MS Exam 2 Flashcards
The nurse is caring for a patient who is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching?
a. Check often for swollen lymph nodes.
b. Watch for excess bleeding or bruising.
c. Take iron supplements to prevent anemia.
d. Wash hands and avoid persons who are ill.
ANS: D
Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after a person has a splenectomy.
The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient?
a. “Are you taking any oral contraceptives?”
b. “Have you been prescribed antiseizure drugs?”
c. “Do you take medication containing salicylates?”
d. “How long have you taken antihypertensive drugs?”
ANS: C
Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia but not clotting disorders or bleeding. Oral contraceptives increase a person’s clotting risk. Antihypertensives do not usually cause problems with decreased clotting.
A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding?
a. Hematocrit of 35%
b. Hemoglobin of 11.8 g/dL
c. Platelet count of 400,000/µL
d. White blood cell (WBC) count of 2800/µL
ANS: D
Because the total WBC count is not usually affected by aging, the low WBC count in this patient would indicate that the patient’s immune function may be compromised and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.
A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure?
a. Elevate the head of the bed to 45 degrees.
b. Have the patient lie on the left side for 1 hour.
c. Apply a sterile 2-inch gauze dressing to the site.
d. Use a half-inch sterile gauze to pack the wound.
ANS: B
To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy, the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication to elevate the patient’s head.
The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect?
a. Yellow-tinged sclerae c. Numbness of the extremities
b. Shiny, smooth tongue d. Gum bleeding and tenderness
ANS: C
Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.
A patient’s complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding?
a. “Have you had a recent weight loss?”
b. “Do you have any history of lung disease?”
c. “Have you noticed any dark or bloody stools?”
d. “What is your dietary intake of meats and protein?”
ANS: B
The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic obstructive pulmonary disease. The other questions would be appropriate for patients who are anemic.
The nurse is reviewing laboratory results and notes a patient’s activated partial thromboplastin time (aPTT) level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication?
a. Aspirin c. Warfarin
b. Heparin d. Erythropoietin
ANS: B
aPTT assesses intrinsic coagulation by measuring factors I, II, V, VIII, IX, X, XI, XII. aPTT is increased (prolonged) in heparin administration. aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production.
The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered?
a. Platelet count c. Hemoglobin level
b. Neutrophil count d. White blood cell count
ANS: C
Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a person’s clotting ability. A neutrophil is a type of white blood cell that helps to fight infection.
The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse?
a. A 2-cm nontender supraclavicular node
b. A 1-cm mobile and nontender axillary node
c. An inability to palpate any superficial lymph nodes
d. Firm inguinal nodes in a patient with an infected foot
ANS: A
Enlarged and nontender nodes are suggestive of malignancies such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender.
A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect?
a. Hematocrit of 46%
b. Hemoglobin of 13.8 g/dL
c. Elevated reticulocyte count
d. Decreased white blood cell (WBC) count
ANS: C
Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding.
The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care?
a. Avoid intramuscular injections. c. Check temperature every 4 hours.
b. Encourage increased oral fluids. d. Increase intake of iron-rich foods.
ANS: A
Thrombocytopenia is a decreased number of platelets, which places the patient at high risk for bleeding. Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. Encouraging fluid intake and iron-rich food intake is not indicated in a patient with thrombocytopenia.
The health care provider’s progress note for a patient states that the complete blood count (CBC) shows a “shift to the left.” Which assessment finding will the nurse expect?
a. Cool extremities c. Elevated temperature
b. Pallor and weakness d. Low oxygen saturation
ANS: C
The term “shift to the left” indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor or weakness, or cool extremities.
The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take before this procedure?
a. Check for any iodine allergy. c. Administer prescribed sedatives.
b. Insert a large-bore IV catheter. d. Assist the patient to a flat position.
ANS: D
During a liver and spleen scan, a radioactive isotope is injected IV, and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter and sedation are not needed. The patient is placed in a flat position before the scan.
A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test?
a. Bone marrow biopsy
b. Abdominal ultrasound
c. Complete blood count (CBC)
d. Activated partial thromboplastin time (aPTT)
ANS: A
A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent.
The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider?
a. Monocytes 4%
b. Hemoglobin 13.6 g/dL
c. Platelet count 168,000/µL
d. White blood cell (WBC) count 15,500/µL
ANS: D
The elevation in WBCs indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patient’s pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal.
Which information shown in the table below about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the health care provider?
Assessment Complete Blood Count Patient History
• BP 110/68
• Pulse 98 beats/min
• Brisk capillary refill
• Multiple ecchymoses on arms • Hgb 10.6 g/dL
• Hct 30%
• WBC 5100/µL
• Platelets 19,500/µL • Occasional aspirin use
• Abdominal pain x 1 week
• Large, dark stool this morning
a. Heart rate c. Abdominal pain
b. Platelet count d. White blood cell count
ANS: B
The platelet count is severely decreased and places the patient at risk for spontaneous bleeding. The other information is also pertinent but not as indicative of the need for rapid treatment as the platelet count.
A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient’s laboratory test findings to include
a. an RBC count of 4,500,000/L.
b. a hematocrit (Hct) value of 38%.
c. normal red blood cell (RBC) indices.
d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).
ANS: D
The patient’s clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal.
Which menu choice indicates that the patient understands the nurse’s teaching about recommended dietary choices for iron-deficiency anemia?
a. Omelet and whole wheat toast c. Strawberry and banana fruit plate
b. Cantaloupe and cottage cheese d. Cornmeal muffin and orange juice
ANS: A
Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.
A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of
a. iron. c. cobalamin (vitamin B12).
b. folic acid. d. ascorbic acid (vitamin C).
ANS: B
Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.
A 52-yr-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states,
a. “I need to start eating more red meat and liver.”
b. “I will stop having a glass of wine with dinner.”
c. “I could choose nasal spray rather than injections of vitamin B12.”
d. “I will need to take a proton pump inhibitor such as omeprazole (Prilosec).”
ANS: C
Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.
An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to
a. provide a diet high in vitamin K.
b. alternate periods of rest and activity.
c. teach the patient how to avoid injury.
d. place the patient on protective isolation.
ANS: B
Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia.
Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate?
a. “I will call my health care provider if my stools turn black.”
b. “I will take a stool softener if I feel constipated occasionally.”
c. “I should take the iron with orange juice about an hour before eating.”
d. “I should increase my fluid and fiber intake while I am taking iron tablets.”
ANS: A
It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the health care provider about this. The other patient statements are correct.
Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia?
a. Potential complication: seizures
b. Potential complication: infection
c. Potential complication: neurogenic shock
d. Potential complication: pulmonary edema
ANS: B
Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.
It is important for the nurse providing care for a patient with sickle cell crisis to
a. limit the patient’s intake of oral and IV fluids.
b. evaluate the effectiveness of opioid analgesics.
c. encourage the patient to ambulate as much as tolerated.
d. teach the patient about high-protein, high-calorie foods.
ANS: B
Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.
Which statement by a patient indicates good understanding of the nurse’s teaching about prevention of sickle cell crisis?
a. “Home oxygen therapy is frequently used to decrease sickling.”
b. “There are no effective medications that can help prevent sickling.”
c. “Routine continuous dosage narcotics are prescribed to prevent a crisis.”
d. “Risk for a crisis is decreased by having an annual influenza vaccination.”
ANS: D
Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises.
Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis?
a. Take a daily multivitamin with iron.
b. Limit fluids to 2 to 3 quarts per day.
c. Avoid exposure to crowds when possible.
d. Drink only two caffeinated beverages daily.
ANS: C
Exposure to crowds increases the patient’s risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.
The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the
a. Schilling test. c. gastric analysis.
b. bilirubin level. d. stool occult blood.
ANS: B
Jaundice is caused by the elevation of bilirubin level associated with red blood cell hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia.
A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care?
a. Prepare for platelet transfusion.
b. Discontinue the heparin infusion.
c. Administer prescribed warfarin (Coumadin).
d. Use low-molecular-weight heparin (LMWH).
ANS: B
All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/µL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.
An expected action by the nurse caring for a patient who has an acute exacerbation of polycythemia vera is to
a. place the patient on bed rest. c. avoid use of aspirin products.
b. administer iron supplements. d. monitor fluid intake and output.
ANS: D
Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis. Iron is contraindicated in patients with polycythemia vera.
Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura?
a. Assign the patient to a private room.
b. Avoid intramuscular (IM) injections.
c. Use rinses rather than a soft toothbrush for oral care.
d. Restrict activity to passive and active range of motion.
ANS: B
IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.
Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)?
a. Prothrombin time
b. Erythrocyte count
c. Fibrinogen degradation products
d. Activated partial thromboplastin time
ANS: D
Platelet aggregation in HIT causes neutralization of heparin, so the activated partial thromboplastin time will be shorter, and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.
The nurse is caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. The nurse should
a. apply heat to the knee.
b. immobilize the knee joint.
c. assist the patient with light weight bearing.
d. perform passive range of motion to the knee.
ANS: B
The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.
A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the
a. platelet count. c. thrombin time.
b. bleeding time. d. prothrombin time.
ANS: B
The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease.
A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. The nurse will plan to teach the patient about
a. blood transfusion.
b. bone marrow biopsy.
c. filgrastim (Neupogen) administration.
d. erythropoietin (Epogen) administration.
ANS: B
Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.
Which action will the admitting nurse include in the care plan for a patient who has neutropenia?
a. Avoid intramuscular injections.
b. Check temperature every 4 hours.
c. Omit fruits or vegetables from the diet.
d. Place a “No Visitors” sign on the door.
ANS: B
The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a “no visitors” policy is not needed.
Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy?
a. Platelet count c. Total lymphocyte count
b. Reticulocyte count d. Absolute neutrophil count
ANS: D
Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts are also important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.
A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate?
a. “If you do not want to have chemotherapy, other treatment options include stem cell transplantation.”
b. “The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy.”
c. “The decision about treatment is one that you and the doctor need to make rather than asking what I would do.”
d. “You don’t need to make a decision about treatment right now because leukemias in adults tend to progress slowly.”
ANS: B
This response uses therapeutic communication by addressing the patient’s question and giving accurate information. The other responses either give inaccurate information or fail to address the patient’s question, which will discourage the patient from asking the nurse for information
A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient?
a. Infuse the PRBCs slowly over 4 hours.
b. Transfuse only leukocyte-reduced PRBCs.
c. Administer the scheduled diuretic before the transfusion.
d. Give the PRN dose of antihistamine before the transfusion.
ANS: B
TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI.
A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to
a. discuss the need for insurance to cover post-HSCT care.
b. ask whether there are questions or concerns about HSCT.
c. emphasize the positive outcomes of a bone marrow transplant.
d. explain that a cure is not possible with any treatment except HSCT.
ANS: B
Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.
Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma?
a. Monitor fluid intake and output.
b. Administer calcium supplements.
c. Assess lymph nodes for enlargement.
d. Limit weight bearing and ambulation.
ANS: A
A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient’s calcium level and are not used.
An appropriate nursing intervention for a patient with non-Hodgkin’s lymphoma whose platelet count drops to 18,000/µL during chemotherapy is to
a. check all stools for occult blood.
b. encourage fluids to 3000 mL/day.
c. provide oral hygiene every 2 hours.
d. check the temperature every 4 hours.
ANS: A
Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.
A patient who has acute myelogenous leukemia develops an absolute neutrophil count of 850/µL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate?
a. Discuss the need for hospital admission to treat the neutropenia.
b. Teach the patient to administer filgrastim (Neupogen) injections.
c. Plan to discontinue the chemotherapy until the neutropenia resolves.
d. Order a high-efficiency particulate air (HEPA) filter for the patient’s home.
ANS: B
The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count <500/µL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient’s home environment.
Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider?
a. The platelet count is 52,000/µL.
b. The patient is difficult to arouse.
c. There are purpura on the oral mucosa.
d. There are large bruises on the patient’s back.
ANS: B
Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia.
The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)?
a. Verify the patient identification (ID) according to hospital policy.
b. Obtain the temperature, blood pressure, and pulse before the transfusion.
c. Double-check the product numbers on the PRBCs with the patient ID band.
d. Monitor the patient for shortness of breath or chest pain during the transfusion.
ANS: B
UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (RN). The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members.
A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?
a. Give the PRN diphenhydramine .
b. Send a urine specimen to the laboratory.
c. Administer PRN acetaminophen (Tylenol).
d. Draw blood for a new type and crossmatch.
ANS: C
The patient’s clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.
A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse’s first action should be to
a. administer oxygen therapy at a high flow rate.
b. obtain a urine specimen to send to the laboratory.
c. notify the health care provider about the symptoms.
d. disconnect the transfusion and infuse normal saline.
ANS: D
The patient’s symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.
Which patient should the nurse assign as the roommate for a patient who has aplastic anemia?
a. A patient with chronic heart failure
b. A patient who has viral pneumonia
c. A patient who has right leg cellulitis
d. A patient with multiple abdominal drains
ANS: A
Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.
Which patient requires the most rapid assessment and care by the emergency department nurse?
a. The patient with hemochromatosis who reports abdominal pain
b. The patient with neutropenia who has a temperature of 101.8° F
c. The patient with thrombocytopenia who has oozing gums after a tooth extraction
d. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours
ANS: B
A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.
A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets?
a. Platelet count is 42,000/L.
b. Petechiae are present on the chest.
c. Blood pressure (BP) is 94/56 mm Hg.
d. Blood is oozing from the venipuncture site.
ANS: A
Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/L unless the patient is actively bleeding. Therefore the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate.
Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider?
a. Leg bruises c. Skin abrasions
b. Tarry stools d. Bleeding gums
ANS: B
Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury but are not indicators of possible serious blood loss.
A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take?
a. Avoid other venipunctures.
b. Apply dressings to the sites.
c. Notify the health care provider.
d. Give prescribed proton-pump inhibitors.
ANS: C
The patient’s new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions are also appropriate, but the most important action should be to notify the health care provider so that DIC treatment can be initiated rapidly.
A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back pain. Which prescribed action will the nurse implement first?
a. Administer morphine sulfate 4 mg IV.
b. Give acetaminophen (Tylenol) 650 mg.
c. Infuse normal saline 500 mL over 30 minutes.
d. Schedule complete blood count and coagulation studies.
ANS: C
The patient’s blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions are also appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient.
Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?
a. Assessing the patient for signs and symptoms of infection
b. Teaching the patient the purpose of neutropenic precautions
c. Administering subcutaneous filgrastim (Neupogen) injection
d. Developing a discharge teaching plan for the patient and family
ANS: C
Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. Patient teaching, assessment, and developing the plan of care require RN level education and scope of practice.
Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first?
a. A 44-yr-old with sickle cell anemia who says his eyes always look sort of yellow
b. A 23-yr-old with no previous health problems who has a nontender lump in the axilla
c. A 50-yr-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue
d. A 19-yr-old with hemophilia who wants to learn to self-administer factor VII replacement
ANS: B
The patient’s age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently.
After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first?
a. A 56-yr-old with frequent explosive diarrhea
b. A 33-yr-old with a fever of 100.8° F (38.2° C)
c. A 66-yr-old who has white pharyngeal lesions
d. A 23-yr-old who is complaining of severe fatigue
ANS: B
Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems.
Which action will the nurse include in the plan of care for a patient who has thalassemia major?
a. Teach the patient to use iron supplements.
b. Avoid the use of intramuscular injections.
c. Administer iron chelation therapy as needed.
d. Notify health care provider of hemoglobin 11 g/dL.
ANS: C
The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients with thalassemia. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater.
Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis?
a. Skin color c. Liver function
b. Hematocrit d. Serum iron level
ANS: D
Because iron chelating agents are used to lower serum iron levels, the most useful information will be the patient’s iron level. The other parameters will also be monitored, but are not the most important to monitor when determining the effectiveness of deferoxamine.
Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider?
a. Hematocrit 55% c. Calf swelling and pain
b. Presence of plethora d. Platelet count 450,000/L
ANS: C
The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.
Following successful treatment of Hodgkin’s lymphoma for a 55-yr-old woman, which topic will the nurse include in patient teaching?
a. Potential impact of chemotherapy treatment on fertility
b. Application of soothing lotions to treat residual pruritus
c. Use of maintenance chemotherapy to maintain remission
d. Need for follow-up appointments to screen for malignancy
ANS: D
The chemotherapy used in treating Hodgkin’s lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. The fertility of a 55-yr-old woman will not be impacted by chemotherapy. Maintenance chemotherapy is not used for Hodgkin’s lymphoma. Pruritus is a clinical manifestation of lymphoma but should not be a concern after treatment.
A patient who has non-Hodgkin’s lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse?
a. Anorexia c. Oral ulcers
b. Vomiting d. Lip swelling
ANS: D
Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy but are not immediately life threatening.
Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider?
a. Serum calcium level is 15 mg/dL.
b. Patient reports no stool for 5 days.
c. Urine sample has Bence-Jones protein.
d. Patient is complaining of severe back pain.
ANS: A
Hypercalcemia may lead to complications such as dysrhythmias or seizures, and should be addressed quickly. The other patient findings will also be discussed with the health care provider but are not life threatening.
When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care?
a. Discourage deep breathing to reduce risk for splenic rupture.
b. Teach the patient to use ibuprofen for left upper quadrant pain.
c. Schedule immunization with the pneumococcal vaccine (e.g., Pneumovax).
d. Avoid the use of acetaminophen (Tylenol) for at least 2 weeks prior to surgery.
ANS: C
Asplenic patients are at high risk for infection with pneumococcal infections and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth, and the patient should be encouraged to take deep breaths.
The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider?
History Physical Assessment Laboratory Results
• Fatigue, which has increased over last month
• Frequent constipation • Conjunctiva pale pink, moist
• Multiple bruises
• Clear lung sounds • Hct 33%
• WBC 1500/µL
• Platelets 70,000/µL
a. Neutropenia c. Increasing fatigue
b. Constipation d. Thrombocytopenia
ANS: A
The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leukopenia. The other information may require further assessment or treatment but does not place the patient at immediate risk for complications.
A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?
ANS:
21
To infuse 250 mL over 2 hours, the calculated drip rate is 20.8 drops/min or 21 drops/min.
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. c. elevated serum aldosterone levels.
b. decreased serum thyroxine. d. low urinary catecholamines excretion.
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.
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.”
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.
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
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.
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?”
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.
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.”
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.
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 c. thyroid hormone
b. catecholamine d. parathyroid hormone
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.
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.
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.
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
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.
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.
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.
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. c. elevated serum potassium.
b. decreased urinary output. d. evidence of fluid overload.
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.
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 c. Activity level
b. Value system d. Visual changes
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.
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. c. a cardiac monitor.
b. glargine insulin. d. 50% dextrose solution.
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.
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.
ANS: C
Physical and emotional stress can affect the results of the free cortisol test. The other tests are not impacted by stress.
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.
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.
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 c. The phosphate level
b. The serum albumin d. The magnesium level
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
A patient is admitted with tetany. Which laboratory value should the nurse plan to monitor?
a. Total protein c. Ionized calcium
b. Blood glucose d. Serum phosphate
ANS: C
Tetany is associated with hypocalcemia. The other values would not be useful for this patient.
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.
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.
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.
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.
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.
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.
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 c. Recent weight loss of 20 lb
b. Allergies to iodine and shellfish d. Complaint of ongoing headaches
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.
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
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.
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.”
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.
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.
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.
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.
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.
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.
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.
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?” c. “Have you lost weight lately?”
b. “Is your urine dark colored?” d. “Do you crave sugary drinks?”
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.
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 c. Glycosylated hemoglobin
b. Oral glucose tolerance d. Urine dipstick for glucose
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.
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.
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.
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.
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.
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.”
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 instruction.
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.
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
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.”
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.
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.
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.
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 c. 2:00 PM
b. 12:00 AM d. 4:0 PM
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.
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.
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 a day.
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) c. Detemir (Levemir)
b. Glargine (Lantus) d. NPH (Humulin N)
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.
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.
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 glyburide.
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.”
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.
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.
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.
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.
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.
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.
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.
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.
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.
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. c. initiate O2 by nasal cannula.
b. insert an IV catheter. d. administer glargine (Lantus) insulin.
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.
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%.
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.
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.
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.
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.
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.
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?”
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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. c. abdomen.
b. buttock. d. upper arm.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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
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.
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. c. when the patient is 39 years old.
b. as soon as possible. d. within the first year after diagnosis.
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.
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.”
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.
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.
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.
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.
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.
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.
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).
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
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.
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
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.
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
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.
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.
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.
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?”
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.
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.
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.
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.
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.
The nurse is assessing a male patient diagnosed with a pituitary tumor causing panhypopituitarism. Assessment findings consistent with panhypopituitarism include
a. high blood pressure. c. elevated blood glucose.
b. decreased facial hair. d. tachycardia and palpitations.
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.
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.
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.
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. c. peripheral edema is increased.
b. urinary output is increased. d. urine specific gravity is increased.
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.
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.”
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.
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. c. increased serum chloride.
b. decreased serum sodium. d. low urine specific gravity.
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.
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.
ANS: C
Nocturia occurs as a result of the polyuria caused by diabetes insipidus. Edema, excess fluid volume, and fluid retention are not expected.
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.
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.
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.
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.
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.
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.
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.
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.
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 c. Nutritional intake
b. Apical pulse rate d. Orientation and alertness
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.
