NSG 4800 ACTUAL FINALS QUESTIONS AND
ANSWERS SET A+
✔✔A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The
initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV)
infusion of short-acting insulin is initiated, along with IV rehydration with normal saline.
The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse
would next prepare to administer which medication?
An ampule of 50% dextrose
NPH insulin subcutaneously
IV fluids containing dextrose
Phenytoin for the prevention of seizures - ✔✔C. Emergency management of DKA
focuses on correcting fluid and electrolyte imbalances and normalizing the serum
glucose level. If the corrections occur too quickly, serious consequences, including
hypoglycemia and cerebral edema, can occur. During management of DKA, when the
blood glucose level falls to 250 to 300 mg/dL (14.2 to 17.1 mmol/L), the IV infusion rate
is reduced and a dextrose solution is added to maintain a blood glucose level of about
250 mg/dL (14.2 mmol/L), or until the client recovers from ketosis. Fifty percent dextrose
is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin is not a
usual treatment measure for DKA.
✔✔A client is being discharged from the emergency department after an evaluation for
a concussion. The nurse reinforces teaching regarding follow-up should the client
develop complications. Which of the following complications, if listed by the client, would
require further instruction?
1.Vomiting
2.Minor headache
3.Difficulty speaking
4.Difficulty awakening - ✔✔2; all others responses would indicate IICP and needs to go
to the ER
✔✔The patient sustained an open fracture of the femur from an automobile accident.
The nurse should assess the client for which type of shock?
A. cardiogenic
, B. hypovolemic
C. neurogenic
D. anaphylactic - ✔✔B. A fractured femur, especially an open fracture, can cause much
soft tissue damage and lead to significant blood loss. Hypovolemic shock can develop.
Cardiogenic shock occurs when cardiac output is decreased as a result of ineffective
pumping. Neurogenic shock occurs as a result of an impaired autonomic nervous
system function. Anaphylactic shock is the result of an allergic reaction.
✔✔The registered nurse has received a report on four clients. The nurse should first
assess the client who has:
A.Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of
89%
B.Parkinson's Disease and is demanding to leave the hospital against medical advice
(AMA)
C.been admitted with suspected Guillian Barre Syndrome and has begun
plasmapheresis therapy
D.Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+) - ✔✔C.
The client admitted with Guillain-Barre' Syndrome should be assessed first because of
the possibility of rapid progression of this illness and neuromuscular respiratory failure;
clients with COPD are likely to have pulse oximetry readings of 90% related to chronic
hypoxia; this client along with the other two choices are important, but not the priority.
✔✔A client with chronic renal failure is receiving hemodialysis three times a week. What
should the nurse do to protect the fistula?
A. Take the blood pressure in the arm with the fistula.
B. Report the loss of a thrill or bruit on the arm with the fistula.
C. Maintain a pressure dressing on the shunt.
D. Start a second IV in the arm with the fistula. - ✔✔B. The nurse must always
auscultate for a bruit and palpate for a thrill in the arm with the fistula and promptly
report the absence of either a thrill or bruit to the health care provider as it indicates an
occlusion. The client should not have a pressure dressing on the shunt and should
avoid wearing tight clothing or carrying heavy items such as a purse over the area of the
shunt to avoid restricting blood flow in the shunt. No procedures such as IV access,
blood pressure measurements, or blood draws are done on an arm with a fistula as they
could damage the fistula.
✔✔The nurse in the mental health unit plans to use which therapeutic communication
techniques when communicating with a client? Select all that apply.
Restating
Listening
Asking the client "Why?"
Maintaining neutral responses
Providing acknowledgment and feedback
Giving advice and approval or disapproval - ✔✔1, 2, 4, 5. Therapeutic communication
techniques include listening, maintaining silence, maintaining neutral responses, using
ANSWERS SET A+
✔✔A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The
initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV)
infusion of short-acting insulin is initiated, along with IV rehydration with normal saline.
The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse
would next prepare to administer which medication?
An ampule of 50% dextrose
NPH insulin subcutaneously
IV fluids containing dextrose
Phenytoin for the prevention of seizures - ✔✔C. Emergency management of DKA
focuses on correcting fluid and electrolyte imbalances and normalizing the serum
glucose level. If the corrections occur too quickly, serious consequences, including
hypoglycemia and cerebral edema, can occur. During management of DKA, when the
blood glucose level falls to 250 to 300 mg/dL (14.2 to 17.1 mmol/L), the IV infusion rate
is reduced and a dextrose solution is added to maintain a blood glucose level of about
250 mg/dL (14.2 mmol/L), or until the client recovers from ketosis. Fifty percent dextrose
is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin is not a
usual treatment measure for DKA.
✔✔A client is being discharged from the emergency department after an evaluation for
a concussion. The nurse reinforces teaching regarding follow-up should the client
develop complications. Which of the following complications, if listed by the client, would
require further instruction?
1.Vomiting
2.Minor headache
3.Difficulty speaking
4.Difficulty awakening - ✔✔2; all others responses would indicate IICP and needs to go
to the ER
✔✔The patient sustained an open fracture of the femur from an automobile accident.
The nurse should assess the client for which type of shock?
A. cardiogenic
, B. hypovolemic
C. neurogenic
D. anaphylactic - ✔✔B. A fractured femur, especially an open fracture, can cause much
soft tissue damage and lead to significant blood loss. Hypovolemic shock can develop.
Cardiogenic shock occurs when cardiac output is decreased as a result of ineffective
pumping. Neurogenic shock occurs as a result of an impaired autonomic nervous
system function. Anaphylactic shock is the result of an allergic reaction.
✔✔The registered nurse has received a report on four clients. The nurse should first
assess the client who has:
A.Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of
89%
B.Parkinson's Disease and is demanding to leave the hospital against medical advice
(AMA)
C.been admitted with suspected Guillian Barre Syndrome and has begun
plasmapheresis therapy
D.Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+) - ✔✔C.
The client admitted with Guillain-Barre' Syndrome should be assessed first because of
the possibility of rapid progression of this illness and neuromuscular respiratory failure;
clients with COPD are likely to have pulse oximetry readings of 90% related to chronic
hypoxia; this client along with the other two choices are important, but not the priority.
✔✔A client with chronic renal failure is receiving hemodialysis three times a week. What
should the nurse do to protect the fistula?
A. Take the blood pressure in the arm with the fistula.
B. Report the loss of a thrill or bruit on the arm with the fistula.
C. Maintain a pressure dressing on the shunt.
D. Start a second IV in the arm with the fistula. - ✔✔B. The nurse must always
auscultate for a bruit and palpate for a thrill in the arm with the fistula and promptly
report the absence of either a thrill or bruit to the health care provider as it indicates an
occlusion. The client should not have a pressure dressing on the shunt and should
avoid wearing tight clothing or carrying heavy items such as a purse over the area of the
shunt to avoid restricting blood flow in the shunt. No procedures such as IV access,
blood pressure measurements, or blood draws are done on an arm with a fistula as they
could damage the fistula.
✔✔The nurse in the mental health unit plans to use which therapeutic communication
techniques when communicating with a client? Select all that apply.
Restating
Listening
Asking the client "Why?"
Maintaining neutral responses
Providing acknowledgment and feedback
Giving advice and approval or disapproval - ✔✔1, 2, 4, 5. Therapeutic communication
techniques include listening, maintaining silence, maintaining neutral responses, using
