Test 5

Question 1

A nurse is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect?

Decreased creatinine level
Hyperkalemia
Hypomagnesaemia
Increased glomerular filtration rate (GFR)

Answer 1

Hyperkalemia

The nurse should expect the client to have an increase in the serum concentration of potassium during the oliguric phase. Potassium can rise to a life-threatening level during this phase and should be monitored closely.

Question 2

A nurse is performing discharge teaching with a client about the care of a newly created ileal conduit. The nurse should instruct the client to empty the appliance

twice a day.
daily at bedtime.
when the bag is 2/3 full.
when the bag is full.

Answer 2

when the bag is 2/3 full.

An ileal conduit is used to divert urine outside of the body when the urinary bladder has been removed. The conduit cannot store urine the way the bladder did; therefore, urine will be flowing continuously, and an appliance must be worn as a collecting device. The bag should be emptied when it becomes 2/3 full to prevent leakage, skin irritation, and infection.

Question 3

A nurse is caring for a client who has chronic glomerulonephritis. The nurse should expect to find a decrease in which of the following serum laboratory values?

Potassium
Phosphate
Creatinine
RBC

Answer 3

RBC
MY ANSWER
Serum RBCs are decreased in clients who have chronic glomerulonephritis due to the decreased production of erythropoietin, the factor that stimulates production of erythrocytes.

Question 4

A nurse is teaching a client who is scheduled for a cystoscopy. Which of the following information should the nurse include in the teaching?

“You should limit fluids for 12 hr following the procedure.”
“You may have pink-tinged urine after this procedure.”
“You can eat a full liquid meal up to 1 hour before the procedure.”
“You will be placed on your right side during the procedure.”

Answer 4

You should limit fluids for 12 hr following the procedure.”
The client should increase oral fluid intake following the procedure to increase urine output and limit dysuria which can occur due to the procedure.

XXXXX “You may have pink-tinged urine after this procedure.”
MY ANSWER
The client might have blood-tinged, or pink, urine after the procedure. The client should report dark red urine because it is an indication of bleeding.

“You can eat a full liquid meal up to 1 hour before the procedure.”
The provider will prescribe nothing by mouth starting either at midnight the night before the procedure or nothing by mouth for several hours before the procedure.

“You will be placed on your right side during the procedure.”
The procedure is performed with the client in the lithotomy position.

Question 5

A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as the best source of potassium?

Bananas
Cooked carrots
Cheddar cheese
2% milk

Answer 5

Bananas

Question 6

A nurse is planning care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse include in the plan?

Administer antibiotics.
Encourage increased fluid intake.
Obtain weight weekly.
Encourage frequent ambulation.

Answer 6

xxx Administer antibiotics.

Acute glomerulonephritis related to a streptococcal infection is treated with antibiotic therapy, including penicillins and erythromycin.

Encourage increased fluid intake.
Clients who have acute glomerulonephritis are frequently on a fluid restriction due to fluid retention.
Obtain weight weekly.

To provide information about the client’s fluid balance, the nurse should plan to obtain daily weights from a client who has acute glomerulonephritis.

Encourage frequent ambulation.
Clients who have acute glomerulonephritis should conserve energy to prevent further stress on the glomeruli.

Question 7

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

Answer 7

pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
MY ANSWER
The nurse should expect a client who has renal failure to have metabolic acidosis, which is characterized by a low HCO3-, a low pH, and a low or normal PaCO2. Expected reference ranges for these laboratory values are as follows: pH 7.35 to 7.45, HCO3- 21 to 28 mEq/L, and PaCO2 35 to 45 mm Hg.

Question 8

A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD).The nurse should instruct the client to limit which of the following nutrients? (Select all that apply.)

Protein
Calcium
Calories
Phosphorous
Sodium

Answer 8

Protein
Phosphorous
Sodium

Question 9

A nurse is assessing a child who has nephrotic syndrome. Which of the following findings should the nurse expect?

Polyuria
Facial edema
Smokey brown urine
Hypertension

Answer 9

Facial edema

Question 10

A nurse is reviewing the laboratory values of a client who has chronic glomerulonephritis. Which of the following is an expected finding for this client?

Serum creatinine 0.8 mg/dL
RBC 4.9 mm3
BUN 100 mg/dL
Serum potassium 4.0 mEq/L

Answer 10

BUN 100 mg/dL

-creatinine would be high.
RBC low
Bun high
Potassium high

Question 11

A nurse is providing teaching to a client who has nephrotic syndrome. The nurse should recognize that which of the following client statements indicates a need for further teaching?

“I can expect to have swelling in my face.”
“I will lose protein in my urine.”
“I should expect my provider to prescribe a kidney biopsy.”
“I should increase my sodium intake.”

Answer 11

“I should increase my sodium intake.”

A client who has nephrotic syndrome should consume a low-sodium diet to reduce edema and control hypertension.

Question 12

A nurse is teaching a client who has acute kidney disease about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding of the teaching?

“I should consume most of the fluid during the evening.”
“I will make a list of my favorite beverages.”
“I will put beverages in large containers to give the appearance of drinking a lot.”
“I will not add ice cream to the amount of fluid intake.”

Answer 12

“I will make a list of my favorite beverages.”
The nurse should work with the client to develop a schedule for fluid restrictions, and should attempt to include the client’s favorite beverages when possible to promote satisfaction.

Question 13

A nurse is planning care for a client who is scheduled to have a kidney biopsy. Which of the following information should the nurse include in the plan? (Select all that apply).

Obtain a urine specimen prior to the procedure.
Obtain written, informed consent.
Administer diphenhydramine (Benadryl) prior to the procedure.
Maintain NPO status prior to the procedure.
Obtain coagulation studies.

Answer 13

Obtain a urine specimen prior to the procedure is correct. A urine specimen should be obtained prior to the procedure to allow for post-procedure comparison.

Obtain written, informed consent is correct. Because the procedure is invasive it requires written, informed consent.

Administer diphenhydramine (Benadryl) prior to the procedure is incorrect. Benadryl may be prescribed prior to a procedure that uses dye rather than for a kidney biopsy.

Maintain NPO status prior to the procedure is correct. Clients are often prescribed NPO status for six to eight hours prior to the procedure.

Obtain coagulation studies is correct. Coagulation studies are obtained prior to the procedure to evaluate the risk for bleeding from the biopsy site as a potential complication.

Question 14

A nurse is caring for a client who is two days postoperative following creation of an ileal conduit. Which of the following is an unexpected finding associated with this procedure?

Edema of the stoma
Urine in the drainage appliance
Redness of the stoma
Feces in the drainage appliance

Answer 14

Feces in the drainage appliance

Feces in the drainage appliance is an unexpected finding associated with this procedure. The ileal conduit procedure incorporates implantation of the ureters into a portion of the ileum that has been resected from its anatomical position and now functions as a reservoir or conduit for urine. Feces should not be draining from the conduit.

Question 15

The nurse is discharging a client from the hospital who has a new prescription for furosemide. Which of the following client statements indicates an understanding of the teaching?

“I should eat a diet low in potassium while taking this medication.”
“I should limit my fluid intake while taking this medication.”
“My blood pressure will increase while I am taking this medication.”
“I need to limit my sun exposure and wear sunscreen while on this medication.”

Answer 15

“I need to limit my sun exposure and wear sunscreen while on this medication.”

Limiting sun exposure and wearing sunscreen are appropriate while taking furosemide due to the adverse effect of photosensitivity.

I should eat a diet low in potassium while taking this medication.”
A diet high in potassium is appropriate while taking furosemide.

“I should limit my fluid intake while taking this medication.”
Limiting fluids increases the risk for dehydration while taking furosemide.

“My blood pressure will increase while I am taking this medication.”
MY ANSWER
Hypotension is an adverse effect of furosemide.

Question 16

A nurse is caring for a client who reports recurrent flank pain, nausea, and vomiting for 24 hr. Which of the following actions is the nurse’s priority?

Monitor intake and output.
Strain the urine.
Administer pain medication.
Administer an antiemetic.

Answer 16

Administer pain medication.

Question 17

A nurse is caring for a school-age child who has acute glomerulonephritis with peripheral edema and is producing 35 mL of urine per hour. The nurse should place the client on which of the following diets?

Answer 17

Low-sodium, fluid-restricted
A low-sodium, fluid-restricted diet will prevent complications.
Regular diet, no added salt
A regular diet with no added salt is not an appropriate diet for a client who has acute glomerulonephritis with peripheral edema.
Low-carbohydrate, low-protein diet
A low-carbohydrate, low-protein diet is not an appropriate diet for a client who has acute glomerulonephritis with peripheral edema and a urinary output of 35 mL/hr.
Low-protein, low-potassium diet
MY ANSWER
A low-protein, low-potassium diet is not an appropriate diet for a client who has acute glomerulonephritis with peripheral edema and a urinary output of 35 mL/hr. Potassium intake is restricted in periods of oliguria.

Question 18

A nurse is assessing a client who has heart failure and is prescribed furosemide. Which of the following findings is an adverse effect of this medication?

Weight gain
Increased blood pressure
Hypoglycemia
Leg cramps

Answer 18

Leg cramps
MY ANSWER
Leg cramps is a manifestation of hypokalemia, an adverse effect of furosemide. The nurse should assess the client for hypokalemia and monitor the client’s potassium level.

Hyperglycemia is an adverse effect of furosemide.

Question 19

A nurse is caring for a client who has polycystic kidney disease (PKD). Which of the following findings should the nurse expect?

Flank pain
Hypotension
Confusion
Urinary retention

Answer 19

Flank pain
Flank pain is a finding associated with PKD.

Polyuria, rather than urinary retention, is associated with PKD.

Question 20

A nurse is caring for a client who will have blood sampling for a serum creatinine level and asks what this test shows. Which of the following responses should the nurse make?

“This test will tell your doctor how your kidneys are functioning.”
“You’ll have to ask your doctor.”
“This test will tell if you have severe renal impairment or a disease.”
“We’ll find out if any medications, such as steroids, are interfering with your kidney function.”

Answer 20

This test will tell your doctor how your kidneys are functioning.”
MY ANSWER
This response is appropriate because it answers the client’s question simply rather than avoiding it.

Question 21

A nurse is teaching a group of nursing students about pyelonephritis. Which of the following statements should the nurse include in the teaching?

“Pyelonephritis increases a pregnant woman’s risk for preterm labor.”
“Pyelonephritis is most often caused by Staphylococcus saprophyticus.”
“Pyelonephritis is an infection of the lower urinary tract.”
“Pyelonephritis often causes no symptoms in affected clients.”

Answer 21

Pyelonephritis increases a pregnant woman’s risk for preterm labor.”
MY ANSWER
Pyelonephritis is a serious complication of pregnancy that can lead to preterm labor.

Question 22

A nurse is caring for a client who has chronic glomerulonephritis. The nurse should expect to find a decrease in which of the following serum laboratory values?

Potassium
Phosphate
Creatinine
RBC

Answer 22

RBC

Question 23

A nurse is providing teaching to a client about completing a creatinine clearance test. Which of the following instructions should the nurse include in the teaching?

“You will need to collect all of your urine for the next 12 hours.”
“You will need to store the urine container in a dark location.”
“You will need to start the collection time with your first urine specimen of the day.”
“You will need to avoid rigorous exercise during the test.”

Answer 23

The nurse should instruct the client to avoid exercising during the testing time because it can cause an increase in the creatinine values.

“You will need to collect all of your urine for the next 12 hours.”
A creatinine clearance test requires the client to collect urine for a period of 24 hr.
“You will need to store the urine container in a dark location.”
The nurse should instruct the client to store the urine on ice or refrigerate it.
“You will need to start the collection time with your first urine specimen of the day.”
The nurse should instruct the client to discard the first urine specimen.

Question 24

A nurse is teaching a client who has a new prescription for bumetanide. Which of the following instructions should the nurse include in the teaching?

“Report changes in hearing.”
“Avoid foods high in potassium.”
“Take the prescribed second dose at nighttime.”
“Limit your fluid intake to no more than 1.5 L a day.”

Answer 24

xxxx “Report changes in hearing.”
MY ANSWER
Bumetanide is a high-ceiling loop diuretic. It promotes diuresis by inhibiting sodium and chloride reabsorption in the thick ascending limb of the loop of Henle. High-ceiling loop diuretics can cause ototoxicity. Concurrent use of aminoglycosides, such as gentamycin, increases the risk of ototoxicity. Inform clients about possible hearing loss, and instruct clients to notify the prescriber if a hearing deficit or tinnitus develops.
“Avoid foods high in potassium.”
Hypokalemia is an adverse effect of bumetanide due to potassium loss through the distal nephron. The client should consume foods high in potassium content (such as dried fruits, nuts, bananas, and potatoes) to minimize the risk for hypokalemia. The client should be taught to monitor for manifestations of hypokalemia, such as irregular heartbeat, muscle weakness, and leg cramps.
“Take the prescribed second dose at nighttime.”
Inform the client to expect increased urine volume and frequency of voiding. The client should take diuretics early in the morning when prescribed daily. When prescribed twice per day, the client should take the medication at 0800 and 1400 to avoid frequent diuresis during the night.
“Limit your fluid intake to no more than 1.5 L a day.”
The client should consume 2-3 L of fluid per day to prevent dehydration due to loss of sodium, chloride, and water.

Question 25

A nurse is preparing a client for a kidney biopsy. Which of the following client conditions should the nurse identify as a contraindication for this diagnostic test?

Elevated creatinine level
Flank pain
Urinary retention
Bleeding tendencies

Answer 25

Bleeding tendencies
One of the risks of a kidney biopsy is bleeding from the biopsy site. Therefore, a history of bleeding tendencies or coagulation disorders is a contraindication for a kidney biopsy.

Question 25

A nurse is monitoring a client who has acute kidney injury. Which of the following laboratory findings should the nurse expect?

Hypokalemia
Metabolic alkalosis
Hypercalcemia
Elevated BUN

Answer 25

Elevated BUN
MY ANSWER
Client who are in acute kidney injury will have an elevated BUN as damage to the kidneys leads to a build-up of nitrogenous wastes in the blood.

Question 26

A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take?

Check the results of the client’s most recent CBC.
Assess the client for a hypersensitivity reaction.
Evaluate the client for hypercalcemia.
Examine the client for hepatomegaly.

Answer 26

Check the results of the client’s most recent CBC.
MY ANSWER
The client might have anemia as a result of myelosuppression (bone marrow suppression) from the chemotherapy. If so, she might require treatment for the anemia (transfusion, medication) and the provider might have to delay further chemotherapy until her blood counts are higher.

Question 27

A nurse is planning care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse include in the plan?

Administer antibiotics.
Encourage increased fluid intake.
Obtain weight weekly.
Encourage frequent ambulation.

Answer 27

Administer antibiotics.
MY ANSWER
Acute glomerulonephritis related to a streptococcal infection is treated with antibiotic therapy, including penicillins and erythromycin.

Question 28

A patient with CKD is most likely to experience which of the following complications?

A. Fluid volume overload
B. Liver failure
C. Seizures
D. Low blood sugar

Answer 28

A. Fluid volume overload

Question 29

A nurse is assessing a patient with CKD for signs of pruritis. What assessment finding would be most consistent with this complication?

A. Dry, flaky skin
B. Intense itching

C. Yellowish sclerae
D. Muscle weakness

Answer 29

B.** Intense itching Correct

Question 30

Which of the following is NOT a risk factor for CKD?

A. Age
B. Acute liver injury

C. Dehydration
D. Hypertension

Answer 30

*B.** Acute liver injury Correct

Question 31

A staff nurse is teaching a client who has Addison’s disease about the disease process. The client asks the nurse what causes Addison’s disease. Which of the following responses should the nurse make?

“It is caused by the lack of production of insulin by the pancreas..”
“It is caused by the lack of production of aldosterone by the adrenal gland.”
“It is caused by the overproduction of growth hormone by the pituitary gland.”
“It is caused by the overproduction of parathormone by the parathyroid gland.”

Answer 31

“It is caused by the lack of production of aldosterone by the adrenal gland.”
MY ANSWER
Addison’s disease is caused by a lack of production of the adrenocorticotropic hormones (cortisol and aldosterone) by the adrenal gland.

Question 32

A nurse is assessing a client who has myxedema. Which of the following findings should the nurse expect?

Diarrhea
Facial edema
Tachycardia
Heat intolerance

Answer 32

Facial edema
MY ANSWER
Facial edema is an expected finding of myxedema, which is a severe form of hypothyroidism. A client who has myxedema typically experiences non-pitting edema everywhere, especially around the eyes and in the hands and feet.

Question 32

A nurse is assessing a client who is taking levothyroxine. The nurse should recognize that which of the following findings is a manifestation of levothyroxine overdose?

Insomnia
Constipation
Drowsiness
Hypoactive deep-tendon reflexes

Answer 32

Insomnia
Levothyroxine overdose will result in manifestations of hyperthyroidism, which include insomnia, tachycardia, and hyperthermia.

Question 33

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?

Answer 33

Acetone odor to breath
Because of the lack of insulin, the body is unable to use glucose and instead breaks down fats resulting in excessive ketones. The large amount of ketones causes the body to become acidotic and causes a fruity, or acetone odor to the breath

Question 34

A nurse is caring for a client who is 8 hr postoperative following a subtotal thyroidectomy. In which of the following positions should the nurse keep the client?

High Fowler’s with neck extended
High Fowler’s with neck in a neutral position.
Semi-Fowler’s with neck extended
Semi-Fowler’s with neck in a neutral position

Answer 34

Semi-Fowler’s with neck in a neutral position
MY ANSWER
Semi-Fowler’s is the most comfortable position for a client who has had thyroid surgery. Neck flexion could compromise the airway, and neck extension could place excessive tension on the operative area and the sutures. A neutral position is essential.

High Fowler’s does not support the head and neck area well enough and could place excess pressure on the operative area.

Question 34

A nurse is reviewing the medical record of a client who has been on levothyroxine for several months. Which of the following findings indicates a therapeutic response to the medication?

Decrease in level of thyroxine (T4)
Increase in weight
Increase in hr of sleep per night
Decrease in level of thyroid stimulating hormone (TSH).

Answer 34

Decrease in level of thyroid stimulating hormone (TSH).
MY ANSWER
In hypothyroidism, the nonfunctioning thyroid gland is unable to respond to the TSH, and no endogenous thyroid hormones are released. This results in an elevation of the TSH level as the anterior pituitary continues to release the TSH to stimulate the thyroid gland. Administration of exogenous thyroid hormones, such as levothyroxine, turns off this feedback loop, which results in a decreased level of TSH.

Question 35

A nurse is caring for a client who has Cushing’s syndrome. Which of the following interventions should the nurse expect to perform? (Select all that apply.)

Assess blood glucose level
Assess for neck vein distention
Monitor for an irregular heart rate
Monitor for postural hypotension
Weigh the client daily

Answer 35

Assess blood glucose level
Assess for neck vein distention
Weigh the client daily

Cushing’s syndrome affects blood glucose levels by causing increased release of glucose from the liver and decreased sensitivity of insulin receptors. This can result in elevated blood glucose levels.

Question 36

A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider?

Glucocorticoid medications
Dextrose 5% in 0.45% sodium chloride
Oral hypoglycemic medications
0.9% sodium chloride IV bolus

Answer 36

0.9% sodium chloride IV bolus
The nurse should expect a prescription for an IV bolus of 0.9% sodium chloride to be administered at 15 to 20 mL/kg/hr for the first hour to restore volume and maintain perfusion to the vital organs.

Oral hypoglycemic medications are prescribed for clients who have type 2 diabetes mellitus.

Question 37

A nurse is assessing a client who has Graves’ disease. The nurse should expect which of the following laboratory results?

Decreased thyroid-stimulating hormone (TSH) level
Decreased triiodothyronine (T3) level
Decreased thyroxine (T4) level
Decreased thyroid-stimulating immunoglobulins (TSI) percentage

Answer 37

Decreased thyroid-stimulating hormone (TSH) level
MY ANSWER
The nurse should expect a TSH level below the expected reference range in a client who has Graves’ disease.

The nurse should expect TSI above the expected reference range in a client who has Graves’ disease.

Question 38

A nurse is assessing a client who has hyperthyroidism. The nurse should expect the client to report which of the following manifestations?

Sensitivity to cold
Constipation
Frequent mood changes
Weight gain of 4.5 kg (10 lb) in 3 weeks

Answer 38

Frequent mood changes
MY ANSWER
Hyperthyroidism develops when the thyroid gland produces an excess of the thyroid hormones that regulate the metabolic rate. Clients experience emotional lability that fluctuates between emotional hyperexcitability and irritability. They often cannot sit quietly.

Question 39

A nurse is caring for a client who has developed agranulocytosis as a result of taking propylthiouracil to treat hyperthyroidism. The nurse should understand that this client is at increased risk for which of the following conditions?

Excessive bleeding
Ecchymosis
Infection
Hyperglycemia

Answer 39

Infection
MY ANSWER
Agranulocytosis is a failure of the bone marrow to make enough white blood cells, causing neutropenia and lowering the body defenses against infection.

Question 40

A nurse is assessing an adolescent who has an exacerbation of Graves’ disease. Which of the following findings should the nurse expect?

Weight gain
Bradycardia
Lethargy
Heat intolerance

Answer 40

Heat intolerance
MY ANSWER
An exacerbation of Graves’ disease can cause heat intolerance due to an increased metabolic rate, which leads to warm flushed moist skin and extreme diaphoresis.

Question 40

A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client?

NPH insulin
Insulin glargine
Insulin detemir
Regular insulin

Answer 40

Regular insulin
Regular insulin is classified as a short-acting insulin. It can be given intravenously with an onset of action of less than 30 min. This is the insulin that is most appropriate in emergency situations of severe hyperglycemia or diabetic ketoacidosis.

Question 41

A nurse is assessing a client who is admitted for elective surgery and has a history of Addison’s disease. Which of the following findings should the nurse expect?

Hyperpigmentation
Intention tremors
Hirsutism
Purple striations

Answer 41

Hyperpigmentation
Addison’s disease is an endocrine disorder that occurs when the adrenal glands do not produce enough of the hormone cortisol, and in some cases, the hormone aldosterone. The disease is characterized by weight loss, muscle weakness, fatigue, low blood pressure, and hyperpigmentation (darkening) of the skin in both exposed and non-exposed parts of the body.

Question 42

A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following data should the nurse identify as the priority to monitor?

Airway patency
Temperature
Urination
Pain control

Answer 42

Airway patency
MY ANSWER
When using the airway, breathing, circulation approach to client care, the nurse should determine it is the priority to monitor the client’s airway. Nerve damage, hypocalcemia induced tetany, and edema can all impair the airway following thyroidectomy.

Question 42

A nurse is teaching about levothyroxine with a client who has primary hypothyroidism. Which of the following statements should the nurse use when teaching the client?

“Take this medication until your symptoms are gone and then discontinue.”
“Tremors, nervousness, and insomnia may indicate your dose is too high.”
“Symptoms improve immediately after starting the medication.”
“The medication decreases the overproduction of the thyroid hormone thyroxine.”

Answer 42

“Take this medication until your symptoms are gone and then discontinue.”
The nurse should teach that the medication replacement therapy is lifelong not discontinued.

“Tremors, nervousness, and insomnia may indicate your dose is too high.”
MY ANSWER
The nurse should teach that tremors, nervousness, and insomnia may indicate an overdose of the medication and to notify the provider.

“Symptoms improve immediately after starting the medication.”
The nurse should teach that It may take up to 6 weeks for the medication to reach the full effect.

“The medication decreases the overproduction of the thyroid hormone thyroxine.”
The nurse should teach that the medication is a synthetic thyroid hormone replacement and is not used to decrease overproduction the thyroxine.

Question 43

FLAG
A nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?

Check the pedal pulses.
Verify the most recent calcium level.
Request prescription for a relaxant.
Administer an oral potassium supplement.

Answer 43

Verify the most recent calcium level.
A client who has had a thyroidectomy is at risk of hypocalcemia due to the possible disruption of the parathyroid gland during surgery. The parathyroid glands are four small glands located inside the thyroid gland that are responsible for calcium regulation. If they are damaged during a thyroidectomy, there is a risk of hypocalcemia. Low calcium levels can be manifested as numbness and tingling of the fingers and around the mouth, muscle spasms (particularly of the hands and feet), and hyperactive reflexes. If a client develops any of these manifestations following a thyroidectomy, the nurse should check the client’s latest calcium level. The expected reference range for calcium is 8.5 to 10.5 mg/dL. If the calcium level is low, the provider should be notified, and oral or intravenous calcium replacement should be administered.

Clients who have low potassium levels often have leg cramps, rather than spasms. There is not a risk of low potassium associated with a thyroidectomy, and therefore this should not be a suspected cause of muscle cramps in this client. Additionally, the nurse should only administer a potassium supplement to a client who has confirmed hypokalemia.

Question 44

A nurse is caring for a client who has Addison’s disease and is at risk for Addisonian crisis. Which of the following actions should the nurse take?

Provide a low-carbohydrate diet.
Weigh the client daily.
Administer oral corticosteroids.
Restrict fluid intake.

Answer 44

Weigh the client daily.
MY ANSWER
Addison’s disease is an endocrine disorder that causes weight loss, muscle weakness, fatigue, low blood pressure, and hyperpigmentation (darkening) of the skin. Obtaining the client’s daily weight will alert the nurse that dehydration is developing, which could indicate an impending crisis.

Question 45

A nurse is reviewing guidelines to prevent DKA during periods of illness with a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

“Test your blood glucose level every 8 hours.”
“Check your urine for ketones when blood glucose levels are greater than 240 mg/dL.”
“Withhold your usual daily dose of insulin.”
“Drink 240 to 360 milliliters of calorie-free liquids every 8 hours.”

Answer 45

“Check your urine for ketones when blood glucose levels are greater than 240 mg/dL.”
MY ANSWER
The client should check his urine for ketones when blood glucose levels are greater than 240 mg/dL in order to detect DKA. The client should contact the provider if he has moderate or large amounts of ketones in his urine.

Question 46

A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse’s initial action?

Document the amount of drainage.
Obtain a culture of the drainage.
Check the drainage for glucose.
Notify the client’s provider.

Answer 46

Check the drainage for glucose.
A potential complication of hypophysectomy is cerebral spinal fluid (CSF) leakage. Fluid leakage from the nose is a sign that this complication has occurred. The first action the nurse should take using the nursing process is to assess the drainage for the presence of glucose, which would indicate that the drainage is CSF.

Question 47

A nurse is caring for a client who has diabetic ketoacidosis and hypoxia. Which of the following actions should the nurse take first?

Obtain a prescription to administer insulin.

Obtain a prescription to check the client’s glucose level.

Obtain a prescription for supplemental oxygen.

Obtain a prescription to administer intravenous fluids.

Answer 47

Obtain a prescription for supplemental oxygen.
CORRECT
My Answer
The first action the nurse should take when using the airway, breathing, circulation approach to client care is to obtain a prescription for supplemental oxygen. Supplemental oxygen is indicated in clients who have hypoxia to improve oxygenation.

Question 48

A nurse is caring for a child who has Addison’s disease. Which of the following actions should the nurse take?

Teach the parents about cortisol replacement therapy.
Place the child on a low-sodium diet.
Monitor the child for fluid volume excess.
Discuss the manifestations of hyperglycemia with the parents.

Answer 48

Teach the parents about cortisol replacement therapy.
The nurse should plan to teach the child’s parents about cortisol replacement therapy. Administration of glucocorticoids and mineralocorticoids is necessary because inadequate supplies or a sudden cessation of the medications can cause acute adrenal crisis.

Question 49

A nursing is providing dietary teaching for a client who has Cushing’s disease. Which of the following recommendations should nurse include in the teaching?

Limit intake of potassium-rich foods.
Restrict sodium intake.
Increase carbohydrate intake.
Decrease protein intake.

Answer 49

Restrict sodium intake.
MY ANSWER
The nurse should recommend the client to restrict sodium intake to control fluid volume. This restriction can range from “no-added-salt” to table foods to a restriction of 2 g/day.

Question 50

A nurse is assessing four clients on a medical unit. The nurse should identify which of the following clients as exhibiting positive manifestations of hypercortisolism?

A client who has a butterfly rash on his face.
Moon face
A client who has a positive Chvostek’s sign.
A client who has muscle hypertrophy.

Answer 50

Moon face
MY ANSWER
A client who has a moon face and fat pads on his neck, back and shoulders is exhibiting manifestations of hypercortisolism or Cushing’s syndrome.

Question 51

A nurse is caring for a client who had total thyroidectomy and a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect?

Tingling of the extremities
Hypoactive deep tendon reflexes.
Shortened QT intervals.
Constipation

Answer 51

Tingling of the extremities
A serum calcium level of 7.6 mg/dL is below the expected reference range, indicating hypocalcemia. A client who undergoes a total thyroidectomy is at risk for parathyroid injury which can lead to hypocalcemia. The nurse should monitor the client for reports of tingling and numbness of the extremities and around the mouth, muscle tremors, cramps and cardiac dysrhythmias.

Question 52

A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client?

Chvostek’s sign
Babinski’s sign
Brudzinski’s sign
Kernig’s sign

Answer 52

Chvostek’s sign
MY ANSWER
The nurse should suspect that the client has hypocalcemia, a possible complication following subtotal thyroidectomy. Manifestations of hypocalcemia include numbness and tingling in the hands, the soles of the feet, and around the lips, typically appearing between 24 and 48 hr after surgery. To elicit Chvostek’s sign, the nurse should tap the client’s face at a point just below and in front of the ear. A positive response would be twitching of the ipsilateral (same side only) facial muscles, suggesting neuromuscular excitability due to hypocalcemia.

Babinski’s sign
Babinski’s sign is a diagnostic test for brain damage or upper motor neuron damage. It is positive if the toes flare up when the nurse strokes the plantar aspect of the foot.
Brudzinski’s sign
Brudzinski’s sign is an indication of meningeal irritation, such as in clients who have meningitis. With the client supine, the nurse should place one hand behind his head and places her other hand on his chest. The nurse then raises the client’s head with her hand behind his head, while the hand on his chest restrains him and prevents him from rising. Flexion of the client’s lower extremities constitutes a positive sign.
Kernig’s sign
Kernig’s sign is an indication of meningeal irritation, such as in clients who have meningitis. The nurse performs the maneuver with the client supine with his hips and knees in flexion. The inability to extend the client’s knees fully without causing pain constitutes a positive test.

Question 53

A nurse is caring for a client who has Cushing’s syndrome. The nurse should recognize that which of the following are manifestations of Cushing’s syndrome? (Select all that apply.)

Alopecia
Tremors
Moon face
Purple striations
Buffalo hump

Answer 53

Alopecia
Moon face
Purple striations
Buffalo hump

Question 54

A nurse is assessing a client who has thyrotoxicosis after taking too high of a level of levothyroxine. Which of the following manifestations should the nurse expect?

Drowsiness
Bradycardia
Dry skin
Heat intolerance

Answer 54

Heat intolerance
MY ANSWER
The client who has an acute overdose of levothyroxine will exhibit heat intolerance, sweating, and hyperthermia. These manifestations are indications of excessive levels of thyroid hormone that could lead to death.

Question 55

A nurse is assessing a client who is admitted with hyperthyroidism. The client reports a weight loss of 5.4 kg (12 lb) in the last 2 months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. Which of the following actions should the nurse take to prevent a thyroid crisis?

Provide a quiet, low-stimulus environment.
Administer aspirin as prescribed for any sign of hyperthermia.
Keep the client NPO.
Observe the client carefully for signs of hypocalcemia.

Answer 55

Provide a quiet, low-stimulus environment.
MY ANSWER
Thyroid crisis can occur in response to a stressor, so the nurse should minimize stressful stimuli in the client’s environment.

Question 56

A nurse is caring for a client who is in a myxedema coma. Which of the following actions should the nurse take?

Turn the client ever 4 hr.
Check the client’s blood pressure every 2 hr.
Initiate measures to cool the client.
Place the client on aspiration precautions.

Answer 56

Place the client on aspiration precautions.
MY ANSWER
The nurse should place the client on aspiration precautions because the client can have decreased mental status and is at risk for laryngeal edema and tongue thickening.