NUR 325 Exam 3 Study Questions With Complete Solutions
A 22-year-old who is hospitalized with anorexia nervosa is 5 ft 5
in (163 cm) tall and weighs 90 pounds (41 kg). Laboratory tests
reveal hypokalemia and iron-deficiency anemia. Which nursing
diagnosis has the highest priority for the patient?
a. Risk for activity intolerance related to anemia and weakness
b. Risk for electrolyte imbalance related to poor eating patterns
c. Ineffective health maintenance related to obsession with body
image
d. Imbalanced nutrition: less than body requirements related to
refusal to eat Correct Answer ANS: B
The patients hypokalemia may lead to life-threatening cardiac
dysrhythmias. The other diagnoses also are appropriate for this
patient but are not associated with immediate risk for fatal
complications.
A 66-year-old patient has a body mass index (BMI) of 31
kg/m2, a normal C-reactive protein level, and low transferrin
and albumin levels. The nurse will plan patient teaching to
increase the patients intake of foods that are high in
a. iron.
b. protein.
c. calories.
d. carbohydrate. Correct Answer ANS: B
The patients C-reactive protein and transferrin levels indicate
low protein stores. The BMI is in the obese range, so increasing
caloric intake is not indicated. The data do not indicate a need
for increased carbohydrate or iron intake.
,A diabetic patient is admitted with ketoacidosis and the health
care provider writes these orders. Which order should the nurse
implement first?
a. Administer regular IV insulin 30 U.
b. Infuse 1 liter of normal saline per hour.
c. Give sodium bicarbonate 50 mEq IV push.
d. Start an infusion of regular insulin at 50 U/hr. Correct
Answer ANS: B
The most urgent patient problem is the hypovolemia associated
with diabetic ketoacidosis (DKA), and the priority is to infuse
IV fluids. The other actions can be accomplished after the
infusion of normal saline is initiated.
A diabetic patient is brought into the emergency department
unresponsive. The arterial pH is 7.28. Besides the blood pH,
which clinical manifestation is seen in uncontrolled diabetes
mellitus and ketoacidosis?
a. Oral temperature of 38.9 Celsius
b. Severe orthostatic hypotension
c. Increased rate and depth of respiration
d. Extremity tremors followed by seizure activity Correct
Answer ANS: C
Ketoacidosis decreases the pH of the blood, stimulating the
respiratory control area of the brain to buffer the effects of the
increasing acidosis. The rate and depth of respirations are
increased (Kussmauls respirations) to excrete more acids by
exhalation.
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
a. give 50% dextrose as a bolus.
b. insert a large-bore IV catheter.
c. initiate oxygen by nasal cannula.
d. administer glargine (Lantus) insulin. Correct Answer ANS:
B
HHNC is initially treated with large volumes of IV fluids to
correct hypovolemia. Regular insulin is administered, not a
long-acting insulin. There is no indication that the patient
requires oxygen. Dextrose solutions will increase the patients
blood glucose and would be contraindicated.
A hospitalized diabetic patient who received 34 U of NPH
insulin at 7:00 AM is away from the nursing unit, awaiting
diagnostic testing when lunch trays are distributed. To prevent
hypoglycemia, the best action by the nurse is to
a. save the lunch tray to be provided upon the patients return to
the unit.
b. call the diagnostic testing area and ask that a 5% dextrose IV
be started.
c. ensure that the patient drinks a glass of milk or orange juice at
noon in the diagnostic testing area.
d. request that the patient be returned to the unit to eat lunch if
testing will not be completed promptly. Correct Answer 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. Waiting to eat until after the procedure is likely to
cause hypoglycemia. Administration of an IV solution is
unnecessarily invasive for the patient. 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 nurse is developing a plan of care for an older client with
diabetic neuropathy of the lower extremities resulting from type
2 diabetes mellitus. Which problem does the nurse recognize as
the highest priority for this client?
a) Change in body image
b) Increased risk for injury
c) Increased risk of depression
d) Lower level of physical activity Correct Answer b)
Increased risk for injury
A nurse is planning dietary measures for an older client who is
experiencing dysphagia. Which action should the nurse include
in the plan of care?
a) Encouraging the client to feed herself
b) Ensuring that most of the diet consists of liquids
c) Monitoring the client during meals to ensure that food is
swallowed
d) Consulting with the health care provider regarding feeding
through an enteral tube Correct Answer d) Consulting with the
health care provider regarding feeding through an enteral tube
A nurse is teaching a patient relaxation techniques to decreases
stress. Which finding will support the nurse's evaluation that the
therapy is effective?
a) Dilated pupils
b) Increased blood sugar
c) Decreased heart rate
A 22-year-old who is hospitalized with anorexia nervosa is 5 ft 5
in (163 cm) tall and weighs 90 pounds (41 kg). Laboratory tests
reveal hypokalemia and iron-deficiency anemia. Which nursing
diagnosis has the highest priority for the patient?
a. Risk for activity intolerance related to anemia and weakness
b. Risk for electrolyte imbalance related to poor eating patterns
c. Ineffective health maintenance related to obsession with body
image
d. Imbalanced nutrition: less than body requirements related to
refusal to eat Correct Answer ANS: B
The patients hypokalemia may lead to life-threatening cardiac
dysrhythmias. The other diagnoses also are appropriate for this
patient but are not associated with immediate risk for fatal
complications.
A 66-year-old patient has a body mass index (BMI) of 31
kg/m2, a normal C-reactive protein level, and low transferrin
and albumin levels. The nurse will plan patient teaching to
increase the patients intake of foods that are high in
a. iron.
b. protein.
c. calories.
d. carbohydrate. Correct Answer ANS: B
The patients C-reactive protein and transferrin levels indicate
low protein stores. The BMI is in the obese range, so increasing
caloric intake is not indicated. The data do not indicate a need
for increased carbohydrate or iron intake.
,A diabetic patient is admitted with ketoacidosis and the health
care provider writes these orders. Which order should the nurse
implement first?
a. Administer regular IV insulin 30 U.
b. Infuse 1 liter of normal saline per hour.
c. Give sodium bicarbonate 50 mEq IV push.
d. Start an infusion of regular insulin at 50 U/hr. Correct
Answer ANS: B
The most urgent patient problem is the hypovolemia associated
with diabetic ketoacidosis (DKA), and the priority is to infuse
IV fluids. The other actions can be accomplished after the
infusion of normal saline is initiated.
A diabetic patient is brought into the emergency department
unresponsive. The arterial pH is 7.28. Besides the blood pH,
which clinical manifestation is seen in uncontrolled diabetes
mellitus and ketoacidosis?
a. Oral temperature of 38.9 Celsius
b. Severe orthostatic hypotension
c. Increased rate and depth of respiration
d. Extremity tremors followed by seizure activity Correct
Answer ANS: C
Ketoacidosis decreases the pH of the blood, stimulating the
respiratory control area of the brain to buffer the effects of the
increasing acidosis. The rate and depth of respirations are
increased (Kussmauls respirations) to excrete more acids by
exhalation.
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
a. give 50% dextrose as a bolus.
b. insert a large-bore IV catheter.
c. initiate oxygen by nasal cannula.
d. administer glargine (Lantus) insulin. Correct Answer ANS:
B
HHNC is initially treated with large volumes of IV fluids to
correct hypovolemia. Regular insulin is administered, not a
long-acting insulin. There is no indication that the patient
requires oxygen. Dextrose solutions will increase the patients
blood glucose and would be contraindicated.
A hospitalized diabetic patient who received 34 U of NPH
insulin at 7:00 AM is away from the nursing unit, awaiting
diagnostic testing when lunch trays are distributed. To prevent
hypoglycemia, the best action by the nurse is to
a. save the lunch tray to be provided upon the patients return to
the unit.
b. call the diagnostic testing area and ask that a 5% dextrose IV
be started.
c. ensure that the patient drinks a glass of milk or orange juice at
noon in the diagnostic testing area.
d. request that the patient be returned to the unit to eat lunch if
testing will not be completed promptly. Correct Answer 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. Waiting to eat until after the procedure is likely to
cause hypoglycemia. Administration of an IV solution is
unnecessarily invasive for the patient. 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 nurse is developing a plan of care for an older client with
diabetic neuropathy of the lower extremities resulting from type
2 diabetes mellitus. Which problem does the nurse recognize as
the highest priority for this client?
a) Change in body image
b) Increased risk for injury
c) Increased risk of depression
d) Lower level of physical activity Correct Answer b)
Increased risk for injury
A nurse is planning dietary measures for an older client who is
experiencing dysphagia. Which action should the nurse include
in the plan of care?
a) Encouraging the client to feed herself
b) Ensuring that most of the diet consists of liquids
c) Monitoring the client during meals to ensure that food is
swallowed
d) Consulting with the health care provider regarding feeding
through an enteral tube Correct Answer d) Consulting with the
health care provider regarding feeding through an enteral tube
A nurse is teaching a patient relaxation techniques to decreases
stress. Which finding will support the nurse's evaluation that the
therapy is effective?
a) Dilated pupils
b) Increased blood sugar
c) Decreased heart rate
