Ati nur 285 med surg exam
Total Questions : 45
Showing 25 questions, Sign in for moreA patient is transferred to the emergency department from the outpatient clinic with a diagnosis of hyperkalemia. Kayexalate was prescribed. Which of the following nursing actions will the nurse perform before administering Kayexalate?
Explanation
A. Starting IV 0.9% sodium chloride may be necessary for hydration but is not a priority action before administering Kayexalate.
B. Assessing for bowel sounds is essential because Kayexalate works by exchanging potassium for sodium in the intestine, and bowel motility must be adequate to ensure the medication is effective and to prevent complications such as bowel obstruction.
C. Starting oxygen is unnecessary unless the patient exhibits signs of respiratory distress, which is not indicated here.
D. While checking potassium levels is important, it is often done as part of the initial assessment and does not need to be repeated immediately before administering Kayexalate if levels were already assessed and are high.
Following an intravenous pyelogram (IVP) using contrast medium, the nurse should anticipate incorporating which of the following measures the client's plan of care?
Explanation
A. Maintaining bed rest is not typically required after an IVP unless otherwise indicated for the patient's condition.
B. Administering a laxative is not a standard intervention following an IVP unless the patient specifically requires it for bowel preparation or constipation.
C. Encouraging adequate fluid intake is crucial after the administration of contrast medium to help flush the kidneys and minimize the risk of contrast-induced nephropathy.
D. While assessing for hematuria may be appropriate, it is not a primary intervention directly related to the IVP procedure itself.
A nurse is teaching a client who has a new diagnosis of Type 1 diabetes mellitus about self-administration of insulin. Which of the following instructions should the nurse include?
Explanation
A. Pulling back on the plunger after injecting insulin is incorrect and could cause the medication to leak out, leading to inadequate dosing.
B. Storing the current bottle of insulin at room temperature (if not in use) helps maintain the insulin's effectiveness and reduces discomfort during injections.
C. Massaging the injection site is not recommended as it can cause the insulin to absorb too quickly and lead to variable blood sugar levels.
D. Each syringe should only be used once to prevent contamination and ensure accurate dosing.
A nurse is teaching a client who has type 1 diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching?
Explanation
A. Soaking feet regularly is not advised as it can lead to skin breakdown and increases the risk of infection, especially in diabetic patients.
B. Applying lotion between the toes is discouraged because moisture in this area can promote fungal infections.
C. Wearing sandals is fine, but the type of footwear should be considered carefully to avoid injury.
D. Checking feet daily for sores and bruises is essential for diabetes management, as individuals with diabetes have a higher risk of foot complications due to reduced sensation and circulation.
A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine?
Explanation
A. Bright yellow urine is typical of well-hydrated individuals but is not expected after a prostatectomy.
B. Dark amber urine may indicate dehydration or concentrated urine, which is not the expected outcome post-surgery.
C. Bright red urine can indicate significant bleeding, which should be reported; however, some blood may be expected immediately after surgery.
D. Pale pink urine is a common and expected variation after a transurethral prostatectomy, indicating minor bleeding or irritation without significant risk.
A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function?
Explanation
A. Urine-specific gravity provides information on the kidney's ability to concentrate urine but is not the most direct measure of renal function.
B. Blood urea nitrogen (BUN) can indicate kidney function but is influenced by factors other than kidney health, such as hydration status and protein intake.
C. Serum sodium levels are not a specific indicator of renal function and can vary based on many factors unrelated to kidney health.
D. Serum creatinine is the best indicator of renal function, as it is produced from muscle metabolism and cleared by the kidneys; elevated levels indicate decreased renal function.
A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic a few months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient?
Explanation
A. Glycosylated hemoglobin A1C provides an average of the patient's blood glucose levels over the past 2-3 months and is the standard test used to evaluate long-term glycemic control in patients with diabetes.
B. A urine dipstick for glucose measures glucose in the urine but does not provide an accurate assessment of overall blood glucose control or effectiveness of treatment.
C. Fasting blood glucose is useful for assessing current blood sugar levels but does not reflect long-term management or control.
D. An oral glucose tolerance test is typically used for diagnosing diabetes rather than for ongoing monitoring of treatment effectiveness.
A nurse is caring for a client who has diabetes and a new prescription for 16 units of regular insulin and 26 units of NPH insulin subcutaneously at breakfast daily. What is the total number of units of insulin that the nurse should prepare in the insulin syringe?
Explanation
A. Preparing only 16 units would mean administering just the regular insulin and not the NPH insulin, which is also prescribed.
B. The total number of insulin units is calculated by adding the units of regular insulin (16 units) and NPH insulin (26 units), resulting in 42 units to be administered together.
C. Preparing only 26 units would mean administering only the NPH insulin and not the regular insulin, which is not appropriate.
D. Preparing 32 units is incorrect as it does not accurately reflect the sum of both insulin types prescribed.
A nurse is teaching about self-monitoring to a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
Explanation
A. Checking urine for ketones is generally recommended when blood glucose is consistently high, but once daily may not be sufficient during illness or hyperglycemic episodes.
B. Monitoring blood glucose every 4 hours during illness helps manage potential fluctuations and prevent diabetic ketoacidosis, making this statement correct.
C. A pre-meal blood glucose of 120 mg/dL is within the acceptable range, so notifying the provider is unnecessary.
D. Checking blood glucose every 5 minutes is excessive and not standard practice, even if feeling lightheaded.
The health care provider suspects the Somogyi effect in a 66-yr-old patient whose 2:00 AM blood glucose is 66 mg/dL. Which action will the nurse teach the patient to take?
Explanation
A. Giving carbohydrates at 3:00 AM might prevent hypoglycemia temporarily but does not address the underlying issue.
B. Having a snack at bedtime helps prevent nighttime hypoglycemia, which can lead to rebound hyperglycemia, known as the Somogyi effect.
C. Increasing the insulin dose could exacerbate nocturnal hypoglycemia, worsening the Somogyi effect.
D. Doing nothing is inappropriate as the low 2:00 AM glucose level is a sign of the Somogyi effect.
The nurse is caring for a client who has prostate cancer. Which of the following manifestations is commonly associated with advanced prostate cancer?
Explanation
A. Increased urinary frequency can be a symptom but is more common in early stages or with benign prostatic hyperplasia.
B. Erectile dysfunction may occur but is not as specific to advanced prostate cancer.
C. Severe hematuria is not commonly associated with advanced prostate cancer.
D. Bone pain and fractures are common in advanced stages due to metastasis, particularly to the bones.
A nurse is caring for a client who has the following arterial blood gas results: HCO, 20 mEq, PaCO2 40 mm Hg and pH 7.32. The nurse recognizes the client is experiencing which of the following acid base imbalances?
Explanation
A. Metabolic alkalosis would show a high HCO₃ level and elevated pH, which is not seen here.
B. Respiratory alkalosis would present with decreased PaCOâ‚‚ and elevated pH.
C. Metabolic acidosis is indicated by a low HCO₃ level (below 22 mEq/L) and low pH, consistent with the given values.
D. Respiratory acidosis would present with elevated PaCOâ‚‚ and a low pH, not shown in these results.
A nurse is caring for a client who has developed diseases of large and medium-sized blood vessels because of diabetes. Which of the following should the nurse anticipate if the client has cerebrovascular disease, cardiovascular disease, and peripheral vascular disease?
Explanation
A. Macrovascular angiopathy refers to damage in large and medium-sized vessels, which is associated with cerebrovascular, cardiovascular, and peripheral vascular disease in diabetic patients.
B. Diabetic nephropathy involves the kidneys, not the large or medium blood vessels.
C. Diabetic neuropathy affects nerves rather than blood vessels.
D. Microvascular angiopathy involves small vessels, typically affecting the eyes, kidneys, and nerves.
A client is reporting chills, fever, and left costovertebral pain. Which diagnostic test should the nurse expect the healthcare provider to prescribe first?
Explanation
A. A sonogram may help identify kidney abnormalities but is not the initial test for suspected infection.
B. A CT scan may be needed for further evaluation but is typically not the first test ordered.
C. A midstream urine culture is often the initial diagnostic test for suspected urinary tract infections or pyelonephritis, based on symptoms of chills, fever, and flank pain.
D. An intravenous pyelogram is used to detect structural abnormalities, such as renal calculi, but is not the initial test for infection symptoms.
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?
Explanation
A. Hypocalcemia is associated with hyperactive, not hypoactive, deep tendon reflexes.
B. Tingling of the extremities, known as paresthesia, is a common symptom of hypocalcemia, which can occur after thyroidectomy due to potential damage or removal of the parathyroid glands.
C. Constipation is more commonly associated with hypercalcemia.
D. Hypocalcemia typically presents with a prolonged, not shortened, QT interval.
A nurse is monitoring a client who is admitted with severe hemorrhage from traumatic injury who is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
Explanation
A. Weight may fluctuate but is not a direct indication of immediate fluid resuscitation adequacy.
B. A decrease in heart rate is a sign of improved perfusion and stabilization, suggesting that fluid replacement is effective in compensating for blood loss.
C. Adequate fluid replacement is indicated by an increase, not a decrease, in urine output.
D. Blood pressure should stabilize or increase with fluid replacement, rather than decrease.
Before the client starts taking phenazopyridine hydrochloride (Pyridium), she should be taught about which of the drugs side effects?
Explanation
A. Constipation is not a common side effect of phenazopyridine.
B. Incontinence is not associated with this medication.
C. Slight drowsiness is not a typical effect of phenazopyridine.
D. Bright orange-red urine is a well-known and harmless side effect of phenazopyridine, and patients should be informed to avoid alarm.
A nurse is caring for a client who is 6hrs postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?
Explanation
A. Irrigating the catheter may be necessary, but the nurse should first assess for a simpler cause of the obstruction, such as a kink.
B. Checking for kinks is the priority, as it is a common cause of catheter obstruction and can be easily corrected.
C. Notifying the provider is unnecessary unless troubleshooting measures fail to resolve the issue.
D. Adjusting the bladder irrigant rate may be considered, but only after ensuring the tubing is free from kinks.
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for?
Explanation
A. Urinary retention is a concern but is not as immediately life-threatening as hemorrhage.
B. Pain management is essential, but monitoring for life-threatening complications like hemorrhage takes priority.
C. Hemorrhage is a serious and potentially life-threatening complication after TURP, making it the priority for monitoring in the immediate postoperative period.
D. Infection is a concern postoperatively, but hemorrhage is the immediate priority.
A nurse is assessing a client who has experienced significant blood loss. Which of the following is a clinical sign of hypovolemia?
Explanation
A. Bradycardia is not typical in hypovolemia; tachycardia is more common as the body compensates for fluid loss.
B. Hypotension, rather than hypertension, occurs due to reduced blood volume.
C. Polyuria is not a feature of hypovolemia; decreased urine output is expected.
D. Cool, clammy skin is a classic sign of hypovolemic shock as blood flow to the skin decreases in response to blood loss.
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?
Explanation
A. Oral hypoglycemics are not appropriate for managing DKA, as immediate and effective control of blood glucose levels is required through IV insulin.
B. Dextrose solutions are not initially indicated, as they could elevate blood glucose further. Dextrose may be considered once blood glucose reaches a safer level (around 250 mg/dL).
C. Glucocorticoids can increase blood glucose levels, so they are contraindicated in DKA management.
D. 0.9% sodium chloride IV bolus is essential to address dehydration commonly seen in DKA due to osmotic diuresis and to restore blood volume.
A nurse working for a home health agency is teaching a client who has diabetes mellitus about disease management. Which of the following glycosylated hemoglobin (HbA1c) values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels?
Explanation
A. An HbA1c of 10% is significantly elevated and suggests poor glycemic control.
B. An HbA1c of 8.5% is above the recommended target for most diabetic patients, indicating less than optimal control.
C. An HbA1c of 6.3% falls within the target range for well-managed diabetes, generally below 7%. This value indicates effective glucose control.
D. An HbA1c of 7.8% is slightly elevated and may require adjustments in diabetes management.
A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client?
Explanation
A. Low back pain is a symptom that may indicate pyelonephritis but is not specific to older adults.
B. Incontinence can occur in UTIs but is common in older adults for various reasons and is not specific to a UTI.
C. Urinary retention is not a distinguishing feature of UTI in older adults.
D. Confusion or altered mental status is a common sign of UTI in older adults, often the primary symptom due to age-related changes in cognition.
A client diagnosed with renal calculi is admitted to the medical unit with renal colic. Which interventions should the nurse implement the first?
Explanation
A. Pain assessment and management are a priority in renal colic due to the severe discomfort it causes, and prompt treatment is necessary.
B. Monitoring urinary output is important but is secondary to immediate pain management.
C. Safety during ambulation is necessary, but assessing and managing pain takes precedence in an acute setting.
D. Increasing fluid intake can help flush out stones but is typically addressed after pain management.
A nurse is teaching a client who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching?
Explanation
A. Shakiness is a classic symptom of hypoglycemia due to adrenaline release as the body responds to low glucose levels.
B. Decreased appetite is not typical of hypoglycemia; in fact, hunger may increase as the body signals the need for energy.
C. Increased thirst is a symptom of hyperglycemia, not hypoglycemia.
D. Skin is typically cool and clammy during hypoglycemia, not warm and moist.
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