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A client diagnosed with type 1 diabetes mellitus has a capillary blood glucose of 60 mg/dL (3.3 mmol/L) and reports hunger, sweating, tachycardia, and tremulousness. Which food choices does the nurse select that provide the client with 15 grams of an oral carbohydrate? (Select all that apply.)
1.8 oz of regular soda.
2.Half cup of plain pasta.
3.Half cup of canned fruit.
4.2 teaspoons of sugar.
5.1 cup of whole milk.
6.125 mL of apple juice.
2. one half cup of plain pasta
3. one half cup of canned fruit
6. 125 mL of apple juice
The nurse finds a client restless, cyanotic, and clutching the throat between the thumb and fingers. Which action is appropriate for the nurse to implement? (Select all that apply.)
1.Slap the client on the back.
2.Call for help.
3.Insert a nasopharyngeal airway.
4.Deliver abdominal thrusts.
5.Ask if the client can speak.
2. call for help
4. Deliver an abdominal thrust
5. ask if the client can speak
A client recovering from a complicated vaginal hysterectomy experiences a large amount of light brown, foul-smelling drainage from the perianal area. Which situation will the nurse suspect is occurring with this client?
1.Dehiscence.
2.Fistula.
3.Keloid.
4.Hemorrhage.
2. Fistula
The nurse provides care for a client who experienced a spinal cord injury at the level of T-2. The nurse enters the room and notes that the client’s face is flushed, is sweating profusely, and the blood pressure is 260/160 mm Hg. Which medication does the nurse prepare to administer?
1.Docusate sodium 100 mg PO.
2.Prochlorperazine 10 mg IM.
3.Hydralazine hydrochloride 10 mg IV.
4.Diazepam 20 mg IV.
3.Hydralazine hydrochloride 10 mg IV.
The nurse provides care to a client with a venous thromboembolism. For which symptom does the nurse notify the health care provider?
1.Pain in the lower back.
2.Soreness on the elbows and heels.
3.Heaviness in the chest.
4.Difficulty staying in bed.
3.Heaviness in the chest.
The nurse teaches a client diagnosed with Cushing syndrome about the disease process. Which client statements indicate to the nurse that teaching is effective? (Select all that apply.)
1.“My diagnosis helps to explain why my bones are weak.”
2.“I need to increase my daily caloric intake.”
3.“My health care provider may prescribe a diuretic for me.”
4.“I need to avoid people who have infections.”
5.“I may have to take potassium supplements.”
6.“I feel weak because the syndrome makes my blood glucose low.”
1.“My diagnosis helps to explain why my bones are weak.”
3.“My health care provider may prescribe a diuretic for me.”
4.“I need to avoid people who have infections.”
5.“I may have to take potassium supplements.”
The nurse provides care for a client diagnosed with prerenal acute kidney injury. The nurse recognizes that which cause likely led to this diagnosis?
1.Acute tubular necrosis.
2.Glomerular injury.
3.Ureteral obstruction
4. Hypovolemia.
4. Hypovolemia
The home care nurse provides care for the client diagnosed with stage 3 heart failure (HF). Which measure is included in the plan of care? (Select all that apply.)
1.Instruct the client to check weight daily.
2.Educate the client on a low-sodium diet.
3.Review the prescription for daily digoxin therapy.
4.Institute a cardiac rehabilitation program.
5.Assess for adverse effects of an angiotensin converting enzyme (ACE) inhibitor.
6.Teach the client when to stop taking medications.
1.Instruct the client to check weight daily.
2.Educate the client on a low-sodium diet.
3.Review the prescription for daily digoxin therapy.
4.Institute a cardiac rehabilitation program.
5.Assess for adverse effects of an angiotensin converting enzyme (ACE) inhibitor.
The unlicensed assistive personnel (UAP) calls the nurse and states, “The client in room 218 is reporting shortness of breath.” Which response by the nurse is appropriate?
1.“Call the respiratory therapist and request an arterial blood gas be performed.”
2.“Ask the client when the shortness of breath started.”
3.“Ensure the nasal cannula is in the client’s nares.”
4.“Listen to the client’s lung sounds and notify me if you hear wheezing or crackles.”
3.“Ensure the nasal cannula is in the client’s nares.”
The clinic nurse provides care for a client who reports a sore throat and fever. A throat culture indicates group A beta-hemolytic Streptococcus infection. Urinalysis reveals protein and numerous RBCs. Antibiotics are prescribed. The client is leaving soon for a 6-week international conference. Which action should the nurse take next ?
1.Determine if the client is allergic to penicillin.
2.Instruct the client to schedule an appointment before leaving the country.
3.Ask the client in which country the conference is to be held.
4.Ascertain when the client is scheduled to leave.
2.Instruct the client to schedule an appointment before leaving the country.
The nurse provides care for a client diagnosed with peripheral artery disease (PAD). The client reports leg pain occurs frequently when walking. Which action does the nurse advise the client to take?
1.Lie down with feet elevated above the heart when experiencing pain.
2.Apply a heating pad to the legs for 15 minutes before walking.
3.Walk until client experiences pain, rest, and then resume walking.
4.Perform stretching exercises 20 minutes before starting to walk.
3.Walk until client experiences pain, rest, and then resume walking.
The nurse assesses a client with Addison disease. Which finding will the nurse expect the client to exhibit?
1.Muscle cramps, fatigue, and hypotension.
2.Shortness of breath, pallor, and hirsutism.
3.Rales, maculopapular rash, and weight loss.
4.Hypertension, peripheral edema, and petechiae.
1.Muscle cramps, fatigue, and hypotension.
The nurse provides care to a client who just underwent left modified radical mastectomy. When assisting the client with positioning, the nurse implements which action?
1.Extend the client's left arm flat along the affected side.
2.Elevate the client's left arm on a pillow.
3.Rest the client's left arm across her chest.
4.Place the client's left arm below the level of her torso.
2.Elevate the client's left arm on a pillow.
The nurse provides care for the client who is a strict vegetarian. Which assessment data does the nurse document to support the current diagnosis of vitamin B12 deficiency? (Select all that apply.)
1.Fatigue.
2.Bradycardia.
3.Hypertension.
4.Constipation.
5.Sore tongue.
6.Diarrhea.
1.Fatigue.
4.Constipation.
5.Sore tongue.
6.Diarrhea.
The nurse assesses a client with diabetes insipidus. Which symptom will the nurse expect to find that is consistent with the diagnosis?
1.Diarrhea.
2.Polyuria.
3.Fatigue.
4.Weight gain.
2. Polyuria
The nurse assists a graduate nurse with the care of a client whose blood glucose is 525 mg/dL (29.14 mmol/L), pH is 7.1, and serum bicarbonate level is 14 mEq/L (14 mmol/L) and has ketonuria. The nurse intervenes if the graduate nurse makes which statement? (Select all that apply.)
1."I should add 5% dextrose to the IV fluids when the client's blood glucose drops below 100 mg/dL (5.55 mmol/L)."
2."The client's potassium level will increase as the blood glucose decreases."
3."The client's laboratory results are characteristic of hyperglycemic hyperosmolar syndrome (HHS)."
4."The client requires a STAT electrocardiogram (ECG)."
5."I should check the client's blood glucose every 2 hours."
1."I should add 5% dextrose to the IV fluids when the client's blood glucose drops below 100 mg/dL (5.55 mmol/L)."
2."The client's potassium level will increase as the blood glucose decreases."
3."The client's laboratory results are characteristic of hyperglycemic hyperosmolar syndrome (HHS)."
5."I should check the client's blood glucose every 2 hours."
The nurse assesses a client diagnosed with a perforated duodenal ulcer. Which initial symptom will the nurse expect to observe upon assessment?
1.Emesis.
2.Pain.
3.Diarrhea.
4.Fever.
2. Pain
The nurse reviews the prescription for hormone therapy for a client with prostate cancer. Which goal of treatment will the nurse identify as important when planning care for this client?
1.Increase prostaglandin levels.
2.Increase testosterone levels.
3.Increase circulating androgens.
4.Limit the amount of circulating androgens.
4. Limit the amount of circulating androgens.
A client with a history of hypertension experiences a subarachnoid hemorrhage, head laceration, and ulnar fracture from a motor vehicle crash. Which finding indicates to the nurse that the client's condition is deteriorating? (Select all that apply.)
1.Urine output 5000 mL in 24 hours.
2.Pink drainage on laceration dressing.
3.Radial and apical pulse 120 beats per minute.
4.Diminished pupillary response.
5.Glasgow Coma Scale score of 15.
1.Urine output 5000 mL in 24 hours.
3.Radial and apical pulse 120 beats per minute.
4.Diminished pupillary response.
The nurse provides care for a client 24 hours after an ischemic stroke. The nurse notes a BP of 222/128 mm Hg, a radial pulse of 92 beats/min, a respiratory rate of 22 breaths/min, a temperature of 98.9°F (37.2°C), and an oxygen saturation of 96%. Which actions are appropriate for the nurse to implement in this situation? (Select all that apply.)
1.Provide supplemental oxygen of 2 L/min by nasal cannula.
2.Contact the health care provider.
3.Administer intravenous labetalol as prescribed.
4.Place the client in high-Fowler position.
5.Increase intravenous flow rate to 100 mL/hr.
1.Provide supplemental oxygen of 2 L/min by nasal cannula.
2.Contact the health care provider.
3.Administer intravenous labetalol as prescribed.
The nurse provides care for a client diagnosed with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which data does the nurse expect upon assessment?
1.BP 150/90 mm Hg, P 64 beats/min, R 12 breaths/min.
2.Urinary output of 3000 mL in 24 hours.
3.Serum sodium of 115 mEq/L (115 mmol/L).
4.Urine specific gravity of 1.005.
3.Serum sodium of 115 mEq/L (115 mmol/L).
The home care nurse visits a client undergoing external radiation therapy after a lumpectomy of the right breast. Which statement, made by the client, indicates that the nurse’s teaching is effective?
1.“I should wear a loose-fitting bra made of 100% cotton.”
2.“I can apply scented lotion to the right side of my chest.”
3.“I should expose my right breast to the air and sun.”
4.“I can apply cold compresses to the right side of my chest.”
1.“I should wear a loose-fitting bra made of 100% cotton.”
The nurse provides care to a client who is suspected of having a respiratory infection. When collecting a sputum sample for culture and sensitivity testing, which action does the nurse implement?
1.Ask the client to expectorate into a clean emesis basin.
2.Collect the specimen at night just before the client goes to sleep.
3.Use a sterile plastic container for obtaining the specimen.
4.Collect the specimen immediately after the client eats a meal.
3.Use a sterile plastic container for obtaining the specimen.
T
he school nurse teaches a group of high school students about the Heimlich/abdominal thrust maneuver. Which statement made by one of the students indicates to the nurse that teaching is effective?
1.“The maneuver is used to dislodge food or other foreign bodies in the throat.”
2.“To begin the maneuver, you hit the person on the back several times.”
3.“The maneuver should not be done if the person is conscious.”
4.“The maneuver should be used as a last resort if all other efforts fail.”
1.“The maneuver is used to dislodge food or other foreign bodies in the throat.”
A client is placed on NPO status because of an esophageal mass. A family member gives the client juice, which is vomited immediately. Which are appropriate nursing actions? (Select all that apply.)
1.Suction the client ’s mouth with an oral suction.
2.Elevate the head of the bed to 45 degrees.
3.Notify the health care provider immediately.
4.Auscultate the client ’s breath sounds frequently.
5.Draw blood for arterial blood gas assessments.
1.Suction the client ’s mouth with an oral suction.
2.Elevate the head of the bed to 45 degrees.
3.Notify the health care provider immediately.
4.Auscultate the client ’s breath sounds frequently.