NSG 4100 Exam 2 Actual exam with
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Nurse is caring for a client after hypophysectomy and notes clear nasal drainage from
the client's nostril. The nurse should take which initial action?
a. lower the head of the bed
b. test drainage for glucose
c. obtain culture of drainage
d. continue to observe drainage - CORRECT ANSWER --B
Nurse is admitting a client who is diagnosed w/ SIADH and has serum sodium of 118
mEq/L. Which physician prescription should the nurse anticipate receiving? Select all
that apply:
a. Initiate infusion of 3% NaCl
b. administer IV furosemide
c. Restrict fluids to 800ml over 24hrs
d. elevate HOB to high fowler's
e. administer a vasopressin antagonist as prescribed - CORRECT ANSWER --A, C, E
Nurse performing an assessment on a client w/ pheochromocytoma. Which assessment
data would indicate potential complication with this disease?
a. urinary output of 50ml/h
b. coagulation time of 5 mins
c. HR that is 90bpm & irregular
d. BUN of 20 mg/dL - CORRECT ANSWER --C
Client is to have transsphenoidal hypophysectomy to remove a large, invasive pituitary
tumor. The nurse should instruct the client that the surgery will be performed through an
incision in the
a. back of mouth
b. nose
, c. sinus channel below right eye
d. upper gingival mucosa in the space between the upper gum and lip - CORRECT
ANSWER --D
Nurse teaches client to report s/s of which potential complication after a
hypophysectomy?
a. acromegaly
b. Cushing's ds
c. diabetes mellitus
d. hypopituitarism - CORRECT ANSWER --D
After pituitary surgery, the nurse should assess the client for
a. urine gravity <1.010
b. UO between 1-2L/day
c. BG >300 mg/dL
d. urine negative for glucose & ketones - CORRECT ANSWER --A
Client with type 1 diabetes is admitted to ED w/ recurrent DKA. Current glucose level is
603 w/ moderate bicarbonate levels. The client is drowsy but responds appropriately.
Vital signs are BP 90/42, sinus tachycardia 132/min, RR 36/min, temp 102F, & minimal
UO. What does the nurse anticipate as the highest priority for the client?
a. culture urine, blood, and sputum for bacteria
b. start insulin drop following bolus of 7 units of rapid insulin
c. start large bore IV access to allow rapid insulin of fluids
d. give rapid acting insulin IM while waiting for labs - CORRECT ANSWER --C
19 y/o woman was admitted to ICU following high-velocity MVA in which she sustained
a severe closed head injury. Nurse noticed she has been producing a large amount of
urine for the past 3 hrs and is becoming tachycardia and hypotensive. The nurse knows
that this client needs to be closely monitored for developing which condition?
a. Cushing syndrome, which is treated w/ intermittent doses of corticoids
b. DI, which is treated w/ antidiuretic hormone (Vasopressin)
c. SIADH, which is create w/ ADH
d. DM, which is treated w/ basal analog insulin - CORRECT ANSWER --B
Client w/ pituitary tumor developed SIADH. Which intervention should the nurse
implement?
a. assess for dehydration and monitor BG level
b. assess for n/v & weigh daily
c. monitor potassium level & encourage fluid intake
d. administer vasopressin IV and conduct fluid deprivation test - CORRECT ANSWER --
B
Nurse is admitting a client to the neurological ICU who is postoperative transsphenoidal
hypophysectomy. Which data warrants immediate intervention?
a. client is alert to name but unable to tell nurse the location
best questions and verified answers
latest update
Nurse is caring for a client after hypophysectomy and notes clear nasal drainage from
the client's nostril. The nurse should take which initial action?
a. lower the head of the bed
b. test drainage for glucose
c. obtain culture of drainage
d. continue to observe drainage - CORRECT ANSWER --B
Nurse is admitting a client who is diagnosed w/ SIADH and has serum sodium of 118
mEq/L. Which physician prescription should the nurse anticipate receiving? Select all
that apply:
a. Initiate infusion of 3% NaCl
b. administer IV furosemide
c. Restrict fluids to 800ml over 24hrs
d. elevate HOB to high fowler's
e. administer a vasopressin antagonist as prescribed - CORRECT ANSWER --A, C, E
Nurse performing an assessment on a client w/ pheochromocytoma. Which assessment
data would indicate potential complication with this disease?
a. urinary output of 50ml/h
b. coagulation time of 5 mins
c. HR that is 90bpm & irregular
d. BUN of 20 mg/dL - CORRECT ANSWER --C
Client is to have transsphenoidal hypophysectomy to remove a large, invasive pituitary
tumor. The nurse should instruct the client that the surgery will be performed through an
incision in the
a. back of mouth
b. nose
, c. sinus channel below right eye
d. upper gingival mucosa in the space between the upper gum and lip - CORRECT
ANSWER --D
Nurse teaches client to report s/s of which potential complication after a
hypophysectomy?
a. acromegaly
b. Cushing's ds
c. diabetes mellitus
d. hypopituitarism - CORRECT ANSWER --D
After pituitary surgery, the nurse should assess the client for
a. urine gravity <1.010
b. UO between 1-2L/day
c. BG >300 mg/dL
d. urine negative for glucose & ketones - CORRECT ANSWER --A
Client with type 1 diabetes is admitted to ED w/ recurrent DKA. Current glucose level is
603 w/ moderate bicarbonate levels. The client is drowsy but responds appropriately.
Vital signs are BP 90/42, sinus tachycardia 132/min, RR 36/min, temp 102F, & minimal
UO. What does the nurse anticipate as the highest priority for the client?
a. culture urine, blood, and sputum for bacteria
b. start insulin drop following bolus of 7 units of rapid insulin
c. start large bore IV access to allow rapid insulin of fluids
d. give rapid acting insulin IM while waiting for labs - CORRECT ANSWER --C
19 y/o woman was admitted to ICU following high-velocity MVA in which she sustained
a severe closed head injury. Nurse noticed she has been producing a large amount of
urine for the past 3 hrs and is becoming tachycardia and hypotensive. The nurse knows
that this client needs to be closely monitored for developing which condition?
a. Cushing syndrome, which is treated w/ intermittent doses of corticoids
b. DI, which is treated w/ antidiuretic hormone (Vasopressin)
c. SIADH, which is create w/ ADH
d. DM, which is treated w/ basal analog insulin - CORRECT ANSWER --B
Client w/ pituitary tumor developed SIADH. Which intervention should the nurse
implement?
a. assess for dehydration and monitor BG level
b. assess for n/v & weigh daily
c. monitor potassium level & encourage fluid intake
d. administer vasopressin IV and conduct fluid deprivation test - CORRECT ANSWER --
B
Nurse is admitting a client to the neurological ICU who is postoperative transsphenoidal
hypophysectomy. Which data warrants immediate intervention?
a. client is alert to name but unable to tell nurse the location
