Endocrine
Rotation sites for insulin injection should be separated from one another by 2.5 cm (1 inch) and should be used only every:
C. 1-2 weeks
Rotation of sites for insulin injection should be done every week or two. Frequently using the same spot over time can cause fat cells to break down or build up (lipodystrophy) causing lumps under the skin and may interfere with insulin absorption.
The nurse is caring for a client admitted with end-stage renal disease (ESRD). Which lab value is the priority to report to the health care provider (HCP)?
Blood Urea Nitrogen (BUN) 54 mg/dL
Creatinine (Cr) 6.8 mg/dL
Potassium 5.8 mmol/L
Phosphorus 4.4 mg/dL
Potassium 5.8 mmol/L
This answer is correct because the normal range for potassium is 3.5-5.0 mmol/L. A level of 5.8 is significantly elevated and puts the client at risk for cardiac dysrhythmias. This needs to be addressed and reported immediately.
The client diagnosed with diverticulitis is complaining of severe pain in the left lower quadrant and has an oral temperature of 100.6F. Which intervention should the nurse implement first?
A with tumor lysis syndrome (TLS) is taking allopurinol (Zyloprim). Which laboratory value should the nurse monitor to determine the effectiveness of the medication?
1)Blood urea nitrogen (BUN)
2)Serum phosphate
3)Serum potassium
4)Uric acid level
Uric acid level
Allopurinol is used to decrease uric acid levels. BUN. potassium. and phosphate levels are also increased in TLS but are not affected by allopurinol therapy.
Nurse Louie is developing a teaching plan for a male client diagnosed with diabetes insipidus. The nurse should include information about which hormone lacking in clients with diabetes insipidus?
a. antidiuretic hormone (ADH).
b. thyroid-stimulating hormone (TSH).
c. follicle-stimulating hormone (FSH).
d. luteinizing hormone (LH).
A. antidiuretic hormone (ADH). ADH is the hormone clients with diabetes insipidus lack. The client's TSH, FSH, and LH levels won't be affected.
Which of these signs suggests that a male client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?
a. Tetanic contractions
b. Neck vein distention
c. Weight loss
d. Polyuria
7. B. Neck vein distention SIADH secretion causes antidiuretic hormone overproduction, which leads to fluid retention. Severe SIADH can cause such complications as vascular fluid overload, signaled by neck vein distention. This syndrome isn't associated with tetanic contractions. It may cause weight gain and fluid retention (secondary to oliguria).
You have a patient that is receiving peritoneal dialysis. What should you do when you notice the return fluid is slowly draining?
A. Check for kinks in the outflow tubing.
Tubing problems are a common cause of outflow difficulties, check the tubing for kinks and ensure that all clamps are open. Other measures include having the patient change positions (moving side to side or sitting up), applying gentle pressure over the abdomen, or having a bowel movement. Assess the patency of catheter, noting difficulty in draining. Note the presence of fibrin strings and plugs. Slowing of flow rate and presence of fibrin suggests partial catheter occlusion requiring further evaluation and intervention.
Brenda, a 36 y.o. patient is on your floor with acute pancreatitis. Treatment for her includes:
A Continuous peritoneal lavage.
B Regular diet with increased fat.
C Nutritional support with TPN.
D Insertion of a T tube to drain the pancreas.
C
With acute pancreatitis, you need to rest the GI tract by TPN as nutritional support.
A nurse has received a report on a client being admitted with anemia who requires a blood transfusion. The nurse will anticipate which assessment findings? Select all
that apply.
1. Tachycardia
2. Hypertension
3. Headache
4. Diaphoresis
5. Bounding peripheral pulses
Answer: 1, 3 Rationale: Key features of anemia include coolness to touch, intolerance to cold, tachycardia, ortho-static hypotension, and headaches. The other options are not
associated with anemia.
After the first hemodialysis treatment, your patient develops a headache, hypertension, restlessness, mental confusion, nausea, and vomiting. Which condition is indicated?
A. Disequilibrium syndrome
Disequilibrium occurs when excess solutes are cleared from the blood more rapidly than they can diffuse from the body’s cells into the vascular system. The dialysis disequilibrium syndrome is defined as a clinical syndrome of neurologic deterioration that is seen in patients who undergo hemodialysis. It is more likely to occur in patients during or immediately after their first treatment but can occur in any patient who receives hemodialysis.
30. A patient with SIADH is treated with water restriction and administration of IV fluids. The nurses evaluates that treatment has been effective when the patient experiences
a. increased urine output, decreased serum sodium, and increased urine specific gravity
b. increased urine output, increased serum sodium, and decreased urine specific gravity
c. decreased urine output, increased serum sodium, and decreased urine specific gravity
d. decreased urine output, decreased serum sodium, and increased urine specific gravity
B. increased urine output, increased serum sodium, and decreased urine specific gravity (rationale- the patient with SIADH has water retention with hyponatremia, decreased urine output and concentrated urine with high specific gravity. improvement in the patient's condition reflected by increased urine output, normalization of serum sodium, and more water in the urine, decreasing the specific gravity.)
Clinical manifestations of acute glomerulonephritis include which of the following?
C. Hematuria and proteinuria
Hematuria and proteinuria indicate acute glomerulonephritis. These findings result from increased permeability of the glomerular membrane due to the antigen-antibody reaction. Generalized edema is seen most often in nephrosis. The most common presenting symptom is gross hematuria as it occurs in 30 to 50% of cases with acute PSGN; patients often describe their urine as smoky, tea-colored, cola-colored, or rusty. The hematuria can be described as postpharyngitic (hematuria seen after weeks of infection).
The nurse is caring for a male client with a diagnosis of chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency?
A Vitamin A
B Vitamin B12
C Vitamin C
D Vitamin E
B
Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of the function of the parietal cells. The source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia. The client is not at risk for vitamin A, C, or E deficiency.
The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which of the following would the nurse recognize as cause for the symptoms?
A. Tissue hypoxia
When the hemoglobin falls sufficiently to produce clinical manifestations, the signs and symptoms are directly attributable to tissue hypoxia, a decrease in the oxygen carrying capacity of the blood
A male client with a peptic ulcer is scheduled for a vagotomy and the client asks the nurse about the purpose of this procedure. Which response by the nurse best describes the purpose of a vagotomy?
A Halts stress reactions
B Heals the gastric mucosa
C Reduces the stimulus to acid secretions
D Decreases food absorption in the stomach
C
A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion. Options A, B, and D are incorrect descriptions of a vagotomy.
18. Which outcome indicates that treatment of a male client with diabetes insipidus has been effective?
a. Fluid intake is less than 2,500 ml/day.
b. Urine output measures more than 200 ml/hour.
c. Blood pressure is 90/50 mm Hg.
d. The heart rate is 126 beats/minute.
A. Fluid intake is less than 2,500 ml/day Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant thirst, and an unusually high oral intake of fluids. Treatment with the appropriate drug should decrease both oral fluid intake and urine output. A urine output of 200 ml/hour indicates continuing polyuria. A blood pressure of 90/50 mm Hg and a heart rate of 126 beats/minute indicate compensation for the continued fluid deficit, suggesting that treatment hasn't been effective.
The most common early sign of kidney disease is:
B. Elevated BUN level
Increased BUN is usually an early indicator of decreased renal function. Although, immediately after a renal insult, blood urea nitrogen (BUN) or creatinine levels may be within the normal range. The only sign of the acute kidney injury may be a decline in urine output. AKI can lead to the accumulation of water, sodium, and other metabolic products. It can also result in several electrolyte disturbances.
You’re assessing the stoma of a patient with a healthy, well-healed colostomy. You expect the stoma to appear:
A Pale, pink and moist
B Red and moist
C Dark or purple colored
D Dry and black
B
Good circulation causes tissues to be moist and red, so a healthy, well-healed stoma appears red and moist.
7. The nurse is discharging a client dx with anemia. Which discharge instruction should the nurse teach?
A. Take prescribed iron until it is completely gone
B. Monitor P and BP at local pharmacy weekly
C. Have complete blood count checked at the HCP's office
D. Perform isometric exercise three times a week
C
Rationale: The client should have a CBC regularly to determine the status of anemia.
Why it is not the rest: Antibiotics should be taken until complete, not iron. Pulse is indirectly affected by anemia when
the body attempts to compensate for the lack of O2 supply, but this is an indirect measure, and blood pressure is not
monitored for anemia. Isometric exercises are bodybuilding exercises, and the client should not be exerting him-
/herself in this manner
Which lab result would the nurse expect in the client diagnosed with DIC?
1. A decreased prothrombin time (PT)
2. A low fibrinogen level
3. An increased platelet count
4. An increased white blood cell count
2. Fibrinogen level helps predict bleeding in DIC. As it becomes lower, the risk of bleeding increases.
The nurse is planning care for a client with hyperthyroidism. Which of the following nursing interventions are appropriate? Select all that apply
a) instill isotonic eye drops as necessary
b) provide several, small, well-balanced meals
c) provide rest periods
d) keep environment warm
e) encourage frequent visitors and conversation
f) weigh the client daily
(a) The client with hyperthyroidism may experience exopthalmos. This requires instillation of eye drops to prevent dryness and ulceration of the cornea. (b and f) The client experiences weight loss because of hypermetabolism. Several, small, well-balanced meals are given to improve nutritional status of the client and daily weights should be monitored. Weight is the most objective indicator of nutritional status. (c) The client is usually exhausted due to restlessness and agitation. Frequent rest periods help the client regain energy.
What is the priority nursing diagnosis with your patient diagnosed with end-stage renal disease?
B. Fluid volume excess
Fluid volume excess because the kidneys aren’t removing fluid and wastes. The other diagnoses may apply, but they don’t take priority. Renal disorder impairs glomerular filtration that results in fluid overload. With fluid volume excess, hydrostatic pressure is higher than the usual pushing excess fluids into the interstitial spaces.
Nurse Joy is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse would:
A Position the client supine to assist in medication absorption
B Aspirate the nasogastric tube after medication administration to maintain patency
C Clamp the nasogastric tube for 30 minutes following administration of the medication
D Change the suction setting to low intermittent suction for 30 minutes after medication administration
C
If a client has a nasogastric tube connected to suction, the nurse should wait up to 30 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered. The client should not be placed in the supine position because of the risk for aspiration.
Which client would be most at risk for developing disseminated intravascular coagulation (DIC)?
1. A 35 year old pregnant client with placenta previa
2. A 42 year old client with a pulmonary embolus
3. A 60 year old client receiving hemodialyasis 3 days a week
4. A 78 year old client with septicemia
4. DIC is a clinical syndrome that develops as a complication of a wide variety of other disorders, with sepsis being the most common cause of DIC
When caring for a male client with diabetes insipidus, nurse Juliet expects to administer:
a. vasopressin (Pitressin Synthetic)
b. furosemide (Lasix).
c. regular insulin.
d. 10% dextrose.
A. vasopressin (Pitressin Synthetic) Because diabetes insipidus results from decreased antidiuretic hormone (vasopressin) production, the nurse should expect to administer synthetic vasopressin for hormone replacement therapy. Furosemide, a diuretic, is contraindicated because a client with diabetes insipidus experiences polyuria. Insulin and dextrose are used to treat diabetes mellitus and its complications, not diabetes insipidus.