Quiz 1 27-30, Q2 1
An older adult with an indwelling urinary catheter becomes increasingly lethargic with new confusion. The patient is afebrile but has decreased urine output and cloudy urine. No urinary complaints are reported. Which explanation best justifies whether the nurse is concerned about CAUTI in this patient?
Absence of fever rules out infection
Older adults often lack typical UTI symptoms
Cloudy urine is expected with dehydration
Confusion is most likely medication‑related
Older adults often lack typical UTI symptoms
The nurse is reviewing laboratory values on four clients. Which client should the nurse assess first?
HgbA1C of 9.5% (0.095)
nighttime glucose of 60 mg/dl (3.3 mmol/l)
fasting blood glucose of 130 mg/dl (7.0 mmol/l)
two-hour postprandial glucose of 250 mg/dl (13.9 mmol/l)
nighttime glucose of 60 mg/dl (3.3 mmol/l)
The nurse is teaching the parents of a young patient who has recently been diagnosed with diabetes insipidus about the disease. The child is not secreting enough of which hormone?
antidiuretic hormone (ADH)
adrenocorticotropic hormone (ACTH)
thyroid stimulating hormone (TSH)
luteinizing hormone (LH)
antidiuretic hormone (ADH)
A nurse is caring for a 1-year-old patient with a history of congenital adrenal hyperplasia. The patient has the following vital signs: BP 70/40 mmHg, HR 178 bpm, RR 42/min, Temp 96.6°F (35.9°C). Which order should the nurse prioritize?
Administer IV hydrocortisone
Administer oral levothyroxine
Initiate a low-sodium diet
Restrict fluid intake
Administer IV hydrocortisone
A patient in diabetic ketoacidosis (DKA) is receiving a continuous IV insulin infusion. The nurse notes the blood glucose has dropped from 320 mg/dL to 180 mg/dL in one hour and the latest electrolyte panel still indicates acidosis (low CO2). The nurse will anticipate that they will:
Stop the insulin infusion as the BG is nearing normal
Increase the insulin rate by a multiplier of 1.5X
Continue the insulin infusion per protocol and anticipate adding dextrose containing IV fluids
Transition to subcutaneous insulin protocol with pre-meal and pre-bedtime (AC/HS) blood glucose checks and sliding scale insulin
Continue the insulin infusion per protocol and anticipate adding dextrose containing IV fluids
A 56-year-old male presents to the ED with fever, chills, confusion, and a blood pressure lower than baseline (120s/70s, patient on anti-hypertensives). He has a history of diabetes and chronic kidney disease. The nurse suspects sepsis.
The nurse prepares to implement the provider’s orders for suspected sepsis. Select the correct order of interventions.
“The nurse should first (blank) and then (blank) completing both tasks within a 60-minute timeframe.”
what happens first and second in sepsis protocol?
obtain blood cultures and lactate level and then administer IV antibiotics
The nurse is providing teaching to a child with new-onset type 1 diabetes. Which statement(s) made by the child demonstrates understanding of the pathophysiology of diabetes? Select all that apply.
"I do not make enough insulin on my own."
"If I avoid sweet foods, I will not need to take insulin."
"I can tell my glucose is getting high if I feel extra tired."
"Insulin injections will help regulate my glucose levels."
"My body is attacking my liver to reduce the amount of insulin I make."
"I do not make enough insulin on my own."
"I can tell my glucose is getting high if I feel extra tired."
"Insulin injections will help regulate my glucose levels."
An older adult patient diagnosed with type 2 diabetes is brought to the emergency department with hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Which nursing action(s) would be anticipated in the first 24 hours? Select all that apply.
Administering antihypertensive medications
Administering sodium bicarbonate intravenously
Reversing hyperglycemic state by administering insulin
Rehydrate aggressively to correct profound dehydration
Correct electrolyte disturbances
Reversing hyperglycemic state by administering insulin
Rehydrate aggressively to correct profound dehydration
Correct electrolyte disturbances
A 14-year-old client has just been diagnosed with Graves disease. Which symptom(s) is likely to be noted in the assessment? Select all that apply.
Nervousness
Exophthalmos
Sweaty skin
Increased basal metabolic rate
obesity
lethargy
Nervousness
Exophthalmos
Sweaty skin
Increased basal metabolic rate
A nurse is caring for multiple patients in a rural intensive care unit. Which findings require immediate intervention for potential endocrine emergency? (Select all that apply.)
3-day-old infant with vomiting, dehydration, and hyperkalemia
Adult with type 1 diabetes, blood glucose 540 mg/dL, Kussmaul respirations
Patient with Graves’ disease, HR 112 bpm, mild anxiety
Patient with Addison’s disease, BP 82/48 mmHg, confusion
Patient with Cushing’s syndrome, weight gain and moon face
3-day-old infant with vomiting, dehydration, and hyperkalemia
Adult with type 1 diabetes, blood glucose 540 mg/dL, Kussmaul respirations
Patient with Addison’s disease, BP 82/48 mmHg, confusion
enteric contact precautions.
The nurse is teaching the patient and family about isolation precautions for C. difficile. Select the correct teaching points.
“The nurse should explain that (blank)
How do you wash hands?
What do the visitors need to do?
Should the patient leave the room?
hand hygiene must be done with soap and water visitors must wear gowns and gloves the patient should stay in the room unless medically necessary
A medical nurse is caring for a patient diagnosed with type 1 diabetes. The patient's medication administration record includes the administration of regular insulin three times daily to cover meals. Knowing that the patient's lunch tray will arrive at 11:45, when should the nurse administer the patient's insulin?
10:45
When the tray arrives
As soon as the patient completes their tray
11:50
When the tray arrives
The nurse is assessing a 9-year-old client during a routine well-child visit and notes that the child’s height has risen sharply on the growth chart since the last visit, crossing several percentile lines upward. Which assessment should the nurse prioritize at this time?
Growth hormone
thyroid hormones
insulin
none; the child is within normal range for their age
Growth hormone
Match the medication you expect to be ordered for the associated condition:
1.Hypoparathyroidism
2.diabetes insipidus
3.Adrenal crisis
4.Hypothyroidism
A. Levothyroxine
B. Vasopressin
C. Calcium gluconate
D. Hydrocortisone
Hypoparathyroidism - calcium gluconate
diabetes insipidus - vasopressin
Adrenal crisis - hydrocortisone
Hypothyroidism - Levothyroxine
A nurse is assessing a patient after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which serious complication?
Tetany
Hemorrhage
Thyroid storm
Laryngeal nerve damage
Tetany
A 68-year-old female is admitted to the medical-surgical unit with pneumonia and has a PICC line in place for IV antibiotics and fluids.
The nurse is preparing to perform routine care to prevent a central line-associated bloodstream infection (CLABSI). Select the appropriate nursing actions.
“To prevent CLABSI, the nurse should
What PPE?
How long do you clean?
What do you document?
use sterile gloves and mask
during dressing changes,
scrub the hub for 15 seconds
when accessing the line, and
document redness, swelling, or drainage
when assessing the site.”
The nurse is educating a client regarding macrovascular complications of diabetes. Which statement(s) made by the patient indicates the education is effective? Select all that apply.
“I will have frequent eye examinations.”
“There is a higher risk that I will have a heart attack.”
“There is a relationship between kidney function and blood glucose levels.”
“I need to monitor my urine for the presence of albumin.”
“My risk for stroke is higher with diabetes.”
“There is a higher risk that I will have a heart attack.”
“My risk for stroke is higher with diabetes.”
A patient living with Addison's disease is being admitted for a planned outpatient surgery. To prevent complications, the nurse should anticipate preoperative administration of which of the following?
IV antibiotics
Oral antihypertensives
Parenteral nutrition
IV corticosteroids
IV corticosteroids
A 65-year-old client with long-standing diabetes reports numbness and burning in both feet. On assessment, the nurse notes decreased sensation to light touch. Which intervention should the nurse implement first?
Educate the client to inspect feet daily
Recommend warm foot soaks
Apply heating pads to improve circulation
Encourage walking barefoot at home
Educate the client to inspect feet daily
What should the nurse suspect when a patient post-craniotomy exhibits a urine output of 1,500 mL per hour for 2 consecutive hours?
Cushing's syndrome
Syndrome of inappropriate antidiuretic hormone (SIADH)
Adrenal crisis
Diabetes insipidus
Diabetes insipidus
The nurse is caring for a child with the transfer of care notes.
A 7 year old child is brought in by the parents after a visit to the health care providers office. The child missed several days of school due to having cold-like symptoms. The child reports an increase in hunger and thirst. The client reports feeling tired after school and being unable to play with friends. The child weighs 52lb (23.6kg) and has lost 2.2lbs (1kg) over the past 2 weeks. The client reports wetting the bed twice over the past 2 weeks.
The health care provider is currently writing new orders. Which order takes priority?
Gather a urine sample.
Consult a registered dietitian.
Draw a complete blood count.
Obtain a fingerstick blood glucose.
Obtain a fingerstick blood glucose.
A 12-year-old client arrives at the emergency room experiencing nausea, vomiting, headache, and seizures. The client is diagnosed with bacterial meningitis. Other findings include a decrease in urine production, hyponatremia, and water intoxication. Which pituitary gland disorder is most associated with these symptoms?
syndrome of inappropriate antidiuretic hormone (SIADH)
diabetes insipidus (DI)
hyposecretion of somatotropin
hypersecretion of growth hormone
syndrome of inappropriate antidiuretic hormone (SIADH)
A newborn is diagnosed with the salt-losing form of congenital adrenogenital hyperplasia. When developing the plan of care, the nurse would focus interventions to prevent which condition?
Dehydration
Hypoglycemia
Bleeding tendency
Excessive cortisone secretion
Dehydration
A 52-year-old client with type 2 diabetes presents for a routine visit. The nurse reviews the chart:
A1C: 9.4%
BP: 150/88 mmHg
Reports “vision is fine”
Last eye exam: 4 years ago
Which nurse teaching points are most appropriate to prevent diabetic retinopathy progression? (Select all that apply.)
“Managing your blood pressure is important for eye health.”
“Controlling your blood sugar can help protect your vision.”
“You should have a dilated eye exam at least once a year.”
“You only need an eye exam if you notice vision changes.”
“Wearing glasses will prevent diabetic eye disease.”
“Managing your blood pressure is important for eye health.”
“Controlling your blood sugar can help protect your vision.”
“You should have a dilated eye exam at least once a year.”
The nurse is instructing an adolescent patient on the treatment plan for a new diagnosis of hypothyroidism. Which nursing outcome indicates that the teaching has been successful?
The patient states understanding that this is a lifetime medication.
The parents recognize that thyroid medication must be taken with food.
The patient verbalizes the requirement to restrict future athletic activities.
The parents acknowledge the need for a follow-up appointment in a year.
The patient states understanding that this is a lifetime medication.