Exam 1: Test Banks Metabolism

Question 1

A nurse is teaching a client with diabetes mellitus who asks, “Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL (3.3 mmol/L)?” How would the nurse respond?

a. “Glucose is the only fuel used by the body to produce the energy that it needs.”
b. “Your brain needs a constant supply of glucose because it cannot store it.”
c. “Without a minimum level of glucose, your body does not make red blood cells.”
d. “Glucose in the blood prevents the formation of lactic acid and prevents acidosis.”

Answer 1

b. “Your brain needs a constant supply of glucose because it cannot store it.”

Rationale: Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the body’s circulation is needed to meet the fuel demands of the central nervous system.
The nurse would want to educate the patient to prevent
hypoglycemia.
The body can use other sources of fuel, including fat and protein, and glucose is not involved in the production of
red blood cells.
Glucose in the blood will encourage glucose metabolism but is not directly responsible for lactic acid formation.

Question 2

The nurse is assessing a client for risk of developing metabolic syndrome. Which risk factor is associated with this health
condition?

a. Hypotension
b. Hyperthyroidism
c. Abdominal obesity
d. Hypoglycemia

Answer 2

c. Abdominal obesity

Rationale: The client at risk for metabolic syndrome typically has hypertension, abdominal obesity, hyperlipidemia, and hyperglycemia.

Question 3

After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client’s
understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations?

a. “At my age, I should continue seeing the ophthalmologist as I usually do.”
b. “I will see the eye doctor when I have a vision problem and yearly after age 40.”
c. “My vision will change quickly. I should see the ophthalmologist twice a year.”
d. “Diabetes can cause blindness, so I should see the ophthalmologist yearly.”

Answer 3

d. “Diabetes can cause blindness, so I should see the ophthalmologist yearly.”

Rationale: Diabetic retinopathy is a leading cause of blindness in North America.
All clients with diabetes, regardless of age, should be
examined by an ophthalmologist (rather than an optometrist or optician) at diagnosis and at least yearly thereafter.

Question 4

A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. What action would the nurse take first?

a. Document the finding in the client’s chart.
b. Assess tactile sensation in the client’s hands.
c. Examine the client’s feet for signs of injury.
d. Notify the primary health care provider.

Answer 4

c. Examine the client’s feet for signs of injury.

Rationale: Diabetic neuropathy is common when the disease is of long duration.
The client is at great risk for injury in any area with decreased
sensation because he or she is less able to feel injurious events.
Feet are common locations for neuropathy and injury, so the nurse would inspect them for any signs of injury.
After assessment, the nurse would document findings in the client’s chart.
Testing sensory perception in the hands may or may not be needed.
The primary health care provider can be notified after assessment and documentation have been completed.

Question 5

A nurse cares for a client who has a family history of diabetes mellitus. The client states, “My father has type 1 diabetes mellitus. Will I develop this disease as well?” How would the nurse respond?

a. “Your risk of diabetes is higher than the general population, but it may not occur.”
b. “No genetic risk is associated with the development of type 1 diabetes mellitus.”
c. “The risk for becoming a diabetic is 50% because of how it is inherited.”
d. “Female children do not inherit diabetes mellitus, but male children will.”

Answer 5

a. “Your risk of diabetes is higher than the general population, but it may not occur.”

Rationale: The risk for type 1 diabetes is determined by the inheritance of genes coding for HLA-DR and HLA-DQ tissue types.
Clients who have one parent with type 1 diabetes are at increased risk for its development.
Diabetes (type 1) seems to require interaction between
inherited risk and environmental factors, so not everyone with these genes develops diabetes.
The other statements are not accurate.

Question 6

A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement would the nurse include in this client’s plan of care to delay the onset of microvascular and macrovascular complications?

a. “Maintain tight glycemic control and prevent hyperglycemia.”
b. “Restrict your fluid intake to no more than 2 L a day.”
c. “Prevent hypoglycemia by eating a bedtime snack.”
d. “Limit your intake of protein to prevent ketoacidosis.”

Answer 6

a. “Maintain tight glycemic control and prevent hyperglycemia.”

Rationale: Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications.
Maintaining tight glycemic control will help delay the onset of complications.
Restricting fluid intake is not part of the treatment plan for patients with diabetes.
Preventing hypoglycemia and ketosis, although important, is not as important as maintaining daily glycemic control.

Question 7

A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk?

a. A 19-year-old Caucasian
b. A 22-year-old African American
c. A 44-year-old Asian American
d. A 58-year-old American Indian

Answer 7

d. A 58-year-old American Indian

Rationale: Diabetes is a particular problem among African Americans, Hispanics, and American Indians.
The incidence of diabetes increases in all races and ethnic groups with age.
Being both an American Indian and middle age places this patient at the highest risk.

Question 8

A nurse teaches a patient about self-monitoring of blood glucose levels. Which statement would the nurse include in this client’s teaching to prevent bloodborne infections?

a. “Wash your hands after completing each test.”
b. “Do not share your monitoring equipment.”
c. “Blot excess blood from the strip with a cotton ball.”
d. “Use gloves when monitoring your blood glucose.”

Answer 8

b. “Do not share your monitoring equipment.”

Rationale: Small particles of blood can adhere to the monitoring device, and infection can be transported from one user to another.
Hepatitis B in particular can survive in a dried state for about a week.
The client would be taught to avoid sharing any equipment, including the lancet holder.
The client would also be taught to wash his or her hands before testing.
He or she would not need to blot excess blood away from the strip or wear gloves.

Question 9

A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement would the nurse include in this client’s teaching?

a. “Change positions slowly when you get out of bed.”
b. “Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs).”
c. “If you miss a dose of this drug, you can double the next dose.”
d. “Discontinue the medication if you develop a urinary infection.”

Answer 9

b. “Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs).”

Rationale: NSAIDs potentiate the hypoglycemic effects of sulfonylurea agents.
Glipizide is a sulfonylurea.
The other statements are not applicable to glipizide.

Question 10

A nurse cares for a client with diabetes mellitus who asks, “Why do I need to administer more than one injection of insulin each day?” How would the nurse respond?

a. “You need to start with multiple injections until you become more proficient at self-injection.”
b. “A single dose of insulin each day would not match your blood insulin levels and your food intake patterns.”
c. “A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates.”
d. “A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock.”

Answer 10

b. “A single dose of insulin each day would not match your blood insulin levels and your food intake patterns.”

Rationale: Even when a single injection of insulin contains a combined dose of different-acting insulin types, the timing of the actions and the timing of food intake may not match well enough to prevent wide variations in blood glucose levels.
One dose of insulin would not be appropriate even if the patient decreased carbohydrate intake.
Additional injections are not required to allow the client practice with injections, nor will one dose increase the client’s risk of insulin shock.

Question 11

After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for further teaching?

a. “The lower abdomen is the best location because it is closest to the pancreas.”
b. “I can reach my thigh the best, so I will use the different areas of my thighs.”
c. “By rotating the sites in one area, my chance of having a reaction is decreased.”
d. “Changing injection sites from the thigh to the arm will change absorption rates.”

Answer 11

a. “The lower abdomen is the best location because it is closest to the pancreas.”

Rationale: The abdominal site has the fastest rate of absorption because of blood vessels in the area, not because of its proximity to the pancreas.
The other statements are accurate assessments of insulin administration.

Question 12

A nurse reviews the laboratory test values for a client with a new diagnosis of diabetes mellitus type 2. Which A1C value would the nurse expect?

a. 5.0%
b. 5.7%
c. 6.2%
d. 7.4%

Answer 12

d. 7.4%

Rationale: A client is diagnosed with diabetes if the client’s A1C is 6.5% or greater.
All listed values are below that level except for 7.4%.

Question 13

After teaching a client who has diabetes mellitus with retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the teaching?

a. “I have so many complications; exercising is not recommended.”
b. “I will exercise more frequently because I have so many complications.”
c. “I used to run for exercise; I will start training for a marathon.”
d. “I should look into swimming or water aerobics to get my exercise.”

Answer 13

d. “I should look into swimming or water aerobics to get my exercise.”

Rationale: Exercise is not contraindicated for this client, although modifications based on existing pathology are necessary to prevent further injury.
Swimming or water aerobics will give the client exercise without the worry of having the correct shoes or developing a foot injury.
The client should not exercise too vigorously.

Question 14

The nurse assesses a client with diabetic ketoacidosis. Which assessment finding would the nurse correlate with this condition?

a. Increased rate and depth of respiration
b. Extremity tremors followed by seizure activity
c. Oral temperature of 102° F (38.9° C)
d. Severe orthostatic hypotension

Answer 14

a. Increased rate and depth of respiration

Rationale: Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis.
The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation.
Tremors, elevated temperature, and orthostatic hypotension are not associated with ketoacidosis.

Question 15

A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take?

a. Administration of oxygen via facemask
b. Intravenous administration of 10% glucose
c. Implementation of seizure precautions
d. Administration of intravenous insulin

Answer 15

d. Administration of intravenous insulin

Rationale: The rapid, deep respiratory efforts of Kussmaul respirations are the body’s attempt to reduce the acids produced by using fat rather than glucose for fuel.
Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells
and to be used for fuel instead of fat.
The patient who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen.
Giving the patient glucose would be contraindicated. The patient does not require seizure precautions.

Question 16

A nurse teaches a client with type 1 diabetes mellitus. Which statement would the nurse include in this client’s teaching to decrease the client’s insulin needs?

a. “Limit your fluid intake to 2 L a day.”
b. “Animal organ meat is high in insulin.”
c. “Limit your carbohydrate intake to 80 g a day.”
d. “Walk at a moderate pace for 1 mile daily.”

Answer 16

d. “Walk at a moderate pace for 1 mile daily.”

Rationale: Moderate exercise such as walking helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for patients with type 1 diabetes mellitus. Restricting fluids and eating organ meats will not reduce insulin needs.
People with diabetes need at least 130 g of carbohydrates each day.

Question 17

After teaching a client who is recovering from pancreas transplantation, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for further teaching?

a. “If I develop an infection, I should stop taking my corticosteroid.”
b. “If I have pain over the transplant site, I will call the surgeon immediately.”
c. “I should avoid people who are ill or who have an infection.”
d. “I should take my cyclosporine exactly the way I was taught.”

Answer 17

a. “If I develop an infection, I should stop taking my corticosteroid.”

Rationale: Immunosuppressive agents should not be stopped without the consultation of the transplantation physician, even if an infection is present.
Stopping immunosuppressive therapy endangers the transplanted organ.
The other statements are correct. Pain over the graft site may indicate rejection.
Antirejection drugs cause immunosuppression, and the patient should avoid crowds and people who are ill.
Changing the routine of antirejection medications may cause them to not work optimally.

Question 18

A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement would the nurse include in this client’s teaching to prevent injury?

a. “Examine your feet using a mirror every day.”
b. “Rotate your insulin injection sites every week.”
c. “Check your blood glucose level before each meal.”
d. “Use a bath thermometer to test the water temperature.”

Answer 18

d. “Use a bath thermometer to test the water temperature.”

Rationale: Clients with diminished sensory perception can easily experience a burn injury when bathwater is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer.
Examining the feet daily does not prevent injury, although
daily foot examinations are important to find problems so they can be addressed.
Rotating insulin and checking blood glucose levels will not prevent injury.

Question 19

A nurse assesses a client with diabetes mellitus. Which assessment finding would alert the nurse to decreased kidney function in this client?

a. Urine specific gravity of 1.033
b. Presence of protein in the urine
c. Elevated capillary blood glucose level
d. Presence of ketone bodies in the urine

Answer 19

b. Presence of protein in the urine

Rationale: Renal dysfunction often occurs in the client with diabetes.
Proteinuria is a result of renal dysfunction.
Specific gravity is elevated with dehydration.
Elevated capillary blood glucose levels and ketones in the urine are consistent with diabetes mellitus but are not specific to renal function.

Question 20

A nurse assesses a client who has diabetes mellitus and notes that the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of orange juice, the client’s signs and symptoms have not changed. What action would the nurse take next?

a. Administer another half-cup (120 mL) of orange juice.
b. Administer a half-ampule of dextrose 50% intravenously.
c. Administer 10 units of regular insulin subcutaneously.
d. Administer 1 mg of glucagon intramuscularly.

Answer 20

a. Administer another half-cup (120 mL) of orange juice.

Rationale: This patient is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, the nurse would administer oral glucose in the form of orange juice.
If the symptoms do not resolve immediately, the treatment would be repeated.
The patient does not need intravenous dextrose, insulin, or glucagon.

Question 21

A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which would alert the nurse to intervene immediately?

a. Serum chloride level of 98 mEq/L (98 mmol/L)
b. Serum calcium level of 8.8 mg/dL (2.2 mmol/L)
c. Serum sodium level of 132 mEq (132 mmol/L)
d. Serum potassium level of 2.5 mEq/L (2.5 mmol/L)

Answer 21

d. Serum potassium level of 2.5 mEq/L (2.5 mmol/L)

Rationale: Insulin activates the sodium–potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia.
In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium.
The chloride level is normal.
The calcium and sodium levels are slightly low, but this would not be related to hyperglycemia and insulin administration.

Question 22

A nurse teaches a client with diabetes mellitus about sick-day management. Which statement would the nurse include in this client’s teaching?

a. “When ill, avoid eating or drinking to reduce vomiting and diarrhea.”
b. “Monitor your blood glucose levels at least every 4 hours while sick.”
c. “If vomiting, do not use insulin or take your oral antidiabetic agent.”
d. “Try to continue your prescribed exercise regimen even if you are sick.”

Answer 22

b. “Monitor your blood glucose levels at least every 4 hours while sick.”

Rationale: When ill, the client should monitor his or her blood glucose at least every 4 hours.
The client should continue taking the medication regimen while ill.
The client should continue to eat and drink as tolerated but should not exercise while sick.

Question 23

When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, “I will never be able to stick myself with a needle.” How would the nurse respond?

a. “I can give your injections to you while you are here in the hospital.”
b. “Everyone gets used to giving themselves injections. It really does not hurt.”
c. “Your disease will not be managed properly if you refuse to administer the shots.”
d. “Tell me what it is about the injections that are concerning you.”

Answer 23

d. “Tell me what it is about the injections that are concerning you.”

Rationale: Devote as much teaching time as possible to insulin injection and blood glucose monitoring.
Clients with newly diagnosed diabetes are often fearful of giving themselves injections.
If the client is worried about giving the injections, it is best to try to find out what specifically is causing the concern, so it can be addressed.
Giving injections for the client does not promote self-care ability.
Telling the client that others give themselves injections may cause the client to feel bad.
Stating that you don’t know another way to manage the disease is dismissive of the client’s concerns.

Question 24

A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. What action would the nurse take?

a. Apply ice to the site to reduce inflammation.
b. Consult the provider for a new administration route.
c. Assess the client for other signs of cellulitis.
d. Instruct the client to rotate sites for insulin injection.

Answer 24

d. Instruct the client to rotate sites for insulin injection.

Rationale: The client’s tissue has been damaged from continuous use of the same site. The client would be educated to rotate sites.
The damaged tissue is not caused by cellulitis or any type of infection, and applying ice may cause more damage to the tissue.
Insulin can only be administered subcutaneously and intravenously.
It would not be appropriate or practical to change the administration route.

Question 25

After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?

a. “I should increase my intake of vegetables with higher amounts of dietary fiber.”
b. “My intake of saturated fats should be no more than 10% of my total calorie intake.”
c. “I should decrease my intake of protein and eliminate carbohydrates from my diet.”
d. “My intake of water is not restricted by my treatment plan or medication regimen.”

Answer 25

c. “I should decrease my intake of protein and eliminate carbohydrates from my diet.”

Rationale: The client should not completely eliminate carbohydrates from the diet, and should reduce protein if microalbuminuria is present.
The client should increase dietary intake of complex carbohydrates, including vegetables, and decrease intake of fat.
Water does not need to be restricted unless kidney failure is present.

Question 26

A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen:
* Fasting blood glucose: 75 mg/dL (4.2 mmol/L)
* Postprandial blood glucose: 200 mg/dL (11.1 mmol/L)
* Hemoglobin A1C level: 5.5%
How would the nurse interpret these laboratory findings?

a. Increased risk for developing ketoacidosis
b. Good control of blood glucose
c. Increased risk for developing hyperglycemia
d. Signs of insulin resistanc

Answer 26

b. Good control of blood glucose

Rationale: The client is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen.
Because the client’s glycemic control is good, he or she is not at higher risk for ketoacidosis or hyperglycemia and is not showing signs of insulin resistance.

Question 27

The nurse is caring for a newly admitted older adult who has a blood glucose of 300 mg/dL (16.7 mmol/L), a urine output of 185 mL in the past 8 hours, and a blood urea nitrogen (BUN) of 44 mg/dL (15.7 mmol/L). What diabetic complication does the nurse suspect?

a. Diabetic ketoacidosis (DKA)
b. Severe hypoglycemia
c. Chronic kidney disease (CKD)
d. Hyperglycemic-hyperosmolar state (HHS)

Answer 27

d. Hyperglycemic-hyperosmolar state (HHS)

Rationale: The client most likely has diabetes mellitus type 2 and has a high blood glucose causing increased blood osmolarity and dehydration, as evidenced by an insufficient urinary output and increased BUN.
Older adults are at the greatest risk for dehydration
due to age-related physiologic changes.

Question 28

The nurse is caring for a newly admitted client who is diagnosed with a hyperglycemic-hyperosmolar state (HHS). What is the nurse’s priority action at this time?

a. Assess the client’s blood glucose level.
b. Monitor the client’s urinary output every hour.
c. Establish intravenous access to provide fluids.
d. Give regular insulin per agency policy.

Answer 28

c. Establish intravenous access to provide fluids.

Rationale: The first priority in caring for a client with HHS is to increase blood volume to prevent shock or severe hypotension from dehydration.
The nurse would monitor vital signs, urinary output, and blood glucose to determine if interventions were effective.
Regular insulin is also indicated but not as the first priority action.

Question 29

A nurse assesses adults at a health fair. Which adults would the nurse counsel to be tested for diabetes? (Select all that apply.)

a. A 56-year-old African-American male
b. A 22-year-old female with a 30-lb (13.6 kg) weight gain during pregnancy
c. A 60-year-old male with a history of liver trauma
d. A 48-year-old female with a sedentary lifestyle
e. A 50-year-old male with a body mass index greater than 25 kg/m2
f. A 28-year-old female who gave birth to a baby weighing 9.2 lb (4.2 kg)

Answer 29

a. A 56-year-old African-American male
d. A 48-year-old female with a sedentary lifestyle
e. A 50-year-old male with a body mass index greater than 25 kg/m2
f. A 28-year-old female who gave birth to a baby weighing 9.2 lb (4.2 kg)

Rationale: Risk factors for type 2 diabetes include certain ethnic/racial groups (African Americans, American Indians, and Hispanics), obesity and physical inactivity, and giving birth to large babies.
Liver trauma and a 30-lb (13.6 kg) gestational weight gain are not risk factors.

Question 30

A nurse assesses a patient who is experiencing diabetic ketoacidosis (DKA). For which assessment findings would the nurse monitor the client? (Select all that apply.)

a. Deep and fast respirations
b. Decreased urine output
c. Tachycardia
d. Dependent pulmonary crackles
e. Orthostatic hypotension

Answer 30

a. Deep and fast respirations
c. Tachycardia
e. Orthostatic hypotension

Rationale: DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension.
Usually, patients have Kussmaul respirations, which are fast and deep.
Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.

Question 31

A nurse teaches a client with diabetes mellitus about foot care. Which statements would the nurse include in this client’s teaching? (Select all that apply.)

a. “Do not walk around barefoot.”
b. “Soak your feet in a tub each evening.”
c. “Trim toenails straight across with a nail clipper.”
d. “Treat any blisters or sores with Epsom salts.”
e. “Wash your feet every other day.”

Answer 31

a. “Do not walk around barefoot.”
c. “Trim toenails straight across with a nail clipper.”

Rationale: Clients who have diabetes mellitus are at high risk for wounds on the feet secondary to peripheral neuropathy and poor arterial circulation.
The client would be instructed to not walk around barefoot or wear sandals with open toes.
These actions place the client at higher risk for skin breakdown of the feet.
The client would be instructed to trim toenails straight across with a nail clipper.
Feet should be washed daily with lukewarm water and soap, but feet should not be soaked in the tub.
The client should contact the primary health care provider immediately if blisters or sores appear and should not use home remedies to treat these wounds.

Question 32

A nurse provides diabetic education at a public health fair. Which disorders would the nurse include as complications of diabetes mellitus? (Select all that apply.)

a. Stroke
b. Kidney failure
c. Blindness
d. Respiratory failure
e. Cirrhosis

Answer 32

a. Stroke
b. Kidney failure
c. Blindness

Rationale: Complications of diabetes mellitus are caused by macrovascular and microvascular changes.
Macrovascular complications include coronary artery disease, cerebrovascular disease, and peripheral vascular disease.
Microvascular complications include nephropathy, retinopathy, and neuropathy.
Respiratory failure and cirrhosis are not complications of diabetes mellitus.

Question 33

A nurse collaborates with the interprofessional team to develop a plan of care for a client who is newly diagnosed with diabetes mellitus. Which team members would the nurse include in this interprofessional team meeting? (Select all that apply.)

a. Registered dietitian nutritionist
b. Clinical pharmacist
c. Occupational therapist
d. Primary health care provider
e. Speech-language pathologist

Answer 33

a. Registered dietitian nutritionist
b. Clinical pharmacist
d. Primary health care provider

Rationale: When planning care for a client newly diagnosed with diabetes mellitus, the nurse would collaborate with a registered dietitian nutritionist, clinical pharmacist, and primary health care provider.
The focus of treatment for a newly diagnosed client would be
nutrition, medication therapy, and education.
The nurse could also consult with a diabetic educator.
There is no need for occupational therapy or speech therapy at this time.

Question 34

The nurse is caring for a client who has severe hypoglycemia and is experiencing a seizure. What actions will the nurse take at this time? (Select all that apply.)

a. Administer glucagon 1 mg subcutaneously.
b. Be sure the bed side rails are in the up position.
c. Notify the primary health care provider immediately.
d. Monitor the client’s blood glucose level.
e. Increase the intravenous infusion rate immediately.

Answer 34

a. Administer glucagon 1 mg subcutaneously.
b. Be sure the bedside rails are in the up position.
c. Notify the primary health care provider immediately.
d. Monitor the client’s blood glucose level.

Rationale: The client who has severe hypoglycemia often has a blood sugar of less than 20 mg/dL (1.0 mmol/L) and may be unconscious or seizing.
Therefore, the client cannot swallow and needs glucagon.
To keep the client safe during the seizure, the nurse ensures that the side rails are up to prevent the client from falling out of bed.
The nurse would also monitor the client’s blood sugar to evaluate the effectiveness of the interventions.

Question 35

The nurse is caring for a client who has diabetes mellitus type 1 and is experiencing hypoglycemia. Which assessment findings will the nurse expect? (Select all that apply.)

a. Warm, dry skin
b. Nervousness
c. Rapid deep respirations
d. Dehydration
e. Ketoacidosis
f. Blurred vision

Answer 35

b. Nervousness
f. Blurred vision

Rationale: The client who has hypoglycemia is often anxious, nervous, and possibly confused.
Due to a lack of glucose, vision may be blurred or the client may report diplopia (double vision).
Clients who have hyperglycemia from diabetes mellitus type 1 have warm skin, Kussmaul respirations that are rapid and deep, dehydration due to elevated blood glucose, and ketoacidosis.

Question 36

The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. Which physician order should the nurse question?

a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
b. Furosemide (Lasix) 20 mg PO now
c. Oxygen via face mask at 8 L/min
d. KCl 20 mEq PO two times per day

Answer 36

a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr

Rationale: A patient with decompensated heart failure has extracellular fluid volume (ECV) excess.
The IV of 0.9% NaCl is normal saline,
which should be questioned because it would expand ECV and place an additional load on the failing heart.
Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion.
Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess.

Question 37

The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report immediately to the
physician?

a. Swollen ankles in patient with compensated heart failure
b. Positive Chvostek sign in patient with acute pancreatitis
c. Dry mucous membranes in patient taking a new diuretic
d. Constipation in patient who has advanced breast cancer

Answer 37

b. Positive Chvostek sign in patient with acute pancreatitis

Rationale: Positive Chvostek sign indicates increased neuromuscular excitability, which can progress to dangerous laryngospasm or seizures and thus needs to be reported first. The other assessment findings are less urgent and need further assessment.
Bilateral ankle edema is a sign of ECV excess, and follow-up is needed, but the situation is not immediately life-threatening.
Dry mucous membranes in a patient taking a diuretic may be associated with ECV deficit; however, additional assessments of ECV deficit are required before reporting to the physician.
Constipation has many causes, including hypercalcemia and opioid analgesics, and it
needs action, but not as urgently as a positive Chvostek sign.

Question 38

The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should
cause the nurse to hold the IV solution and contact the physician?

a. Weight gain of 2 pounds since last week
b. Dry mucous membranes and skin tenting
c. Urine output 8 mL/hr
d. Blood pressure 98/58

Answer 38

c. Urine output 8 mL/hr

Rationale: Administering IV potassium to a patient who has oliguria is not safe, because potassium intake faster than potassium output can cause hyperkalemia with dangerous cardiac dysrhythmias.
Dry mucous membranes, skin tenting, and blood pressure 98/58 are consistent with the need for IV 0.9% NaCl.
Weight gain of 2 pounds in a week does not necessarily indicate fluid overload, because it can be from increased nutritional intake.
An overnight weight gain indicates a fluid gain.

Question 39

At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia?

a. Vomiting all day and not replacing any fluid
b. Tumor that secretes excessive antidiuretic hormone (ADH)
c. Tumor that secretes excessive aldosterone
d. Tumor that destroyed the posterior pituitary gland

Answer 39

b. Tumor that secretes excessive antidiuretic hormone (ADH)

Rationale: ADH causes renal reabsorption of water, which dilutes the body fluids.
Excessive ADH thus causes hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia.
The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia.
Vomiting without fluid replacement causes ECV deficit and hypernatremia.

Question 40

The patient is receiving tube feedings due to jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration?

a. Development of ankle or sacral edema
b. Increased skin tenting and dry mouth
c. Postural hypotension and tachycardia
d. Decreased level of consciousness

Answer 40

d. Decreased level of consciousness

Rationale: Tube feedings pose a risk for hypernatremia unless adequate water is administered between tube feedings. Hypernatremia causes the level of consciousness to decrease.
The serum sodium concentration is a laboratory measure for osmolality imbalances, not ECV imbalances.
Edema is a sign of ECV excess, not hypernatremia.
Skin tenting, dry mouth, postural hypotension, and tachycardia all can be signs of ECV deficit.

Question 41

The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium?

a. Severe hemorrhage
b. Diabetes insipidus
c. Oliguric renal disease
d. Adrenal insufficiency

Answer 41

c. Oliguric renal disease

Rationale: When renal excretion is decreased, magnesium intake must be decreased also, to prevent hypermagnesemia.
The other conditions are not likely to require adjustment of magnesium intake.

Question 42

The patient’s laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the priority nursing intervention?

a. Raise bed side rails due to potential decreased level of consciousness and confusion.
b. Examine sacral area and patient’s heels for skin breakdown due to potential edema.
c. Establish seizure precautions due to potential muscle twitching, cramps, and seizures.
d. Institute fall precautions due to potential postural hypotension and weak leg muscles.

Answer 42

d. Institute fall precautions due to potential postural hypotension and weak leg muscles.

Rationale: Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities.
Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.

Question 43

The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient? (Select all that apply.)

a. Test for skin tenting.
b. Measure rate and character of pulse.
c. Measure postural blood pressure and heart rate.
d. Check Trousseau sign.
e. Observe for flatness of neck veins when upright.
f. Observe for flatness of neck veins when supine.

Answer 43

a. Test for skin tenting.
b. Measure rate and character of pulse.
f. Observe for flatness of neck veins when supine.

Rationale: ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when supine, which can be assessed in this patient.
Although ECV deficit also causes postural blood pressure drop with tachycardia, this assessment is not appropriate for a
patient with recent bilateral, above-the-knee amputations.
Trousseau sign is a test for increased neuromuscular excitability, which
is not characteristic of ECV deficit.
Flat neck veins when upright is a normal finding.

Question 44

A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration?

a. A 36 year old who is prescribed long-term steroid therapy.
b. A 55 year old who recently received intravenous fluids.
c. A 76 year old who is cognitively impaired.
d. An 83 year old with congestive heart failure.

Answer 44

c. A 76 year old who is cognitively impaired.

Rationale: Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration.
Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at
high risk for dehydration.
The client with heart failure has a risk for both fluid imbalances.
Long-term steroids and recent IV fluid
administration do not increase the risk of dehydration.

Question 45

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best?

a. Measure intake and output every 4 hours.
b. Assess client further for fall risk.
c. Increase the IV flow rate to 250 mL/hr.
d. Place the client in a high-Fowler position.

Answer 45

b. Assess client further for fall risk.

Rationale: Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion.
The client with dehydration
is at risk for falls because of this confusion, orthostatic hypotension, dysrhythmia, and/or muscle weakness.
The nurse’s best
response is to do a more thorough evaluation of the client’s risk for falls.
Measuring intake and output may need to occur more
frequently than every 4 hours, but does not address a critical need.
The nurse would not adjust the IV flow rate without a prescription or standing protocol. For an older adult, this rapid an infusion rate could lead to fluid overload.
Sitting the client in a high-Fowler position may or may not be comfortable but still does not address the most important issue which is safety.

Question 46

After teaching a client who is being treated for dehydration, a nurse assesses the client’s understanding. Which statement indicates that the client correctly understood the teaching?

a. “I must drink a quart (liter) of water or other liquid each day.”
b. “I will weigh myself each morning before I eat or drink.”
c. “I will use a salt substitute when making and eating my meals.”
d. “I will not drink liquids after 6 p.m. so I won’t have to get up at night.”

Answer 46

b. “I will weigh myself each morning before I eat or drink.”

Rationale: One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb (0.2 kg) daily is indicative of excessive fluid loss.
One liter of fluid a day is insufficient. A salt substitute is not related to dehydration. Clients may want to limit fluids after dinner so they won’t have to get up, but this does not address dehydration if the patient drinks the recommended amount of fluid during the earlier parts of the day.

Question 47

A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for
insensible water loss?

a. Client taking furosemide.
b. Anxious client who has tachypnea.
c. Client who is on fluid restrictions.
d. Client who is constipated with abdominal pain.

Answer 47

b. Anxious client who has tachypnea.

Rationale: Insensible water loss is water loss through the skin, lungs, and stool.
Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning.
Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk.
The client taking furosemide will have increased fluid loss, but not insensible water loss.
The other two clients on a fluid restriction and with constipation are not at risk for insensible fluid loss.

Question 48

A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan?

a. Increased respiratory rate from 12 to 22 breaths/min
b. Decreased skin turgor on the client’s posterior hand and forehead
c. Increased urine specific gravity from 1.012 to 1.030 g/mL
d. Decreased orthostatic changes when standing

Answer 48

d. Decreased orthostatic changes when standing

Rationale: The focus of management for clients with dehydration is to increase fluid volumes to normal.
When blood volume is normal,
orthostatic blood pressure and pulse changes will not occur.
This assessment finding shows a therapeutic response to treatment.
Increased respirations, decreased skin turgor, and higher urine specific gravity all are indicators of continuing dehydration.

Question 49

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client’s understanding. Which food choice for lunch indicates that the client correctly understood the teaching?

a. Slices of smoked ham with potato salad
b. Bowl of tomato soup with a grilled cheese sandwich
c. Salami and cheese on whole-wheat crackers
d. Grilled chicken breast with glazed carrots

Answer 49

d. Grilled chicken breast with glazed carrots

Rationale: Clients on restricted sodium diets generally avoid processed, smoked, and pickled foods and those with sauces and other condiments.
Foods lowest in sodium include fish, poultry, and fresh produce.
The ham, tomato soup, salami, and crackers are usually high in sodium.

Question 50

A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia?

a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions.
b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic.
c. A 67 year old who is experiencing pain and is prescribed ibuprofen.
d. A 73 year old with tachycardia who is receiving digoxin.

Answer 50

a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions.

Rationale: Dextrose 5% in water (D5W) contains no electrolytes.
The dextrose is rapidly metabolized when infused, leaving the solution
hypotonic.
Aggressive ingestion (or infusion) of hypotonic solutions can lead to hyponatremia.
Because the client is not taking any
food or fluids by mouth (NPO), normal sodium excretion can also lead to hyponatremia.
The sulfonamide antibiotic, ibuprofen, and
digoxin will not put a client at risk for hyponatremia.

Question 51

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client’s teaching?

a. “Have you spouse watch you for irritability and anxiety.”
b. “Notify the clinic if you notice muscle twitching.”
c. “Call your primary health care provider for diarrhea.”
d. “Bake or grill your meat rather than frying it.”

Answer 51

c. “Call your primary health care provider for diarrhea.”

Rationale: One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be taught to call the primary health care provider if this is noticed.
Irritability and anxiety are common neurologic signs of hypokalemia.
Muscle twitching is related to hypernatremia.
Cooking methods are not a cause of hyponatremia.

Question 52

A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse
complete first?

a. Depth of respirations
b. Bowel sounds
c. Grip strength
d. Electrocardiography

Answer 52

a. Depth of respirations

Rationale: A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips.
The nurse would assess the client’s respiratory status first to ensure that
respirations are sufficient.
The respiratory assessment would include rate and depth of respirations, respiratory effort, and oxygen saturation.
The other assessments are important but are secondary to the client’s respiratory status.

Question 53

A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first?

a. Prepare to administer patiromer by mouth.
b. Provide a heart-healthy, low-potassium diet.
c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
d. Prepare the client for hemodialysis treatment.

Answer 53

c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push.

Rationale: A client with a critically high serum potassium level and cardiac changes would be treated immediately to reduce the extracellular potassium level.
Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps.
Insulin will decrease both serum potassium and glucose levels and therefore would be administered with dextrose to prevent
hypoglycemia.
Patiromer may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first intervention the nurse would implement.
Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client’s current potassium level.

Question 54

The nurse is caring for a client who has fluid overload. What action by the nurse takes priority?

a. Administer high-ceiling (loop) diuretics.
b. Assess the client’s lung sounds every 2 hours.
c. Place a pressure-relieving overlay on the mattress.
d. Weigh the client daily at the same time on the same scale.

Answer 54

b. Assess the client’s lung sounds every 2 hours.

Rationale: All interventions are appropriate for the client who is overhydrated.
However, client safety is the priority. A client with fluid overload can easily go into pulmonary edema, which can be life-threatening.
The nurse would closely monitor the client’s
respiratory status.

Question 55

A nurse is assessing a client with hypokalemia, and notes that the client’s handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first?

a. Assess the client’s respiratory rate, rhythm, and depth.
b. Measure the client’s pulse and blood pressure.
c. Document findings and monitor the client.
d. Call the health care primary health care provider.

Answer 55

a. Assess the client’s respiratory rate, rhythm, and depth.

Rationale: In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia.
The most life-threatening complication of hypokalemia is respiratory insufficiency.
It is imperative for the nurse to perform a
respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with
hypokalemia.
The client’s pulse and blood pressure would be assessed after assessing respiratory status. Next, the nurse would call the health care primary health care provider to obtain orders for potassium replacement.
Documenting findings and continuing to
monitor the client would occur during and after potassium replacement therapy.

Question 56

A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition?

a. Assesses the client’s Chvostek and Trousseau sign.
b. Keeps the client’s room quiet and dimly lit.
c. Moves the client carefully to avoid fracturing bones.
d. Administers bisphosphonates as prescribed.

Answer 56

d. Administers bisphosphonates as prescribed.

Rationale: Bisphosphonates are used to treat hypercalcemia.
The Chvostek and Trousseau signs are used to assess for hypocalcemia.
Keeping the client in a low-stimulus environment is important because the excitable nervous system cells are overstimulated.
Long-standing hypocalcemia can cause fragile, brittle bones which can be fractured.

Question 57

A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first?

a. Encourage oral fluid intake.
b. Connect the client to a cardiac monitor.
c. Assess urinary output.
d. Administer oral calcitonin.

Answer 57

b. Connect the client to a cardiac monitor.

Rationale: This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias.
Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine
output, and administering calcitonin are treatments for hypercalcemia but are not the highest priority.

Question 58

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital?

a. Ask family members to speak quietly to keep the client calm.
b. Assess urine color, amount, and specific gravity each day.
c. Encourage the client to drink at least 1 L of fluids each shift.
d. Dangle the client on the bedside before ambulating.

Answer 58

d. Dangle the client on the bedside before ambulating.

Rationale: An older adult with moderate dehydration may experience orthostatic hypotension.
The client needs to dangle on the bedside before ambulating.
Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion.
Assessing the client’s urine may assist with the diagnosis of dehydration but would not prevent injury.
Clients are encouraged to drink fluids, but 1 L of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid
overload, especially if the client has heart failure or renal insufficiency.

Question 59

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find?
(Select all that apply.)

a. Increased pulse rate
b. Distended neck veins
c. Decreased blood pressure
d. Warm and pink skin
e. Skeletal muscle weakness
f. Visual disturbances

Answer 59

a. Increased pulse rate
b. Distended neck veins
e. Skeletal muscle weakness
f. Visual disturbances

Rationale: Signs and symptoms of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, skeletal muscle weakness, and visual disturbances.
Decreased blood pressure would be seen in dehydration.
Warm and pink skin is a normal finding.

Question 60

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential
complications will the nurse assess? (Select all that apply.)

a. Urine output of 25 mL/hr
b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L)
c. Urine specific gravity of 1.02 g/mL
d. Serum sodium level of 128 mEq/L (128 mmol/L)
e. Blood osmolality of 250 mOsm/kg (250 mmol/kg)

Answer 60

b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L)
e. Blood osmolality of 250 mOsm/kg (250 mmol/kg)

Rationale: Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium.
Any drug or condition that disrupts aldosterone secretion or release increases the client’s risk for excessive water loss (increased urine output), increased potassium reabsorption, decreased blood osmolality, and increased urine specific gravity.
The client would not be at risk for sodium imbalance.

Question 61

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? (Select all that apply.)

a. Hypokalemia—muscle weakness with respiratory depression
b. Hypermagnesemia—bradycardia and hypotension
c. Hyponatremia—decreased level of consciousness
d. Hypercalcemia—positive Trousseau and Chvostek signs
e. Hypomagnesemia—hyperactive deep tendon reflexes
f. Hypernatremia—weak peripheral pulses

Answer 61

a. Hypokalemia—muscle weakness with respiratory depression
b. Hypermagnesemia—bradycardia and hypotension
c. Hyponatremia—decreased level of consciousness
e. Hypomagnesemia—hyperactive deep tendon reflexes
f. Hypernatremia—weak peripheral pulses

Rationale: Hypokalemia is associated with muscle weakness and respiratory depression. Hypermagnesemia manifests with bradycardia and hypotension.
Hyponatremia can present with decreased level of consciousness.
Hypomagnesemia can be assessed through
hyperactive deep tendon reflexes.
Weak peripheral pulses are felt in hypernatremia.
Positive Trousseau and Chvostek signs are seen in hypocalcemia.

Question 62

After administering potassium chloride, a nurse evaluates the client’s response. Which signs and symptoms indicate that treatment is improving the client’s hypokalemia? (Select all that apply.)

a. Respiratory rate of 8 breaths/min
b. Absent deep tendon reflexes
c. Strong productive cough
d. Active bowel sounds
e. U waves present on the electrocardiogram (ECG)

Answer 62

c. Strong productive cough
d. Active bowel sounds

Rationale: A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance.
Active bowel sounds also indicate that treatment is working.
A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all signs and symptoms of hypokalemia and do not demonstrate that treatment is working.