Physiological Adaption QUESTIONS AND ANSWERS| 100% CORRECT
A nurse is caring for a client diagnosed with diabetes. The nurse notes that the
client has a mild tremor, slight diaphoresis and is fully oriented. Which of the
following nursing actions should have the highest priority? Correct Answer: a.
Administer 50% Dextrose via IV push.
b. Assess the client's blood glucose level.
c. Call the lab for a stat glucose level.
d. Give the client 4 ounces of orange juice
Answer: b.
A client is admitted to the surgical unit after sustaining a compound fracture of the
left femur. The client is alert and oriented with the following vital signs: T 99.4 F,
P 88, R 20, B/P 94/58. The nurse notes a 4 cm. area of bright red blood on the
pressure dressing on the left lower extremity. The client is receiving intravenous
fluids of normal saline at 150 ml/hr. One hour after being admitted to the unit, the
nurse finds the client confused and combative. Which of the following is the most
likely cause of the change in the client's condition? Correct Answer: a. Hypoxia
related to fat embolism from the fractured bone.
b. Infectious process related to contamination of the open wound.
c. Hypovolemic shock related to hemorrhage from the open wound
d. Fluid overload related to aggressive isotonic volume replacement
Answer: a.
A nurse is caring for a client on the telemetry unit who is two days post coronary
artery bypass grafting (CABG). The nurse recognizes a cardiac rhythm change
from normal sinus rhythm to atrial fibrillation. Which of the following should be
completed first? Correct Answer: a. Assess the client's blood pressure.
b. Notify the health care provider.
c. Prepare a diltizem drip.
d. Prepare the client for cardio-version.
Answer: a.
The nurse is planning care for a client who is prescribed antiembolic stocking
following abdominal surgery. Which of the following interventions should the
, nurse include? Correct Answer: a. Remove stockings one to three times per day
for skin care and inspection.
b. Ensure stockings are loose fitting over client's calves.
c. Encourage client to only wear stockings when out of bed.
d. Remove stocking every 2 hours then reapply after 1 hour off.
Answer: a.
A nurse is teaching lifestyle modifications to a client diagnosed with hypertension.
Which of the following statements made by the client indicates a need for further
teaching? Correct Answer: a. "I don't like to walk, but I do aerobics and work out
at the gym during the week."
b. "We have a glass of wine a couple of times a week with dinner."
c. "Losing weight is so hard, but so far I am losing 2 pounds a week."
d. "I will substitute mushrooms for the bacon in my daily omelets."
Answer: d.
A nurse is caring for a client with Addison's disease. Which of the following diets
should the nurse teach the client to follow? Correct Answer: a. High Sodium, low
potassium and increased fluids.
b. High Sodium, low calcium and increased fluids.
c. Low Sodium, high potassium and decreased fluids.
d. Low Sodium, high calcium and decreased fluids.
Answer: a.
A nurse is caring for a client who is experiencing a sodium level of 119 mEq/L.
Which nursing action would be most appropriate at this time? Correct Answer: a.
Encourage water and other fluids.
b. Monitor for diminished breath sounds.
c. Administer 0.9% Normal Saline.
d. Provide oral hygiene and comfort measures.
Answer: c.
A nurse is caring for a client with diabetes insipidus (DI) who has been prescribed
aqueous vasopressin. Which of the following outcomes indicates that treatment has
been effective? Correct Answer: a. Blood pressure of 90/50 mm Hg
b. Fluid intake of 2,400mL in 24 hours
A nurse is caring for a client diagnosed with diabetes. The nurse notes that the
client has a mild tremor, slight diaphoresis and is fully oriented. Which of the
following nursing actions should have the highest priority? Correct Answer: a.
Administer 50% Dextrose via IV push.
b. Assess the client's blood glucose level.
c. Call the lab for a stat glucose level.
d. Give the client 4 ounces of orange juice
Answer: b.
A client is admitted to the surgical unit after sustaining a compound fracture of the
left femur. The client is alert and oriented with the following vital signs: T 99.4 F,
P 88, R 20, B/P 94/58. The nurse notes a 4 cm. area of bright red blood on the
pressure dressing on the left lower extremity. The client is receiving intravenous
fluids of normal saline at 150 ml/hr. One hour after being admitted to the unit, the
nurse finds the client confused and combative. Which of the following is the most
likely cause of the change in the client's condition? Correct Answer: a. Hypoxia
related to fat embolism from the fractured bone.
b. Infectious process related to contamination of the open wound.
c. Hypovolemic shock related to hemorrhage from the open wound
d. Fluid overload related to aggressive isotonic volume replacement
Answer: a.
A nurse is caring for a client on the telemetry unit who is two days post coronary
artery bypass grafting (CABG). The nurse recognizes a cardiac rhythm change
from normal sinus rhythm to atrial fibrillation. Which of the following should be
completed first? Correct Answer: a. Assess the client's blood pressure.
b. Notify the health care provider.
c. Prepare a diltizem drip.
d. Prepare the client for cardio-version.
Answer: a.
The nurse is planning care for a client who is prescribed antiembolic stocking
following abdominal surgery. Which of the following interventions should the
, nurse include? Correct Answer: a. Remove stockings one to three times per day
for skin care and inspection.
b. Ensure stockings are loose fitting over client's calves.
c. Encourage client to only wear stockings when out of bed.
d. Remove stocking every 2 hours then reapply after 1 hour off.
Answer: a.
A nurse is teaching lifestyle modifications to a client diagnosed with hypertension.
Which of the following statements made by the client indicates a need for further
teaching? Correct Answer: a. "I don't like to walk, but I do aerobics and work out
at the gym during the week."
b. "We have a glass of wine a couple of times a week with dinner."
c. "Losing weight is so hard, but so far I am losing 2 pounds a week."
d. "I will substitute mushrooms for the bacon in my daily omelets."
Answer: d.
A nurse is caring for a client with Addison's disease. Which of the following diets
should the nurse teach the client to follow? Correct Answer: a. High Sodium, low
potassium and increased fluids.
b. High Sodium, low calcium and increased fluids.
c. Low Sodium, high potassium and decreased fluids.
d. Low Sodium, high calcium and decreased fluids.
Answer: a.
A nurse is caring for a client who is experiencing a sodium level of 119 mEq/L.
Which nursing action would be most appropriate at this time? Correct Answer: a.
Encourage water and other fluids.
b. Monitor for diminished breath sounds.
c. Administer 0.9% Normal Saline.
d. Provide oral hygiene and comfort measures.
Answer: c.
A nurse is caring for a client with diabetes insipidus (DI) who has been prescribed
aqueous vasopressin. Which of the following outcomes indicates that treatment has
been effective? Correct Answer: a. Blood pressure of 90/50 mm Hg
b. Fluid intake of 2,400mL in 24 hours
