MEDSERGE 2 FLASHCARDS

MEDSERGE 2 FLASHCARDS A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) A. Increased heart rate B. Increased blood pressure C. Increased respiratory rate D. Increase hematocrit E. Increased temperature Increased heart rate B. Increased blood pressure C. Increased respiratory rate A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin? prothrombin time .A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first? stop the infusion of blood .A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect? hemolytic A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect? hemorrhagic stroke Upgrade to remove ads Only $3/month A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock increase heart rate ftom 88 to 110/min A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? 0.45% sodium chloride A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation? different apical and radial pulses A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take assess the apical pulse for a full minute A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity? Anorexia Rationale:Anorexia, vomiting, confusion, headache, and vision changes are manifestations of digoxin toxicity .A nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect? systolic BP is increaed A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make? a headache is an expected adverse effect of this medication A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include? eat foods that contain potassium loop diuretics lose potassium! A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0 to 10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take? administer another nitroglycerin tablet A nurse is caring for a client who is at 6 weeks of gestation and has pneumonia. While the nurse is obtaining the client's history, the client tells the nurse that she takes the herb feverfew for migraine headaches. Which of the following actions should the nurse take? explain to the client that she should not take this herb while pregnant A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following dysrhythmias A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time place the client on his left side in trendelenburg position Upgrade to remove ads Only $3/month A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding? oliguria A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect? Blood pressure 115/68 mmHg Rationale:The sympathetic nervous system is stimulated, resulting in the release of epinephrine and norepinephrine. These catecholamines help maintain the client's blood pressure remains within normal limits during the compensatory stage of shock. A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG? A fib A nurse is among the first responders to a mass-casualty incident and does not know what type of personal protective equipment (PPE) is needed. Which of the following actions should the nurse take choose highest level of protection equipment available A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client? a private room A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? Abnormally prominent U wave Rationale:Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression. A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider? dyspnea .A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following findings should the nurse expect? (Select all that apply.) hypotension weak pulses murmur A nurse is caring for an 8-year-old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission? auscultating the rate and characteristics of the childs heart sounds A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? the clients bladder becomes distended severe hyperkalemia.. widedned P wave before QRS A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? "DIC is caused by abnormal coagulation involving fibrinogen." A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect? excessive thrombosis and bleeding A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? assess apical pulse for a full minute A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect? lab values are prolonged A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers? the left second intercostal space aortic area right second intercostal space tricuspid area left fifth intercostal space mitral area (point of maximal impulse) left fifth intercostal space at midclavicular line A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? shivering A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a manifestation of acute hemolytic reaction? client report low back pain A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes which of the following as a manifestation of hypokalemia? shallow respirations .A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload? dyspnea A nurse is assessing an IV infusion site on an infant's left hand. Which of the following findings should the nurse identify as an indication of an infiltration? edema in the palm of the hand A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. If this medication is effective, the nurse should expect which of the following changes on the client's ECG? reduction of T wave amplitude A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg PO daily. Available is digoxin PO 0.25 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 0.5 tablets A nurse is preparing to administer amoxicillin 30 mg/kg/day divided equally every 12 hr to a toddler who weighs 32 lb (14.5 kg). Available is amoxicillin 200 mg/5 mL suspension. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 5.5 mL A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products? recombinant A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first? Measure the circumference of both upper arms. Rationale:The first action the nurse should take using the nursing process is to assess the client. The nurse should measure the arm and compare the result with the circumference of the other arm. If the arm is swollen, the nurse should notify the provider who inserted the PICC line. Swelling could indicate formation of a clot above the site or even catheter rupture. A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects? dysrhythmias A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first? take clients vitals A nurse is reviewing data for four children. Which of the following children should the nurse assess first? 10-year old child who has sickle cell anemia who reports severe chest pain A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? antiplatelet aggregate A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give? heparin does not dissolve clots. it stops new clots from forming .A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord? two arteries one vein A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select? median vein the in forearm A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication? hypotension A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication? decreased BP A nurse on an oncology unit is preparing to administer doxorubicin to a client who has breast cancer. Prior to beginning the infusion, the nurse verifies the client's current cumulative lifetime dose of the medication. For which of the following reasons is this verification necessary? An excess amount of doxorubicin can lead to cardiomyopathy A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following statements by the client indicates an adverse effect of the medication? I feel nasueated and have no appetite While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care? impaired tissue perfusion .A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching? I will take my medication at the first sign of an attack A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? these tests help determine the degree of damage to the heart tissue Another Flashcard A nurse is caring for a client who has Addison's disease and is at risk for Addisonian crisis. Nursing care of this client should include which of the following nursing actions? Taking daily weights Addison's disease is an endocrine disorder that occurs in all age groups and affects men and women equally. The disease is characterized by weight loss, muscle weakness, fatigue, low blood pressure, and hyperpigmentation (darkening) of the skin in both exposed and unexposed parts of the body. Daily weight will alert the nurse that dehydration is occurring, which could indicate an impending crisis. A nurse is caring for a client after a craniotomy for pituitary tumor who has developed diabetes insipidus. The client is receiving vasopressin (Pitressin). The desired response to the medication is evident when the nurse observes which of the following findings? A decrease in urine output. The major manifestations of diabetes insipidus are excessive urination and extreme thirst. Pitressin is used to control frequent urination, increased thirst, and loss of water associated with diabetes insipidus. A decreased urine output is the desired response. A nurse is preparing teaching for a female client who smokes, is obese, and has hypertension. In establishing health promotion goals for the client, the nurse should recognize that which of the following is an inappropriate recommendation for the client? Eliminate sodium from the diet. A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? (Select all that apply.) *Diaphoresis is correct. Acromegaly is a chronic metabolic disorder caused by an excess of growth hormone after normal growth of the skeleton and other organs is complete. The physical manifestations associated with acromegaly include enlarged sebaceous glands with excessive sweating. *Coarse facial features is correct. The physical manifestations associated with acromegaly include enlarged facial bones with thickening of the skin, leading to coarse facial features. *Enlarged distal extremities is correct. The physical manifestations associated with acromegaly include enlarged hands and feet with thickening of the skin. *Muscle weakness is correct. The physical manifestations associated with acromegaly include fatigue and muscle weakness. A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications? Shivering The hypothermia (cooling) blanket, if used improperly (at inappropriately low temperatures, or without skin protection), can cause the client to cool too fast, leading to shivering. To prevent heat loss from the skin, the body becomes peripherally vasoconstricted in an attempt to reduce heat loss. The body will also try to increase heat production by shivering, which can increase the metabolic rate by two to five times and in doing so greatly raise oxygen consumption. A nurse is caring for a client who is suspected of having diabetes insipidus and is scheduled for a water deprivation test. During the test, the nurse should know to frequently assess the client for the development of hypotension. A client who has diabetes insipidus will continue to excrete urine even though there is no intake. Hypovolemia, with resulting hypotension, is possible. Upgrade to remove ads Only $3/month A nurse is caring for a client who sustained a basal skull fracture. On assessment, the nurse notices a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? Test the drainage for glucose. This is the priority nursing action. Because of the high risk of cerebral spinal fluid (CSF) leak in clients with basal skull fractures, the nurse should realize there is a possibility that the clear fluid coming from the client's nostril is CSF. A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client? Regular (Humulin R) 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 hyperglycemia. A nurse is caring for a client admitted with end-stage cirrhosis of the liver. Which of the following interventions should the nurse anticipate taking to decrease the client's serum ammonia level? Start the client on a low-protein, high-calorie diet. A low-protein, high-calorie diet will reduce the source of ammonia and provide adequate carbohydrates for energy requirements while sparing protein from breakdown for energy. A nurse is caring for a client admitted with a diagnosis of hyperthyroidism. The client reports a weight loss of 5.4 kg (12 lb) in the last 2 months despite increased appetite. Additional symptoms reported include increased perspiration, fatigue, menstrual irregularity, and restlessness. Which of the following measures should the nurse include in the client's plan of care to prevent a thyroid crisis? Provide a quiet, low-stimulus environment. Thyroid crisis can occur in response to a stressor, so the client should not be exposed to other clients who have active infections or an environment that is noisy and stimulating. A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize which of the following as manifestations of Cushing's syndrome? (Select all that apply.) Cushing's syndrome have hirsutism, excessive body hair, rather than alopecia, hair loss. Tremors are not a common finding in Cushing's syndrome. *Moon face is correct. Moon face, manifested by a round, red, full face, is common in Cushing's syndrome. *Purple striations is correct. Purple striations on the skin of the abdomen, thighs, and breasts are a common manifestation in Cushing's syndrome. Obese extremities is incorrect. Clients who have Cushing's syndrome have truncal obesity (a protuberant abdomen) with thin extremities. *Buffalo hump is correct. Buffalo hump, a collection of fat between the shoulder blades, is a common manifestation in Cushing's syndrome. A nurse is caring for a client admitted with a severe burn injury who is receiving intravenous fluid replacement therapy. The nurse evaluates the therapy to be inadequate if the client developed an increase in heart rate. The client's increased heart rate is likely to be caused by hypovolemia, which indicates inadequate fluid replacement. A nurse is caring for a client whose blood work indicates that the client has hyperthyroidism. The nurse should expect the client to report frequent mood changes. Hyperthyroidism develops when the thyroid gland produces an excess of the thyroid hormones that regulates metabolic rate. Nervousness; frequent mood changes; hand tremors; a rapid, pounding, irregular heartbeat; heat intolerance; diarrhea; and weight loss are common manifestations of hyperthyroidism. The client will have increased peristalsis and may experience diarrhea Hyperthyroidism causes an increased rate of body metabolism, so the client may experience heat intolerance Hyperthyroidism causes an increased rate of body metabolism, so the client may experience weight loss A nurse in a clinic is reviewing the laboratory values obtained from a client being seen for suspected hypothyroidism. If this diagnosis is accurate, the nurse should expect to see an elevated thyroid stimulating hormone (TSH). In hypothyroidism, the nonfunctioning thyroid gland is unable to respond to the TSH, and no endogenous thyroid hormones, such as T3, T4, and free thyroxine, are released. Low levels of T3 and T4 are the underlying stimuli for the release of TSH from the anterior pituitary. This results in an elevation of the TSH level as the anterior pituitary continues to release TSH to stimulate the thyroid gland to release the thyroid hormones T3 and T4. A nurse is caring for a client whose total parenteral nutrition (TPN) was stopped for an hour by mistake. After restarting the infusion pump, the nurse should watch the client carefully for the development of shakiness and diaphoresis. When a sudden interruption in the infusion of TPN occurs, the client is at risk for hypoglycemia. Shakiness and diaphoresis are manifestations of hypoglycemia. A nurse is performing teaching with a client who has newly diagnosed type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following manifestations of hypoglycemia? (Select all that apply.) Manifestations of hyperglycemia include polyuria (excessive urination). *Vertigo is correct. Manifestations of hypoglycemia include vertigo (dizziness). Manifestations of hyperglycemia include polydipsia (excessive thirst). *Tachycardia is correct. Manifestations of hypoglycemia include tachycardia. Manifestations of hyperglycemia include acetone breath (due to ketosis). *Moist, clammy skin is correct. A client who is newly diagnosed with type 2 diabetes mellitus should be taught to recognize the manifestations of hypoglycemia (decreased blood sugar) that may occur as a result of an insulin reaction, inadequate intake of glucose, or increased exercise. Manifestations of hypoglycemia include moist, clammy skin. A nurse is assessing a client admitted with Cushing's syndrome. Which of the following manifestations should the nurse expect the client to report? Increased bruising A client who has Cushing's syndrome will have thin skin that is fragile and easily bruised or traumatized. Ecchymoses, petechiae (small intradermal or submucosal bleeds), and striae (purple lines on the skin of the abdomen, thighs, and breasts) will often develop as well. The eye complications associated with Cushing's syndrome are glaucoma and corneal lesions. A client who has Cushing's syndrome will have a weight gain due to overproduction of adrenal cortical hormone. A nurse is discontinuing a course of prednisone (Deltasone) for a client with an exacerbation of asthma. The nurse should taper the dose so that the client does not experience adrenocortical insufficiency. Prednisone, a corticosteroid, is similar to cortisol, the glucocorticoid hormone produced by the adrenal glands. It relieves inflammation and is used to treat certain forms of arthritis, severe allergies, autoimmune disorders, and asthma. Administration of glucocorticoids may depress the body's normal adrenocortical activity, and abrupt withdrawal of the drug can lead to a syndrome of adrenal insufficiency. Upgrade to remove ads Only $3/month A nurse is caring for a client who is newly diagnosed with diabetes mellitus and is prescribed glipizide (Glucotrol). When instructing the client about this medication, the nurse should describe its method of action with which of the following statements? "Glucotrol stimulates your pancreas to release adequate insulin." Glipizide is an oral antidiabetic medication in the pharmacological classification of sulfonylurea agents. These medications help to lower blood glucose levels in clients who have type 2 diabetes mellitus using several methods, including reducing glucose output by the liver, increasing peripheral sensitivity to insulin, and stimulating the release of insulin from the beta cells of the pancreas. Glipizide is an oral antidiabetic medication in the pharmacological classification of sulfonylurea agents Sulfonylurea agents reduce the glucose output of the liver. A nurse is teaching a client who is morbidly obese and has been prescribed orlistat (Xenical). The nurse should recognize that the client has a good understanding of the medication if the client states which of the following? "I will take Xenical three times a day, just before each meal." Orlistat, a lipase inhibitor, is used as an aid to help clients who are morbidly obese to lose weight. Orlistat prevents the absorption of some of the fat in the client's dietary intake at each meal. Therefore, the client should take the medication during the meal or within 1 hr of eating. On the first postoperative day following a subtotal thyroidectomy, the client reports a tingling sensation in the hands, soles of the feet, and around the lips. For which of the following should the nurse assess the client? Positive Chvostek's sign. The nurse suspects that the client has hypocalcemia, a possible complication following subtotal thyroidectomy. Symptoms of hypocalcemia include numbness and tingling in the hands, soles of the feet, and around the lips. These symptoms typically appear between 24 and 48 hours after surgery. To elicit Chvostek's sign, the nurse taps the client's face at a point just anterior to the ear and just below the zygomatic bone. A positive response would be twitching of the ipsilateral (same side only) facial muscles, suggestive of neuromuscular excitability caused by hypocalcemia. -Babinski sign is a diagnostic test for brain damage or upper motor neuron damage. It is considered positive if the toes flare up upon stroking the plantar aspect of the foot. -Brudzinski's sign is an indication of meningeal irritation, which may be positive in clients with meningitis. With the client supine, the nurse places one hand behind the client's head and places the other hand on the client's chest. The nurse then raises the client's head (with the hand behind the head) while the hand on the chest restrains the client and prevents the client from rising. Flexion of the client's lower extremities constitutes a positive sign. -Kernig's sign is an indication of meningeal irritation, which may be positive in clients with meningitis. The maneuver is usually performed with the client supine with hips and knees in flexion. Extension of the knees is attempted, and the inability to extend the client's knees beyond 135 degrees without causing pain constitutes a positive test. A nurse is caring for a client who has been on levothyroxine (Synthroid) for several months. If the dose of this medication has been adequate, the nurse should expect to see a decrease in the thyroid stimulating hormone (TSH). In hypothyroidism, the nonfunctioning thyroid gland is unable to respond to the TSH, and no endogenous thyroid hormones are released. This results in an elevation of the TSH level as the anterior pituitary continues to release the TSH to stimulate the thyroid gland. Administration of exogenous thyroid hormones, such as levothyroxine, turns off this feedback loop, which results in a decreased level of TSH. A nurse is completing an assessment on a client who is admitted for elective surgery and has a history of Addison's disease. Which of the following findings should the nurse expect? Hyperpigmentation Addison's disease is an endocrine disorder that occurs when the adrenal glands do not produce enough of the hormone cortisol, and in some cases, the hormone aldosterone. The disease is characterized by weight loss, muscle weakness, fatigue, low blood pressure, and hyperpigmentation (darkening) of the skin in both exposed and non- exposed parts of the body. A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. To detect an electrolyte imbalance caused by corticosteroid use, the nurse should monitor the client for which of the following? Muscle weakness Corticosteroid use can lead to hypokalemia, which features manifestations of muscle weakness and cardiac arrhythmia. Another flashcard a nurse is reviewing the lab results of an adolescent female client and notes a WBC count of 16,000/ mm3 with increased immature neutrophils and normal monocytes which of the following is the appropriate analysis of the results? a) an acute infectious process b) neutropenia c) allergic reaction d) a resolving inflammatory process a) an acute infectious process - the WBC count is greatly elevated indicates infection or inflammation; the elevated neutrophil count sometimes referred as 'shift to the left' indicates an acute process a nurse is caring for a client who is HIV positive and is one day post-op following an appendectomy the nurse should wear a gown as personal protective equipment when taking which of the following actions? a) talking to the client at bedside b) administering an intermittent IV bolus medication c) completing a dressing change d) administering an IM injection c) completing a dressing change - standard precautions require personal protective equipment when there is a risk of contact with body fluids; a dressing change presents a risk for coming into contact with body fluids a group of nurses are discussing risk factors for transmission of HIV from clients which of the following individuals should the nurse identify as being the greatest risk for contracting HIV? a) occupational therapist who works with client who has HIV b) personal trainer who works with client who has HIV c) phlebotomist who collects blood from clients who have HIV d) nurse who works for insurance company and collects urine samples from clients who have HIV c) phlebotomist who collects blood from clients who have HIV - greatest risk for exposure to HIV is from a needle stick a nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE) the nurse should recognize the need for further teaching when the client identifies which of the following a a factor that can exacerbate SLE? a) sunlight b) pregnancy c) infection d) exercise d) exercise - the nurse should encourage client to engage in conditioning exercises with alternated periods of rest a nurse is admitting a client who has a partial hearing loss which is the priority action by the nurse? a) speak using usual tone of voice b) stand directly in front of client c) rephrase statements the client does not hear d) determine if the client uses hearing aids d) determine if the client uses hearing aids - first action is to assess the client, find out if they have hearing aids and whether they are in place and functioning nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB? a) chest x-ray b) sputum culture for acid-fast bacillus c) sputum smear d) mantoux test b) sputum culture for acid-fast bacillus - although the mantoux (skin test) and chest X-ray may be useful for TB, the presence of acid-fast bacillus noted in the sputum secretions or tissues is the only method that can confirm the diagnosis Upgrade to remove ads Only $3/month a nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T-cell count the nurse should recognize the client is at risk for developing which of the following infectious oral conditions? a) halitosis b) gingivitis c) xerostomia d) candidiasis d) candidiasis (yeast infection) - occurs most often in infants, toddlers, older adults, & clients whose immune systems have been compromised by illness, such as AIDS, or medications a nurse is preparing a presentation at a senior center about age related musculoskeletal changes which of the following should she include? a) decreased muscle mass b) thickened vertebral disks c) reduced chest width d) increased force of isometric contraction a) decreased muscle mass - decrease in muscle mass and strength occur with aging nurse is assessing a client who has SLE which of the following findings should the nurse expect? a) wrinkles in the skin b) constipation c) iritis d) facial rash d) facial rash "butterfly" rash that is dry, scaly, red a nurse is caring for a client who is postop following a left corneal transplant nurse observes purulent drainage from the affected eye which is the priority action for the nurse? a) notify the surgeon b) instill an abx solution in both eyes c) clean eye from inner to outer cants d) apply a non-pressure patch to the affected eye a) notify the surgeon - this is a manifestation of infection and should be reported to surgeon immediately nurse is planning care for a client who has immunosuppression following chemo which of the following interventions should the nurse include in the plan of care? a) insert indwelling catheter to monitor sediment in urine b) take client's temp once per shift c) provide client with fresh fruit to avoid constipation d) limit the # of health care workers entering the room d) limit the # of health care workers entering the room - nurse should do this to prevent possible overexposure to microorganisms that can lead to infection a nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops which of the following instructions should the nurse provide? a) med is to be applied when the client is experiencing eye pain b) med will be used until the client's intraocular pressure returns to normal c) med should be applied on a regular schedule for the rest of the client's life d) med is to be used for approx. 10 days, followed by gradual tapering off c) the med should be applied on a regular schedule for the rest of the client's life a nurse in a clinic is interviewing a client who will undergo diagnostic testing the nurse should ask about a client's potential allergies during which phase of the nursing process? a) planning b) evaluation c) assessment d) implementation c) assessment a nurse is administering timolol eye drops to a client who has glaucoma which of the following actions should the nurse take? a) apply pressure to the bridge of the nose after administration b) wipe the eye from the outer canthus to the inner cants before instillation c) drop prescribed amount of medication into the conjunctival sac d) protect the distal portion of the eyedropper using clean technique c) drop prescribed amount of medication into the conjunctival sac Another A nurse is collecting data regarding a client after a thyroidectomy and notes that the client has developed hoarseness and a weak voice. Which nursing action is appropriate? 1. Check for signs of bleeding. 2. Administer calcium gluconate. 3. Notify the registered nurse immediately. 4. Reassure the client that this is usually a temporary condition. rationale Weakness and hoarseness of the voice can occur as a result of trauma of the laryngeal nerve. If this develops, the client should be reassured that the problem will subside in a few days. Unnecessary talking should be discouraged. It is not necessary to notify the registered nurse immediately. These signs do not indicate bleeding or the need to administer calcium gluconate. A nurse is assisting with preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. Which instruction should be included in the plan of care? 1. Soak the feet in hot water. 2. Avoid using soap to wash the feet. 3. Apply a moisturizing lotion to dry feet, but not between the toes. 4. Always have a podiatrist cut your toenails; never cut them yourself. rationale The client should use a moisturizing lotion on his or her feet, but should avoid applying the lotion between the toes. The client should also be instructed to not soak the feet and to avoid hot water to prevent burns. The client may cut the toenails straight across and even with the toe itself, but he or she should consult a podiatrist if the toenails are thick or hard to cut or if his or her vision is poor. The client should be instructed to wash the feet daily with a mild soap. A nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. Which statement, if made by the client, indicates the need for further teaching? 1. "I'll eat a balanced meal plan." 2. "I need to drink diet soft drinks." 3. "I need to buy special dietetic foods." 4. "I will snack on fruit instead of cake." rationale It is important to emphasize to the client and family that they are not eating a diabetic diet but rather following a balanced meal plan. Adherence to nutrition principles is an important component of diabetic management, and an individualized meal plan should be developed for the client. It is not necessary for the client to purchase special dietetic foods. A nurse reinforces teaching with a client with diabetes mellitus regarding differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that glucose will be taken if which symptom develops? 1. Polyuria 2. Shakiness 3. Blurred vision 4. Fruity breath odor rationale Shakiness is a sign of hypoglycemia, and it would indicate the need for food or glucose. Fruity breath odor, blurred vision, and polyuria are signs of hyperglycemia. When the nurse is teaching a client who has been newly diagnosed with type 1 diabetes mellitus, which statement by the client would indicate that teaching has been effective? 1. "I will stop taking my insulin if I'm too sick to eat." 2. "I will decrease my insulin dose during times of illness." 3. "I will adjust my insulin dose according to the level of glucose in my urine." 4. "I will notify my health care provider if my blood glucose level is greater than 250 mg/dL." rationale During illness, the client should monitor the blood glucose level, and he or she should notify the health care provider (HCP) if the level is greater than 250 mg/dL. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the HCP's advice. A nurse is monitoring a client who has been newly diagnosed with diabetes mellitus for signs of complications. Which of the following, if exhibited by the client, would indicate hyperglycemia and thus warrant health care provider notification? 1. Polyuria 2. Bradycardia 3. Diaphoresis 4. Hypertension rationale The classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Options 2, 3, and 4 are not signs of hyperglycemia. Upgrade to remove ads Only $3/month A nurse is reinforcing instructions with a client with diabetes mellitus who is recovering from diabetic ketoacidosis (DKA) regarding measures to prevent a recurrence. Which instruction is important for the nurse to emphasize? 1. Eat six small meals daily. 2. Test the urine ketone levels. 3. Monitor blood glucose levels frequently. 4. Receive appropriate follow-up health care. rationale Client education after DKA should emphasize the need for home glucose monitoring four to five times per day. It is also important to instruct the client to notify the health care provider when illness occurs. The presence of urinary ketones indicates that DKA has already occurred. The client should eat well-balanced meals with snacks, as prescribed. A nurse is reviewing discharge teaching with a client who has Cushing's syndrome. Which statement by the client indicates that the instructions related to dietary management were understood? 1. "I can eat foods that contain potassium." 2. "I will need to limit the amount of protein in my diet." 3. "I am fortunate that I can eat all the salty foods I enjoy." 4. "I am fortunate that I do not need to follow any special diet." rationale A diet that is low in calories, carbohydrates, and sodium but ample in protein and potassium content is encouraged for a client with Cushing's syndrome. Such a diet promotes weight loss, the reduction of edema and hypertension, the control of hypokalemia, and the rebuilding of wasted tissue. A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia. Which statement by the client indicates a correct understanding of NPH insulin and exercise? 1. "I should not exercise after lunch." 2. "I should not exercise after breakfast." 3. "I should not exercise in the late evening." 4. "I should not exercise in the late afternoon." rationale A hypoglycemic reaction may occur in response to increased exercise. Clients should avoid exercise during the peak time of insulin. NPH insulin peaks at 12 to 14 hours; therefore, late afternoon exercise would occur during the peak of the medication. A nurse is caring for a postoperative parathyroidectomy client. Which of the following would require the nurse's immediate attention? 1. Incisional pain 2. Laryngeal stridor 3. Difficulty voiding 4. Abdominal cramps rationale During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which cause swelling and the compression of adjacent tissue. Laryngeal stridor is a harsh, high-pitched sound heard on inspiration and expiration that is caused by the compression of the trachea and that leads to respiratory distress. It is an acute emergency situation that requires immediate attention to avoid the complete obstruction of the airway. When a nurse notes that a client with type 1 diabetes mellitus has lipodystrophy on both upper thighs, what information should the nurse obtain from the client? 1. Plan of injection rotation 2. Consistency of aspiration 3. Preparation of the injection site 4. Angle at which the medication is administered rationale Lipodystrophy (i.e., the hypertrophy of subcutaneous tissue at the injection site) occurs in some diabetic clients when the same injection sites are used for prolonged periods of time. Thus, clients are instructed to adhere to a rotating injection site plan to avoid tissue changes. Preparation of the site, aspiration, and the angle of insulin administration do not produce tissue damage. A nurse is monitoring a client receiving glipizide (Glucotrol). Which outcome indicates an ineffective response from the medication? 1. A decrease in polyuria 2. A decrease in polyphagia 3. A fasting plasma glucose of 100 mg/dL 4. A glycosylated hemoglobin level of 12% rationale Glipizide (Glucotrol) is an oral hypoglycemic agent administered to decrease the serum glucose level and the signs and symptoms of hyperglycemia. Therefore, a decrease in both polyuria and polyphagia would indicate a therapeutic response. Laboratory values are also used to monitor a client's response to treatment. A fasting blood glucose level of 100 mg/dL is within normal limits. However, glycosylated hemoglobin of 12% indicates poor glycemic control. A nurse assists in developing a plan of care for a client with hyperparathyroidism receiving calcitonin-human (Cibacalcin). Which outcome has the highest priority regarding this medication? 1. Relief of pain 2. Absence of side effects 3. Reaching normal serum calcium levels 4. Verbalization of appropriate medication knowledge rationale Hypercalcemia can occur in clients with hyperparathyroidism, and calcitonin is used to lower plasma calcium level. The highest priority outcome in this client situation would be a reduction in serum calcium level. Option 1 is unrelated to this medication. Although options 2 and 4 are expected outcomes, they are not the highest priority for administering this medication. A nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement by the student indicates an accurate understanding of this disorder? 1. "Cushing's disease is characterized by an oversecretion of insulin." 2. "Cushing's disease is characterized by an oversecretion of glucocorticoid hormones." 3. "Cushing's disease is characterized by an undersecretion of corticotropic hormones." 4. "Cushing's disease is characterized by an undersecretion of glucocorticoid hormones." rationale Cushing's syndrome is characterized by an oversecretion of glucocorticoid hormones. Addison's disease is characterized by the failure of the adrenal cortex to produce and secrete adrenocortical hormones. Options 1 and 4 are inaccurate regarding Cushing's syndrome. A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is providing instructions to the client regarding the program. Which of the following should the nurse include in the teaching plan? 1. Try to exercise before mealtime. 2. Administer insulin after exercising. 3. Take a blood glucose test before exercising. 4. Exercise should be performed during peak times of insulin. rationale A blood glucose test performed before exercising provides information to the client regarding the need to eat a snack first. Exercising during the peak times of insulin effect or before mealtime places the client at risk for hypoglycemia. Insulin should be administered as prescribed. A nurse would expect to note which interventions in the plan of care for a client with hypothyroidism? Select all that apply. 1. Provide a cool environment for the client. 2. Instruct the client to consume a high-fat diet. 3. Instruct the client about thyroid replacement therapy. 4. Encourage the client to consume fluids and high-fiber foods in the diet. 5. Instruct the client to contact the health care provider if episodes of chest pain occur. 6. Inform the client that iodine preparations will be prescribed to treat the disorder. rationale The clinical manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormone. Interventions are aimed at replacement of the hormones and providing measures to support the signs and symptoms related to a decreased metabolism. The nurse encourages the client to consume a well-balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to prevent constipation. The client often has cold intolerance and requires a warm environment. The client would notify the health care provider if chest pain occurs since it could be an indication of overreplacement of thyroid hormone. Iodine preparations are used to treat hyperthyroidism. These medications decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone. Which client complaint would alert the nurse to a possible hypoglycemic reaction? 1. Tremors 2. Anorexia 3. Hot, dry skin 4. Muscle cramps rationale Decreased blood glucose levels produce automatic nervous system symptoms, which are classically manifested as nervousness, irritability, and tremors. Option 3 is more likely to occur with hyperglycemia. Options 2 and 4 are unrelated to the signs of hypoglycemia. Which nursing action would be appropriate to implement when a client has a diagnosis of pheochromocytoma? 1. Weigh the client. 2. Test the client's urine for glucose. 3. Monitor the client's blood pressure. 4. Palpate the client's skin to determine warmth. rationale Hypertension is the major symptom that is associated with pheochromocytoma. The blood pressure status is monitored by taking the client's blood pressure. Glycosuria, weight loss, and diaphoresis are also clinical manifestations of pheochromocytoma, but hypertension is the major symptom. A nurse is caring for a client with pheochromocytoma. The client is scheduled for an adrenalectomy. During the preoperative period, the priority nursing action would be to monitor the: 1. Vital signs 2. Intake and output 3. Blood urea nitrogen (BUN) level 4. Urine for glucose and acetone rationale Hypertension is the hallmark of pheochromocytoma. Severe hypertension can precipitate a brain attack (stroke) or sudden blindness. Although all of the options are accurate nursing interventions for the client with pheochromocytoma, the priority nursing action is to monitor the vital signs, particularly the blood pressure. A nurse is caring for a client with pheochromocytoma. The client asks for a snack and something warm to drink. The appropriate choice for this client to meet nutritional needs would be which of the following? 1. Crackers with cheese and tea 2. Graham crackers and warm milk 3. Toast with peanut butter and cocoa 4. Vanilla wafers and coffee with cream and sugar rationale The client with pheochromocytoma needs to be provided with a diet that is high in vitamins, minerals, and calories. Of particular importance is that food or beverages that contain caffeine (e.g., chocolate, coffee, tea, and cola) are prohibited. A nurse is caring for a client with pheochromocytoma. Which data would indicate a potential complication associated with this disorder? 1. A urinary output of 50 mL/hr 2. A coagulation time of 5 minutes 3. Congestion heard on auscultation of the lungs 4. A blood urea nitrogen (BUN) level of 20 mg/dL rationale The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, congestive heart failure (CHF), increased platelet aggregation, and stroke. Death can occur from shock, stroke, renal failure, dysrhythmias, or dissecting aortic aneurysm. Congestion heard on auscultation of the lungs is indicative of CHF. A urinary output of 50 mL/hr is an appropriate output; the nurse would become concerned if the output were less than 30 mL/hr. A coagulation time of 5 minutes is normal. A BUN level of 20 mg/dL is a normal finding. A nurse is caring for a client after thyroidectomy and monitoring for signs of thyroid storm. The nurse understands that which of the following is a manifestation associated with this disorder? 1. Bradycardia 2. Hypotension 3. Constipation 4. Hypothermia rationale Clinical manifestations associated with thyroid storm include a fever as high as 106° F (41.1° C), severe tachycardia, profuse diarrhea, extreme vasodilation, hypotension, atrial fibrillation, hyperreflexia, abdominal pain, diarrhea, and dehydration. With this disorder, the client's condition can rapidly progress to coma and cardiovascular collapse. When caring for a client who is having clear drainage from his nares after transsphenoidal hypophysectomy, which action by the nurse is appropriate? 1. Lower the head of the bed. 2. Test the drainage for glucose. 3. Obtain a culture of the drainage. 4. Continue to observe the drainage. rationale After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid (CSF) leak. If this occurs, the drainage should be collected and tested for glucose, indicating the presence of CSF. The head of the bed should not be lowered to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication. After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse understands that which symptom is indicative of this disorder? 1. Diarrhea 2. Polydipsia 3. Weight gain 4. Blurred vision rationale Polydipsia and polyuria are classic symptoms of diabetes insipidus. The urine is pale in color, and its specific gravity is low. Anorexia and weight loss occur. Diarrhea, weight loss, and blurred vision are not manifestations of the disorder. Which clinical manifestation should the nurse expect to note when assessing a client with Addison's disease? 1. Edema 2. Obesity 3. Hirsutism 4. Hypotension rationale Common manifestations of Addison's disease include postural hypotension from fluid loss, syncope, muscle weakness, anorexia, nausea, vomiting, abdominal cramps, weight loss, depression, and irritability. The manifestations in options 1, 2, and 3 are not associated with Addison's disease. What would the nurse anticipate being included in the plan of care for a client who has been diagnosed with Graves' disease? 1. Provide a high-fiber diet. 2. Provide a restful environment. 3. Provide three small meals per day. 4. Provide the client with extra blankets. rationale Because of the hypermetabolic state, the client with Graves' disease needs to be provided with an environment that is restful both physically and mentally. Six full meals a day that are well balanced and high in calories are required, because of the accelerated metabolic rate. Foods that increase peristalsis (e.g., high-fiber foods) need to be avoided. These clients suffer from heat intolerance and require a cool environment. A licensed practical nurse (LPN) is assisting a high school nurse in conducting a session with female adolescents regarding the menstrual cycle. The LPN tells the adolescents that the normal duration of the menstrual cycle is about: 1. 14 days 2. 28 days 3. 30 days 4. 45 days rationale The normal duration of the menstrual cycle is about 28 days, although it may range from 20 to 45 days. The first day of the menstrual period is counted as day 1 of the woman's cycle. Options 1, 3, and 4 are incorrect. A maternity nursing instructor asks a nursing student to identify the hormones that are produced by the ovaries. Which of the following, if identified by the student, indicates an understanding of the hormones produced by this endocrine gland? 1. Oxytocin 2. Luteinizing hormone (LH) 3. Estrogen and progesterone 4. Follicle-stimulating hormone (FSH) rationale The ovaries are the endocrine glands that produce estrogen and progesterone. Oxytocin is produced by the posterior pituitary gland and stimulates the uterus to produce contractions. LH and FSH are produced by the anterior pituitary gland. Which statement by the client would cause the nurse to suspect that the thyroid test results drawn on the client this morning may be inaccurate? 1. "I had a radionuclide test done 3 days ago." 2. "When I exercise I sweat more than normal." 3. "I drank some water before the blood was drawn." 4. "That hamburger I ate before the test sure tasted good." rationale Option 1 indicates that a recent radionuclide scan had been performed. Recent radionuclide scans performed before the test can affect thyroid laboratory results. No food, fluid, or activity restrictions are required for this test, so options 2, 3, and 4 are incorrect. A nurse is preparing to provide instructions to a client with Addison's disease regarding diet therapy. The nurse understands that which of the following diets would likely be prescribed for this client? 1. Low-protein diet 2. Low-sodium diet 3. High-sodium diet 4. Low-carbohydrate diet rationale A high-sodium, high-complex carbohydrate, and high-protein diet will be prescribed for the client with Addison's disease. To prevent excess fluid and sodium loss, the client is instructed to maintain an adequate salt intake of up to 8 g of sodium daily and to increase salt intake during hot weather, before strenuous exercise, and in response to fever, vomiting, or diarrhea. Upgrade to remove ads Only $3/month Which of the following statements made by the nursing student demonstrates an understanding of the hormone oxytocin? 1. "Production of oxytocin occurs in the ovaries." 2. "It is produced by the anterior pituitary gland." 3. "It causes contractions of the uterus during birth." 4. "Release of oxytocin stimulates the pancreas to produce insulin." rationale Oxytocin is produced by the posterior pituitary, not the anterior pituitary gland, and stimulates the uterus to produce contractions during birth. The ovaries are the endocrine glands that produce estrogen and progesterone. The pancreas produces insulin and other enzymes that aid digestion. Oxytocin does not stimulate the pancreas to produce insulin. A nurse is caring for a client with a diagnosis of hypoparathyroidism. The nurse reviews the laboratory results drawn on the client and notes that the calcium level is extremely low. The nurse would expect to note which of the following on data collection of the client? 1. Positive Trousseau's sign 2. Negative Chvostek's sign 3. Unresponsive pupils 4. Hyperactive bowel sounds rationale Hypoparathyroidism is related to a lack of parathyroid hormone secretion or to a decreased effectiveness of parathyroid hormone on target tissues. The end result of this disorder is hypocalcemia. When serum calcium levels are critically low, the client may exhibit positive Chvostek's and Trousseau's signs, which indicate potential tetany. Options 2, 3, and 4 are not related to the presence of hypocalcemia. A nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which of the following specific signs of this complication should be included on the list? 1. Decreased urine output 2. Profuse sweating 3. Increased thirst 4. Shakiness rationale The classic signs of hyperglycemia include polydipsia, polyuria, and polyphagia. Profuse sweating and shakiness would be noted in a hypoglycemic condition. A nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed, and the pulse and respiratory rate are elevated from the client's baseline. The nurse would immediately: 1. Prepare for the administration of an insulin drip. 2. Give the client a glass of orange juice. 3. Prepare for the administration of a bolus dose of 50% dextrose. 4. Check the client's capillary blood glucose. rationale The nurse must first obtain a blood glucose reading to determine the client's problem. Options 2 and 3 would be implemented as needed in the treatment of hypoglycemia. Insulin therapy is guided by blood glucose measurement. A client with diabetes mellitus calls the clinic nurse to report that the blood glucose level is 150 mg/dL. After obtaining further data from the client, the nurse determines that the client ate lunch approximately 2 hours ago. The nurse would interpret these results to be: 1. Normal 2. Lower than the normal value 3. Slightly higher than the normal value 4. A value that indicates immediate health care provider notification rationale Normal fasting blood glucose values range from 70 to 120 mg/dL. The 2-hour postprandial blood glucose level should be less than 140 mg/dL. In this situation, the blood glucose value was 150 mg/dL 2 hours after the client ate, which is slightly elevated above normal. This value does not require health care provider notification. A client with type 1 diabetes mellitus takes NPH insulin every morning and checks the blood glucose level four times per day. The client tells the nurse that yesterday the late afternoon blood glucose was 60 mg/dL and that she "felt funny." Which statement by the client would indicate an understanding of this occurrence? 1. "My blood glucose levels are running low because I'm tired." 2. "I forgot to take my usual afternoon snack yesterday." 3. "I took less insulin this morning so I won't feel funny today." 4. "I don't know why I have to check my blood glucose four times a day. That seems too much." rationale Hypoglycemia is a blood glucose level of 60 mg/dL or less. The causes are multiple, but, in this case, omitting the afternoon snack is the cause. Fatigue and self- adjustment of dose are incorrect options. Recommended blood glucose testing for the client with type 1 diabetes mellitus is at least four times a day. A nurse caring for a client scheduled for a transsphenoidal hypophysectomy to remove a tumor in the pituitary gland assists to develop a plan of care for the client. The nurse suggests including which specific information in the preoperative teaching plan? 1. Hair will need to be shaved. 2. Deep breathing and coughing will be needed after surgery. 3. Toothbrushing will not be permitted for at least 2 weeks following surgery. 4. Spinal anesthesia is used. rationale Based on the location of the surgical procedure, spinal anesthesia would not be used. In addition, the hair would not be shaved. Although coughing and deep breathing are important, specific to this procedure is avoiding toothbrushing to prevent disruption of the surgical site. Also, coughing may disrupt the surgical site. Following hypophysectomy, a client complains of being very thirsty and having to urinate frequently. The initial nursing action is to: 1. Document the complaints. 2. Increase fluid intake. 3. Check the urine specific gravity. 4. Check for urinary glucose. rationale Following hypophysectomy, diabetes insipidus can occur temporarily because of antidiuretic hormone deficiency. This deficiency is related to surgical manipulation. The nurse should check the urine for specific gravity and report the results if they are less than 1.005. Urinary glucose and diabetes mellitus is not a concern here. In this situation, increasing fluid intake would require a health care provider's prescription. The client's complaint would be documented but not as an initial action. A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome