NR 354 EXAM 1 2024-2025 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED ANSWERS |FR, Exams of Nursing

Download NR 354 EXAM 1 2024-2025 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED ANSWERS |FR and more Exams Nursing in PDF only on Docsity! 1 | P a g e NR 354 EXAM 1 2024-2025 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED ANSWERS |FREQUENTLY TESTED QUESTIONS AND SOLUTIONS |ALREADY GRADED A+|NEWEST|GUARANTEED PASS|LATEST UPDATE A 38-year-old male patient is admitted to the hospital in Addisonian crisis. Which patient statement supports a nursing diagnosis of ineffective self-health management related to lack of knowledge about management of Addison's disease? a. "I frequently eat at restaurants, and my food has a lot of added salt." b. "I had the stomach flu earlier this week, so I couldn't take the hydrocortisone." c. "I always double my dose of hydrocortisone on the days that I go for a long run." d. "I take twice as much hydrocortisone in the morning dose as I do in the afternoon." ANS: B The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given A 29-year-old woman with systemic lupus erythematosus has been prescribed 2 weeks of high-dose prednisone therapy. Which information about the prednisone is most important for the nurse to include? a. "Weigh yourself daily to monitor for weight gain caused by increased appetite." b. "A weight-bearing exercise program will help minimize the risk for osteoporosis." 2 | P a g e c. "The prednisone dose should be decreased gradually rather than stopped suddenly." d. "Call the health care provider if you experience mood alterations with the prednisone." ANS: C Acute adrenal insufficiency may occur if exogenous corticosteroids are suddenly stopped A 56-year-old female patient has an adrenocortical adenoma, causing hyperaldosteronism. The nurse providing care should a. monitor the blood pressure every 4 hours. b. elevate the patient's legs to relieve edema. c. monitor blood glucose level every 4 hours. d. order the patient a potassium-restricted diet. ANS: A Hypertension caused by sodium retention is a common complication of hyperaldosteronism The nurse will plan to monitor a patient diagnosed with a pheochromocytoma for a. flushing. b. headache. c. bradycardia. d. hypoglycemia. ANS: B The classic clinical manifestations of pheochromocytoma are hypertension, tachycardia, severe headache, diaphoresis, and abdominal or chest pain After a 22-year-old female patient with a pituitary adenoma has had a hypophysectomy, the nurse will teach about the need for a. sodium restriction to prevent fluid retention. b. insulin to maintain normal blood glucose levels. c. oral corticosteroids to replace endogenous cortisol. d.chemotherapy to prevent malignant tumor recurrence. ANS: C Antidiuretic hormone (ADH), cortisol, and thyroid hormone replacement will be needed for life after hypophysectomy 5 | P a g e d. The patient's cardiac rate is 112 beats/minute. ANS: B The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction Which assessment finding of a 42-year-old patient who had a bilateral adrenalectomy requires the most rapid action by the nurse? a. The blood glucose is 176 mg/dL. b. The lungs have bibasilar crackles. c. The blood pressure (BP) is 88/50 mm Hg. d. The patient reports 5/10 incisional pain. ANS: C The decreased BP indicates possible adrenal insufficiency. The nurse should immediately notify the health care provider so that corticosteroid medications can be administered. A 23-year-old patient is admitted with diabetes insipidus. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Titrate the infusion of 5% dextrose in water. b. Teach the patient how to use desmopressin (DDAVP) nasal spray. c. Assess the patient's hydration status every 8 hours. d. Administer subcutaneous DDAVP. ANS: D Administration of medications is included in LPN/LVN education and scope of practice. Which information is most important for the nurse to communicate rapidly to the health care provider about a patient admitted with possible syndrome of inappropriate antidiuretic hormone (SIADH)? a. The patient has a recent weight gain of 9 lb. b. The patient complains of dyspnea with activity. c. The patient has a urine specific gravity of 1.025. d. The patient has a serum sodium level of 118 mEq/L. ANS: D A serum sodium of less than 120 mEq/L increases the risk for complications such as seizures and needs rapid correction. 6 | P a g e After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? a. A 31-year-old female with Cushing syndrome and a blood glucose level of 244 mg/dL b. A 70-year-old female taking levothyroxine (Synthroid) who has an irregular pulse of 134 c. A 53-year-old male who has Addison's disease and is due for a scheduled dose of hydrocortisone (Solu-Cortef). d. A 22-year-old male admitted with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 130 mEq/L ANS: B Initiation of thyroid replacement in older adults may cause angina and cardiac dysrhythmias. The patient's high pulse rate needs rapid investigation by the nurse to assess for and intervene with any cardiac problems. Which question will the nurse in the endocrine clinic ask to help determine a patient's risk factors for goiter? a. "How much milk do you drink?" b. "What medications are you taking?" c. "Are your immunizations up to date?" d. "Have you had any recent neck injuries?" ANS: B Medications that contain thyroid-inhibiting substances can cause goiter. Which finding by the nurse when assessing a patient with a large pituitary adenoma is most important to report to the health care provider? a. Changes in visual field b. Milk leaking from breasts c. Blood glucose 150 mg/dL d. Nausea and projectile vomiting ANS: D Nausea and projectile vomiting may indicate increased intracranial pressure, which will require rapid actions for diagnosis and treatment 7 | P a g e Which finding by the nurse when assessing a patient with Hashimoto's thyroiditis and a goiter will require the most immediate action? a. New-onset changes in the patient's voice b.Apical pulse rate at rest 112 beats/minute c. Elevation in the patient's T3 and T4 levels d. Bruit audible bilaterally over the thyroid gland ANS: A Changes in the patient's voice indicate that the goiter is compressing the laryngeal nerve and may lead to airway compression Which information obtained by the nurse in the endocrine clinic about a patient who has been taking prednisone (Deltasone) 40 mg daily for 3 weeks is most important to report to the health care provider? a. Patient's blood pressure is 148/94 mm Hg. b. Patient has bilateral 2+ pitting ankle edema. c. Patient stopped taking the medication 2 days ago. d. Patient has not been taking the prescribed vitamin D. ANS: C Sudden cessation of corticosteroids after taking the medication for a week or more can lead to adrenal insufficiency, with problems such as severe hypotension and hypoglycemia. The patient will need immediate evaluation by the health care provider to prevent and/or treat adrenal insufficiency The cardiac telemetry unit charge nurse receives status reports from other nursing units about four patients who need cardiac monitoring. Which patient should be transferred to the cardiac unit first? a. Patient with Hashimoto's thyroiditis and a heart rate of 102 b. Patient with tetany who has a new order for IV calcium chloride c. Patient with Cushing syndrome and a blood glucose of 140 mg/dL 10 | P a g e ANS: D Exposure to the chemicals involved with working as a hairdresser and in smoking both increase the risk of bladder cancer, and the nurse should assess whether the patient understands this risk. Which medication taken at home by a 47-year-old patient with decreased renal function will be of most concern to the nurse? a. ibuprofen (Motrin) b. warfarin (Coumadin) c. folic acid (vitamin B9) d. penicillin (Bicillin LA) ANS: A The nonsteroidal antiinflammatory medications (NSAIDs) are nephrotoxic and should be avoided in patients with impaired renal function. A 79-year-old man has been admitted with benign prostatic hyperplasia. What is most appropriate to include in the nursing plan of care? a. Limit fluid intake to no more than 1000 mL/day. b. Leave a light on in the bathroom during the night. c. Ask the patient to use a urinal so that urine can be measured. d. Pad the patient's bed to accommodate overflow incontinence. ANS: B The patient's age and diagnosis indicate a likelihood of nocturia, so leaving the light on in the bathroom is appropriate. Fluids should be encouraged because dehydration is more common in older patients. The nurse completing a physical assessment for a newly admitted male patient is unable to feel either kidney on palpation. Which action should the nurse take next? a. Obtain a urine specimen to check for hematuria. b. Document the information on the assessment form. c. Ask the patient about any history of recent sore throat. d. Ask the health care provider about scheduling a renal ultrasound. ANS: B The kidneys are protected by the abdominal organs, ribs, and muscles of the back, and may not be 11 | P a g e palpable under normal circumstances, so no action except to document the assessment information is needed. How will the nurse assess for flank tenderness in a 30-year-old female patient with suspected pyelonephritis? a. Palpate along both sides of the lumbar vertebral column. b. Strike a flat hand covering the costovertebral angle (CVA). c. Push fingers upward into the two lowest intercostal spaces. d. Percuss between the iliac crest and ribs along the midaxillary line. ANS: B Checking for flank pain is best performed by percussion of the CVA and asking about pain. What glomerular filtration rate (GFR) would the nurse estimate for a 30-year-old patient with a creatinine clearance result of 60 mL/min? a. 60 mL/min b. 90 mL/min c. 120 mL/min d. 180 mL/min ANS: A The creatinine clearance approximates the GFR. The nurse assessing the urinary system of a 45-year-old female would use auscultation to a. determine kidney position. b. identify renal artery bruits. c. check for ureteral peristalsis. d. assess for bladder distention. ANS: B The presence of a bruit may indicate problems such as renal artery tortuosity or abdominal aortic aneurysm. A patient gives the nurse health information before a scheduled intravenous pyelogram (IVP). Which item has the most immediate implications for the patient's care? 12 | P a g e a. The patient has not had food or drink for 8 hours. b. The patient lists allergies to shellfish and penicillin. c. The patient complains of costovertebral angle (CVA) tenderness. d. The patient used a bisacodyl (Dulcolax) tablet the previous night. ANS: B Iodine-based contrast dye is used during IVP and for many computed tomography (CT) scans. The nurse will need to notify the health care provider before the procedures so that the patient can receive medications such as antihistamines or corticosteroids before the procedures are started. A patient passing bloody urine is scheduled for a cystoscopy with cystogram. Which description of the procedure by the nurse is accurate? a. "Your doctor will place a catheter into an artery in your groin and inject a dye that will visualize the blood supply to the kidneys." b. "Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted through the tube into your kidney." c. "Your doctor will insert a lighted tube into the bladder through your urethra, inspect the bladder, and instill a dye that will outline your bladder on x-ray." d. "Your doctor will inject a radioactive solution into a vein in your arm and the distribution of the isotope in your kidneys and bladder will be checked." ANS: C In a cystoscope and cystogram procedure, a cystoscope is inserted into the bladder for direct visualization, and then contrast solution is injected through the scope so that x-rays can be taken. The nurse caring for a patient after cystoscopy plans that the patient a. learns to request narcotics for pain. b. understands to expect blood-tinged urine. c. restricts activity to bed rest for a 4 to 6 hours. d. remains NPO for 8 hours to prevent vomiting. ANS: B Pink-tinged urine and urinary frequency are expected after cystoscopy. 15 | P a g e b. Trace protein c. WBC 20 to 26/hpf d. Specific gravity 1.021 ANS: C The increased number of white blood cells (WBCs) indicates the presence of urinary tract infection or inflammation Which statement by a patient who had a cystoscopy the previous day should be reported immediately to the health care provider? a. "My urine looks pink." b. "My IV site is bruised." c. "My sleep was restless." d. "My temperature is 101." ANS: D The patient's elevated temperature may indicate a bladder infection, a possible complication of cystoscopy. The health care provider should be notified so that antibiotic therapy can be started. Which assessment of a 62-year-old patient who has just had an intravenous pyelogram (IVP) requires immediate action by the nurse? a. The heart rate is 58 beats/minute. b. The patient complains of a dry mouth. c. The respiratory rate is 38 breaths/minute. d. The urine output is 400 mL after 2 hours. ANS: C The increased respiratory rate indicates that the patient may be experiencing an allergic reaction to the contrast medium used during the procedure. The nurse should immediately assess the patient's oxygen saturation and breath sounds. When working in the urology/nephrology clinic, which patient could the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? 16 | P a g e a. Patient who is scheduled for a renal biopsy after a recent kidney transplant b. Patient who will need monitoring for several hours after a renal arteriogram c. Patient who requires teaching about possible post-cystoscopy complications d. Patient who will have catheterization to check for residual urine after voiding ANS: D LPN/LVN education includes common procedures such as catheterization of stable patients. Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct? a. Insulin is not used to control blood glucose in patients with type 2 diabetes. b. Complications of type 2 diabetes are less serious than those of type 1 diabetes. c. Changes in diet and exercise may control blood glucose levels in type 2 diabetes. d. Type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma. ANS: C For some patients with type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control. A 48-year-old male patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about a.self-monitoring of blood glucose. b. using low doses of regular insulin. c. lifestyle changes to lower blood glucose. d. effects of oral hypoglycemic medications. ANS: C The patient's impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. 17 | P a g e A 28-year-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching? a. The patient always carries hard candies when engaging in exercise. b. The patient goes for a vigorous walk when his glucose is 200 mg/dL. c. The patient has a peanut butter sandwich before going for a bicycle ride. d. The patient increases daily exercise when ketones are present in the urine. ANS: D When the patient is ketotic, exercise may result in an increase in blood glucose level. The nurse is assessing a 22-year-old patient experiencing the onset of symptoms of type 1 diabetes. Which question is most appropriate for the nurse to ask? a. "Are you anorexic?" b. "Is your urine dark colored?" c. "Have you lost weight lately?" d. "Do you crave sugary drinks?" ANS: C Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient? a. Urine dipstick for glucose b. Oral glucose tolerance test c. Fasting blood glucose level d. Glycosylated hemoglobin level ANS: D The glycosylated hemoglobin (A1C or HbA1C) test shows the overall control of glucose over 90 to 120 days. A 55-year-old female patient with type 2 diabetes has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which goal is most important for this patient? a. The patient will reach a glycosylated hemoglobin level of less than 7%. b. The patient will follow a diet and exercise plan that results in weight loss. c. The patient will choose a diet that distributes calories throughout the day. 20 | P a g e ANS: A The rapid-acting insulins peak in 1 to 3 hours. Which patient action indicates a good understanding of the nurse's teaching about the use of an insulin pump? a. The patient programs the pump for an insulin bolus after eating. b. The patient changes the location of the insertion site every week. c. The patient takes the pump off at bedtime and starts it again each morning. d. The patient plans for a diet that is less flexible when using the insulin pump. ANS: A In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, with the dosage depending on the oral intake. A 32-year-old patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage? a. Lispro (Humalog) b. Glargine (Lantus) c. Detemir (Levemir) d. NPH (Humulin N) ANS: A Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. Which information will the nurse include when teaching a 50-year-old patient who has type 2 diabetes about glyburide (Micronase, DiaBeta, Glynase)? a. Glyburide decreases glucagon secretion from the pancreas. b. Glyburide stimulates insulin production and release from the pancreas. c. Glyburide should be taken even if the morning blood glucose level is low. d. Glyburide should not be used for 48 hours after receiving IV contrast media. ANS: B The sulfonylureas stimulate the production and release of insulin from the pancreas 21 | P a g e The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching? a. "If I overeat at a meal, I will still take the usual dose of medication." b. "Other medications besides the Glucotrol may affect my blood sugar." c. "When I am ill, I may have to take insulin to control my blood sugar." d. "My diabetes won't cause complications because I don't need insulin." ANS: D The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone (Deltasone). The nurse will anticipate that the patient may a. need a diet higher in calories while receiving prednisone. b. develop acute hypoglycemia while taking the prednisone. c. require administration of insulin while taking prednisone. d. have rashes caused by metformin-prednisone interactions. ANS: C Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to a. save the lunch tray for the patient's later return to the unit. b. ask that diagnostic testing area staff to start a 5% dextrose IV. c. send a glass of milk or orange juice to the patient in the diagnostic testing area. d. request that if testing is further delayed, the patient be returned to the unit to eat. 22 | P a g e ANS: D Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose a. washes the puncture site using warm water and soap. b. chooses a puncture site in the center of the finger pad. c. hangs the arm down for a minute before puncturing the site. d. says the result of 120 mg indicates good blood sugar control. ANS: B The patient is taught to choose a puncture site at the side of the finger pad because there are fewer nerve endings along the side of the finger pad. The nurse is preparing to teach a 43-year-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first? a. Ask the patient's family to participate in the diabetes education program. b. Assess the patient's perception of what it means to have diabetes mellitus. c. Demonstrate how to check glucose using capillary blood glucose monitoring. d. Discuss the need for the patient to actively participate in diabetes management. ANS: B Before planning teaching, the nurse should assess the patient's interest in and ability to self-manage the diabetes. An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to a. give a bolus of 50% dextrose. b. insert a large-bore IV catheter. c. initiate oxygen by nasal cannula. d. administer glargine (Lantus) insulin. ANS: B HHS is initially treated with large volumes of IV fluids to correct hypovolemia. A 26-year-old female with type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and a blood glucose level of 210 25 | P a g e ANS: D The BUN indicates possible renal failure, and metformin should not be used in patients with renal failure. A diabetic patient who has reported burning foot pain at night receives a new prescription. Which information should the nurse teach the patient about amitriptyline (Elavil)? a. Amitriptyline decreases the depression caused by your foot pain. b. Amitriptyline helps prevent transmission of pain impulses to the brain. c. Amitriptyline corrects some of the blood vessel changes that cause pain. d. Amitriptyline improves sleep and makes you less aware of nighttime pain. ANS: B Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain Which information is most important for the nurse to report to the health care provider before a patient with type 2 diabetes is prepared for a coronary angiogram? a. The patient's most recent HbA1C was 6.5%. b. The patient's admission blood glucose is 128 mg/dL. c. The patient took the prescribed metformin (Glucophage) today. d. The patient took the prescribed captopril (Capoten) this morning. ANS: C To avoid lactic acidosis, metformin should be discontinued a day or 2 before the coronary arteriogram and should not be used for 48 hours after IV contrast media are administered. Which action by a patient indicates that the home health nurse's teaching about glargine and regular insulin has been successful? a. The patient administers the glargine 30 minutes before each meal. b. The patient's family prefills the syringes with the mix of insulins weekly. 26 | P a g e c. The patient draws up the regular insulin and then the glargine in the same syringe. d. The patient disposes of the open vials of glargine and regular insulin after 4 weeks. ANS: D Insulin can be stored at room temperature for 4 weeks. A 26-year-old patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to administer the morning insulin? a. thigh. b. buttock. c. abdomen. d. upper arm. ANS: C Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The nurse is interviewing a new patient with diabetes who receives rosiglitazone (Avandia) through a restricted access medication program. What is most important for the nurse to report immediately to the health care provider? a. The patient's blood pressure is 154/92. b. The patient has a history of emphysema. c. The patient's blood glucose is 86 mg/dL. d. The patient has chest pressure when walking. ANS: D Rosiglitazone can cause myocardial ischemia. The nurse should immediately notify the health care provider and expect orders to discontinue the medication The nurse is taking a health history from a 29-year-old pregnant patient at the first prenatal visit. The patient reports no personal history of diabetes but has a parent who is diabetic. Which action will the nurse plan to take first? a. Teach the patient about administering regular insulin. b. Schedule the patient for a fasting blood glucose level. c. Discuss an oral glucose tolerance test for the twenty-fourth week of pregnancy. 27 | P a g e d. Provide teaching about an increased risk for fetal problems with gestational diabetes. ANS: B Patients at high risk for gestational diabetes should be screened for diabetes on the initial prenatal visit. A 27-year-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first? a. Place the patient on a cardiac monitor. b. Administer IV potassium supplements. c. Obtain urine glucose and ketone levels. d. Start an insulin infusion at 0.1 units/kg/hr. ANS: A Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with electrocardiogram (ECG) monitoring. Because potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. A 54-year-old patient is admitted with diabetic ketoacidosis. Which admission order should the nurse implement first? a. Infuse 1 liter of normal saline per hour. b. Give sodium bicarbonate 50 mEq IV push. c. Administer regular insulin 10 U by IV push. d. Start a regular insulin infusion at 0.1 units/kg/hr. ANS: A The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids. A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first? a. Infuse dextrose 50% by slow IV push. 30 | P a g e c. "I should take my daily aspirin at least an hour before the Byetta." d. "I will take the pill at the same time I eat breakfast in the morning." ANS: C Since exenatide slows gastric emptying, oral medications should be taken at least an hour before the exenatide to avoid slowing absorption. A few weeks after an 82-year-old with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding by the nurse is most important to discuss with the health care provider? a. Hemoglobin A1C level is 7.9%. b. Last eye exam was 18 months ago. c. Glomerular filtration rate is decreased. d. Patient has questions about the prescribed diet. ANS: C The decrease in renal function may indicate a need to adjust the dose of metformin or change to a different medication The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next? a. Give the patient 4 to 6 oz more orange juice. b. Administer the PRN glucagon (Glucagon) 1 mg IM. c. Have the patient eat some peanut butter with crackers. d. Notify the health care provider about the hypoglycemia. ANS: A The "rule of 15" indicates that administration of quickly acting carbohydrates should be done 2 to 3 times for a conscious patient whose glucose remains less than 70 mg/dL before notifying the health care provider Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the diabetic clinic? a. Measure the ankle-brachial index. b. Check for changes in skin pigmentation. 31 | P a g e c. Assess for unilateral or bilateral foot drop. d. Ask the patient about symptoms of depression. ANS: A Checking systolic pressure at the ankle and brachial areas and calculating the ankle-brachial index is a procedure that can be done by UAP who have been trained in the procedure. After change-of-shift report, which patient will the nurse assess first? a. 19-year-old with type 1 diabetes who was admitted with possible dawn phenomenon b. 35-year-old with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL c. 60-year-old with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa d. 68-year-old with type 2 diabetes who has severe peripheral neuropathy and complains of burning foot pain ANS: C The patient's diagnosis of HHS and signs of dehydration indicate that the nurse should rapidly assess for signs of shock and determine whether increased fluid infusion is needed. After change-of-shift report, which patient should the nurse assess first? a. 19-year-old with type 1 diabetes who has a hemoglobin A1C of 12% b. 23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL c. 40-year-old who is pregnant and whose oral glucose tolerance test is 202 mg/dL d. 50-year-old who uses exenatide (Byetta) and is complaining of acute abdominal pain ANS: B Because the brain requires glucose to function, untreated hypoglycemia can cause unconsciousness, seizures, and death. The nurse will rapidly assess and treat the patient with low blood glucose. To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select all that apply)? a. Chest x-ray b. Blood pressure 32 | P a g e c. Serum creatinine d. Urine for microalbuminuria e. Complete blood count (CBC) f. Monofilament testing of the foot ANS: B, C, D, F Blood pressure, serum creatinine, urine testing for microalbuminuria, and monofilament testing of the foot are recommended at least annually to screen for possible microvascular and macrovascular complications of diabetes In which order will the nurse take these steps to prepare NPH 20 units and regular insulin 2 units using the same syringe? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Rotate NPH vial. b. Withdraw regular insulin. c. Withdraw 20 units of NPH. d. Inject 20 units of air into NPH vial. e. Inject 2 units of air into regular insulin vial ANS: A, D, E, B, C When mixing regular insulin with NPH, it is important to avoid contact between the regular insulin and the additives in the NPH that slow the onset, peak, and duration of activity in the longer-acting insulin. A 45-year-old male patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask? a. "Have you had a recent head injury?" b. "Do you have to wear larger shoes now?" c. "Is there a family history of acromegaly?" d. "Are you experiencing tremors or anxiety?" ANS: B Acromegaly causes an enlargement of the hands and feet. A 42-year-old female patient is scheduled for transsphenoidal hypophysectomy to treat a pituitary adenoma. During preoperative teaching, the nurse instructs the patient about the need to 35 | P a g e ANS: B When water is retained, the serum sodium level will drop below normal, causing the clinical manifestations reported by the patient. An expected nursing diagnosis for a 30-year-old patient admitted to the hospital with symptoms of diabetes insipidus is a. excess fluid volume related to intake greater than output. b. impaired gas exchange related to fluid retention in lungs. c. sleep pattern disturbance related to frequent waking to void. d. risk for impaired skin integrity related to generalized edema. ANS: C Nocturia occurs as a result of the polyuria caused by diabetes insipidus. Which information will the nurse teach a 48-year-old patient who has been newly diagnosed with Graves' disease? a. Exercise is contraindicated to avoid increasing metabolic rate. b. Restriction of iodine intake is needed to reduce thyroid activity. c. Antithyroid medications may take several months for full effect. d. Surgery will eventually be required to remove the thyroid gland. ANS: C Medications used to block the synthesis of thyroid hormones may take 2 to 3 months before the full effect is seen. A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next? a. Suction the patient's airway. b. Administer IV calcium gluconate. c. Plan for emergency tracheostomy. d. Prepare for endotracheal intubation. 36 | P a g e ANS: B The patient's clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Which nursing action will be included in the plan of care for a 55-year-old patient with Graves' disease who has exophthalmos? a. Place cold packs on the eyes to relieve pain and swelling. b. Elevate the head of the patient's bed to reduce periorbital fluid. c. Apply alternating eye patches to protect the corneas from irritation. d. Teach the patient to blink every few seconds to lubricate the corneas. ANS: B The patient should sit upright as much as possible to promote fluid drainage from the periorbital area A 62-year-old patient with hyperthyroidism is to be treated with radioactive iodine (RAI). The nurse instructs the patient a. about radioactive precautions to take with all body secretions. b. that symptoms of hyperthyroidism should be relieved in about a week. c. that symptoms of hypothyroidism may occur as the RAI therapy takes effect. d. to discontinue the antithyroid medications taken before the radioactive therapy. ANS: C There is a high incidence of postradiation hypothyroidism after RAI, and the patient should be monitored for symptoms of hypothyroidism. Which nursing assessment of a 69-year-old patient is most important to make during initiation of thyroid replacement with levothyroxine (Synthroid)? a. Fluid balance b. Apical pulse rate c. Nutritional intake d. Orientation and alertness 37 | P a g e ANS: B In older patients, initiation of levothyroxine therapy can increase myocardial oxygen demand and cause angina or dysrhythmias An 82-year-old patient in a long-term care facility has several medications prescribed. After the patient is newly diagnosed with hypothyroidism, the nurse will need to consult with the health care provider before administering a. docusate (Colace). b. ibuprofen (Motrin). c. diazepam (Valium). d. cefoxitin (Mefoxin). ANS: C Worsening of mental status and myxedema coma can be precipitated by the use of sedatives, especially in older adults. The nurse should discuss the use of diazepam with the health care provider before administration A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving and expected to be discharged in 2 days. Which teaching strategy will be best for the nurse to use? a. Provide written reminders of self-care information. b. Offer multiple options for management of therapies. c. Ensure privacy for teaching by asking visitors to leave. d. Delay teaching until patient discharge date is confirmed. ANS: A Written instructions will be helpful to the patient because initially the hypothyroid patient may be unable to remember to take medications and other aspects of self-care. A 63-year-old patient with primary hyperparathyroidism has a serum phosphorus level of 1.7 mg/dL (0.55 mmol/L) and calcium of 14 mg/dL (3.5 mmol/L). Which nursing action should be included in the plan of care? a. Restrict the patient to bed rest. b. Encourage 4000 mL of fluids daily. c. Institute routine seizure precautions. 40 | P a g e ANS: A Clinical manifestations of Addison's disease include hyponatremia and an increase in sodium level indicates improvement. SBAR situation, background, assessment, recommendation potassium 3.5-5.0 treatment for hypokalemia 10-20 mEq K+ per hour treatment for hyperkalemia DICK, lasix What are the ECG changes in hyperkalemia? tall peaked T waves sodium 135-145 cause of hypernatremia dehydration (water loss) cause of hyponatremia excess water consumption, diuretics s/s of hypernatremia confusion, neuromuscular excitability, seizures s/s of hyponatremia fatigue, confusion, n/v treatment for hypernatremia IV rehydration (0.9% NaCl) treatment for hyponatremia 41 | P a g e IV sodium, oral intake risks for hypervolemia (FVE) too much oral intake, excess IV fluid, edema 1L fluid weighs? 2.2lbs (1 kg) treatment for FVE diuretics, fluid restriction, ted hose (monitor daily weights, I&O, assess/reassess) risks for hypovolemia (FVD) GI loss, hemorrhage, infection/fever treatment for FVD IV and oral fluids, Zofran (monitor I&O, daily weights, renal panel, CBC) acute upper respiratory disorder short-term infections of the nose and throat caused by viruses or bacteria (ex. RSV, influenza) common causes of metabolic alkalosis prolonged vomiting/GI suctioning, diuretics, excess HCO3 common causes of respiratory alkalosis hyperventilation, anxiety, PE, mechanical ventilation common causes of metabolic acidosis DKA, ESRD, diarrhea, sepsis (shock) common causes of respiratory acidosis anesthesia, drug overdose, COPD, pneumonia, atelectasis acute lower respiratory disorder infection of the lung alveoli (ex. pneumonia, bronchitis) COPD post infection, lung tissues turning into scar tissue fluticasone 42 | P a g e opens up passages, dries up drainage corticosteroids dec. inflammation s/s of COPD exacerbation coughing, SOB, wheezing, edema, excess mucus production treatment for COPD SABA, anticholinergics, corticosteroids, fluticasone, duoneb asthma narrowing of airway > impaired O2 intake s/s of asthma exacerbation airway constriction, SOB, difficulty breathing, mucus production treatment for asthma SABA, anticholinergics, corticosteroids, fluticasone TB pt. education hand hygiene, complete full course of antibiotics PPE for TB N95, gloves, negative pressure room treatment for TB antibiotics (9 months), breathing treatments Kayexalate (polystyrene sulfonate) used to dec. K+ labs to monitor w/ kayexalate hypokalemia proventil/ventolin (albuterol) 45 | P a g e hypercapnia, hypoventilation cause of laryngeal cancer smoking treatment of laryngeal cancer surgery, chemo, radiation, palliative lung cancer pt. education stop smoking lung cancer priority assessment hypercapnia, and hypoventilation cause of lung cancer smoking, air pollution treatment for lung cancer surgery, chemo, radiation, palliative obstructive sleep apnea (OSA) repetitive pharyngeal collapse during sleep, which leads to absence of breathing pleural effusion fluid outside of the lung, causing poor expansion of the lungs empyema fluid due to infection around the lung 46 | P a g e pneunmothorax excess air in the thoracic cavity pulmonary embolism (PE) starts as DVT > clots gets thrown into lungs > obstruction atelectasis caused by lack of motion post surgically (not fully breathing) common post-op complications infection, PE, DVT atelectasis, airway obstruction, pneumonia treatment for post-op complications antibiotics, ambulation, SCD, supplemental O2 s/s of post-op respiratory complications SOB, dec. SpO2, pneumonia treatment albuterol, antibiotics, mucolytics, antipyretics, oral fluids, suctioning, monitor labs antipyretics reduce fever pneumonia prevention vaccination, hand hygiene, cough etiquette pneumonia pt. education ambulation, vaccination (65+) risk factors for COVID-19 obesity, smoking, age PPE COVID-19 droplet gown, gloves, N95, face shield 47 | P a g e s/s SARS-CoV-2 (COVID-19) chills, body aches, SOB, cough, runny nose pulmonary edema CHF > abnormal accumulation of fluid in alveoli, lung tissue, or both electyrolyte, fluid imbalances, lab interpretations/interventions magnesium 1.6-2.3 treatment for hypermagnesemia lasix, calcium gluconate treatment for hypomagnesemia oral, IV magnesium calcium 8.6-10.2 treatment for hypocalcemia IV calcium gluconate treatment for hypercalcemia isotonic solution, furosemide (loop diuretic) bilirubin 0.3-1.2 (+ impaired hepatic) creatinine 0.8-1.2 (+ impaired renal) aPTT 30-45 (+ low clotting) what is used to diagnose asthma? Spirometry s/e prednisone hypokalemia, hyperglycemia, immunosppresion, adrenal insufficiency (not for long term) 50 | P a g e s/s of metabolic acidosis kussmaul respirations, hyperkalemia, warrm flushed skin s/s metabolic alkalosis tachycardia, n/v, tremors, muscle cramping, confusion isotonic fluid fluid resuscitation- 0.9% NaCl- Lactated Ringers (LR) hypotonic fluid maintenance- D5W- 0.45% NaCl (1/2 NS) hypertonic fluid critical care only!- 3% NaCl- solutions w/ >0.9%(pulls fluid back into blood vessels out of cell) ex of pt who needs isotonic? post surgical NPO pt., pt. w/ n/v pts at risk for third spacing CHF, liver failure, renal failure s/s of atelectasis SOB cor pulmonale Right sided heart failure, blood backs up in the right ventricle. B/c of COPD they are meeting resistance, when the right ventricle has to work harder it gets bigger. s/s hypocalcemia Trousseau sign, Chvostek's sign, seizures s/s of hypercalcemia stomach upset, n/v, constipation, muscular hyper-excitability s/s of hypomagnesmia tremors, tetany, seizures, dysrhythmias, confusion s/s of hypermagnesemia hypotension, n/v, dysrhythmias, muscle weakness s/s of hyperphosphatemia muscle cramps, tetany, SOB 51 | P a g e s/s of hypophosphatemia anemia, bruising, coma s/s of hyperkalemia tall peaked T-wave, SOB, heart palpitations s/s of hypokalemia ST-wave depression, low blood pressure, lethargic, leg cramps s/s of hyponatremia stupor, orthostatic hypotension, seizures s/s of hyperatremia Fever and flushed skin, restlessness, increased bp