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A nurse is teaching a client with Barrett's esophagus who is scheduled to undergo an
esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in
the teaching?
a. "This procedure is performed to measure the presence of acid in your esophagus."
b. "This procedure can determine how well the lower part of your esophagus works."
c. "This procedure is performed while you are under general anesthesia."
d. "This procedure can determine if you have colon cancer."
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B. "This procedure can determine how well the lower part of your esophagus works."---An EGD is
useful in determining the function of the esophageal lining and the extent of inflammation, potential
scarring, and strictures.
A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the following
manifestations should the nurse expect?
a. Increased blood pressure
b. Decreased heart rate
c. Yellowing of the skin
d. Boardlike abdomen
Correct Answer: D. Boardlike abdomen---The nurse should expect this client who is experiencing
perforation of a peptic ulcer to exhibit manifestations of a board-like abdomen and severe pain in the
abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the
perforation causes hemorrhaging.
A nurse in a provider's office is reviewing the medical records of a group of clients. Which of the
following clients is at risk for iron deficiency? (Select all that apply.)
a. A client who is postmenopausal
b. A client who is a vegetarian
c. A middle adult male client
d. A client who is pregnant
e. A toddler who is overweight
B. A client who is a vegetarian
D. A client who is pregnant
E. A toddler who is overweight---A client who is a vegetarian might require additional iron because the
availability of iron in vegetable food sources is limited. During pregnancy, maternal blood volume
increases, and the fetus requires additional iron. Therefore, the RDA of iron for clients who are
pregnant is increased to 27 mg per day. Toddlers who are overweight may get most of their calories
from milk and foods that are not considered healthy, which increases their risk for iron-deficiency
anemia.
A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following
manifestations of the client's skin should the nurse expect?
a. Confluent, honey-colored, crusted lesions
b. A large, tender nodule located on a hair follicle
c. Unilateral, localized, nodular skin lesions
d. A fluid-filled vesicular rash in the genital region
C. Unilateral, localized, nodular skin lesions--- Herpes zoster, or shingles, results from the reactivation
of a dormant varicella virus. It is the acute, unilateral inflammation of the dorsal root ganglion. The
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infection typically develops in adults and produces localized vesicular lesions confined to a
dermatome. It produces localized, nodular skin lesions.
A nurse is conducting a home visit for an older adult client who has diabetes mellitus and takes regular
insulin subcutaneously before each meal. The client appears disoriented and weak and has slurred
speech. Which of the following conditions should the nurse consider first when responding to these
manifestations?
a. Dementia
b. Hypoglycemia
c. Infection
d. Transient ischemic attack
B. Hypoglycemia---Evidence-based practice indicates the nurse should first check the client for
hypoglycemia by drawing a blood glucose level. A client who has hypoglycemia can have slurred
speech, disorientation, weakness, and confusion near meal time each day because regular insulin
peaks in 2 to 4 hours, causing a drop in the client's blood glucose. Other manifestations of
hypoglycemia include irritability, mental confusion, double vision, hunger, tachycardia, diaphoresis,
and palpitations.
A nurse is teaching a client who has diabetes mellitus about hypoglycemia. Which of the following
manifestations should the nurse include? (Select all that apply.)
a. Bradycardia
b. Diaphoresis
c. Deep, rapid respirations
d. Palpitations
e. Shakiness
B. Diaphoresis
D. Palpitations
E. Shakiness---Diaphoresis, palpitations, and shakiness are sympathetic nervous system responses to
hypoglycemia.
A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following
findings should the nurse expect?
a. Flattened T waves
b. Prolonged QT intervals
c. Shortened QT intervals
d. Widened QRS complexes
B. Prolonged QT intervals--- Manifestations of hypocalcemia include tingling, numbness, tetany,
seizures, prolonged QT intervals, and laryngospasm. Causes include hypoparathyroidism, chronic
kidney disease, and diarrhea.
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, NR 222 ACTUAL EXAM
A nurse is providing teaching to a client who has a new diagnosis of type 2 DM. The nurse should
recognize that the clients understands the teaching when he identifies which of the following as
manifestations of hypoglycemia. (Select all that apply)
a. Polyuria
b. Blurred vision
c. Polydipsia
d. Tachycardia
e. Moist, clammy skin
B) blurred vision
D) tachycardia
E) moist, clammy skin
A nurse is caring for an adolescent client who has a long hx of DM & is being admitted to the
emergency department confused, flushed, & with an acetone odor on the breath. DKA is suspected.
The nurse should anticipate using which of the following types of insulin to treat this client?
a. NPH insulin
b. Insulin glargine
c. Insulin detemir
d. Regular insulin
D) Regular insulin--- regular insulin is classified as a short-acting insulin. It can be given intravenously
with an onset of action of less than 30 min. This is the insulin that is most appropriate in emergency
situations of severe hyperglycemia or DKA
A nurse is teaching a client who has diabetes about which dietary source should provide the greatest
percentage of calories. Which of the following statements indicates the client understands the
teaching?
a. "Most of my calories each day should be from fats"
b. "I should eat more calories from complex carbohydrates than anything else"
c. "Simple sugars are needed more than other calorie sources"
d. "Protein should be my main source of calories"
B) "I should eat more calories from complex carbohydrates than anything else"--- The client who has
diabetes should consume the majority of calories from complex carbs, such as whole grains, fruits, and
veggies
A nurse is caring for a client who reports recurrent flank pain, nausea, & vomiting for 24 hr. Which of
the following actions is the nurse's priority?
a. Monitor I&O
b. Strain the urine
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