Medical Surgical Nursing Assessment and Management of Clinical Problems,10th Edition by Sharon L. Lewis – Test Bank

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Medical Surgical Nursing Assessment and Management of Clinical Problems,10th Edition by Sharon L. Lewis – Test Bank

Chapter 02: Health Disparities and Culturally Competent Care

Lewis: Medical-Surgical Nursing, 10th Edition

 

MULTIPLE CHOICE

 

  1. The nurse is obtaining a health history from a new patient. Which data will be the focus of patient teaching?
a. Age and gender c. Hispanic/Latino ethnicity
b. Saturated fat intake d. Family history of diabetes

 

 

ANS:  B

Behaviors are strongly linked to many health care problems. The patient’s saturated fat intake is a behavior that the patient can change. The other information will be useful as the nurse develops an individualized plan for improving the patient’s health, but will not be the focus of patient teaching.

 

DIF:    Cognitive Level: Apply (application)                              REF:   18

TOP:   Nursing Process: Planning              MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse works in a clinic located in a community with many Hispanics. Which strategy, if implemented by the nurse, would decrease health care disparities for the Hispanic patients?
a. Improve public transportation to the clinic.
b. Update equipment and supplies at the clinic.
c. Obtain low-cost medications for clinic patients.
d. Teach clinic staff about Hispanic health beliefs.

 

 

ANS:  D

Health care disparities are caused by stereotyping, biases, and prejudice of health care providers. The nurse can decrease these through staff education. The other strategies may also be addressed by the nurse but will not directly impact health disparities.

 

DIF:    Cognitive Level: Apply (application)                              REF:   19

TOP:   Nursing Process: Planning              MSC:  NCLEX: Health Promotion and Maintenance

 

  1. What information should the nurse collect when assessing the health status of a community?
a. Air pollution levels c. Most common causes of death
b. Number of health food stores d. Education level of the individuals

 

 

ANS:  C

Health status measures of a community include birth and death rates, life expectancy, access to care, and morbidity and mortality rates related to disease and injury. Although air pollution, access to health food stores, and education level are factors that affect a community’s health status, they are not health measures.

 

DIF:    Cognitive Level: Understand (comprehension)               REF:   18

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is caring for a Native American patient who has traditional beliefs about health and illness. Which action by nurse is most appropriate?
a. Avoid asking questions unless the patient initiates the conversation.
b. Ask the patient whether it is important that cultural healers are contacted.
c. Explain the usual hospital routines for meal times, care, and family visits.
d. Obtain further information about the patient’s cultural beliefs from a family member.

 

 

ANS:  B

Because the patient has traditional health care beliefs, it is appropriate for the nurse to ask whether the patient would like a visit by a shaman or other cultural healer. There is no cultural reason for the nurse to avoid asking the patient questions because these questions are necessary to obtain health information. The patient (rather than the family) should be consulted about personal cultural beliefs. The hospital routines for meals, care, and visits should be adapted to the patient’s preferences rather than expecting the patient to adapt to the hospital schedule.

 

DIF:    Cognitive Level: Apply (application)                              REF:   24

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse is caring for an Asian patient who is being admitted to the hospital. Which action would be most appropriate for the nurse to take when interviewing this patient?
a. Avoid eye contact with the patient.
b. Observe the patient’s use of eye contact.
c. Look directly at the patient when interacting.
d. Ask a family member about the patient’s cultural beliefs.

 

 

ANS:  B

Observation of the patient’s use of eye contact will be most useful in determining the best way to communicate effectively with the patient. Looking directly at the patient or avoiding eye contact may be appropriate, depending on the patient’s individual cultural beliefs. The nurse should assess the patient, rather than asking family members about the patient’s beliefs.

 

DIF:    Cognitive Level: Apply (application)                              REF:   25

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A female staff nurse is assessing a male patient of Arab descent who is admitted with complaints of severe headaches. It is most important for the charge nurse to intervene if the nurse takes which action?
a. The nurse explains the 0 to 10 intensity pain scale.
b. The nurse asks the patient when the headaches started.
c. The nurse sits down at the bedside and closes the privacy curtain.
d. The nurse calls for a male nurse to bring a hospital gown to the room.

 

 

ANS:  C

Many men of Arab ethnicity do not believe it is appropriate to be alone with any female except for their spouse. The other actions are appropriate.

 

DIF:    Cognitive Level: Apply (application)                              REF:   25

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse is caring for a patient who speaks a different language. If an interpreter is not available, which action by the nurse is most appropriate?
a. Talk slowly so that each word is clearly heard.
b. Speak loudly in close proximity to the patient’s ears.
c. Repeat important words so that the patient recognizes their significance.
d. Use simple gestures to demonstrate meaning while talking to the patient.

 

 

ANS:  D

The use of gestures will enable some information to be communicated to the patient. The other actions will not improve communication with the patient.

 

DIF:    Cognitive Level: Understand (comprehension)               REF:   31

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse plans care for a hospitalized patient who uses culturally based treatments. Which action by the nurse is best?
a. Encourage the use of diagnostic procedures.
b. Coordinate the use of folk treatments with ordered medical therapies.
c. Ask the patient to discontinue the cultural treatments during hospitalization.
d. Teach the patient that folk remedies will interfere with orders by the health care provider.

 

 

ANS:  B

Many culturally based therapies can be accommodated along with the use of Western treatments and medications. The nurse should attempt to use both traditional folk treatments and the ordered Western therapies as much as possible. Some culturally based treatments can be effective in treating “Western” diseases. Not all folk remedies interfere with Western therapies. It may be appropriate for the patient to continue some culturally based treatments while he or she is hospitalized.

 

DIF:    Cognitive Level: Apply (application)                              REF:   22

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse is caring for a newly admitted patient. Which intervention is the best example of a culturally appropriate nursing intervention?
a. Insist family members provide most of the patient’s personal care.
b. Maintain a personal space of at least 2 feet when assessing the patient.
c. Ask permission before touching a patient during the physical assessment.
d. Consider the patient’s ethnicity as the most important factor in planning care.

 

 

ANS:  C

Many cultures consider it disrespectful to touch a patient without asking permission, so asking a patient for permission is always culturally appropriate. The other actions may be appropriate for some patients but are not appropriate across all cultural groups or for all individual patients. Ethnicity may not be the most important factor in planning care, especially if the patient has urgent physiologic problems.

 

DIF:    Cognitive Level: Understand (comprehension)               REF:   28

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A staff nurse expresses frustration that a Native American patient always has several family members at the bedside. Which action by the charge nurse is most appropriate?
a. Remind the nurse that family support is important to this family and patient.
b. Have the nurse explain to the family that too many visitors will tire the patient.
c. Suggest that the nurse ask family members to leave the room during patient care.
d. Ask about the nurse’s personal beliefs about family support during hospitalization.

 

 

ANS:  D

The first step in providing culturally competent care is to understand one’s own beliefs and values related to health and health care. Asking the nurse about personal beliefs will help achieve this step. Reminding the nurse that this cultural practice is important to the family and patient will not decrease the nurse’s frustration. The remaining responses (suggest that the nurse ask family members to leave the room and have the nurse explain to family that too many visitors will tire the patient) are not culturally appropriate for this patient.

 

DIF:    Cognitive Level: Apply (application)                              REF:   23

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. An older Asian American patient tells the nurse that she has lived in the United States for 50 years. The patient speaks English and lives in a predominantly Asian neighborhood. Which action by the nurse is most appropriate?
a. Include a shaman when planning the patient’s care.
b. Avoid direct eye contact with the patient during care.
c. Ask the patient about any special cultural beliefs or practices.
d. Involve the patient’s oldest son to assist with health care decisions.

 

 

ANS:  C

Further assessment of the patient’s health care preferences is needed before making further plans for culturally appropriate care. The other responses indicate stereotyping of the patient based on ethnicity and would not be appropriate initial actions.

 

DIF:    Cognitive Level: Apply (application)                              REF:   23

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse plans health care for a community with a large number of recent immigrants from Vietnam. Which intervention is the most important for the nurse to implement?
a. Hepatitis testing c. Contraceptive teaching
b. Tuberculosis screening d. Colonoscopy information

 

 

ANS:  B

Tuberculosis (TB) is endemic in many parts of Asia, and the incidence of TB is much higher in immigrants from Vietnam than in the general U.S. population. Teaching about contraceptive use, colonoscopy, and testing for hepatitis may also be appropriate for some patients but is not generally indicated for all members of this community.

 

DIF:    Cognitive Level: Apply (application)                              REF:   28

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. When doing an admission assessment for a patient, the nurse notices that the patient pauses before answering questions about the health history. Which action by the nurse is most appropriate?
a. Interview a family member instead.
b. Wait for the patient to answer the questions.
c. Remind the patient that you have other patients who need care.
d. Give the patient an assessment form listing the questions and a pen.

 

 

ANS:  B

Patients from some cultures take time to consider a question carefully before answering. The nurse will show respect for the patient and help develop a trusting relationship by allowing the patient time to give a thoughtful answer. Asking the patient why the answers are taking so much time, stopping the assessment, and handing the patient a form indicate that the nurse does not have time for the patient.

 

DIF:    Cognitive Level: Apply (application)                              REF:   30

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. Which strategy should be a priority when the nurse is planning care for a diabetic patient who is uninsured?
a. Obtain less expensive medications.
b. Follow evidence-based practice guidelines.
c. Assist with dietary changes as the first action.
d. Teach about the impact of exercise on diabetes.

 

 

ANS:  B

The use of standardized evidence-based guidelines will reduce the incidence of health care disparities among various socioeconomic groups. The other strategies may also be appropriate, but the priority concern should be that the patient receives care that meets the accepted standard.

 

DIF:    Cognitive Level: Apply (application)                              REF:   28

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A Hispanic patient complains of abdominal cramping caused by empacho. Which action should the nurse take first?
a. Ask the patient what treatments are likely to help.
b. Massage the patient’s abdomen until the pain is gone.
c. Administer prescribed medications to decrease the cramping.
d. Offer to contact a curandero(a) to make a visit to the patient.

 

 

ANS:  A

Further assessment of the patient’s cultural beliefs is appropriate before implementing any interventions for a culture-bound syndrome such as empacho. Although medication, a visit by a curandero(a), or massage may be helpful, more information about the patient’s beliefs is needed to determine which intervention(s) will be most helpful.

 

DIF:    Cognitive Level: Apply (application)                              REF:   29

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse performs a cultural assessment with a patient from a different culture. Which action by the nurse should be taken first?
a. Request an interpreter before interviewing the patient.
b. Wait until a family member is available to help with the assessment.
c. Ask the patient about any affiliation with a particular cultural group.
d. Tell the patient what the nurse already knows about the patient’s culture.

 

 

ANS:  C

An early step in performing a cultural assessment is to determine whether the patient feels an affiliation with any cultural group. The other actions may be appropriate if the patient does identify with a particular culture.

 

DIF:    Cognitive Level: Apply (application)                              REF:   30

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse working in a clinic in a primarily African American community notes a higher incidence of uncontrolled hypertension in the patients. To correct this health disparity, which action should the nurse take first?
a. Initiate a regular home-visit program by nurses working at the clinic.
b. Schedule teaching sessions about low-salt diets at community events.
c. Assess the perceptions of community members about the care at the clinic.
d. Obtain low-cost antihypertensive drugs using funding from government grants.

 

 

ANS:  C

Before other actions are taken, additional assessment data are needed to determine the reason for the disparity. The other actions also may be appropriate, but additional assessment is needed before the next action is selected.

 

DIF:    Cognitive Level: Apply (application)                              REF:   29

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. The nurse is performing an admission assessment for a non–English-speaking patient who is from China. Which actions could the nurse take to enhance communication (select all that apply)?
a. Use an electronic translation application.
b. Use a telephone-based medical interpreter.
c. Wait until an agency interpreter is available.
d. Ask the patient’s teenage daughter to interpret.
e. Use exaggerated gestures to convey information.

 

 

ANS:  A, B, C

Electronic translation applications, telephone-based interpreters, and agency interpreters are all appropriate to use to communicate with non–English-speaking patients. When no interpreter is available, family members may be considered, but some information that will be needed in an admission assessment may be misunderstood or not shared if a child is used as the interpreter. Gestures are appropriate to use, but exaggeration of the gestures is not needed.

 

DIF:    Cognitive Level: Apply (application)                              REF:   31

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

 

Chapter 16: Fluid, Electrolyte, and Acid-Base Imbalances

Lewis: Medical-Surgical Nursing, 10th Edition

 

MULTIPLE CHOICE

 

  1. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?
a. Urine output is 30 mL/hr.
b. Blood pressure is 90/40 mm Hg.
c. Oral fluid intake is 100 mL for the past 8 hours.
d. There is prolonged skin tenting over the sternum.

 

 

ANS:  B

The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss because of the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient’s fluid intake but not as urgently as the hypotension.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    276

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?
a. Serum hematocrit of 42%
b. Serum sodium level of 120 mg/dL
c. Reported weight gain of 2.2 lb (1 kg)
d. Urinary output of 280 mL during past 8 hours

 

 

ANS:  B

Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention.

 

DIF:    Cognitive Level: Apply (application)                              REF:   279

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?
a. Skin turgor c. Urine output
b. Daily weight d. Edema presence

 

 

ANS:  B

Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    277

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Physiological Integrity

 

  1. The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake?
a. “Drink more fluids in the late evening.”
b. “Increase fluids if your mouth feels dry.”
c. “More fluids are needed if you feel thirsty.”
d. “If you feel confused, you need more to drink.”

 

 

ANS:  B

An alert older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur.

 

DIF:    Cognitive Level: Apply (application)                              REF:   277

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. Which action is appropriate for the nurse to take?
a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
c. Recommend the patient avoid drinking orange juice with meals.
d. Suggest that the health care provider order a basic metabolic panel.

 

 

ANS:  D

Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient is hypokalemic. Loose stools are associated with hyperkalemia.

 

DIF:    Cognitive Level: Apply (application)                              REF:   281

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?
a. “I will try to drink at least 8 glasses of water every day.”
b. “I will use a salt substitute to decrease my sodium intake.”
c. “I will increase my intake of potassium-containing foods.”
d. “I will drink apple juice instead of orange juice for breakfast.”

 

 

ANS:  D

Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.

 

DIF:    Cognitive Level: Apply (application)                              REF:   281

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. A patient with new-onset confusion and hyponatremia is being admitted. When making room assignments, the charge nurse should take which action?
a. Assign the patient to a semi-private room.
b. Assign the patient to a room near the nurse’s station.
c. Place the patient in a room nearest to the water fountain.
d. Place the patient on telemetry to monitor for peaked T waves..

 

 

ANS:  B

The patient should be placed near the nurse’s station if confused for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room.

 

DIF:    Cognitive Level: Apply (application)                              REF:   280

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 10 mEq/hour.
c. Only give the KCl through a central venous line.
d. Discontinue cardiac monitoring during the infusion.

 

 

ANS:  B

IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias.

 

DIF:    Cognitive Level: Apply (application)                              REF:   282

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?
a. Infuse 5% dextrose in water at 125 mL/hr.
b. Administer 3% saline at 50 mL/hr for a total of 200 mL.
c. Administer IV morphine sulfate 4 mg every 2 hours PRN.
d. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.

 

 

ANS:  A

Because the patient’s gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer’s solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.

 

DIF:    Cognitive Level: Apply (application)                              REF:   276

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
a. Metabolic acidosis c. Respiratory acidosis
b. Metabolic alkalosis d. Respiratory alkalosis

 

 

ANS:  D

The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

 

DIF:    Cognitive Level: Apply (application)                              REF:   288

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?
a. Give the prescribed PRN lorazepam (Ativan).
b. Encourage the patient to take deep slow breaths.
c. Start the prescribed PRN oxygen at 2 to 4 L/min.
d. Administer the prescribed normal saline bolus and insulin.

 

 

ANS:  D

The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis.

 

DIF:    Cognitive Level: Apply (application)                              REF:   289

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?
a. Pallor c. Confusion
b. Edema d. Restlessness

 

 

ANS:  B

The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.

 

DIF:    Cognitive Level: Apply (application)                              REF:   273

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?
a. Lung sounds c. Peripheral pulses
b. Urinary output d. Peripheral edema

 

 

ANS:  A

Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

 

DIF:    Cognitive Level: Apply (application)                              REF:   274

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient’s condition has improved?
a. Hematocrit 28% c. Decreased peripheral edema
b. Absence of skin tenting d. Blood pressure 110/72 mm Hg

 

 

ANS:  C

Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient’s protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.

 

DIF:    Cognitive Level: Apply (application)                              REF:   273

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Physiological Integrity

 

  1. A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?
a. Metabolic acidosis c. Respiratory acidosis
b. Metabolic alkalosis d. Respiratory alkalosis

 

 

ANS:  A

The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.

 

DIF:    Cognitive Level: Apply (application)                              REF:   288

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?
a. Digoxin (Lanoxin) 0.25 mg/day
b. Metoprolol (Lopressor) 12.5 mg/day
c. Ibuprofen (Motrin) 400 mg every 6 hours
d. Lantus insulin 24 U subcutaneously every evening

 

 

ANS:  A

Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level.

 

DIF:    Cognitive Level: Apply (application)                              REF:   283

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
a. Maintain the patient on bed rest.
b. Auscultate lung sounds every 4 hours.
c. Monitor for Trousseau’s and Chvostek’s signs.
d. Encourage fluid intake up to 4000 mL every day.

 

 

ANS:  D

To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau’s and Chvostek’s signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.

 

DIF:    Cognitive Level: Apply (application)                              REF:   283

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient’s food tray?
a. Skim milk c. Mixed green salad
b. Grape juice d. Fried chicken breast

 

 

ANS:  A

Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits and juices are not high in phosphate and are not restricted.

 

DIF:    Cognitive Level: Apply (application)                              REF:   294

OBJ:   Special Questions: Delegation        TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value?
a. Daily alcohol intake
b. Dietary protein intake
c. Multivitamin/mineral use
d. Over-the-counter (OTC) laxative use

 

 

ANS:  A

Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements tend to increase magnesium levels.

 

DIF:    Cognitive Level: Apply (application)                              REF:   286

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is accurate?
a. “The prescribed infusion can be given more rapidly when the patient has a central line.”
b. “The hypertonic solution will be more rapidly diluted when given through a central line.”
c. “There is a decreased risk for infection when 25% dextrose is infused through a central line.”
d. “The required blood glucose monitoring is based on samples obtained from a central line.”

 

 

ANS:  B

The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.

 

DIF:    Cognitive Level: Apply (application)                              REF:   273

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?
a. Avoid using friction when cleaning around the CVAD insertion site.
b. Use the push-pause method to flush the CVAD after giving medications.
c. Obtain an order from the health care provider to change CVAD dressing.
d. Position the patient’s face toward the CVAD during injection cap changes.

 

 

ANS:  B

The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled. A provider’s order is not necessary. The patient should turn away from the CVAD during cap changes.

 

DIF:    Cognitive Level: Apply (application)                              REF:   297

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?
a. K+ 3.4 mEq/L (3.4 mmol/L) c. Na+ 154 mEq/L (154 mmol/L)
b. Ca+2 7.8 mg/dL (1.95 mmol/L) d. PO4-3 4.8 mg/dL (1.55 mmol/L)

 

 

ANS:  C

The elevated serum sodium level is consistent with the patient’s neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium, phosphate, and calcium levels vary slightly from normal but do not require immediate action by the nurse.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    276

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?
a. Oral temperature of 100.1°F
b. Serum sodium level of 138 mEq/L (138 mmol/L)
c. Gradually decreasing level of consciousness (LOC)
d. Weight gain of 2 pounds (1 kg) over the admission weight

 

 

ANS:  C

The patient’s history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported but do not indicate a need for rapid action to avoid complications.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    271

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient has peripheral edema and shortness of breath. Which assessment should the nurse complete first?
a. Skin turgor c. Mental status
b. Heart sounds d. Capillary refill

 

 

ANS:  C

Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds may also be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    279

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first?
a. Notify the patient’s health care provider.
b. Obtain an order to draw a potassium level.
c. Review the last magnesium level on the patient’s chart.
d. Teach the patient about magnesium-containing antacids.

 

 

ANS:  A

The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patient’s current symptoms are not consistent with hyperkalemia.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    286

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient complains of anxiety and incisional pain. The patient’s respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?
a. Check to make sure the nasogastric tube is patent.
b. Give the patient the PRN IV morphine sulfate 4 mg.
c. Notify the health care provider about the ABG results.
d. Teach the patient how to take slow, deep breaths when anxious.

 

 

ANS:  B

The patient’s respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse’s first action should be to medicate the patient for pain. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain. Checking the nasogastric tube can wait until the patient has been medicated for pain.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    288

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/LVN)?
a. Flush a saline lock with normal saline.
b. Verify blood products prior to administration.
c. Remove the patient’s central venous catheter.
d. Titrate the flow rate of vasoactive IV medications.

 

 

ANS:  A

A LPN/LVN has the education, experience, and scope of practice to flush a saline lock with normal saline. Administration of blood products, adjustment of vasoactive infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice.

 

DIF:    Cognitive Level: Apply (application)                              REF:   294

OBJ:   Special Questions: Delegation        TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?
a. The patient is experiencing laryngeal stridor.
b. The patient complains of generalized fatigue.
c. The patient’s bowels have not moved for 4 days.
d. The patient has numbness and tingling of the lips.

 

 

ANS:  A

Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient’s calcium level. The other data are also consistent with hypocalcemia, but do not indicate a need for as immediate action as laryngospasm.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    284

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Following a thyroidectomy, a patient complains of “a tingling feeling around my mouth.” Which assessment should the nurse complete?
a. Presence of the Chvostek’s sign
b. Abnormal serum potassium level
c. Decreased thyroid hormone level
d. Bleeding on the patient’s dressing

 

 

ANS:  A

The patient’s symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury or removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.

 

DIF:    Cognitive Level: Apply (application)                              REF:   284

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?
a. Arterial blood pH is 7.32.
b. Serum calcium is 18 mg/dL.
c. Serum potassium is 5.1 mEq/L.
d. Arterial oxygen saturation is 91%.

 

 

ANS:  B

The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life threatening.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    283

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?
a. The bibasilar breath sounds are decreased.
b. The patellar and triceps reflexes are absent.
c. The patient has been sleeping most of the day.
d. The patient reports feeling “sick to my stomach.”

 

 

ANS:  B

The loss of the deep tendon reflexes indicates that the patient’s magnesium level may be reaching toxic levels. Nausea and lethargy are also side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    286

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?
a. The patient’s radial pulse is 105 beats/min.
b. There are crackles throughout both lung fields.
c. There is sediment and blood in the patient’s urine.
d. The blood pressure increases from 120/80 to 142/94 mm Hg.

 

 

ANS:  B

Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine should also be reported, but they are not as dangerous as the presence of fluid in the alveoli.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    292

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next?
a. Monitor ionized calcium level.
b. Give oral calcium citrate tablets.
c. Check parathyroid hormone level.
d. Administer vitamin D supplements.

 

 

ANS:  A

This patient with chronic malnutrition is likely to have a low serum albumin level, which will affect the total serum calcium. A more accurate reflection of calcium balance is the ionized calcium level. Most of the calcium in the blood is bound to protein (primarily albumin). Alterations in serum albumin levels affect the interpretation of total calcium levels. Low albumin levels result in a drop in the total calcium level, although the level of ionized calcium is not affected. The other actions may be needed if the ionized calcium is also decreased.

 

DIF:    Cognitive Level: Apply (application)                              REF:   284

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. A patient comes to the clinic complaining of frequent, watery stools for the past 2 days. Which action should the nurse take first?
a. Obtain the baseline weight.
b. Check the patient’s blood pressure.
c. Draw blood for serum electrolyte levels.
d. Ask about extremity numbness or tingling.

 

 

ANS:  B

Because the patient’s history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the patient’s perfusion status.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    276

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?
a. Notify the health care provider.
b. Offer reassurance to the patient.
c. Auscultate the patient’s breath sounds.
d. Give prescribed PRN morphine sulfate IV.

 

 

ANS:  C

The initial action should be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax. The other actions may be appropriate, but further assessment of the patient is needed before notifying the health care provider, offering reassurance, or administration of morphine.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    296

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. After receiving change-of-shift report, which patient should the nurse assess first?
a. Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping
b. Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water
c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes
d. Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates

 

 

ANS:  C

The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The other patients have mild electrolyte disturbances or symptoms that require action, but they are not at risk for life-threatening complications.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    286

OBJ:   Special Questions: Prioritization | Special Questions: Multiple Patients

TOP:   Nursing Process: Planning              MSC:  NCLEX: Safe and Effective Care Environment

 

  1. During the admission process, the nurse obtains information about a patient through a physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate?
a. Deficient fluid volume c. Risk for injury: seizures
b. Impaired gas exchange d. Risk for impaired skin integrity

 

 

ANS:  C

The patient’s muscle cramps and low serum calcium level indicate that the patient is at risk for seizures, tetany, or both. The other diagnoses are not supported by the data because the skin turgor is good. The lungs are clear, arterial blood gases are normal, and there is no evidence of edema or dehydration that might suggest that the patient is at risk for impaired skin integrity.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    284

TOP:   Nursing Process: Diagnosis             MSC:  NCLEX: Physiological Integrity

 

 

Chapter 32: Hypertension

Lewis: Medical-Surgical Nursing, 10th Edition

 

MULTIPLE CHOICE

 

  1. Which action will the nurse in the hypertension clinic take to obtain an accurate baseline blood pressure (BP) for a new patient?
a. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second.
b. Have the patient sit in a chair with the feet flat on the floor.
c. Assist the patient to the supine position for BP measurements.
d. Obtain two BP readings in the dominant arm and average the results.

 

 

ANS:  B

The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, and the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg per second.

 

DIF:    Cognitive Level: Understand (comprehension)               REF:   696

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse obtains the following information from a patient newly diagnosed with prehypertension. Which finding is most important to address with the patient?
a. Low dietary fiber intake
b. No regular physical exercise
c. Drinks a beer with dinner every night
d. Weight is 5 pounds above ideal weight

 

 

ANS:  B

The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fiber, but increasing fiber alone will not prevent hypertension from developing. The patient’s alcohol intake is within guidelines and will not increase the hypertension risk.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    689

TOP:   Nursing Process: Planning              MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which action should the nurse take when giving the initial dose of oral labetalol to a patient with hypertension?
a. Encourage the use of hard candy to prevent dry mouth.
b. Teach the patient that headaches often occur with this drug.
c. Instruct the patient to call for help if heart palpitations occur.
d. Ask the patient to request assistance before getting out of bed.

 

 

ANS:  D

Labetalol decreases sympathetic nervous system activity by blocking both a- and b-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dry mouth, dehydration, and headaches are possible side effects of other antihypertensives.

 

DIF:    Cognitive Level: Apply (application)                              REF:   692

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been most effective?
a. The patient avoids eating nuts or nut butters.
b. The patient restricts intake of chicken and fish.
c. The patient drinks low-fat milk with each meal.
d. The patient has two cups of coffee in the morning.

 

 

ANS:  C

For the prevention of hypertension, the Dietary Approaches to Stop Hypertension (DASH) recommendations include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not included in the recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet.

 

DIF:    Cognitive Level: Apply (application)                              REF:   687

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Physiological Integrity

 

  1. A patient has just been diagnosed with hypertension and has been started on captopril . Which information is most important to include when teaching the patient about this drug?
a. Include high-potassium foods such as bananas in the diet.
b. Increase fluid intake if dryness of the mouth is a problem.
c. Change position slowly to help prevent dizziness and falls.
d. Check blood pressure (BP) in both arms before taking the drug.

 

 

ANS:  C

The angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the drug, and the patient is taught to use gum or hard candy to relieve dry mouth. The BP should be taken in the nondominant arm by newly diagnosed patients in the morning, before taking the drug, and in the evening. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.

 

DIF:    Cognitive Level: Apply (application)                              REF:   691

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this drug when the patient reveals a history of
a. daily alcohol use. c. reactive airway disease.
b. peptic ulcer disease. d. myocardial infarction (MI).

 

 

ANS:  C

Nonselective b-blockers block b1– and b2-adrenergic receptors and can cause bronchospasm, especially in patients with a history of asthma. b-Blockers will have no effect on the patient’s peptic ulcer disease or alcohol use. b-Blocker therapy is recommended after MI.

 

DIF:    Cognitive Level: Apply (application)                              REF:   692

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A 56-yr-old patient who has no previous history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that
a. a BP recheck should be scheduled in a few weeks.
b. dietary sodium and fat content should be decreased.
c. diagnosis, treatment, and ongoing monitoring will be needed.
d. there is an immediate danger of a stroke, requiring hospitalization.

 

 

ANS:  C

A sudden increase in BP in a patient older than age 50 years with no previous hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that dietary salt or fat intake have contributed to this sudden increase in BP, and reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.

 

DIF:    Cognitive Level: Apply (application)                              REF:   684

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. Which action will be included in the plan of care when the nurse is caring for a patient who is receiving nicardipine (Cardene) to treat a hypertensive emergency?
a. Organize nursing activities so that the patient has undisturbed sleep for 8 hours at night.
b. Keep the patient NPO to prevent aspiration caused by nausea and possible vomiting.
c. Assist the patient up in the chair for meals to avoid complications associated with immobility.
d. Use an automated noninvasive blood pressure machine to obtain frequent measurements.

 

 

ANS:  D

Frequent monitoring of BP is needed when the patient is receiving rapid-acting IV antihypertensive medications. This can be most easily accomplished with an automated BP machine or arterial line. The patient will require frequent assessments, so allowing 8 hours of undisturbed sleep is not reasonable. When patients are receiving IV vasodilators, bed rest is maintained to prevent decreased cerebral perfusion and fainting. There is no indication that this patient is nauseated or at risk for aspiration, so an NPO status is unnecessary.

 

DIF:    Cognitive Level: Apply (application)                              REF:   699

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. The nurse has just finished teaching a hypertensive patient about the newly prescribed drug, ramipril (Altace). Which patient statement indicates that more teaching is needed?
a. “The medication may not work well if I take aspirin.”
b. “I can expect some swelling around my lips and face.”
c. “The doctor may order a blood potassium level occasionally.”
d. “I will call the doctor if I notice that I have a frequent cough.”

 

 

ANS:  B

Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor should be discontinued. The patient should be taught that if any swelling of the face or oral mucosa occurs, the health care provider should be immediately notified because this could be life threatening. The other patient statements indicate that the patient has an accurate understanding of ACE inhibitor therapy.

 

DIF:    Cognitive Level: Apply (application)                              REF:   692

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Physiological Integrity

 

  1. During change-of-shift report, the nurse obtains the following information about a hypertensive patient who received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient needs immediate intervention?
a. The patient’s pulse has dropped from 68 to 57 beats/min.
b. The patient complains that the fingers and toes feel quite cold.
c. The patient has developed wheezes throughout the lung fields.
d. The patient’s blood pressure (BP) reading is now 158/91 mm Hg.

 

 

ANS:  C

The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of the noncardioselective b-blockers) is occurring. The nurse should immediately obtain an O2 saturation measurement, apply supplemental O2, and notify the health care provider. The mild decrease in heart rate and complaint of cold fingers and toes are associated with b-receptor blockade but do not require any change in therapy. The BP reading may indicate that a change in medication type or dose may be indicated. However, this is not as urgently needed as addressing the bronchospasm.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    692

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Physiological Integrity

 

  1. An older patient has been diagnosed with possible white coat hypertension. Which planned action by the nurse best addresses the suspected cause of the hypertension?
a. Instruct the patient about the need to decrease stress levels.
b. Teach the patient how to self-monitor and record BPs at home.
c. Schedule the patient for regular blood pressure (BP) checks in the clinic.
d. Inform the patient and caregiver that major dietary changes will be needed.

 

 

ANS:  B

In the phenomenon of “white coat” hypertension, patients have elevated BP readings in a clinical setting and normal readings when BP is measured elsewhere. Having the patient self-monitor BPs at home will provide a reliable indication about whether the patient has hypertension. Regular BP checks in the clinic are likely to be high in a patient with white coat hypertension. There is no evidence that this patient has elevated stress levels or a poor diet, and those factors do not cause white coat hypertension.

 

DIF:    Cognitive Level: Apply (application)                              REF:   687

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 48-yr-old patient with newly diagnosed hypertension?
a. 98/56 mm Hg c. 128/92 mm Hg
b. 128/76 mm Hg d. 142/78 mm Hg

 

 

ANS:  B

The 8th Joint National Committee’s recommended goal for antihypertensive therapy for a 30- to 59-yr-old patient with hypertension is a BP below 140/90 mm Hg. The BP of 98/56 mm Hg may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient’s treatment.

 

DIF:    Cognitive Level: Apply (application)                              REF:   684

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Physiological Integrity

 

  1. Which information is most important for the nurse to include when teaching a patient with newly diagnosed hypertension?
a. Most people are able to control BP through dietary changes.
b. Annual BP checks are needed to monitor treatment effectiveness.
c. Hypertension is usually asymptomatic until target organ damage occurs.
d. Increasing physical activity alone controls blood pressure (BP) for most people.

 

 

ANS:  C

Hypertension is usually asymptomatic until target organ damage has occurred. Lifestyle changes (e.g., physical activity, dietary changes) are used to help manage BP, but drugs are needed for most patients. Home BP monitoring should be taught to the patient and findings checked by the health care provider frequently when starting treatment for hypertension and then every 3 months when stable.

 

DIF:    Cognitive Level: Apply (application)                              REF:   685

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?
a. 48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain
b. 52-yr-old with a blood pressure of 198/90 mm Hg who has intermittent claudication
c. 50-yr-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.7 mg/dL
d. 43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria

 

 

ANS:  A

The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention are needed. The symptoms of the other patients also show target organ damage but are not indicative of acute processes.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    695

OBJ:   Special Questions: Prioritization | Special Questions: Multiple Patients

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Safe and Effective Care Environment

 

  1. The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider?
a. Serum creatinine of 2.8 mg/dL c. Serum hemoglobin of 14.7 g/dL
b. Serum potassium of 4.5 mEq/L d. Blood glucose level of 96 mg/dL

 

 

ANS:  A

The elevated serum creatinine indicates renal damage caused by the hypertension. The other laboratory results are normal.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    686

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up on these findings?
a. “Have you recently taken any antihistamines?”
b. “Have you consistently taken your medications?”
c. “Did you take any acetaminophen (Tylenol) today?”
d. “Have there been recent stressful events in your life?”

 

 

ANS:  B

Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.

 

DIF:    Cognitive Level: Apply (application)                              REF:   691

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?
a. Urine output over 8 hours is 250 mL less than the fluid intake.
b. The patient cannot move the left arm and leg when asked to do so.
c. Tremors are noted in the fingers when the patient extends the arms.
d. The patient complains of a headache with pain at level 7 of 10 (0 to 10 scale).

 

 

ANS:  B

The patient’s inability to move the left arm and leg indicates that a stroke may be occurring and will require immediate action to prevent further neurologic damage. The other clinical manifestations are also likely caused by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the neurologic changes.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    699

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action should the nurse take first?
a. Tell the patient why a change in drug dosage is needed.
b. Ask the patient if the medication is being taken as prescribed.
c. Inform the patient that multiple drugs are often needed to treat hypertension.
d. Question the patient regarding any lifestyle changes made to help control BP.

 

 

ANS:  B

Because nonadherence with antihypertensive therapy is common, the nurse’s initial action should be to determine whether the patient is taking the atenolol as prescribed. The other actions also may be implemented, but these would be done after assessing patient adherence with the prescribed therapy.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    695

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside . Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?
a. Evaluate effectiveness of nitroprusside therapy on blood pressure (BP).
b. Assess the patient’s environment for adverse stimuli that might increase BP.
c. Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg.
d. Set up the automatic noninvasive BP machine to take readings every 15 minutes.

 

 

ANS:  D

LPN/LVN education and scope of practice include the correct use of common equipment such as automatic noninvasive blood pressure machines. The other actions require advanced nursing judgment and education, and should be done by RNs.

 

DIF:    Cognitive Level: Apply (application)                              REF:   696

OBJ:   Special Questions: Delegation        TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient to
a. increase the dietary intake of high-potassium foods.
b. make an appointment with the dietitian for teaching.
c. check the blood pressure (BP) at home at least once a day.
d. move slowly when moving from lying to sitting to standing.

 

 

ANS:  A

The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect. The other teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just started therapy with enalapril.

 

DIF:    Cognitive Level: Apply (application)                              REF:   691

OBJ:   Special Questions: Delegation        TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. Which assessment finding for a patient who is receiving IV furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider?
a. Blood glucose level of 175 mg/dL
b. Serum potassium level of 3.0 mEq/L
c. Orthostatic systolic BP decrease of 12 mm Hg
d. Most recent blood pressure (BP) reading of 168/94 mm Hg

 

 

ANS:  B

Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-threatening dysrhythmias. The health care provider should be notified of the potassium level immediately and administration of potassium supplements initiated. The elevated blood glucose and BP also indicate a need for collaborative interventions but will not require action as urgently as the hypokalemia. An orthostatic drop of 12 mm Hg will require intervention only if the patient is symptomatic.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    688

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. Which nursing action should the nurse take first to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes?
a. Collect a detailed diet history.
b. Provide a list of low-sodium foods.
c. Help the patient make an appointment with a dietitian.
d. Teach the patient about foods that are high in potassium.

 

 

ANS:  A

The initial nursing action should be assessment of the patient’s baseline dietary intake through a thorough diet history. The other actions may be appropriate, but assessment of the patient’s baseline should occur first.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    694

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a 70-yr-old patient who uses hydrochlorothiazide and enalapril (Norvasc) but whose self-monitored blood pressure (BP) continues to be elevated. Which patient information may indicate a need for a change?
a. Patient takes a daily multivitamin tablet.
b. Patient checks BP daily just after getting up.
c. Patient drinks wine three to four times a week.
d. Patient uses ibuprofen (Motrin) treat osteoarthritis.

 

 

ANS:  D

Because use of nonsteroidal antiinflammatory drugs (NSAIDs) can prevent adequate BP control, the patient may need to avoid the use of ibuprofen. A multivitamin tablet will help supply vitamin D, which may help lower BP. BP decreases while sleeping, so self-monitoring early in the morning will result in obtaining pressures that are at their lowest. The patient’s alcohol intake is not excessive.

 

DIF:    Cognitive Level: Apply (application)                              REF:   691

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

SHORT ANSWER

 

  1. The nurse obtains a blood pressure of 176/82 mm Hg for a patient. What is the patient’s mean arterial pressure (MAP)?

 

ANS:

113 mm Hg

 

MAP = (SBP + 2 DBP)/3

 

DIF:    Cognitive Level: Apply (application)                              REF:   699

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

 

Chapter 48: Diabetes Mellitus

Lewis: Medical-Surgical Nursing, 10th Edition

 

MULTIPLE CHOICE

 

  1. Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct?
a. Insulin is not used to control blood glucose in patients with type 2 diabetes.
b. Complications of type 2 diabetes are less serious than those of type 1 diabetes.
c. Changes in diet and exercise may control blood glucose levels in type 2 diabetes.
d. Type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma.

 

 

ANS:  C

For some patients with type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control. Insulin is frequently used for type 2 diabetes, complications are equally severe as for type 1 diabetes, and type 2 diabetes is usually diagnosed with routine laboratory testing or after a patient develops complications such as frequent yeast infections.

 

DIF:    Cognitive Level: Understand (comprehension)               REF:   1134

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about
a. self-monitoring of blood glucose.
b. using low doses of regular insulin.
c. lifestyle changes to lower blood glucose.
d. effects of oral hypoglycemic medications.

 

 

ANS:  C

The patient’s impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or oral hypoglycemics for glucose control and does not need to self-monitor blood glucose.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1133

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. A 28-yr-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching?
a. The patient always carries hard candies when engaging in exercise.
b. The patient goes for a vigorous walk when his glucose is 200 mg/dL.
c. The patient has a peanut butter sandwich before going for a bicycle ride.
d. The patient increases daily exercise when ketones are present in the urine.

 

 

ANS:  D

When the patient is ketotic, exercise may result in an increase in blood glucose level. Patients with type 1 diabetes should be taught to avoid exercise when ketosis is present. The other statements are correct.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1134

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is assessing a 22-yr-old patient experiencing the onset of symptoms of type 1 diabetes. To which question would the nurse anticipate a positive response?
a. “Are you anorexic?” c. “Have you lost weight lately?”
b. “Is your urine dark colored?” d. “Do you crave sugary drinks?”

 

 

ANS:  C

Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar-containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1121

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient?
a. Fasting blood glucose c. Glycosylated hemoglobin
b. Oral glucose tolerance d. Urine dipstick for glucose

 

 

ANS:  C

The glycosylated hemoglobin (A1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes but is not used for monitoring glucose control after diabetes has been diagnosed.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1124

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is assessing a 55-yr-old female patient with type 2 diabetes who has a body mass index (BMI) of 31 kg/m2.Which goal in the plan of care is most important for this patient?
a. The patient will reach a glycosylated hemoglobin level of less than 7%.
b. The patient will follow a diet and exercise plan that results in weight loss.
c. The patient will choose a diet that distributes calories throughout the day.
d. The patient will state the reasons for eliminating simple sugars in the diet.

 

 

ANS:  A

The complications of diabetes are related to elevated blood glucose and the most important patient outcome is the reduction of glucose to near-normal levels. A BMI of 30?9?kg/m2 or above is considered obese, so the other outcomes are appropriate but are not as high in priority.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1124

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. A patient who has type 1 diabetes plans to swim laps for an hour daily at 1:00 PM. The clinic nurse will plan to teach the patient to
a. check glucose level before, during, and after swimming.
b. delay eating the noon meal until after the swimming class.
c. increase the morning dose of neutral protamine Hagedorn (NPH) insulin.
d. time the morning insulin injection so that the peak occurs while swimming.

 

 

ANS:  A

The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1132

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. The nurse determines a need for additional instruction when the patient with newly diagnosed type 1 diabetes says which of the following?
a. “I will need a bedtime snack because I take an evening dose of NPH insulin.”
b. “I can choose any foods, as long as I use enough insulin to cover the calories.”
c. “I can have an occasional beverage with alcohol if I include it in my meal plan.”
d. “I will eat something at meal times to prevent hypoglycemia, even if I am not hungry.”

 

 

ANS:  B

Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1132

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Physiological Integrity

 

  1. To assist an older patient with diabetes to engage in moderate daily exercise, which action is most important for the nurse to take?
a. Determine what types of activities the patient enjoys.
b. Remind the patient that exercise improves self-esteem.
c. Teach the patient about the effects of exercise on glucose level.
d. Give the patient a list of activities that are moderate in intensity.

 

 

ANS:  A

Because consistency with exercise is important, assessment for the types of exercise that the patient finds enjoyable is the most important action by the nurse in ensuring adherence to an exercise program. The other actions may be helpful but are not the most important in improving compliance.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1134

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which statement by the patient indicates a need for additional instruction in administering insulin?
a. “I need to rotate injection sites among my arms, legs, and abdomen each day.”
b. “I can buy the 0.5-mL syringes because the line markings will be easier to see.”
c. “I do not need to aspirate the plunger to check for blood before injecting insulin.”
d. “I should draw up the regular insulin first, after injecting air into the NPH bottle.”

 

 

ANS:  A

Rotating sites is no longer recommended because there is more consistent insulin absorption when the same site is used consistently. The other patient statements are accurate and indicate that no additional instruction is needed.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1128

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which patient action indicates good understanding of the nurse’s teaching about administration of aspart (NovoLog) insulin?
a. The patient avoids injecting the insulin into the upper abdominal area.
b. The patient cleans the skin with soap and water before insulin administration.
c. The patient stores the insulin in the freezer after administering the prescribed dose.
d. The patient pushes the plunger down while removing the syringe from the injection site.

 

 

ANS:  B

Cleaning the skin with soap and water is acceptable. Insulin should not be frozen. The patient should leave the syringe in place for about 5 seconds after injection to be sure that all the insulin has been injected. The upper abdominal area is one of the preferred areas for insulin injection.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1128

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Physiological Integrity

 

  1. A patient receives aspart (NovoLog) insulin at 8:00 AM. At which time would the nurse anticipate the highest risk for hypoglycemia?
a. 10:00 AM c. 2:00 PM
b. 12:00 AM d. 4:0 PM

 

 

ANS:  A

The rapid-acting insulins peak in 1 to 3 hours. The patient is not at a high risk for hypoglycemia at the other listed times, although hypoglycemia may occur.

 

DIF:    Cognitive Level: Understand (comprehension)               REF:   1132

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Physiological Integrity

 

  1. Which patient action indicates a good understanding of the nurse’s teaching about the use of an insulin pump?
a. The patient programs the pump for an insulin bolus after eating.
b. The patient changes the location of the insertion site every week.
c. The patient takes the pump off at bedtime and starts it again each morning.
d. The patient plans a diet with more calories than usual when using the pump.

 

 

ANS:  A

In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, with the dosage depending on the oral intake. The insertion site should be changed every 2 or 3 days. There is more flexibility in diet and exercise when an insulin pump is used, but it does not provide for consuming a higher calorie diet. The pump will deliver a basal insulin rate 24 hours a day.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1129

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage?
a. Lispro (Humalog) c. Detemir (Levemir)
b. Glargine (Lantus) d. NPH (Humulin N)

 

 

ANS:  A

Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1125

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. Which information will the nurse include when teaching a patient who has type 2 diabetes about glyburide ?
a. Glyburide decreases glucagon secretion from the pancreas.
b. Glyburide stimulates insulin production and release from the pancreas.
c. Glyburide should be taken even if the morning blood glucose level is low.
d. Glyburide should not be used for 48 hours after receiving IV contrast media.

 

 

ANS:  B

The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking glyburide because hypoglycemia can occur with this class of medication. Metformin should be held for 48 hours after administration of IV contrast media, but this is not necessary for glyburide. Glucagon secretion is not affected by glyburide.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1130

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching?
a. “If I overeat at a meal, I will still take the usual dose of medication.”
b. “Other medications besides the Glucotrol may affect my blood sugar.”
c. “When I am ill, I may have to take insulin to control my blood sugar.”
d. “My diabetes won’t cause complications because I don’t need insulin.”

 

 

ANS:  D

The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glipizide.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1130

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Physiological Integrity

 

  1. When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone. The nurse will anticipate that the patient may
a. need a diet higher in calories while receiving prednisone.
b. develop acute hypoglycemia while taking the prednisone.
c. require administration of insulin while taking prednisone.
d. have rashes caused by metformin-prednisone interactions.

 

 

ANS:  C

Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a side effect of prednisone. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient may have an increased appetite when taking prednisone but will not need a diet that is higher in calories.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1124

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to
a. save the lunch tray for the patient’s later return to the unit.
b. ask that diagnostic testing area staff to start a 5% dextrose IV.
c. send a glass of milk or orange juice to the patient in the diagnostic testing area.
d. request that if testing is further delayed, the patient be returned to the unit to eat.

 

 

ANS:  D

Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1127

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose
a. washes the puncture site using warm water and soap.
b. chooses a puncture site in the center of the finger pad.
c. hangs the arm down for a minute before puncturing the site.
d. says the result of 120 mg indicates good blood sugar control.

 

 

ANS:  B

The patient is taught to choose a puncture site at the side of the finger pad because there are fewer nerve endings along the side of the finger pad. The other patient actions indicate that teaching has been effective.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1136

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is preparing to teach a 43-yr-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first?
a. Ask the patient’s family to participate in the diabetes education program.
b. Assess the patient’s perception of what it means to have diabetes mellitus.
c. Demonstrate how to check glucose using capillary blood glucose monitoring.
d. Discuss the need for the patient to actively participate in diabetes management.

 

 

ANS:  B

Before planning teaching, the nurse should assess the patient’s interest in and ability to self-manage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1139

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to
a. give 50% dextrose. c. initiate O2 by nasal cannula.
b. insert an IV catheter. d. administer glargine (Lantus) insulin.

 

 

ANS:  B

HHS is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires O2. Dextrose solutions will increase the patient’s blood glucose and would be contraindicated.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1145

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. A 26-yr-old female with type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and a blood glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. The nurse advises the patient to
a. use only the lispro insulin until the symptoms are resolved.
b. limit intake of calories until the glucose is less than 120 mg/dL.
c. monitor blood glucose every 4 hours and notify the clinic if it continues to rise.
d. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%.

 

 

ANS:  C

Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with lispro insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to diabetic ketoacidosis (DKA). Decreasing carbohydrate or caloric intake is not appropriate because the patient will need more calories when ill. Glycosylated hemoglobin testing is not used to evaluate short-term alterations in blood glucose.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1139

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. The health care provider suspects the Somogyi effect in a 50-yr-old patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take?
a. Avoid snacking at bedtime.
b. Increase the rapid-acting insulin dose.
c. Check the blood glucose during the night
d. Administer a larger dose of long-acting insulin.

 

 

ANS:  C

If the Somogyi effect is causing the patient’s increased morning glucose level, the patient will experience hypoglycemia between 2:00 and 4:00 AM. The dose of insulin will be reduced, rather than increased. A bedtime snack is used to prevent hypoglycemic episodes during the night.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1129

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. Which action should the nurse take after a patient treated with intramuscular glucagon for hypoglycemia regains consciousness?
a. Assess the patient for symptoms of hyperglycemia.
b. Give the patient a snack of peanut butter and crackers.
c. Have the patient drink a glass of orange juice or nonfat milk.
d. Administer a continuous infusion of 5% dextrose for 24 hours.

 

 

ANS:  B

Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood glucose rapidly, but the cheese and crackers will stabilize blood glucose. Administration of IV glucose might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1129

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. Which question during the assessment of a patient who has diabetes will help the nurse identify autonomic neuropathy?
a. “Do you feel bloated after eating?”
b. “Have you seen any skin changes?”
c. “Do you need to increase your insulin dosage when you are stressed?”
d. “Have you noticed any painful new ulcerations or sores on your feet?”

 

 

ANS:  A

Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient. The other questions are also appropriate to ask but would not help in identifying autonomic neuropathy.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1150

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. Which information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs?
a. Choose flat-soled leather shoes.
b. Set heating pads on a low temperature.
c. Use callus remover for corns or calluses.
d. Soak feet in warm water for an hour each day.

 

 

ANS:  A

The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided. The patient should see a specialist to treat these problems.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1151

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. Which finding indicates a need to contact the health care provider before the nurse administers metformin (Glucophage)?
a. The patient’s blood glucose level is 174 mg/dL.
b. The patient is scheduled for a chest x-ray in an hour.
c. The patient has gained 2 lb (0.9 kg) in the past 24 hours.
d. The patient’s blood urea nitrogen (BUN) level is 52 mg/dL.

 

 

ANS:  D

The BUN indicates possible renal failure, and metformin should not be used in patients with renal failure. The other findings are not contraindications to the use of metformin.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1130

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A patient who has diabetes and reported burning foot pain at night receives a new prescription. Which information should the nurse teach the patient about amitriptyline ?
a. Amitriptyline decreases the depression caused by your foot pain.
b. Amitriptyline helps prevent transmission of pain impulses to the brain.
c. Amitriptyline corrects some of the blood vessel changes that cause pain.
d. Amitriptyline improves sleep and makes you less aware of nighttime pain.

 

 

ANS:  B

Tricyclic antidepressants (TCAs) decrease the transmission of pain impulses to the spinal cord and brain. TCAs also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by TCAs.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1150

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. A patient who has type 2 diabetes is being prepared for an elective coronary angiogram. Which information would the nurse anticipate might lead to rescheduling the test?
a. The patient’s most recent A1C was 6.5%.
b. The patient’s blood glucose is 128 mg/dL.
c. The patient took the prescribed metformin today.
d. The patient took the prescribed captopril this morning.

 

 

ANS:  C

To avoid lactic acidosis, metformin should be discontinued a day or 2 before the coronary angiogram and should not be used for 48 hours after IV contrast media are administered. The other patient data will also be reported but do not indicate any need to reschedule the procedure.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1130

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. Which action by a patient indicates that the home health nurse’s teaching about glargine and regular insulin has been successful?
a. The patient administers the glargine 30 minutes before each meal.
b. The patient’s family prefills the syringes with the mix of insulins weekly.
c. The patient discards the open vials of glargine and regular insulin after 4 weeks.
d. The patient draws up the regular insulin and then the glargine in the same syringe.

 

 

ANS:  C

Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and stored. Short-acting regular insulin is administered before meals, and glargine is given once daily.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1127

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Physiological Integrity

 

  1. A patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to use to administer the morning insulin?
a. thigh. c. abdomen.
b. buttock. d. upper arm.

 

 

ANS:  C

Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1128

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is interviewing a new patient with diabetes who takes rosiglitazone (Avandia). Which information would the nurse anticipate resulting in the health care provider discontinuing the medication?
a. The patient’s blood pressure is 154/92.
b. The patient’s blood glucose is 86 mg/dL.
c. The patient reports a history of emphysema.
d. The patient has chest pressure when walking.

 

 

ANS:  D

Rosiglitazone can cause myocardial ischemia. The nurse should immediately notify the health care provider and expect orders to discontinue the medication. A blood glucose level of 86 mg/dL indicates a positive effect from the medication. Hypertension and a history of emphysema do not contraindicate this medication.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1130

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is taking a health history from a 29-yr-old pregnant patient at the first prenatal visit. The patient reports that she has no personal history of diabetes, but her mother has diabetes. Which action will the nurse plan to take?
a. Teach the patient about administering regular insulin.
b. Schedule the patient for a fasting blood glucose level.
c. Teach about an increased risk for fetal problems with gestational diabetes.
d. Schedule an oral glucose tolerance test for the twenty-fourth week of pregnancy.

 

 

ANS:  B

Patients at high risk for gestational diabetes should be screened for diabetes on the initial prenatal visit. An oral glucose tolerance test may also be used to check for diabetes, but it would be done before the twenty-fourth week. Teaching plans would depend on the outcome of a fasting blood glucose test and other tests.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1138

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. A 27-yr-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first?
a. Place the patient on a cardiac monitor.
b. Administer IV potassium supplements.
c. Ask the patient about home insulin doses.
d. Start an insulin infusion at 0.1 units/kg/hr.

 

 

ANS:  A

Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with electrocardiogram (ECG) monitoring. Because potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be administered without cardiac monitoring because insulin infusion will further decrease potassium levels. Discussion of home insulin and possible causes can wait until the patient is stabilized.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1146

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient with diabetic ketoacidosis is brought to the emergency department. Which prescribed action should the nurse implement first?
a. Infuse 1 L of normal saline per hour.
b. Give sodium bicarbonate 50 mEq IV push.
c. Administer regular insulin 10 U by IV push.
d. Start a regular insulin infusion at 0.1 units/kg/hr.

 

 

ANS:  A

The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids. The other actions can be done after the infusion of normal saline is initiated.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1144

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first?
a. Infuse dextrose 50% by slow IV push.
b. Administer 1 mg glucagon subcutaneously.
c. Obtain a glucose reading using a finger stick.
d. Have the patient drink 4 ounces of orange juice.

 

 

ANS:  C

The patient’s clinical manifestations are consistent with hypoglycemia, and the initial action should be to check the patient’s glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon or dextrose 50% might be given if the patient’s symptoms become worse or if the patient is unconscious.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1135

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A female patient is scheduled for an oral glucose tolerance test. Which information from the patient’s health history is important for the nurse to communicate to the health care provider regarding this test?
a. The patient uses oral contraceptives.
b. The patient runs several days a week.
c. The patient has been pregnant three times.
d. The patient has a family history of diabetes.

 

 

ANS:  A

Oral contraceptive use may falsely elevate oral glucose tolerance test (OGTT) values. Exercise and a family history of diabetes both can affect blood glucose but will not lead to misleading information from the OGTT. History of previous pregnancies may provide informational about gestational glucose tolerance but will not lead to misleading information from the OGTT.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1124

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP) indicates an urgent need for the nurse’s assessment of the patient?
a. Bedtime glucose of 140 mg/dL
b. Noon blood glucose of 52 mg/dL
c. Fasting blood glucose of 130 mg/dL
d. 2-hr postprandial glucose of 220 mg/dL

 

 

ANS:  B

The nurse should assess the patient with a blood glucose level of 52 mg/dL for symptoms of hypoglycemia and give the patient a carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range or not immediately dangerous for a patient with diabetes.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1152

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?
a. Communicate the blood glucose level and insulin dose to the circulating nurse in surgery.
b. Discuss the reason for the use of insulin therapy during the immediate postoperative period.
c. Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery.
d. Plan strategies to minimize the risk for hypoglycemia or hyperglycemia during the postoperative period.

 

 

ANS:  C

LPN/LVN education and scope of practice includes administration of insulin. Communication about patient status with other departments, planning, and patient teaching are skills that require RN education and scope of practice.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1152

OBJ:   Special Questions: Delegation        TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. An active 32-yr-old male who has type 1 diabetes is being seen in the endocrine clinic. Which finding indicates a need for the nurse to discuss a possible a change in therapy with the health care provider?
a. Hemoglobin A1C level of 6.2%
b. Blood pressure of 140/88 mmHg
c. Heart rate at rest of 58 beats/minute
d. High density lipoprotein (HDL) level of 65 mg/dL

 

 

ANS:  B

To decrease the incidence of macrovascular and microvascular problems in patients with diabetes, the goal blood pressure is usually 130/80 mm Hg. An A1C less than 6.5%, a low resting heart rate (consistent with regular aerobic exercise in a young adult), and an HDL level of 65 mg/dL all indicate that the patient’s diabetes and risk factors for vascular disease are well controlled.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1148

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A 30-yr-old patient has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye examination
a. every 2 years. c. when the patient is 39 years old.
b. as soon as possible. d. within the first year after diagnosis.

 

 

ANS:  B

Because many patients have some diabetic retinopathy when they are first diagnosed with type 2 diabetes, a dilated eye examination is recommended at the time of diagnosis and annually thereafter. Patients with type 1 diabetes should have dilated eye examinations starting 5 years after they are diagnosed and then annually.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1149

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. After the nurse has finished teaching a patient who has a new prescription for exenatide (Byetta), which patient statement indicates that the teaching has been effective?
a. “I may feel hungrier than usual when I take this medicine.”
b. “I will not need to worry about hypoglycemia with the Byetta.”
c. “I should take my daily aspirin at least an hour before the Byetta.”
d. “I will take the pill at the same time I eat breakfast in the morning.”

 

 

ANS:  C

Because exenatide slows gastric emptying, oral medications should be taken at least 1 hour before the exenatide to avoid slowing absorption. Exenatide is injected and increases feelings of satiety. Hypoglycemia can occur with this medication.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1132

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Physiological Integrity

 

  1. A few weeks after an 82-yr-old patient with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding should the nurse promptly discuss with the health care provider?
a. Hemoglobin A1C level is 7.9%.
b. Last eye examination was 18 months ago.
c. Glomerular filtration rate is decreased.
d. Patient has questions about the prescribed diet.

 

 

ANS:  C

The decrease in renal function may indicate a need to adjust the dose of metformin or change to a different medication. In older patients, the goal for A1C may be higher in order to avoid complications associated with hypoglycemia. The nurse will plan on scheduling the patient for an eye examination and addressing the questions about diet, but the area for prompt intervention is the patient’s decreased renal function.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1130

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next?
a. Give the patient 4 to 6 oz more orange juice.
b. Administer the PRN glucagon (Glucagon) 1 mg IM.
c. Have the patient eat some peanut butter with crackers.
d. Notify the health care provider about the hypoglycemia.

 

 

ANS:  A

The “rule of 15” indicates that administration of quickly acting carbohydrates should be done two or three times for a conscious patient whose glucose remains less than 70 mg/dL before notifying the health care provider. More complex carbohydrates and fats may be used after the glucose has stabilized. Glucagon should be used if the patient’s level of consciousness decreases so that oral carbohydrates can no longer be given.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1146

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which nursing action can the nurse delegate to experienced unlicensed assistive personnel (UAP) who are working in the diabetic clinic?
a. Measure the ankle-brachial index.
b. Check for changes in skin pigmentation.
c. Assess for unilateral or bilateral foot drop.
d. Ask the patient about symptoms of depression.

 

 

ANS:  A

Checking systolic pressure at the ankle and brachial areas and calculating the ankle-brachial index is a procedure that can be done by UAP who have been trained in the procedure. The other assessments require more education and critical thinking and should be done by the registered nurse (RN).

 

DIF:    Cognitive Level: Apply (application)                              REF:   1152

OBJ:   Special Questions: Delegation        TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. After change-of-shift report, which patient will the nurse assess first?
a. A 19-yr-old patient with type 1 diabetes who was admitted with possible dawn phenomenon
b. A 35-yr-old patient with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL
c. A 60-yr-old patient with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa
d. A 68-yr-old patient with type 2 diabetes who has severe peripheral neuropathy and complains of burning foot pain

 

 

ANS:  C

The patient’s diagnosis of HHS and signs of dehydration indicate that the nurse should rapidly assess for signs of shock and determine whether increased fluid infusion is needed. The other patients also need assessment and intervention but do not have life-threatening complications.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1146

OBJ:   Special Questions: Multiple Patients | Special Questions: Prioritization

TOP:   Nursing Process: Planning              MSC:  NCLEX: Safe and Effective Care Environment

 

  1. After change-of-shift report, which patient should the nurse assess first?
a. A 19-yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12%
b. A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL
c. A 40-yr-old patient who is pregnant and whose oral glucose tolerance test is 202 mg/dL
d. A 50-yr-old patient who uses exenatide (Byetta) and is complaining of acute abdominal pain

 

 

ANS:  B

Because the brain requires glucose to function, untreated hypoglycemia can cause unconsciousness, seizures, and death. The nurse will rapidly assess and treat the patient with low blood glucose. The other patients also have symptoms that require assessments or interventions, but they are not at immediate risk for life-threatening complications.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1146

OBJ:   Special Questions: Prioritization | Special Questions: Multiple Patients

TOP:   Nursing Process: Planning              MSC:  NCLEX: Safe and Effective Care Environment

 

MULTIPLE RESPONSE

 

  1. To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select all that apply)?
a. Chest x-ray
b. Blood pressure
c. Serum creatinine
d. Urine for microalbuminuria
e. Complete blood count (CBC)
f. Monofilament testing of the foot

 

 

ANS:  B, C, D, F

Blood pressure, serum creatinine, urine testing for microalbuminuria, and monofilament testing of the foot are recommended at least annually to screen for possible microvascular and macrovascular complications of diabetes. Chest x-ray and CBC might be ordered if the patient with diabetes presents with symptoms of respiratory or infectious problems but are not routinely included in screening.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1148

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

OTHER

 

  1. In which order will the nurse take these steps to prepare NPH 20 units and regular insulin 2 units using the same syringe? (Put a comma and a space between each answer choice [A, B, C, D, E]).
  2. Rotate NPH vial.
  3. Withdraw regular insulin.
  4. Withdraw 20 units of NPH.
  5. Inject 20 units of air into NPH vial.
  6. Inject 2 units of air into regular insulin vial.

 

ANS:

A, D, E, B, C

 

When mixing regular insulin with NPH, it is important to avoid contact between the regular insulin and the additives in the NPH that slow the onset, peak, and duration of activity in the longer-acting insulin.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1126

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

 

Chapter 68: Emergency and Disaster Nursing

Lewis: Medical-Surgical Nursing, 10th Edition

 

MULTIPLE CHOICE

 

  1. During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next?
a. Palpate extremities for bilateral pulses.
b. Observe the patient’s respiratory effort.
c. Check the patient’s level of consciousness.
d. Examine the patient for any external bleeding.

 

 

ANS:  B

Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient’s breathing. The other actions are also part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1630

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. During the primary survey of a patient with severe leg trauma, the nurse observes that the patient’s left pedal and posterior tibial pulses are absent and the entire leg is swollen. Which action will the nurse take next?
a. Send blood to the lab for a complete blood count.
b. Assess further for a cause of the decreased circulation.
c. Finish the airway, breathing, circulation, disability survey.
d. Start normal saline fluid infusion with a large-bore IV line.

 

 

ANS:  D

The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a complete blood count is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1630

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care?
a. Initiate cooling per protocol.
b. Avoid the use of sedative drugs.
c. Check mental status every 15 minutes.
d. Rewarm if temperature is below 91° F (32.8° C).

 

 

ANS:  A

When therapeutic hypothermia is used postresuscitation, external cooling devices or cold normal saline infusions are used to rapidly lower body temperature to 89.6° F to 93.2° F (32° C to 34° C). Because hypothermia will decrease brain activity, assessing mental status every 15 minutes is not done at this stage. Sedative drugs are given during therapeutic hypothermia.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1634

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should
a. obtain a complete set of vital signs.
b. obtain a Glasgow Coma Scale score.
c. attach an electrocardiogram monitor.
d. ask about chronic medical conditions.

 

 

ANS:  B

The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1632

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A 19-yr-old patient is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving
a. tetanus immunoglobulin (TIG) only.
b. TIG and tetanus-diphtheria toxoid (Td).
c. tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only.
d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).

 

 

ANS:  D

For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1634

TOP:   Nursing Process: Planning              MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of
a. peritoneal lavage.
b. abdominal ultrasonography.
c. nasogastric (NG) tube placement.
d. magnetic resonance imaging (MRI).

 

 

ANS:  B

For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in the diagnosis of intraabdominal bleeding.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1633

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement?
a. “I’ll take salt tablets when I work outdoors in the summer.”
b. “I should take acetaminophen (Tylenol) if I start to feel too warm.”
c. “I need to drink extra fluids when working outside in hot weather.”
d. “I’ll move to a cool environment if I notice that I’m feeling confused”

 

 

ANS:  C

Oral fluids and electrolyte replacement solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia. Antipyretic drugs are not effective in lowering body temperature elevations caused by excessive exposure to heat. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1637

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Physiological Integrity

 

  1. A 22-yr-old patient who experienced a drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?
a. Auscultate heart sounds. c. Auscultate breath sounds.
b. Palpate peripheral pulses. d. Check mental orientation.

 

 

ANS:  C

Because pulmonary edema is a common complication after drowning, the nurse should assess the breath sounds frequently. The other information also will be obtained by the nurse, but it is not as pertinent to the patient’s admission diagnosis.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1640

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. When planning the response to the potential use of smallpox as a biological weapon, the emergency department (ED) nurse manager will plan to obtain adequate quantities of
a. vaccine. c. antibiotics.
b. atropine. d. whole blood.

 

 

ANS:  A

Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other agents of terrorism but not for smallpox.

 

DIF:    Cognitive Level: Understand (comprehension)               REF:   1645

TOP:   Nursing Process: Planning              MSC:  NCLEX: Safe and Effective Care Environment

 

  1. When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F (30.6° C), which finding indicates that the nurse should discontinue active rewarming?
a. The patient begins to shiver.
b. The BP decreases to 86/42 mm Hg.
c. The patient develops atrial fibrillation.
d. The core temperature is 94° F (34.4° C).

 

 

ANS:  D

A core temperature of at least 89.6° F to 93.2° F (32° C to 34° C) indicates that sufficient rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during rewarming, and should be treated but are not an indication to stop rewarming the patient.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1634

TOP:   Nursing Process: Evaluation           MSC:  NCLEX: Physiological Integrity

 

  1. When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse should be first?
a. “You should not go home.”
b. “Do you feel safe at home?”
c. “Would you like to see a social worker?”
d. “I need to report my concerns to the police.”

 

 

ANS:  B

The nurse’s initial response should be to further assess the patient’s situation. Telling the patient not to return home may be an option once further assessment is done. A social worker or police report may be appropriate once further assessment is completed.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1644

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient arrives in the emergency department (ED) several hours after taking “25 to 30” acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?
a. Give N-acetylcysteine.
b. Discuss the use of chelation therapy.
c. Start oxygen using a non-rebreather mask.
d. Have the patient drink large amounts of water.

 

 

ANS:  A

N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose. The other actions might be used for other types of poisoning, but they will not be appropriate for a patient with acetaminophen poisoning.

 

DIF:    Cognitive Level: Understand (comprehension)               REF:   1643

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, “I had a temperature of 103.9° F (39.9° C) at home.” The nurse’s first action should be to
a. assess the patient’s current vital signs.
b. give acetaminophen (Tylenol) per agency protocol.
c. ask the patient to provide a clean-catch urine for urinalysis.
d. tell the patient that it will be 1 to 2 hours before seeing a health care provider.

 

 

ANS:  A

The patient’s pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be appropriate, but this would be done after the vital signs are taken. The nurse will not give acetaminophen before confirming a current temperature elevation.

 

DIF:    Cognitive Level: Analyze (analysis)                                           REF:    1632

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment?
a. A patient with no pedal pulses
b. A patient with an open femur fracture
c. A patient with bleeding facial lacerations
d. A patient with paradoxical chest movement

 

 

ANS:  D

Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxical chest movements should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries only has lacerations. The other two patients also need rapid intervention but do not have airway or breathing problems.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1629

OBJ:   Special Questions: Multiple Patients

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Safe and Effective Care Environment

 

  1. The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?
a. Remove the patient’s rings.
b. Apply ice packs to both hands.
c. Apply calamine lotion to itching areas.
d. Give diphenhydramine (Benadryl) 50 mg PO.

 

 

ANS:  A

The patient’s rings should be removed first because it might not be possible to remove them if swelling develops. The other orders should also be implemented as rapidly as possible after the nurse has removed the jewelry.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1640

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?
a. Insert a large-bore orogastric tube.
b. Assist with intubation of the patient.
c. Prepare a 60-mL syringe with saline.
d. Give first dose of activated charcoal.

 

 

ANS:  B

In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1630

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. A patient arrives in the emergency department (ED) after topical exposure to powdered lime at work. Which action should the nurse take first?
a. Obtain the patient’s vital signs.
b. Obtain a baseline complete blood count.
c. Decontaminate the patient by showering with water.
d. Brush off any visible powder on the skin and clothing.

 

 

ANS:  D

The initial action should be to protect staff members and decrease the patient’s exposure to the toxin by decontamination. Patients exposed to powdered lime should not be showered; instead, any and all visible powder should be brushed off. The other actions can be done after the decontamination is completed.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1643

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient’s core temperature is 105.4° F (40.8° C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. The nurse will plan to
a. apply wet sheets and a fan to the patient.
b. provide O2 at 2 L/min with a nasal cannula.
c. start lactated Ringer’s solution at 1000 mL/hr.
d. give acetaminophen (Tylenol) rectal suppository.

 

 

ANS:  A

The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke and 100% O2  should be given, which requires a high flow rate through a non-rebreather mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 mL/hr.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1637

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first?
a. Pulse c. Breath sounds
b. Heart rhythm d. Body temperature

 

 

ANS:  A

The priority assessment in an unresponsive patient relates to CAB (circulation, airway, breathing) so a pulse check should be performed first. While assessing the pulse, the nurse should look for signs of breathing. The other data will also be collected rapidly but are not as essential as determining if there is a pulse.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1630

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which patient will the nurse need to assess first?
a. A patient with a red tag c. A patient with a black tag
b. A patient with a blue tag d. A patient with a yellow tag

 

 

ANS:  A

The red tag indicates a patient with a life-threatening injury requiring rapid treatment. The other tags indicate patients with less urgent injuries or those who are likely to die.

 

DIF:    Cognitive Level: Remember (knowledge)                       REF:   1646

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. Family members are in the patient’s room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next?
a. Keep the family in the room and assign a staff member to explain the care given and answer questions.
b. Ask the family to wait outside the patient’s room with a designated staff member to provide emotional support.
c. Ask the family members whether they would prefer to remain in the patient’s room or wait outside the room.
d. Tell the family members that patients are comforted by having family members present during resuscitation efforts.

 

 

ANS:  C

Although many family members and patients report benefits from family presence during resuscitation efforts, the nurse’s initial action should be to determine the preference of these family members. The other actions may be appropriate, but this will depend on what is learned when assessing family preferences.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1632

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take?
a. Prepare to administer rabies immune globulin (BayRab).
b. Assist the health care provider with suturing of the bite wounds.
c. Teach the patient the reason for the use of prophylactic antibiotics.
d. Keep the wounds dry until the health care provider can assess them.

 

 

ANS:  C

Because human bites of the hand frequently become infected, prophylactic antibiotics are usually prescribed to prevent infection. To minimize infection, deep bite wounds on the extremities are left open. Rabies immune globulin might be used after an animal bite. Initial treatment of bite wounds includes copious irrigation to help clean out contaminants and microorganisms.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1642

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite?
a. Use tweezers to remove any remaining ticks.
b. Check the vital signs, including temperature.
c. Give doxycycline (Vibramycin) 100 mg orally.
d. Obtain information about recent outdoor activities.

 

 

ANS:  A

Because neurotoxic venom is released as long as the tick is attached to the patient, the initial action should be to remove any ticks using tweezers or forceps. The other actions are also appropriate, but the priority is to minimize venom release.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1641

OBJ:   Special Questions: Prioritization     TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. Which interventions will the nurse plan for a comatose patient who is to begin therapeutic hypothermia (select all that apply)?
a. Assist with endotracheal intubation.
b. Insert an indwelling urinary catheter.
c. Begin continuous cardiac monitoring.
d. Obtain an order to restrain the patient.
e. Prepare to give sympathomimetic drugs.

 

 

ANS:  A, B, C

Cooling can produce dysrhythmias, so the patient’s heart rhythm should be continuously monitored and dysrhythmias treated if necessary. Bladder catheterization and endotracheal intubation are needed during cooling. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation. Patients receiving therapeutic hypothermia are comatose or do not follow commands so restraints are not indicated.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1634

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. The emergency department (ED) nurse is starting therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)?
a. Continuously monitor heart rhythm.
b. Assess neurologic status every 2 hours.
c. Give acetaminophen (Tylenol) 650 mg.
d. Place cooling blankets above and below patient.
e. Attach rectal temperature probe to cooling blanket control panel.

 

 

ANS:  C, D, E

Experienced LPN/LVNs have the education and scope of practice to implement hypothermia measures (e.g., cooling blanket, temperature probe) and administer medications under the supervision of a registered nurse (RN). Assessment of neurologic status and monitoring the heart rhythm require RN-level education and scope of practice and should be done by the RN.

 

DIF:    Cognitive Level: Apply (application)                              REF:   1634

OBJ:   Special Questions: Delegation        TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe and Effective Care Environment

 

OTHER

 

  1. The following four patients arrive in the emergency department (ED) after a motor vehicle collision. In which order should the nurse assess them? (Put a comma and a space between each answer choice [A, B, C, D, E].)
  2. A 74-yr-old patient with palpitations and chest pain
  3. A 43-yr-old patient complaining of 7/10 abdominal pain
  4. A 21-yr-old patient with multiple fractures of the face and jaw
  5. A 37-yr-old patient with a misaligned lower left leg with intact pulses

 

ANS:

C, A, B, D

 

The highest priority is to assess the 21-yr-old patient for airway obstruction, which is the most life-threatening injury. The 74-yr-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 43-yr-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 37-yr-old patient appears to have a possible fracture of the left leg and should be seen soon, but this patient has the least life-threatening injury.

 

DIF:    Cognitive Level: Analyze (analysis)                                          REF:    1629

OBJ:   Special Questions: Prioritization | Special Questions: Multiple Patients

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

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