DKA/HHS
An older adult client with type 2 diabetes is brought to the emergency department by the client’s daughter. The client is found to have a blood glucose level of 600 mg/dL (33.3 mmol/L). The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority?
A. Administration of antihypertensive medications
B. Administering sodium bicarbonate intravenously
C. Reversing acidosis by administering insulin
D. Fluid and electrolyte replacement
ANS: D
Rationale: The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration. Antihypertensive medications are not indicated, as hypotension generally accompanies HHS due to dehydration. Sodium bicarbonate is not given to clients with HHS, as their plasma bicarbonate level is usually normal. Insulin administration plays a less important role in the treatment of HHS because it is not needed for reversal of acidosis, as in diabetic ketoacidosis (DKA).
A client with acute pancreatitis is experiencing abdominal pain. Which intervention can help reduce the patient’s pain?
A. Ambulate patient frequently
B. Provide easy to chew meals
C. Make the patient NPO
D. Minimize repositioning
ans: C
Feedback:
General: Rationale: Patient’s should maintain bedrest to help reduce pancreatic and gastric enzymes. Maintaining NPO status helps reduce pancreatic secretion, which helps reduce abdominal pain. Hinkle & Cheever, p. 1446 Rationale: Patient’s should maintain bedrest to help reduce pancreatic and gastric enzymes. Maintaining NPO status helps reduce pancreatic secretion, which helps reduce abdominal pain. Hinkle & Cheever, p. 1446
he results of a client's most recent blood work and physical assessment are suggestive of immune thrombocytopenic purpura (ITP). This client should undergo testing for which of the following potential causes? Select all that apply.
A. Hepatitis
B. Acute kidney injury
C. HIV
D. Malignant melanoma
E. Cholecystitis
ANS: A, C
Rationale: Viral illnesses have the potential to cause ITP. Acute kidney injury, malignancies, and gallbladder inflammation are not typical causes of ITP.
A 70 year old male client is 48 hours post operative for a knee replacement and is exhibiting dyspnea, and restlessness. The nurse auscultates his lungs and hears diminished lower lobe sounds. A chest x-ray and Arterial blood gases are ordered. His results come back pH 7.29, PaCO2 48, HCO3 25. Which of the following is occurring?
A. respiratory acidosis
b. respir alkalosis
c. metabolic acidosis
d. metabolic alklosis
Answer: A pH shows acidosis, the PaCO2 is high and acidotic, and the HCO3 is normal. This client is in respiratory acidosis.
A client is in asystole, is nonresponsive, and does not have a pulse. What is the priority intervention for this client?
A. Defibrillation
B. Amiodarone
C. Magnesium Sulfate
D. Chest compressions
D. Chest compressions
Which client would be most at risk for developing disseminated intravascular coagulation (DIC)?
A. A 38 year old client pregnant with twins
B. A 45 year old client with a pulmonary embolus
C. A 65 year old alcoholic client with acute pancreatitis
D. A 40 year old client with septicemia
ans: D
Module 8: DIC
general: Rationale: Predisposing risk factors for DIC include pregnancy complications (placental abruption, PreE), trauma, cancer, vessel damage, and infective processes. Rationale: Predisposing risk factors for DIC include pregnancy complications (placental abruption, PreE), trauma, cancer, vessel damage, and infective processes.<br>
A diabetes nurse educator is teaching a group of clients with type 1 diabetes about "sick day rules." What guideline applies to periods of illness in a diabetic client?
A. Do not eliminate insulin when nauseated and vomiting.
B. Report elevated glucose levels greater than 150 mg/dL (8.3 mmol/L).
C. Eat three substantial meals a day, if possible.
D. Reduce food intake and insulin doses in times of illness.
ANS: A
Rationale: The most important issue to teach clients with diabetes who become ill is not to eliminate insulin doses when nausea and vomiting occur. Rather, they should take their usual insulin or oral hypoglycemic agent dose, and then attempt to consume frequent, small portions of carbohydrates. In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL (16.6 mmol/L).
The nurse is admitting a client with acute pancreatitis. What should the nurse include in the immediate plan of care?
A. Place the client on fluid restriction and bowel rest
B. Ambulate the client every 2 hours to promote digestion
C. Obtain IV access and administer ordered pain medication
D. Assess the client for decreased deep tendon reflexes
ans: C
Feedback:
General: Rationale: The immediate plan of care for a client with acute pancreatitis include bowel rest, gastric decompression, pain management and NPO. Fluid status is important and can be achieved via IV fluids.
A client with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal varices; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect the care team to prescribe for this client?
A. Packed red blood cells (PRBCs)
B. Vitamin K
C. Oral anticoagulants
D. Heparin infusion
ANS: A
Rationale: Clients with liver dysfunction may have life-threatening hemorrhage from peptic ulcers or esophageal varices. In these cases, replacement with fresh-frozen plasma, PRBCs, and platelets is usually required. Vitamin K may be prescribed once the bleeding is stopped, but that is not what is needed to stop the bleeding of the varices. Anticoagulants would exacerbate the client's bleeding.
A client presents to the emergency department after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling of not being able to breathe enough. The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of which respiratory problem?
A. Pneumoconiosis
B. Pleural effusion
C. Acute respiratory failure
D. Pneumonia
ANS: C Acute respir failure
Rationale: Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms.
A client presents to the provider’s office with complaints of dyspnea on exertion and dizziness. The nurse auscultates the client’s heart and hears a loud, rough and vibrating systolic murmur at the right 2nd intercostal space. Which valve involvement is most consistent with these findings?
A. Mitral valve prolapse
B. Mitral valve stenosis
C. Aortic valve regurgitation
D. Aortic valve stenosis
ans: D
general: Rationale: Murmur heard at the aortic space on systole indicates aortic valve involvement. The loud grating sound indicated stenosis. Rationale: Murmur heard at the aortic space on systole indicates aortic valve involvement. The loud grating sound indicated stenosis
A client on a cardiac care unit with a history of a myocardial infarction (MI) is complaining of chest pain. Upon assessment the nurse notes, dyspnea, blood pressure of 80/50 mm Hg, jugular venous distention and lung crackles. What should the nurse do first?
A. Apply oxygen
B. Initiate rapid fluid resuscitation
C. Draw cardiac labs
D. Turn the client to their left side
Answer : A
Module 9
general: Rationale: The client is showing signs of cardiogenic shock. The initial treatment management is to increase oxygen supply to the heart and decrease demand. Apply O2, give medication to increase contractility and pain management are initial treatments.
Hinkle & Cheever pp. 309-311
The nurse is discussing macrovascular complications of diabetes with a client. The nurse would address what topic during this dialogue?
A. The need for frequent eye examinations for clients with diabetes
B. The fact that clients with diabetes have an elevated risk of myocardial infarction
C. The relationship between kidney function and blood glucose levels
D. The need to monitor urine for the presence of albumin
ANS: B
Rationale: Myocardial infarction and stroke are considered macrovascular complications of diabetes, while the effects on vision and kidney function are considered to be microvascular.
A nurse who provides care in a community clinic assesses a wide range of individuals. The nurse should identify which client as having the highest risk for chronic pancreatitis?
A. A 45-year-old obese woman with a high-fat diet
B. An 18-year-old man who is a weekend binge drinker
C. A 39-year-old man with chronic alcoholism
D. A 51-year-old woman who smokes one-and-a-half packs of cigarettes per day
ANS: C
Rationale: Excessive and prolonged consumption of alcohol accounts for most cases of chronic pancreatitis in Western societies.
A client newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the client asks the nurse to explain the condition. The nurse explains to this client that this condition occurs due to which factor?
A. An attack on the platelets by antibodies
B. Decreased production of platelets
C. Impaired communication between platelets
D. An autoimmune process causing platelet malfunction
B. decreased production of platlets
Body is not producing enough platlets
Which of the following interventions are critical in preventing VAP Ventilator-associated pneumonia? Select all that apply
a. Perform daily sedation vacations and assess readiness to extubate
b. Elevate the HOB 30- 45 degrees
c. Ensure good hand hygiene prior to suctioning the client
d. Perform daily oral care
E. administer prophylactic antibiotics
A,B,C,D
a.Perform daily sedation vacations and assess readiness to extubate
b. Elevate the HOB 30- 45 degrees
c. Ensure good hand hygiene prior to suctioning the client
d. Perform daily oral care
The nurse is closely monitoring a client who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the client’s aneurysm?
A. A sudden increase in blood pressure and a decrease in heart rate
B. Cessation of pulsating in an aneurysm that has previously been pulsated visibly
C. Sudden onset of severe back or abdominal pain
D. New onset of hemoptysis
ans: C
p842 signs of impending rupture include sever back or abdominal pain, which may be persistent or intermittent.
The nurse in the critical care unit is assessing a client recently admitted with full and partial thickness burn injury of the chest, head, and neck. Which assessment finding requires immediate intervention?
A. Heart rate 100 beats per minute
B. Dysphagia
C. Pain level of 7 on a scale of 10
D. Urinary output of 25 mL/hour
ans: B
feedback:
Module 9 Burns
general: Rationale: Difficulty swallowing could indicate possible swelling and airway compromise and is the priority. Urine output may be low due to fluid volume deficit but is not the priority. Heart rate is normal and pain relief is important but not the priority.<br>
A medical nurse is aware of the need to screen specific clients for their risk of hyperglycemic hyperosmolar syndrome (HHS). In what client population does this syndrome most often occur?
A. Clients who are obese and who have no known history of diabetes
B. Clients with type 1 diabetes and poor dietary control
C. Adolescents with type 2 diabetes and sporadic use of antihyperglycemics
D. Middle-aged or older people with either type 2 diabetes or no known history of diabetes
ANS: D
Rationale: HHS occurs most often in older clients (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes. HHS is a serious metabolic disorder resulting from a relative insulin deficiency initiated by an illness that raises the demand for insulin
A client's assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment question(s) addresses likely etiologic factors? Select all that apply.
A. "How many alcoholic drinks do you typically consume in a week?"
B. "Have you ever been tested for diabetes?"
C. "Have you ever been diagnosed with gallstones?"
D. "Would you say that you eat a particularly high-fat diet?"
E. "Does anyone in your family have cystic fibrosis?"
ANS: A, B, C, D
Rationale: Eighty percent of clients with acute pancreatitis have biliary tract disease such as gallstones or a history of long-term alcohol abuse. Diabetes and high-fat consumption are also associated with pancreatitis. Cystic fibrosis is not a noted etiologic factor for pancreatitis.
A client with a recent diagnosis of ITP has asked the nurse why the care team has not chosen to administer platelets, stating, "I have low platelets, so why not give me a transfusion of exactly what I'm missing?" How should the nurse best respond?
A. "Transfused platelets usually aren't beneficial because they're rapidly destroyed in the body."
B. "A platelet transfusion often further blunts your body's own production of platelets."
C. "Finding a matching donor for a platelet transfusion is exceedingly difficult."
D. "A very small percentage of the platelets in a transfusion are actually functional."
ANS: A
Rationale: Despite extremely low platelet counts, platelet transfusions are usually avoided. Transfusions tend to be ineffective not because the platelets are nonfunctional but because the client's antiplatelet antibodies bind with the transfused platelets, causing them to be destroyed. Matching the client's blood type is not usually necessary for a platelet transfusion. Platelet transfusions do not exacerbate low platelet production.
The nurse is educating a client recovering from a pulmonary embolism about prevention of future venous thrombosis after discharge. What should the nurse include in the teaching?
A. Elevate your legs in bed by placing a pillow behind your knees.
B. Reduce your fluid intake to 1500 mL a day.
C. Do not sit with your legs crossed while working at your desk.
D. Apply ice packs to legs when you feel soreness or pain.
ans: C
Rationale: Preventing thrombus formation is an important part of PE prevention. Clients should elevate the legs but not place anything behind the knees, should not sit with legs crossed. If the client has calf pain they should be evaluated for DVT and not place ice packs on the area. Hinkle & Cheever, p. 617, Abrams, 153.
A client has been brought to the emergency department by paramedics after being found unconscious. The client's MedicAlert bracelet indicates that the client has type 1 diabetes and the client's blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should anticipate what intervention?
A. IV administration of 50% dextrose in water
B. Subcutaneous administration of 10 units of Humalog
C. Subcutaneous administration of 12 to 15 units of regular insulin
D. IV bolus of 5% dextrose in 0.45% NaCl
ANS: A
Rationale: In hospitals and emergency departments, for clients who are unconscious or cannot swallow, 25 to 50 mL of 50% dextrose in water (D50W) may be administered IV for the treatment of hypoglycemia. Five percent dextrose would be inadequate, and insulin would exacerbate the client's condition.
A nurse is providing discharge instructions to a client with chronic pancreatitis. What should the nurse include in the education?
A. You should limit your alcohol intake to 2-3 drinks per week
B. You should try to eat more frequent, smaller meals
C. You should decrease your intake of calories if you have bloating
D. Add more fatty foods to your diet if you experience loose stools
ans: B
feedback:
general: Rationale: Clients with chronic pancreatitis are at risk for malnutrition and should increase their intake of high protein foods to replace calories and enhance nutritional status. Alcohol should be eliminated and fatty foods should be avoided. Rationale: Clients with chronic pancreatitis are at risk for malnutrition and should increase their intake of high protein foods to replace calories and enhance nutritional status. Alcohol should be eliminated and fatty foods should be avoided.
A nurse is caring for a client with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?
A. Asterixis
B. Constructional apraxia
C. Fetor hepaticus
D. Palmar erythema
ANS: A
Rationale: The nurse will document that a client exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the
While caring for a client with an endotracheal tube, the nurse should normally provide suctioning how often?
A. Every 2 hours when the client is awake
B. When adventitious breath sounds are auscultated
C. When there is a need to prevent the client from coughing
D. When the nurse needs to stimulate the cough reflex
ANS: B adventitious breath sounds
Rationale: It is usually necessary to suction the client's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present.