NUR 255 TEST 2 NCLEX TEST WITH
CORRECT ANSWERS
The patient's clinical manifestations are consistent with hypoglycemia,
and the initial action should be to check the patient's glucose with a
finger stick or order a stat blood glucose. If the glucose is low, the
patient should ingest a rapid-acting carbohydrate, such as orange juice.
Glucagon or dextrose 50% might be given if the patient's symptoms
become worse or if the patient is unconscious
After change-of-shift report, which patient will the nurse assess first?
a. A 19-yr-old patient with type 1 diabetes who was admitted with dawn
phenomenon
b. A 35-yr-old patient with type 1 diabetes whose most recent blood
glucose reading was 230 mg/dL
c. A 68-yr-old patient with type 2 diabetes who has severe peripheral
neuropathy and reports burning foot pain
d. A 60-yr-old patient with hyperosmolar hyperglycemic syndrome who
has poor skin turgor and dry oral mucosa - CORRECT ANSWER- D
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. The other patients also need
assessment and intervention but do not have life-threatening
complications.
The nurse is delivering teaching to a female patient newly diagnosed
with systemic lupus erythematosus (SLE). Which statement
demonstrates the patient's need for further teaching about the disease?
, "I'll try my best to stay out of the sun this summer."
"I know that I have a high chance of getting arthritis."
"I'm hoping surgery will be an option for me in the future."
"I understand I'm going to be vulnerable to getting infections." -
CORRECT ANSWER- "I'm hoping surgery will be an option for me in
the future."
Rationale:
Surgery is not a key treatment modality for SLE, so this indicates a need
for further teaching. SLE carries an increased risk of infection, sun
damage, and arthritis.
A 24-yr-old female patient with systemic lupus erythematosus (SLE) tells
the nurse she wants to have a baby and is considering getting pregnant.
Which response by the nurse is most appropriate?
"Infertility can result from some medications used to control your
disease."
"Temporary remission of your signs and symptoms is common during
pregnancy."
"Autoantibodies transferred to the baby during pregnancy will cause
heart defects."
"The baby is at high risk for neonatal lupus erythematosus being
diagnosed at birth." - CORRECT ANSWER- "Infertility can result from
some medications used to control your disease."
Rationale:
Infertility may be caused by renal involvement and the previous use of
high-dose corticosteroid and chemotherapy drugs. Neonatal lupus
erythematosus rarely occurs in infants born to women with SLE.
Exacerbation is common after pregnancy during the postpartum period.
Spontaneous abortion, stillbirth, and intrauterine growth retardation are
CORRECT ANSWERS
The patient's clinical manifestations are consistent with hypoglycemia,
and the initial action should be to check the patient's glucose with a
finger stick or order a stat blood glucose. If the glucose is low, the
patient should ingest a rapid-acting carbohydrate, such as orange juice.
Glucagon or dextrose 50% might be given if the patient's symptoms
become worse or if the patient is unconscious
After change-of-shift report, which patient will the nurse assess first?
a. A 19-yr-old patient with type 1 diabetes who was admitted with dawn
phenomenon
b. A 35-yr-old patient with type 1 diabetes whose most recent blood
glucose reading was 230 mg/dL
c. A 68-yr-old patient with type 2 diabetes who has severe peripheral
neuropathy and reports burning foot pain
d. A 60-yr-old patient with hyperosmolar hyperglycemic syndrome who
has poor skin turgor and dry oral mucosa - CORRECT ANSWER- D
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. The other patients also need
assessment and intervention but do not have life-threatening
complications.
The nurse is delivering teaching to a female patient newly diagnosed
with systemic lupus erythematosus (SLE). Which statement
demonstrates the patient's need for further teaching about the disease?
, "I'll try my best to stay out of the sun this summer."
"I know that I have a high chance of getting arthritis."
"I'm hoping surgery will be an option for me in the future."
"I understand I'm going to be vulnerable to getting infections." -
CORRECT ANSWER- "I'm hoping surgery will be an option for me in
the future."
Rationale:
Surgery is not a key treatment modality for SLE, so this indicates a need
for further teaching. SLE carries an increased risk of infection, sun
damage, and arthritis.
A 24-yr-old female patient with systemic lupus erythematosus (SLE) tells
the nurse she wants to have a baby and is considering getting pregnant.
Which response by the nurse is most appropriate?
"Infertility can result from some medications used to control your
disease."
"Temporary remission of your signs and symptoms is common during
pregnancy."
"Autoantibodies transferred to the baby during pregnancy will cause
heart defects."
"The baby is at high risk for neonatal lupus erythematosus being
diagnosed at birth." - CORRECT ANSWER- "Infertility can result from
some medications used to control your disease."
Rationale:
Infertility may be caused by renal involvement and the previous use of
high-dose corticosteroid and chemotherapy drugs. Neonatal lupus
erythematosus rarely occurs in infants born to women with SLE.
Exacerbation is common after pregnancy during the postpartum period.
Spontaneous abortion, stillbirth, and intrauterine growth retardation are
