MD3

Question 1

A young adult contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient’s illness, the nurse would expect serologic testing to reveal

a. antibody to hepatitis D (anti-HDV).
b. hepatitis B surface antigen (HBsAg).
c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG).
d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).

Answer 1

ANS: D
Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity

Question 2

The nurse evaluates that administration of hepatitis B vaccine to a healthy patient has been effective when the patient’s blood specimen reveals

A HBsAg.
B Anti-HBs.
C. Anti-HBc IgG
D. Anti-HBc IgM

Answer 2

ANS: B
The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV

Question 3

A patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate?

a. Schedule the patient for HCV genotype testing.
b. Administer the HCV vaccine and immune globulin.
c. Teach the patient about ribavirin (Rebetol) treatment.
d. Explain that the infection will resolve over a few months.

Answer 3

ANS: A
Genotyping of HCV has an important role in managing treatment and is done before drug therapy is initiated. Because most patients with acute HCV infection convert to the chronic state, the nurse should not teach the patient that the HCV will resolve in a few months. Immune globulin or vaccine is not available for HCV. Ribavirin is used for chronic HCV infectIon

Question 4

The nurse will plan to teach the patient diagnosed with acute hepatitis B about

a. administering α-interferon
b. side effects of nucleotide analogs.
c. measures for improving the appetite.
d. ways to increase activity and exercise.

Answer 4

ANS: C
Maintaining adequate nutritional intake is important for regeneration of hepatocytes. Interferon and antivirals may be used for chronic hepatitis B, but they are not prescribed for acute hepatitis B infection. Rest is recommended.

Question 5

The nurse administering α-interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C will plan to monitor for

a. leukopenia.
b. hypokalemia.
c. polycythemia.
d. hypoglycemia.

Answer 5

ANS: A
Therapy with ribavirin and α-interferon may cause leukopenia. The other problems are not associated with this drug therapy.

Question 6

Which information given by a 70-yr-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C?

a. The patient had a blood transfusion in 2005.
b. The patient used IV drugs about 20 years ago.
c. The patient frequently eats in fast-food restaurants.
d. The patient traveled to a country with poor sanitation.

Answer 6

ANS: B
Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992 (when an antibody test for hepatitis C became available) do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries.

Question 7

A patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is appropriate?

a. “Do you have a history of IV drug use?”
b. “Do you use any over-the-counter drugs?”
c. “Have you used corticosteroids for any reason?”
d. “Have you recently traveled to a foreign country?”

Answer 7

ANS: B
The patient’s symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.

Question 8

Which focused data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis?

a. Hemoglobin
b. Temperature
c. Activity level
d. Albumin level

Answer 8

ANS: D
The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters are not directly associated with the patient’s edema.

Question 9

Which topic is most important to include in patient teaching for a 41-yr-old patient diagnosed with early alcoholic cirrhosis?

a. Taking lactulose
b. Maintaining good nutrition
c Avoiding alcohol ingestion
d. Using vitamin B supplements

Answer 9

ANS: C
The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.

Question 10

A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take?

a. Withhold both drugs.
b. Administer both drugs
c Administer the furosemide
d. Administer the spironolactone.

Answer 10

ANS: D
Spironolactone is a potassium-sparing diuretic and will help increase the patient’s potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient’s potassium level and should be held until the nurse talks with the health care provider.

Question 11

Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy?

a. Request that the patient stand on one foot.
b. Ask the patient to extend both arms forward.
c. Request that the patient walk with eyes closed.
d. Ask the patient to perform the Valsalva maneuver.

Answer 11

ANS: B
Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests might also be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.

Question 12

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis?

a. The patient is alert and oriented.
b. The patient denies nausea or anorexia.
c. The patient’s bilirubin level decreases.
d. The patient has at least one stool daily.

Answer 12

ANS: A
The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.

Question 13

A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care?

a. Instruct the patient to cough every hour.
b. Monitor the patient for shortness of breath.
c. Verify the position of the balloon every 4 hours.
d. Deflate the gastric balloon if the patient reports nausea.

Answer 13

ANS: B
The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. Balloons may be deflated briefly every 8 to 12 hours to avoid tissue necrosis, but if only the gastric balloon is deflated, the esophageal balloon may occlude the airway. Balloons are not deflated for nausea.

Question 14

To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor

a. bilirubin levels.
b. ammonia levels.
c. potassium levels
d. prothrombin time.

Answer 14

ANS: B
The protein in the blood in the gastrointestinal tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but they will not be affected by the bleeding episode.

Question 15

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?

a. Restrict daily dietary protein intake.
b. Reposition the patient every 4 hours.
c. Perform passive range of motion twice daily.
d. Place the patient on a pressure-relief mattress.

Answer 15

ANS: D
The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take the pressure off areas such as the sacrum that are vulnerable to breakdown.

Question 16

Which finding indicates to the nurse that a patient’s transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?

a. Increased serum albumin level
b. Decreased indirect bilirubin level
c. Improved alertness and orientation
d. Fewer episodes of bleeding varices

Answer 16

ANS: D
TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.

Question 17

To prepare a patient with ascites for paracentesis, the nurse

a. places the patient on NPO status.
b. assists the patient to lie flat in bed.
c. asks the patient to empty the bladder.
d. positions the patient on the right side.

Answer 17

ANS: C
The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler’s position and would not be able to lie flat without compromising breathing. Because no sedation is required for paracentesis, the patient does not need to be NPO.

Question 18

Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago?

a. Dry palpebral and oral mucosa
b. Crackles at bilateral lung bases
c. Temperature 100.8F (38.2C)
d. No bowel movement for 4 days

Answer 18

ANS: C
The risk of infection is high in the first few months after liver transplant, and fever is frequently the only sign of infection. The other patient data indicate the need for further assessment or nursing actions and might be communicated to the health care provider, but they do not indicate a need for urgent action.

Question 19

Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a patient who has acute pancreatitis?

a. Calcium
b. Bilirubin
c. Amylase
d. Potassium

Answer 19

ANS: C
Amylase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be useful in evaluating whether the prescribed therapies have been effective.

Question 20

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis?

a. Nausea and vomiting
b. Hypotonic bowel sounds
c. Muscle twitching and finger numbness
d. Upper abdominal tenderness and guarding

Answer 20

ANS: C
Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered. Although the other findings should also be reported to the health care provider, they do not indicate complications that require rapid action.

Question 21

The nurse will ask a patient being admitted with acute pancreatitis specifically about a history of

a. diabetes mellitus.
b. high-protein diet.
c. cigarette smoking
d. alcohol consumption.

Answer 21

ANS: D
Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors.

Question 22

The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase)

a. at bedtime.
b. with meals.
c. in the morning.
d. for abdominal pain.

Answer 22

ANS: B

Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal.

Question 23

The nurse recognizes that teaching a patient following a laparoscopic cholecystectomy has been effective when the patient makes which statement?

a. “I can expect yellow-green drainage from the incision for a few days.”
b. “I can remove the bandages on my incisions tomorrow and take a shower.”
c. “I should plan to limit my activities and not return to work for 4 to 6 weeks.”
d. “I will need to maintain a low-fat diet for life because I no longer have a
gallbladder. ”

Answer 23

ANS: B
After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions. Patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a lifelong requirement.

Question 24

The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?

a. The patient complains of right upper-quadrant pain with palpation.
b. The patient’s hands flap back and forth when the arms are extended.
c. The patient has ascites and a 2-kg weight gain from the previous day.
d. The patient’s abdominal skin has multiple spider-shaped blood vessels.

Answer 24

ANS: B
Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain indicate the need for treatment but not as urgently as the changes in neurologic status.

Question 25

A patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator to the nurse that the medication has been effective?

a. The patient reports no chest pain.
b. Blood pressure is 140/90 mm Hg.
c. Stools test negative for occult blood.
d. The apical pulse rate is 68 beats/minute.

Answer 25

ANS: C
Because the purpose of β-blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk for bleeding from esophageal varices.

Question 26

Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient admitted with bleeding esophageal varices?

a. The medication will reduce the risk for aspiration.
b. The medication will inhibit development of gastric ulcers.
c. The medication will prevent irritation of the enlarged veins.
d. The medication will decrease nausea and improve the appetite.

Answer 26

ANS: C
Esophageal varices are dilated submucosal veins. The therapeutic action of H2-receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purposes for H2-receptor blockade in this patient.

Question 27

When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient’s right hand. Which action should the nurse take next?

a. Ask the patient about any arm pain.
b. Retake the patient’s blood pressure.
c. Check the calcium level in the chart.
d. Notify the health care provider immediately.

Answer 27

ANS: C
The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau’s sign. The health care provider should be notified after the nurse checks the patient’s calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain

Question 28

A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective?

a. Bowel sounds are present.
b. Grey Turner sign resolves.
c. Electrolyte levels are normal
d. Abdominal pain is decreased.

Answer 28

ANS: D
NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status has been effective. Electrolyte levels may be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this to occur to determine whether treatment was effective.

Question 29

Which assessment finding is of most concern for a patient with acute pancreatitis?

a. Absent bowel sounds
b. Abdominal tenderness
c. Left upper quadrant pain
d. Palpable abdominal mass

Answer 29

ANS: D
A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications.

Question 30

Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?

a. Teach symptoms of variceal bleeding.
b. Draw blood for hepatitis serology testing.
c. Discuss the need to increase caloric intake.
d. Review the patient’s current medication list.

Answer 30

ANS: D
Some medications can increase the risk for NAFLD, and they should be eliminated. NAFLD is not associated with hepatitis, weight loss is usually indicated, and variceal bleeding would not be a concern in a patient with asymptomatic NAFLD.

Question 31

A patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the health care provider before administration?

a. Ribavirin (Rebetol, Copegus) 600 mg PO bid
b. Diphenhydramine 25 mg PO every 4 hours PRN itching
c. Pegylated α-interferon (PEG-Intron, Pegasys) 1.5 mcg/kg PO daily
d. Dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea

Answer 31

ANS: C
Pegylated α-interferon is administered subcutaneously, not orally. The medications are all appropriate for a patient with chronic hepatitis C infection.

Question 32

During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?

a. A 40-yr-old patient with chronic pancreatitis who has gnawing abdominal pain
b. A 58-yr-old patient who has compensated cirrhosis and is complaining of
anorexia
c. A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102°
F (38.8° C)
d. A 36-yr-old patient recovering from a laparoscopic cholecystectomy who has
severe shoulder pain

Answer 32

ANS: C
This patient’s history and fever suggest possible spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.

Question 33

Which goal has the highest priority in the plan of care for a 26-yr-old patient who is homeless who was admitted with viral hepatitis who has severe anorexia and fatigue?

a. Increase activity level.
b. Maintain adequate nutrition.
c. Establish a stable environment.
d. Identify source of hepatitis exposure.

Answer 33

ANS: B
The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as ensuring adequate nutrition. Although the patient’s activity level will be gradually increased, rest is indi cated during the acute phase of hepatitis

Question 34

Which action should the nurse in the emergency department take first for a new patient who is vomiting blood?

a. Insert a large-gauge IV catheter.
b. Draw blood for coagulation studies.
c. Check blood pressure and heart rate.
d. Place the patient in the supine position.

Answer 34

ANS: C
The nurse’s first action should be to determine the patient’s hemodynamic status by assessing vital signs. Drawing blood for coagulation studies and inserting an IV catheter are also appropriate. However, the vital signs may indicate the need for more urgent actions. Because aspiration is a concern for this patient, the nurse will need to assess the patient’s vital signs and neurologic status before placing the patient in a supine position.

Question 35

The nurse is planning care for a patient with acute severe pancreatitis. The highest priority patient outcome is

a. maintaining normal respiratory function.
b. expressing satisfaction with pain control.
c. developing no ongoing pancreatic disease.
d. having adequate fluid and electrolyte balance

Answer 35

ANS: A
Respiratory failure can occur as a complication of acute pancreatitis and maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

Question 36

The nurse is caring for a patient with pancreatic cancer. Which nursing action is the highest priority?

a. Offer psychologic support for depression.
b. Offer high-calorie, high-protein dietary choices.
c. Administer prescribed opioids to relieve pain as needed.
d. Teach about the need to avoid scratching any pruritic areas.

Answer 36

ANS: C
Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to teaching, or manage anxiety or depression.

Question 37

Which assessment information will be most important for the nurse to report to the health care provider about a patient with acute cholecystitis?

a. The patient’s urine is bright yellow.
b. The patient’s stools are tan colored.
c. The patient has increased pain after eating.
d. The patient complains of chronic heartburn

Answer 37

ANS: B
Tan or gray stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, although the nurse would also report the other assessment information to the health care provider.

Question 38

A patient had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to

a. perform leg exercises hourly while awake.
b. ambulate the evening of the operative day.
c. turn, cough, and deep breathe every 2 hours.
d. choose preferred low-fat foods from the menu.

Answer 38

ANS: C
Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions are also important to implement but are not as high a priority as ensuring adequate ventilation.

Question 39

For a patient with cirrhosis, which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?

a. Assessing the patient for jaundice
b. Providing oral hygiene after a meal
c. Palpating the abdomen for distention
d. Teaching the patient the prescribed diet

Answer 39

ANS: B
Providing oral hygiene is within the scope of UAP. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher level nursing education and scope of practice and would be delegated to licensed practical/vocational nurses (LPNs/LVNs) or RNs.

Question 40

Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B?

a. Advise limiting alcohol intake to 1 drink daily.
b. Schedule for liver cancer screening every 6 months.
c. Initiate administration of the hepatitis C vaccine series.
d. Monitor anti-hepatitis B surface antigen (anti-HBs) levels.

Answer 40

ANS: B
Patients with chronic hepatitis are at higher risk for development of liver cancer and should be screened for liver cancer every 6 to 12 months. Patients with chronic hepatitis are advised to completely avoid alcohol. There is no hepatitis C vaccine. Because anti-HBs is present whenever there has been a past hepatitis B infection or vaccination, there is no need to regularly monitor for this antibody.

Question 41

A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical examination?

a. Start the hepatitis B immunization series.
b. Teach the patient about hepatitis A immune globulin.
c. Ask whether the patient has been screened for hepatitis C.
d. Test for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM).

Answer 41

ANS: C
Current CDC guidelines indicate that all patients who were born between 1945 and 1965 should be screened for hepatitis C because many individuals who are positive have not been diagnosed. Although routine hepatitis B immunization is recommended for infants, children, and adolescents, vaccination for hepatitis B is recommended only for adults at risk for blood-borne infections. Because the patient has already had hepatitis A, immunization and anti-HAV IgM levels will not be needed.

Question 42

A patient has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider?

a. Asterixis and lethargy
b. Jaundiced sclera and skin
c. Elevated total bilirubin level
d. Liver 3 cm below costal margin

Answer 42

ANS: A
The patient’s findings of asterixis and lethargy are consistent with grade 2 hepatic encephalopathy. Patients with acute liver failure can deteriorate rapidly from grade 1 or 2 to grade 3 or 4 hepatic encephalopathy and need early transfer to a transplant center. The other findings are typical of patients with hepatic failure and would be reported but would not indicate a need for an immediate change in the therapeutic plan.

Question 43

A 36-yr-old female patient is receiving treatment for chronic hepatitis C with pegylated interferon (PEG-Intron, Pegasys), ribavirin (Rebetol), and telaprevir (Incivek). Which finding is important to communicate to the health care provider to suggest a change in therapy?

a. Weight loss of 2 lb (1 kg)
b. Positive urine pregnancy test
c. Hemoglobin level of 10.4 g/dL
d. Complaints of nausea and anorexia

Answer 43

ANS: B
Because ribavirin is teratogenic, the medication will need to be discontinued immediately. Anemia, weight loss, and nausea are common adverse effects of the prescribed regimen and may require actions such as patient teaching, but they would not require immediate cessation of the therapy

Question 44

A nurse is considering which patient to admit to the same room as a patient who had a liver transplant 3 weeks ago and is now hospitalized with acute rejection. Which patient would be the best choice?

a. Patient who is receiving chemotherapy for liver cancer
b. Patient who is receiving treatment for acute hepatitis C
c. Patient who has a wound infection after cholecystectomy
d. Patient who requires pain management for chronic pancreatitis

Answer 44

ANS: D
The patient with chronic pancreatitis does not present an infection risk to the immunosuppressed patient who had a liver transplant. The other patients either are at risk for infection or currently have an infection, which will place the immunosuppressed patient at risk for infection

Question 45

In reviewing the medical record shown in the accompanying figure for a patient admitted with acute pancreatitis, the nurse sees that the patient has a positive Cullen’s sign. Indicate the area where the nurse will assess for this change.

a. 1
b. 2
c. 3
d. 4

Answer 45

ANS: C
The area around the umbilicus should be indicated. Cullen’s sign consists of ecchymosis around the umbilicus. Cullen’s sign occurs because of seepage of bloody exudates from the inflamed pancreas and indicates severe acute pancreatitis.

Question 46

After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select all that apply)?

a. Administer hepatitis B vaccine.
b. Test for antibodies to hepatitis B.
c. Teach about α-interferon therapy.
d. Give hepatitis B immune globulin.
e. Teach about choices for oral antiviral therapy.

Answer 46

ANS: A, B, D
The recommendations for hepatitis B exposure include both vaccination and immune globulin administration. In addition, baseline testing for hepatitis B antibodies will be needed. Interferon and oral antivirals are not used for hepatitis B prophylaxis

Question 47

A young adult patient is being seen in the clinic with increased secretion of the anterior pituitary hormones. The nurse would expect the laboratory test results to show

a. increased urinary cortisol.
b. decreased serum thyroxine.
c. elevated serum aldosterone levels
d. low urinary catecholamines excretion.

Answer 47

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

Question 48

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

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

Answer 48

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

Question 49

A patient seen in the emergency department for severe headache and acute confusion has a serum sodium level of 118 mEq/L. The nurse will anticipate the need for which diagnostic test?

a. Urinary 17-ketosteroids
b. Antidiuretic hormone level
c. Growth hormone stimulation test
d. Adrenocorticotropic hormone level

Answer 49

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

Question 50

Which question from a nurse during a patient interview will provide focused information about a possible thyroid disorder?

a. “What methods do you use to help cope with stress?”
b. “Have you experienced any blurring or double vision?”
c. “Have you had a recent unplanned weight gain or loss?”
d. “Do you have to get up at night to empty your bladder?”

Answer 50

ANS: C
Because thyroid function affects metabolic rate, changes in weight may indicate hyperfunction or hypofunction of the thyroid gland. Nocturia, visual difficulty, and changes in stress level are associated with other endocrine disorders.

Question 51

A patient will be scheduled in the outpatient clinic for blood cortisol testing. Which instruction will the nurse provide?

a. “Avoid adding any salt to your foods for 24 hours before the test.”
b. “You will need to lie down for 30 minutes before the blood is drawn.”
c. “Come to the laboratory to have the blood drawn early in the morning.”
d. “Do not have anything to eat or drink before the blood test is obtained.”

Answer 51

ANS: C
Cortisol levels are usually drawn in the morning, when levels are highest. The other instructions would be given to patients who were having other endocrine testing.

Question 52

A 61-yr-old female patient admitted with pneumonia has a total serum calcium level of 13.3 mg/dL (3.3 mmol/L). The nurse will anticipate the need to teach the patient about testing for _____ levels.

a. calcitonin
b. catecholamine
c. thyroid hormone
d. parathyroid hormone

Answer 52

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

Question 53

During the nurse’s physical examination of a young adult, the patient’s thyroid gland cannot be felt. The most appropriate action by the nurse is to

a. palpate the patient’s neck more deeply.
b. document that the thyroid was nonpalpable.
c. notify the health care provider immediately.
d. teach the patient about thyroid hormone testing.

Answer 53

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

Question 54

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?

a. Thyroxine (T4) level
b. Triiodothyronine (T3) level
c. Thyroid-stimulating hormone (TSH) level
d. Thyrotropin-releasing hormone (TRH) level

Answer 54

ANS: C
A low TSH level indicates that the patient’s hypothyroidism is caused by decreased anterior pituitary secretion of TSH. Low T3and T4 levels are not diagnostic of the primary cause of the hypothyroidism. TRH levels indicate the function of the hypothalamus.

Question 55

The nurse reviews a patient’s glycosylated hemoglobin (A1C) results to evaluate

a. fasting preprandial glucose levels.
b. glucose levels 2 hours after a meal.
c. glucose control over the past 90 days.
d. hypoglycemic episodes in the past 3 months

Answer 55

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

Question 56

A patient is taking spironolactone (Aldactone), a drug that blocks the action of aldosterone on the kidney, for hypertension. The nurse will monitor for

a. increased serum sodium.
b. decreased urinary output.
c. elevated serum potassium
d. evidence of fluid overload.

Answer 56

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

Question 57

A 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?

a. Ideal weight
b. Value system
c. Activity level
d. Visual changes

Answer 57

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

Question 58

An 18-yr-old male patient with small stature is scheduled for a growth hormone stimulation test. In preparation for the test, the nurse will obtain

a. ice in a basin.
b. glargine insulin.
c. a cardiac monitor
d. 50% dextrose solution.

Answer 58

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

Question 59

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

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

Answer 59

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

Question 60

The nurse will teach a patient who is scheduled to complete a 24-hour urine collection for 17-ketosteroids to

a. insert and maintain a retention catheter.
b. keep the specimen refrigerated or on ice.
c. drink at least 3 L of fluid during the 24 hours.
d. void and save that specimen to start the collection.

Answer 60

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

Question 61

Which additional information will the nurse need to consider when reviewing the laboratory results for a patient’s total calcium level?

a. The blood glucose
b. The serum albumin
c. The phosphate level
d. The magnesium level

Answer 61

ANS: B
Part of the total calcium is bound to albumin, so hypoalbuminemia can lead to misinterpretation of calcium levels. The other laboratory values will not affect total calcium interpretation.

Question 62

A patient is admitted with tetany. Which laboratory value should the nurse plan to monitor?

a. Total protein
b. Blood glucose
c. Ionized calcium
d. Serum phosphate

Answer 62

ANS: C

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

Question 63

Which information about a patient who is scheduled for an oral glucose tolerance test should be reported to the health care provider before starting the test?

a. The patient reports having occasional orthostatic dizziness.
b. The patient takes oral corticosteroids for rheumatoid arthritis.
c. The patient has had a 10-lb weight gain in the last month.
d. The patient drank several glasses of water an hour previously.

Answer 63

ANS: B
Corticosteroids can affect blood glucose results. The other information will be provided to the health care provider but will not affect the test results.

Question 64

A registered nurse (RN) is caring for a patient with a goiter and possible hyperthyroidism. Which action by the RN indicates that the charge nurse needs to provide the RN with additional teaching?

a. The RN checks the blood pressure in both arms.
b. The RN palpates the neck to assess thyroid size.
c. The RN orders saline eye drops to lubricate the patient’s bulging eyes.
d. The RN lowers the thermostat to decrease the temperature in the room.

Answer 64

ANS: B
Palpation can cause the release of thyroid hormones in a patient with an enlarged thyroid and should be avoided. The other actions by the new RN are appropriate when caring for a patient with an enlarged thyroid.

Question 65

The nurse is caring for a 45-yr-old male patient during a water deprivation test. Which finding is most important for the nurse to communicate to the health care provider?

a. The patient complains of intense thirst.
b. The patient has a 5-lb (2.3-kg) weight loss.
c. The patient’s urine osmolality does not increase.
d. The patient feels dizzy when sitting on the edge of the bed.

Answer 65

ANS: B
A drop in the weight of more than 2 kg indicates severe dehydration, and the test should be discontinued. The other assessment data are not unusual with this test.

Question 66

A patient with a possible pituitary adenoma is scheduled for a computed tomography (CT) scan with contrast media. Which patient information is important for the nurse to communicate to the health care provider before the test?

a. Bilateral poor peripheral vision
b. Allergies to iodine and shellfish
c. Recent weight loss of 20Ib
d. Complaint of ongoing headaches

Answer 66

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

Question 67

The nurse is caring for a 63-yr-old with a possible pituitary tumor who is scheduled for a computed tomography scan with contrast. Which information about the patient is important to discuss with the health care provider before the test?

a. History of renal insufficiency
b. Complains of chronic headache
c. Recent bilateral visual field loss
d. Blood glucose level of 134 mg/dL

Answer 67

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

Question 68

Which statements will the nurse include when teaching a patient who is scheduled for oral glucose tolerance testing in the outpatient clinic (select all that apply)?

a. “You will need to avoid smoking before the test.”
b. “Exercise should be avoided until the testing is complete.”
c. “Several blood samples will be obtained during the testing.”
d. “You should follow a low-calorie diet the day before the test.”
e. “The test requires that you fast for at least 8 hours before testing.”

Answer 68

ANS: A, C, E
Smoking may affect the results of oral glucose tolerance tests. Blood samples are obtained at baseline and at 30, 60, and 120 minutes. Accuracy requires that the patient be fasting before the test. The patient should consume at least 1500 calories/day for 3 days before the test. The patient should be ambulatory and active for accurate test results.

Question 69

Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct?

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

Answer 69

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

Question 70

A 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

a. self-monitoring of blood glucose.
b. using low doses of regular insulin.
c. lifestyle changes to lower blood glucose.
d. effects of oral hypoglycemic medications

Answer 70

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

Question 71

A 28-yr-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?

a. The patient always carries hard candies when engaging in exercise.
b. The patient goes for a vigorous walk when his glucose is 200 mg/dL.
c. The patient has a peanut butter sandwich before going for a bicycle ride.
d. The patient increases daily exercise when ketones are present in the urine.

Answer 71

ANS: D
When the patient is ketotic, exercise may result in an increase in blood glucose level. Patients with type 1 diabetes should be taught to avoid exercise when ketosis is present. The other statements are correct.

Question 72

The nurse is assessing a 22-yr-old patient experiencing the onset of symptoms of type 1 diabetes. To which question would the nurse anticipate a positive response?

a. “Are you anorexic?”
b. “Is your urine dark colored?”
c. “Have you lost weight lately?”
d. “Do you crave sugary drinks?”

Answer 72

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

Question 73

A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient?

a. Fasting blood glucose
b. Oral glucose tolerance
c. Glycosylated hemoglobin
d. Urine dipstick for glucose

Answer 73

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

Question 74

The nurse is assessing a 55-yr-old female patient with type 2 diabetes who has a body mass index (BMI) of 31 kg/m2.Which goal in the plan of care is most important for this patient?

a. The patient will reach a glycosylated hemoglobin level of less than 7%.
b. The patient will follow a diet and exercise plan that results in weight loss.
c. The patient will choose a diet that distributes calories throughout the day.
d. The patient will state the reasons for eliminating simple sugars in the diet.

Answer 74

ANS: A
The complications of diabetes are related to elevated blood glucose and the most important patient outcome is the reduction of glucose to near-normal levels. A BMI of 30?9?kg/m2 or above is considered obese, so the other outcomes are appropriate but are not as high in priority.

Question 75

A patient who has type 1 diabetes plans to swim laps for an hour daily at 1:00 PM. The clinic nurse will plan to teach the patient to

a. check glucose level before, during, and after swimming.
b. delay eating the noon meal until after the swimming class.
c. increase the morning dose of neutral protamine Hagedorn (NPH) insulin.
d. time the morning insulin injection so that the peak occurs while swimming

Answer 75

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

Question 76

The nurse determines a need for additional instruction when the patient with newly diagnosed type 1 diabetes says which of the following?

a. “I will need a bedtime snack because I take an evening dose of NPH insulin.”
b. “I can choose any foods, as long as I use enough insulin to cover the calories.”
c. “I can have an occasional beverage with alcohol if I include it in my meal plan.”
d. “I will eat something at meal times to prevent hypoglycemia, even if I am not
hungry.

Answer 76

ANS: B
Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instrucation.

Question 77

To assist an older patient with diabetes to engage in moderate daily exercise, which action is most important for the nurse to take?

a. Determine what types of activities the patient enjoys.
b. Remind the patient that exercise improves self-esteem.
c. Teach the patient about the effects of exercise on glucose level.
d. Give the patient a list of activities that are moderate in intensity.

Answer 77

ANS: A
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 may be helpful but are not the most important in improving compliance.

Question 78

Which statement by the patient indicates a need for additional instruction in administering insulin?

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

Answer 78

ANS: A
Rotating sites is no longer recommended because there is more consistent insulin absorption when the same site is used consistently. The other patient statements are accurate and indicate that no additional instruction is needed.

Question 79

Which patient action indicates good understanding of the nurse’s teaching about administration of aspart (NovoLog) insulin?

a. The patient avoids injecting the insulin into the upper abdominal area.
b. The patient cleans the skin with soap and water before insulin administration.
c. The patient stores the insulin in the freezer after administering the prescribed
dose.
d. The patient pushes the plunger down while removing the syringe from the
injection site.

Answer 79

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

Question 80

A patient receives aspart (NovoLog) insulin at 8:00 AM. At which time would the nurse anticipate the highest risk for hypoglycemia?

a. 10:00 AM
b. 12:00 AM
c. 2:00 PM
d. 4:00 PM

Answer 80

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

Question 81

Which patient action indicates a good understanding of the nurse’s teaching about the use of an insulin pump?

a. The patient programs the pump for an insulin bolus after eating.
b. The patient changes the location of the insertion site every week.
c. The patient takes the pump off at bedtime and starts it again each morning.
d. The patient plans a diet with more calories than usual when using the pump.

Answer 81

ANS: A
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, but it does not provide for consuming a higher calorie diet. The pump will deliver a basal insulin rate 24 hours day.

Question 82

A patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage?

a. Lispro (Humalog)
b. Glargine (Lantus)
c. Detemir (Levemir)
d. NPH (Humulin N)

Answer 82

ANS: A
Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin.

Question 83

Which information will the nurse include when teaching a patient who has type 2 diabetes about glyburide ?

a. Glyburide decreases glucagon secretion from the pancreas.
b. Glyburide stimulates insulin production and release from the pancreas.
c. Glyburide should be taken even if the morning blood glucose level is low.
d. Glyburide should not be used for 48 hours after receiving IV contrast media.

Answer 83

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

Question 84

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?

a. “If I overeat at a meal, I will still take the usual dose of medication.”
b. “Other medications besides the Glucotrol may affect my blood sugar.”
c. “When I am ill, I may have to take insulin to control my blood sugar.”
d. “My diabetes won’t cause complications because I don’t need insulin”

Answer 84

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

Question 85

When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone. The nurse will anticipate that the patient may

a. need a diet higher in calories while receiving prednisone.
b. develop acute hypoglycemia while taking the prednisone.
c. require administration of insulin while taking prednisone.
d. have rashes caused by metformin-prednisone interactions.

Answer 85

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

Question 86

A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to

a. save the lunch tray for the patient’s later return to the unit.
b. ask that diagnostic testing area staff to start a 5% dextrose IV.
c. send a glass of milk or orange juice to the patient in the diagnostic testing area.
d. request that if testing is further delayed, the patient be returned to the unit to eat.

Answer 86

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

Question 87

The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose

a. washes the puncture site using warm water and soap.
b. chooses a puncture site in the center of the finger pad.
c. hangs the arm down for a minute before puncturing the site.
d. says the result of 120 mg indicates good blood sugar control.

Answer 87

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

Question 88

The nurse is preparing to teach a 43-yr-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first?

a. Ask the patient’s family to participate in the diabetes education program.
b. Assess the patient’s perception of what it means to have diabetes mellitus.
c. Demonstrate how to check glucose using capillary blood glucose monitoring.
d. Discuss the need for the patient to actively participate in diabetes management

Answer 88

ANS: B
Before planning teaching, the nurse should assess the patient’s interest in and ability to self-manage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient.

Question 89

An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to

a. give 50% dextrose.
b. insert an IV catheter.
c. initiate 02 by nasal cannula.
d. administer glargine (Lantus)

Answer 89

ANS: B
HHS is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires O2. Dextrose solutions will increase the patient’s blood glucose and would be contraindicated.

Question 90

A 26-yr-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

a. use only the lispro insulin until the symptoms are resolved.
b. limit intake of calories until the glucose is less than 120 mg/dL.
c. monitor blood glucose every 4 hours and notify the clinic if it continues to rise.
d. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%

Answer 90

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

Question 91

The health care provider suspects the Somogyi effect in a 50-yr-old patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take?

a. Avoid snacking at bedtime.
b. Increase the rapid-acting insulin dose.
c. Check the blood glucose during the night
d. Administer a larger dose of long-acting insulin.

Answer 91

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

Question 92

Which action should the nurse take after a patient treated with intramuscular glucagon for hypoglycemia regains consciousness?

a. Assess the patient for symptoms of hyperglycemia.
b. Give the patient a snack of peanut butter and crackers.
c. Have the patient drink a glass of orange juice or nonfat milk.
d. Administer a continuous infusion of 5% dextrose for 24 hours.

Answer 92

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

Question 93

Which question during the assessment of a patient who has diabetes will help the nurse identify autonomic neuropathy?

a. “Do you feel bloated after eating?”
b. “Have you seen any skin changes?”
c. “Do you need to increase your insulin dosage when you are stressed?”
d. “Have you noticed any painful new ulcerations or sores on your feet?”

Answer 93

ANS: A
Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient. The other questions are also appropriate to ask but would not help in identifying autonomic neuropathy.

Question 94

Which information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs?

a. Choose flat-soled leather shoes.
b. Set heating pads on a low temperature.
c. Use callus remover for corns or calluses.
d. Soak feet in warm water for an hour each day.

Answer 94

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

Question 95

Which finding indicates a need to contact the health care provider before the nurse administers metformin (Glucophage)?

a. The patient’s blood glucose level is 174 mg/dL.
b. The patient is scheduled for a chest x-ray in an hour.
c. The patient has gained 2 lb (0.9 kg) in the past 24 hours.
d. The patient’s blood urea nitrogen (BUN) level is 52 mg/dL

Answer 95

ANS: D
The BUN indicates possible renal failure, and metformin should not be used in patients with renal failure. The other findings are not contraindications to the use of metformin

Question 96

A patient who has diabetes and reported burning foot pain at night receives a new prescription. Which information should the nurse teach the patient about amitriptyline ?

a. Amitriptyline decreases the depression caused by your foot pain.
b. Amitriptyline helps prevent transmission of pain impulses to the brain.
c. Amitriptyline corrects some of the blood vessel changes that cause pain.
d. Amitriptyline improves sleep and makes you less aware of nighttime pain.

Answer 96

ANS: B
Tricyclic antidepressants (TCAs) decrease the transmission of pain impulses to the spinal cord and brain. TCAs 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 TCAs

Question 97

A patient who has type 2 diabetes is being prepared for an elective coronary angiogram. Which information would the nurse anticipate might lead to rescheduling the test?

a. The patient’s most recent A1C was 6.5%.
b. The patient’s blood glucose is 128 mg/dL.
c. The patient took the prescribed metformin today.
d. The patient took the prescribed captopril this morning.

Answer 97

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

Question 98

Which action by a patient indicates that the home health nurse’s teaching about glargine and regular insulin has been successful?

a. The patient administers the glargine 30 minutes before each meal.
b. The patient’s family prefills the syringes with the mix of insulins weekly.
c. The patient discards the open vials of glargine and regular insulin after 4 weeks.
d. The patient draws up the regular insulin and then the glargine in the same syringe

Answer 98

ANS: C
Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and stored. Short-acting regular insulin is administered before meals, and glargine is given once daily.

Question 99

A patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to use to administer the morning insulin?

a. thigh.
b. buttock.
c. abdomen
d. upper arm.

Answer 99

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

Question 100

The nurse is interviewing a new patient with diabetes who takes rosiglitazone (Avandia). Which information would the nurse anticipate resulting in the health care provider discontinuing the medication?

a. The patient’s blood pressure is 154/92.
b. The patient’s blood glucose is 86 mg/dL.
c. The patient reports a history of emphysema.
d. The patient has chest pressure when walking.

Answer 100

ANS: D
Rosiglitazone can cause myocardial ischemia. The nurse should immediately notify the health care provider and expect orders to discontinue the medication. A blood glucose level of 86 mg/dL indicates a positive effect from the medication. Hypertension and a history of emphysema do not contraindicate this medication.

Question 101

The nurse is taking a health history from a 29-yr-old pregnant patient at the first prenatal visit. The patient reports that she has no personal history of diabetes, but her mother has diabetes. Which action will the nurse plan to take?

a. Teach the patient about administering regular insulin.
b. Schedule the patient for a fasting blood glucose level.
c. Teach about an increased risk for fetal problems with gestational diabetes.
d. Schedule an oral glucose tolerance test for the twenty-fourth week of pregnancy.

Answer 101

ANS: B
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. Teaching plans would depend on the outcome of a fasting blood glucose test and other tests.

Question 102

A 27-yr-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first?

a. Place the patient on a cardiac monitor.
b. Administer IV potassium supplements.
c. Ask the patient about home insulin doses.
d. Start an insulin infusion at 0.1 units/kg/hr

Answer 102

ANS: A
Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with electrocardiogram (ECG) monitoring. Because potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be administered without cardiac monitoring because insulin infusion will further decrease potassium levels. Discussion of home insulin and possible causes can wait until the patient is stabilized.

Question 103

A patient with diabetic ketoacidosis is brought to the emergency department. Which prescribed action should the nurse implement first?

a. Infuse 1 L of normal saline per hour.
b. Give sodium bicarbonate 50 mEq IV push.
c. Administer regular insulin 10 U by IV push.
d. Start a regular insulin infusion at 0.1 units/kg/hr

Answer 103

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

Question 104

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?

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

Answer 104

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

Question 105

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

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

Answer 105

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

Question 106

Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP) indicates an urgent need for the nurse’s assessment of the patient?

a. Bedtime glucose of 140 mg/dL
b. Noon blood glucose of 52 mg/dL
c. Fasting blood glucose of 130 mg/dL
d. 2-hr postprandial glucose of 220 mg/dL

Answer 106

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

Question 107

When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?

a. Communicate the blood glucose level and insulin dose to the circulating nurse in
surgery.
b. Discuss the reason for the use of insulin therapy during the immediate
postoperative period.
c. Administer the prescribed lispro (Humalog) insulin before transporting the patient
to surgery.
d. Plan strategies to minimize the risk for hypoglycemia or hyperglycemia during
the postoperative period

Answer 107

ANS: C
LPN/LVN education and scope of practice includes administration of insulin. Communication about patient status with other departments, planning, and patient teaching are skills that require RN education and scope of practice.

Question 108

An active 32-yr-old male who has type 1 diabetes is being seen in the endocrine clinic. Which finding indicates a need for the nurse to discuss a possible a change in therapy with the health care provider?

a. Hemoglobin A1C level of 6.2%
b. Blood pressure of 140/88 mmHg
c. Heart rate at rest of 58 beats/minute
d. High density lipoprotein (HDL) level of 65 mg/dL

Answer 108

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

Question 109

A 30-yr-old patient has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye examination

a. every 2 years.
b. as soon as possible.
c. when the patient is 39 years old
d. within the first year after diagnosis.

Answer 109

ANS: B
Because many patients have some diabetic retinopathy when they are first diagnosed with type 2 diabetes, a dilated eye examination is recommended at the time of diagnosis and annually thereafter. Patients with type 1 diabetes should have dilated eye examinations starting 5 years after they are diagnosed and then annually.

Question 110

After the nurse has finished teaching a patient who has a new prescription for exenatide (Byetta), which patient statement indicates that the teaching has been effective?

a. “I may feel hungrier than usual when I take this medicine.”
b. “I will not need to worry about hypoglycemia with the Byetta.”
c. “I should take my daily aspirin at least an hour before the Byetta.”
d. “I will take the pill at the same time I eat breakfast in the morning.

Answer 110

ANS: C
Because exenatide slows gastric emptying, oral medications should be taken at least 1 hour before the exenatide to avoid slowing absorption. Exenatide is injected and increases feelings of satiety. Hypoglycemia can occur with this medication

Question 111

A few weeks after an 82-yr-old patient with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding should the nurse promptly discuss with the health care provider?

a. Hemoglobin A1C level is 7.9%.
b. Last eye examination was 18 months ago.
c. Glomerular filtration rate is decreased.
d. Patient has questions about the prescribed diet.

Answer 111

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

Question 112

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?

a. Give the patient 4 to 6 oz more orange juice.
b. Administer the PRN glucagon (Glucagon) 1 mg IM.
c. Have the patient eat some peanut butter with crackers.
d. Notify the health care provider about the hypoglycemia

Answer 112

ANS: A
The “rule of 15” indicates that administration of quickly acting carbohydrates should be done two or three 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 after 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.
DIF: Cognitive Level: Analyze (analysis) REF: 1146
OBJ: Special Questions: Prioritization

Question 113

Which nursing action can the nurse delegate to experienced unlicensed assistive personnel (UAP) who are working in the diabetic clinic?

a. Measure the ankle-brachial index.
b. Check for changes in skin pigmentation.
c. Assess for unilateral or bilateral foot drop.
d. Ask the patient about symptoms of depression

Answer 113

ANS: A
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).
DIF: Cognitive Level: Apply (ap

Question 114

After change-of-shift report, which patient will the nurse assess first?

a. A 19-yr-old patient with type 1 diabetes who was admitted with possible dawn
phenomenon
b. A 35-yr-old patient with type 1 diabetes whose most recent blood glucose reading
was 230 mg/dL
c. A 60-yr-old patient with hyperosmolar hyperglycemic syndrome who has poor
skin turgor and dry oral mucosa
d. A 68-yr-old patient with type 2 diabetes who has severe peripheral neuropathy
and complains of burnIng foot pain.

Answer 114

ANS: C
The patient’s diagnosis of HHS and signs of dehydration indicate that the nurse should rapidly assess for signs of shock and determine whether increased fluid infusion is needed. The other patients also need assessment and intervention but do not have life-threatening complications.
DIF: Cognitive Level: Analyze (analysis) REF: 1146
OBJ: Special Questions: Multiple

Question 115

After change-of-shift report, which patient should the nurse assess first?

a. A 19-yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12%
b. A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL
c. A 40-yr-old patient who is pregnant and whose oral glucose tolerance test is 202
mg/dL
d. A 50-yr-old patient who uses exenatide (Byetta) and is complaining of acute
abdominal pain

Answer 115

ANS: B
Because the brain requires glucose to function, untreated hypoglycemia can cause unconsciousness, seizures, and death. The nurse will rapidly assess and treat the patient with low blood glucose. The other patients also have symptoms that require assessments or interventions, but they are not at immediate risk for life-threatening complications.

Question 116

To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select all that apply)?

a. Chest x-ray
b. Blood pressure
c. Serum creatinine
d. Urine for microalbuminuria
e. Complete blood count (CBC)
f. Monofilament testing of the foot

Answer 116

ANS: B, C, D, F
Blood pressure, serum creatinine, urine testing for microalbuminuria, and monofilament testing of the foot are recommended at least annually to screen for possible microvascular and macrovascular complications of diabetes. Chest x-ray and CBC might be ordered if the patient with diabetes presents with symptoms of respiratory or infectious problems but are not routinely included in screening.
DIF: Cognitive Level: Apply (

Question 117

In which order will the nurse take these steps to prepare NPH 20 units and regular insulin 2 units using the same syringe? (Put a comma and a space between each answer choice [A, B, C, D, E]).

a. Rotate NPH vial.
b. Withdraw regular insulin.
c. Withdraw 20 units of NPH.
d. Inject 20 units of air into NPH vial.
e. Inject 2 units of air into regular insulin vial.

Answer 117

ANS:
A, D, E, B, C
When mixing regular insulin with NPH, it is important to avoid contact between the regular insulin and the additives in the NPH that slow the onset, peak, and duration of activity in the longer-acting insulin.
DIF: Cognitive Level: Analyze (analysis)
OBJ: Special Questions: Prioritization

Question 118

A 40-yr-old patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask?

a. “Have you had a recent head injury?”
b. “Do you have to wear larger shoes now?”
c. “Is there a family history of acromegaly?”
d. “Are you experiencing tremors or anxiety?”

Answer 118

ANS: B
Acromegaly causes an enlargement of the hands and feet. Head injury and family history are not risk factors for acromegaly. Tremors and anxiety are not clinical manifestations of acromegaly.

Question 119

A patient is scheduled for transsphenoidal hypophysectomy to treat a pituitary adenoma. During preoperative teaching, the nurse instructs the patient about the need to

a. cough and deep breathe every 2 hours postoperatively.
b. remain on bed rest for the first 48 hours after the surgery.
c. avoid brushing teeth for at least 10 days after the surgery.
d. be positioned flat with sandbags at the head postoperatively.

Answer 119

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

Question 120

The nurse is planning postoperative care for a patient who is being admitted to the surgical unit from the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included?

a. Palpate extremities for edema.
b. Measure urine volume every hour.
c. Check hematocrit every 2 hours for 8 hours.
d. Monitor continuous pulse oximetry for 24 hours

Answer 120

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

Question 121

The nurse is assessing a male patient diagnosed with a pituitary tumor causing panhypopituitarism. Assessment findings consistent with panhypopituitarism include

a. high blood pressure.
b. decreased facial hair.
c. elevated blood glucose
d. tachycardia and palpitations.

Answer 121

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

Question 122

Which information will the nurse include when teaching a 50-yr-old male patient about somatropin (Genotropin)?

a. The medication will be needed for 3 to 6 months.
b. Inject the medication subcutaneously every day.
c. Blood glucose levels may decrease when taking the medication.
d. Stop taking the medication if swelling of the hands or feet occurs.

Answer 122

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

Question 123

The nurse determines that demeclocycline is effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH) based on finding that the patient’s

a. weight has increased
b. urinary output is increased.
c. peripheral edema is increased
d. urine specific gravity is increased.

Answer 123

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

Question 124

The nurse determines that additional instruction is needed for a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH) when the patient makes which statement?

a. “I need to shop for foods low in sodium and avoid adding salt to food.”
b. “I should weigh myself daily and report any sudden weight loss or gain.”
c. “I need to limit my fluid intake to no more than 1 quart of liquids a day.”
d. “I should eat foods high in potassium because diuretics cause potassium loss.”

Answer 124

ANS: A
Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed. The other patient statements are correct and indicate successful teaching has occurred.

Question 125

A 56-yr-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with possible syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would expect the initial laboratory results to include a(n)

a. elevated hematocrit.
b. decreased serum sodium.
c. increased serum chloride
d. low urine specific gravity.

Answer 125

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

Question 126

An expected patient problem for a patient admitted to the hospital with symptoms of diabetes insipidus is

a. excess fluid volume related to intake greater than output.
b. impaired gas exchange related to fluid retention in lungs.
c. sleep pattern disturbance related to frequent waking to void.
d. risk for impaired skin integrity related to generalized edema.

Answer 126

ANS: C
Nocturia occurs as a result of the polyuria caused by diabetes insipidus. Edema, excess fluid volume, and fluid retention are not expected.

Question 127

Which information will the nurse teach a patient who has been newly diagnosed with Graves’ disease?

a. Exercise is contraindicated to avoid increasing metabolic rate.
b. Restriction of iodine intake is needed to reduce thyroid activity.
c. Antithyroid medications may take several months for full effect.
d. Surgery will eventually be required to remove the thyroid gland.

Answer 127

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

Question 128

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?

a. Suction the patient’s airway.
b. Administer IV calcium gluconate.
c. Plan for emergency tracheostomy.
d. Prepare for endotracheal intubation.

Answer 128

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

Question 129

Which nursing action will be included in the plan of care for a patient with Graves’ disease who has exophthalmos?

a. Place cold packs on the eyes to relieve pain and swelling.
b. Elevate the head of the patient’s bed to reduce periorbital fluid.
c. Apply alternating eye patches to protect the corneas from irritation.
d. Teach the patient to blink every few seconds to lubricate the corneas.

Answer 129

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

Question 130

A 62-yr-old patient with hyperthyroidism is to be treated with radioactive iodine (RAI). The nurse instructs the patient

a. about radioactive precautions to take with all body secretions.
b. that symptoms of hyperthyroidism should be relieved in about a week.
c. that symptoms of hypothyroidism may occur as the RAI therapy takes effect.
d. to discontinue the antithyroid medications taken before the radioactive therapy.

Answer 130

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

Question 131

Which nursing assessment of a 70-yr-old patient is most important to make during initiation of thyroid replacement with levothyroxine (Synthroid)?

a. Fluid balance
b. Apical pulse rate
c. Nutritional intake
d. Orientation and alertness

Answer 131

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

Question 132

An 82-yr-old patient in a long-term care facility is newly diagnosed with hypothyroidism. The nurse will need to consult with the health care provider before administering the prescribed

a. docusate (Colace).
b. ibuprofen (Motrin).
c. diazepam (Valium)
d. cefoxitin (Mefoxin).

Answer 132

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

Question 133

A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving. Discharge is expected to occur in 2 days. Which teaching strategy is likely to result in effective patient self-management at home?

a. Delay teaching until closer to discharge date.
b. Provide written reminders of information taught.
c. Offer multiple options for management of therapies.
d. Ensure privacy for teaching by asking the family to leave.

Answer 133

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

Question 134

A 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?

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

Answer 134

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

Question 135

A patient develops carpopedal spasms and tingling of the lips following a parathyroidectomy. Which action will provide the patient with rapid relief from the symptoms?

a. Administer the prescribed muscle relaxant.
b. Have the patient rebreathe from a paper bag.
c. Start the PRN O2 at 2 L/min per cannula.
d. Stretch the muscles with passive range of motion.

Answer 135

ANS: B
The patient’s symptoms suggest mild hypocalcemia. The symptoms of hypocalcemia will be temporarily reduced by having the patient breathe into a paper bag, which will raise the PaCO2 and create a more acidic pH. Applying as-needed O2 or range of motion will have no impact on the ionized calcium level. Calcium supplements will be given to normalize calcium levels quickly, but oral supplements will take time to be absorbed.

Question 136

A patient who had radical neck surgery to remove a malignant tumor developed hypoparathyroidism. The nurse should plan to teach the patient about

a. bisphosphonates to reduce bone demineralization.
b. calcium supplements to normalize serum calcium levels.
c. increasing fluid intake to decrease risk for nephrolithiasis.
d. including whole grains in the diet to prevent constipation.

Answer 136

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

Question 137

Which finding for a patient who has hypothyroidism and hypertension indicates that the nurse should contact the health care provider before administering levothyroxine (Synthroid)?

a. Increased thyroxine (T4) level
b. Blood pressure 112/62 mm Hg
c. Distant and difficult to hear heart sounds
d. Elevated thyroid stimulating hormone level

Answer 137

ANS: A
An increased thyroxine level indicates the levothyroxine dose needs to be decreased. The other data are consistent with hypothyroidism and the nurse should administer the levothyroxine.

Question 138

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

a. Chronically low blood pressure
b. Bronzed appearance of the skin
c. Purplish streaks on the abdomen
d. Decreased axillary and pubic hair

Answer 138

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

Question 139

A 44-yr-old female patient with Cushing syndrome is admitted for adrenalectomy. Which intervention by the nurse will be most helpful for the patient problem of disturbed body image related to changes in appearance?

a. Reassure the patient that the physical changes are very common in patients with
Cushing syndrome.
b. Discuss the use of diet and exercise in controlling the weight gain associated with
Cushing syndrome.
c. Teach the patient that the metabolic impact of Cushing syndrome is of more
importance than appearance.
d. Remind the patient that most of the physical changes caused by Cushing
syndrome will resolve after surgery.

Answer 139

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

Question 140

Which finding indicates to the nurse that the current therapies are effective for a patient with acute adrenal insufficiency?

a. Increasing serum sodium levels
b. Decreasing blood glucose levels
c. Decreasing serum chloride levels
d. Increasing serum potassium levels

Answer 140

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

Question 141

The nurse admits a patient to the hospital in Addisonian crisis. Which patient statement supports the need to plan additional teaching?

a. “I frequently eat at restaurants, and my food has a lot of added salt.”
b. “I had the flu earlier this week, so I couldn’t take the hydrocortisone.”
c. “I always double my dose of hydrocortisone on the days that I go for a long run.”
d. “I take twice as much hydrocortisone in the morning dose as I do in the
afternoon. ”

Answer 141

ANS: B
The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given. The other patient statements indicate appropriate management of the Addison’s disease.

Question 142

A 29-yr-old woman with systemic lupus erythematosus has been prescribed 2 weeks of high-dose prednisone therapy. Which information about the prednisone is most important for the nurse to include?

a. “Weigh yourself daily to monitor for weight gain.”
b. “The prednisone dose should be decreased gradually.”
c. “A weight-bearing exercise program will help minimize risk for osteoporosis.”
d. “Call the health care provider if you have mood changes with the prednisone.”

Answer 142

ANS: B
Acute adrenal insufficiency may occur if exogenous corticosteroids are suddenly stopped. Mood alterations and weight gain are possible adverse effects of corticosteroid use, but these are not life-threatening effects. Osteoporosis occurs when patients take corticosteroids for longer periods.

Question 143

The nurse providing care for a patient who has an adrenocortical adenoma causing hyperaldosteronism should

a. monitor the blood pressure every 4 hours.
b. elevate the patient’s legs to relieve edema.
c. monitor blood glucose level every 4 hours.
d. order the patient a potassium-restricted diet.

Answer 143

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

Question 144

The nurse will plan to monitor a patient diagnosed with a pheochromocytoma for

a. flushing.
b. headache.
c. bradycardia
d. hypoglycemia.

Answer 144

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

Question 145

After a patient with a pituitary adenoma has had a hypophysectomy, the nurse will teach about the need for

a. sodium restriction to prevent fluid retention.
b. insulin to maintain normal blood glucose levels.
c. oral corticosteroids to replace endogenous cortisol.
d. chemotherapy to prevent malignant tumor recurrence.

Answer 145

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

Question 146

Which intervention will the nurse include in the plan of care for a patient with syndrome of inappropriate antidiuretic hormone (SIADH)?

a. Encourage fluids to 2 to 3 L/day.
b. Monitor for increasing peripheral edema.
c. Offer the patient hard candies to suck on.
d. Keep head of bed elevated to 30 degrees.

Answer 146

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

Question 147

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

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

Answer 147

ANS: C
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.
DIF: Cognitive Le

Question 148

The nurse is caring for a patient following an adrenalectomy. The highest priority in the immediate postoperative period is to

a. protect the patient’s skin.
b. monitor for signs of infection.
c balance fluids and electrolytes
d. prevent emotional disturbances.

Answer 148

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

Question 149

The nurse is caring for a patient admitted with diabetes insipidus (DI). Which information is most important to report to the health care provider?

a. The patient is confused and lethargic.
b. The patient reports a recent head injury.
c. The patient has a urine output of 400 mL/hr.
d. The patient’s urine specific gravity is 1.003.

Answer 149

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

Question 150

Which prescribed medication should the nurse expect will have rapid effects on a patient admitted to the emergency department in thyroid storm?

a. Iodine
b. Methimazole
c. Propylthiouracil
d. Propranolol (Inderal)

Answer 150

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

Question 151

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

a. Heart rate 136 beats/mins
b. Severe bilateral exophthalmos
c. Temperature 103.8F (40.4C)
d. Blood pressure 166/100 mm Hg

Answer 151

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

Question 152

A 37-yr-old patient has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy. Which information about the patient is most important to communicate to the surgeon?

a. Difficult to awaken.
b. Increasing neck swelling.
c. Reports 7/10incisional pain
d. Cardiac rate 112 beats/minute.

Answer 152

ANS: B
The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction. The incisional pain should be treated but is not unusual after surgery. A heart rate of 112 beats/min is not unusual in a patient who has been hyperthyroid and has just arrived in the PACU from surgery. Sleepiness in the immediate postoperative period is expected.

Question 153

Which assessment finding of a 42-yr-old patient who had a bilateral adrenalectomy requires the most rapid action by the nurse?

a. The blood glucose is 192 mg/dL.
b. The lungs have bibasilar crackles.
c. The patient reports 6/10 incisional pain.
d. The blood pressure (BP) is 88/50 mm Hg.

Answer 153

ANS: D
The decreased BP indicates possible adrenal insufficiency. The nurse should immediately notify the health care provider so that corticosteroid medications can be administered. The nurse should also address the elevated glucose, incisional pain, and crackles with appropriate collaborative or nursing actions, but prevention and treatment of acute adrenal insufficiency are the priorities after adrenalectomy.

Question 154

A patient is admitted with diabetes insipidus. Which action will be appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?

a. Titrate the infusion of 5% dextrose in water.
b. Administer prescribed subcutaneous DDAVP.
c. Assess the patient’s overall hydration status every 8 hours.
d. Teach the patient how to use desmopressin (DDAVP) nasal spray.

Answer 154

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

Question 155

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)?

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

Answer 155

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

Question 156

After receiving change-of-shift report about the following four patients, which patient should the nurse assess first?

a. A 31-yr-old female patient with Cushing syndrome and a blood glucose level of
244 mg/dL
b. A 70-yr-old female patient taking levothyroxine (Synthroid) who has an irregular
pulse of 134
c. A 53-yr-old male patient who has Addison’s disease and is due for a prescribed
dose of hydrocortisone (Solu-Cortef).
d. A 22-yr-old male patient admitted with syndrome of inappropriate antidiuretic
hormone (SIADH) who has a serum sodium level of 130 mEq/L

Answer 156

ANS: B
Initiation of thyroid replacement in older adults may cause angina and cardiac dysrhythmias. The patient’s high pulse rate needs rapid investigation by the nurse to assess for and intervene with any cardiac problems. The other patients also require nursing assessment and/or actions but are not at risk for life-threatening complications.

Question 157

Which question will the nurse in the endocrine clinic ask to help determine a patient’s risk factors for goiter?

a. “How much milk do you drink?”
b. “What medications are you taking?”
c. “Are your immunizations up to date?”
d. “Have you had any recent neck injuries?”

Answer 157

ANS: B
Medications that contain thyroid-inhibiting substances can cause goiter. Milk intake, neck injury, and immunization history are not risk factors for goiter.

Question 158

Which finding by the nurse when assessing a patient with a large pituitary adenoma is most important to report to the health care provider?

a. Changes in visual field
b. Milk leaking from breasts
c. Blood glucose 150mg/dL
d. Nausea and projectile vomiting

Answer 158

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

Question 159

Which finding by the nurse when assessing a patient with Hashimoto’s thyroiditis and a goiter will require the most immediate action?

a. New-onset changes in the patient’s voice
b. Elevation in the patient’s T3 and T4 levels
c. Resting apical pulse rate 112 beats/minute
d. Bruit audible bilaterally over the thyroid gland

Answer 159

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

Question 160

Which information obtained by the nurse in the endocrine clinic about a patient who has been taking prednisone 40 mg daily for 3 weeks is most important to report to the health care provider?

a. Patient’s blood pressure is 148/94 mm Hg.
b. Patient has bilateral 2+ pitting ankle edema.
c. Patient stopped taking the medication 2 days ago.
d. Patient has not been taking the prescribed vitamin D.

Answer 160

ANS: C
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 or treat adrenal insufficiency. The other information will also be reported but does not require rapid treatment.

Question 161

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?

a. Patient with Hashimoto’s thyroiditis and a heart rate of 102
b. Patient with tetany who has a new order for IV calcium chloride
c. Patient with Cushing syndrome and a blood glucose of 140 mg/dL
d. Patient with Addison’s disease who takes hydrocortisone twice daily

Answer 161

ANS: B
Emergency treatment of tetany requires IV administration of calcium; electrocardiographic monitoring will be required because cardiac arrest may occur if high calcium levels result from too-rapid administration. The information about the other patients indicates that they are more stable than the patient with tetany.

Question 162

After obtaining the information shown in the accompanying figure regarding a patient with Addison’s disease, which prescribed action will the nurse take first?

a. Give 4 oz of fruit juice orally.
b. Recheck the blood glucose level.
c. Infuse 5% dextrose and 0.9% saline.
d. Administer O2 therapy as needed.

Answer 162

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

Question 163

A patient is to receive methylprednisolone (Solu-Medrol) 100 mg. The label on the medication states: methylprednisolone 125 mg in 2 mL. How many milliliters will the nurse administer?

Answer 163

ANS: 1.6

A concentration of 125 mg in 2 mL will result in 100 mg in 1.6 mL.