Exam #2 Units 4,5,6 Med Surg

Exam #2 Units 4,5,6 Med Surg 1. The nurse is monitoring fluid volume status of the client who has heart failure and is at risk for clinical dehydration. Which of the following interventions is the most effective for monitoring this client? Answer: weigh the client every morning before breakfast 2. The nurse is caring for assigned clients who have fluid overload and are at risk for the development of complications. Which clients from the box below should the nurse identify at being at the greatest risk? Answer: 22 yr. old diagnosed with congenital heart failure at age 5, 62 yr. old who is recently diagnosed with hepatic cirrhosis, 36 yr. old who received hemodialysis 3 times a week for chronic kidney disease. 3.The nurse is caring for a client who is receiving prescribed 0.9% sodium chloride or normal saline IV at a rate of 200ml/hr. for treatment of dehydration. Which of the following findings requires immediate follow-up by the nurse? Answer: distended neck veins when the patient is in semi-fowlers position. 4. The nurse has attended a staff education conference about fluid and electrolyte imbalances. Which of the following statements by the nurse indicates a correct understanding of the conference? Answer: The client who has hyponatremia is likely to develop acute onset of confusion. 5. A nurse is preparing to administer 10 mEq of potassium chloride IV to a client who has a potassium level of 2.6 mEq/L. Which of the following actions should the nurse take? Answer: adequate blood return of the IV access before administration. 6. A nurse is caring for a client whose electrocardiogram demonstrates changing characteristics of hypokalemia. Which of the following assessment finding should the nurse suspect? Answer: hypoactive bowel sounds 7. The nurse is caring for a client who has a serum potassium level of 2.7 mEq/L. Which of the following medications is prescribed for the client should the nurse question? Answer: hydrochlorothiazide or HCTZ—because it is not potassium sparing. 8. The nurse is caring for a client who has been receiving prescribed furosemide and has a potassium level of 2.8 mEq/L. Which of the following assessments should the nurse perform first? Answer: Apical pulse rate and depth of respirations 9. The nurse is caring for a client who has cardiac dysrhythmias. The nurse should be concerned about which of the following laboratory values? Answer: Potassium level of 6 mEq/L 10. The nurse is assigned to four clients on a medical surgical floor. Which of the following clients should the nurse determine has the greatest risk for developing hypercalcemia? Answer: a client with hyperparathyroidism 11. The nurse is assigned to four clients who have fluid and electrolyte imbalances after receiving the change of shift report. Which of the following clients should the nurse assess first? Answer: Client who has serum magnesium level of 4.2 and is drowsy and has a pulse of 54. (This patient is more symptomatic) -other answers given are: Client who has serum potassium level of 5 mEq/L and is reporting occasional palpitations. Client who has a serum sodium level of 147mEq and has a dry mouth and pulse of 101. Client who has a serum calcium level of 11 and who has hypoactive bowels and constipation. 12. The nurse is caring for a client who has metabolic alkalosis. Which of the following clinical manifestations should the nurse monitor? Answer: Skeletal muscle weakness 13. The nurse is caring for a client who takes antacids for heartburn. The nurse should consider that this client is at risk of developing… Answer: Metabolic alkalosis 14. The nurse is reviewing the medical records of the following assigned clients who have an acid-base imbalance. Which client should the nurse recognize at being at risk for metabolic acidosis? Answer: The client who has renal failure with oliguria. 15. The nurse is reviewing the laboratory values for a client who has respiratory acidosis. Which of the following findings should the nurse expect? Answer: pH of 7.15 which indicates respiratory acidosis. 16. The nurse is collecting data from a client who has pneumonia and is experiencing acute respiratory acidosis and hypokalemia. Which of the following manifestations should the nurse expect to find? Answer: weak decreased pulses 17. The nurse is caring for a client who has acidosis and is awake, alert, and oriented. Which of the following actions should the nurse perform next? Answer: Take the clients vital signs and analyze the electrocardiogram ecg strip 18. The nurse is in the post anesthesia care unit (PACU) and is caring for a client who had abdominal surgery under general anesthesia. The client is receiving oxygen at 40% by a face mask and respirations are shallow at a rate of 8. Which of the following arterial blood gas results are consistent with the client’s respiratory assessment? Answer: pH of 7.31 (go with the low pH) Other answer given are pao2 of 73, paco2 of 50, Hco3 of 22, Sao2 of 85. pH of 7.35, 7.45, and 7.50. 19. The nurse is assessing clients who are at risk for developing diabetes mellitus type 1. Which of the following clients should the nurse identify as being at risk? Answer: 1.) 25 yr. old Caucasian (go with younger person for type 1 DM) 2.) 56 yr. old African American (type 2 DM) 3.) 44 yr. old Asian (type 2 DM) 4.) 32 yr. old native Hawaiian (type 2 DM) 20. The nurse is teaching a client who has diabetes mellitus type 2 and must start self-injections of insulin to control blood glucose levels. Which of the following statements made by the client indicates a need for additional teaching? Answer: If the client states to give injections on the inside of a 2-inch radius of the umbilicus is the preferred location of the injection. It is always given on the outside of a 2-inch radius. Never inside!! 21. The nurse is preparing to administer regular with NPH insulin to a client. Place the nurse’s actions in the box below in the correct order to administer these injections. There are 7 items to place in order Answer: 1.) Inspect the bottles for expiration date 2.) Gently roll bottle of NPH between your hands 3.) Clean rubber stoppers with alcohol 4.) Inject air into the NPH insulin bottle 5.) Then, inject air into the regular insulin bottle 6.) Then withdrawal the regular insulin, 7.) Then withdrawal the NPH insulin 22. The nurse is caring for a client who has DM type 1. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 0700. At which of the following times should the nurse assess the client for potential problems related to the NPH insulin? Answer: 1600, this is when the NPH will peak or take effect. 23. The nurse is reinforcing nutritional counseling provided to a client who has DM. Which of the following client statements indicates correct understanding of the teaching? Answer: I will need to adjust my carbohydrate intake with unplanned exercise 24. The nurse is caring for a client who has DM type 2 and is newly prescribed pioglitazone that requires follow up with the primary health care provider if the client has? Answer: A history of symptomatic heart failure 25. The nurse is reviewing laboratory results for a client with DM type 2 who is prescribed an intensified insulin regimen. Which of the following is an appropriate interpretation of the laboratory findings indicated in the exhibit below? Answer: FBG 75, Postprandial reading of 160, and HbAIC of 5.5- all normal findings 26. A nurse is teaching a client who has DM1 about self-monitoring. Which of the following statements by the client indicate correct understanding of the teaching? -I will check my blood glucose frequently when I exercise. 27. The nurse is teaching the client with DM2 who is experiencing numbness and reduced sensation which of the following should the nurse include in the clients teaching to prevent injury? - Remove excess lotion from in between the toes 28. The nurse is assessing a patient who has DM it is most important for the nurse to follow up with the client… -who reports feeling cold and sweaty 29. The nurse is caring for a client who has DM1 who is unarousable and has a blood glucose of 19. Which of the following actions should the nurse take? -Administer prescribed PRN intramuscular glucagon 30. The nurse is instructing a client on hypoglycemia at home which of the following statements demonstrates correct understanding of the teaching? -If patient states” I will drink half a cup of fruit juice if I start to feel irritable and shaky. 31. The nurse is teaching the client who has DM2 about what to do if the client gets sick. Which of the following statements should the nurse include? -expect to have s/s of hyperglycemia 32. The nurse is caring for a client who has DM2 that blood glucose results that vary as indicated below. Which of the following should the nurse expect the patient to be experiencing? 2100-85 0200-60 0800-200 -signs of Somogyi phenomena