Exam #3 PN 2 Ch. 64, 46-48, 41-44
Know what the left temporal lobe of brain affects as far as the senses
1. 1. A nurse prepares to teach a client who has experienced damage to the
left temporal lobe of the brain. Whic
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Exam #3 PN 2 Ch. 64, 46-48, 41-44
Know what the left temporal lobe of brain affects as far as the senses
1. 1. A nurse prepares to teach a client who has experienced damage to the
left temporal lobe of the brain. Which action should the nurse take when
providing education about newly prescribed medications to this client?
a. Help the client identify each medication by its color.
b. Provide written materials with large print size.
c. Sit on the clients right side and speak into the right ear.
d. Allow the client to use a white board to ask questions.
ANS: C
The temporal lobe contains the auditory center for sound interpretation.
The clients hearing will be impaired in the left ear. The nurse should sit on
the clients right side and speak into the right ear. The other interventions
do not address the clients left temporal lobe damage.
Know what hypoactive deep tendon reflexes affect
2. A nurse plans care for a client who has a hypoactive response to a test of
deep tendon reflexes. Which intervention should the nurse include in this clients
plan of care?
a. Check bath water temperature with a thermometer.
b. Provide the client with assistance when ambulating.
c. Place elastic support hose on the clients legs.
d. Assess the clients feet for wounds each shift.
ANS: B
Hypoactive deep tendon reflexes and loss of vibration sense can impair balance
and coordination, predisposing the client to falls. The nurse should plan to
provide the client with ambulation assistance to prevent injury. The other
interventions do not address the clients problem.
Know what things can interfere with MRI scans
10. A nurse obtains a focused health history for a client who is scheduled for
magnetic resonance imaging (MRI). Which condition should alert the nurse to
contact the provider and cancel the procedure?
a. Creatine phosphokinase (CPK) of 100 IU/L
b. Atrioventricular graft
c. Blood urea nitrogen (BUN) of 50 mg/dL
d. Internal insulin pump
ANS: D
Metal devices such as internal pumps, pacemakers, and prostheses interfere
with the accuracy of the image and can become displaced by the magnetic force
generated by an MRI procedure. An atrioventricular graft does not contain any
metal. CPK and BUN levels have no impact on an MRI procedure.
14. After teaching a client who is scheduled for magnetic resonance imaging
(MRI), the nurse assesses the clients understanding. Which client statement
indicates a correct understanding of the teaching?
a. I must increase my fluids because of the dye used for the MRI.
b. My urine will be radioactive so I should not share a bathroom.
c. I can return to my usual activities immediately after the MRI.
d. My gag reflex will be tested before I can eat or drink anything.
ANS: C
No postprocedure restrictions are imposed after MRI. The client can return to
normal activities after the test is complete. There are no dyes or radioactive
materials used for the MRI; therefore, increased fluids are not needed and the
clients urine would not be radioactive. The procedure does not impact the
clients gag reflex.
Know what a single-photon emission computed tomography (SPECT) scan is
and if there is any care required afterwards
20. A nurse cares for a client who is recovering from a single-photon emission
computed tomography (SPECT) with a radiopharmaceutical agent. Which
statement should the nurse include when discussing the plan of care with this
client?
a. You may return to your previous activity level immediately.
b. You are radioactive and must use a private bathroom.
c. Frequent assessments of the injection site will be completed.
d. We will be monitoring your renal functions closely.
ANS: A
The client may return to his or her previous activity level immediately.
Radioisotopes will be eliminated in the urine after SPECT, but no monitoring or
special precautions are required. The injection site will not need to be assessed
after the procedure is complete.
Know what imitrex is and any side effects associated with it
3. A nurse obtains a health history on a client prior to administering prescribed
sumatriptan succinate (Imitrex) for migraine headaches. Which condition should
alert the nurse to hold the medication and contact the health care provider?
a. Bronchial asthma
b. Prinzmetals angina
c. Diabetes mellitus
d. Chronic kidney disease
ANS: B
Sumatriptan succinate effectively reduces pain and other associated symptoms
of migraine headache by binding to serotonin receptors and triggering cranial
vasoconstriction. Vasoconstrictive effects are not confined to the cranium and
can cause coronary vasospasm in clients with Prinzmetals angina. The other
conditions would not affect the clients treatment.
What is bacterial meningitis and how is it contracted?
9. A nurse obtains a focused health history for a client who is suspected of
having bacterial meningitis. Which question should the nurse ask?
a. Do you live in a crowded residence?
b. When was your last tetanus vaccination?
c. Have you had any viral infections recently?
d. Have you traveled out of the country in the last month?
ANS: A
Meningococcal meningitis tends to occur in multiple outbreaks. It is most likely
to occur in areas of high-density population, such as college dormitories,
prisons, and military barracks. A tetanus vaccination would not place the client
at increased risk for meningitis or protect the client from meningitis. A viral
infection would not lead to bacterial meningitis but could lead to viral
meningitis. Simply knowing if the client traveled out of the country does not
provide enough information. The nurse should ask about travel to specific
countries in which the disease is common, for example, sub-Saharan Africa.
What are clinical manifestations of Parkinson’s?
10. After teaching the wife of a client who has Parkinson disease, the nurse
assesses the wifes understanding. Which statement by the clients wife indicates
she correctly understands changes associated with this disease?
a. His masklike face makes it difficult to communicate, so I will use a white
board.
b. He should not socialize outside of the house due to uncontrollable drooling.
c. This disease is associated with anxiety causing increased perspiration.
d. He may have trouble chewing, so I will offer bite-sized portions.
ANS: D
Because chewing and swallowing can be problematic, small frequent meals and
a supplement are better for meeting the clients nutritional needs. A masklike
face and drooling are common in clients with Parkinson disease. The client
should be encouraged to continue to socialize and communicate as normally as
possible. The wife should understand that the clients masklike face can be
misinterpreted and additional time may be needed for the client to
communicate with her or others. Excessive perspiration is also common in
clients with Parkinson disease and is associated with the autonomic nervous
systems response.
11. A nurse plans care for a client with Parkinson disease. Which intervention
should the nurse include in this clients plan of care?
a. Ambulate the client in the hallway twice a day.
b. Ensure a fluid intake of at least 3 liters per day.
c. Teach the client pursed-lip breathing techniques.
d. Keep the head of the bed at 30 degrees or greater.
ANS: D
Elevation of the head of the bed will help prevent aspiration. The other options
will not prevent aspiration, which is the greatest respiratory complication of
Parkinson disease, nor do these interventions address any of the complications
of Parkinson disease. Ambulation in the hallway is usually implemented to
prevent venous thrombosis. Increased fluid intake flushes out toxins from the
clients blood. Pursed-lip breathing increases exhalation of carbon dioxide.
Know patient/family teaching for Alzheimer’s and what the medications do
12. A nurse is teaching the daughter of a client who has Alzheimers disease. The
daughter asks, Will the medication my mother is taking improve her dementia?
How should the nurse respond?
a. It will allow your mother to live independently for several more years.
b. It is used to halt the advancement of Alzheimers disease but will not cure it.
c. It will not improve her dementia but can help control emotional responses.
d. It is used to improve short-term memory but will not improve problem solving.
ANS: C
Drug therapy is not effective for treating dementia or halting the advancement
of Alzheimers disease. However, certain drugs may help suppress emotional
disturbances and psychiatric manifestations. Medication therapy may not allow
the client to safely live independently.
13. A nurse assesses a client with Alzheimers disease who is recently admitted
to the hospital. Which psychosocial assessment should the nurse complete?
a. Assess religious and spiritual needs while in the hospital.
b. Identify the clients ability to perform self-care activities.
c. Evaluate the clients reaction to a change of environment.
d. Ask the client about relationships with family members.
ANS: C
As Alzheimers disease progresses, the client experiences changes in emotional
and behavioral affect. The nurse should be alert to the clients reaction to a
change in environment, such as being hospitalized, because the client may
exhibit an exaggerated response, such as aggression, to the event. The other
assessments should be completed but are not as important as assessing the
clients reaction to environmental change.
14. A nurse witnesses a client with late-stage Alzheimers disease eat breakfast.
Afterward the client states, I am hungry and want breakfast. How should the
nurse respond?
a. I see you are still hungry. I will get you some toast.
b. You ate your breakfast 30 minutes ago.
c. It appears you are confused this morning.
d. Your family will be here soon. Lets get you dressed.
ANS: A
Use of validation therapy with clients who have Alzheimers disease involves
acknowledgment of the clients feelings and concerns. This technique has proved
more effective in later stages of the disease, when using reality orientation only
increases agitation. Telling the client that he or she already ate breakfast may
agitate the client. The other statements do not validate the clients concerns.
16. A nurse cares for a client with advanced Alzheimers disease. The clients
caregiver states, She is always wandering off. What can I do to manage this
restless behavior? How should the nurse respond?
a. This is a sign of fatigue. The client would benefit from a daily nap.
b. Engage the client in scheduled activities throughout the day.
c. It sounds like this is difficult for you. I will consult the social worker.
d. The provider can prescribe a mild sedative for restlessness.
ANS: B
Several strategies may be used to cope with restlessness and wandering. One
strategy is to engage the client in structured activities. Another is to take the
client for frequent walks. Daily naps and a mild sedative will not be as effective
in the management of restless behavior. Consulting the social worker does not
address the caregivers concern.
17. A nurse prepares to discharge a client with Alzheimers disease. Which
statement should the nurse include in the discharge teaching for this clients
caregiver?
a. Allow the client to rest most of the day.
b. Place a padded throw rug at the bedside.
c. Install deadbolt locks on all outside doors.
d. Provide a high-calorie and high-protein diet.
ANS: C
How do you treat lower back pain?
1. A nurse promotes the prevention of lower back pain by teaching clients at a
community center. Which instruction should the nurse include in this education?
a. Participate in an exercise program to strengthen muscles.
b. Purchase a mattress that allows you to adjust the firmness.
c. Wear flat instead of high-heeled shoes to work each day.
d. Keep your weight within 20% of your ideal body weight.
ANS: A
Exercise can strengthen back muscles, reducing the incidence of low back pain.
The other options will not prevent low back pain.
2. A nurse plans care for a client with lower back pain from a work-related injury.
Which intervention should the nurse include in this clients plan of care?
a. Encourage the client to stretch the back by reaching toward the toes.
b. Massage the affected area with ice twice a day.
c. Apply a heating pad for 20 minutes at least four times daily.
d. Advise the client to avoid warm baths or showers.
ANS: C
Heat increases blood flow to the affected area and promotes healing of injured
nerves. Stretching and ice will not promote healing, and there is no need to
avoid warm baths or showers.
4. A nurse assesses clients at a community center. Which client is at greatest
risk for lower back pain?
a. A 24-year-old female who is 25 weeks pregnant
b. A 36-year-old male who uses ergonomic techniques
c. A 45-year-old male with osteoarthritis
d. A 53-year-old female who uses a walker
ANS: C
Osteoarthritis causes changes to support structures, increasing the clients risk
for low back pain. The other clients are not at high risk.
What happens with spinal cord injuries at level T5? Clinical manifestations?
7. A nurse assesses a client with a spinal cord injury at level T5. The clients
blood pressure is 184/95 mm Hg, and the client presents with a flushed face and
blurred vision. Which action should the nurse take first?
a. Initiate oxygen via a nasal cannula.
b. Place the client in a supine position.
c. Palpate the bladder for distention.
d. Administer a prescribed beta blocker.
ANS: C
The client is manifesting symptoms of autonomic dysreflexia. Common causes
include bladder distention, tight clothing, increased room temperature, and fecal
impaction. If persistent, the client could experience neurologic injury.
Precipitating conditions should be eliminated and the physician notified. The
other actions would not be appropriate.
7. A nurse assesses a client who experienced a spinal cord injury at the T5 level
12 hours ago. Which manifestations should the nurse correlate with neurogenic
shock? (Select all that apply.)
a. Heart rate of 34 beats/min
b. Blood pressure of 185/65 mm Hg
c. Urine output less than 30 mL/hr
d. Decreased level of consciousness
e. Increased oxygen saturation
ANS: A, C, D
Neurogenic shock with acute spinal cord injury manifests with decreased oxygen
saturation, symptomatic bradycardia, decreased level of consciousness,
decreased urine output, and hypotension.
What happens in cervical spine injuries? Clinical manifestations?
8. An emergency room nurse initiates care for a client with a cervical spinal cord
injury who arrives via emergency medical services. Which action should the
nurse take first?
a. Assess level of consciousness.
b. Obtain vital signs.
c. Administer oxygen therapy.
d. Evaluate respiratory status.
ANS: D
The first priority for a client with a spinal cord injury is assessment of respiratory
status and airway patency. Clients with cervical spine injuries are particularly
prone to respiratory compromise and may even require intubation. The other
assessments should be performed after airway and breathing are assessed
What is the purpose of rehabilitation for patients with paraplegia?
11. A nurse is caring for a client with paraplegia who is scheduled to participate
in a rehabilitation program. The client states, I do not understand the need for
rehabilitation; the paralysis will not go away and it will not get better. How
should the nurse respond?
a. If you dont want to participate in the rehabilitation program, Ill let the
provider know.
b. Rehabilitation programs have helped many clients with your injury. You should
give it a chance.
c. The rehabilitation program will teach you how to maintain the functional
ability you have and prevent further disability.
d. When new discoveries are made regarding paraplegia, people in rehabilitation
programs will benefit first.
ANS: C
Participation in rehabilitation programs has many purposes, including prevention
of disability, maintenance of functional ability, and restoration of function. The
other responses do not meet this clients needs.
6. A nurse assesses a client with paraplegia from a spinal cord injury and notes
reddened areas over the clients hips and sacrum. Which actions should the
nurse take? (Select all that apply.)
a. Apply a barrier cream to protect the skin from excoriation.
b. Perform range-of-motion (ROM) exercises for the hip joint.
c. Re-position the client off of the reddened areas.
d. Get the client out of bed and into a chair once a day.
e. Obtain a low-air-loss mattress to minimize pressure.
ANS: C, E
What are the clinical manifestations of early multiple sclerosis (MS)?
13. A nurse assesses a client with early-onset multiple sclerosis (MS). Which
clinical manifestation should the nurse expect to find?
a. Hyperresponsive reflexes
b. Excessive somnolence
c. Nystagmus
d. Heat intolerance
ANS: C
Early signs and symptoms of MS include changes in motor skills, vision, and
sensation. Hyperresponsive reflexes, excessive somnolence, and heat
intolerance are later manifestations of MS.
Know what Gilenya medication is used for and any side effects that can be
caused
15. A nurse assesses a client with multiple sclerosis after administering
prescribed fingolimod (Gilenya). For which adverse effect should the nurse
monitor?
a. Peripheral edema
b. Black tarry stools
c. Bradycardia
d. Nausea and vomiting
ANS: C
Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia,
especially within the first 6 hours after administration. Peripheral edema, black
and tarry stools, and nausea and vomiting are not adverse effects of fingolimod.
Know the late clinical manifestation of ALS
17. A nurse assesses a client with a neurologic disorder. Which assessment
finding should the nurse identify as a late manifestation of amyotrophic lateral
sclerosis (ALS)?
a. Dysarthria
b. Dysphagia
c. Muscle weakness
d. Impairment of respiratory muscles
ANS: D
In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops.
Eventually, the respiratory muscles are involved, which leads to respiratory
compromise. Dysarthria, dysphagia, and muscle weakness are early clinical
manifestations of ALS.
What is Guillain-Barre? What are the clinical manifestations? How is it treated?
1. A client is admitted with Guillain-Barr syndrome (GBS). What assessment
takes priority?
a. Bladder control
b. Cognitive perception
c. Respiratory system
d. Sensory functions
ANS: C
Clients with GBS have muscle weakness, possibly to the point of paralysis. If
respiratory muscles are paralyzed, the client may need mechanical ventilation,
so the respiratory system is the priority. The nurse will complete urinary,
cognitive, and sensory assessments as part of a thorough evaluation.
2. The nurse learns that the pathophysiology of Guillain-Barr syndrome includes
segmental demyelination. The nurse should understand that this causes what?
a. Delayed afferent nerve impulses
b. Paralysis of affected muscles
c. Paresthesia in upper extremities
d. Slowed nerve impulse transmission
ANS: D
Demyelination leads to slowed nerve impulse transmission. The other options
are not correct.
3. A client with Guillain-Barr syndrome is admitted to the hospital. The nurse
plans caregiving priority to interventions that address which priority client
problem?
a. Anxiety
b. Low fluid volume
c. Inadequate airway
d. Potential for skin breakdown
ANS: C
Airway takes priority. Anxiety is probably present, but a physical diagnosis takes
priority over a psychosocial one. The client has no reason to have low fluid
volume unless he or she has been unable to drink for some time. If present,
airway problems take priority over a circulation problem. An actual problem
takes precedence over a risk for a problem.
12. An older client is hospitalized with Guillain-Barr syndrome. A family member
tells the nurse the client is restless and seems confused. What action by the
nurse is best?
a. Assess the clients oxygen saturation.
b. Check the medication list for interactions.
c. Place the client on a bed alarm.
d. Put the client on safety precautions.
ANS: A
In the older adult, an early sign of hypoxia is often confusion and restlessness.
The nurse should first assess the clients oxygen saturation. The other actions
are appropriate, but only after this assessment occurs.
4. An older adult client is hospitalized with Guillain-Barr syndrome. The client is
given amitriptyline (Elavil). After receiving the hand-off report, what actions by
the nurse are most important? (Select all that apply.)
a. Administering the medication as ordered
b. Advising the client to have help getting up
c. Consulting the provider about the drug
d. Cutting the dose of the drug in half
e. Placing the client on safety precautions
ANS: B, C, E
5. The nurse caring for a client with Guillain-Barr syndrome has identified the
priority client problem of decreased mobility for the client. What actions by the
nurse are best? (Select all that apply.)
a. Ask occupational therapy to help the client with activities of daily living.
b. Consult with the provider about a physical therapy consult.
c. Provide the client with information on support groups.
d. Refer the client to a medical social worker or chaplain.
e. Work with speech therapy to design a high-protein diet.
ANS: A, B, E
How do patients protect their eyes? What teaching can we provide?
1. The nurse has given a community group a presentation on eye health. Which
statement by a participant indicates a need for more instruction?
a. I always lose my sunglasses, so I dont wear them.
b. I have diabetes and get an annual eye exam.
c. I will not share my contact solution with others.
d. I will wear safety glasses when I mow the lawn.
ANS: A
Know the normal range for the IOP
5. A clients intraocular pressure (IOP) is 28 mm Hg. What action by the nurse is
best?
a. Educate the client on corneal transplantation.
b. Facilitate scheduling the eye surgery.
c. Plan to teach about drugs for glaucoma.
d. Refer the client to local Braille classes.
ANS: C
This increased IOP indicates glaucoma. The nurses main responsibility is
teaching the client about drug therapy. Corneal transplantation is not used in
glaucoma. Eye surgery is not indicated at this time. Braille classes are also not
indicated at this time.
What should we teach patients about eye drops? How do they instill eye drops?
2. A client is seen in the ophthalmology clinic with bacterial conjunctivitis. Which
statements by the client indicate a good understanding of home management of
this condition? (Select all that apply.)
a. As long as I dont wipe my eyes, I can share my towel.
b. Eye irrigations should be done with warm saline or water.
c. I will throw away all my eye makeup when I get home.
d. I wont touch the tip of the eyedrop bottle to my eye.
e. When the infection is gone, I can use my contacts again.
ANS: C, D
How do you treat external otitis?
5. A client has external otitis. On what comfort measure does the nurse instruct
the client?
a. Applying ice four times a day
b. Instilling vinegar-and-water drops
c. Use of a heating pad to the ear
d. Using a home humidifier
ANS: C
A heating pad on low or a warm moist pack can provide comfort to the client
with otitis externa. The other options are not warranted.
What are the steps for instilling ear drops?
10. A nursing student is instructed to remove a clients ear packing and instill
eardrops. What action by the student requires intervention by the registered
nurse?
a. Assessing the eardrum with an otoscope
b. Inserting a cotton ball in the ear after the drops
c. Warming the eardrops in water for 5 minutes
d. Washing the hands and removing the packing
ANS: D
The student should wash his or her hands, don gloves, and then remove the
packing. The other actions are correct.
What should you teach patients concerning how to prevent hearing loss?
13. A nurse is teaching a community group about preventing hearing loss. What
instruction is best?
a. Always wear a bicycle helmet.
b. Avoid swimming in ponds or lakes.
c. Dont go to fireworks displays.
d. Use a soft cotton swab to clean ears.
ANS: A
Avoiding head trauma is a practical way to help prevent hearing loss. Swimming
can lead to hearing loss if the client has repeated infections. Fireworks displays
are loud, but usually brief and only occasional. Nothing smaller than the clients
fingertip should be placed in the ear canal.
What is mastoiditis and what complications can occur from it?
-No answer for this one.. Mastoiditis is an infection of the mastoid air cells
caused by progressive otitis media. Antibx therapy is used to treat the middle
ear infection before it progresses to mastoiditis. If mastoiditis is not managed
appropriately, it can lead to brain abscess, meningitis and death.
Know what labs to check with diabetes and polyuria
-keytones and specific gravity, A1C
1.A nurse is teaching a client with diabetes mellitus who asks, Why is it
necessary to maintain my blood glucose levels no lower than about 60 mg/dL?
How should the nurse respond?
a. Glucose is the only fuel used by the body to produce the energy that it needs.
b. Your brain needs a constant supply of glucose because it cannot store it.
c. Without a minimum level of glucose, your body does not make red blood cells.
d. Glucose in the blood prevents the formation of lactic acid and prevents acidosis.
ANS: B
2.A nurse reviews laboratory results for a client with diabetes mellitus who
presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which
laboratory result should the nurse correlate with the clients polyuria?
a. Serum sodium: 163 mEq/L
b. Serum creatinine: 1.6 mg/dL
c. Presence of urine ketone bodies
d. Serum osmolarity: 375 mOsm/kg
ANS: D
Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to
polyuria from an osmotic diuresis. The clients serum osmolarity is high. The
clients sodium would be expected to be high owing to dehydration. Serum
creatinine and urine ketone bodies are not related to the polyuria.
Know what to teach patients about controlling their diabetes and why they
should control it
6.A nurse teaches a client who is diagnosed with diabetes mellitus. Which
statement should the nurse include in this clients plan of care to delay the onset
of microvascular and macrovascular complications?
a. Maintain tight glycemic control and prevent hyperglycemia.
b. Restrict your fluid intake to no more than 2 liters a day.
c. Prevent hypoglycemia by eating a bedtime snack.
d. Limit your intake of protein to prevent ketoacidosis.
ANS: A
36.After teaching a client with type 2 diabetes mellitus, the nurse assesses the
clients understanding. Which statement made by the client indicates a need for
additional teaching?
a. I need to have an annual appointment even if my glucose levels are in good control.
b. Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick.
c. I can still develop complications even though I do not have to take insulin at this time.
d. If I have surgery or get very ill, I may have to receive insulin injections for a short time.
ANS: B
Clients with diabetes need to be seen at least annually to monitor for long-term
complications, including visual changes, microalbuminuria, and lipid analysis.
The client may develop complications and may need insulin in the future.
36.After teaching a client with type 2 diabetes mellitus, the nurse assesses the
clients understanding. Which statement made by the client indicates a need for
additional teaching?
a. I need to have an annual appointment even if my glucose levels are in good control.
b. Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick.
c. I can still develop complications even though I do not have to take insulin at this time.
d. If I have surgery or get very ill, I may have to receive insulin injections for a short time.
ANS: B
How is insulin stored?
15.A nurse cares for a client with diabetes mellitus who is visually impaired. The
client asks, Can I ask my niece to prefill my syringes and then store them for
later use when I need them? How should the nurse respond?
a
.
Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position
with the needle pointing up.
b
.
Yes. Syringes can be filled with insulin and stored for a month in a location that is
protected from light.
c
.
Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass
syringes.
d
.
No. Insulin syringes cannot be prefilled and stored for any length of time outside of the
container.
ANS: A
Insulin is relatively stable when stored in a cool, dry place away from light. When
refrigerated, prefilled plastic syringes are stable for up to 3 weeks. They should
be stored in the refrigerator in the vertical position with the needle pointing up
to prevent suspended insulin particles from clogging the needle.
What causes Kussmaul respirations and what is it?
20.A nurse cares for a client experiencing diabetic ketoacidosis who presents
with Kussmaul respirations. Which action should the nurse take?
a. Administration of oxygen via face mask
b. Intravenous administration of 10% glucose
c. Implementation of seizure precautions
d. Administration of intravenous insulin
ANS: D
The rapid, deep respiratory efforts of Kussmaul respirations are the bodys
attempt to reduce the acids produced by using fat rather than glucose for fuel.
2.A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For
which manifestations should the nurse monitor the client? (Select all that
apply.)
a. Deep and fast respirations
b. Decreased urine output
c. Tachycardia
d. Dependent pulmonary crackles
e. Orthostatic hypotension
ANS: A, C, E
DKA leads to dehydration, which is manifested by tachycardia and orthostatic
hypotension. Usually clients have Kussmaul respirations, which are fast and
deep. Increased urinary output (polyuria) is severe. Because of diuresis and
dehydration, peripheral edema and crackles do not occur.
Know how to detect decreased kidney function and know the normal value for
urine specific gravity
29.A nurse assesses a client with diabetes mellitus. Which clinical manifestation
should alert the nurse to decreased kidney function in this client?
a. Urine specific gravity of 1.033
b. Presence of protein in the urine
c. Elevated capillary blood glucose level
d. Presence of ketone bodies in the urine
ANS: B
Renal dysfunction often occurs in the client with diabetes. Proteinuria is a result
of renal dysfunction.
Know which electrolytes are affected by insulin and why
32.A nurse reviews the laboratory results of a client who is receiving intravenous
insulin. Which should alert the nurse to intervene immediately?
a. Serum chloride level of 98 mmol/L
b. Serum calcium level of 8.8 mg/dL
c. Serum sodium level of 132 mmol/L
d. Serum potassium level of 2.5 mmol/L
ANS: D
Insulin activates the sodium-potassium ATPase pump, increasing the movement
of potassium from the extracellular fluid into the intracellular fluid, resulting in
hypokalemia. In hyperglycemia, hypokalemia can also result from excessive
urine loss of potassium. The chloride level is normal. The calcium and sodium
levels are slightly low, but this would not be related to hyperglycemia and
insulin administration.
Know which medications are safe or not safe to give after IV contrast has been
given (Actos, Amaryl, Glucotrol, Glucophage)
39.A nurse reviews the medication list of a client recovering from a computed
tomography (CT) scan with IV contrast to rule out small bowel obstruction.
Which medication should alert the nurse to contact the provider and withhold
the prescribed dose?
a. Pioglitazone (Actos)
b. Glimepiride (Amaryl)
c. Glipizide (Glucotrol)
d. Metformin (Glucophage)
ANS: D
Glucophage should not be administered when the kidneys are attempting to
excrete IV contrast from the body. This combination would place the client at
high risk for kidney failure. The nurse should hold the metformin dose and
contact the provider. The other medications are safe to administer after
receiving IV contrast.
Know the normal ranges for : Fasting blood glucose, postprandial blood
glucose, hemoglobin A1C
41.A nurse reviews laboratory results for a client with diabetes mellitus who is
prescribed an intensified insulin regimen:
Fasting blood glucose: 75 mg/dL
Postprandial blood glucose: 200 mg/dL
Hemoglobin A1c level: 5.5%
How should the nurse interpret these laboratory findings?
a. Increased risk for developing ketoacidosis
b. Good control of blood glucose
c. Increased risk for developing hyperglycemia
d. Signs of insulin resistance
ANS: B
The client is maintaining blood glucose levels within the defined ranges for goals
in an intensified regimen. Because the clients glycemic control is good, he or
she is not at higher risk for ketoacidosis or hyperglycemia and is not showing
signs of insulin resistance.
Know complications that occur after an implantation of a vagal nervestimulation device
8. A nurse assesses a client who is recovering from the implantation of a vagal
nerve stimulation device. For which clinical manifestations should the nurse
assess as common complications of this procedure? (Select all that apply.)
a. Bleeding
b. Infection
c. Hoarseness
d. Dysphagia
e. Seizures
ANS: C, D
Know what meningitis is and what lab values can be affected
9. A nurse is caring for a client with meningitis. Which laboratory values should
the nurse monitor to identify potential complications of this disorder? (Select all
that apply.)
a. Sodium level
b. Liver enzymes
c. Clotting factors
d. Cardiac enzymes
e. Creatinine level
ANS: A, C
Know the care of a patient wearing a halo fixator
8. A nurse plans care for a client with a halo fixator. Which interventions should
the nurse include in this clients plan of care? (Select all that apply.)
a. Tape a halo wrench to the clients vest.
b. Assess the pin sites for signs of infection.
c. Loosen the pins when sleeping.
d. Decrease the clients oral fluid intake.
e. Assess the chest and back for skin breakdown.
ANS: A, B, E
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