Med Surg Success-Exam3

Question 1

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?

1. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
2. Discuss the precipitating factors that caused the symptoms.
3. Schedule for a STAT computed tomography (CT) scan of the head.
4. Notify the speech pathologist for an emergency consult.

Answer 1

3. Schedule for a STAT computed tomography (CT) scan of the head.

A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or ischemic accident and guide treatment.

Question 2

The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document?

1. Hemiparesis of the client’s left arm and apraxia
2. Paralysis of the right side of the body and ataxia
3. Homonymous hemianopsia and diplopia
4. Impulsive behavior and hostility toward family

Answer 2

2. Paralysis of the right side of the body and ataxia

The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement.

Question 3

A client diagnosed with a right-sided CVA is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply.

1. Position the client to prevent shoulder adduction.
2. Turn and reposition the client every shift.
3. Encourage the client to move the affected side
4. Perform quadriceps exercises three (3) times a day.
5. Instruct the client to hold the fingers in a fist.

Answer 3

1. Position the client to prevent shoulder adduction
2. Encourage the client to move the affected side

Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture.
The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible.

Question 4

The nurse is planning care for a client experiencing agnosia secondary to a CVA. Which collaborative intervention will included in the plan of care?

1. Observe the client swallowing for possible aspiration.
2. Position the client in a semi-Fowler’s position when sleeping
3. Place a suction setup at the client’s bedside during meals
4. Refer the client to an occupational therapist for evaluation

Answer 4

4. Refer the client to an occupational therapist for evaluation

A collaborative intervention is an intervention in which another health-care discipline–in this case, occupational therapy–is used in the care of the client

Question 5

The 85 year-old- client diagnosed with a stroke is complaining of a sever headache. Which intervention should the nurse implement first?

1. Administer a nonnarcotic analgesic
2. Prepare for STAT magnetic resonance imaging (MRI)
3. Start an intravenous infusion with D5W at 100 mL/hr
4. Complete a neurological assessment

Answer 5

4. Complete a neurological assessment

The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action

Question 6

A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement?

1. Administer a stool softener b.i.d
2. Encourage the client to cough hourly
3. Monitor neurological status every shift
4. Maintain the dopamine drip to keep Bp at 160/90

Answer 6

1. Administer a stool softener b.i.d

The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore, stool softeners would be appropriate.

Question 7

The client diagnosed with type 1 diabetes has a glycosylated hemoglobin (A1C) of 8.1%. Which interpretation should the nurse make based on this result?

1. This result is below normal levels
2. This result is within acceptable levels
3. This result is above recommended levels
4. This result is dangerously high

Answer 7

3. This result is above recommended levels

Diagnosis of diabetes mellitus is made through one of the following four methods.
1. A1C of 6.5% or higher
2. FPG > or equal to 126 mg/dL
3. 2-hour plasma glucose level > or equal to 200mg/dL during an OGTT, using a glucose load of 75g
4. Random plasma glucose > or equal to 200 mg/dL
1-3 need repeat testing to rule out error

Question 8

The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with type 1 diabetes at 1600. Which intervention should the nurse implement?

1. Ensure the client eats the bedtime snack.
2. Determine how much food the client ate at lunch
3. Perform a glucometer reading at 0700
4. Offer the client protein after administering insulin

Answer 8

1. Ensure the client eats the bedtime snack.

Humulin N peaks in 6 to 8 hours, making the client at risk for hypoglycemia around midnight, which is why the client should receive a bedtime snack. This snack will prevent nighttime hypoglycemia.

Question 9

The nurse is discussing the importance of exercising with a client diagnosed with type 2 diabetes whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes?

1. Eat a simple carbohydrate snack before exercising
2. Carry peanut butter crackers when exercising
3. Encourage the client to walk 20 minutes three (3) times a week.
4. Perform warmup and cool-down exercises

Answer 9

4. Perform warmup and cool-down exercises

All clients who exercise should perform warmup and cool-down exercises to help prevent muscle strain and injury. The client diagnosed with type 2 diabetes who is not taking insulin or oral agents does not need extra food before exercise. The client with diabetes who is at risk for hypoglycemia when exercising should carry a simple carb. Clients with diabetes controlled by diet and exercise must exercise daily at the same time and in the same amount to control the glucose level.

Question 10

The home health nurse is completing the admission assessment for a 76-year-old client diagnosed with type 2 diabetes controlled with 70/30 insulin. Which intervention should be included in the plan of care?

1. Assess the client’s ability to read small print
2. Monitor the client’s serum PT level
3. Teach the client how to perform a hemoglobin A1C test daily.
4. Instruct the client to check the feet weekly

Answer 10

1. Assess the client’s ability to read small print

Age-related visual changes and diabetic retinopathy could cause the client to have difficulty in reading and drawing up insulin dosage accurately

Question 11

The client with type 2 diabetes controlled with biguanide oral diabetic medication is scheduled for a CT scan with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement?

1. Provide a high-fat diet 24 hours prior to test
2. Hold the biguanide medication for 48 hours prior to test
3. Obtain an informed consent form for the test
4. Administer pancreatic enzymes prior to the test

Answer 11

2.Hold the biguanide medication for 48 hours prior to test

Biguanide medication must be held for a test with contrast medium because it increases the risk for lactic acidosis, which leads to renal problems. High fat diets are not recommended for clients diagnosed with diabetes, and food does not have an effect on a CT scan with contrast. Informed consent is not required for a CT scan.

Question 12

The diabetic educator is teaching a class on diabetes type 1 and is discussing sick-day rules. Which interventions should the diabetes educator included in the discussion? Select all that apply.

1. Take diabetic medication even if unable to eat the client’s normal diabetic diet
2. If unable to eat, drink liquids equal to the client’s normal caloric intake
3. It is not necessary to notify the health-care provider if ketones are in the urine.
4. Test blood glucose levels and test urine ketones once a day and keep a record
5. Call the health-care provider if glucose levels are higher than 180 mg/dL

Answer 12

1. Take diabetic medication even if unable to eat the client’s normal diabetic diet
2. If unable to eat, drink liquids equal to the client’s normal caloric intake
3. Call the health-care provider if glucose levels are higher than 180 mg/dL

The most important issue to teach clients is to take insulin even if they are unable to eat. Glucose levels are increased with illness and stress. The client should drink liquids such as regular cola or orange juice, or eat regular gelatin, which provide enough glucose to prevent hypoglycemia when receiving insulin. The HCP should be notified if the blood glucose level is high

Question 13

The client received 10 units of Humulin R, fast-acting insulin, at 0700. At 1030 the UAP tells the nurse that the client has a headache and is really acting “funny.” Which intervention should the nurse implement first?

1. Instruct the UAP to obtain the blood glucose level.
2. Have the client drink eight (8) ounces of of orange juice
3. Go to the client’s room and assess the client for hypoglycemia
4. Prepare to administer one (1) ampule 50% dextrose intravenously

Answer 13

3. Go to the client’s room and assess the client for hypoglycemia

Regular insulin peaks in 2 to 4 hours. Therefore, the nurse should think about the possibility the client having a hypoglycemic reaction and should assess the client. The nurse should not delegate nursing tasks to a UAP if the client is unstable. The blood glucose level should be obtained, but it is not the first intervention. If it is determined the client is having a hypoglycemic reaction, orange juice is appropriate. Dextrose 50% is only administered if the client is unconscious and the nurse suspects hypoglycemia

Question 14

The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse identifies the problem “high risk for hyperglycemia related to noncompliance with the medication regimen.” Which statement is an appropriate short-term goal for the client?

1. The client will have a blood glucose level between 90 and 140 mg/dL
2. The client will demonstrate appropriate insulin rejection technique
3. The nurse will monitor the client’s blood glucose levels four (4) times a day
4. The client will maintain normal kidney function with 30-mL/hr urine output

Answer 14

1. The client will have a blood glucose level between 90 and 140 mg/dL

The short-term goal must address the response part of the nursing diagnoses, which is “high risk for hyperglycemia,” and this blood glucose level is within acceptable ranges for a client who is noncompliant

Question 15

The client diagnosed with type 2 diabetes is admitted to the intensive care unit with hyperosmolar hyperglycemic nonketonic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit?

1. Kussmaul’s respirations
2. Diarrhea and epigastric pain
3. Dry mucous membranes
4. Ketone breath odor

Answer 15

3. Dry mucous membranes

Dry mucous membranes are a result of the hyperglycemia and occur with both HHNS and DKA. Diarrhea and epigastric pain are not associated with HHNS. Kussmaul’s respirations occur with DKA as a result of the breakdown of fat, resulting in ketones.

Question 16

The elderly client is admitted to the ICU diagnosed with severe HHNS. Which collaborative intervention should the nurse include in the plan of care?

1. Infuse 0.9% normal saline intravenously
2. Administer intermediate-acting insulin
3. Perform blood glucometer checks daily
4. Monitor arterial blood gas results

Answer 16

1. Infuse 0.9% normal saline intravenously

The initial fluid replacement is 0.9% normal saline (an isotonic solution) intravenously, followed by o.45% saline. The rate depends on the client’s fluid volume status and physical health, especially of the heart. Regular insulin, not intermediate, is the insulin of choice because of its quick onset and peak in 2-4 hours.

Question 17

Which electrolyte replacement should the nurse anticipate being ordered by the HCP in the client diagnosed with DKA who has just been admitted to the ICU?

1. Glucose
2. Potassium
3. Calcium
4. Sodium

Answer 17

2. Potassium

The client in DKA loses potassium from increased urinary output, acidosis, catabolic state, and vomiting. Replacement is essential for preventing cardiac dysrhythmias secondary to hypokalemia

Question 18

The client diagnosed with HHNS was admitted yesterday with a blood glucose level of 780 mg/dL. The client’s blood glucose level is now 300 mg/dL. Which intervention should the nurse implement?

1. Increase the regular insulin IV drip
2. Check the client’s urine for ketones
3. Provide the client with a therapeutic diabetic meal
4. Notify the HCP to obtain an order to decrease insulin

Answer 18

4. Notify the HCP to obtain an order to decrease insulin

When the glucose level is decreased to around 300 mg/dL, the regular insulin infusion therapy is decreased. Subcutaneous insulin will be administered per sliding scale

Question 19

The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first?

1. Administer 50% dextrose IVP
2. Notify the HCP
3. Move the client to the ICU
4. Check the serum glucose level

Answer 19

1. Administer 50% dextrose IVP

The nurse should assume the client is hypoglycemic and administer IVP dextrose, which will rouse the client immediately. If the collapse is the result of hyperglycemia, this additional dextrose will not further injure the client.

Question 20

Which assessment data indicate the client diagnosed with DKA is responding to the medical treatment?

1. the client has tented skin turgor and dry mucous membranes
2. The client is alert and oriented x 3
3. The client’s ABG results are pH 7.29, PaCO2 44, HCO3 15
4. The client’s serum potassium level is 3.3 mEq/L

Answer 20

2. The client is alert and oriented x 3

The client’s level of consciousness can be altered because of dehydration and acidosis. If the client’s sensorium is intact, the client is getting better and responding to medical treatment. These ABGs indicate metabolic acidosis and the potassium level is low and indicates hypokalemia

Question 21

The emergency department nurse is caring for a client diagnosed with HHNS who has a blood glucose of 680 mg/dL. Which question should the nurse ask the client to determine the cause of this acute complication?

1. When is the last time you took your insulin?
2. When did you have your last meal?
3. Have you had some type of infection lately?
4. How long have you had diabetes?

Answer 21

3. Have you had some type of infection lately?

The most common precipitating factor is infection. The manifestations may be slow to appear, with onset ranging from 24 hours to 2 weeks.
A client with type 2 diabetes usually is prescribed oral hypoglycemic medications, not insulin. the client could not eat enough food cause a 680-mg/dL blood glucose level; therefore this question does not need to be asked.

Question 22

The nurse is discussing ways to prevent DKA with the client diagnosed with type 1 diabetes. Which instruction is most important to discuss with the client?

1. Refer the client to the American Diabetes Association
2. Do not take any over-the-counter medications
3. Take the prescribed insulin even when unable to eat because of illness
4. Explain the need to get the annual flu and pneumonia vaccines

Answer 22

3. Take the prescribed insulin even when unable to eat because of illness

Illness increases blood glucose levels; therefore, the client must take insulin and consume high carbohydrate foods such as regular Jell-O, regular pop
popsicles, and orange juice

Question 23

The charge nurse is making client assignments in the ICU. Which client should be assigned to the most experienced nurse?

1. The client with type 2 diabetes who has a blood glucose level of 348 mg/dL
2. The client diagnosed with type 1 diabetes who is experiencing hypoglycemia
3. The client with DKA who has multifocal premature ventricular contractions
4. The client with HHNS who has a plasma osmolarity of 290mOsm/L

Answer 23

3. The client with DKA who has multifocal premature ventricular contractions

Multifocal PVCs, which are secondary to hypokalemia and can occur in clients with DKA, are a potentially life-threatening emergency. This client needs an experienced nurse.

Question 24

Which ABG result should the nurse expect in the client diagnosed with DKA?

1. pH 7.34, Pao2 99, PaCo2 48, HCO3 24
2. pH 7.38, Pao2 95, PaCo2 40, HCO3 22
3. pH 7.46, Pao2 85, PaCo2 30, HCO3 26
4. pH 7.30, Pao2 90, PaCo2 30, HCO3 18

Answer 24

4. pH 7.30, Pao2 90, PaCo2 30, HCO3 18

This ABG indicates metabolic acidosis, which is expected in a client diagnosed with DKA

Question 25

The client is admitted to the ICU diagnosed with DKA. Which interventions should the nurse implement? Select all that apply. 1. Maintain adequate ventilation 2. Assess fluid volume status 3. Administer intravenous potassium 4. Check for urinary ketones 5. Monitor intake and output

Answer 25

1,2,3,4,5 The nurse should always address the airway when a client is seriously ill. The client must be assessed for fluid volume deficit and then for fluid volume excess are fluid replacement is started. The electrolyte imbalance of primary concern is depletion of potassium. Ketones are excreted in the urine; levels are documented from negative to large amount. Ketones should be monitored frequently. The nurse must ensure the client's fluid intake and output are equal.

Question 26

The nurse is teaching a community class to people with type 2 diabetes mellitus. Which explanation explains the development of type 2 diabetes? 1. The islet cells in the pancreas stop producing insulin 2. The client eats too many foods high in sugar 3. The pituitary gland does not produce vasopressin 4. The cells become more resistant to the circulating insulin

Answer 26

4. The cells become more resistant to the circulating insulin Normally insulin binds to special receptors sites on the cell and initiates a series pf reactions involved in metabolism. In type 2 diabetes, these reactions are diminished primarily as a result of obesity and aging.

Question 27

The nurse is teaching the client diagnosed with type 2 diabetes mellitus about diet. Which diet selection indicates the client understands the teaching? 1. A submarine sandwich, potato chips, and diet cola 2. Four (4) slices of supreme thin-crust pizza and milk 3. Smoked turkey sandwich, celery sticks, and unsweetened tea 4. A roast beef sandwich, fried onion rings and a cola

Answer 27

3. Smoked turkey sandwich, celery sticks, and unsweetened tea Turkey is a low-fat meat. A sandwich usually means normal slices of bread and the client needs at least 50% carbohydrates in each meal. Celery sticks are not counted as carbs.

Question 28

The client diagnosed with type 1 diabetes mellitus received regular insulin two (2) hours ago. The client is complaining of being jittery and nervous. Which interventions should the nurse implement? List in order of priority. 1. Call the laboratory to confirm blood glucose level 2. Administer a quick-acting carbohydrate 3. Have the client eat a bologna sandwich 4. Check the client's blood glucose level at the bedside 5. Determine if the client has had anything to eat

Answer 28

5, 2, 4, 1, 3 Regular insulin peaks in 2-4 hours; therefore, the nurse should suspect a hypoglycemic reaction if the client has not eaten anything. The Antidote for insulin is glucose; therefore, the nurse should give the client some type of quick-acting food source. The nurse should obtain the client's blood glucose level as soon as possible, most hospitals require a confirmatory serum blood glucose level. Do not wait for results to give food. A source of long-acting carbohydrate and protein should be given to prevent a reoccurrence of hypoglycemia

Question 29

A client is receiving NPH insulin 20 units subcutaneously at 0700 hours daily. At 1500 hours, the nurse finds the client apparently sleep. How would the nurse know whether the client was having a hypoglycemic reaction? 1. Feel the client and bed for dampness 2. Observe the client for Kussmaul respirations 3. Smell the client's breath for acetone odor 4. Note if the client is incontinent of urine

Answer 29

1. Feel the client and bed for dampness When clients are sleeping, the only observable symptom of hypoglycemia is diaphoresis. Kussmaul breathing and acetone odor to breath are indicative of hyperglycemia. Incontinence is not associated with hypoglycemia and polyuria may be associated with hyperglycemia

Question 30

A client is found to be comatose and hypoglycemic with a blood glucose level of 50mg/dL. What nursing action is implemented first? 1. infuse 1000mL of D5W over a 12-hour period 2. Administer 50% glucose intravenously 3. Check the client's urine for the presence of sugar and acetone 4. Encourage the client to drink orange juice with added sugar

Answer 30

2. Administer 50% glucose intravenously The unconscious, hypoglycemic client needs immediate treatment with 50% intravenous glucose (highly concentrated). Administering 1000mL of D5W over 12 hours does not provide enought glucose to treat the problem. Trying to give oral fluids to an unconscious client should never be done because it increases the risk for aspiration. Urine sugar does not need to be evaluated if the serum blood glucose is available.

Question 31

What will the nurse teach the client with diabetes regarding exercise in the treatment program? Select all that apply. 1. During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insulin. 2. With an increase in activity, the body will use more carbohydrates; therefore, more insulin will be required. 3. Exercise increases the HDL and decreases the chance of stroke and heart disease. 4. The increase in activity results in an increase in the use of insulin; therefore, the client should decrease his or her carbohydrate intake. 5. Exercise will improve pancreatic circulation and stimulate the islets of Langerhans to increase the production of intrinsic insulin.

Answer 31

1. During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insulin. 3. Exercise increases the HDL and decreases the chance of stroke and heart disease. As carbohydrates are used for energy, insulin needs decrease. Therefore during exercise, carbohydrate intake should be increased to cover the increased energy requirements. The beneficial effects of regular exercise may result in a decreased need for diabetic medications in order to read target blood glucose levels. Furthermore, it may help to reduce triglycerides, LDL cholesterol levels, increase HDLs, reduce blood pressure, and improve circulation.

Question 32

A client with a diagnosis of type 2 diabetes has been ordered a course of prednisone for severe arthritic pain. An expected change that requires close monitoring by the nurse is: 1. Increased blood glucose level 2. Increased platelet aggregation 3. Increased creatinine clearance 4. Decreased white blood cell count

Answer 32

1. Increased blood glucose level An adverse reaction to corticosteriods is hyperglycemia. A client with type 2 diabetes must monitor blood glucose levels closely while taking steroids. Clients taking corticosteroids are at an increased risk for infection due to suppressed immune response

Question 33

It is important for the nurse to teach the client which of the following about metformin (Glucophage)? 1. It may cause constipation 2. It should be taken at night 3. It should be taken with meals 4. It may increase the effects of aspirin

Answer 33

3. It should be taken with meals Metformin (Glucophage) is administered with meals to minimize gastrointestinal effects. These adverse effects are abdominal bloating, diarrhea, nausea, vomiting, and an unpleasant metallic taste. Metformin is contraindicated in heart failure and liver disease and in clients with compromised renal function.

Question 34

A client with diabetes receives a combination of regular and NPH insulin at 0700 hours. The nurse teaches the client to be alert for signs of hypoglycemia at: 1. 12p to 1p (1200 to 1300 hours) 2. 9a and 5p (0900 and 1700 hours) 3. 10a and 10p (1000 and 2200 hours) 4. 8a and 11a (0800 and 1100 hours)

Answer 34

2. 9a and 5p (0900 and 1700 hours) Regular insulin (a short-acting insulin) peaks in 2 to 3 hours, and NPH (an intermediate-acting insulin) peaks in 4 to 10 hours. Hypoglycemia would most likely occur between 9am and 5pm (0900 to 1700 hours)

Question 35

Which patient with type 1 diabetes mellitus would be at the highest risk for developing hypoglycemic unawareness? 1. A 58-year-old patient with diabetic retinopathy 2. A 73-year-old patient who takes propranolol (Inderal) 3. A 19-year-old patient who is on the school track team 4. A 24-year-old patient with a hemoglobin A1C of 8.9%

Answer 35

2. A 73-year-old patient who takes propranolol (Inderal) Hypoglycemic unawareness is a condition in which a person does not experience the warning signs and symptoms of hypoglycemia until the person becomes incoherent and combative or loses consciousness. Hypoglycemic awareness is related to autonomic neuropathy of diabetes that interferes with the secretion of counterregulatory hormones that produce these symptoms. Older patients and patients who use â-adrenergic blockers (e.g., propranolol) are at risk for hypoglycemic unawareness.

Question 36

The nurse is teaching a 60-year-old woman with type 2 diabetes mellitus how to prevent diabetic nephropathy. Which statement made by the patient indicates that teaching has been successful? 1. “Smokeless tobacco products decrease the risk of kidney damage.” 2. “I can help control my blood pressure by avoiding foods high in salt.” Correct 3. “I should have yearly dilated eye examinations by an ophthalmologist.” 4. “I will avoid hypoglycemia by keeping my blood sugar above 180 mg/dL.”

Answer 36

2. “I can help control my blood pressure by avoiding foods high in salt.” Diabetic nephropathy is a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney. Risk factors for the development of diabetic nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia. Patients with diabetes are screened for nephropathy annually with a measurement of the albumin-to-creatinine ratio in urine; a serum creatinine is also needed.