exam 1 questions Flashcards
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).
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.
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.
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.
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.
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.
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.
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.
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.
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
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.”
“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.
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.
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.
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)
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.”
“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.
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.
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.
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.
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.
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.
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.
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
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.
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).
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.
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.”
“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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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).
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.
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.
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
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
The nurse will anticipate teaching a patient with nephrotic syndrome who develops flank pain about treatment with
antibiotics.
antifungals.
anticoagulants.
antihypertensives.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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
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.
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
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.
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.”
“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.
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.”
“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.
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.
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.
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
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.
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.
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.
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.
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.
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
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.
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
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.
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.
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.
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.
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.
A 44-year-old patient is admitted with tetany. Which laboratory value should the nurse monitor
Total protein
Blood glucose
Ionized calcium
Serum phosphate
Ionized calcium
Tetany is associated with hypocalcemia. The other values would not be useful for this patient.
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)
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.
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.
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.
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.
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.
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.”
“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.
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
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.
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.
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.
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.
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.
Which equipment will the nurse obtain to perform a Rinne test
Otoscope
Tuning fork
Audiometer
Ticking watch
Tuning fork
Rinne testing is done using a tuning fork. The other equipment is used for other types of ear examinations.
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.
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.
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.
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.
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
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.
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.
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.
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.”
“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.
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.”
“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
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.
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.
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
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.
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)
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.
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.
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.
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).
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.
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%.
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.
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
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.
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
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.
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.
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.
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
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.
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.
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.
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.
both near and distant vision.
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.
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.
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
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.
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.
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.
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.
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.
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)
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.
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.
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.
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
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.
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.
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.
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.
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.
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
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.
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
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.
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
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.
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.
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.
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.”
“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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
