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sem 1 med surg final
| Question | Answer |
|---|---|
| when the nurse removes an NG tube that has been placed for 7 days, the pt develops nosebleeds. To control nosebleeds, the nurse should: | pinch the soft lower portion of the nose for 10-15 min |
| When the nurse is deflatin the cuff of a tracheostomy tube to evaluate the patient's ability to swallow, it is important to: | suction the pt's mouth before deflating the cuff |
| A patient returns from surgery with a trach tube aafter a total laryngectomy and radial neck dissection. In caring for the pt in the first 24 hours, the priority nursing action is to: | Assess the airway and breath sounds |
| Following assessment of a pt with pneumonia, whe nurse identifies a nursing dx of "ineffective airway clearance". Which info best supports this dx? | weak, nonproductive cough effort |
| To promote airway clearance in a pt with pneumonia, the nurse instructs the pt to | splint the chest when coughing |
| To protect at from aspiration pneumonia, the nurse will | positon pt with altered LOC laterally |
| A pt with possible TB presents, the best time to take a sputum culture is: | immediately upon waking in the AM |
| In a pt with active TB, the disease can be transmitted to others until: | 3 acid fast bacilli smears are negative |
| An alcoholic homeless pt is diagnosed with TB. What is the most effective intervention to ensure adherance to tx? | daily noontime meal with meds at the community center |
| Pt has in injury from a MVA. What is the initial assessment that is most concerning? | Paradoxical chest wall movement |
| A patient with incision pain, poor cough effort and ronchi has a dx of "ineffective airway clearance" after a pneumonectomy - what is your first action to promote airway clearance? | qMedicate the pt with morphine |
| A 68yo male w/ hx of COPD is admitted with cor pulmonale. What clinical manifestation is consistent with cor pulmonale? | 3+edema in LE |
| A at is admitted w/ pneumonia and c/o sharp pain when taking a deep breath. What shoud the nurse do? | Listen to the lungs |
| A pt receiving is receiving SQ heparin to treat a PE. Which assessment data is most important to tell the HCP? | BP 90/46 |
| a nurse has four clients, which one will she assess first? | 46 yo who is having dyspnea one hour after thoracentesis |
| A patient just had a total laryngectomy and a radical neck dissection. The nurse should assess and intervene for theses problems in the following order: | client is laying in bed w/ head elevated a zero degrees, client is coughing up blood tinged secretions from tracheostomy, hemovac has 200ml of bloody drainiage, NG tube is disconnected from suction and clamped off |
| The following strategy is a priority when planning care for a PT with HTN who has no insurance: | follow evidence-based national guidelines |
| To check if aromatherapy was effective on a pt after surgery: | the nurse will assess the client's pulse and BP |
| A client w/ resp distress is admited to the hospital. The nurse, during her first assessment, should: | do a focused resp assessment and ask questions that are specific to this exacerbation of resp distress |
| An 80yo client is on RA and has an ABG analysis, which of the following is normal? | PAO2 40mm, O2sat=92%, PH 7.38, PaCO@ 82 |
| A nurse is caring for a patient with respiratory disease. The patient's SpO2 drops from 94% to 85% while ambulating. The nurse determines: | supplemental O2 should be used when the pt exercises |
| A pt w/ chronic hypoxemia (89-90%) caused by COPD has been admitted with increased SOB. Which of the following actions by the nurse will be the most effective in improving compliance with discharge teaching? | Arrange for the pt's spouse to be present during teaching |
| A pt who had a rhinoplasty to correct nasal deformities from a MVA. Aht is the most appropriate nursing intervention? | instruct the pt to keep head elevated for 48 hours to minimize swelling |
| When teaching a pt with allergic rhinitis about management, the RN explains: | identification and avoidance of triggers is the best way to managed |
| The nurse will plan on administering the flu vaccine to: | a 30yo who takes corticosteroids for RA |
| A 76yo pt has influenza, what should the nurse report to the HCP? | diffuse crackles in the lungs |
| The RN can delegate whoch to a UAP? | remind the pt to apply a CPAP at bedtime |
| An 82yo pt w/ nosebleed has nasal packing. What assessment requires immediate action? | O2 sat 89% |
| A pt w/ pneumonia has a fever of 101.2, nonproductive cough, 02 89%. He is very weak and needs assistance getting out of bed. Best nursing dx is: | impaired gas exchange r/t respiratory congestion |
| Pt w/ rt lower lobe pneumonia has had IV antibiotics for 2 days. Which lab indicates effectiveness? | WBC count 9000 |
| After two mo. of tx for TB w/ the standard 4 drug regimen, the pt continues to have positive sputum smears. The nurse discusses with tx regimen with the pt knowing that: | direct observed therapy (DOT) will be needed if the medications have not been taken correctly |
| A pt is scheduled for a lobectomy for stage 1 non-small cell lung cancer, the pt says they would rather die than have radiation or the surgery. which is the most appropriate response by the nurse? | tell me what you know about the various treatments available. |
| A newly diagnosed lung cancer patient says"I think I am going to die soon". THe best response by the nurse is: | can you tell me what makes you think that you will die soon? |
| Pt is admitted to the ER with a stab wound to his chest. Air can be heard entering the chest with each inspiration. To decrease the possibility of tension pneumothorax, the nurse should: | tape a nonporous dressing on three sides over the chest wound |
| A 76yo is admittd to the Er with confusion, chills, CP that worsens on inspiration. What is the highest priority nursing task? | obtain vitals and O2 sat |
| A pt with a pleural effusion is scheduled for a thoracentesis. Prior to the procedure, the nurse will plan to: | position the pt sitting upright on the edge of the bed and leaning forward |
| All are orders for a pt with possible pneumonia and sepsis. Which is the priority? | Obtain blood cultures from two sites |
| A pt with asthma has a prescription for Advair diskus (fluticasone and salmeterol). What is the purpose of these two drugs? | one drug is to decrease the inflamation and the other is a bronchodilator |
| THe healthcare provider prescribes triamcinalone MDI - 2 puffs q8h and pirbuterol MDI 2 puffs 4x per day. What should the nurse teach the pt about MDI's. | using a spacer with the MDI improves the inhalation of the medications |
| Which finding best indicates that acute asthma exacerbation is responding to bronchodilator therapy? | Wheezes are more easily heard |
| During an assessment of a pt w/ a hx of asthma, the nurse notes wheezing and dyspnea. The nurse will anticipate giving medications to reduce: | airway narrowing |
| Pt w/ an acute exacerbation of COPD has the following ABG's - PH 7.32, PaO2 55mmhg, PaCO2 55mmhg, SaO2 86%. the nurse recognizes this as evidence of | Respiratory acidosis |
| Pt is seen in the clinic with COPD. Which information given by the pt would help most in confirming a dx of chronic bronchitis? | Pt c/o productive cough every winter for two months |
| A nurse teaches a pt w/ COPD how to do pursed lip breathing, explaining that this will assist respiration by: | preventing airway collapse and air trapping in the lungs duing expiration |
| Pt w/ COPD asks home health nurse about O2 use. The nurse should teach teh pt that long term O2 therapy: | can improve the pt prognosis and quality of life |
| To have the best gas exchange in a pt with COPD, position the pt: | sitting up at the bedside in a chair, leaning slightly forward |
| A 26 yo with CF has harsh lung changes and cor pulmonale. Expected outcome: | achieve a realistic attitude toward tx |
| 23yo has CF. Nursing interventions would be to: | perform chest physiotherapy q4h to mobilize secretions |
| The nurse knows that teaching about nutrition is effective in the COPD pt when the pt states: | i will have an ice cream snack every day |
| Teaching is successful with homecare of an asthma pt when pt states: | no changes in my medication are needed if my peak flow is at 80% of normal |
| The nurse is assessing a 36yo woman admitted for knee surgery. Which info obtained during the preoperative assessment should be communicated to the surgeon prior to surgery? | th pt states her LMP was 8 wks ago |
| When the nurse is performing a physical examination of a pt who smokes and who is being admitted on the day of surgery, it is especially important to: | auscultate for adventitious breath sounds |
| Appropriate preoperative teaching fo a pt scheduled for abdominal surgery includes: | methods for effective C&DB |
| 10 mins after receiving the ordered preoperative opioid by IV injection the pt asks to get up and go to the bathroom. The most appropriate action by the nurse is to: | offer a urinal or a bedpan and position clint to promote voiding |
| A 52yo pt has a new dx of pernicious anemia. After teaching the pt about pernicious anemia, the nurse determines understanding when the pt states: | i will need to have cobalamin (b12) injections for the rest of my life |
| Intraoperative activity performed by perioperative circulating nurse is: | admitting, identifying and assessing the pt |
| orientation of new staff to the scrub nurse role. Nurse knows that teaching has been effective when the new nurse: | keeps both hands above the operating table |
| Data obtained during the peri-op assessment that indicate a need for special protectiontechniques during surgery include: | having a hx of spinal and hip arthritis |
| A pt asks, "will the dr put me to sleep with a mask?" | a drug will be injected through the IV which will induce sleep |
| The nurse recognizes that the use of local anesthesia would be particularly beneficial to the pt if the pt" | has recently taken in food or fluids |
| During surgery a pt receives a neuromuscular blocking agent as an adjunct to a general anesthetic. After surgery it is most important for the nurse to monitor: | weak chest wall movement |
| Which of these actions by an inexperienced staff memeber would cause the nurse to intervene? | walking into the hallway outside the OR without hair covered |
| 42yo patient is in the PACU. BP 124/70, 30 min later 112/60, pulse 72, warm dry skin. What should you do? | continue to monitor VS q 15 min. |
| There is a new nurse in the PACU. The charge nurse evaluates her orientation successfully when: | she turns the pt on their side upon arrival in the PACU |
| When a pt is transferred from the PACU to the unit, the first action by the RN on the unit should be to: | take the pt's vital signs |
| The NG tube is removed on the second postoperative day for a pt who had abdominal surgery. A clear liquid diet is ordered. Four hours later, the pt c/o of abdominal distension and sharp, cramping gas pain. The most appropriate nursing action is to: | assist the pt to ambulate down the hall |
| in intervening to promote ambulation, C&DB and turning in a pt on the first postoperative day, which action by the nurse is most helpful? | Administer ordered analgesics before the activities |
| A pt w/ a hx of Fe deficency anemia who has not taken Fe supplement for several years is experiencing increased fatigue and occasional palpations. The nurse would expect the pts lab findings to include: | Hgb 8.6 |
| A pt w/ chronic lymphocitic leukemia is hospitalized for tx of severe hemolytic anemia. An appropriate nursing intervention for the pt is to | plan alternate periods of rest and activity |
| When talking about appropriate food choices to a person with Fe deficiency anemia who follows a low cholesterol diet, the nurse should encourage increased intake of: | legumes and dried fruits |
| A pt in a sickle cell crisis asks the nurse why sickling causes pain. the best response by the nurse is: | tissue hypoxia as a result of small vessel occlusion |
| Which data, for a pt with thrombocytopenia, should be reported to the PCP? | the pt is difficult to arouse |
| All of these pts are waiting to be seen in the ER. Which has priority? | a pt w/ chemo-induced neutropenia and a temp of 100.8 |
| a 24yo pt who uses a diuretic for BP control is scheduled for abdominal surgery. Which information should be told to the surgeon prior to surgery? | Potassium level of 3.3 |
| Gathering data to evaluate pt outcomes regarding pain control, the nurse should: | include pt complaints of pain in the pre-op report |
| A 26yo pt with stage 2 Hodgkins Lymphoma asks the nurse, "how long do I have to live?" The nurse responds correctly with: | most patients with your stage of the disease are treated successfully |
| To relieve sx of a lower UTI for a pt on antibiotics, the nurse suggests phenazopyradine(pyridium) but cautions the pt that this med might: | cause urine to turn reddish orange and can stain clothing |
| IN a pt with acute glomerulonephritis, the nurse will ask about: | recent fever or sore throat |
| The HCP orderd IV glucose and insulin to be given to a pt in ARF whose potassium is 6.3. To evaluate the effectiveness, the nurse will: | obtain serum potassium levels |
| A client with chronic kidney disease is on hemodialysis. What diet change is needed? | More protein will be allowed b/c of the removal of urea and creatinine |
| A male is hospitalized because of gross hematuria and severe colicky left flank pain that radiates to his left testicle. He has a hx of kidney stones. priority dx is: | Accute pain r/t irritation by the stone |
| A recipient of a kidney transplant is in the immediate post-op period. IV fluids should be administered: | determined hourly based on every ML of UOP |
| A patient with a neurogenic bladderis being educated by the home health nurse on how to use catheterization for bladder emptying. What statement indicates understanding? | I will wash the catheter with soap and water before and after each catheterization |
| With a patient who has a lower UTI, the nurse will first question: | pain with urination |
| Instructions for at pt with cystitis to prevent future infections: | empty bladder every 3-4 hours during the day |
| Which nursing assessment is most important to communicate to the HCP regarding a pt with a bladder infection? | left sided flank pain |
| A pt is admitted with severe crushing injury. Which lab level is the nurse most concerned with? | potassium |
| Acute renal failure pt has a gradual increase to 3400ml/day of UOP, BUN of 92 and serum creatinine of 4.2. the nurse should plan to | monitor for hypotension by taking BP |
| Which order will the nurse question for a pt with renal insufficiency scheduled for IVP? | ibuprofen 40mg prn for apin |
| Before administering Kayexalate to a pt with hyperkalema, assess: | pt's bowel sounds |
| Before administering calcitrol to a pt with CKD, the nurse should check | serum phosphate |
| differences between arteriovenous fistula and a graft -- the nurse says that one advantage of a fistula is that: | it is much less likely to clot |
| A pt with CKD is thinking about using continuous ambulatory peritoneal dialysis. The nurse informs the pt that | pts with diabetes who use CAPD have fewer dialysis related complications than those on hemodialysis |
| A client with CKD brought all her meds from home to the hospital so the nurse could look over them. Which of the following meds shows that the pt needs more teaching? | MOM 30mg administered orally |
| A client in ARF needs hemodialysis. She recieves temporary vascular access by placing a catheter in the left femoral vein. After assessing the client, the nurse will plan to: | place the client on bedrest |
| A client is having an elective hysterectomy and tells the nurse she doesnt know if she can go through with it b/c her mother died during her hysterectomy. The nurses best response is: | Tell me more about what happened to your mother. |
| To help w/ enous return in the LE of a pt who just had a cholecystectomy, the nurse should promote: | dorsiflexion and plantar flexion of feet, ankle circles and pressing the back of her knees to the bed while lying supine |
| A femal client a second recurrence of pyelonephritis. The nurse should expect the following labs: | elevated BUN, positive leukocyte esterase and bacteria |
| The nurse is caring for a pt who has 20 second periods of deep and rapid breathing followed by...the nurse should document this finding as: | cheyne stokes |
| A nurse admits pt with AIDS who has cryptococcal meningitis. The pt tells her "if my heart or breathing stops, I dont want to be resuscitated" the nurse: | asks the pt if these wishes have been discussed with the provider |
| Which of these pts is most appropriate for the nurse to refer to hospice? | a 28 yo with aids related dementia who needs palliative care and pain management. |
| A pt w/ difficulty swallowing is started on continuous tube feedings at 100ml/hr. the pt has 6 diarrhea stools on the first day. The nurse: | slows the tube feeding rate |
| Pt who is receiving continuous tub feeding through small bore silicone feeding tube has a CT scan ordered and will have to be placed in the flat position for the scan. The nurse: | shuts off the tube feeding 30-60 mins before the scan |
| PEG tube nursing actions that an LPN can perform: | provide skin care around the tube |
| Pt with NG tube to low intermittent suction and PCA pump after gastroplasty. The RN needs to: | support the incision while coughing to prevent dehiscence |
| The following are orders for a dehydrated pt. Which do you act on first? | Infuse ns at 250 ml/hr |
| CVA pt is unresponsive and unconcious. The pt has a hx of GERD. The RN first assesses: | breath sounds |
| Patient is prescribed Nexium for heartburn. the nurse explains that the drug: | treats GERD by decreasing stomach acid production |
| A pt who is nauseated and vomiting blood-tinged fluid is admitted with acute gastritis. It is most important for the nurse to ask about: | NSAID use |
| A pt vomiting bright red blood is admitted to the ER. Which assessment should the nurse do first? | BP and pulse |
| Why is a pt who has suffered severe abdominal trauma recieving famotidine (Pepcid)? The nurse explains: | the medication will inhibit stress ulcers |
| A pt w/ and acute GI bleed has NS infusing at 500 ml/h. Which data is most important to communicate to the HCP? | pt has audible midline crackles |
| Pt has abdominal pain and watery dirrhea. The are dx w/ c. diff. The nurse should: | place pt in a private room under contact isolation |
| A pt who recently had an exploratory laprotomy w/ resection of a short segment of small bowel is c/o gas pains and abdominal distension. The nurse should respond by: | assisting the client to ambulate to increase peristalsis |
| A client has an acute exacerbation of Ulcerative Colitis and is having 14-16 bloody stools/day. Additionally, they have cramping abdominal pain associated w/ the diarrhea. the nurse should: | make the client NOPO to rest the bowel |
| A pt has a hx of IBD. the nurse realizes the pt has ulcerative colitis rather than Chrons b/c the pt tells the nurse: | they are experiencing bloody stools |
| a 26yo client is dx w/ Chron's after having many frequent stool was well as losing 10lbs in 2mo. The nurse should: | teach the client about oral corticosteroids |
| A nursing hx is being taken on a 55yo scheduled for a colonoscopy. THe nurse should be concrned when the pt tells her: | he has recently had blood in his stools |
| during the initial assessment of a post op stoma, the nurse finds it to be red with moderate edeme and a small amt of bleeding. The nurse should: | document the findings |
| A homeless pt with severe anorexia, fatigue, jaundice and hepatomegaly is dx w/ viral hepatitis. The highes priority is: | maintain adaquate nutrition |
| a 32yo w/ early alcohol chirrosis is dx via liver biopsy. Priority teaching is: | abstenence from alcohol |
| during tx w/ MN balloon tampanade for bleeding espohogeal varicies, which nursing intervention should be included? | Monitor for SOB |
| THe RN identifies the collaborative problems of electrolyte imbalance for pt w/ severe acute pancreatitis. Assessment findings that alert the nurse to this is: | muscle twitching and finger numbness |
| A patient with acute pancreatitis has and NG tube set to suction and is NPO. What indicates these therapies have been effective? | Deacrease in abdominal pain |
| A client has acute pancreatitis. What findin is priority? | lying BP 120/80 pulse 80. Standing BP 94/70 pulse 110 |
| Which is a lab finding suggestive of hepatitis | ALT 45U/L |
| lab results for a pt w/ chirrosis have elevated ammonia levels. What diet should be ordered? | low protein |
| The RN reviews the physicians orders for a pt w/ acute pancreatitis. She questions which order on the chart? | morphine for pain |
| HHN visits a diabetic pt w/ infected heel wound to do a daily dressing change and assessment. The nurse dx this pt w/ impaired tissue integrity. To evaluate the outcome, the nurse collects data about: | the wound appearance and pt temp |
| A nursing student carinng for a dying pt asks the nurse how will we know when pt has died? | the pt is comatose, apneic and w/o brainstem reflexes |
| A pt near death has a decrease in all body system functions except a HR of 124 and RR of 28. Nurse explains to family that: | these are normal responses before these functions decrease |
| A pt close to death says "im not ready to die yet". what is the most important thing for the nurse to do? | sat at the bedside and ask if there is anything the pt needs |
| Hopsice nurse becomes close to pt and family. when wht pt dies, the nurse feels like crying. What is appropriate? | it si acceptable and healthy to cry with the family |
| During an assessment of a vegan pt the nurse aserves for nutritional deficency. What are the manifestations most common in those on a vegitarian diet? | pallor and changes in sensation& mvt in the extremeties |
| The nurse teaches the pt who is being stabilized on a therapeutic dose of Warfarin : | not to alter intake of green leafys, dairy or meat because they are high in vit K |
| 72 yo. 5'2", 92lbs. Massive infection. Lab results hgb 10.2, albumin 2.0. Which info will be most useful when the nurse is determining nutritional status? | presence of edema |
| with a nutriritonal screening tool, the nurse can identify a deficiency exclusively when the pt has: | pressure ulcers |
| 22yo w/ anorexia nervosa. labs reveal hypokalemia and Fe deficency anemia. Priority dx is: | risk for decreased CO r/t electrolyte imbalance |
| taking a health hx for an obese pt, info that is most helpful in determine pts success w/ wt loss is: | Pt says "im ready to make changes" |
| Pt who is consistentlyfollowin diet and ex program has been losing 1 lb per week, but has lost no weght in the last month. It is important for the nurse to ask: | whether there have been any changes in diet and exercise patterns |
| nurse is developing a wt loss program for a 21yo obese pt. What stament is most likely to help pt adhere to the 800cal diet? | Youll notice changes in how you feel in just a few weeks. |
| When working with an obese pt in a behavior mod program which nursing action is appropriate? | Suggest a reward (sugarless candy) when pt has been successful |
| Moderately obese on a 1000 cal diet and meridia for 10 weeks. What is important to tell the HCP? | that the pt has had occasional palpitations |
| Pt has fecal impaction resulting in bowel obstruction. Assessment consistent with a bowel obstruction is | abdominal distension |
| Pt postop with colostomy and perineal incisions with 2JP drains. What is the highest priority post op day 1? | Assessing the perineal drainage and incision. |
| 69yo pt has developed frequent watery stool after a 10 day course of antibx. Pt wil need: | to provide a stool sample to be tested for c diff. |
| Findongs of a biliary obstruction include: | yellow sclera, clay colored stools, dark urine |
| Coamtose pt receiving continuous tube feedin through NG tube has developed crackles in lungs what do you do? (in order) | turn off tube feeding. obtain O2 sat, chec residual volume, notify pts HCP |
| Pt dx with HIV 3years ago admitted w/ pneumocystis jiroveci. Pt now dx as having: | AIDS |
| posttest counseling for a pt who has + HIV test, pt is anxious and not listening. Most important for the nurse to: | remind pt to retrun for testing to verify results |
| interventions such as promotion of nutrition, exercise and stress reduction should be promoted by nurse for clients with HIV because: | they will improve the clients immune function |
| Drug therapy is considered of an HIV pt with CD4 count of 400. Most important in determining drug therapy is: | client's willingness and ability to comply with stringent med schedules |
| When teaching a pt with HIV about antretroviral therapy, the nurse explains that these drugs: | work in various ways to decrease viral replication in the blood |
| To evaluate effectiveness of ART, the pt is scheduled for | viral load testing |
| When designing a program to decrease the incidence of HIV, the RN will plan to educate on | prevention of transmission between sexual partners |
| The difference between a benign tumor and a malignant is that benign: | do not spread to other organs or tissues |
| In cancer prevention, the RN stresses promotion of exercise, normal body wt and low fat diet because: | dietary fat and obesity promote cancer growth |
| A pt is scheduled for a needle biopsy of prostate. RN explains that a needle biopsy is done to: | biopsy will help doctor decide on what treatment to use |
| Pt with metastatic cancer of the colon experiences severe vomiting after each chemo tx. What intervention is important? | administering prescribed antiemetic 1 hr before tx |
| when administering resican chemo agent via IV, an important consideration is: | to stop the infusion if swelling is observed at the site |
| a pt is receiving head and neck radiation & systemic chemo. there are lesions on oral mucosa and tongue, ropey saliva. The nurse teaches: | to rinse mouth before and after each meal and at bedtime with saline solution |
| a pt w/ terminal liver cancer is cared for by family at home. Tells the nurse, "i have intense pain most of the time". Teachin regarding pain mgt is: | take opioids round the clock w/ additional doses for breakthrough pain |
| In reviewing lab results for a pt on chemo, it is important for the nurse to communicate: | WBC 1700 |
| Which action by a CNA who is pancytopenic indicates a need for the RN to intervene? | assists the pt in using dental floss after eating |
| Pt screened for diabetes has a fasting plasma glucose level of 120. Rn will teach pt about: | maintaining a healthy wt |
| Whan assessing a pt experiencing symptoms of DMII, pt reports following a reduced calorie diet. Pt has not lost weight and does not have record of glucose. Nurse will anticipate: | HGB A1C |
| college student w/ DM1 plans to start swimmin each afternoon at 1pm, nurse teaches pt to: | check glucose before, during and after swimming. |
| Diabetic is admitted with DKA. The HCP writes the following orders, which do you implement first? | infuse 1L NS |
| Dx of HHNC for pt w/ type 2 brought to the ER in unresponsive state. The nurse will: | insert large bore IV |
| Patient with type I using Lantus and Humalog develops a sore throat, cough and fever. Pt reports a BS of 210. THe nurse: | tells client to monitor BS q4h and notify if continues to rise |
| Whn hospitalized and recovering from DKA, pt calls the nurse and says feeling anxious, sweaty, nervous. Nurse should: | obtain glucose with finger stick |
| Pt recovering from DKA asks how acidosis occurs? | insulin deficient metabolis of fat storage produces acidic ketones |
| IM glucagon is given to tx hypoglycemia in an unresponsive client, after regaining conciousness, the client should: | have cheese and crackers |
| 3 mile a day runner was just dx w/ DM 1. What is the education: | plan to eat breakfast an hour before you run |
| in the labs of a diabetic client, which needs further assessment? | noon glucose of 52 |
| A client with ADH secreting small cell cancer of the lung is receiving demeclocycline to help sx of SIADH. this med is appropriate when: | UOP is increased |
| Pt possible has SIADH. exibiing confusion, headache, muscle twitching. Labs would indicate: | serum sodium of 125 |
| Pt was just admitted for diabetes insipidus. What assessment is of the greatest concern? | pt is lethargic and confused |
| When teaching a pt about a new dx of Graves disease inform them that: | the antithyroid medication takes several weeks to have an effect |
| during initial tx of thyroid replacement with synthroid, the most important assessment is: | cardiac function |
| in teaching a pt with a new dx of hypothyroidism: | provide written handouts for pts reference |
| Hyperparathyroid levels before surg are Ca 14, Phos 1.7, creatinine 2.2 and high urine calcium. What should the nurse encourage? | drink 4000 ml of fluid |
| in Hypoparathyroidism neck surgery the nurse should teach the pt: | to use calcium supplementation to achieve normal levels |
| A cushing syndrome pt has an adrenalectomy. The highest priority initially is: | maintaining fluid and lyte status |
| pt is on prednisone every other day for RA. Asks the nurse about taking the prednisone daily. The nurse says: | there is less effect on normal adrenal fx when prednisone is taken every other day |
| pt is on high doses of prednisone to control an acute exacerbation of systemic lupus. What teaching is most important? | do not stop taking the prednison sudenly. It should be decreased gradually. |
| Adrenocortical adenoma causing hypoaldosteronism and scheduled for surgery. Before surgery: | monitor BP q4h |
| Which client has priority? | 70yo who recently started on levothyroxine and has an irregulat pulse of 134 |
| Pt experiencing hypercalcemic crisis. The nurse should question the order that states: | restrict the fluid intake to 100ml/24h |
| Pt is in adrenal crisis. The nurse caring for her should quesiotn what order? | giving the pt insulin to treat acute hypokalemia |
| in a pt w/ HHNK the following is least likely to be a sx of the episode: | abdominal pain |
| DI and DM have the following in common: | polydipsia and polyuria |
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