the patient indicates a need for a change in the patient's regimen? B Rationale: To avoid lactic acidosis. the glycosylated hemoglobin will be elevated. The patient takes metformin (Glucophage) every morning. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. Elevated insulin levels do not cause the damage to blood vessels that can occur with IFG. the health care provider prescribes prednisone (Deltasone) to control inflammation. A program of weight loss and exercise is recommended for a patient with impaired fasting glucose (IFG). b. which will eventually exhaust the ability of the pancreas to produce insulin. Glycosylated hemoglobin levels will not be elevated in IFG and the Hb A1C test is not included in prediabetes testing. require administration of insulin while taking prednisone. the liver is producing excessive glucose. A patient with type 2 diabetes that is controlled with diet and metformin (Glucophage) also has severe rheumatoid arthritis (RA). A patient with type 2 diabetes is scheduled for an outpatient coronary arteriogram. the patient should see a specialist to treat these problems. over-the-counter (OTC) callus remover may be used to remove callus and prevent pressure. The other patient data indicate that the a. but it will be important to avoid weight gain for the patient with RA. the high insulin levels associated with this syndrome damage the lining of blood vessels. Commercial callus and corn removers should be avoided. The patient's most recent hemoglobin A1C was 6%. d. The liver does not produce increased levels of glucose in IFG . The feet should be washed. b. d. but not soaked. The patient is likely to have an increased appetite when taking prednisone. but this risk can be decreased with lifestyle changes. develop acute hypoglycemia during the RA exacerbation. c.test for short-term alterations in blood glucose. c. Hypoglycemia is not a complication of RA exacerbation or prednisone use. During an acute exacerbation of the patient's arthritis. A patient with type 2 diabetes has sensory neuropathy of the feet and legs and peripheral vascular disease evidenced by decreased peripheral pulses and dependent rubor. The patient's admission blood glucose is 128 mg/dl. heating pads should always be set at a very low temperature. A Rationale: Glucose levels increase when patients are taking CORTICOsteroids. patient is managing the diabetes appropriately. need a diet higher in calories while receiving prednisone. leading to vascular disease. b. When teaching the patient about the reason for these lifestyle changes. The patient uses captopril (Capoten) for hypertension. and insulin may be required to control blood glucose. b. flat-soled leather shoes are the best choice to protect the feet from injury. c. have rashes caused by metforminprednisone interactions. although the fasting plasma glucose levels do not currently indicate diabetes. the feet should be soaked in warm water on a daily basis. and exercise will D Rationale: The patient with IFG is at risk for developing type 2 diabetes. metformin should not be used for 48 hours after IV contrast media are administered. Although a prescription for ostomy supplies is needed. "Do you notice any bloating feeling after eating?" d. Instructing the client to report redness. which action by the patient indicates that the teaching has been successful? a. Nothing can be done about the concerns of odor with the appliance. Freezing alters the insulin molecule and should not be done. Information appropriate for this intervention would include: a. The patient disposes of the open insulin vials after 4 weeks. but these are not associated with autonomic neuropathy. If the patient can feel painful areas on the feet. swelling. Glargine should not be mixed with other insulins or prefilled and stored. neuropathy has not occurred. d." Which question by the nurse will help identify a possible reason for the patient's hypoglycemic unawareness? a. the onset of diabetes and the associated cardiovascular risks can be delayed or prevented by weight loss and exercise. or pain at the site to the physician for evaluation of infection b. you can order the supplies from any medical supplier. fever. which would also cause delayed gastric emptying. b. After having a transverse colostomy constructed for colon cancer. The appliance will not be needed when traveling. fever. Instructing the client to report redness. c. There are supplies avaliable for clients to help control odor that may be incurred because of the ostomy. "Have you observed any recent skin changes?" c.normalize glucose production. The patient stores extra vials of both types of insulin in the freezer until needed. . A thirty five year old male has been an insulin-dependent diabetic for five years and now is unable to urinate. appliances are almost always worn throughout the day and when traveling After the home health nurse has taught a patient and family about how to use glargine and regular insulin safely. Dependent on the location and trainability of the ostomy. actions are not appropriate. The patient draws up the regular insulin in the syringe and then draws up the glargine. discharge planning for home care would include teaching about the ostomy appliance. Which of the following would you most likely suspect? A: Atherosclerosis B: Diabetic nephropathy C: Autonomic neuropathy D: Somatic neuropathy C: Autonomic neuropathy A type 1 diabetic patient who was admitted with severe hypoglycemia and treated tells the nurse. although adrenergic blockers can prevent patients from having symptoms of hypoglycemia. swelling. or pain at the site to the physician for evaluation of infection Signs and symptoms for monitoring infection at the ostomy site are a priority evaluation for clients with new ostomies. Skin changes can occur with diabetes. Calcium-channel blockers are not associated with hypoglycemic unawareness. The patient's family prefills the syringes weekly and stores them in the refrigerator. c. d. Ordering appliances through the client's health care provider d. A Rationale: Insulin can be stored at room temperature for 4 weeks. "Do you use any calcium-channel blocking drugs for blood pressure?" b. "Have you noticed any painful new ulcerations or sores on your feet?" C Rationale: Hypoglycemic unawareness is caused by autonomic neuropathy. The remaining a. "I did not have any of the usual symptoms of hypoglycemia. A Rationale: The hypokalemia associated with metabolic acidosis can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation. A1C levels of 6. b. and the client can self-administer a bolus with an additional dose form the pump before each meal dose of regular insulin subcutaneously throughout the day and night. The nurse bases the response on the information that the pump: D. Regular insulin is used in an insulin pump. fluid overload resulting from aggressive fluid replacement. Blood sugar is well controlled when Hemoglobin A1C is: a. but cardiac monitoring would not detect theses. which in turn releases the insulin into the bloodstream d) gives a small continuously dose of regular insulin subcutaneously. A Rationale: Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain. The nurse recognizes that this measure is important to identify a. A1C of 6% to 6. d. which would be detected with ECG monitoring. Used as a diagnostic tool. Between 12%-15% c. client newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. Amitriptyline will help prevent the transmission of pain impulses to the brain.5% is considered prediabetes. and the client can self-administer a bolus with an additional dose from the pump before each meal as needed. Amitriptyline will improve sleep and make you less aware of nighttime pain. Tricyclics also improve sleep quality and are used for depression. b. d.Amitriptyline (Elavil) is prescribed for a diabetic patient with peripheral neuropathy who has burning foot pain occurring mostly at night.5% or higher on two tests indicate diabetes. Cardiac monitoring is initiated for a patient in diabetic ketoacidosis (DKA).) gives a small continuously dose of regular insulin subcutaneously. An external insulin pump is prescribed for a client with diabetes mellitus and the client asks the nurse about the functioning of the pump. hypovolemia. Between 90 and 130 mg/dL that is glycated and determines average blood glucose during the 2 to 3 months prior to testing. A nurse prepares a discharge teaching plan regarding the insulin and plans d) systematically rotate insulin injections within one anatomic site Insulin doses should not be adjusted nor . but that is not the major purpose for their use in diabetic neuropathy. cardiovascular collapse resulting from the effects of hyperglycemia. c. the presence of hypovolemic shock related to osmotic diuresis. Fluid overload. and the client can self-administer a bolus with an additional dose form the pump before each meal An insulin pump provides a small continuous a) is timed to release programmed doses of regular or NPH insulin into the bloodstream at specific intervals b) continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels c) is surgically attached to the pancreas and infuses regular insulin into the pancreas. Less than 180 mg/dL d. Which information should the nurse include when teaching the patient about the new medication? a. An external pump is not attached surgically to the pancreas. and cardiovascular collapse are possible complications of DKA. Below 7% A1c measures the percentage of hemoglobin a. electrocardiographic (ECG) changes and dysrhythmias related to hypokalemia. c. Amitriptyline will correct some of the blood vessel changes that cause pain. The blood vessel changes that contribute to neuropathy are not affected by tricyclics. Below 7% b. Amitriptyline will decrease the depression caused by the pain. d. Approximately 40% to 50% should be from complex carbohydrates. If ketones are found in the urine. Monitor the patient for shortness of breath. Research provides no evidence that carbohydrates from simple sugars are digested and absorbed more rapidly than are complex carbohydrates. The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis. In addition. c. hemorroids c. b. The health care provider inserts the tube and verifies the position. d. the esophageal balloon may slip upward and occlude the airway. < 130 mg/dl Intramuscular glucagon is administered to an unresponsive patient for treatment of hypoglycemia. it possibly may indicate the need for additional insulin. but if the gastric balloon is deflated. Injection sites should be rotated systematically within one anatomic site. but having a . the nurse tells the client that 50% to 60% of daily calories should come from carbohydrates. < 130 mg/dl c. <80 mg/dl b. <6% b. ulcerative colitis Chronic ulcerative colitis. The other conditions listed have no known effect on the colon cancer risk. and they do not appear to affect blood sugar control. which nursing action will be included in the plan of care? a. the esophageal balloon may occlude the airway. Monitor the patient for shortness of breath.to reinforce which of the following concepts? a) always keep insulin vials refrigerated b) ketones in the urine signify a need for less insulin c) increase the amount of insulin before unusual exercise d) systematically rotate insulin injections within one anatomic site increased before unusual exercise. Simple sugars should never be consumed by someone with diabetes. Try to limit simple sugars to between 10% and 20% of daily calories. he goal for pre-prandial blood glucose for those with Type 1 diabetes mellitus is: a. During a teaching session. if the gastric balloon ruptures. Simple carbohydrates are absorbed more rapidly than complex carbohydrates. b. Rationale: The most common complication of balloon tamponade is aspiration pneumonia. <180 mg/dl d. Encourage the patient to cough and deep breathe. hiatal hernia d. c. During treatment of a patient with a Minnesota balloon tamponade for bleeding esophageal varices. ulcerative colitis familial polyps seem to increase a person's chance of developing colon cancer. What should the nurse say about the types of carbohydrates that can be eaten? a. appendicitis b. Colon cancer is most closely associated with which of the following conditions? d. The remaining 10% to 20% of carbohydrates could be from simple sugars. Which action should the nurse take after the patient regains consciousness? A Rationale: Rebound hypoglycemia can occur after glucagon administration. Simple sugars cause a rapid spike in glucose levels and should be avoided c. and a. To minimize the discomfort associated with insulin injections. D It is recommended that carbohydrates provide 50% to 60% of the daily calories. insulin should be administered at room temperature. Deflate the gastric balloon q8-12hr. Insert the tube and verify its position q4hr. Coughing increases the pressure on the varices and increases the risk for bleeding. granulomas. performing frequent mouth care. protein and fat will help prevent hypoglycemia. Administration of glucose intravenously might be used in patients who were unable to take in nutrition orally. Decrease the client's need for insulin c. d. Release insulin evenly throughout the day and control basal glucose levels. evaluating capillary refill in extremities. Liver biopsy: Right side position post procedure to prevent patient from bleeding. L. Release insulin evenly throughout the day and control basal glucose levels. Perineal itching d. the nurse caring for Mr. The nurse recognizes that these interventions will: a. While the balloon tamponade is in place. NG tube to low intermittent suction. d. Reduce the secretion of pancreatic enzymes b. Anorexia b. An Esophageal Balloon Tamponade tube was inserted to tamponade the bleeding esophageal varices. Give the patient a snack of cheese and crackers. Physician's orders for a client with acute pancreatitis include the following: strict NPO.meal containing complex carbohydrates plus a. b. auscultating breath sounds. Glargine (Lantus) insulin is designed to a. Prevent secretion of gastric acid d. has a seven-year history of hepatic cirrhosis. Assess the patient for symptoms of hyperglycemia. He was brought to the emergency room because he began vomiting large amounts of dark-red blood. assessing his stools for occult blood. gives the highest priority to a. Release insulin rapidly throughout the day to help control basal glucose. d. Have the patient drink a glass of orange juice or nonfat milk. Cause hypoglycemia with other manifestation of other adverse reactions. c. L. but the cheese and crackers will stabilize blood sugar. Rationale: Airway obstruction and aspiration of gastric contents are potential serious complications of balloon tamponade. Administer a continuous infusion of 5% dextrose for 24 hours. auscultating breath sounds. Eliminate the need for analgesia a. c. The patient should be assessed for symptoms of hypoglycemia after glucagon administration. b. Orange juice and nonfat milk will elevate blood sugar rapidly. Mr. Reduce the secretion of pancreatic enzymes . Pain intolerance c. Frequent assessment of the client's respiratory status is the priority. c. c. Weight loss d. release insulin evenly throughout the day and control basal glucose levels. Perineal itching One of the benefits of Glargine (Lantus) insulin is its ability to: b. b. Simplify the dosing and better control blood glucose levels during the day. Of which of the following symptoms might an older woman with diabetes mellitus complain? a. Native Hawaiians. history of gestational diabetes. and Native Americans are at greater risk of developing diabetes than whites. Laser surgery abnormal blood vessels in an effort to preserve vision. Olestra and Oatrim are fat replacers and tannin is an acid found in some foods such as tea. Fluorescein angiogram c. Obesity c. Radiation therapy is used to treat colon cancer before surgery for which of the following reasons? a. The client tells the nurse that the client really misses having sugar with tea in the morning. Reducing the size of the tumor b. it is used to detect macular edema. A fluorescein angiogram is a diagnostic test that traces the flow of dye through the blood vessels in the retina. Weight loss and increasing physical activity can help people with prediabetes prevent or postpone the onset of type 2 diabetes. Risk factors for type 2 diabetes include all of the following except: a. it is removed in a procedure known as vitrectomy. When there is significant bleeding in the eye. phenylalanine and aspartic acid. Physical inactivity C: smoking Additional risk factors for type 2 diabetes are a family history of diabetes.Prediabetes is associated with all of the following except: a. a. impaired glucose metabolism. saturated fat and cholesterol . Hispanics/Latinos. Advanced age b. and race/ethnicity. Pacific Islanders. Increased risk of heart disease and stroke d. Eliminating the malignant cells c. The guidelines for Carbohydrate Counting as medical nutrition therapy for diabetes mellitus includes all of the following EXCEPT: b. can't eliminate the malignant cells (though it helps define tumor margins). Increased risk of developing type 2 diabetes b. Helping the bowel heal after surgery a. tannin The doctor is interested in how well a client has controlled their blood glucose since their last visit. Antibiotics d. Asian Americans. Laser surgery Scatter laser treatment is used to shrink a. Impaired glucose tolerance c. Reducing the size of the tumor Radiation therapy is used to treat colon cancer before surgery to reduce the size of the tumor. What lab values could the nurse evaluate to determine how well the client has controlled their blood glucose over the past three months? C HbgA1c is a blood test used to determine how well blood glucose has been controlled for the last three months. Tonometry b. Radiation therapy isn't curative. making it easier to be resected. African-Americans. Increased risk of developing type 1 diabetes D: Increased risk of developing type 1 diabetes Persons with elevated glucose levels that do not yet meet the criteria for diabetes are considered to have prediabetes and are at increased risk of developing type 2 diabetes. can could slow postoperative healing. sucralose b. Oatrim c. Tonometry is a diagnostic test that measures pressure inside the eye. Smoking d. Unlimited intake of total fat. Proliferative retinopathy is often treated using: d. Olestra d. C Aspartame is the generic name for a sweetener composed of two amino acids. Curing the cancer d. What is an alternative that the nurse could advise them to help sweeten their drink. turn the patient every 4 hours. hyperglycemia. and peripheral neuropathy are signs of cirrhosis that aren't relieved or treated by paracentesis. Unlimited intake of total fat. The client has developed ascites and requires a paracentesis. Lactated Ringer's solution c. d. Dietary protein intake may be increased in patients with ascites to improve oncotic pressure. A Rationale: Muscle twitching and finger numbness indicate hypocalcemia. The other data indicate other complications of acute pancreatitis but are not indicators of electrolyte imbalance.a. vegetables and the dairy group d. Turning the patient every 4 hours will not be adequate to maintain skin integrity. paralytic ileus and abdominal distention. restrict dietary protein intake. Hypothermia related to slowed metabolic rate . jaundice. 0. 5% dextrose in water (D5W) The nurse identifies a nursing diagnosis of risk for impaired skin integrity for a patient with cirrhosis who has ascites and 4+ pitting edema of the feet and legs.45% normal saline solution a. Applicable to with either Type 1 or Type 2 diabetes mellitus The nurse assisting in the admission of a client with diabetic ketoacidosis will anticipate the physician ordering which of the following types of intravenous solution if the client cannot take fluids orally? a. D. B Rationale: The pressure-relieving mattress will decrease the risk for skin breakdown for this patient.9 normal saline solution d. Correct answer: B Ascites (fluid buildup in the abdomen) puts pressure on the diaphragm. c. perform passive range of motion QID. Passive range of motion will not take pressure off areas like the sacrum that are vulnerable to breakdown. muscle twitching and finger numbness. c. saturated fat and cholesterol c. Jaundice. The nurse is caring for a client with cirrhosis of the liver. resulting in difficulty breathing and dyspnea. The nurse is caring for a patient with a diagnosis of hypothyroidism. Peripheral neuropathy. arrange for a pressure-relieving mattress. Which nursing diagnosis should the nurse most seriously c. Which of the following symptoms is associated with ascites and should be relieved by the paracentesis? A. b.45% normal saline solution b. Paracentesis (surgical puncture of the abdominal cavity to aspirate fluid) is done to remove fluid from the abdominal cavity and thus reduce pressure on the diaphragm in order to relieve the dyspnea. An appropriate nursing intervention for this problem is to a. 0. hypotension. The nurse identifies the collaborative problem of potential complication: electrolyte imbalance for a patient with severe acute pancreatitis. Dyspnea. d. Flexibility in types and amounts of foods consumed b. Pruritus. 0. b. B. Assessment findings that alert the nurse to electrolyte imbalances associated with acute pancreatitis include a. a potential complication of acute pancreatitis. Including adequate servings of fruits. Pruritus. C. A decrease in the client's daily weight of one (1) pound. ANS: A. Diarrhea related to increased peristalsis c. An increase in abdominal girth of two (2) inches. the liver is unable to metabolize protein adequately. High risk for aspiration related to severe vomiting b. This causes problems such as hepatic encephalopathy (neurologic syndrome that develops as a result of rising blood ammonia levels). Oral mucous membrane. In liver failure. such as fat and carbohydrates. A decrease in the serum direct bilirubin to 0. The nurse is caring for patients in the student health center. b. Determine exposure before implementing. . meaning that the client's condition is becoming more serious and should be reported to the health-care provider. and does predispose the older adult to a host of other health-related issues. Correct answer: A Meats and beans are high-protein foods and are restricted with liver failure. C. Cakes and pastries. An increase in urine output after administration of a diuretic. Potatoes and pasta. The nurse is caring for the client diagnosed with ascites from hepatic cirrhosis. What information should the nurse report to the health-care provider? c. causing protein by-products to build up in the body rather than be excreted. "You'll receive the Hepatitis B immune globulin HBIG d. A patient confides to the nurse that the patient's boyfriend informed her that he tested positive for Hepatitis B. may be regulated. and regular soft drinks should be avoided. B. The nurse is educating a pregnant client who has gestational diabetes. but not in excessive amounts. b. Weight gain should continue. injections may be necessary. Cakes.consider when analyzing the needs of the patient? Thyroid hormone deficiency results in reduction in the metabolic rate. would indicate that the ascites is increasing.6 mg/dL. Rationale: An increase in abdominal girth a. Meats and beans. D Gestational diabetes can occur between the 16th and 28th week of pregnancy. candies. An increase in abdominal girth of two (2) inches. Hypothermia related to slowed metabolic rate d. Concentrated sugars should be avoided. C. insulin a. "That must have been a real shock to you" b. Which of the following statements should the nurse make to the client? Select all that apply. D. Hepatitis B is transmitted through parenteral drug abuse and sexual contact. Which of the following foods should the nurse advise them to limit in the client's diet? A. "Have you had unprotected sex with your boyfriend" D. If not responsive to diet and exercise. resulting in hypothermia. c. Although other nutrients. d. Butter and gravies. cookies. it's most important to limit protein in the diet of the client with liver failure. Which of the following responses by the nurse is BEST? a. "You should be tested for Hepatitis B" c. Gestational diabetes increases the risk that the mother will develop diabetes later in life. altered related to disease process One quarter of affected elderly experience constipation. a. B. The nurse is doing teaching with the family of a client with liver failure. High calorie. fluid and electrolyte balance c. It is MOST important for the nurse to instruct the patient about: a. Which of the following goals for the client which if met. Which procedure will increase the blood flow to the area to ensure an adequate specimen? a. e. However. low carbohydrate b. The mother should strive to gain no more weight during the pregnancy. Raise the hand on a pillow to increase venous flow. gestational diabetes disappears after the infant is born. low fat The nurse is working with an overweight client who has a high-stress job and smokes. Lose a pound a week until weight is in normal range for height and exercise 30 minutes daily C. Gestational diabetes usually resolves after the baby is born. steroid replacement d. Pierce the skin with the lancet in the middle of the finger pad.c. Usually. The baby will likely be born with diabetes f. The nurse is planning dietary changes for a client following an episode of pancreatitis. Lose a pound a week until weight is in normal range for height and exercise 30 minutes daily When type II diabetics lose weight through diet and exercise they sometimes have an improvement in insulin efficiency sufficient to the degree they no longer require oral hypoglycemic agents. Wrap the finger in a warm cloth for 30-60 seconds. low fat c. This client has just received a diagnosis of Type II Diabetes and has just been started on an oral hypoglycemic agent. Pierce the skin at a 45-degree angle. Wrap the finger in a warm cloth for 30-60 seconds. Low calorie. high carbohydrate b. Low protein. seizure precautions d. Which diet is suitable for the client? a. . d. signs and symptoms of infection b. c. The nurse is having difficulty obtaining a capillary blood sample from a client's finger to measure blood glucose using a blood glucose monitor. steroid replacement steroid replacement is the most important information the client needs to know. high fat d. b. would be most likely to lead to an improvement in insulin efficiency to the point the client would no longer require oral hypoglycemic agents? a. Quit the use of any tobacco products by the end of three months c. Comply with medication regimen 100% for 6 months b. c. High protein. The nurse is performing discharge teaching for a patient with Addison's disease. The hand is lowered to increase venous flow. The finger is pierced lateral to the middle of the pad perpendicular to the skin surface. diabetes can develop 5 to 10 years after the pregnancy. d. High calorie. Insulin injections may be necessary. the nurse would be concerned that the client would develop what complication? A When a client's carbohydrate consumption is inadequate ketones are produced from the breakdown of fat. the nurse asks the patient to a. c. acidosis b. arm. d. extend both arms. a. The nurse realizes that diagnostic criteria developed by the American Diabetes Association for diabetes include classic diabetic symptoms plus which of the following fasting plasma glucose levels? a. "How long have you felt anorexic?" d. b. buttock. These ketones lower the pH of the blood. Higher than 140 mg/dl d. atherosclerosis c. In this instance. a classic sign of hepatic encephalopathy. D Rationale: Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The patient is thirsty but does not necessarily crave sugar.d. glycosuria d. thigh. When assessing the patient experiencing the onset of symptoms of type 1 diabetes. Practice relaxation techniques for at least five minutes five times a day for at least five months The nurse teaches the diabetic patient who rides a bicycle to work every day to administer morning insulin into the a. Greater than 126 mg/dl c. Greater than 106 mg/dl b. Higher than 160 mg/dl Thyroidectomy: Semi Fowler and avoid hyperflexion and hyperextension of the neck When a client learned that the symptoms of diabetes were caused by high levels of blood glucose the client decided to stop eating carbohydrates. Higher than 160 mg/dl d. potentially causing acidosis that can lead to a diabetic coma. "Have you lost any weight lately?" b. The thigh. The other tests might also be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy. The nurse working in the physician's office is reviewing lab results on the clients seen that day. which question should the nurse ask? a. and arm are all exercised by riding a bicycle. d. b. c.containing fluids. One of the clients who has classic diabetic symptoms had an eight-hour fasting plasma glucose test done. Increased appetite is a classic symptom of type 1 diabetes. stand on one foot. retinopathy When assessing the neurologic status of a patient with a diagnosis of hepatic encephalopathy. ambulate with the eyes closed. "Is your urine unusually dark-colored?" A Rationale: Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. With the classic symptom of . abdomen. perform the Valsalva maneuver. C Rationale: Extending the arms allows the nurse to check for asterixis. "Do you crave fluids containing sugar?" c. buttock. An increase in three areas: thirst. d. alcohol use. and leg ulcers. A woman who is at 90% of standard body weight after delivering an eight-pound baby b. c. the nurse asks the patient specifically about a history of A. and prevent bearing down during bowel movements (which could lead to esophageal bleeding). and high-protein diets are not risk factors. . polyphagia (increased hunger). the nurse will recommend routine screening for diabetes when the person has one or more of seven risk criteria. diabetes mellitus D. weight gain. and. Certain races but not including Caucasian. A client with an HDL cholesterol level of 40 mg/dl and a triglyceride level of 300 mg/dl The seven risk criteria include: greater than 120% of standard body weight. rapid weight gain. wound healing. b. When lactulose (Cephulac) 30 ml QID is ordered for a patient with advanced cirrhosis. HDL greater than 35 mg/dl or a. The nurse explains to the patient that it is still important to take the drug because the lactulose will d. c. diabetes. promote fluid loss. intake of fluids. diabetes mellitus. and depression d. improve nervous system function. When working in the community. Cigarette smoking. Although the medication may promote fluid a. and hunger The primary manifestations of diabetes type I are polyuria (increased urine output). urine will be very dilute. Which of the following persons that the nurse comes in contact with most needs to be screened for diabetes based on the seven risk criteria? d. prevent constipation. An increase in three areas: thirst. the patient complains that it causes diarrhea. c. improve nervous system function. Lack of energy. prevent constipation. lastly. Which of the following manifestations are considered the primary manifestations of diabetes type I and would be most suggestive of diabetes type I and require follow-up investigation? a. B Rationale: Alcohol use is one of the most common risk factors for pancreatitis in the United States. Rationale: The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. high-fat dietary intake Answer: B pancreatitis is associated with alcoholism When taking a health history. smoking B. d. the medication is not ordered for these purposes for this patient. alcohol use C. and hunger D. loss through the stool. impaired glucose tolerance or impaired fasting glucose on prior testing. When obtaining a health history from a patient with acute pancreatitis. b. A middle-aged Caucasian male triglyceride level greater than 250 or a triglyceride level of greater than 250 mg/dl. Poor circulation.polyuria. the nurse screens for manifestations suggestive of diabetes type I. high-protein diet. prevent gastrointestinal (GI) bleeding. Excessive intake of calories. hypertensive. cigarette smoking. the nurse asks the patient specifically about a history of a. intake of fluids. polydipsia (increased thirst). When obtaining a health history from a patient with acute pancreatitis. delivery of a baby weighing more than 9 pounds or a diagnosis of gestational diabetes. and difficulty losing weight b. Alphaglucosidase inhibitors block the breakdown of starches and some sugars.) a. Carbohydrates and protein aren't necessarily associated with colon cancer. Biguanides Biguanides. HbA1C evaluates long-term glucose control. Finger stick glucose three times daily include FPG and OGTT. appropriate testing would a. Age over 45 years b. low fiber. There is an increase in atherosclerosis with DM due to the metabolic syndrome and sedentary lifestyle. low fat high fiber c. Two-hour Oral Glucose Tolerance Test (OGTT) c. Abdominal x-ray and CT scan can help establish tumor size and metastasis. A LOW FAT HIGH FIBER diet is recommended to help avoid colon cancer. low carb. A client with an HDL cholesterol level of 40 mg/dl and a triglyceride level of 300 mg/dl Which laboratory test should a nurse anticipate a physician would order when an older person is identified as high-risk for diabetes mellitus? (Select all that apply. Age over 45 years b. high fat b. Sulfonylureas and Meglitinides stimulate the beta cells of the pancreas to produce more insulin. high protein increases the chance of constipation. The OGTT is to determine how the body responds to the ingestion of carbohydrates in a meal. Biguanides d. Fecal occult blood test d.) a. A FPG greater than 140 mg/dL usually indicates diabetes. which can be removed before they become malignant. Which of the following factors are risks for the development of diabetes mellitus? (Select all that apply. Which of the following diets is most commonly associated with colon cancer? a. Fasting Plasma Glucose (FPG) b. Colonoscopy d. Maintaining a sedentary lifestyle Aging results in reduced ability of beta cells a. A colonoscopy can help locate a tumor as well as polyps. a. Sulfonylureas b. high fat low fiber. Overweight with waist/hip ratio increase is part of the metabolic syndrome of DM II. The metabolic end products of this type of diet are carcinogenic. Glycosylated hemoglobin (HbA1C) d. Which of the following diabetes drugs acts by decreasing the amount of glucose produced by the liver? a. high fat diet reduced motility and a. Fecal occult blood test Surface blood vessels of polyps and cancers are fragile and often bleed with the passage of stools. which helps to reduce blood glucose levels Which of the following diagnostic tests should be performed annually over age 50 to screen for colon cancer? a. Two-hour Oral Glucose Tolerance Test (OGTT) When an older person is identified as highrisk for diabetes. Abdominal x-ray c. low protein. . lower blood glucose by reducing the amount of glucose produced by the liver. Maintaining a sedentary lifestyle to respond with insulin effectively. Meglitinides c. Abdominal CT scan b. high carb d. A finger stick glucose three times daily spotchecks blood glucose levels. Fasting Plasma Glucose (FPG) b. Alpha-glucosidase inhibitors c. Overweight with a waist/hip ratio >1 c.c. such as metformin. An older client who is hypotensive d. Overweight with a waist/hip ratio >1 d. low fiber. Having a consistent HDL level above 40 mg/dl d. An increase in body temperature with colon cancer is a change in bowel habits. Age-specific prevalence of diagnosed diabetes mellitus (DM) is higher for AfricanAmericans and Hispanics than for Caucasians. black women had the highest incidence. A change in bowel habits The most common complaint of the client a. d. Hispanic male. Asian woman. This syndrome occurs mainly in people with Type I Diabetes B. diabetes mellitus. d.8% b. Noon blood glucose of 52 mg/dl c. African-American woman. An increase in body weight d. Which of the following persons would most likely be diagnosed with diabetes mellitus? A 44-year-old: c. A change in bowel habits c. b. It is a medical emergency and has a higher mortality rate than Diabetic A. This condition develops very slowly over hours or days. A change in appetite b. Which of the following symptoms is a client with colon cancer most likely to exhibit? b. secondary abdominal distention. c. Patients who take insulin and engage in strenuous physical exercise might experience hyperglycemia. The client may have anorexia. and give the patient some carbohydrate-containing beverage such as orange juice. Physical exercise can slow the progression of diabetes mellitus. Pinch the skin up and use a 90 degree . a. Insulin and foods both must be adjusted to allow safe participation in exercise. Hemoglobin A1C of 5. c. Strenuous exercise can cause retinal damage. b. The other values are within an acceptable range for a diabetic patient. Adjusting insulin regimen allows for safe participation in all forms of exercise. Among those younger than 75. Physical exercise slows the progression of a. It has a higher mortality rate than Diabetic Ketoacidosis HHNS occurs only in people with Type II Diabetes. Fever isn't associated with colon cancer. Which of the following things must the nurse working with diabetic clients keep in mind about Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)? B. The client with HHNS is in a state of overhydration D. or weight loss.9% d. African-American woman. It has a higher mortality rate than Diabetic Ketoacidosis C.Which of the following is accurate pertaining to physical exercise and type 1 diabetes mellitus? a. Which of these laboratory values noted by the nurse when reviewing the chart of a diabetic patient indicates the need for further assessment of the patient? a. Physical exercise can slow the progression of diabetes mellitus. Caucasian woman. Which one of the following a. Glycosylated hemoglobin of 6. Fasting blood glucose of 130 mg/dl b. because exercise has beneficial effects on carbohydrate metabolism and insulin sensitivity. This condition develops very rapidly Ketoacidosis. Strenuous exercise is beneficial when the blood glucose is high. Noon blood glucose of 52 mg/dl The nurse should assess the patient with a blood glucose level of 52 mg/dl for symptoms of hypoglycemia. and can cause hypoglycemia. Explaining the risks and benefits of the exam b. While hospitalized and recovering from an episode of diabetic ketoacidosis. obtain a glucose reading using a finger stick. Nurse Jay is performing wound care. Candy bars contain fat. Massage the area of injection after injecting the insulin D. which would slow down the absorption of sugar and delay the response to treatment. While preparing the client for a colonoscopy. Instructing the client about medication that will be used to sedate the client d. As long as you only drink two beers and take one aspirin. the nurse should a. b. Aspirin and alcohol will cause the stomach to bleed more when on a sulfonylurea drug d. Instructing the client about the bowel preparation prior to the test The nurse is responsible for instructing the a. Taking alcohol and/or aspirin with a sulfonylurea drug can cause development of hypoglycemiaD. 1. and sweaty.Considering a 1″ edge around the sterile field as being contaminated C. nervous. Which of the following practices violates surgical asepsis? A. During the acute phase of a burn.Alcohol use . Use a 45 degree angle with the skin pinched up C. have the patient drink 4 ounces of orange juice. 4 are the physician's responsibility. the nurse's responsibilities include: b. The client mentions that he usually has a couple of beers each night and takes an aspirin each day to prevent heart attack and/or strokes. have the patient eat a candy bar. such as orange juice.Holding sterile objects above the waist B. c. The area is not massaged and it is not necessary to warm it. the patient calls the nurse and reports feeling anxious. Which of the following responses would be best on the part of the nurse? a. The aspirin is alright but you need to give up drinking any alcoholic beverages c.Opening the outermost flap of a sterile package away from the body 2. the patient should ingest a rapid-acting carbohydrate.Client’s lifestyle B. this should not be a problem b. Pinch the skin up and use a 90 degree angle B. Instructing the client about the bowel preparation prior to the test c. Based on the patient's report. A Rationale: The patient's clinical manifestations are consistent with hypoglycemia and the initial action should be to check the patient's glucose with a finger stick or order a stat blood glucose. d. If the glucose is low.methods/techniques will the nurse use when giving insulin to a thin person? [Hint] A. Warm the skin with a warmed towel or washcloth prior to the injection angle The best angle for a thin person is 90 degrees with the skin pinched up. the nurse in-charge should assess which of the following? A. Glucagon might be given if the patient's symptoms become worse or if the patient is unconscious.Pouring solution onto a sterile field cloth D. administer 1 mg glucagon subcutaneously. 3. Taking alcohol and/or aspirin with a sulfonylurea drug can cause development of hypoglycemia Alcohol and/or aspirin taken with a sulfonylurea can cause development of hypoglycemia. You are doing some teaching with a client who is starting on a sulfonylurea antidiabetic agent. Answers 1. Explaining the results of the exam client about the bowel preparation prior to the test. Full-thickness skin loss C.Cold compress to the affected area B. which intervention should the nurse include in the plan of care? A. or muscle D. The clinic nurse notes that the physician has documented a diagnosis of herpes zoster (shingles) in the male client’s chart.An irregular shaped lesion B. Which activity should she perform first? A.A fiery red skin with edema in the nail beds C.A client who is unable to move about and is confined to bed 9. Nurse Ivy is implementing a teaching plan to a group of adolescents regarding the causes of acne. The clinic nurse assesses the skin of a white characteristic is associated with this skin disorder? A. The nurse determines that which of the following individuals is at the greatest risk for development of an integumentary disorder? A.A firm."A preoperative medication will be given so you will be sleeping and will not feel any pain” .An outdoor construction worker 20. Nurse May is caring for an elderly bedridden adult. and sacral regions 11.Put on latex gloves.Silvery-white scaly patches on the scalp.Slide the client.A generalized body rash C. The appropriate response by the nurse is: A.A pink.A client incontinent of urine feces B.An individual who has experienced a significant amount of emotional distress 8. tendon.A 32 year-old-African American B.Related to fat emboli B. Which of the following would the nurse expect to note on assessment of the client’s sac ral area? A.Apply ice to the site to prevent discomfort C. B. The nurse prepares to care for a male client with acute cellulites of the lower leg.Intact skin B.Related to circumferential eschar 6. which of the following would the nurse expect to note during the assessment? A. edematous hand B.Apply alcohol-soaked dressing twice a day D.Oily skin and no episodes of pruritus D. when turning.“There is no pain associated with this procedure” B.Slowly remove the soiled dressing C. Which of the following characteristics would the nurse expect to note when assessing the lesions of this infection? A.Sacrum C. The nurse understands that which body area would provide the best assessment? A. Which of the following should the nurse include in the instruction? A.Exposed bone.Skin biopsy C.Woo’s light examination 12. The nurse is assigned to care for a female client with herpes zoster (Shingles). Nurse Jane formulates a nursing diagnosis of Impaired physical mobility for a client with third-degree burns on the lower portions of both legs.C. The nurse prepares discharge instructions for a male client following cryosurgery for the treatment of a malignant skin lesion. the nurse should add which “related-to” phrase? A. rather than lifting.Red-purplish scaly lesions C. Which of the following would the nurse note on assessment of the client’s hand? A.A fiery red.A client with a family history of the disorder D.Earlobes D.Red shiny skin around the nail bed B. To prevent pressure ulcers.Patch test B.“The local anesthetic may cause a burning or stinging sensation” C.A pearly papule with a central crater and a waxy border 14.“The actual cause is not known” C.Black fingertips surrounded by an erythematous rash D. Which of the following is an appropriate nursing statement regarding the cause of this disorder? A. which is insensitive to touch 17.White taut skin in the popliteal area C.Post a turning schedule at the client’s bedside.Clean the site with hydrogen peroxide to prevent infection 15. 4. A male client arrives at the emergency room and has experienced frostbites to the right hand.An adolescent B. Based on an understanding of the cause of this disorder. nodular lesion topped with crust D. Based on this di agnosis.“Acne is caused as a result of exposure to heat and humidity” 19.An older female C.Related to infection C. elbow.Partial-thickness skin loss of the dermis 18. knees.Turn and reposition the client at least once every 8 hours. Nurse Carl reviews the client’s chart and notes that the physician has documented a diagnosis of paronychia. The nurse is reviewing the health care record of a male clients scheduled to be seen at the health care clinic.Intermittent heat lamp treatments four times daily D. the nurse in-charge most likely expects to note which of the following? A.Assess the drainage in the dressing.A woman experiencing menopause C.White silvery patches on the elbows D. Which of the following clients would least likely be at risk of developing skin breakdown? A.Clear.A small papule with a dry. the nurse determines that this definitive diagnosis was made following which diagnostic test? A.Alternating hot and cold compresses continuously 10.Warm compress to the affected area C.Avoid showering for 7 to 10 days B.A physical education teacher D. Nurse Kate is changing a dressing and providing wound care. edematous rash on the cheeks 13. The evening nurse reviews the nursing documentation in the male client’s chart and notes that the day nurse has documented th at the client has a stage II pressure ulcer in the sacral area.“Acne is caused by oily skin” B.Swelling of the skin near the parotid gland 16.A client with chronic nutritional deficiencies C. The nurse anticipates that which of the following will be prescribed for the client? A. D.Tobacco use D. rough scale C.Wash hands thoroughly.Clustered skin vesicles B. Which of the following individuals is least likely to be at risk of developing psoriasis? A.Related to femoral artery occlusion D.Vigorously massage lotion into bony prominences. 5. To complete the nursing diagnosis statement. The nurse is assessing for the presence of cyanosis in a male dark-skinned client.Lips B. When assessing a lesion diagnosed as malignant melanoma. C.A white color to the skin.“Acne is caused by eating chocolate” D. B. D. A male client schedule for a skin biopsy is concerned and asks the nurse how painful the procedure is.A client with decreased sensory perception D.Culture of the lesion D. thin nail beds B.Circulatory status 3.Small blue-white spots with a red base D.Back of the hands 7. he will restrict: A. The nurse expects that these lesions will appear to be: A.Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg B. Which of the following statements by the client indicates effective teaching? A.leukocytosis C.D.Candida albicans . While in a skilled nursing facility. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. The client understands postoperative care of artificial skin when he states that during the first 7 days after the procedure. D.Purpura 28. which is diagnosed the day after discharge. The nurse is assessing a male client admitted with second.Purpura B.Shaped like an arc D.Ring-shaped B.and third-degree burns on the face.“Just be careful not to share linens and towels with family members.“I’ll make sure that the bandage is wrapped tightly. An older client’s physical examination reveals the presence of a number of bright red-colored lesions scattered on the trunk and tights.Cherry angioma B.” D.going outdoors. The nurse would document this finding most accurately using which of the following terms? A.” B.swelling 24. a male client is treated with artificial skin.Staphylococcus epidermidis B. Following a full-thickness (third-degree) burn of his left arm.Rectal temperature of 100. but the physician will prescribe an opioid analgesic following the procedure” 21. The nurse interprets that this finding is consistent with early manifestations of which of the following disorders? A.“I’ll eat plenty of fruits and vegetables.erythema B.Perncious anemia C.” C. The nurse reading the culture report understands that which of the following organisms is not part of the normal flora of the skin? A. family members won’t be at risk for contracting scabies. tell him to see a physician right away. A male client seen in an ambulatory clinic has a butterfly rash across the nose.“If someone develops symptoms.“My foot should feel cold. “What should my family do?” The most accurate response from the nurse is: A.” 25.pressurelike pain.protein intake C. and chest. Which finding indicates a potential problem? A. a male client develops fever and anemia. where six other persons are living.“After you’re treated. D. During her visit to the clinic.Urine output of 20 ml/hour C.” D.“I’ll limit my intake of protein.” C.Spider angioma C.” B.Petechiae C.Linear C. The nurse interprets that this indicates which of the following lesions due to alterations in blood vessels of the skin? A.Staphylococcus aureus C.” 22. A female client exhibits s purplish bruise to the skin after a fall.fluid ingestion 23.Ecchymosis D.“There is some pain. A nurse is reviewing the medical record of a male client to be admitted to the nursing unit and notes documentation of reticular skin lesions.“All family members will need to be treated. she asks a staff nurse.Cardiopulmonary disorders D. arms. The nurse is teaching a female client with a leg ulcer about tissue repair and wound healing. Following a small-bowel resection.6° F (38° C) 26. B.Escherichia coli (E. a female client contracted scabies.range of motion.Net-like appearance 29. A female client with cellulites of the lower leg has had cultures done on the affected area. The clie nt is living at her daughter’s home.Erythema 27.Systemic lupus erythematosus (SLE) 30.Venous star D. coli) D.Hyperthyroidism B. Another manifestation that would most suggest necrotizing fasciitis is: A.White pulmonary secretions D.