exam 1 questions

Question 1

A patient in the urology clinic is diagnosed with monilial urethritis. Which action will the nurse include in the plan of care

Teach the patient about the use of antifungal medications.

Tell the patient to avoid tub baths until the symptoms resolve.

Instruct the patient to refer recent sexual partners for treatment.

Teach the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs).

Answer 1

Teach the patient about the use of antifungal medications.

Monilial urethritis is caused by a fungus and antifungal medications such as nystatin (Mycostatin) or fluconazole (Diflucan) are usually used as treatment. Because monilial urethritis is not sexually transmitted, there is no need to refer sexual partners. Warm baths and NSAIDS may be used to treat symptoms.

Question 2

After a ureterolithotomy, a female patient has a left ureteral catheter and a urethral catheter in place. Which action will the nurse include in the plan of care

Provide teaching about home care for both catheters.

Apply continuous steady tension to the ureteral catheter.

Call the health care provider if the ureteral catheter output drops suddenly.

Clamp the ureteral catheter off when output from the urethral catheter stops.

Answer 2

Call the health care provider if the ureteral catheter output drops suddenly.

The health care provider should be notified if the ureteral catheter output decreases because obstruction of this catheter may result in an increase in pressure in the renal pelvis. Tension on the ureteral catheter should be avoided in order to prevent catheter displacement. To avoid pressure in the renal pelvis, the catheter is not clamped. Because the patient is not usually discharged with a ureteral catheter in place, patient teaching about both catheters is not needed.

Question 3

A female patient is scheduled for an oral glucose tolerance test. Which information from the patient’s health history is most important for the nurse to communicate to the health care provider

The patient uses oral contraceptives.
The patient runs several days a week.
The patient has been pregnant three times.
The patient has a family history of diabetes.

Answer 3

The patient uses oral contraceptives.

Oral contraceptive use may falsely elevate oral glucose tolerance test (OGTT) values. Exercise and a family history of diabetes both can affect blood glucose but will not lead to misleading information from the OGTT. History of previous pregnancies may provide informational about gestational glucose tolerance, but will not lead to misleading information from the OGTT.

Question 4

A patient has just arrived on the unit after a thyroidectomy. Which action should the nurse take first

Observe the dressing for bleeding.
Check the blood pressure and pulse.
Assess the patient’s respiratory effort.
Support the patient’s head with pillows.

Answer 4

Assess the patient’s respiratory effort.

Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany. The priority nursing action is to assess the airway. The other actions are also part of the standard nursing care postthyroidectomy but are not as high of a priority.

Question 5

A 44-year-old patient is unable to void after having an open loop resection and fulguration of the bladder. Which nursing action should be implemented first

Assist the patient to soak in a 15-minute sitz bath.

Insert a straight urethral catheter and drain the bladder.

Encourage the patient to drink several glasses of water.

Teach the patient how to do isometric perineal exercises.

Answer 5

Assist the patient to soak in a 15-minute sitz bath.

Sitz baths will relax the perineal muscles and promote voiding. Although the patient should be encouraged to drink fluids and Kegel exercises are helpful in the prevention of incontinence, these activities would not be helpful for a patient experiencing retention. Catheter insertion increases the risk for urinary tract infection (UTI) and should be avoided when possible

Question 6

Which statement by a 50-year-old female patient indicates to the nurse that further assessment of thyroid function may be necessary

“I notice my breasts are tender lately.”
“I am so thirsty that I drink all day long.”
“I get up several times at night to urinate.”
“I feel a lump in my throat when I swallow.”

Answer 6

“I feel a lump in my throat when I swallow.”

Difficulty in swallowing can occur with a goiter. Nocturia is associated with diseases such as diabetes mellitus, diabetes insipidus, or chronic kidney disease. Breast tenderness would occur with excessive gonadal hormone levels. Thirst is a sign of disease such as diabetes.

Question 7

The nurse teaches a 64-year-old woman to prevent the recurrence of renal calculi by

using a filter to strain all urine.
avoiding dietary sources of calcium.
choosing diuretic fluids such as coffee.
drinking 2000 to 3000 mL of fluid a day.

Answer 7

drinking 2000 to 3000 mL of fluid a day.

A fluid intake of 2000 to 3000 mL daily is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.

Question 8

Which prescribed medication should the nurse administer first to a 60-year-old patient admitted to the emergency department in thyroid storm

Propranolol (Inderal)
Propylthiouracil (PTU)
Methimazole (Tapazole)
Iodine (Lugol’s solution)

Answer 8

Propranolol (Inderal)

-Adrenergic blockers work rapidly to decrease the cardiovascular manifestations of thyroid storm. The other medications take days to weeks to have an impact on thyroid function.

Question 9

A 63-year-old patient with primary hyperparathyroidism has a serum phosphorus level of 1.7 mg/dL (0.55 mmol/L) and calcium of 14 mg/dL (3.5 mmol/L). Which nursing action should be included in the plan of care

Restrict the patient to bed rest.
Encourage 4000 mL of fluids daily.
Institute routine seizure precautions.
Assess for positive Chvostek’s sign.

Answer 9

Encourage 4000 mL of fluids daily

The patient with hypercalcemia is at risk for kidney stones, which may be prevented by a high fluid intake. Seizure precautions and monitoring for Chvostek’s or Trousseau’s sign are appropriate for hypocalcemic patients. The patient should engage in weight-bearing exercise to decrease calcium loss from bone.

Question 10

A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first

Infuse dextrose 50% by slow IV push.
Administer 1 mg glucagon subcutaneously.
Obtain a glucose reading using a finger stick.
Have the patient drink 4 ounces of orange juice.

Answer 10

Obtain a glucose reading using a finger stick.

The patient’s clinical manifestations are consistent with hypoglycemia and the initial action should be to check the patient’s glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon or dextrose 50% might be given if the patient’s symptoms become worse or if the patient is unconscious.

Question 11

Which assessment finding for a 33-year-old female patient admitted with Graves’ disease requires the most rapid intervention by the nurse

Bilateral exophthalmos
Heart rate 136 beats/minute
Temperature 103.8° F (40.4° C)
Blood pressure 166/100 mm Hg

Answer 11

Temperature 103.8° F (40.4° C)

The patient’s temperature indicates that the patient may have thyrotoxic crisis and that interventions to lower the temperature are needed immediately. The other findings also require intervention but do not indicate potentially life-threatening complications.

Question 12

The nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary collaborative treatment goal in the plan will be

augmenting fluid volume.
maintaining cardiac output.
diluting nephrotoxic substances.
preventing systemic hypertension.

Answer 12

maintaining cardiac output.

The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient’s heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct.

Question 13

A 76-year-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the health care provider should the nurse implement first

Insert a urinary retention catheter.
Schedule an intravenous pyelogram (IVP).
Draw blood for a serum creatinine level.
Administer lorazepam (Ativan) 0.5 mg PO.

Answer 13

Insert a urinary retention catheter.

The patient’s history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient’s agitation may resolve once the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP is an appropriate test but does not need to be done urgently.

Question 14

Which information is most important for the nurse to communicate rapidly to the health care provider about a patient admitted with possible syndrome of inappropriate antidiuretic hormone (SIADH)

The patient has a recent weight gain of 9 lb.
The patient complains of dyspnea with activity.
The patient has a urine specific gravity of 1.025.
The patient has a serum sodium level of 118 mEq/L.

Answer 14

The patient has a serum sodium level of 118 mEq/L.

A serum sodium of less than 120 mEq/L increases the risk for complications such as seizures and needs rapid correction. The other data are not unusual for a patient with SIADH and do not indicate the need for rapid action.

Question 15

A diabetic patient who has reported burning foot pain at night receives a new prescription. Which information should the nurse teach the patient about amitriptyline (Elavil)

Amitriptyline decreases the depression caused by your foot pain.

Amitriptyline helps prevent transmission of pain impulses to the brain.

Amitriptyline corrects some of the blood vessel changes that cause pain.

Amitriptyline improves sleep and makes you less aware of nighttime pain.

Answer 15

Amitriptyline helps prevent transmission of pain impulses to the brain.

Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain. Tricyclic antidepressants also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by tricyclic antidepressants.

Question 16

The nurse is assessing a 65-year-old patient for presbyopia. Which instruction will the nurse give the patient before the test

“Hold this card and read the print out loud.”

“Cover one eye at a time while reading the wall chart.”

“You’ll feel a short burst of air directed at your eyeball.”

“A light will be used to look for a change in your pupils.”

Answer 16

“Hold this card and read the print out loud.”

The Jaeger card is used to assess near vision problems and presbyopia in persons over 40 years of age. The card should be held 14 inches away from eyes while the patient reads words in various print sizes. Using a penlight to determine pupil change is testing pupil response. A short burst of air may be used to test intraocular pressure but is not used for testing presbyopia. Covering one eye at a time while reading a wall chart at 20 feet describes the Snellen test.

Question 17

Which nursing action is of highest priority for a 68-year-old patient with renal calculi who is being admitted to the hospital with gross hematuria and severe colicky left flank pain

Administer prescribed analgesics.
Monitor temperature every 4 hours.
Encourage increased oral fluid intake.
Give antiemetics as needed for nausea.

Answer 17

Administer prescribed analgesics.

Although all of the nursing actions may be used for patients with renal lithiasis, the patient’s presentation indicates that management of pain is the highest priority action. If the patient has urinary obstruction, increasing oral fluids may increase the symptoms. There is no evidence of infection or nausea.

Question 18

A licensed practical/vocational nurse (LPN/LVN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention

The LPN/LVN administers the erythropoietin subcutaneously.

The LPN/LVN assists the patient to ambulate out in the hallway.

The LPN/LVN administers the iron supplement and phosphate binder with lunch.

The LPN/LVN carries a tray containing low-protein foods into the patient’s room.

Answer 18

The LPN/LVN administers the iron supplement and phosphate binder with lunch.

Oral phosphate binders should not be given at the same time as iron because they prevent the iron from being absorbed. The phosphate binder should be given with a meal and the iron given at a different time. The other actions by the LPN/LVN are appropriate for a patient with renal insufficiency.

Question 19

A male patient in the clinic provides a urine sample that is red-orange in color. Which action should the nurse take first

Notify the patient’s health care provider.

Teach correct midstream urine collection.

Ask the patient about current medications.

Question the patient about urinary tract infection (UTI) risk factors.

Answer 19

Ask the patient about current medications.

A red-orange color in the urine is normal with some over-the-counter (OTC) medications such as phenazopyridine (Pyridium). The color would not be expected with urinary tract infection, is not a sign that poor technique was used in obtaining the specimen, and does not need to be communicated to the health care provider until further assessment is done.

Question 20

A 37-year-old patient is being admitted with a diagnosis of Cushing syndrome. Which findings will the nurse expect during the assessment

Chronically low blood pressure
Bronzed appearance of the skin
Purplish streaks on the abdomen
Decreased axillary and pubic hair

Answer 20

Purplish streaks on the abdomen

Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and bronzed-appearing skin are manifestations of Addison’s disease. Decreased axillary and pubic hair occur with androgen deficiency.

Question 21

Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the

bowel sounds.
blood glucose.
blood urea nitrogen (BUN).
level of consciousness (LOC).

Answer 21

bowel sounds.

Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, blood glucose, and LOC would not affect the nurse’s decision to give the medication.

Question 22

The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching

“If I overeat at a meal, I will still take the usual dose of medication.”

“Other medications besides the Glucotrol may affect my blood sugar.”

“When I am ill, I may have to take insulin to control my blood sugar.”

“My diabetes won’t cause complications because I don’t need insulin.”

Answer 22

“My diabetes won’t cause complications because I don’t need insulin.”

The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glipizide.

Question 23

Which action will the nurse anticipate taking for an otherwise healthy 50-year-old who has just been diagnosed with Stage 1 renal cell carcinoma

Prepare patient for a renal biopsy.

Provide preoperative teaching about nephrectomy.

Teach the patient about chemotherapy medications.

Schedule for a follow-up appointment in 3 months.

Answer 23

Provide preoperative teaching about nephrectomy.

The treatment of choice in patients with localized renal tumors who have no co-morbid conditions is partial or total nephrectomy. A renal biopsy will not be needed in a patient who has already been diagnosed with renal cancer. Chemotherapy is used for metastatic renal cancer. Because renal cell cancer frequently metastasizes, treatment will be started as soon as possible after the diagnosis.

Question 24

The nurse will teach a patient to plan to minimize physical and emotional stress while the patient is undergoing

a water deprivation test.
testing for serum T3 and T4 levels.
a 24-hour urine test for free cortisol.
a radioactive iodine (I-131) uptake test.

Answer 24

a 24-hour urine test for free cortisol.

Physical and emotional stress can affect the results of the free cortisol test. The other tests are not impacted by stress.

Question 25

A female patient being admitted with pneumonia has a history of neurogenic bladder as a result of a spinal cord injury. Which action will the nurse plan to take first Ask about the usual urinary pattern and any measures used for bladder control. Assist the patient to the toilet at scheduled times to help ensure bladder emptying. Check the patient for urinary incontinence every 2 hours to maintain skin integrity. Use intermittent catheterization on a regular schedule to avoid the risk of infection.

Answer 25

Ask about the usual urinary pattern and any measures used for bladder control. Before planning any interventions, the nurse should complete the assessment and determine the patient’s normal bladder pattern and the usual measures used by the patient at home. All the other responses may be appropriate, but until the assessment is complete, an individualized plan for the patient cannot be developed.

Question 26

The nurse observes unlicensed assistive personnel (UAP) taking the following actions when caring for a female patient with a urethral catheter. Which action requires that the nurse intervene Taping the catheter to the skin on the patient’s upper inner thigh Cleaning around the patient’s urinary meatus with soap and water Disconnecting the catheter from the drainage tube to obtain a specimen Using an alcohol-based gel hand cleaner before performing catheter care

Answer 26

Disconnecting the catheter from the drainage tube to obtain a specimen The catheter should not be disconnected from the drainage tube because this increases the risk for urinary tract infection (UTI). The other actions are appropriate and do not require any intervention.

Question 27

The nurse is performing an eye examination on a 76-year-old patient. The nurse should refer the patient for a more extensive assessment based on which finding The patient’s sclerae are light yellow. The patient reports persistent photophobia. The pupil recovers slowly after responding to a bright light. There is a whitish gray ring encircling the periphery of the iris.

Answer 27

The patient reports persistent photophobia. Photophobia is not a normally occurring change with aging, and would require further assessment. The other assessment data are common gerontologic differences and would not be unusual in a 76-year-old patient.

Question 28

Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the diabetic clinic Measure the ankle-brachial index. Check for changes in skin pigmentation. Assess for unilateral or bilateral foot drop. Ask the patient about symptoms of depression.

Answer 28

Measure the ankle-brachial index. Checking systolic pressure at the ankle and brachial areas and calculating the ankle-brachial index is a procedure that can be done by UAP who have been trained in the procedure. The other assessments require more education and critical thinking and should be done by the registered nurse (RN).

Question 29

A patient has arrived for a scheduled hemodialysis session. Which nursing action is most appropriate for the registered nurse (RN) to delegate to a dialysis technician Teach the patient about fluid restrictions. Check blood pressure before starting dialysis. Assess for causes of an increase in predialysis weight. Determine the ultrafiltration rate for the hemodialysis.

Answer 29

Check blood pressure before starting dialysis. Dialysis technicians are educated in monitoring for blood pressure. Assessment, adjustment of the appropriate ultrafiltration rate, and patient teaching require the education and scope of practice of an RN.

Question 30

Which finding by the nurse when assessing a patient with a large pituitary adenoma is most important to report to the health care provider Changes in visual field Milk leaking from breasts Blood glucose 150 mg/dL Nausea and projectile vomiting

Answer 30

Nausea and projectile vomiting Nausea and projectile vomiting may indicate increased intracranial pressure, which will require rapid actions for diagnosis and treatment. Changes in the visual field, elevated blood glucose, and galactorrhea are common with pituitary adenoma, but these do not require rapid action to prevent life-threatening complications

Question 31

The nurse will anticipate teaching a patient with nephrotic syndrome who develops flank pain about treatment with antibiotics. antifungals. anticoagulants. antihypertensives.

Answer 31

anticoagulants Flank pain in a patient with nephrotic syndrome suggests a renal vein thrombosis, and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Fungal pyelonephritis is uncommon and is treated with antifungals. Antihypertensives are used if the patient has high blood pressure.

Question 32

A 26-year-old patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to administer the morning insulin thigh. buttock. abdomen. upper arm.

Answer 32

abdomen. Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle.

Question 33

The nurse is observing a student who is preparing to perform an ear examination for a 30-year-old patient. The nurse will need to intervene if the student pulls the auricle of the ear up and posterior. chooses a speculum larger than the ear canal. stabilizes the hand holding the otoscope on the patient’s head. stops inserting the otoscope after observing impacted cerumen.

Answer 33

chooses a speculum larger than the ear canal. The speculum should be smaller than the ear canal so it can be inserted without damage to the external ear canal. The other actions are appropriate when performing an ear examination.

Question 34

A patient is admitted to the emergency department with possible renal trauma after an automobile accident. Which prescribed intervention will the nurse implement first Check blood pressure and heart rate. Administer morphine sulfate 4 mg IV. Transport to radiology for an intravenous pyelogram. Insert a urethral catheter and obtain a urine specimen.

Answer 34

Check blood pressure and heart rate. Because the kidney is very vascular, the initial action with renal trauma will be assessment for bleeding and shock. The other actions are also important once the patient’s cardiovascular status has been determined and stabilized.

Question 35

The nurse is taking a health history from a 29-year-old pregnant patient at the first prenatal visit. The patient reports no personal history of diabetes but has a parent who is diabetic. Which action will the nurse plan to take first Teach the patient about administering regular insulin. Schedule the patient for a fasting blood glucose level. Discuss an oral glucose tolerance test for the twenty- fourth week of pregnancy. Provide teaching about an increased risk for fetal problems with gestational diabetes.

Answer 35

Schedule the patient for a fasting blood glucose level. Patients at high risk for gestational diabetes should be screened for diabetes on the initial prenatal visit. An oral glucose tolerance test may also be used to check for diabetes, but it would be done before the twenty-fourth week. The other actions may also be needed (depending on whether the patient develops gestational diabetes), but they are not the first actions that the nurse should take.

Question 36

A patient admitted to the hospital with pneumonia has a history of functional urinary incontinence. Which nursing action will be included in the plan of care Demonstrate the use of the Credé maneuver. Teach exercises to strengthen the pelvic floor. Place a bedside commode close to the patient’s bed. Use an ultrasound scanner to check postvoiding residuals.

Answer 36

Place a bedside commode close to the patient’s bed. Modifications in the environment make it easier to avoid functional incontinence. Checking for residual urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence.

Question 37

A 25-year-old male patient has been admitted with a severe crushing injury after an industrial accident. Which laboratory result will be most important to report to the health care provider Serum creatinine level 2.1 mg/dL Serum potassium level 6.5 mEq/L White blood cell count 11,500/µL Blood urea nitrogen (BUN) 56 mg/dL

Answer 37

Serum potassium level 6.5 mEq/L The hyperkalemia associated with crushing injuries may cause cardiac arrest and should be treated immediately. The nurse also will report the other laboratory values, but abnormalities in these are not immediately life threatening.

Question 38

Which additional information will the nurse need to consider when reviewing the laboratory results for a patient’s total calcium level The blood glucose is elevated. The phosphate level is normal. The serum albumin level is low. The magnesium level is normal.

Answer 38

The serum albumin level is low. Part of the total calcium is bound to albumin so hypoalbuminemia can lead to misinterpretation of calcium levels. The other laboratory values will not affect total calcium interpretation.

Question 39

Which information obtained by the nurse in the endocrine clinic about a patient who has been taking prednisone (Deltasone) 40 mg daily for 3 weeks is most important to report to the health care provider Patient’s blood pressure is 148/94 mm Hg. Patient has bilateral 2+ pitting ankle edema. Patient stopped taking the medication 2 days ago. Patient has not been taking the prescribed vitamin D.

Answer 39

Patient stopped taking the medication 2 days ago. Sudden cessation of corticosteroids after taking the medication for a week or more can lead to adrenal insufficiency, with problems such as severe hypotension and hypoglycemia. The patient will need immediate evaluation by the health care provider to prevent and/or treat adrenal insufficiency. The other information will also be reported, but does not require rapid treatment.

Question 40

The nurse completing a physical assessment for a newly admitted male patient is unable to feel either kidney on palpation. Which action should the nurse take next Obtain a urine specimen to check for hematuria. Document the information on the assessment form. Ask the patient about any history of recent sore throat. Ask the health care provider about scheduling a renal ultrasound

Answer 40

Document the information on the assessment form. The kidneys are protected by the abdominal organs, ribs, and muscles of the back, and may not be palpable under normal circumstances, so no action except to document the assessment information is needed. Asking about a recent sore throat, checking for hematuria, or obtaining a renal ultrasound may be appropriate when assessing for renal problems for some patients, but there is nothing in the question stem to indicate that they are appropriate for this patient.

Question 41

A patient has elevated blood urea nitrogen (BUN) and serum creatinine levels. Which bowel preparation order would the nurse question for this patient who is scheduled for a renal arteriogram Fleet enema Tap-water enema Senna/docusate (Senokot-S) Bisacodyl (Dulcolax) tablets

Answer 41

Fleet enema High-phosphate enemas, such as Fleet enemas, should be avoided in patients with elevated BUN and creatinine because phosphate cannot be excreted by patients with renal failure. The other medications for bowel evacuation are more appropriate.

Question 42

A patient passing bloody urine is scheduled for a cystoscopy with cystogram. Which description of the procedure by the nurse is accurate “Your doctor will place a catheter into an artery in your groin and inject a dye that will visualize the blood supply to the kidneys.” “Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted through the tube into your kidney.” “Your doctor will insert a lighted tube into the bladder through your urethra, inspect the bladder, and instill a dye that will outline your bladder on x-ray.” “Your doctor will inject a radioactive solution into a vein in your arm and the distribution of the isotope in your kidneys and bladder will be checked.”

Answer 42

“Your doctor will insert a lighted tube into the bladder through your urethra, inspect the bladder, and instill a dye that will outline your bladder on x-ray.” In a cystoscope and cystogram procedure, a cystoscope is inserted into the bladder for direct visualization, and then contrast solution is injected through the scope so that x-rays can be taken. The response beginning, “Your doctor will place a catheter” describes a renal arteriogram procedure. The response beginning, “Your doctor will inject a radioactive solution” describes a nuclear scan. The response beginning, “Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted” describes a retrograde pyelogram.

Question 43

The home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying. Which patient statement indicates that the teaching has been effective “I will buy seven new catheters weekly and use a new one every day.” “I will use a sterile catheter and gloves for each time I self-catheterize.” “I will clean the catheter carefully before and after each catheterization.” “I will need to take prophylactic antibiotics to prevent any urinary tract infections.”

Answer 43

“I will clean the catheter carefully before and after each catheterization.” Patients who are at home can use a clean technique for intermittent self-catheterization and change the catheter every 7 days. There is no need to use a new catheter every day, to use sterile catheters, or to take prophylactic antibiotics.

Question 44

A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin (Garamycin) 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patient’s blood glucose. urine osmolality. serum creatinine. serum potassium.

Answer 44

serum creatinine. When a patient at risk for chronic kidney disease (CKD) receives a potentially nephrotoxic medication, it is important to monitor renal function with BUN and creatinine levels. The other laboratory values would not be useful in assessing for the adverse effects of the gentamicin.

Question 45

When a patient’s urine dipstick test indicates a small amount of protein, the nurse’s next action should be to send a urine specimen to the laboratory to test for ketones. obtain a clean-catch urine for culture and sensitivity testing. inquire about which medications the patient is currently taking. ask the patient about any family history of chronic renal failure

Answer 45

inquire about which medications the patient is currently taking. Normally the urinalysis will show zero to trace amounts of protein, but some medications may give false-positive readings. The other actions by the nurse may be appropriate, but checking for medications that may affect the dipstick accuracy should be done first.

Question 46

Before administration of captopril (Capoten) to a patient with stage 2 chronic kidney disease (CKD), the nurse will check the patient’s glucose. potassium. creatinine. phosphate.

Answer 46

potassium Angiotensin-converting enzyme (ACE) inhibitors are frequently used in patients with CKD because they delay the progression of the CKD, but they cause potassium retention. Therefore careful monitoring of potassium levels is needed in patients who are at risk for hyperkalemia. The other laboratory values would also be monitored in patients with CKD but would not affect whether the captopril was given or not.

Question 47

When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of persistent skin tenting rapid, deep respirations. bounding peripheral pulses. hot, flushed face and neck.

Answer 47

rapid, deep respirations. Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI.

Question 48

When working in the urology/nephrology clinic, which patient could the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN) Patient who is scheduled for a renal biopsy after a recent kidney transplant Patient who will need monitoring for several hours after a renal arteriogram Patient who requires teaching about possible post-cystoscopy complications Patient who will have catheterization to check for residual urine after voiding

Answer 48

Patient who will have catheterization to check for residual urine after voiding LPN/LVN education includes common procedures such as catheterization of stable patients. The other patients require more complex assessments and/or patient teaching that are included in registered nurse (RN) education and scope of practice.

Question 49

A 58-year-old male patient who is diagnosed with nephrotic syndrome has ascites and 4+ leg edema. Which nursing diagnosis is a priority for the patient Activity intolerance related to rapidly increased weight Excess fluid volume related to low serum protein levels Disturbed body image related to peripheral edema and ascites Altered nutrition: less than required related to protein restriction

Answer 49

Excess fluid volume related to low serum protein levels The patient has massive edema, so the priority problem at this time is the excess fluid volume. The other nursing diagnoses are also appropriate, but the focus of nursing care should be resolution of the edema and ascites.

Question 50

A 58-year-old male patient who weighs 242 lb (110 kg) undergoes a nephrectomy for massive kidney trauma due to a motor vehicle crash. Which postoperative assessment finding is most important to communicate to the surgeon Blood pressure is 102/58. Urine output is 20 mL/hr for 2 hours. Incisional pain level is reported as 9/10. Crackles are heard at bilateral lung bases.

Answer 50

Urine output is 20 mL/hr for 2 hours. Because the urine output should be at least 0.5 mL/kg/hr, a 40 mL output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life threatening as decreased renal perfusion. In addition, the nurse can medicate the patient for pain.

Question 51

The nurse is planning postoperative care for a patient who is being admitted to the surgical unit form the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included Palpate extremities for edema. Measure urine volume every hour. Check hematocrit every 2 hours for 8 hours. Monitor continuous pulse oximetry for 24 hours.

Answer 51

Measure urine volume every hour. After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema. Monitoring of urine output and urine specific gravity is essential. Hemorrhage is not a common problem. There is no need to check the hematocrit hourly. The patient is at risk for dehydration, not volume overload. The patient is not at high risk for problems with oxygenation, and continuous pulse oximetry is not needed.

Question 52

A 44-year-old patient is admitted with tetany. Which laboratory value should the nurse monitor Total protein Blood glucose Ionized calcium Serum phosphate

Answer 52

Ionized calcium Tetany is associated with hypocalcemia. The other values would not be useful for this patient.

Question 53

Which medication taken at home by a 47-year-old patient with decreased renal function will be of most concern to the nurse ibuprofen (Motrin) warfarin (Coumadin) folic acid (vitamin B9) penicillin (Bicillin LA)

Answer 53

ibuprofen (Motrin) The nonsteroidal antiinflammatory medications (NSAIDs) are nephrotoxic and should be avoided in patients with impaired renal function. The nurse also should ask about reasons the patient is taking the other medications, but the medication of most concern is the ibuprofen.

Question 54

The nurse performing an eye examination will document normal findings for accommodation when shining a light into the patient’s eye causes pupil constriction in the opposite eye. a blink reaction follows touching the patient’s pupil with a piece of sterile cotton. covering one eye for 1 minute and noting pupil constriction as the cover is removed. the pupils constrict while fixating on an object being moved closer to the patient’s eyes.

Answer 54

the pupils constrict while fixating on an object being moved closer to the patient’s eyes. Accommodation is defined as the ability of the lens to adjust to various distances. The pupils constrict while fixating on an object being moved far away to near the eyes. The other responses may also be elicited as part of the eye examination, but they do not indicate accommodation.

Question 55

In order to assist an older diabetic patient to engage in moderate daily exercise, which action is most important for the nurse to take Determine what type of activities the patient enjoys. Remind the patient that exercise will improve self-esteem. Teach the patient about the effects of exercise on glucose level. Give the patient a list of activities that are moderate in intensity.

Answer 55

Determine what type of activities the patient enjoys. Because consistency with exercise is important, assessment for the types of exercise that the patient finds enjoyable is the most important action by the nurse in ensuring adherence to an exercise program. The other actions will also be implemented but are not the most important in improving compliance.

Question 56

A 38-year-old male patient is admitted to the hospital in Addisonian crisis. Which patient statement supports a nursing diagnosis of ineffective self-health management related to lack of knowledge about management of Addison’s disease “I frequently eat at restaurants, and my food has a lot of added salt.” “I had the stomach flu earlier this week, so I couldn’t take the hydrocortisone.” “I always double my dose of hydrocortisone on the days that I go for a long run.” “I take twice as much hydrocortisone in the morning dose as I do in the afternoon.”

Answer 56

“I had the stomach flu earlier this week, so I couldn’t take the hydrocortisone.” The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given. The other patient statements indicate appropriate management of the Addison’s disease.

Question 57

A hospitalized patient with possible renal insufficiency after coronary artery bypass surgery is scheduled for a creatinine clearance test. Which equipment will the nurse need to obtain Urinary catheter Cleaning towelettes Large container for urine Sterile urine specimen cup

Answer 57

Large container for urine Because creatinine clearance testing involves a 24-hour urine specimen, the nurse should obtain a large container for the urine collection. Catheterization, cleaning of the perineum with antiseptic towelettes, and a sterile specimen cup are not needed for this test.

Question 58

A 48-year-old male patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about self-monitoring of blood glucose. using low doses of regular insulin. lifestyle changes to lower blood glucose. effects of oral hypoglycemic medications.

Answer 58

lifestyle changes to lower blood glucose. The patient’s impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or oral hypoglycemics for glucose control and does not need to self-monitor blood glucose.

Question 59

Which nursing action is essential for a patient immediately after a renal biopsy Check blood glucose to assess for hyperglycemia or hypoglycemia. Insert a urinary catheter and test urine for gross or microscopic hematuria. Monitor the blood urea nitrogen (BUN) and creatinine to assess renal function. Apply a pressure dressing and keep the patient on the affected side for 30 minutes.

Answer 59

Apply a pressure dressing and keep the patient on the affected side for 30 minutes. A pressure dressing is applied and the patient is kept on the affected side for 30 to 60 minutes to put pressure on the biopsy side and decrease the risk for bleeding. The blood glucose and BUN/creatinine will not be affected by the biopsy. Although monitoring for hematuria is needed, there is no need for catheterization.

Question 60

Which equipment will the nurse obtain to perform a Rinne test Otoscope Tuning fork Audiometer Ticking watch

Answer 60

Tuning fork Rinne testing is done using a tuning fork. The other equipment is used for other types of ear examinations.

Question 61

Which action by a 70-year-old patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD The patient leaves the catheter exit site without a dressing. The patient plans 30 to 60 minutes for a dialysate exchange. The patient cleans the catheter while taking a bath each day. The patient slows the inflow rate when experiencing abdominal pain.

Answer 61

The patient cleans the catheter while taking a bath each day. Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis.

Question 62

A 64-year-old male patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching Increased calories are needed because glucose is lost during hemodialysis. Unlimited fluids are allowed because retained fluid is removed during dialysis. More protein is allowed because urea and creatinine are removed by dialysis. Dietary potassium is not restricted because the level is normalized by dialysis.

Answer 62

More protein is allowed because urea and creatinine are removed by dialysis. Once the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Glucose is not lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes.

Question 63

Which assessment finding is most important to report to the health care provider regarding a patient who has had left-sided extracorporeal shock wave lithotripsy Blood in urine Left flank bruising Left flank discomfort Decreased urine output

Answer 63

Decreased urine output Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to report a drop in urine output. Left flank pain, bruising, and hematuria are common after lithotripsy.

Question 64

A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next Suction the patient’s airway. Administer IV calcium gluconate. Plan for emergency tracheostomy. Prepare for endotracheal intubation.

Answer 64

Administer IV calcium gluconate. The patient’s clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Endotracheal intubation or tracheostomy may be needed if the calcium does not resolve the stridor. Suctioning will not correct the stridor.

Question 65

The nurse determines that further instruction is needed for a patient with interstitial cystitis when the patient says which of the following “I should stop having coffee and orange juice for breakfast.” “I will buy calcium glycerophosphate (Prelief) at the pharmacy.” “I will start taking high potency multiple vitamins every morning.” “I should call the doctor about increased bladder pain or odorous urine.”

Answer 65

“I will start taking high potency multiple vitamins every morning.” High-potency multiple vitamins may irritate the bladder and increase symptoms. The other patient statements indicate good understanding of the teaching.

Question 66

The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) has been effective for a 22-year-old female patient with cystitis when the patient states which of the following “I can use vaginal antiseptic sprays to reduce bacteria.” “I will drink a quart of water or other fluids every day.” “I will wash with soap and water before sexual intercourse.” “I will empty my bladder every 3 to 4 hours during the day.”

Answer 66

“I will empty my bladder every 3 to 4 hours during the day.” Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A quart of fluids is insufficient to provide adequate urine output to decrease risk fo

Question 67

A 46-year-old female patient returns to the clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole (Bactrim) for 3 days. Which action will the nurse plan to take Teach the patient to take the prescribed Bactrim for 3 more days. Remind the patient about the need to drink 1000 mL of fluids daily. Obtain a midstream urine specimen for culture and sensitivity testing. Suggest that the patient use acetaminophen (Tylenol) to treat the symptoms.

Answer 67

Obtain a midstream urine specimen for culture and sensitivity testing. Because uncomplicated urinary tract infections (UTIs) are usually successfully treated with 3 days of antibiotic therapy, this patient will need a urine culture and sensitivity to determine appropriate antibiotic therapy. Acetaminophen would not be as effective as other over-the-counter (OTC) medications such as phenazopyridine (Pyridium) in treating dysuria. The fluid intake should be increased to at least 1800 mL/day. Because the UTI has persisted after treatment with Bactrim, the patient is likely to need a different antibiotic.

Question 68

Which finding by the nurse will be most helpful in determining whether a 67-year-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI) Bladder distention Foul-smelling urine Suprapubic discomfort Costovertebral tenderness

Answer 68

Costovertebral tenderness Costovertebral tenderness is characteristic of pyelonephritis. Bladder distention, foul-smelling urine, and suprapubic discomfort are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI.

Question 69

The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required Multivitamin with iron Magnesium hydroxide Acetaminophen (Tylenol) Calcium phosphate (PhosLo)

Answer 69

Magnesium hydroxide Magnesium is excreted by the kidneys, and patients with CKD should not use over-the-counter products containing magnesium. The other medications are appropriate for a patient with CKD.

Question 70

The nurse determines that demeclocycline (Declomycin) is effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH) based on finding that the patient’s weight has increased. urinary output is increased. peripheral edema is decreased. urine specific gravity is increased.

Answer 70

urinary output is increased. Demeclocycline blocks the action of antidiuretic hormone (ADH) on the renal tubules and increases urine output. An increase in weight or an increase in urine specific gravity indicates that the SIADH is not corrected. Peripheral edema does not occur with SIADH. A sudden weight gain without edema is a common clinical manifestation of this disorder.

Question 71

A 42-year-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed actions should the nurse take first Insert a urinary retention catheter. Place the patient on a cardiac monitor. Administer epoetin alfa (Epogen, Procrit). Give sodium polystyrene sulfonate (Kayexalate).

Answer 71

Place the patient on a cardiac monitor. Because hyperkalemia can cause fatal cardiac dysrhythmias, the initial action should be to monitor the cardiac rhythm. Kayexalate and Epogen will take time to correct the hyperkalemia and anemia. The catheter allows monitoring of the urine output but does not correct the cause of the renal failure.

Question 72

A 26-year-old female with type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and a blood glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. The nurse advises the patient to use only the lispro insulin until the symptoms are resolved. limit intake of calories until the glucose is less than 120 mg/dL. monitor blood glucose every 4 hours and notify the clinic if it continues to rise. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%.

Answer 72

monitor blood glucose every 4 hours and notify the clinic if it continues to rise. Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with lispro insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to diabetic ketoacidosis (DKA). Decreasing carbohydrate or caloric intake is not appropriate because the patient will need more calories when ill. Glycosylated hemoglobin testing is not used to evaluate short-term alterations in blood glucose.

Question 73

Which laboratory value should the nurse review to determine whether a patient’s hypothyroidism is caused by a problem with the anterior pituitary gland or with the thyroid gland Thyroxine (T4) level Triiodothyronine (T3) level Thyroid-stimulating hormone (TSH) level Thyrotropin-releasing hormone (TRH) level

Answer 73

Thyroid-stimulating hormone (TSH) level A low TSH level indicates that the patient’s hypothyroidism is caused by decreased anterior pituitary secretion of TSH. Low T3 and T4 levels are not diagnostic of the primary cause of the hypothyroidism. TRH levels indicate the function of the hypothalamus.

Question 74

A 37-year-old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function Urine volume Creatinine level Glomerular filtration rate (GFR) Blood urea nitrogen (BUN) level

Answer 74

Glomerular filtration rate (GFR) GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status and protein intake. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.

Question 75

A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first Notify the patient’s health care provider. Document the QRS interval measurement. Check the medical record for most recent potassium level. Check the chart for the patient’s current creatinine level.

Answer 75

Check the medical record for most recent potassium level. The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patient’s health care provider. The BUN and creatinine will be elevated in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of the QRS interval is also appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening dysrhythmias.

Question 76

Which menu choice by the patient who is receiving hemodialysis indicates that the nurse’s teaching has been successful Split-pea soup, English muffin, and nonfat milk Oatmeal with cream, half a banana, and herbal tea Poached eggs, whole-wheat toast, and apple juice Cheese sandwich, tomato soup, and cranberry juice

Answer 76

Poached eggs, whole-wheat toast, and apple juice Poached eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup would be high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be high in phosphate.

Question 77

A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft A fistula is much less likely to clot. A fistula increases patient mobility. A fistula can accommodate larger needles. A fistula can be used sooner after surgery.

Answer 77

A fistula is much less likely to clot. Arteriovenous (AV) fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not have an impact on needle size or patient mobility.

Question 78

The nurse evaluates that wearing bifocals improved the patient’s myopia and presbyopia by assessing for strength of the eye muscles. both near and distant vision. cloudiness in the eye lenses. intraocular pressure changes.

Answer 78

both near and distant vision.

Question 79

After a 22-year-old female patient with a pituitary adenoma has had a hypophysectomy, the nurse will teach about the need for sodium restriction to prevent fluid retention. insulin to maintain normal blood glucose levels. oral corticosteroids to replace endogenous cortisol. chemotherapy to prevent malignant tumor recurrence.

Answer 79

oral corticosteroids to replace endogenous cortisol. Antidiuretic hormone (ADH), cortisol, and thyroid hormone replacement will be needed for life after hypophysectomy. Without the effects of adrenocorticotropic hormone (ACTH) and cortisol, the blood glucose and serum sodium will be low unless cortisol is replaced. An adenoma is a benign tumor, and chemotherapy will not be needed.

Question 80

The cardiac telemetry unit charge nurse receives status reports from other nursing units about four patients who need cardiac monitoring. Which patient should be transferred to the cardiac unit first Patient with Hashimoto’s thyroiditis and a heart rate of 102 Patient with tetany who has a new order for IV calcium chloride Patient with Cushing syndrome and a blood glucose of 140 mg/dL Patient with Addison’s disease who takes hydrocortisone twice daily

Answer 80

Patient with tetany who has a new order for IV calcium chloride Emergency treatment of tetany requires IV administration of calcium; ECG monitoring will be required because cardiac arrest may occur if high calcium levels result from too-rapid administration. The information about the other patients indicates that they are more stable than the patient with tetany.

Question 81

The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next Give the patient 4 to 6 oz more orange juice. Administer the PRN glucagon (Glucagon) 1 mg IM. Have the patient eat some peanut butter with crackers. Notify the health care provider about the hypoglycemia.

Answer 81

Give the patient 4 to 6 oz more orange juice. The “rule of 15” indicates that administration of quickly acting carbohydrates should be done 2 to 3 times for a conscious patient whose glucose remains less than 70 mg/dL before notifying the health care provider. More complex carbohydrates and fats may be used once the glucose has stabilized. Glucagon should be used if the patient’s level of consciousness decreases so that oral carbohydrates can no longer be given.

Question 82

A patient complains of dizziness when bending over and of nausea and dizziness associated with physical activities. The nurse will plan to teach the patient about tympanometry. rotary chair testing. pure-tone audiometry. bone-conduction testing.

Answer 82

rotary chair testing. The patient’s clinical manifestations of dizziness and nausea suggest a disorder of the labyrinth, which controls balance and contains three semicircular canals and the vestibule. Rotary chair testing is used to test vestibular function. The other tests are used to test for problems with hearing.

Question 83

Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider Complaint of flank pain Blood pressure 90/48 mm Hg Cloudy and foul-smelling urine Temperature 100.1° F (57.8° C)

Answer 83

Blood pressure 90/48 mm Hg The low blood pressure indicates that urosepsis and septic shock may be occurring and should be immediately reported. The other findings are typical of pyelonephritis.

Question 84

A 68-year-old female patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action will be best to include in the plan of care Restrict fluids between meals and after the evening meal. Apply absorbent incontinent pads liberally over the bed linens. Insert an indwelling catheter until the symptoms have resolved. Assist the patient to the bathroom every 2 hours during the day.

Answer 84

Assist the patient to the bathroom every 2 hours during the day. In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for urinary tract infection (UTI). Incontinent pads increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration.

Question 85

A patient who underwent eye surgery is required to wear an eye patch until the scheduled postoperative clinic visit. Which nursing diagnosis will the nurse include in the plan of care Disturbed body image related to eye trauma and eye patch Risk for falls related to temporary decrease in stereoscopic vision Ineffective health maintenance related to inability to see surroundings Ineffective denial related to inability to admit the impact of the eye injury

Answer 85

Risk for falls related to temporary decrease in stereoscopic vision The loss of stereoscopic vision created by the eye patch impairs the patient’s ability to see in three dimensions and to judge distances. It also increases the risk for falls. There is no evidence in the assessment data for ineffective health maintenance, disturbed body image, or ineffective denial.

Question 86

A 28-year-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching The patient always carries hard candies when engaging in exercise. The patient goes for a vigorous walk when his glucose is 200 mg/dL. The patient has a peanut butter sandwich before going for a bicycle ride. The patient increases daily exercise when ketones are present in the urine.

Answer 86

The patient increases daily exercise when ketones are present in the urine. When the patient is ketotic, exercise may result in an increase in blood glucose level. Type 1 diabetic patients should be taught to avoid exercise when ketosis is present. The other statements are correct.

Question 87

A 79-year-old man has been admitted with benign prostatic hyperplasia. What is most appropriate to include in the nursing plan of care Limit fluid intake to no more than 1000 mL/day. Leave a light on in the bathroom during the night. Ask the patient to use a urinal so that urine can be measured. Pad the patient’s bed to accommodate overflow incontinence.

Answer 87

Leave a light on in the bathroom during the night The patient’s age and diagnosis indicate a likelihood of nocturia, so leaving the light on in the bathroom is appropriate. Fluids should be encouraged because dehydration is more common in older patients. The information in the question does not indicate that measurement of the patient’s output is necessary or that the patient has overflow incontinence.

Question 88

A 35-year-old female patient with a possible pituitary adenoma is scheduled for a computed tomography (CT) scan with contrast media. Which patient information is most important for the nurse to communicate to the health care provider before the test Bilateral poor peripheral vision Allergies to iodine and shellfish Recent weight loss of 20 pounds Complaint of ongoing headaches

Answer 88

Allergies to iodine and shellfish Because the usual contrast media is iodine-based, the health care provider will need to know about the allergy before the CT scan. The other findings are common with any mass in the brain such as a pituitary adenoma.

Question 89

A 40-year-old male patient has been newly diagnosed with type 2 diabetes mellitus. Which information about the patient will be most useful to the nurse who is helping the patient develop strategies for successful adaptation to this disease Ideal weight Value system Activity level Visual changes

Answer 89

Value system When dealing with a patient with a chronic condition such as diabetes, identification of the patient’s values and beliefs can assist the health care team in choosing strategies for successful lifestyle change. The other information also will be useful, but is not as important in developing an individualized plan for the necessary lifestyle changes.

Question 90

The nurse is caring for a patient following an adrenalectomy. The highest priority in the immediate postoperative period is to protect the patient’s skin. monitor for signs of infection. balance fluids and electrolytes. prevent emotional disturbances

Answer 90

balance fluids and electrolytes. After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids. The other goals are also important for the patient but are not as immediately life threatening as the circulatory collapse that can occur with fluid and electrolyte disturbances.

Question 91

Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment has been effective The patient denies pain with voiding. The urine dipstick is negative for nitrites. The antistreptolysin-O (ASO) titer is decreased. The periorbital and peripheral edema is resolved.

Answer 91

The periorbital and peripheral edema is resolved. Because edema is a common clinical manifestation of glomerulonephritis, resolution of the edema indicates that the prescribed therapies have been effective. Nitrites will be negative and the patient will not experience dysuria because the patient does not have a urinary tract infection. Antibodies to streptococcus will persist after a streptococcal infection.

Question 92

A 65-year-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patient’s treatment “I use aspirin when I have a sinus headache.” “I have had frequent episodes of conjunctivitis.” “I take metoprolol (Lopressor) daily for angina.” “I have not had an eye examination for 10 years.”

Answer 92

“I take metoprolol (Lopressor) daily for angina.” It is important to note whether the patient takes any -adrenergic blockers because this classification of medications is also used to treat glaucoma, and there may be an increase in adverse effects. The use of aspirin does not increase intraocular pressure and is safe for patients with glaucoma. Although older patients should have yearly eye examinations, the treatment for this patient will not be affected by the 10-year gap in eye care. Conjunctivitis does not increase the risk for glaucoma.

Question 93

When assessing a patient’s consensual pupil response, the nurse should have the patient cover one eye while facing the nurse. observe for a light reflection in the center of both corneas. instruct the patient to follow a moving object using only the eyes. shine a light into one pupil and observe the response of both pupils.

Answer 93

shine a light into one pupil and observe the response of both pupils. The consensual pupil response is tested by shining a light into one pupil and observing for both pupils to constrict. Observe the corneal light reflex to evaluate for weakness or imbalance of the extraocular muscles. In a darkened room, ask the patient to look straight ahead while a penlight is shone directly on the cornea. The light reflection should be located in the center of both corneas as the patient faces the light source. To perform confrontation visual field testing, the patient faces the examiner and covers one eye, then counts the number of fingers that the examiner brings into the visual field. Instructing the patient to follow a moving object only with the eyes is testing for visual fields and extraocular movements.

Question 94

he nurse is preparing to teach a 43-year-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first Ask the patient’s family to participate in the diabetes education program. Assess the patient’s perception of what it means to have diabetes mellitus. Demonstrate how to check glucose using capillary blood glucose monitoring. Discuss the need for the patient to actively participate in diabetes management.

Answer 94

Assess the patient’s perception of what it means to have diabetes mellitus. Before planning teaching, the nurse should assess the patient’s interest in and ability to self-manage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient.

Question 95

Which patient action indicates a good understanding of the nurse’s teaching about the use of an insulin pump The patient programs the pump for an insulin bolus after eating. The patient changes the location of the insertion site every week. The patient takes the pump off at bedtime and starts it again each morning. The patient plans for a diet that is less flexible when using the insulin pump.

Answer 95

The patient programs the pump for an insulin bolus after eating. In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, with the dosage depending on the oral intake. The insertion site should be changed every 2 or 3 days. There is more flexibility in diet and exercise when an insulin pump is used. The pump will deliver a basal insulin rate 24 hours a day.

Question 96

How will the nurse assess for flank tenderness in a 30-year-old female patient with suspected pyelonephritis Palpate along both sides of the lumbar vertebral column. Strike a flat hand covering the costovertebral angle (CVA). Push fingers upward into the two lowest intercostal spaces. Percuss between the iliac crest and ribs along the midaxillary line.

Answer 96

Strike a flat hand covering the costovertebral angle (CVA). Checking for flank pain is best performed by percussion of the CVA and asking about pain. The other techniques would not assess for flank pain.

Question 97

The nurse is caring for a 45-year-old male patient during a water deprivation test. Which finding is most important for the nurse to communicate to the health care provider The patient complains of intense thirst. The patient has a 5-lb (2.3 kg) weight loss. The patient’s urine osmolality does not increase. The patient feels dizzy when sitting on the edge of the bed.

Answer 97

The patient has a 5-lb (2.3 kg) weight loss. A drop in the weight of more than 2 kg indicates severe dehydration, and the test should be discontinued. The other assessment data are not unusual with this test.

Question 98

The nurse will plan to teach a 27-year-old female who smokes 2 packs of cigarettes daily about the increased risk for kidney stones. bladder cancer. bladder infection. interstitial cystitis.

Answer 98

bladder cancer. Cigarette smoking is a risk factor for bladder cancer. The patient’s risk for developing interstitial cystitis, urinary tract infection (UTI), or kidney stones will not be reduced by quitting smoking.

Question 99

A 74-year-old who is progressing to stage 5 chronic kidney disease asks the nurse, “Do you think I should go on dialysis Which initial response by the nurse is best “It depends on which type of dialysis you are considering.” “Tell me more about what you are thinking regarding dialysis.” “You are the only one who can make the decision about dialysis.” “Many people your age use dialysis and have a good quality of life.”

Answer 99

Tell me more about what you are thinking regarding dialysis.” The nurse should initially clarify the patient’s concerns and questions about dialysis. The patient is the one responsible for the decision and many people using dialysis do have good quality of life, but these responses block further assessment of the patient’s concerns. Referring to which type of dialysis the patient might use only indirectly responds to the patient’s question.

Question 100

The health care provider suspects the Somogyi effect in a 50-year-old patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take Avoid snacking at bedtime. Increase the rapid-acting insulin dose. Check the blood glucose during the night Administer a larger dose of long-acting insulin.

Answer 100

Check the blood glucose during the night If the Somogyi effect is causing the patient’s increased morning glucose level, the patient will experience hypoglycemia between 2:00 and 4:00 AM. The dose of insulin will be reduced, rather than increased. A bedtime snack is used to prevent hypoglycemic episodes during the night.

Question 101

Which assessment data reported by a 28-year-old male patient is consistent with a lower urinary tract infection (UTI) Poor urine output Bilateral flank pain Nausea and vomiting Burning on urination

Answer 101

Burning on urination Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be experienced. Flank pain and nausea are associated with an upper UTI.

Question 102

Which statements will the nurse include when teaching a patient who is scheduled for oral glucose tolerance testing in the outpatient clinic (select all that apply) “You will need to avoid smoking before the test.” “Exercise should be avoided until the testing is complete.” “Several blood samples will be obtained during the testing.” “You should follow a low-calorie diet the day before the test.” “The test requires that you fast for at least 8 hours before testing.”

Answer 102

“You will need to avoid smoking before the test.” “Several blood samples will be obtained during the testing.” “The test requires that you fast for at least 8 hours before testing.” Smoking may affect the results of oral glucose tolerance tests. Blood samples are obtained at baseline and at 30, 60, and 120 minutes. Accuracy requires that the patient be fasting before the test. The patient should consume at least 1500 calories/day for 3 days before the test. The patient should be ambulatory and active for accurate test results.

Question 103

Which finding indicates a need to contact the health care provider before the nurse administers metformin (Glucophage) The patient’s blood glucose level is 174 mg/dL. The patient has gained 2 lb (0.9 kg) since yesterday. The patient is scheduled for a chest x-ray in an hour. The patient’s blood urea nitrogen (BUN) level is 52 mg/dL.

Answer 103

The patient’s blood urea nitrogen (BUN) level is 52 mg/dL. The BUN indicates possible renal failure, and metformin should not be used in patients with renal failure. The other findings are not contraindications to the use of metformin.

Question 104

Which question will provide the most useful information to a nurse who is interviewing a patient about a possible thyroid disorder “What methods do you use to help cope with stress” “Have you experienced any blurring or double vision” “Have you had a recent unplanned weight gain or loss” “Do you have to get up at night to empty your bladder”

Answer 104

“Have you had a recent unplanned weight gain or loss” Because thyroid function affects metabolic rate, changes in weight may indicate hyperfunction or hypofunction of the thyroid gland. Nocturia, visual difficulty, and changes in stress level are associated with other endocrine disorders.

Question 105

A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV Urine volume Calcium level Cardiac rhythm Neurologic status

Answer 105

Cardiac rhythm The calcium gluconate helps prevent dysrhythmias that might be caused by the hyperkalemia. The nurse will monitor the other data as well, but these will not be helpful in determining the effectiveness of the calcium gluconate.

Question 106

After change-of-shift report, which patient should the nurse assess first Patient with a urethral stricture who has not voided for 12 hours Patient who has cloudy urine after orthotopic bladder reconstruction Patient with polycystic kidney disease whose blood pressure is 186/98 mm Hg Patient who voided bright red urine immediately after returning from lithotripsy

Answer 106

Patient with a urethral stricture who has not voided for 12 hours The patient information suggests acute urinary retention, a medical emergency. The nurse will need to assess the patient and consider whether to insert a retention catheter. The other patients will also be assessed, but their findings are consistent with their diagnoses and do not require immediate assessment or possible intervention.

Question 107

A 30-year-old patient seen in the emergency department for severe headache and acute confusion is found to have a serum sodium level of 118 mEq/L. The nurse will anticipate the need for which diagnostic test Urinary 17-ketosteroids Antidiuretic hormone level Growth hormone stimulation test Adrenocorticotropic hormone level

Answer 107

Antidiuretic hormone level Elevated levels of antidiuretic hormone will cause water retention and decrease serum sodium levels. The other tests would not be helpful in determining possible causes of the patient’s hyponatremia.

Question 108

The nurse determines that additional instruction is needed for a 60-year-old patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH) when the patient says which of the following “I need to shop for foods low in sodium and avoid adding salt to food.” “I should weigh myself daily and report any sudden weight loss or gain.” “I need to limit my fluid intake to no more than 1 quart of liquids a day.” “I will eat foods high in potassium because diuretics cause potassium loss.”

Answer 108

“I need to shop for foods low in sodium and avoid adding salt to food.” Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed. The other patient statements are correct and indicate successful teaching has occurred.

Question 109

The nurse determines a need for additional instruction when the patient with newly diagnosed type 1 diabetes says which of the following “I can have an occasional alcoholic drink if I include it in my meal plan.” “I will need a bedtime snack because I take an evening dose of NPH insulin.” “I can choose any foods, as long as I use enough insulin to cover the calories.” “I will eat something at meal times to prevent hypoglycemia, even if I am not hungry.”

Answer 109

“I can choose any foods, as long as I use enough insulin to cover the calories.” Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction.

Question 110

The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose washes the puncture site using warm water and soap. chooses a puncture site in the center of the finger pad. hangs the arm down for a minute before puncturing the site. says the result of 120 mg indicates good blood sugar contro

Answer 110

chooses a puncture site in the center of the finger pad. The patient is taught to choose a puncture site at the side of the finger pad because there are fewer nerve endings along the side of the finger pad. The other patient actions indicate that teaching has been effective.

Question 111

Which statement by a patient who had a cystoscopy the previous day should be reported immediately to the health care provider “My urine looks pink.” “My IV site is bruised.” “My sleep was restless.” “My temperature is 101.”

Answer 111

“My temperature is 101.” The patient’s elevated temperature may indicate a bladder infection, a possible complication of cystoscopy. The health care provider should be notified so that antibiotic therapy can be started. Pink-tinged urine is expected after a cystoscopy. The insomnia and bruising should be discussed further with the patient but do not indicate a need to notify the health care provider.

Question 112

The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider Heart rate Urine output Creatinine clearance Blood urea nitrogen (BUN) level

Answer 112

Urine output Fluid volume is replaced based on urine output after transplant because the urine output can be as high as a liter an hour. The other data will be monitored but are not the most important determinants of fluid infusion rate.

Question 113

A 32-year-old patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage Lispro (Humalog) Glargine (Lantus) Detemir (Levemir) NPH (Humulin N)

Answer 113

Lispro (Humalog) Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin.

Question 114

A 55-year-old female patient with type 2 diabetes has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which goal is most important for this patient The patient will reach a glycosylated hemoglobin level of less than 7%. The patient will follow a diet and exercise plan that results in weight loss. The patient will choose a diet that distributes calories throughout the day. The patient will state the reasons for eliminating simple sugars in the diet.

Answer 114

The patient will reach a glycosylated hemoglobin level of less than 7%. The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels. The other outcomes also are appropriate but are not as high in priority.

Question 115

The nurse is caring for a patient who has had an ileal conduit for several years. Which nursing action could be delegated to unlicensed assistive personnel (UAP) Change the ostomy appliance. Choose the appropriate ostomy bag. Monitor the appearance of the stoma. Assess for possible urinary tract infection (UTI).

Answer 115

Change the ostomy appliance. Changing the ostomy appliance for a stable patient could be done by UAP. Assessments of the site, choosing the appropriate ostomy bag, and assessing for (UTI) symptoms require more education and scope of practice and should be done by the registered nurse (RN).

Question 116

A 68-year-old male patient who has bladder cancer had a cystectomy with creation of an Indiana pouch. Which topic will be included in patient teaching Application of ostomy appliances Barrier products for skin protection Catheterization technique and schedule Analgesic use before emptying the pouch

Answer 116

Catheterization technique and schedule The Indiana pouch enables the patient to self-catheterize every 4 to 6 hours. There is no need for an ostomy device or barrier products. Catheterization of the pouch is not painful.

Question 117

When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone (Deltasone). The nurse will anticipate that the patient may need a diet higher in calories while receiving prednisone. develop acute hypoglycemia while taking the prednisone. require administration of insulin while taking prednisone. have rashes caused by metformin-prednisone interactions.

Answer 117

require administration of insulin while taking prednisone. Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a side effect of prednisone. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient may have an increased appetite when taking prednisone, but will not need a diet that is higher in calories.

Question 118

An active 28-year-old male with type 1 diabetes is being seen in the endocrine clinic. Which finding may indicate the need for a change in therapy Hemoglobin A1C level 6.2% Blood pressure 146/88 mmHg Heart rate at rest 58 beats/minute High density lipoprotein (HDL) level 65 mg/dL

Answer 118

Blood pressure 146/88 mmHg To decrease the incidence of macrovascular and microvascular problems in patients with diabetes, the goal blood pressure is usually 130/80. An A1C less than 6.5%, a low resting heart rate (consistent with regular aerobic exercise in a young adult), and an HDL level of 65 mg/dL all indicate that the patient’s diabetes and risk factors for vascular disease are well controlled.

Question 119

Which finding by the nurse when assessing a patient with Hashimoto’s thyroiditis and a goiter will require the most immediate action New-onset changes in the patient’s voice Apical pulse rate at rest 112 beats/minute Elevation in the patient’s T3 and T4 levels Bruit audible bilaterally over the thyroid gland

Answer 119

New-onset changes in the patient’s voice Changes in the patient’s voice indicate that the goiter is compressing the laryngeal nerve and may lead to airway compression. The other findings will also be reported but are expected with Hashimoto’s thyroiditis and do not require immediate action.

Question 120

A 28-year-old male patient is diagnosed with polycystic kidney disease. Which information is most appropriate for the nurse to include in teaching at this time Complications of renal transplantation Methods for treating severe chronic pain Discussion of options for genetic counseling Differences between hemodialysis and peritoneal dialysis

Answer 120

Discussion of options for genetic counseling Because a 28-year-old patient may be considering having children, the nurse should include information about genetic counseling when teaching the patient. The well-managed patient will not need to choose between hemodialysis and peritoneal dialysis or know about the effects of transplantation for many years. There is no indication that the patient has chronic pain.

Question 121

A 55-year-old woman admitted for shoulder surgery asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which intervention is most appropriate to include in the care plan Assist the patient to the bathroom q3hr. Place a commode at the patient’s bedside. Demonstrate how to perform the Credé maneuver. Teach the patient how to perform Kegel exercises.

Answer 121

Teach the patient how to perform Kegel exercises. Kegel exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence.

Question 122

Which assessment finding of a 42-year-old patient who had a bilateral adrenalectomy requires the most rapid action by the nurse The blood glucose is 176 mg/dL. The lungs have bibasilar crackles. The blood pressure (BP) is 88/50 mm Hg. The patient reports 5/10 incisional pain.

Answer 122

The blood pressure (BP) is 88/50 mm Hg. The decreased BP indicates possible adrenal insufficiency. The nurse should immediately notify the health care provider so that corticosteroid medications can be administered. The nurse should also address the elevated glucose, incisional pain, and crackles with appropriate collaborative or nursing actions, but prevention and treatment of acute adrenal insufficiency is the priority after adrenalectomy.

Question 123

Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis (select all that apply) Avoid commercial salt substitutes. Drink 1500 to 2000 mL of fluids daily. Take phosphate-binders with each meal. Choose high-protein foods for most meals. Have several servings of dairy products daily.

Answer 123

Avoid commercial salt substitutes. Take phosphate-binders with each meal. Choose high-protein foods for most meals. Patients who are receiving peritoneal dialysis should have a high-protein diet. Phosphate binders are taken with meals to help control serum phosphate and calcium levels. Commercial salt substitutes are high in potassium and should be avoided. Fluid intake is limited in patients requiring dialysis. Dairy products are high in phosphate and usually are limited.

Question 124

An 18-year-old male patient with a small stature is scheduled for a growth hormone stimulation test. In preparation for the test, the nurse will obtain ice in a basin. glargine insulin. a cardiac monitor. 50% dextrose solution.

Answer 124

50% dextrose solution. Hypoglycemia is induced during the growth hormone stimulation test, and the nurse should be ready to administer 50% dextrose immediately. Regular insulin is used to induce hypoglycemia (glargine is never given IV). The patient does not require cardiac monitoring during the test. Although blood samples for some tests must be kept on ice, this is not true for the growth hormone stimulation test.

Question 125

A 22-year-old female patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the health care provider Urinary urgency Left-sided flank pain Intermittent hematuria Burning with urination

Answer 125

Left-sided flank pain Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower urinary tract infection (UTI).

Question 126

The nurse is interviewing a new patient with diabetes who receives rosiglitazone (Avandia) through a restricted access medication program. What is most important for the nurse to report immediately to the health care provider The patient’s blood pressure is 154/92. The patient has a history of emphysema. The patient’s blood glucose is 86 mg/dL. The patient has chest pressure when walking.

Answer 126

The patient has chest pressure when walking. Rosiglitazone can cause myocardial ischemia. The nurse should immediately notify the health care provider and expect orders to discontinue the medication. There is no urgent need to discuss the other data with the health care provider.

Question 127

A 54-year-old patient is admitted with diabetic ketoacidosis. Which admission order should the nurse implement first Infuse 1 liter of normal saline per hour. Give sodium bicarbonate 50 mEq IV push. Administer regular insulin 10 U by IV push. Start a regular insulin infusion at 0.1 units/kg/hr.

Answer 127

Infuse 1 liter of normal saline per hour. The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids. The other actions can be done after the infusion of normal saline is initiated.

Question 128

To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select all that apply) ``` Chest x-ray Blood pressure Serum creatinine Urine for microalbuminuria Complete blood count (CBC) Monofilament testing of the foot ```

Answer 128

Blood pressure Serum creatinine Urine for microalbuminuria Monofilament testing of the foot

Question 129

Which information about a 30-year-old patient who is scheduled for an oral glucose tolerance test should be reported to the health care provider before starting the test The patient reports having occasional orthostatic dizziness. The patient takes oral corticosteroids for rheumatoid arthritis. The patient has had a 10-pound weight gain in the last month. The patient drank several glasses of water an hour previously.

Answer 129

The patient takes oral corticosteroids for rheumatoid arthritis. Corticosteroids can affect blood glucose results. The other information will be provided to the health care provider but will not affect the test results.

Question 130

A 38-year-old patient who had a kidney transplant 8 years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone). Which assessment data will be of most concern to the nurse The blood glucose is 144 mg/dL. There is a nontender axillary lump. The patient’s skin is thin and fragile. The patient’s blood pressure is 150/92.

Answer 130

There is a nontender axillary lump. A nontender lump suggests a malignancy such as a lymphoma, which could occur as a result of chronic immunosuppressive therapy. The elevated glucose, skin change, and hypertension are possible side effects of the prednisone and should be addressed, but they are not as great a concern as the possibility of a malignancy.

Question 131

Which information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs Choose flat-soled leather shoes. Set heating pads on a low temperature. Use callus remover for corns or calluses. Soak feet in warm water for an hour each day.

Answer 131

# Choose flat-soled leather shoes. The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided. The patient should see a specialist to treat these problems.

Question 132

A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving and expected to be discharged in 2 days. Which teaching strategy will be best for the nurse to use Provide written reminders of self-care information. Offer multiple options for management of therapies. Ensure privacy for teaching by asking visitors to leave. Delay teaching until patient discharge date is confirmed. Written instructions will be helpful to the patient because initi

Answer 132

Provide written reminders of self-care information. Written instructions will be helpful to the patient because initially the hypothyroid patient may be unable to remember to take medications and other aspects of self-care. Because the treatment regimen is somewhat complex, teaching should be initiated well before discharge. Family members or friends should be included in teaching because the hypothyroid patient is likely to forget some aspects of the treatment plan. A simpler regimen will be easier to understand until the patient is euthyroid.

Question 133

When the nurse is taking a health history of a new patient at the ear clinic, the patient states, “I have to sleep with the television on.” Which follow-up question is most appropriate to obtain more information about possible hearing problems “Do you grind your teeth at night” “What time do you usually fall asleep” “Have you noticed ringing in your ears” “Are you ever dizzy when you are lying down”

Answer 133

“Have you noticed ringing in your ears” Patients with tinnitus may use masking techniques, such as playing a radio, to block out the ringing in the ears. The responses “Do you grind your teeth at night” and “Are you ever dizzy when you are lying down” would be used to obtain information about other ear problems, such as vestibular disorders and referred temporomandibular joint (TMJ) pain. The response “What time do you usually fall asleep” would not be helpful in assessing problems with the patient’s ears.

Question 134

Nursing staff on a hospital unit are reviewing rates of hospital-acquired infections (HAI) of the urinary tract. Which nursing action will be most helpful in decreasing the risk for HAI in patients admitted to the hospital Encouraging adequate oral fluid intake Testing urine with a dipstick daily for nitrites Avoiding unnecessary urinary catheterizations Providing frequent perineal hygiene to patients

Answer 134

Avoiding unnecessary urinary catheterizations Because catheterization bypasses many of the protective mechanisms that prevent urinary tract infection (UTI), avoidance of catheterization is the most effective means of reducing HAI. The other actions will also be helpful, but are not as useful as decreasing urinary catheter use.

Question 135

A 56-year-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with possible syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would expect the initial laboratory results to include a(n) elevated hematocrit. decreased serum sodium. low urine specific gravity. increased serum chloride.

Answer 135

decreased serum sodium. When water is retained, the serum sodium level will drop below normal, causing the clinical manifestations reported by the patient. The hematocrit will decrease because of the dilution caused by water retention. Urine will be more concentrated with a higher specific gravity. The serum chloride level will usually decrease along with the sodium level.

Question 136

The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing A Tono-pen will be applied to the surface of the eye. The test involves reading a Snellen chart from 20 feet. Medications will be used to dilate the pupils for the test. The examination involves checking the pupil’s reaction to light.

Answer 136

A Tono-pen will be applied to the surface of the eye. Glaucoma is caused by an increase in intraocular pressure, which would be measured using the Tono-pen. The other techniques are used in testing for other eye disorders.

Question 137

Which information will the nurse include when teaching a 50-year-old male patient about somatropin (Genotropin) The medication will be needed for 3 to 6 months. Inject the medication subcutaneously every day. Blood glucose levels may decrease when taking the medication. Stop taking the medication if swelling of the hands or feet occurs.

Answer 137

Inject the medication subcutaneously every day. Somatropin is injected subcutaneously on a daily basis, preferably in the evening. The patient will need to continue on somatropin for life. If swelling or other common adverse effects occur, the health care provider should be notified. Growth hormone will increase blood glucose levels.

Question 138

Which action should the nurse take after a 36-year-old patient treated with intramuscular glucagon for hypoglycemia regains consciousness Assess the patient for symptoms of hyperglycemia. Give the patient a snack of peanut butter and crackers. Have the patient drink a glass of orange juice or nonfat milk. Administer a continuous infusion of 5% dextrose for 24 hours.

Answer 138

Give the patient a snack of peanut butter and crackers Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood glucose rapidly, but the cheese and crackers will stabilize blood glucose. Administration of IV glucose might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration.

Question 139

A patient develops carpopedal spasms and tingling of the lips following a parathyroidectomy. Which action should the nurse take first Administer the ordered muscle relaxant. Give the ordered oral calcium supplement. Have the patient rebreathe from a paper bag. Start the PRN oxygen at 2 L/min per cannula.

Answer 139

Have the patient rebreathe from a paper bag. The patient’s symptoms suggest mild hypocalcemia. The symptoms of hypocalcemia will be temporarily reduced by having the patient breathe into a paper bag, which will raise the PaCO2 and create a more acidic pH. The muscle relaxant will have no impact on the ionized calcium level. Although severe hypocalcemia can cause laryngeal stridor, there is no indication that this patient is experiencing laryngeal stridor or needs oxygen. Calcium supplements will be given to normalize calcium levels quickly, but oral supplements will take time to be absorbed.

Question 140

After change-of-shift report, which patient will the nurse assess first 19-year-old with type 1 diabetes who was admitted with possible dawn phenomenon 35-year-old with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL 60-year-old with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa 68-year-old with type 2 diabetes who has severe peripheral neuropathy and complains of burning foot pain

Answer 140

60-year-old with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa The patient’s diagnosis of HHS and signs of dehydration indicate that the nurse should rapidly assess for signs of shock and determine whether increased fluid infusion is needed. The other patients also need assessment and intervention but do not have life-threatening complications.

Question 141

A few weeks after an 82-year-old with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding by the nurse is most important to discuss with the health care provider Hemoglobin A1C level is 7.9%. Last eye exam was 18 months ago. Glomerular filtration rate is decreased. Patient has questions about the prescribed diet.

Answer 141

Glomerular filtration rate is decreased. The decrease in renal function may indicate a need to adjust the dose of metformin or change to a different medication. In older patients, the goal for A1C may be higher in order to avoid complications associated with hypoglycemia. The nurse will plan on scheduling the patient for an eye exam and addressing the questions about diet, but the biggest concern is the patient’s decreased renal function.

Question 142

Which finding for a patient who has hypothyroidism and hypertension indicates that the nurse should contact the health care provider before administering levothyroxine (Synthroid) Increased thyroxine (T4) level Blood pressure 112/62 mm Hg Distant and difficult to hear heart sounds Elevated thyroid stimulating hormone level

Answer 142

Increased thyroxine (T4) level An increased thyroxine level indicates the levothyroxine dose needs to be decreased. The other data are consistent with hypothyroidism and the nurse should administer the levothyroxine.

Question 143

Which action by a patient indicates that the home health nurse’s teaching about glargine and regular insulin has been successful The patient administers the glargine 30 minutes before each meal. The patient’s family prefills the syringes with the mix of insulins weekly. The patient draws up the regular insulin and then the glargine in the same syringe. The patient disposes of the open vials of glargine and regular insulin after 4 weeks.

Answer 143

The patient disposes of the open vials of glargine and regular insulin after 4 weeks. Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and stored. Short-acting regular insulin is administered before meals, while glargine is given once daily.

Question 144

Which information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD) Blood pressure Phosphate level Neurologic status Creatinine clearance

Answer 144

Phosphate level Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease in patients with CKD. The other data will not be helpful in evaluating the effectiveness of calcium carbonate

Question 145

A 27-year-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first Place the patient on a cardiac monitor. Administer IV potassium supplements. Obtain urine glucose and ketone levels. Start an insulin infusion at 0.1 units/kg/hr.

Answer 145

Place the patient on a cardiac monitor. Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with electrocardiogram (ECG) monitoring. Because potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be administered without cardiac monitoring because insulin infusion will further decrease potassium levels. Urine glucose and ketone levels are not urgently needed to manage the patient’s care.

Question 146

A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to save the lunch tray for the patient’s later return to the unit. ask that diagnostic testing area staff to start a 5% dextrose IV. send a glass of milk or orange juice to the patient in the diagnostic testing area. request that if testing is further delayed, the patient be returned to the unit to eat.

Answer 146

request that if testing is further delayed, the patient be returned to the unit to eat. Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items.

Question 147

Which question during the assessment of a diabetic patient will help the nurse identify autonomic neuropathy “Do you feel bloated after eating” “Have you seen any skin changes” “Do you need to increase your insulin dosage when you are stressed” “Have you noticed any painful new ulcerations or sores on your feet”

Answer 147

“Do you feel bloated after eating” Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient. The other questions are also appropriate to ask but would not help in identifying autonomic neuropathy.

Question 148

A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2 L inflows. Which information should the nurse report immediately to the health care provider The patient has an outflow volume of 1800 mL . The patient’s peritoneal effluent appears cloudy. The patient has abdominal pain during the inflow phase. The patient’s abdomen appears bloated after the inflow.

Answer 148

The patient’s peritoneal e ffluent appears cloudy. Cloudy appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient.

Question 149

Which action can the nurse working in the emergency department delegate to experienced unlicensed assistive personnel (UAP) Ask a patient with decreased visual acuity about medications taken at home. Perform Snellen testing of visual acuity for a patient with a history of cataracts. Obtain information from a patient about any history of childhood ear infections. Inspect a patient’s external ear for redness, swelling, or presence of skin lesions.

Answer 149

Perform Snellen testing of visual acuity for a patient with a history of cataracts. The Snellen test does not require nursing judgment and is appropriate to delegate to UAP who have been trained to perform it. History taking about infection or medications and assessment are actions that require critical thinking and should be done by the RN.

Question 150

After obtaining the information shown in the accompanying figure regarding a patient with Addison’s disease, which prescribed action will the nurse take first Give 4 oz of fruit juice orally. Recheck the blood glucose level. Infuse 5% dextrose and 0.9% saline. Administer oxygen therapy as needed.

Answer 150

Recheck the blood glucose level. The patient’s poor skin turgor, hypotension, and hyponatremia indicate an Addisonian crisis. Immediate correction of the hypovolemia and hyponatremia is needed. The other actions may also be needed but are not the initial action for the patient.

Question 151

Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct Insulin is not used to control blood glucose in patients with type 2 diabetes. Complications of type 2 diabetes are less serious than those of type 1 diabetes. Changes in diet and exercise may control blood glucose levels in type 2 diabetes. Type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma.

Answer 151

Changes in diet and exercise may control blood glucose levels in type 2 diabetes. For some patients with type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control. Insulin is frequently used for type 2 diabetes, complications are equally severe as for type 1 diabetes, and type 2 diabetes is usually diagnosed with routine laboratory testing or after a patient develops complications such as frequent yeast infections.

Question 152

A patient gives the nurse health information before a scheduled intravenous pyelogram (IVP). Which item has the most immediate implications for the patient’s care The patient has not had food or drink for 8 hours. The patient lists allergies to shellfish and penicillin. The patient complains of costovertebral angle (CVA) tenderness. The patient used a bisacodyl (Dulcolax) tablet the previous night.

Answer 152

The patient lists allergies to shellfish and penicillin. Iodine-based contrast dye is used during IVP and for many computed tomography (CT) scans. The nurse will need to notify the health care provider before the procedures so that the patient can receive medications such as antihistamines or corticosteroids before the procedures are started. The other information is also important to note and document but does not have immediate implications for the patient’s care during the procedures.

Question 153

A 29-year-old woman with systemic lupus erythematosus has been prescribed 2 weeks of high-dose prednisone therapy. Which information about the prednisone is most important for the nurse to include “Weigh yourself daily to monitor for weight gain caused by increased appetite.” “A weight-bearing exercise program will help minimize the risk for osteoporosis.” “The prednisone dose should be decreased gradually rather than stopped suddenly.” “Call the health care provider if you experience mood alterations with the prednisone.”

Answer 153

“The prednisone dose should be decreased gradually rather than stopped suddenly.” Acute adrenal insufficiency may occur if exogenous corticosteroids are suddenly stopped. Mood alterations and weight gain are possible adverse effects of corticosteroid use, but these are not life-threatening effects. Osteoporosis occurs when patients take corticosteroids for longer periods.

Question 154

The nurse in the eye clinic is examining a 67-year-old patient who says “I see small spots that move around in front of my eyes.” Which action will the nurse take first Immediately have the ophthalmologist evaluate the patient. Explain that spots and “floaters” are a normal part of aging. Inform the patient that these spots may indicate retinal damage. Use an ophthalmoscope to examine the posterior eye chambers.

Answer 154

Use an ophthalmoscope to examine the posterior eye chambers. Although “floaters” are usually caused by vitreous liquefaction and are common in aging patients, they can be caused by hemorrhage into the vitreous humor or by retinal tears, so the nurse’s first action will be to examine the retina and posterior chamber. Although the ophthalmologist will examine the patient, the presence of spots or floaters in a 65-year-old is not an emergency. The spots may indicate retinal damage, but the nurse should assess the eye further before discussing this with the patient.

Question 155

The nurse is testing the visual acuity of a patient in the outpatient clinic. The nurse’s instructions for this test include asking the patient to stand 20 feet from the wall chart. follow the examiner’s finger with the eyes only. look at an object far away and then near to the eyes. look straight ahead while a light is shone into the eyes.

Answer 155

stand 20 feet from the wall chart. When the Snellen chart is used to check visual acuity, the patient should stand 20 feet away. Accommodation is tested by looking at an object at both near and far distances. Shining a pen light into the eyes tests for pupil response. Following the examiner’s fingers with the eyes tests extraocular movements.

Question 156

After receiving change-of-shift report, which patient should the nurse assess first Patient who is scheduled for the drain phase of a peritoneal dialysis exchange Patient with stage 4 chronic kidney disease who has an elevated phosphate level Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L Patient who has just returned from having hemodialysis and has a heart rate of 124/min

Answer 156

Patient who has just returned from having hemodialysis and has a heart rate of 124/min The patient who is tachycardic after hemodialysis may be bleeding or excessively hypovolemic and should be assessed immediately for these complications. The other patients also need assessments or interventions but are not at risk for life-threatening complications.

Question 157

During the physical examination of a 36-year-old female, the nurse finds that the patient’s thyroid gland cannot be palpated. The most appropriate action by the nurse is to palpate the patient’s neck more deeply. document that the thyroid was nonpalpable. notify the health care provider immediately. teach the patient about thyroid hormone testing.

Answer 157

document that the thyroid was nonpalpable. The thyroid is frequently nonpalpable. The nurse should simply document the finding. There is no need to notify the health care provider immediately about a normal finding. There is no indication for thyroid-stimulating hormone (TSH) testing unless there is evidence of thyroid dysfunction. Deep palpation of the neck is not appropriate.

Question 158

A 63-year-old male patient had a cystectomy with an ileal conduit yesterday. Which new assessment data is most important for the nurse to communicate to the physician Cloudy appearing urine Hypotonic bowel sounds Heart rate 102 beats/minute Continuous stoma drainage

Answer 158

Heart rate 102 beats/minute Tachycardia may indicate infection, hemorrhage, or hypovolemia, which are all serious complications of this surgery. The urine from an ileal conduit normally contains mucus and is cloudy. Hypotonic bowel sounds are expected after bowel surgery. Continuous drainage of urine from the stoma is normal.

Question 159

A 23-year-old patient is admitted with diabetes insipidus. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN) Titrate the infusion of 5% dextrose in water. Teach the patient how to use desmopressin (DDAVP) nasal spray. Assess the patient’s hydration status every 8 hours. Administer subcutaneous DDAVP.

Answer 159

Administer subcutaneous DDAVP. Administration of medications is included in LPN/LVN education and scope of practice. Assessments, patient teaching, and titrating fluid infusions are more complex skills and should be done by the RN.

Question 160

The nurse will plan to monitor a patient diagnosed with a pheochromocytoma for flushing. headache. bradycardia. hypoglycemia.

Answer 160

headache. The classic clinical manifestations of pheochromocytoma are hypertension, tachycardia, severe headache, diaphoresis, and abdominal or chest pain. Elevated blood glucose may also occur because of sympathetic nervous system stimulation. Bradycardia and flushing would not be expected.

Question 161

A patient who had surgery for creation of an ileal conduit 3 days ago will not look at the stoma and requests that only the ostomy nurse specialist does the stoma care. The nurse identifies a nursing diagnosis of anxiety related to effects of procedure on lifestyle. disturbed body image related to change in function. readiness for enhanced coping related to need for information. self-care deficit, toileting, related to denial of altered body function.

Answer 161

disturbed body image related to change in function. The patient’s unwillingness to look at the stoma or participate in care indicates that disturbed body image is the best diagnosis. No data suggest that the impact on lifestyle is a concern for the patient. The patient does not appear to be ready for enhanced coping. The patient’s insistence that only the ostomy nurse care for the stoma indicates that denial is not present.

Question 162

Which intervention will the nurse include in the plan of care for a 52-year-old male patient with syndrome of inappropriate antidiuretic hormone (SIADH) Monitor for peripheral edema. Offer patient hard candies to suck on. Encourage fluids to 2 to 3 liters per day. Keep head of bed elevated to 30 degrees.

Answer 162

Offer patient hard candies to suck on. Sucking on hard candies decreases thirst for a patient on fluid restriction. Patients with SIADH are on fluid restrictions of 800 to 1000 mL/day. Peripheral edema is not seen with SIADH. The head of the bed is elevated no more than 10 degrees to increase left atrial filling pressure and decrease antidiuretic hormone (ADH) release.

Question 163

The nurse should report which assessment finding immediately to the health care provider The tympanum is blue-tinged. There is a cone of light visible. Cerumen is present in the auditory canal. The skin in the ear canal is dry and scaly.

Answer 163

The tympanum is blue-tinged. A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be removed before proceeding with the examination but is not unusual or pathologic. The presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal may need further assessment but does not require urgent care.

Question 164

When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula Auscultate for a bruit at the fistula site. Assess the quality of the left radial pulse. Compare blood pressures in the left and right arms. Irrigate the fistula site with saline every 8 to 12 hours.

Answer 164

Auscultate for a bruit at the fistula site. The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula.

Question 165

When obtaining a health history from a 49-year-old patient, which patient statement is most important to communicate to the primary health care provider “My eyes are dry now.” “It is hard for me to see at night.” “My vision is blurry when I read.” “I can’t see as far over to the side.”

Answer 165

“I can’t see as far over to the side.” The decrease in peripheral vision may indicate glaucoma, which is not a normal visual change associated with aging and requires rapid treatment. The other patient statements indicate visual problems (presbyopia, dryness, and lens opacity) that are considered a normal part of aging.

Question 166

A 29-year-old patient in the outpatient clinic will be scheduled for blood cortisol testing. Which instruction will the nurse provide “Avoid adding any salt to your foods for 24 hours before the test.” “You will need to lie down for 30 minutes before the blood is drawn.” “Come to the laboratory to have the blood drawn early in the morning.” “Do not have anything to eat or drink before the blood test is obtained.”

Answer 166

“Come to the laboratory to have the blood drawn early in the morning.” Cortisol levels are usually drawn in the morning, when levels are highest. The other instructions would be given to patients who were having other endocrine testing.

Question 167

After change-of-shift report, which patient should the nurse assess first 19-year-old with type 1 diabetes who has a hemoglobin A1C of 12% 23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL 40-year-old who is pregnant and whose oral glucose tolerance test is 202 mg/dL 50-year-old who uses exenatide (Byetta) and is complaining of acute abdominal pain

Answer 167

23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL Because the brain requires glucose to function, untreated hypoglycemia can cause unconsciousness, seizures, and death. The nurse will rapidly assess and treat the patient with low blood glucose. The other patients also have symptoms that require assessments and/or interventions, but they are not at immediate risk for life-threatening complications.

Question 168

When preparing a female patient with bladder cancer for intravesical chemotherapy, the nurse will teach about premedicating to prevent nausea. obtaining wigs and scarves to wear. emptying the bladder before the medication. maintaining oral care during the treatments.

Answer 168

emptying the bladder before the medication. The patient will be asked to empty the bladder before instillation of the chemotherapy. Systemic side effects are not usually experienced with intravesical chemotherapy.

Question 169

A 61-year-old female patient admitted with pneumonia has a total serum calcium level of 13.3 mg/dL (3.3 mmol/L). The nurse will anticipate the need to teach the patient about testing for _levels. calcitonin catecholamine thyroid hormone parathyroid hormone

Answer 169

parathyroid hormone Parathyroid hormone is the major controller of blood calcium levels. Although calcitonin secretion is a countermechanism to parathyroid hormone, it does not play a major role in calcium balance. Catecholamine and thyroid hormone levels do not affect serum calcium level.

Question 170

It is most important that the nurse ask a patient admitted with acute glomerulonephritis about history of kidney stones. recent sore throat and fever. history of high blood pressure. frequency of bladder infections.

Answer 170

recent sore throat and fever. Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It is not caused by kidney stones, hypertension, or urinary tract infection (UTI).

Question 171

To assess whether there is any improvement in a patient’s dysuria, which question will the nurse ask “Do you have to urinate at night” “Do you have blood in your urine” “Do you have to urinate frequently” “Do you have pain when you urinate”

Answer 171

Do you have pain when you urinate” Dysuria is painful urination. The alternate responses are used to assess other urinary tract symptoms: hematuria, nocturia, and frequency.

Question 172

Which finding indicates to the nurse that the current therapies are effective for a patient with acute adrenal insufficiency Increasing serum sodium levels Decreasing blood glucose levels Decreasing serum chloride levels Increasing serum potassium levels

Answer 172

Increasing serum sodium levels Clinical manifestations of Addison’s disease include hyponatremia and an increase in sodium level indicates improvement. The other values indicate that treatment has not been effective.

Question 173

Which patient action indicates good understanding of the nurse’s teaching about administration of aspart (NovoLog) insulin The patient avoids injecting the insulin into the upper abdominal area. The patient cleans the skin with soap and water before insulin administration. The patient stores the insulin in the freezer after administering the prescribed dose. The patient pushes the plunger down while removing the syringe from the injection site.

Answer 173

The patient cleans the skin with soap and water before insulin administration. Cleaning the skin with soap and water or with alcohol is acceptable. Insulin should not be frozen. The patient should leave the syringe in place for about 5 seconds after injection to be sure that all the insulin has been injected. The upper abdominal area is one of the preferred areas for insulin injection.

Question 174

The charge nurse must intervene immediately if observing a nurse who is caring for a patient with vestibular disease speaking slowly to the patient. facing the patient directly when speaking. encouraging the patient to ambulate independently. administering Rinne and Weber tests to the patient

Answer 174

encouraging the patient to ambulate independently. Vestibular disease affects balance, so the nurse should monitor the patient during activities that require balance. The other actions might be used for patients with hearing disorders.

Question 175

A 72-year-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first Insert urethral catheter. Obtain renal ultrasound. Draw a complete blood count. Infuse normal saline at 50 mL/hour.

Answer 175

Insert urethral catheter. The patient’s elevation in BUN is most likely associated with hydronephrosis caused by the acute urinary retention, so the insertion of a retention catheter is the first action to prevent ongoing postrenal failure for this patient. The other actions also are appropriate, but should be implemented after the retention catheter.

Question 176

A 60-year-old patient is taking spironolactone (Aldactone), a drug that blocks the action of aldosterone on the kidney, for hypertension. The nurse will monitor for increased serum sodium. decreased urinary output. elevated serum potassium. evidence of fluid overload.

Answer 176

elevated serum potassium. Because aldosterone increases the excretion of potassium, a medication that blocks aldosterone will tend to cause hyperkalemia. Aldosterone also promotes the reabsorption of sodium and water in the renal tubules, so spironolactone will tend to cause increased urine output, a decreased or normal serum sodium level, and signs of dehydration

Question 177

Which statement by the patient indicates a need for additional instruction in administering insulin “I need to rotate injection sites among my arms, legs, and abdomen each day.” “I can buy the 0.5 mL syringes because the line markings will be easier to see.” “I should draw up the regular insulin first after injecting air into the NPH bottle.” “I do not need to aspirate the plunger to check for blood before injecting insulin.”

Answer 177

“I need to rotate injection sites among my arms, legs, and abdomen each day.” Rotating sites is no longer recommended because there is more consistent insulin absorption when the same site is used consistently. The other patient statements are accurate and indicate that no additional instruction is needed.

Question 178

The nurse is assessing a 41-year-old African American male patient diagnosed with a pituitary tumor causing panhypopituitarism. Assessment findings consistent with panhypopituitarism include high blood pressure. decreased facial hair. elevated blood glucose. tachycardia and cardiac palpitations.

Answer 178

decreased facial hair. Changes in male secondary sex characteristics such as decreased facial hair, testicular atrophy, diminished spermatogenesis, loss of libido, impotence, and decreased muscle mass are associated with decreases in follicle stimulating hormone (FSH) and luteinizing hormone (LH). Fasting hypoglycemia and hypotension occur in panhypopituitarism as a result of decreases in adrenocorticotropic hormone (ACTH) and cortisol. Bradycardia is likely due to the decrease in thyroid stimulating hormone (TSH) and thyroid hormones associated with panhypopituitarism.

Question 179

A nurse will teach a patient who is scheduled to complete a 24-hour urine collection for 17-ketosteroids to insert and maintain a retention catheter. keep the specimen refrigerated or on ice. drink at least 3 L of fluid during the 24 hours. void and save that specimen to start the collection.

Answer 179

keep the specimen refrigerated or on ice. The specimen must be kept on ice or refrigerated until the collection is finished. Voided or catheterized specimens are acceptable for the test. The initial voided specimen is discarded. There is no fluid intake requirement for the 24-hour collection.

Question 180

Which information will the nurse provide to the patient scheduled for refractometry “You will need to wear sunglasses for a few hours after the exam.” “The surface of your eye will be numb while the doctor does the exam.” “You should not take any of your eye medicines before the examination.” “The doctor will shine a bright light into your eye during the examination.”

Answer 180

“You will need to wear sunglasses for a few hours after the exam.” The pupils are dilated using cycloplegic medications during refractometry. This effect will last several hours and cause photophobia. The other teaching would not be appropriate for a patient who was having refractometry.

Question 181

A 44-year-old female patient with Cushing syndrome is admitted for adrenalectomy. Which intervention by the nurse will be most helpful for a nursing diagnosis of disturbed body image related to changes in appearance Reassure the patient that the physical changes are very common in patients with Cushing syndrome. Discuss the use of diet and exercise in controlling the weight gain associated with Cushing syndrome. Teach the patient that the metabolic impact of Cushing syndrome is of more importance than appearance. Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery.

Answer 181

Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery. The most reassuring communication to the patient is that the physical and emotional changes caused by the Cushing syndrome will resolve after hormone levels return to normal postoperatively. Reassurance that the physical changes are expected or that there are more serious physiologic problems associated with Cushing syndrome are not therapeutic responses. The patient’s physiological changes are caused by the high hormone levels, not by the patient’s diet or exercise choices.

Question 182

A 48-year-old patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which order for the patient will the nurse question NPO for 6 hours before procedure Ibuprofen (Advil) 400 mg PO PRN for pain Dulcolax suppository 4 hours before procedure Normal saline 500 mL IV infused before procedure

Answer 182

Ibuprofen (Advil) 400 mg PO PRN for pain The contrast dye used in IVPs is potentially nephrotoxic, and concurrent use of other nephrotoxic medications such as the nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided. The suppository and NPO status are necessary to ensure adequate visualization during the IVP. IV fluids are used to ensure adequate hydration, which helps reduce the risk for contrast-induced renal failure.

Question 183

A 22-year-old patient is being seen in the clinic with increased secretion of the anterior pituitary hormones. The nurse would expect the laboratory results to show increased urinary cortisol. decreased serum thyroxine. elevated serum aldosterone levels. low urinary catecholamines excretion.

Answer 183

increased urinary cortisol. Increased secretion of adrenocorticotropic hormone (ACTH) by the anterior pituitary gland will lead to an increase in serum and urinary cortisol levels. An increase, rather than a decrease, in thyroxine level would be expected with increased secretion of thyroid stimulating hormone (TSH) by the anterior pituitary. Aldosterone and catecholamine levels are not controlled by the anterior pituitary.

Question 184

A 32-year-old patient who is employed as a hairdresser and has a 15 pack-year history of cigarette smoking is scheduled for an annual physical examination. The nurse will plan to teach the patient about the increased risk for renal failure. kidney stones. pyelonephritis. bladder cancer

Answer 184

bladder cancer Exposure to the chemicals involved with working as a hairdresser and in smoking both increase the risk of bladder cancer, and the nurse should assess whether the patient understands this risk. The patient is not at increased risk for renal failure, pyelonephritis, or kidney stones.

Question 185

Which action by a new registered nurse (RN) caring for a patient with a goiter and possible hyperthyroidism indicates that the charge nurse needs to do more teaching The RN checks the blood pressure on both arms. The RN palpates the neck thoroughly to check thyroid size. The RN lowers the thermostat to decrease the temperature in the room. The RN orders nonmedicated eye drops to lubricate the patient’s bulging eyes.

Answer 185

The RN palpates the neck thoroughly to check thyroid size Palpation can cause the release of thyroid hormones in a patient with an enlarged thyroid and should be avoided. The other actions by the new RN are appropriate when caring for a patient with an enlarged thyroid.

Question 186

A 34-year-old has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye exam every 2 years. as soon as possible. when the patient is 39 years old. within the first year after diagnosis.

Answer 186

as soon as possible. Because many patients have some diabetic retinopathy when they are first diagnosed with type 2 diabetes, a dilated eye exam is recommended at the time of diagnosis and annually thereafter. Patients with type 1 diabetes should have dilated eye exams starting 5 years after they are diagnosed and then annually.

Question 187

A 45-year-old male patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask “Have you had a recent head injury” “Do you have to wear larger shoes now” “Is there a family history of acromegaly” “Are you experiencing tremors or anxiety”

Answer 187

“Do you have to wear larger shoes now” Acromegaly causes an enlargement of the hands and feet. Head injury and family history are not risk factors for acromegaly. Tremors and anxiety are not clinical manifestations of acromegaly.

Question 188

The nurse reviews a patient’s glycosylated hemoglobin (Hb A1C) results to evaluate fasting preprandial glucose levels. glucose levels 2 hours after a meal. glucose control over the past 90 days. hypoglycemic episodes in the past 3 months.

Answer 188

glucose control over the past 90 days. Glycosylated hemoglobin testing measures glucose control over the last 3 months. Glucose testing before/after a meal or random testing may reveal impaired glucose tolerance and indicate prediabetes, but it is not done on patients who already have a diagnosis of diabetes. There is no test to evaluate for hypoglycemic episodes in the past.

Question 189

A 56-year-old female patient is admitted to the hospital with new onset nephrotic syndrome. Which assessment data will the nurse expect Poor skin turgor Recent weight gain Elevated urine ketones Decreased blood pressure

Answer 189

Recent weight gain The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high.

Question 190

Which information will the nurse teach a 48-year-old patient who has been newly diagnosed with Graves’ disease Exercise is contraindicated to avoid increasing metabolic rate. Restriction of iodine intake is needed to reduce thyroid activity. Antithyroid medications may take several months for full effect. Surgery will eventually be required to remove the thyroid gland.

Answer 190

Antithyroid medications may take several months for full effect. Medications used to block the synthesis of thyroid hormones may take 2 to 3 months before the full effect is seen. Large doses of iodine are used to inhibit the synthesis of thyroid hormones. Exercise using large muscle groups is encouraged to decrease the irritability and hyperactivity associated with high levels of thyroid hormones. Radioactive iodine is the most common treatment for Graves’ disease although surgery may be used.

Question 191

Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid prescribed after kidney transplantation Postural hypotension Recurrent tachycardia Knee and hip joint pain Increased serum creatinine

Answer 191

Knee and hip joint pain Aseptic necrosis of the weight-bearing joints can occur when patients take corticosteroids over a prolonged period. Increased creatinine level, orthostatic dizziness, and tachycardia are not caused by corticosteroid use.

Question 192

What glomerular filtration rate (GFR) would the nurse estimate for a 30-year-old patient with a creatinine clearance result of 60 mL/min 60 mL/min 90 mL/min 120 mL/min 180 mL/min

Answer 192

60 mL/min The creatinine clearance approximates the GFR. The other responses are not accurate.

Question 193

The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication Atenolol (Tenormin) taken to prevent angina Acetaminophen (Tylenol) taken frequently for headaches Ibuprofen (Advil) taken for 20 years to treat osteoarthritis Albuterol (Proventil) taken since childhood to treat asthma

Answer 193

Ibuprofen (Advil) taken for 20 years to treat osteoarthritis Nonsteroidal antiinflammatory drugs (NSAIDs) are potentially ototoxic. Acetaminophen, atenolol, and albuterol are not associated with hearing loss.

Question 194

Which information about a patient with Goodpasture syndrome requires the most rapid action by the nurse Blood urea nitrogen level is 70 mg/dL. Urine output over the last 2 hours is 30 mL. Audible crackles bilaterally over the posterior chest to the midscapular level. Elevated level of antiglomerular basement membrane (anti-GBM) antibodies.

Answer 194

Audible crackles bilaterally over the posterior chest to the midscapular level. Crackles heard to a high level indicate a need for rapid actions such as assessment of oxygen saturation, reporting the findings to the health care provider, initiating oxygen therapy, and dialysis. The other findings will also be reported, but are typical of Goodpasture syndrome and do not require immediate nursing action.

Question 195

The nurse is caring for a 63-year-old with a possible pituitary tumor who is scheduled for a computed tomography (CT) scan with contrast. Which information about the patient is most important to discuss with the health care provider before the test History of renal insufficiency Complains of chronic headache Recent bilateral visual field loss Blood glucose level of 134 mg/dL

Answer 195

History of renal insufficiency Because contrast media may cause acute kidney injury in patients with poor renal function, the health care provider will need to prescribe therapies such as IV fluids to prevent this complication. The other findings are consistent with the patient’s diagnosis of a pituitary tumor.

Question 196

A patient arrives in the emergency department complaining of eye itching and pain after sleeping with contact lenses in place. To facilitate further examination of the eye, fluorescein angiography is ordered. The nurse will teach the patient to hold a card and fixate on the center dot. report any burning or pain at the IV site. remain still while the cornea is anesthetized. let the examiner know when images shown appear clear.

Answer 196

report any burning or pain at the IV site. Fluorescein angiography involves injecting IV dye. If extravasation occurs, fluorescein is toxic to the tissues. The patient should be instructed to report any signs of extravasation such as pain or burning. The nurse should closely monitor the IV site as well. The cornea is anesthetized during ultrasonography. Refractometry involves measuring visual acuity and asking the patient to choose lenses that are the sharpest; it is a painless test. The Amsler grid test involves using a hand held card with grid lines. The patient fixates on the center dot and records any abnormalities of the grid lines.

Question 197

An 82-year-old patient in a long-term care facility has several medications prescribed. After the patient is newly diagnosed with hypothyroidism, the nurse will need to consult with the health care provider before administering docusate (Colace). ibuprofen (Motrin). diazepam (Valium). cefoxitin (Mefoxin).

Answer 197

diazepam (Valium). Worsening of mental status and myxedema coma can be precipitated by the use of sedatives, especially in older adults. The nurse should discuss the use of diazepam with the health care provider before administration. The other medications may be given safely to the patient.

Question 198

The nurse is caring for a patient admitted with diabetes insipidus (DI). Which information is most important to report to the health care provider The patient is confused and lethargic. The patient reports a recent head injury. The patient has a urine output of 400 mL/hr. The patient’s urine specific gravity is 1.003.

Answer 198

The patient is confused and lethargic. The patient’s confusion and lethargy may indicate hypernatremia and should be addressed quickly. In addition, patients with DI compensate for fluid losses by drinking copious amounts of fluids, but a patient who is lethargic will be unable to drink enough fluids and will become hypovolemic. A high urine output, low urine specific gravity, and history of a recent head injury are consistent with diabetes insipidus, but they do not require immediate nursing action to avoid life-threatening complications.

Question 199

A female patient with a suspected urinary tract infection (UTI) is to provide a clean-catch urine specimen for culture and sensitivity testing. To obtain the specimen, the nurse will have the patient empty the bladder completely, then obtain the next urine specimen that the patient is able to void. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup. insert a short sterile “mini” catheter attached to a collecting container into the urethra and bladder to obtain the specimen. clean the area around the meatus with a povidone-iodine (Betadine) swab, and then have the patient void into a sterile container.

Answer 199

teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup. This answer describes the technique for obtaining a clean-catch specimen. The answer beginning, “insert a short, small, ‘mini’ catheter attached to a collecting container” describes a technique that would result in a sterile specimen, but a health care provider’s order for a catheterized specimen would be required. Using Betadine before obtaining the specimen is not necessary, and might result in suppressing the growth of some bacteria. The technique described in the answer beginning “have the patient empty the bladder completely” would not result in a sterile specimen.

Question 200

A 38-year-old patient who has type 1 diabetes plans to swim laps daily at 1:00 PM. The clinic nurse will plan to teach the patient to check glucose level before, during, and after swimming. delay eating the noon meal until after the swimming class. increase the morning dose of neutral protamine Hagedorn (NPH) insulin. time the morning insulin injection so that the peak occurs while swimming.

Answer 200

check glucose level before, during, and after swimming. The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise.

Question 201

Which nursing action will be included in the plan of care for a 55-year-old patient with Graves’ disease who has exophthalmos Place cold packs on the eyes to relieve pain and swelling. Elevate the head of the patient’s bed to reduce periorbital fluid. Apply alternating eye patches to protect the corneas from irritation. Teach the patient to blink every few seconds to lubricate the corneas.

Answer 201

Elevate the head of the patient’s bed to reduce periorbital fluid. The patient should sit upright as much as possible to promote fluid drainage from the periorbital area. With exophthalmos, the patient is unable to close the eyes completely to blink. Lubrication of the eyes, rather than eye patches, will protect the eyes from developing corneal scarring. The swelling of the eye is not caused by excessive blood flow to the eye, so cold packs will not be helpful.

Question 202

The nurse caring for a patient after cystoscopy plans that the patient learns to request narcotics for pain. understands to expect blood-tinged urine. restricts activity to bed rest for a 4 to 6 hours. remains NPO for 8 hours to prevent vomiting.

Answer 202

understands to expect blood-tinged urine. Pink-tinged urine and urinary frequency are expected after cystoscopy. Burning on urination is common, but pain that requires opioids for relief is not expected. A good fluid intake is encouraged after this procedure. Bed rest is not required following cystoscopy.

Question 203

A patient who had radical neck surgery to remove a malignant tumor developed hypoparathyroidism. The nurse should plan to teach the patient about bisphosphonates to reduce bone demineralization. calcium supplements to normalize serum calcium levels. increasing fluid intake to decrease risk for nephrolithiasis. including whole grains in the diet to prevent constipation.

Answer 203

calcium supplements to normalize serum calcium levels. Oral calcium supplements are used to maintain the serum calcium in normal range and prevent the complications of hypocalcemia. Whole grain foods decrease calcium absorption and will not be recommended. Bisphosphonates will lower serum calcium levels further by preventing calcium from being reabsorbed from bone. Kidney stones are not a complication of hypoparathyroidism and low calcium levels.

Question 204

Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes for the first 4 hours. Which nursing action is most appropriate Monitor the patient’s intake and output over night. Have the patient drink small amounts of fluid frequently. Use an ultrasound scanner to check the postvoiding residual volume. Reassure the patient that this is normal after rectal surgery because of anesthesia.

Answer 204

Use an ultrasound scanner to check the postvoiding residual volume. An ultrasound scanner can be used to check for residual urine after the patient voids. Because the patient’s history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the patient drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiologic problem, not just reassure the patient. The patient may develop reflux into the renal pelvis and discomfort from a full bladder if the nurse waits to address the problem for several hours.

Question 205

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine (Pyridium) Pyridium may cause photosensitivity Pyridium may change the urine color. Take the Pyridium for at least 7 days. Take Pyridium before sexual intercourse.

Answer 205

Pyridium may change the urine color. Patients should be taught that Pyridium will color the urine deep orange. Urinary analgesics should only be needed for a few days until the prescribed antibiotics decrease the bacterial count. Pyridium does not cause photosensitivity. Taking Pyridium before intercourse will not be helpful in reducing the risk for UTI.

Question 206

When planning teaching for a 59-year-old male patient with benign nephrosclerosis the nurse should include instructions regarding preventing bleeding with anticoagulants. monitoring and recording blood pressure. obtaining and documenting daily weights. measuring daily intake and output volumes.

Answer 206

monitoring and recording blood pressure. Hypertension is the major symptom of nephrosclerosis. Measurements of intake and output and daily weights are not necessary unless the patient develops renal insufficiency. Anticoagulants are not used to treat nephrosclerosis.

Question 207

A 55-year-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication Creatinine 1.6 mg/dL Oxygen saturation 89% Hemoglobin level 13 g/dL Blood pressure 98/56 mm Hg

Answer 207

Hemoglobin level 13 g/dL High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) when erythropoietin (EPO) is administered to a target hemoglobin of >12 g/dL. Hemoglobin levels higher than 12 g/dL indicate a need for a decrease in epoetin alfa dose. The other information also will be reported to the health care provider but will not affect whether the medication is administered.

Question 208

To prevent recurrence of uric acid renal calculi, the nurse teaches the patient to avoid eating milk and cheese. sardines and liver. legumes and dried fruit. spinach, chocolate, and tea.

Answer 208

sardines and liver. Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.

Question 209

A 42-year-old female patient is scheduled for transsphenoidal hypophysectomy to treat a pituitary adenoma. During preoperative teaching, the nurse instructs the patient about the need to cough and deep breathe every 2 hours postoperatively. remain on bed rest for the first 48 hours after the surgery. avoid brushing teeth for at least 10 days after the surgery. be positioned flat with sandbags at the head postoperatively.

Answer 209

avoid brushing teeth for at least 10 days after the surgery. To avoid disruption of the suture line, the patient should avoid brushing the teeth for 10 days after surgery. It is not necessary to remain on bed rest after this surgery. Coughing is discouraged because it may cause leakage of cerebrospinal fluid (CSF) from the suture line. The head of the bed should be elevated 30 degrees to reduce pressure on the sella turcica and decrease the risk for headaches.

Question 210

Which assessment finding alerts the nurse to provide patient teaching about cataract development History of hyperthyroidism Unequal pupil size and shape Blurred vision and light sensitivity Loss of peripheral vision in both eyes

Answer 210

Blurred vision and light sensitivity Classic signs of cataracts include blurred vision and light sensitivity. Thyroid problems are a major cause of exophthalmos. Unequal pupil is indicative of anisocoria, not cataracts. Loss of peripheral vision is a sign of glaucoma.

Question 211

The nurse assessing the urinary system of a 45-year-old female would use auscultation to determine kidney position. identify renal artery bruits. check for ureteral peristalsis. assess for bladder distention.

Answer 211

identify renal artery bruits. The presence of a bruit may indicate problems such as renal artery tortuosity or abdominal aortic aneurysm. Auscultation would not be helpful in assessing for the other listed urinary tract information.

Question 212

During routine hemodialysis, the 68-year-old patient complains of nausea and dizziness. Which action should the nurse take first Slow down the rate of dialysis. Check patient’s blood pressure (BP). Review the hematocrit (Hct) level. Give prescribed PRN antiemetic drugs.

Answer 212

Check patient’s blood pressure (BP). The patient’s complaints of nausea and dizziness suggest hypotension, so the initial action should be to check the BP. The other actions may also be appropriate based on the blood pressure obtained.

Question 213

The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider The urine output is 900 to 1100 mL/hr. The patient’s central venous pressure (CVP) is decreased. The patient has a level 7 (0 to 10 point scale) incisional pain. The blood urea nitrogen (BUN) and creatinine levels are elevated.

Answer 213

The patient’s central venous pressure (CVP) is decreased. The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant.

Question 214

Which information from a patient who had a transurethral resection with fulguration for bladder cancer 3 days ago is most important to report to the health care provider The patient is voiding every 4 hours. The patient is using opioids for pain. The patient has seen clots in the urine. The patient is anxious about the cancer.

Answer 214

The patient has seen clots in the urine Clots in the urine are not expected and require further follow-up. Voiding every 4 hours, use of opioids for pain, and anxiety are typical after this procedure.

Question 215

Assessment of a patient’s visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 50 feet and the right eye can see at 20 feet what a person with normal vision can see at 40 feet. The nurse records which finding OS 20/50; OD 20/40 OU 20/40; OS 50/20 OD 20/40; OS 20/50 OU 40/20; OD 50/20

Answer 215

OS 20/50; OD 20/40 When documenting visual acuity, the first number indicates the standard (for normal vision) of 20 feet and the second number indicates the line that the patient is able to read when standing 20 feet from the Snellen chart. OS is the abbreviation for left eye and OD is the abbreviation for right eye. The remaining three answers do not correctly describe the patient’s visual acuity.

Question 216

Which action should the nurse take when providing patient teaching to a 76-year-old with mild presbycusis Use patient education handouts rather than discussion. Use a higher-pitched tone of voice to provide instructions. Ask for permission to turn off the television before teaching Wait until family members have left before initiating teaching.

Answer 216

Ask for permission to turn off the television before teaching Normal changes with aging make it more difficult for older patients to filter out unwanted sounds, so a quiet environment should be used for teaching. Loss of sensitivity for high-pitched tones is lost with presbycusis. Because the patient has mild presbycusis, the nurse should use both discussion and handouts. There is no need to wait until family members have left to provide patient teaching.

Question 217

A 56-year-old female patient has an adrenocortical adenoma, causing hyperaldosteronism. The nurse providing care should monitor the blood pressure every 4 hours. elevate the patient’s legs to relieve edema. monitor blood glucose level every 4 hours. order the patient a potassium-restricted diet.

Answer 217

monitor the blood pressure every 4 hours. Hypertension caused by sodium retention is a common complication of hyperaldosteronism. Hyperaldosteronism does not cause an elevation in blood glucose. The patient will be hypokalemic and require potassium supplementation before surgery. Edema does not usually occur with hyperaldosteronism.

Question 218

Which information in a patient’s history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation The patient has type 1 diabetes. The patient has metastatic lung cancer. The patient has a history of chronic hepatitis C infection. The patient is infected with the human immunodeficiency virus.

Answer 218

The patient has metastatic lung cancer. Disseminated malignancies are a contraindication to transplantation. The conditions of the other patients are not contraindications for kidney transplant.

Question 219

The nurse working in the vision and hearing clinic receives telephone calls from several patients who want appointments in the clinic as soon as possible. Which patient should be seen first 71-year-old who has noticed increasing loss of peripheral vision 74-year-old who has difficulty seeing well enough to drive at night 60-year-old who has difficulty hearing clearly in a noisy environment 64-year-old who has decreased hearing and ear “stuffiness” without pain

Answer 219

71-year-old who has noticed increasing loss of peripheral vision Increasing loss of peripheral vision is characteristic of glaucoma and the patient should be scheduled for an examination as soon as possible. The other patients have symptoms commonly associated with aging: presbycusis, possible cerumen impaction, and impaired night vision.

Question 220

A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia 10: 00 AM 12: 00 AM 2: 00 PM 4: 00 PM

Answer 220

10:00 AM The rapid-acting insulins peak in 1 to 3 hours. The patient is not at a high risk for hypoglycemia at the other listed times, although hypoglycemia may occur.

Question 221

The nurse is caring for a 68-year-old hospitalized patient with a decreased glomerular filtration rate who is scheduled for an intravenous pyelogram (IVP). Which action will be included in the plan of care Monitor the urine output after the procedure. Assist with monitored anesthesia care (MAC). Give oral contrast solution before the procedure. Insert a large size urinary catheter before the IVP.

Answer 221

Monitor the urine output after the procedure. Patients with impaired renal function are at risk for decreased renal function after IVP because the contrast medium used is nephrotoxic, so the nurse should monitor the patient’s urine output. MAC sedation and retention catheterization are not required for the procedure. The contrast medium is given IV, not orally.

Question 222

Which nursing assessment of a 69-year-old patient is most important to make during initiation of thyroid replacement with levothyroxine (Synthroid) Fluid balance Apical pulse rate Nutritional intake Orientation and alertness

Answer 222

Apical pulse rate In older patients, initiation of levothyroxine therapy can increase myocardial oxygen demand and cause angina or dysrhythmias. The medication also is expected to improve mental status and fluid balance and will increase metabolic rate and nutritional needs, but these changes will not result in potentially life-threatening complications.

Question 223

Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP) indicates the most urgent need for the nurse’s assessment of the patient Bedtime glucose of 140 mg/dL Noon blood glucose of 52 mg/dL Fasting blood glucose of 130 mg/dL 2-hr postprandial glucose of 220 mg/dL

Answer 223

Noon blood glucose of 52 mg/dL The nurse should assess the patient with a blood glucose level of 52 mg/dL for symptoms of hypoglycemia and give the patient a carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range or not immediately dangerous for a diabetic patient.

Question 224

The nurse is assessing a 22-year-old patient experiencing the onset of symptoms of type 1 diabetes. Which question is most appropriate for the nurse to ask “Are you anorexic” “Is your urine dark colored” “Have you lost weight lately” “Do you crave sugary drinks”

Answer 224

“Have you lost weight lately” Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar-containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute.

Question 225

An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to give a bolus of 50% dextrose. insert a large-bore IV catheter. initiate oxygen by nasal cannula. administer glargine (Lantus) insulin.

Answer 225

insert a large-bore IV catheter. HHS is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires oxygen. Dextrose solutions will increase the patient’s blood glucose and would be contraindicated.

Question 226

A 32-year-old patient with a history of polycystic kidney disease is admitted to the surgical unit after having shoulder surgery. Which of the routine postoperative orders is most important for the nurse to discuss with the health care provider Infuse 5% dextrose in normal saline at 75 mL/hr. Order regular diet after patient is awake and alert. Give ketorolac (Toradol) 10 mg PO PRN for pain. Draw blood urea nitrogen (BUN) and creatinine in 2 hours.

Answer 226

Give ketorolac (Toradol) 10 mg PO PRN for pain. The nonsteroidal antiinflammatory drugs (NSAIDs) should be avoided in patients with decreased renal function because nephrotoxicity is a potential adverse effect. The other orders do not need any clarification or change.

Question 227

After receiving change-of-shift report about the following four patients, which patient should the nurse assess first A 31-year-old female with Cushing syndrome and a blood glucose level of 244 mg/dL A 70-year-old female taking levothyroxine (Synthroid) who has an irregular pulse of 134 A 53-year-old male who has Addison’s disease and is due for a scheduled dose of hydrocortisone (Solu-Cortef). A 22-year-old male admitted with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 130 mEq/L

Answer 227

A 70-year-old female taking levothyroxine (Synthroid) who has an irregular pulse of 134 Initiation of thyroid replacement in older adults may cause angina and cardiac dysrhythmias. The patient’s high pulse rate needs rapid investigation by the nurse to assess for and intervene with any cardiac problems. The other patients also require nursing assessment and/or actions but are not at risk for life-threatening complications.

Question 228

A patient has been diagnosed with urinary tract calculi that are high in uric acid. Which foods will the nurse teach the patient to avoid (select all that apply) ``` Milk Liver Spinach Chicken Cabbage Chocolate ```

Answer 228

Liver Chicken Meats contain purines, which are metabolized to uric acid. The other foods might be restricted in patients who have calcium or oxalate stones.

Question 229

A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient Urine dipstick for glucose Oral glucose tolerance test Fasting blood glucose level Glycosylated hemoglobin level

Answer 229

Glycosylated hemoglobin level The glycosylated hemoglobin (A1C or HbA1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes, but is not used for monitoring glucose control once diabetes has been diagnosed.

Question 230

Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check laboratory results for potassium level. total cholesterol. serum phosphate. serum creatinine.

Answer 230

serum phosphate. If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. The calcium carbonate should not be given until the phosphate level is lowered. Total cholesterol, creatinine, and potassium values do not affect whether calcium carbonate should be administered.

Question 231

Which information is most important for the nurse to report to the health care provider before a patient with type 2 diabetes is prepared for a coronary angiogram The patient’s most recent HbA1C was 6.5%. The patient’s admission blood glucose is 128 mg/dL . The patient took the prescribed metformin (Glucophage) today. The patient took the prescribed captopril (Capoten) this morning.

Answer 231

The patient took the prescribed metformin (Glucophage) today. To avoid lactic acidosis, metformin should be discontinued a day or 2 before the coronary arteriogram and should not be used for 48 hours after IV contrast media are administered. The other patient data will also be reported but do not indicate any need to reschedule the procedure.

Question 232

A 62-year-old female patient has been hospitalized for 8 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider The creatinine level is 3.0 mg/dL. Urine output over an 8-hour period is 2500 mL. The blood urea nitrogen (BUN) level is 67 mg/dL. The glomerular filtration rate is <30 mL/min/1.73m2.

Answer 232

Urine output over an 8-hour period is 2500 mL. The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy.

Question 233

After the insertion of an arteriovenous graft (AVG) in the right forearm, a 54-year-old patient complains of pain and coldness of the right fingers. Which action should the nurse take Teach the patient about normal AVG function. Remind the patient to take a daily low-dose aspirin tablet. Report the patient’s symptoms to the health care provider. Elevate the patient’s arm on pillows to above the heart level.

Answer 233

Report the patient’s symptoms to the health care provider. The patient’s complaints suggest the development of distal ischemia (steal syndrome) and may require revision of the AVG. Elevation of the arm above the heart will further decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts.

Question 234

Which information will the nurse include when teaching a 50-year-old patient who has type 2 diabetes about glyburide (Micronase, DiaBeta, Glynase) Glyburide decreases glucagon secretion from the pancreas. Glyburide stimulates insulin production and release from the pancreas. Glyburide should be taken even if the morning blood glucose level is low. Glyburide should not be used for 48 hours after receiving IV contrast media.

Answer 234

Glyburide stimulates insulin production and release from the pancreas. The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking the glyburide, because hypoglycemia can occur with this class of medication. Metformin should be held for 48 hours after administration of IV contrast media, but this is not necessary for glyburide. Glucagon secretion is not affected by glyburide.

Question 235

An expected nursing diagnosis for a 30-year-old patient admitted to the hospital with symptoms of diabetes insipidus is excess fluid volume related to intake greater than output. impaired gas exchange related to fluid retention in lungs. sleep pattern disturbance related to frequent waking to void. risk for impaired skin integrity related to generalized edema.

Answer 235

sleep pattern disturbance related to frequent waking to void. Nocturia occurs as a result of the polyuria caused by diabetes insipidus. Edema, excess fluid volume, and fluid retention are not expected.

Question 236

Which assessment of a 62-year-old patient who has just had an intravenous pyelogram (IVP) requires immediate action by the nurse The heart rate is 58 beats/minute. The patient complains of a dry mouth. The respiratory rate is 38 breaths/minute. The urine output is 400 mL after 2 hours.

Answer 236

The respiratory rate is 38 breaths/minute. The increased respiratory rate indicates that the patient may be experiencing an allergic reaction to the contrast medium used during the procedure. The nurse should immediately assess the patient’s oxygen saturation and breath sounds. The other data are not unusual findings following an IVP.

Question 237

Which question will the nurse in the endocrine clinic ask to help determine a patient’s risk factors for goiter “How much milk do you drink” “What medications are you taking” “Are your immunizations up to date” “Have you had any recent neck injuries”

Answer 237

“What medications are you taking” Medications that contain thyroid-inhibiting substances can cause goiter. Milk intake, neck injury, and immunization history are not risk factors for goiter.

Question 238

Which information from a patient’s urinalysis requires that the nurse notify the health care provider pH 6.2 Trace protein WBC 20 to 26/hpf Specific gravity 1.021

Answer 238

WBC 20 to 26/hpf The increased number of white blood cells (WBCs) indicates the presence of urinary tract infection or inflammation. The other findings are normal.

Question 239

A patient complains of leg cramps during hemodialysis. The nurse should first massage the patient’s legs. reposition the patient supine. give acetaminophen (Tylenol). infuse a bolus of normal saline.

Answer 239

infuse a bolus of normal saline. Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps.

Question 240

A 62-year-old patient with hyperthyroidism is to be treated with radioactive iodine (RAI). The nurse instructs the patient about radioactive precautions to take with all body secretions. that symptoms of hyperthyroidism should be relieved in about a week. that symptoms of hypothyroidism may occur as the RAI therapy takes effect. to discontinue the antithyroid medications taken before the radioactive therapy.

Answer 240

that symptoms of hypothyroidism may occur as the RAI therapy takes effect. There is a high incidence of postradiation hypothyroidism after RAI, and the patient should be monitored for symptoms of hypothyroidism. RAI has a delayed response, with the maximum effect not seen for 2 to 3 months, and the patient will continue to take antithyroid medications during this time. The therapeutic dose of radioactive iodine is low enough that no radiation safety precautions are needed.

Question 241

Which statement by a 62-year-old patient with stage 5 chronic kidney disease (CKD) indicates that the nurse’s teaching about management of CKD has been effective “I need to get most of my protein from low-fat dairy products.” “I will increase my intake of fruits and vegetables to 5 per day.” “I will measure my urinary output each day to help calculate the amount I can drink.” “I need to take erythropoietin to boost my immune system and help prevent infection.”

Answer 241

“I will measure my urinary output each day to help calculate the amount I can drink.” The patient with end-stage kidney disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD.

Question 242

When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) Communicate the blood glucose level and insulin dose to the circulating nurse in surgery. Discuss the reason for the use of insulin therapy during the immediate postoperative period. Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery. Plan strategies to minimize the risk for hypoglycemia or hyperglycemia during the postoperative period.

Answer 242

Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery. LPN/LVN education and scope of practice includes administration of insulin. Communication about patient status with other departments, planning, and patient teaching are skills that require RN education and scope of practice.

Question 243

Which intervention will be included in the plan of care for a male patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral vein Start continuous pulse oximetry. Restrict physical activity to bed rest. Restrict the patient’s oral protein intake. Discontinue the urethral retention catheter.

Answer 243

Restrict physical activity to bed rest. The patient with a femoral vein catheter must be on bed rest to prevent trauma to the vein. Protein intake is likely to be increased when the patient is receiving dialysis. The retention catheter is likely to remain in place because accurate measurement of output will be needed. There is no indication that the patient needs continuous pulse oximetry.

Question 244

A 34-year-old male patient seen at the primary care clinic complains of feeling continued fullness after voiding and a split, spraying urine stream. The nurse will ask about a history of recent kidney trauma. gonococcal urethritis. recurrent bladder infection. benign prostatic hyperplasia.

Answer 244

gonococcal urethritis. The patient’s clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal urethritis. These symptoms are not consistent with benign prostatic hyperplasia, kidney trauma, or bladder infection.

Question 245

When the patient turns his head quickly during the admission assessment, the nurse observes nystagmus. What is the indicated nursing action Assess the patient with a Rinne test. Place a fall-risk bracelet on the patient. Ask the patient to watch the mouths of staff when they are speaking. Remind unlicensed assistive personnel to speak loudly to the patient.

Answer 245

Place a fall-risk bracelet on the patient. Problems with balance related to vestibular function may present as nystagmus or vertigo and indicate an increased risk for falls. The Rinne test is used to check hearing. Reading lips and louder speech are compensatory behaviors for decreased hearing.

Question 246

After the nurse has finished teaching a patient who has a new prescription for exenatide (Byetta), which patient statement indicates that the teaching has been effective “I may feel hungrier than usual when I take this medicine.” “I will not need to worry about hypoglycemia with the Byetta.” “I should take my daily aspirin at least an hour before the Byetta.” “I will take the pill at the same time I eat breakfast in the morning.”

Answer 246

“I should take my daily aspirin at least an hour before the Byetta.” Since exenatide slows gastric emptying, oral medications should be taken at least an hour before the exenatide to avoid slowing absorption. Exenatide is injected and increases feelings of satiety. Hypoglycemia can occur with this medication.