Exam 3: PRN1178/ PRN 1178 (2026/ 2027 Updated) Client-Centered Care II Review| Questions and Verified Answers| 100% Correct| A Grade - Rasmussen

Exam 3: PRN1178/ PRN 1178 (2026/ 2027 Updated) Client-Centered Care II Review| Questions and Verified Answers| 100% Correct| A Grade - Rasmussen Q. The nurse is caring for the client who is immediately postoperative with a new ileostomy. What intervention is most important for the nurse to implement at this time? ANSWER Provide emotional support. Q. A 36 year old client who had an ascending colostomy angrily stated. "I don't want this thing on my body. This bag I have now is not me" Which response is most appropriate for the nurse to make? ANSWER What about this colostomy concerns you the most? Q. The nurse is providing pre operative care to a client who will undergo ostomy creation. Which of the following is most regarding ostomies? ANSWER A colostomy connects part of the colon to an opening in the abdominal wall. Q. Type 1 and type 2 diabetes differ in that type 1 diabetes is associated with which of the following? ANSWER Insulin dependence Q. A nurse is caring for a client one day postoperative after a transverse colostomy. When observing the stoma. Which finding requires the nurses immediate action? ANSWER A purplish colored stoma. Q. The nurse is caring for a client who is recovering from a flare up of crowns disease. Which of the following should the nurse reinforce? ANSWER Increase fiber intake as tolerated. Q. The nurse is helping discharge a client diagnosed with diverticulitis. Which instruction should the nurse reinforce? ANSWER Eat a high fiber diet Q. Which of the following gastrointestinal disorders is characterized by hypersensitivy of the bowel wall? ANSWER IBS Irritable bowel syndrome Q. Excessive secretion of growth hormones or gigantism. Symptoms? ANSWER Enlarge feet Q. Which type of insulin is considered rapid acting? ANSWER insulin aspart Q. A client on prolonged steroid therapy presents to the clinic with facial swelling. Enlarged abdomen and hypertension. Which condition does the nurse suspect? ANSWER Cushing syndrome Q. Which of the following is the most appropriate nursing intervention for a client diagnosed with diabetes insipidus? ANSWER Monitor intake and output Q. The nurse notes that the HBA1c level of an assigned client demonstrated a drop from 9.4% to 5.4%. What do those findings indicate? ANSWER The clients blood glucose control has improved over the past few months Q. After administering prescribed insulin to a client with diabetes mellitus. The nurse monitors for hyperglycemia. Which of the following are signs and symptoms of hypoglycemia? SELECT ALL THAT APPLY ANSWER Anixety Tremors Tachycradia Hunger Q. The ED nurse is caring for a client with the right lower quadrant pain and muscle guarding. The clients temperature is 100.5 degrees, and they report nausea and vomiting. Which of the following does the nurse suspect? ANSWER Appendicitis Q. A client with type 1 diabetes mellitus is preparing for a moderate 30 minute exercise period. Which action best indicates that the client understands condition management? ANSWER The client consumes a simple carbohydrate snack after 30 minutes of activity. Q. A client is being evaluated by the healthcare provider for possible hyperthyroidism. The nurse notes which of the following symptoms that support a diagnosis of hyperthyroidism? SELECT ALL THAT APPLY ANSWER Nervousness Weightloss Insomnia Q. When discussing exercise programs with a diabetic client, which instruction is important for the nurse to include? SELECT ALL THAT APPLY ANSWER Delay exercise until glucose is controlled. Keep a quick source of glucose readily available. Begin slowly and build up to 30-45 minutes. Q. A client comes to the ED complaining of abdominal pain. The nurse observes dry hot skin, fruity breaths, and deep respiration. Which of the following does the nurse support? ANSWER Ketoacidosis. Q. A client has ordered 500mg IV every 6 hours of a medication. Which is available in 25 mg/ml. How many mL will be administered 24 hours? ANSWER 80 mL Q. The nurse is preparing to administer an enema. After positioning the client and putting on gloves. Which action should the nurse take next? ANSWER Expel air from the tubing. Q. A client with weakness and malaise is diagnosed with Addison disease. The nurse understands that Addison disease is due to which of the following? ANSWER Adrenal insuffciency Q. Which of the following hormones are secreted by the pituitary gland? SELECT ALL THAT APPLY ANSWER Adrenocorticotroic hormone Thyroid stimulating hormone Growth hormone Q. A client is prescribed cephalexin 250 mg by mouth every 6 hours for 10 days. The medication is available in 250 mg capsules. How many capsules will the client need for the 10 day course of therapy? ANSWER 60 capsules Q. The nurse administering insulin glargine to a client knows that the duration of this insulin is how long? ANSWER 24 hours Q. The nurse working at gastroenterology practice knows that colonoscopies may be indicated for the following reasons. SELECT ALL THAT APPLY ANSWER Rule out inflammatory bowel disease. Screen for colon cancer. Remove pre cancerous colon polyps. Q. The nurse is caring for a client with IBS which teaching points should the nurse reinforce? ANSWER Keep a diary to identify foods that cause symptoms Q. The nurse is reinforcing teaching to a client with a colostomy. Which food should the nurse recommend to help decrease stool Oder? ANSWER Yogurt Q. The provider has order a 100 mg/ a day IM divided into two doses. The medication is available in 50 mg/mL. How many mL will you administer per dose? ANSWER 1 mL Q. The nurse is caring for a hospitalized client who is ordered sodium to prevent constipation. When reinforcing teaching about the medication. Which instruction should the nurse include? ANSWER Take with a full glass of water Q. The nurse is caring for a client with diabetes insipidus. Which of the following manifestations does the nurse anticipate the client will have? ANSWER Profound diuresis Q. The nurse is reviewing the medical hx of a client prescribed metformin. The nurse would question the order for metformin if the clients hx contained which of the following? ANSWER Renal failure. Q. The nurse is caring for a client with type 1 diabetes who is diaphoretic and clammy. The client complains of hunger but denies pain. The nurse performs a bedside blood glucose check. What should the nurse do next? ANSWER Give 6 oz of OJ Q. A client with chronic constipation asks about high fiber dietary selections. Which menu selection should the nurse recommend? ANSWER Turkey sand which on whole wheat toast, pears and tea Q. The nurse is reinforcing teaching to a client with a colostomy. Which of the following foods will increase the risk of obstruction? ANSWER Shrimp Popcorn Celery The nurse is caring for a client admitted into med-surgical unit for intestinal obstruction. The client complains of 10/100pain despite administration of pain medication. Which action should the nurse take? Notify MD immediately Which of the following statement explain a reason for weight and type 1 diabetes? SELECT ALL THAT APPLY Absence of sufficient insulin Stressful lifestyle Loss of body fluid The nurse is reinforcing teaching to a client with diverticulitis. Which statement by the client indicates that teaching was successful? "If left untreated, the inflamed bowel can perforate and cause peritonitis. The nurse caring for a client with hypothyroidism anticipates. Which medication to be prescribed? Levothyroxine The nurse is caring for a client with syndrome of inappropriate anti diuretic hormone. (SIADH) Which of the following is a priority for the nurse to monitor? Fluid balance Cells that are affected by endocrine hormones are called which of the following? Target cells The nurse is reinforcing teaching about peristomal skin care. Which information should the nurse include? Apply a skin barrier to the peristomal area. The following nurses receives a report on the following clients. Which client should the nurse see first? A client with a gastric ulcer who complains of severe abdominal pain and distention. What is the correct term for enlarged thyroid gland? Goiter Which of the following is term for diabetes that develops during pregnancy? Gestational disbetes Which nurse is explaining the underlying pathophysiology of type 1 diabetes to a newly diagnosed client. Which information accurately explains why the type 1 diabetic does not produce adequate insulin? The immune system destroys beta cells of the pancreas. When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? Place a mask on the client to limit the spread of micro-organisms into the surgical wound A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? -The flap farthest from the body A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (SELECT ALL THAT APPLY) -- The inner wrapping of an item on the sterile field -- An irrigation syringe on the sterile field -- One gloved hand with the other gloved hand A nurse is reviewing hand hygiene techniques with a group of assistive personal (AP). Which of the following instructions should the nurse include when discussing handwashing? (SELECT ALL THAT APPLY) -Wash the hands with soap and water for at least 15 seconds. - Use a clean paper towel to turn off hand faucets. A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (SELECT ALL THAT APPLY) -- The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. -- The procedure is delayed by 1 hr because the provider receives an emergency call. -- The nurse turns to speak to someone who enters through the door behind the nurse A nurse is caring for a client whose partner passed away 4 months ago. The client has a recent diagnosis of diabetes mellitus. The client is tearful and states, "How could you possibly understand what I am going through?" Which of the following responses should the nurse make? "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling." A nurse is caring for a client awaiting transport to the surgical site for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the clients blood pressure and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaption syndrome (GAS). Alarm stage A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client's role problem? Role conflict A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (SELECT ALL THAT APPLY) -- Allow the client to provide input on the treatment plan. -- Assist the client with time management, and address the client's priorities. -- Encourage the client in the expression of feelings and concerns A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? Convening a family meeting A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADL's. Which of the following rationales for self-care should the nurse communicate to the family? The client's sense of loss can be lessened through retaining control of some areas of life A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my child's wedding." Based on the Kubler-Ross model, which stage of grief is the client experiencing? Bargaining A nurse is consoling the partner of a client who just died after a long battle with liver cancer. The grieving partner states, "I hate them for leaving me." Which of the following statements should the nurse make to facilitate mourning for the partner? (SELECT ALL THAT APPLY) -- "Would you like me to contact the chaplain to come and speak with you?" -- "You know, it is quite normal to feel anger toward your loved one at this time." --"Tell me more about how you are feeling." A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client's family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse include? Decreased muscle tone A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (SELECT ALL THAT APPLY) --Apply fresh linens and place a clean gown on the body -- Remove all equipment from the bedside -- Dim the lights in the room A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? (SELECT ALL THAT APPLY) -- Decrease or avoid caffeine -- Avoid taking drinking alcohol A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? Check to see whether the catheter is patent. . A nurse is caring for a client who has prescription for a 24-hr urine collection. Which of the following actions should the nurse take? Discard the first voiding A nurse is reviewing factors that increase the risk of urinary tract infections (UTI's) with a client who has recurrent UTIs. Which of the following factors should the nurse include? (SELECT ALL THAT APPLY) -- Frequent sexual intercourse -- Location of the urethra closer to the anus -- Frequent catheterization A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (SELECT ALL THAT APPLY) -- Have the client record urination times. -- Gradually increase the urination intervals. -- Remind the client to hold urine until the next scheduled urination time. A nurse is caring for a client who had a stroke and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (SELECT ALL THAT APPLY) --Make sure only one person speaks at a time. --Allow plenty of time for the client to respond --Use brief sentences with simple words A nurse is caring for a client who had an amphetamine toxicity and has sensory overload. Which of the following interventions should the nurse implement? Provide a private room, and limit stimulation A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (SELECT ALL THAT APPLY) -- Weber test showing lateralization to the right ear -- Rinne test showing less time for air and bone conduction A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications the client currently takes should alert the nurse to a further risk for ototoxicity? (SELECT ALL THAT APPLY) -- Furosemide -- Ibuprofen A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "I take the batteries out of my hearing aids when I take them off at night." S/S of cold stress -tachypnea -hypoxia -respiratory distress -hypoglycemia -metabolic acidosis -jaundice Nursing care for infants of diabetic moms -early feeding -BS management Respiratory Distress Syndromes result of surfactant deficiency, poor gas exchange, or ventilatory failure 1. Asphyxia: Fetal hypoxia that leads to metabolic acidosis 2. Meconium Aspiration: fetal hypoxia causes anal sphincter to relax. Reflex gasp causes aspiration and blocks air flow Risk for RDS -preterm -GDM -male -Caucasian -PROM -Maternal hypotension -CS without labor S/S of respiratory distress -tachypnea 60 -grunting -nasal flaring -retractions -cyanosis -flaccid -apnea -increase BMR -can disrupt temp Hypoglycemia for newborn -value is lowest 60-90 min after birth -stay between 50-60 Risks for Fetal Hypoglycemia -GDM -LGA/SGA -Cold stress -Hypoxia S/S of fetal hypoglycemia (please just try candy & a little honey) -poor feeding -jitters -tremors -cyanosis -apnea -lethargy -hypothermia Nursing care for fetal hypoglycemia -skin to skin while treating -BS 60 minutes after birth -BF within 30 min S/S of newborn sepsis -temp instability -low temp -lethargy -jittery -high bands -resp distress -jaundice Risks for Newborn Sepsis -PROM -TORCH -meconium aspiration -maternal substance use -UTI -GBS (greatest risk) Nursing care for newborn sepsis -respiratory support -temp maintenance Risks for shoulder dystocia/ LGA -Multiple fetal presentation -abnormal presentation, prolonged labor, forceps, vacuum -oligohydramnios -cephalopelvic disproportion -congenital anomalies Assessment of newborn LGA or birth trauma -irritability -weak horse cry -seizure within 72 hours -flaccid muscle tone -limited ROM -localized discoloration/ edema Preterm timeline after 20wks before 37 wks Late preterm 34-36 6/7 weeks early term 37-38 6/7 wks SGA complication respiratory distress Risks for preterm SGA -maternal HTN -maternal age -substance use -hx of preterm -cervical insufficiency -PROM Assessment of a SGA newborn -inability to coordinate suck swallow -grunting, apnea -hypotonic -lethargy -minimal subq fat Neonatal substance withdrawal S/S -high pitch shrill cry -irritability -tremors -hyperactivity -congestion -yawning -sweating temp 99 -poor sucking -vomiting -diarrhea -nasal flaring -retractions -tachypnea Nursing care for newborn with congenital anomalies -thermoregulation and circulation -adequate nutrition -bonding Hormone therapy for menopause can increase risk for what diseases Hormone therapy is estrogen and progesterone increases risk for heart disease and breast cancer. take at lowest dose for shortest duration Alternative therapies to relieve menopause symptoms -soy rich foods -vitamin E for hot flashes -layered clothes, icepacks, icewater, fans -avoid curries or spicy foods why is GDM more commonly diagnosed in 2nd and 3rd trimester -increase fetal needs -increased intake causes glucose levels to rise and be more sustained. -placental hormones, cortisol and insulinase, cause insulin needs to increase. Describe the 2 step insulin sensitivity test 1. 1 hr 50 gram glucose test. If more than 130-140= positive 2. If test one is positive 3hr 100 gram test. After night of fasting and days of normal carb intake and physical activity. Blood glucose taken at 1,2, and 3 hours. If two or more exceed normal range= GDM diagnosis Maternal risks associated with GDM -C-sections -preeclampsia -Type II DM later in life fetal risks associated with GDM -macrosomia and associated birth trauma -electrolyte imbalance -hypoglycemia -hyperinsulinemia Fasting glucose 1hr glucose 2hr glucose 95 140 120 Diet modification for GDM carbs less than 50-60% of diet When would someone with GDM check their BG -Upon awakening -1-2 hrs after breakfast -before and after lunch -before dinner -bedtime What does metformin do decreases hepatic glucose production and increases peripheral insulin sensitivity Why would a woman need to have a nonstress test 2x a week after 32 weeks -poorly managed BG -taking meds for GDM -HTN -Hx of macrosomia -History of stillbirth How often is BG monitored during labor for a mother with GDM every hour. Maintain between 80-100 ** avoid IV fluids with dextrose