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Med Surg Prev Ques

Carroll NRS Med Surg Questions

QuestionAnswer
When the nurse removes an NG tube that has been placed for 7 days, the patient develops a nosebleed. To control the bleeding, the nurse should: pinch the soft lower portion of the nose for 10-15 minutes
When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patient's ability to swallow, it is important to: suction the patient's mouth and trachea before deflating the cuff
A patient returns from surgery with a tracheostomy tube after a total laryngectomy and radial neck dissection. In caring for the patient during the first 24 hours after surgery, the priority nursing action is: assess the airway and breath sounds
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis? Weak, nonproductive cough effort
To promote airway clearance in a patient with pneumonia the nurse instructs the patient to: splint the chest when coughing
To protect a patient from aspiration pneumonia the nurse will position the patient with an altered LOC laterally
A patient with possible tuberculosis. The best time for a sputum culture is: immediately upon awakening in the morning.
The nurse is caring for a client with active TB. The disease can be transmitted to others until: Three acid fast bacilli smears are negative
An alcoholic homeless patient is diagnosed with TB. The most effective treatment for this patient which promotes adherence to the treatment is: daily noon time meals with medications at the community center
A patient is brought in with an injury from a motor vehicle accident. The initial assessment that is most concerning is: paradoxical chest wall movements.
The nurse comes to a diagnosis of ineffective airway clearance for a patient with incision pain, poor cough effot, and rhonchi after a pneumonectomy, the first action to promote airway clearance is to: medicate with morphine.
A 68 year old male with a history of COPD is admitted with cor pulmonale, which clinical manifestation is consistent with cor pulmonale? 3+ edema in the lower extremities
A patient admitted with pneumonia complains of sharp pain when taking a deep breath. Which action should the nurse take? Listen to the lungs
A patient is receiving subcutaneous heparin to treat a pulmonary embolism. Which assessment data is most important to tell the healthcare provider? a BP is 90/64. This could be indicative of an internal bleed.
The nurse has four clients. Which one will the plan to assess first? a 46 year old patient who is having dyspnea one hour after a thoracentesis.
A patient just had a total laryngectomy and radial neck dissection surgery. the nurse should assess and intervene for these problems in the following order. 1. The client is laying in bed laterally with the HOB at zero degrees. 2. The client is coughing blood tinged sputum from this tracheostomy. 3. The hemovac has 200 mL of drainage which is bloody. 4.The NG tube is disconnected from suction and clamped
The following strategy is a priority when planning care for a patient with hypertension who have no insurance: follow evidence-based national guidelines.
To check if aromatherapy was effective on a patient following surgery the nurse will assess: BP and pulse
A client has respiratory distress and is admitted to the hospital. The nurse, during her first assessment should: do a focused respiratory assessment and ask questions that are specific to this exacerbation of respiratory distress.
An 80 year old client is on room air and has an ABG analysis. Which finding is normal? PaCO2 40 mmHg, O2Sat 92%, pH 7.38, PaCO2 82 mmHg.
The nurse is caring for a patient with a respiratory disease. The patient's oxygen saturation drops form 94% to 85% while ambulating. The nurse determines: supplemental oxygen should be used when ever exercising.
A patient with chronic hypoxemia caused by COPD has been admitted with increased shortness of breath. Which of the following actions by the RN will be most effective in improving compliance with discharge teaching? Start instructions on the day of admission OR arrange for the patient's spouse to be present for teaching.
A patient had a rhinoplasty to correct a nasal deformity resulting from an automobile accident. Which intervention is the most appropriate post-operation? instruct the patient to keep the head elevated for at least 48 hours to minimize swelling.
When teaching the patient with allergic rhinitis about management the nurse explains: identification and avoidance of trigger is the best way to manage.
The nurse will plan on administering the flu vaccine to: a 30 year old patient who takes corticosteriods for rheumatoid arthritis.
A 76 year old patient with influenza is admitted to the floor. Which finding should the nurse report to the doctor? Diffuse crackles in the lungs
The nurse can delegate what nursing intervention to an assistant for a patient with sleep apnea: Remind the patient to apply the CPAP at bedtime.
An 82 year old patient with a nosebleed has nasal packing. Which assessment requires immediate action? An oxygen saturation of 89%.
A patient with pneumonia has a fever of 101.2 F, a nonproductive cough, and an oxygen saturation of 89%. He is very weak and needs assistance out of bed. The best nursing diagnosis is: Impaired gas exchange r/t respiratory congestion
A patient with right lower lobe pneumonia has had IV antibiotics for two days. Which laboratory finding indicates its effectiveness? A WBC count of 9,000.
After two months of TB treatment with the standard 4-drug regimen, a patient still continues to have possible sputum smears. The nurse discusses a treatment regimen with the patient knowing: Direct observed therapy (DOT) will be needed if the medications have not been taken correctly.
A patient is scheduled for a lobectomy for a stage one non-small cell lung cancer. The patient states that they would rather have radiation than surgery. Which is an appropriate response by the nurse: Tell me what you know about various treatments that are available.
A newly diagnosed lung cancer patient says "I think I am going to die soon." The best response by the nurse is: "Can you tell me what it is that makes you think you will die soon?"
A patient is admitted to the ER with a stab wound to the right chest. Air can be heard entering his chest with inspiration. To decrease the possibility of a tension pneumothorax, the nurse should: tape a nonporous dressing on three sides over the chest wound.
A 76 year old patient is admitted to the ER with confusion, chills and chest pain that worsens with inspiration. Which is the priority nursing task? Obtain vital signs and oxygen saturation.
A patient with a pleural effusion is scheduled for a thoracentesis. Prior to the procedure the nurse will plan to: position the patient sitting upright on the edge of the bed and leaning forward.
All of the following are ordered for a patient with probable pneumonia and sepsis. Which will the nurse to first? Obtain blood cultures from two sites.
A patient with asthma has a new prescription for an Advair Diskus (fluticasone and salmeterol). What is the purpose of using two drugs? One drug is to decrease the inflammation and the other is a bronchodilator.
The health care provider prescribes triamcinalone (Azmacort) MDI two puffs every eight hours and pirbuteral (Maxair) MDI two puffs four times a day. What should the nurse teach the patient about MDIs? Using a spacer with MDIs improves the inhalation of the medications.
Which finding best indicates that acute asthma exacerbation is responding to bronchodilator therapy. Wheezes are more easily heard.
During an assessment of a patient with a history of asthma, the nurse notes wheezing and dyspnea. The nurse will anticipate giving medications to reduce: airway narrowing
A patient with an acute exacerbation of COPD has the following findings: pH 7.32, PaO2 58, PaCO2 55, and Pulse oximetry of 86%. The nurse recognizes this as evidence of: respiratory acidosis.
A patient is seen in the clinic with COPD. Which information given by the patient would help the most in confirming the diagnosis of chronic bronchitis A patient complaining of having a productive cough every winter for two months
A nurse teaches a patient with COPD how to do pursed lip breathing, explaining that this will assist respiration by: preventing airway collapse and air trapping in the lungs during expiration.
A patient with COPD asks the home health nurse about the use of oxygen. The nurse should teach the patient that long term home oxygen therapy: can improve the patient's prognosis and quality of life.
To have the best gas exchange in a patient with COPD, the nurse should position the patient: sitting up at the bedside in a chair, leaning slightly forward.
A 23 year old patient with cystic fibrosis has harsh lung changes and cor pulmonale. The expected outcome for the patient is: to achieve a realistic attitude toward treatment.
The nurse knows that teaching about nutrition is effective to a COPD patient when they state: I will have ice cream as a snack everyday.
Teaching is successful with homecare of an asthma patient when the patient states: No changes in my medications are needed if my peak flow is at 80% of normal.
The nurse is assessing a 36 year old woman who has been admitted for knee surgery. Which information obtained during the preoperative assessment should be reported to the surgeon before surgery The patient's statement that her last menstrual period was 8 weeks previously
When the nurse is performing a physical examination of a patient who smokes and who is being admitted on the day of surgery, it is espeically important to Auscultate for normal and adventitious breath sounds
Appropriate preoperative teaching for a patient scheduled for abdominal surgery includes Methods for effective deep breathing and coughing
10 minutes after recieving the ordered preoperative opioid by IV injection, the patient asks to get up to go to the bathroom to urinate. The most appropriate action by the nurse is to Offer a urinal or bedpan and position the patient in bed to promote voiding
A 52 year old patient has a new diagnosis of pernicious anemia. After teaching the patient about pernicious anemia, the nurse determines that the patient understands the disorder when the patient states "I will need to have cobalamin (B12) injections regularly for the rest of my life."
Intra-operative activity performed by peri-operative circulating nurse is Admitting, identifying and assessing the patient (Remember the Circulating nurse is not sterile, and is not in the OR!)
Orientation of new staff to the scrub nurse role, the nurse knows that teaching was effective when the new nurse Keeps both hands above the OR table level
Data obtained during the peri-op assessment that indicate a need for special protection techniques during surgery Having a hx of spinal and hip arthritis (positioning)
Pt. asks will the doctor put me to sleep with a mask A drug will be injected through the IV which will induce sleep
nurse recognizes use of local anesthesia would be particularly beneficial to patient pt recently take foods/fluids
surgery receives neuromuscular blocking agent as adjunct to general anesthetic, after surgery most important nurse monitor weak chest-wall movement
which of these actions by inexperienced staff member nurse intervene walking into hallway outside OR w/ out hair covered
42 yr old in PACU, BP 124/70, 30 min. later 112/60, pulse of 72, warm, dry skin continue to monitor VS every 15 min.
new nurse in PACU, charge nurse evaluate orientation successfully turns pt to side when arrived in PACU.
When a patient is transferred from the PACU to the clinical surgical unit, the first action by the RN on the surgical unit should be to Take the patient’s vital signs
The NG tube is removed on the 2ns postop day for a patient who had abdominal surgery. A clear liquid diet is ordered. 4 hours later, the patient complains of abdominal distention and sharp, cramping gas pains. The most appropriate nursing action is to Assist the patient to ambulate down the hall
In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which action by the nurse is most helpful Administer ordered analgesic medications before these activities
A patient with a history of iron-deficiency anemia who has not taken iron supplements for several years is experiencing increased fatigue and occasional palpitations. The nurse would expect the patient’s laboratory findings to include Hgb 8.6
A patient with chronic lymphocytic leukemia is hospitalized for treatment of severe hemolytic anemia. An appropriate nursing intervention for the patient is to Plan care to alternate periods of rest and activity.
When talking about appropriate food choices for a patient with iron-deficiency anemia who follows a low cholesterol diet, the nurse would encourage and increased intake of legumes and dried fruits
A patient in a sickle cell crisis asks the nurse why sickling causes pain. This pain is a result of tissue hypoxia as a result of small vessel occlusion
Which data, for a patient with thrombocytopenia, should be reported to a PCP The patient is hard to arouse
All of these patients are waiting for an emergency room nurse. Which has priority A patient with chemotherapy-induced neutropenia and has a temperature of 100.8 F.
A 24 y/o patient who uses a diuretic for blood pressure control is scheduled for abdominal surgery. Which information should be told to the surgeon prior to surgery A serum potassium of 3.3 mEq/L
Gathering data to evaluate patient outcomes regarding pain control, the nurse should include patient complaints of pain in pre-Op
26 y/o with stage 2 Hodgkins asks nurse "How long do I have to live?” most patients with your stage of the disease are treated successfully
Relieve symptoms of lower UTI for patient on antibiotics. Nurse suggests phenazopyridine (Pyridium) but cautions patient that this med might? cause urine to turn reddish orange and can stain clothing
Patient with acute glomerulonephritis nurse will ask about? recent fever or sore throat
HCP orders IV glucose and insulin to be given to ARF patient whose potassium is 6.3mEq/l. To evaluate effectiveness of med the nurse will? obtain serum potassium levels
A client with CKD is beginning hemodialysis. What diet change is needed? More protein will be allowed because of the removal of urea and creatinine
A male is hospitalized because of gross hematuria and severe colicky left flank pain that radiates to his left testicle. He has a history of kidney stones. Priority nursing diagnosis is Acute pain r/t irritation by the stone
Recipient of kidney transplant is in immediate post-op period. IV fluids should be administered Determined hourly, based on every milliliter of urine output
Patient with neurogenic bladder is being educated by home health nurse on how to use periodic catheterization of bladder emptying. What statement shows the patient understands? I will wash the catheter with soap and water before and after each catheterization
With a patient who has a lower UTI, the nurse will first question Pain with urination
Instructions for a patient with cystitis to prevent future UTIs empty the bladder every 3-4 hours during the day
Which nursing assessment is most important to report to the HCP for patient with a bladder infection Left-sided flank pain
A patient admitted for severe crushing injury; which lab level is the nurse most concerned with potassium
ARF patient have a gradual increase to 3400 ml/day of urine output, a BUN of 92, and a serum creatinine of 4.2, the nurse should plan to monitor for hypotension by taking the BP
Which order will the nurse question for a patient with renal insufficiency scheduled for IVP (intravenous pyelogram) Ibuprofen (Advil) 40 mg PO prn for pain
Before administering sodium polystyrene sulfonate (Kayexalate) to patient with hyperkalemia, assess The patient's bowel sounds
Before administering calcitrol (Rocaltrol) to patient with CKD, nurse should check Serum phosphate
Differences between arterivenous (AV) fistula and a graft, nurse says one advantage of the fistula is that It is much less likely to clot
A patient with CKD is thinking about using continuous ambulatory peritoneal dialysis (CAPD). The nurse informs the patient that Patients with diabetes who use CAPD have fewer dialysis related complications than those on hemodialysis
Immediately post-op, nurse is caring for a patient who is a recipient of a kidney transplant would expect that fluid therapy would involve administering of IV fluids To be determined hourly, based on every milliliter of urine output
A client with Chronic Kidney Disease brought all her meds from home to the hospital so the nurse could look over them. Which of the following meds that the patient is using shows that they need more teaching? Milk of magnesia 30 ml administered orally
A client in ARF needs hemodialysis. She receives a temporary vascular access by placing a catheter in the left femoral vein. After assessing the client, the nurse will plan to Place the client on bed rest
A client that is having an elective hysterectomy performed tells the nurse that she is not sure che can go through with the surgery because she knows she will die like her mother did during surgery. The nurse should respond by "Tell me more about what happened to your mom."
To help with venous return in the lower extremities of a patient who just had a cholecystectomy, the nurse should promote the following exercises dorisflexion and plantar flexion of her feet, rotation of her ankles (in circles), and pressing the back of her knees into her bed while she is lying supine.
A female clinet has a 2nd reoccurrence of pyelonephritis. The nurse should expect the following labs an elevated BUN, a positive leukocyte esterase, and bacteria
The nurse is caring for a patient who has 20 second periods of deep and rapid breathing. The nurse should document this finding as Cheyne-Stokes respirations
As the nurse admits a patient with AIDS who has cryptococcal meningitis, the patient tells the nurse, "If my heart or breathing stops, I do not want to be resuscitated." The nurse should Ask the patient if these wishes have been discussed with the admitting health care provider
Which of these patients is most appropriate for the nurse to refer to hospice care? A 28 year old with AIDS-related dementia who needs palliative care and pain management
A patient with difficulty swallowing is started on continuous tube feedings of a full-strength commercial formula at 100 ml/hr. The patient has 6 diarrhea stools on the 1st day. The action that is most appropriate is Slow the tube feeding flow rate
A patient who is receiving continuous tube feeding through a small-bore silicone feeding tube has a CT scan ordered and will have to be placed in a flat position for the scan. The nurse will plan to Shut the feeing off 30-60 minutes before the scan
PEG tube nursing actions that an LPN can perform Provide skin care around tube
Pt. with NG tube to LIS and PCA following gastroplasty. The RN needs to Support incision during coughing to prevent dehiscence
Orders for a dehydrated pt. Act first on Infusing normal saline at 250ml/hr
CVA pt. is unresponsive and unconscious with a hx of GERD. RN assesses Breath Sounds
Nexium for heart burn. RN explains that the drug Treats GERD by decreasing stomach acid production
Pt nauseated and vomiting blood tinged fluid is admitted with acute gastritis. Most important to ask pt about? frequent NSAID use
Pt vomiting bright red blood admitted to ER, which assessment should nurse do first? BP and pulse
Why is pt who suffered severe abdominal trauma receiving famotidine (Pepcid)? Nurse explains medication will inhibit stress ulcers
Pt with acute GI bleed has NS infusing at 500ml/hr. Which data is most important to communicate to HCP? Pt lungs have audible midline crackles
Pt has abdominal pain and watery incontinent diarrhea is diagnosed with C.diff. The nurse will? place pt in private room under contact isolation
A patient who recently had an exploratory laparotomy w/a resection of a short segment of a small bowel is complaining of gas pains and abdominal distension. The nurse should respond by Assisting the client to ambulate to increase peristalsis
A client has an acute exacerbation of ulcerative colitis and is having 14-16 bloody stools a day. Additionally, they have crampy abdominal pains associated with this diarrhea. The nurse should make the client NPO to rest the bowel
A patient has a h/o IBD, the nurse realizes that the patient has ulcerative colitis rather than crohn’s b/c the patient tells that nurse they are experiencing bloody stools
A 26 y/o client is diagnosed with crohn’s disease after having many frequent stools as well as losing 10 pounds in 2 months. The nurse should teach the client about oral corticosteroids
A nursing history is being taken on a 55 y/o who is scheduled for a colonoscopy. The nurse should be concerned when the patient tells her he has recently had blood in his stools
during initial assessment of post-op stoma the nurse finds it to be red with moderate edema and small amount of bleeding. The RN should Document findings
a homeless patient with severe anorexia, fatigue, jaundice and hepatomegaly is diagnosed with viral hepatitis. RN assumes highest priority to maintain adequate nutrition
32-year old with early alcohol cirrohis is diagnosed via liver biopsy. Priority teaching is abstinence from alcohol
during treatment of patient with Minnesota balloon tamponade for bleeding esophageal varices which nursing intervention is included? monitor for shortness of breath
RN identifies collaborative problems electrolyte imbalance for patient with severe acute pancreatitis. Assessment findings that alert the nurse to this is
A patient with acute pancreatitis has an NG tube to suction and is NPO. What indicates therapies have been effective? Decrease in abdominal pain
A client has acute pancreatitis. What finding is the priority? Lying BP 120/80, pulse 80. Standing BP 94/70, pulse 110
Lab finding suggestive of hepatitis ALT 45 units/L
Lab results for pt with cirrhosis have elevated ammonia levels. What diet should be ordered? low protein
RN reviewing physician’s orders for a pt with acute pancreatitis. Questions which order noted on the chart? morphine for pain
Home health nurse visits a diabetic patient with infected heel wound to do a daily dressing change and wound assessment. The nurse diagnosed this patient with impaired tissued integrity and to evaluate outcome, the nurse collects data about the wound appearance and patient temperature
Nursing student caring for dying patient asks the nurse how will we know when the patient has died? the patient is comatose, apneic and without brainstem reflexes
A patient near death has a decrease in all body system functions except for a heart rate of 124 and respiratory rate of 28. Nurse explains to family that these are normal response before the functions decrease
A patient very close to death is very restless and repeats, "I'm not ready to die." The most important intervention the nurse can do is to sit at bedside and ask if there is anything the patient needs
Hospice nurse becomes very close to a terminally ill patient. Family and nurse are present when patient dies. The family cries softly and the nurse also feesl like crying. The nurse knows that it is acceptable and healthy to cry with family during this phase of the grief process
During the assessment of a patient who is a vegan the nurse observes for nutritional deficiency. The most common nutritional deficiency related to a strict vegan diet would manifest as pallor & changes in sensation & movement of the extremities.
The nurse teaches the patient who is being stabilized on therapeutic dose of warfarin (Coumadin) not to alter normal intake of green, leafy vegetables, dairy products, or meats because they are sources of vitamin K & may alter the action of warfarin.
A 72 year old patient with a massive infection is 5'2" and 92 lbs. Laboratory results include hgb 10.5 g/dL & albumin 2.0 g/dL. Which information will be most useful when nurse is determining nutritional status The presence of edema.
With a nutritional screening tool, the nurse can identify a patient at nutritional risk without further assessment when the patient has pressure ulcers.
A 22 year old patient has anorexia nervosa. The patient is 5'5" & 90 lbs. Labs reveal hypokalemia & iron deficiency anemia. In planning care for the patient the nurse places the highest priority on the nursing diagnosis at risk for decreased cardiac output related to electrolyte imbalance.
When taking a health hx for an obese pt, which info obtained is most helpful in seeing the pt's success c losing weight Pt says, "I'm ready to make changes in my lifestyle."
Pt who has been consistently following a diet and exercise program and successfully losing 1lb weekly for several months is weighed and hasn't lost any weight for the last month. Nurse should first ask pt whether there have been changes in exercise/diet patterns
Nurse is developing a wt loss program for a 21 y/o obese pt. What statement by the nurse is most likely to help the pt lose wt on the 800-calorie diet? "You're likely to notice changes in how you feel in just a few weeks of diet/exercise."
When working c an obese pt enrolled in a behavior mod program, which nursing action is appropriate? Suggesting the pt has a reward, like a piece of sugarless candy, p achieving wt loss goal
A moderately obese pt has been on a 1000-calorie diet c a daily exercise routine and a prescription for sibutramine (Meridia) for 10 weeks. What info obtained by the nurse is important to report to the HCP? pt tells nurse about occasional palpitations
Patient has fecal impaction resulting in bowel obstruction. Assessment consistent with large bowel obstruction is Abdominal distension
A patient is post-op following abdominal-perineal resection w/ sigmoid colostomy & abdominal perineal incisions. Colostomy has petroleum jelly gauze & dry gauze dressings. Peri incision partially closed with 2 JP drains. Highest priority post-op day 1 is Assessing perineal drainage and incision
69 year old patient has developed frequent, watery diarrhea following respiratory infection with 10-day course of antibiotics. Patient will need Bring a stool specimen in to be tested for c. difficile
Check all that apply- Findings of biliary instruction Yellow sclera, clay colored stools, dark urine
Put in correct order. Comatose patient is receiving continuous tube feeding through NG tube and has developed crackles in lungs. Which order will nurse take the following actions Turn off tube feeding, Obtain pt. O2 sat, check tube feeding residual volume, notify the patients health care provider (answer on the test was B-A-D-C)
HIV 3 years ago admitted with pneumocystitis jiroveci pneumonia. THe patient is diagnosed as having AIDS
Posttest counseling for a patient who has positive testing for HIV, the patient is anxious and does not appear to hear what the nurse is saying. Most important that the nurse Remind the patient about the need to return for retesting to verify the results
Interventions such as promotion of nutrition, exercise, and stress reductiong should be promoted by the nurse for patients who have HIV infection, primarily because these interventions will Improve the patient's immune function
4. Drug therapy is being considered for an HIV-infected patient who has a CD4+ cell count of 400/ul. The nursing assessment that is most important in determining whether therapy will be used is the patients Willingness and ability to comply with stringent medications schedules
When teaching a patient with HIV infection about antiretroviral therapy, the nurse explains that these drugs Work in various ways to decrease viral replication in the blood.
To evaluate the effectiveness of ART, the RN should anticipate scheduling the patient for Viral load testing
When designing a program to decrease the incidence of HIV, and RN will educate on How to prevent transmission b/t sexual partners
The difference between a benign tumor and a malignant tumor is that benign tumors Do not spread to other tissues and organs
Cancer prevention, the RN stresses promotion of exercise, normal body weight, and a low fat diet because Dietary fat and obesity promote cancer growth
A patient is scheduled for a needle biopsy of the prostate. The RN explains that a needle biopsy is needed because A biopsy will help the doctor decide on what treatment to use
metastatic cancer of the colon experiences severe vomiting following each chemo tx important nursing intervention for the pt administering prescribed antiemetics 1 hr before tx
administering resicant chemotherapeutic agent IV important consideration stop infusion swelling is observed at site
pt receiving had & neck radiation & systemic chemo-lesions oral mucosa & tongue, ropey saliva, nurse teach intervention rinse mouth before and after each meal & at bedtime w/ saline solution
terminal cancer of liver & is cared for by family at home tells nurse "I have intense pain most of the time now," teaching regarding pain management take opiods around clock & use additional doses for breakthrough pain
reviewing lab results pt receiving chemo report to HCP when WBC of 1700 u/L
Which action by a CAN when caring for a patient who is pancytopenic indicates a need for the RN to intervene? The CAN assists the patient to use dental floss after eating.
A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL. The RN will plan to teach the patient about maintenance of a healthy weight.
When assessing the patient experiencing the onset of symptoms of type I DM, which question should the RN ask? “Have you lost any weight lately?”
During a clinic visit 3 months following a diagnosis of DM II, the patient reports following a reduced-calorie diet. The pt has not lost any weight and did not bring the glucose-monitoring record. The RN will plan to obtain a Hgb A1c (aka glycosylated hemoglobin).
A college student who has DM I normally walks each evening as part of an exercise regimen. The student now plans to take a swimming class every day at 1 00 pm. The clinic RN teaches the pt to
When talking about appropriate food choices for a patient with iron-deficiency anemia who follows a low cholesterol diet, the nurse would encourage and increased intake of legumes and dried fruits
A patient in a sickle cell crisis asks the nurse why sickling causes pain. This pain is a result of tissue hypoxia as a result of small vessel occlusion
Which data, for a patient with thrombocytopenia, should be reported to a PCP? The patient is hard to arouse
All of these patients are waiting for an emergency room nurse. Which has priority? A patient with chemotherapy-induced neutropenia and has a temperature of 100.8 F.
A 24 y/o patient who uses a diuretic for blood pressure control is scheduled for abdominal surgery. Which information should be told to the surgeon prior to surgery A serum potassium of 3.3 mEq/L
Diabetic admitted with DKA, the HCP writes following orders, which implement first? infuse 1L NS per hour
Dx of HHNC for patient with Type 2 brought to the ER in unresponsive state, nurse will? insert large bore IV
Patient with Type 1 using Lantus and Humalog develops sore throat, cough and fever. Patient calls and reports BS of 210 nurse tells client to? monitor BS q4hr and notify if continues to rise
When hospitalized and recovering from DKA, patient calls nurse and says feeling anxious, nervous, sweaty. Based on report nurse should? obtain glucose with finger stick
Patient recovering form DKA asks how does acidosis occur? insulin deficit promotes metabolism of fat storage which produces acidic ketones
IM glucagon is given to treat hypoglycemia in a client who is unresponsive. Upon regaining consciousness, what should the nurse do? Give patient snack of cheese and crackers
A 3 mile a day runner was just diagnosed with type 1 DM. What should the nurse educate the patient on before running? Plan to eat breakfast about an hour before you run
Looking at labs of a diabetic client, which lab needs further assessment of the client? Noon blood glucose of 52 mg/dl
A client with ADH-secreting small cell cancer of the lung is receiving demeclocycline (Declomycin) to help the symptoms of SIADH. The med is appropriate when Urine output is increased
A patient possibly has SIADH. The patient is exhibiting confusion, headache, muscle cramps and twitching. Labs would indicate Serum sodium of 125 mEq/L (125 mmol/L)
A patient was just admitted for diabetes insipitus, what assessment is the nurses greatest concern? confused and lethargic
When teaching a patient with a new diagnosis of Grave’s disease about the disorder antithyroid medication take weeks to have an effect
During initiation of thyroid replacement with Synthroid for hypothyroidism the most important assessment is cardiac function
Teaching for a patient with a new diagnosis of hypothyroidism provide written handouts for patient’s continued reference
Hyperparathyroidism levels before surgery are calcium 14, phosphorus 1.7, creatinine 2.2, and high urine calcium, what should the nurse encourage drink 4000 ml of fluid
hypoparathyroidism after neck surgery, nurse should teach patient Calcium supplementation to normalize levels
Cushing syndrome patient has adrenalectomy, highest priority initially is Maintaining fluid and electrolyte status
Patient is on prednisone therapy every other day for rheumatoid arthritis; patient feels not as good on non-prednisone days and asks the nurse about taking prednisone daily, best response is There is less effect on normal adrenal function when prednisone is taken every other day
High doses of prednisone to control an acute exacerbation of systemic lupus erythematosus. When teaching about prednisone, which information is important? Do not stop taking the prednisone suddenly, it should be decreased gradually
Adrenocortical adenoma causing hyperaldosteronism and scheduled for surgery, before surgery Monitor the blood pressure every 4 hours
The nurse should put the following client at the top of her priority list a 70 y/o who recently started on the hypothyroidism med levothyroxine and also has an irregular pulse of 134
A patient is experiencing a hypercalcemic crisis – the nurse taking care of him should question the order by the doctor that states Restrict the fluid intake of the patient to only 1000 mL per 24 hours
A patient is in an adrenal crisis. The nurse caring for her should question the following doctor's order giving the patient insulin to treat acute hypokalemia
In a patient with HHNK, the following is least likely to be a sign or sx of the episode abdominal pain
DI and DM have the following sx in common polyuria and polydipsia
Created by: 1607130040 on 2009-12-15



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