RN NCLEX Questions And Answers 2022 A nurse is caring for an older adult client who has a new diagnosis of type 2 diabetes mellitus and reports difficulty following the diet and remembering to ta... ke the prescribed medication. Which of the following actions should the nurse take to promote client compliance? (SATA) A. Ask the dietitian to assist with meal planning B. Contact the client's support system C. Assess for age-related cognitive awareness D. Encourage the use of a daily medication dispenser E. Provide educational materials for home use - Answer- A, B, D, E A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. On the basis of this test result, the nurse plans to teach the client about the need for which measure? A. Avoiding infection B. Taking in adequate fluids C. Preventing and recognizing hypoglycemia D. Preventing and recognizing hyperglycemia - Answer- D Rationale: The normal reference range for the glycosylated hemoglobin A1c is less than 6.0%. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Erythrocytes live for about 120 days, giving feedback about blood glucose for the past 120 days. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus, the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. The estimated average glucose for a glycosylated hemoglobin A1c of 8% is 205 mg/dL (11.42 mmol/L). Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes. The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? A. After a shower or bath B. While standing to void C. After having a bowel movement D. While lying in bed before arising - Answer- A Rationale: The nurse needs to teach the client how to perform a TSE. The nurse should instruct the client to perform the exam on the same day each month. The nurse should also instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. Palpation is easier and the client will be better able to identify any abnormalities. The client would stand to perform the exam, but it would be difficult to perform the exam while voiding. Having a bowel movement is unrelated to performing a TSE. The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. A. Auscultating lung sounds B. Obtaining the client's temperature C. Assessing the strength of peripheral pulses D. Obtaining information about the client's respirations E. Performing a musculoskeletal and neurological examination F. Asking the client about a family history of any illness or disease - Answer- A, B, D Rationale: A focused assessment focuses on a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete assessment includes a complete health history and physical examination and forms a baseline database. Assessing the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete assessment. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment. The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse should tell the parent that which factor motivates good and bad actions for the child at the preconventional level? A. Peer pressure B. Social pressure C. Parents' behavior D. Punishment and reward - Answer- D Rationale: In the preconventional stage, morals are thought to be motivated by punishment and reward. If the child is obedient and is not punished, then the child is being moral. The child sees actions as good or bad. If the child's actions are good, the child is praised. If the child's actions are bad, the child is punished. Options 1, 2, and 3 are not associated factors for this stage of moral development. The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure? A. Allow the newborn infant to signal a need. B. Anticipate all needs of the newborn infant. C. Attend to the newborn infant immediately when crying. D. Avoid the newborn infant during the first 10 minutes of crying. - Answer- A Rationale:According to Erikson, the caregiver should not try to anticipate the newborn infant's needs at all times but must allow the newborn infant to signal needs. If a newborn infant is not allowed to signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn infant's signal would inhibit the development of trust and lead to mistrust of others. A nursing student is presenting a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student explains to the group that which characteristic relates to the anal stage? A. This stage is associated with toilet training. B. This stage is characterized by the gratification of self. C. This stage is characterized by a tapering off of conscious biological and sexual urges. D. This stage is associated with pleasurable and conflicting feelings about the genital organs. - Answer- A Rationale: In general, toilet training occurs during the anal stage. According to Freud, the child gains pleasure from the elimination of feces and from their retention. Option 2 relates to the oral stage. Option 3 relates to the latency period. Option 4 relates to the phallic stage. The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff. The nurse should tell that staff that which child behavior is characteristic of the formal operations stage? A. The child has the ability to think abstractly. B. The child begins to understand the environment. C. The child is able to classify, order, and sort facts. D. The child learns to think in terms of past, present, and future. - Answer- A Rationale: In the formal operations stage, the child has the ability to think abstractly and logically. Option 2 identifies the sensorimotor stage. Option 3 identifies the concrete operational stage. Option 4 identifies the preoperational stage. The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response? A. "You need to be concerned." B. "You need to monitor the child's behavior closely." C. "At this age, the child is developing his own personality." D. "You need to provide more praise to the child to stop this behavior." - Answer- C Rationale:According to Erikson, during school-age years (6 to 12 years of age), the child begins to move toward peers and friends and away from the parents for support. The child also begins to develop special interests that reflect his or her own developing personality instead of the parents'. Therefore, options 1, 2, and 4 are incorrect responses. The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information should the nurse include in the session? Select all that apply A. Individuals move through all 6 stages in a sequential fashion. B. Moral development progresses in relationship to cognitive development. C. A person's ability to make moral judgments develops over a period of time. D. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. E. In stage 1 (punishment-obedience orientation), children are expected to reason as mature members of society. F. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned. - Answer- B, C, D, F Rationale: Kohlberg's theory states that individuals move through stages of development in a sequential fashion but that not everyone reaches stages 5 and 6 in his or her development of personal morality. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. It states that moral development progresses in relationship to cognitive development and that a person's ability to make moral judgments develops over a period of time. In stage 1, ages 2 to 3 years (punishment-obedience orientation), children cannot reason as mature members of society. In stage 2, ages 4 to 7 years (instrumentalrelativist orientation), the child conforms to rules to obtain rewards or have favors returned. A parent of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, which instructions should the nurse provide to the parent? Select all that apply. A. Set limits on the child's behavior. B. Ignore the child when this behavior occurs. C. Allow the behavior, because this is normal at this age period. D. Provide a simple explanation of why the behavior is unacceptable. E. Punish the child every time the child says "no" to change the behavior. - AnswerA, D Rationale: According to Erikson, the child focuses on gaining some basic control over self and the environment and independence between ages 1 and 3 years. Gaining independence often means that the child has to rebel against the parents' wishes. Saying things like "no" or "mine" and having temper tantrums are common during this period of development. Being consistent and setting limits on the child's behavior are necessary elements. Providing a simple explanation of why certain behaviors are unacceptable is an appropriate action. Options 2 and 3 do not address the child's behavior. Option 5 is likely to produce a negative response during this normal developmental pattern. A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears? A. Encourage the child's parents to stay with the child. B. Encourage play with other children of the same age. C. Advise the family to visit only during the scheduled visiting hours. D. Provide a private room, allowing the child to bring favorite toys from home. - Answer- A Rationale: Although the preschooler already may be spending some time away from parents at a day care center or preschool, illness adds a stressor that makes separation more difficult. The child may ask repeatedly when parents will be coming for a visit or may constantly want to call the parents. Options 3 and 4 increase stress related to separation anxiety. Option 2 is unrelated to the subject of the question and, in addition, may not be appropriate for a child who may be immunocompromised and at risk for infection. A 16-year-old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively? A. Encourage the client to rest and read. B. Encourage the parents to room in with the client. C. Allow the family to bring in the client's favorite computer games. D. Allow the client to interact with others in his or her same age group. - Answer- D Rationale: Adolescents often are not sure whether they want their parents with them when they are hospitalized. Because of the importance of their peer group, separation from friends is a source of anxiety. Ideally, the members of the peer group will support their ill friend. Options 1, 2, and 3 isolate the client from the peer group. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? A. Weight loss and dry skin B. Flat neck and hand veins and decreased urinary output C. An increase in blood pressure and increased respirations D. Weakness and decreased central venous pressure (CVP) - Answer- C Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit. Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply. A. Obtain an intravenous (IV) infusion pump. B. Monitor urine output during administration. C. Prepare the medication for bolus administration. D. Monitor the IV site for signs of infiltration or phlebitis. E. Ensure that the medication is diluted in the appropriate volume of fluid. F. Ensure that the bag is labeled so that it reads the volume of potassium in the solution. - Answer- A, B, D, E, F Rationale: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag containing the potassium chloride should always be labeled with the volume of potassium it contains. The IV site is monitored closely, because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors urinary output during administration and contacts the primary health care provider if the urinary output is less than 30 mL/hr. The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? A. Twitching B. Hypoactive bowel sounds C. Negative Trousseau's sign D. Hypoactive deep tendon reflexes - Answer- A Rationale: A client with lactose intolerance is at risk for developing hypocalcemia, because food products that contain calcium also contain lactose. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL (2 mmol/L). Which patterns would the nurse watch for on the electrocardiogram? Select all that apply. A. U waves B. Widened T wave C. Prominent U wave D. Prolonged QT interval E. Prolonged ST segment - Answer- D, E Rationale: A client with Crohn's disease is at risk for hypocalcemia. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia. The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. A. ST depression B. Prominent U wave C. Tall peaked T waves D. Prolonged ST segment E. Widened QRS complexes - Answer- C, E Rationale: The client with chronic kidney disease is at risk for hyperkalemia. The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave occurs in hypokalemia. A prolonged ST segment occurs in hypocalcemia. The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? A. A client with an ileostomy B. A client with heart failure C. A client on long-term corticosteroid therapy D. A client receiving frequent wound irrigations - Answer- A Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess. The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis - Answer- B Rationale: Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations. A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? A. A decreased pH and an increased Paco2 B. An increased pH and a decreased Paco2 C. A decreased pH and a decreased HCO3- D. An increased pH and an increased HCO3- - Answer- D Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms experienced by the client would include a decrease in the respiratory rate and depth, and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition. The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. A. Respirations that are shallow B. Respirations that are increased in rate C. Respirations that are abnormally slow D. Respirations that are abnormally deep E. Respirations that cease for several seconds - Answer- B, D Rationale: Kussmaul's respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs. In bradypnea, respirations are regular but abnormally slow. Apnea is described as respirations that cease for several seconds. The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? A. Respiratory acidosis from inadequate ventilation B. Respiratory alkalosis from anxiety and hyperventilation C. Metabolic acidosis from calcium loss due to broken bones D. Metabolic alkalosis from taking analgesics containing base products - Answer- A Rationale: Respiratory acidosis is most often caused by hypoventilation. The client with broken ribs will have difficulty with breathing adequately and is at risk for hypoventilation and resultant respiratory acidosis. The remaining options are incorrect. Respiratory alkalosis is associated with hyperventilation. There are no data in the question that indicate calcium loss or that the client is taking analgesics containing base products. A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription? A. Adding a dose of heparin sodium B. Holding the next dose of warfarin C. Increasing the next dose of warfarin D. Administering the next dose of warfarin - Answer- B Rationale: The normal PT is 11 to 12.5 seconds (conventional therapy and SI units). A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the value of 35 seconds is high, the nurse should anticipate that the client would not receive further doses at this time. Therefore, the prescriptions noted in the remaining options are incorrect. A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? A. "I will be sure to ask my client what his pain level is on a scale of 0 to 10." B. "I know that I should follow up after giving medication to make sure it is effective." C. "I will be sure to cue in to any indicators that the client may be exaggerating their pain." D. "I know that pain in the older client might manifest as sleep disturbances or depression." - Answer- C Rationale: Pain is a highly individual experience, and the new graduate nurse should not assume that the client is exaggerating his pain. Rather, the nurse should frequently assess the pain and intervene accordingly through the use of both nonpharmacological and pharmacological interventions. The nurse should assess pain using a number-based scale or a picture-based scale for clients who cannot verbally describe their pain to rate the degree of pain. The nurse should follow up with the client after giving medication to ensure that the medication is effective in managing the pain. Pain experienced by the older client may be manifested differently than pain experienced by clients in other age groups, and they may have sleep disturbances, changes in gait and mobility, decreased socialization, and depression; the nurse should be aware of this attribute in this population. A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? A. 1.3 mg/dL (1.08 mmol/L) B. 2.15 mg/dL (5.4 mmol/L) C. 3.29 mg/dL (10.44 mmol/L) D. 4.35 mg/dL (12.6 mmol/L) - Answer- B Rationale: The normal BUN level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Values of 29 mg/dL (10.44 mmol/L) and 35 mg/dL (12.6 mmol/L) reflect continued dehydration. A value of 3 mg/dL (1.08 mmol/L) reflects a lower than normal value, which may occur with fluid volume overload, among other conditions. A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed? A. Discontinuing the heparin infusion B. Increasing the rate of the heparin infusion C. Decreasing the rate of the heparin infusion D. Leaving the rate of the heparin infusion as is - Answer- D Rationale: The normal aPTT varies between 30 and 40 seconds (30 and 40 seconds), depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 (45 to 60) and 2.5 (75 to 100) times normal. This means that the client's value should not be less than 45 seconds or greater than 100 seconds. Thus, the client's aPTT is within the therapeutic range and the dose should remain unchanged. A client with a history of heart failure is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? A. 3.2 mEq/L (3.2 mmol/L) B. 3.8 mEq/L (3.8 mmol/L) C. 4.2 mEq/L (4.2 mmol/L) D. 4.8 mEq/L (4.8 mmol/L) - Answer- A Rationale: The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The correct option is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The remaining options are within the normal range. The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to contact the primary health care provider (PHCP) if the client is also taking which medications? Select all that apply. A. Warfarin B. Glimepiride C. Amlodipine D. Simvastatin E. Atorvastatin - Answer- A, B, C Rationale: Nonsteroidal antiinflammatory drugs (NSAIDs) can amplify the effects of anticoagulants; therefore, these medications should not be taken together. Hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral antidiabetic agent such as glimepiride; these medications should not be combined. A high risk of toxicity exists if the client is taking ibuprofen concurrently with a calcium channel blocker such as amlodipine; therefore, this combination should be avoided. There is no known interaction between ibuprofen and simvastatin or atorvastatin. The nurse is caring for a client with a diagnosis of breast cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value? A. 2000 mm3 (2.0 × 109/L) B. 5800 mm3 (5.8 × 109/L) C. 8400 mm3 (8.4 × 109/L) D. 11,500 mm3 (11.5 × 109/L) - Answer- A Rationale: The normal WBC count ranges from 5000 to 10,000 mm3 (5 to 10 × 109/L). The client who has a decrease in the number of circulating WBCs is immunosuppressed. The nurse implements neutropenic precautions when the client's values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. The remaining options are normal values. The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2° F (36.2° C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next? A. Document the findings. B. Attempt to arouse the client. C. Contact the primary health care provider (PHCP) immediately. D. Check the medication administration history on the PCA pump - Answer- B Rationale: The primary concern with opioid analgesics is respiratory depression and hypotension. Based on the assessment findings, the nurse should suspect opioid overdose. The nurse should first attempt to arouse the client and then reassess the vital signs. The vital signs may begin to normalize once the client is aroused, because sleep can also cause decreased heart rate, blood pressure, respiratory rate, and oxygen saturation. The nurse should also check to see how much medication has been taken via the PCA pump and should continue to monitor the client closely to determine whether further action is needed. The nurse should contact the PHCP and document the findings after all data are collected, after the client is stabilized, and if an abnormality still exists after arousing the client. An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history? A. Dehydration B. Heart failure C. Iron deficiency anemia D. Chronic obstructive pulmonary disease - Answer- C Rationale: The normal hemoglobin level for an adult female client is 12 to 16 g/dL (120 to 160 mmol/L). Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body's need for more oxygen-carrying capacity. A client with a history of upper gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse should take which action after seeing the laboratory results? A. Report the abnormally low count. B. Report the abnormally high count. C. Place the client on bleeding precautions. D. Place the normal report in the client's medical record. - Answer- D Rationale: A normal platelet count ranges from 150,000 to 400,000 mm3 (300 × 109/L) is not an elevated count. The count also is not low; therefore, bleeding precautions are not needed. A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate? A. "Have you ever had surgery?" B. "Do you plan to have any other children?" C. "Do either of you have diabetes mellitus?" D. "Do either of you have problems with high blood pressure?" - Answer- B Rationale: Sterilization is a method of contraception for couples who have completed their families. It should be considered a permanent end to fertility, because reversal surgery is not always successful. The nurse would ask the couple about their plans for having children in the future. Options 1, 3, and 4 are unrelated to this procedure. A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response? A. "How often do you have sexual relations?" B. "Please share with me more about your concerns." C. "You are still young and have nothing to be concerned about." D. "You should not have a decline in testosterone until you are in your 80s." - Answer- B Rationale: The nurse needs to establish trust when discussing sexual relationships with men. The nurse should open the conversation with broad statements to determine the true nature of the client's concerns. The frequency of intercourse is not a relevant first question to establish trust. Testosterone declines with the aging process. A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? A. "Come to the emergency department." B. "Apply calamine lotion immediately to the exposed skin areas." C. "Take a shower immediately, lathering and rinsing several times." D. "It is not necessary to do anything if you cannot see anything on your skin." - Answer- C Rationale: When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to cleanse the area by showering immediately and to lather the skin several times and rinse each time in running water. Removing the poison ivy sap will decrease the likelihood of irritation. Calamine lotion may be one product recommended for use if dermatitis develops. The client does not need to be seen in the emergency department at this time. A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding? A. An inflammation of the epidermis only B. A skin infection of the dermis and underlying hypodermis C. An acute superficial infection of the dermis and lymphatics D. An epidermal and lymphatic infection caused by Staphylococcus - Answer- B Rationale: Cellulitis is an infection of the dermis and underlying hypodermis that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics. The infection is not superficial and extends deeper than the epidermis. The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply. A. Presence of striae B. Palpable radial pulses C. Absence of any ecchymosis on the extremities D. Thinner and decrease in number of reddish papules E. Scarce amount of silvery-white scaly patches on the arms - Answer- D, E Rationale: Psoriasis skin lesions include thick reddened papules or plaques covered by silverywhite patches. A decrease in the severity of these skin lesions is noted as an improvement. The presence of striae (stretch marks), palpable pulses, or lack of ecchymosis is not related to psoriasis. The clinic nurse notes that the primary health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? A. Positive patch test B. Positive culture results C. Abnormal biopsy results D. Wood's light examination indicative of infection - Answer- B Rationale: With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin. A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply. A. Lesion is painful to touch. B. Lesion is highly metastatic. C. Lesion is a nevus that has changes in color. D. Skin under the lesion is reddened and warm to touch. E. Lesion occurs in body areas exposed to outdoor sunlight. - Answer- B, C Rationale: Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. Melanomas cause changes in a nevus (mole), including color and borders. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment. Melanomas are not painful or accompanied by sign of inflammation. Although sun exposure increases the risk of melanoma, lesions may occur any place on the body, especially where birthmarks or new moles are apparent. When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. A. An irregularly shaped lesion B. A small papule with a dry, rough scale C. A firm, nodular lesion topped with crust D. A pearly papule with a central crater and a waxy border E. Location in the bald spot atop the head that is exposed to outdoor sunlight - Answer- D, E Rationale: Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Exposure to ultraviolet sunlight is a major risk factor. A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration. A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? A. A pink, edematous hand B. Fiery red skin with edema in the nailbeds C. Black fingertips surrounded by an erythematous rash D. A white color to the skin, which is insensitive to touch - Answer- D Rationale: Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect. The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage II pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? A. Intact skin B. Full-thickness skin loss C. Exposed bone, tendon, or muscle D. Partial-thickness skin loss of the dermis - Answer- D Rationale: In a stage II pressure injury, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulceration with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV. The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? A. Increased calcium level B. Increased white blood cells C. Decreased blood urea nitrogen level D. Decreased number of plasma cells in the bone marrow - Answer- A Rationale: Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen level. An increased white blood cell count may or may not be present and is not related specifically to multiple myeloma. The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? A. Encouraging fluids B. Providing frequent oral care C. Coughing and deep breathing D. Monitoring the red blood cell count - Answer- A Rationale: Hypercalcemia caused by bone destruction is a priority concern in the client with multiple myeloma. The nurse should administer fluids in adequate amounts to maintain a urine output of 1.5 to 2 L/day; this requires about 3 L of fluid intake per day. The fluid is needed not only to dilute the calcium overload but also to prevent protein from precipitating in the renal tubules. Options 2, 3, and 4 may be components of the plan of care but are not the priority in this client. A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client? A. Fatigue B. Weakness C. Weight gain D. Enlarged lymph nodes - Answer- D Rationale: Hodgkin's disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur but are not related significantly to the disease. During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease? A. Diarrhea B. Hypermenorrhea C. Abnormal bleeding D. Abdominal distention - Answer- D Rationale: Clinical manifestations of ovarian cancer include abdominal distention, urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, constipation, ascites with dyspnea, and ultimately general severe pain. Abnormal bleeding, often resulting in hypermenorrhea, is associated with uterine cancer. The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply. A. Facial edema in the morning B. Weight loss of 20 lb (9 kg) in 1 month C. Serum calcium level of 12 mg/dL (3.0 mmol/L) D. Serum sodium level of 136 mg/dL (136 mmol/L) E. Serum potassium level of 3.4 mg/dL (3.4 mmol/L) F. Numbness and tingling of the lower extremities - Answer- A, C, F Rationale: Oncological emergencies include sepsis, disseminated intravascular coagulation, syndrome of inappropriate antidiuretic hormone, spinal cord compression, hypercalcemia, superior vena cava syndrome, and tumor lysis syndrome. Blockage of blood flow to the venous system of the head resulting in facial edema is a sign of superior vena cava syndrome. A serum calcium level of 12 mg/dL (3.0 mmol/L) indicates hypercalcemia. Numbness and tingling of the lower extremities could be a sign of spinal cord compression. Mild hypokalemia and weight loss are not oncological emergencies. A sodium level of 136 mg/dL (136 mmol/L) is a normal level. A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition? A. Rupture of the bladder B. The development of a vesicovaginal fistula C. Extreme stress caused by the diagnosis of cancer D. Altered perineal sensation as a side effect of radiation therapy - Answer- B Rationale: A vesicovaginal fistula is a genital fistula that occurs between the bladder and vagina. The fistula is an abnormal opening between these two body parts, and if this occurs, the client may experience drainage of urine through the vagina. The client's complaint is not associated with options 1, 3, or 4. The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma. What assessment findings should the nurse expect to note? Select all that apply. A. Pathological fracture B. Urinalysis positive for Bence Jones protein C. Hemoglobin level of 15.5 g/dL (155 mmol/L) D. Calcium level of 8.6 mg/dL (2.15 mmol/L) E. Serum creatinine level of 2.0 mg/dL (176.6 mcmol/L) - Answer- A, B, E Rationale: Multiple myeloma is a B cell neoplastic condition characterized by abnormal malignant proliferation of plasma cells and the accumulation of mature plasma cells in the bone marrow. The client with multiple myeloma may experience pathological fractures, hypercalcemia, anemia, recurrent infections, and renal failure. In addition, Bence Jones proteinuria is a finding. A serum calcium level of 8.6 mg/dL (2.15 mmol/L) and a hemoglobin level of 15.5 g/dL (155 mmol/L) are normal values. A serum creatinine level of 2.0 mg/dL (176.6 mcmol/L) is elevated indicating a renal problem. The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor? A. Age younger than 50 years B. History of colorectal polyps C. Family history of colorectal cancer D. Chronic inflammatory bowel disease - Answer- A Rationale: Colorectal cancer risk factors include age older than 50 years, a family history of the disease, colorectal polyps, and chronic inflammatory bowel disease. The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? A. Clamp the surgical drain. B. Change the dressing as prescribed. C. Notify the surgeon. D. Remove and replace the perineal packing. - Answer- B Rationale: Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. Therefore, the nurse should change the dressing as prescribed. A surgical drain should not be clamped, because this action will cause the accumulation of drainage within the tissue. The nurse does not need to notify the surgeon at this time. Drains and packing are removed gradually over a period of 5 to 7 days as prescribed. The nurse should not remove the perineal packing. The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common sign or symptom of this type of cancer? A. Dysuria B. Hematuria C. Urgency on urination D. Frequency of urination - Answer- B Rationale: The most common sign in clients with cancer of the bladder is hematuria. The client also may experience irritative voiding symptoms such as frequency, urgency, and dysuria, and these symptoms often are associated with carcinoma in situ. Dysuria, urgency, and frequency of urination are also symptoms of a bladder infection. The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care? A. "I change my pouch every week." B. "I change the appliance in the morning." C. "I empty the urinary collection bag when it is two-thirds full." D. "When I'm in the shower I direct the flow of water away from my stoma." - AnswerC Rationale: The urinary collection bag should be changed when it is one-third full to prevent pulling of the appliance and leakage. The remaining options identify correct statements about the care of a urinary stoma. A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the primary health care provider will request which prescriptions? Select all that apply. A. Radiation B. Chemotherapy C. Increased fluid intake D. Decreased oral sodium intake E. Serum sodium level determination F. Medication that is antagonistic to antidiuretic hormone - Answer- A, B, E, F Rationale: Cancer is a common cause of SIADH. In SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. The syndrome is managed by treating the condition and cause and usually includes fluid restriction, increased sodium intake, and medication with a mechanism of action that is antagonistic to antidiuretic hormone. Sodium levels are monitored closely because hypernatremia can develop suddenly as a result of treatment. The immediate institution of appropriate cancer therapy, usually radiation or chemotherapy, can cause tumor regression so that antidiuretic hormone synthesis and release processes return to normal. The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency? A. Cyanosis B. Arm edema C. Periorbital edema D. Mental status changes - Answer- C Rationale: Superior vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Cyanosis and mental status changes are late signs. The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign or symptom of this oncological emergency? A. Headache B. Dysphagia C. Constipation D. Electrocardiographic changes - Answer- D Rationale: Hypercalcemia is a manifestation of bone metastasis in late-stage cancer. Headache and dysphagia are not associated with hypercalcemia. Constipation may occur early in the process. Electrocardiogram changes include shortened ST segment and a widened T wave. As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement? A. "I should avoid blowing my nose." B. "I may need a platelet transfusion if my platelet count is too low." C. "I'm going to take aspirin for my headache as soon as I get home." D. "I will count the number of pads and tampons I use when menstruating." - Answer- C Rationale: During the period of greatest bone marrow suppression (the nadir), the platelet count may be low, less than 20,000 cells mm3 (20.0 × 109/L). The correct option describes an incorrect statement by the client. Aspirin and nonsteroidal antiinflammatory drugs and products that contain aspirin should be avoided because of their antiplatelet activity. Options 1, 2, and 4 are correct statements by the client to prevent and monitor bleeding. A client is diagnosed as having a intestinal tumor. The nurse should monitor the client for which complications of this type of tumor? Select all that apply. A. Flatulence B. Peritonitis C. Hemorrhage D. Fistula formation E. Bowel perforation F. Lactose intolerance - Answer- B, C, D, E Rationale: Complications of intestinal tumors include bowel perforation, which can result in hemorrhage and peritonitis. Other complications include bowel obstruction and fistula formation. Flatulence can occur but is not a complication; lactose intolerance also is not a complication of intestinal tumor. The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? A. Placing cool compresses on the affected arm B. Elevating the affected arm on a pillow above heart level C. Avoiding arm exercises in the immediate postoperative period D. Maintaining an intravenous site below the antecubital area on the affected side - Answer- B Rationale: Following mastectomy, the arm should be elevated above the level of the heart. Simple arm exercises should be encouraged. No blood pressure readings, injections, intravenous lines, or blood draws should be performed on the affected arm. Cool compresses are not a suggested measure to prevent lymphedema from occurring. The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply. A. Nuts B. Corn C. Liver D. Apples E. Lentils F. Bananas - Answer- A, C, E Rationale: Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of function of the parietal cells. The source of intrinsic factor is lost, which results in an inability to absorb vitamin B12, leading to development of pernicious anemia. Clients must increase their intake of vitamin B12 by increasing consumption of foods rich in this vitamin, such as nuts, organ meats, dried beans, citrus fruits, green leafy vegetables, and yeast. The nurse is instructing a client with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the client? A. Administer the iron at mealtimes. B. Administer the iron through a straw. C. Mix the iron with cereal to administer. D. Add the iron to apple juice for easy administration. - Answer- B Rationale: In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. An oral iron supplement should be administered through a straw or medicine dropper placed at the back of the mouth, because the iron stains the teeth. The client should be instructed to brush or wipe their teeth after administration. Iron is administered between meals, because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not mixed with cereal or other food items. Laboratory studies are performed for a client suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia? A. Elevated hemoglobin level B. Decreased reticulocyte count C. Elevated red blood cell count D. Red blood cells that are microcytic and hypochromic - Answer- D Rationale: In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. The results of a complete blood cell count in clients with iron deficiency anemia show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated. Chemotherapy dosage is frequently based on total body surface area (BSA), so it is important for the nurse to perform which assessment before administering chemotherapy? A. Measure the client's abdominal girth. B. Calculate the client's body mass index. C. Measure the client's current weight and height. D. Ask the client about his or her weight and height. - Answer- C Rationale: To ensure that the client receives optimal doses of chemotherapy, dosing is usually based on the total BSA, which requires a current accurate height and weight for BSA calculation (before each medication administration). Asking the client about his or her height and weight may lead to inaccuracies in determining a true BSA and dosage. Calculating body mass index and measuring abdominal girth will not provide the data needed. A clinic nurse prepares a teaching plan for a client receiving an antineoplastic medication. When implementing the plan, the nurse should make which statement to the client? A. "You can take aspirin as needed for headache." B. "You can drink beverages containing alcohol in moderate amounts each evening." C. "You need to consult with the primary health care provider (PHCP) before receiving immunizations." D. "It is fine to receive a flu vaccine at the local health fair without PHCP approval because the flu is so contagious." - Answer- C Rationale: Because antineoplastic medications lower the resistance of the body, clients must be informed not to receive immunizations without the PHCP's approval. Clients also need to avoid contact with individuals who have recently received a live virus vaccine. Clients need to avoid aspirin and aspirin-containing products to minimize the risk of bleeding, and they need to avoid alcohol to minimize the risk of toxicity and side/adverse effects. The nurse is analyzing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value would the nurse specifically note as a result of the massive cell destruction that occurred from the chemotherapy? A. Anemia B. Decreased platelets C. Increased uric acid level D. Decreased leukocyte count - Answer- C Rationale: Hyperuricemia is especially common following treatment for leukemias and lymphomas, because chemotherapy results in massive cell kill. Although options 1, 2, and 4 also may be noted, an increased uric acid level is related specifically to cell destruction. A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated primary health care provider's prescription? A. Endotracheal intubation B. 100 units of NPH insulin C. Intravenous infusion of normal saline D. Intravenous infusion of sodium bicarbonate - Answer- C Rationale: The primary goal of treatment in hyperosmolar hyperglycemic syndrome (HHS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous (IV) fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHS. An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? A. It is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream at specific intervals. B. It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels. C. It is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases insulin into the bloodstream. D. It administers a small continuous dose of short-duration insulin subcutaneously. The client can selfadminister an additional bolus dose from the pump before each meal. - Answer- D Rationale: An insulin pump provides a small continuous dose of short-duration (rapid- or shortacting) insulin subcutaneously throughout the day and night. The client can selfadminister an additional bolus dose from the pump before each meal as needed. Short-duration insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply. A. Increase in pH B. Comatose state C. Deep, rapid breathing D. Decreased urine output E. Elevated blood glucose level - Answer- B, C, E Rationale: Because of the profound deficiency of insulin associated with DKA, glucose cannot be used for energy and the body breaks down fat as a secondary source of energy. Ketones, which are acid by-products of fat metabolism, build up, and the client experiences a metabolic ketoacidosis. High serum glucose contributes to an osmotic diuresis and the client becomes severely dehydrated. If untreated, the client will become comatose due to severe dehydration, acidosis, and electrolyte imbalance. Kussmaul's respirations, the deep rapid breathing associated with DKA, is a compensatory mechanism by the body. The body attempts to correct the acidotic state by blowing off carbon dioxide (CO2), which is an acid. In the absence of insulin, the client will experience severe hyperglycemia. Option 1 is incorrect, because in acidosis the pH would be low. Option 4 is incorrect because a high serum glucose will result in an osmotic diuresis and the client will experience polyuria. The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply. A. Polyuria B. Shakiness C. Palpitations D. Blurred vision E. Lightheadedness F. Fruity breath odor - Answer- B, C, E Rationale: Shakiness, palpitations, and lightheadedness are signs/symptoms of hypoglycemia and would indicate the need for food or glucose. Polyuria, blurred vision, and a fruity breath odor are manifestations of hyperglycemia. A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client's anxiety? A. Administer a sedative. B. Convey empathy, trust, and respect toward the client. C. Ignore the signs and symptoms of anxiety, anticipating that they will soon disappear. D. Make sure that the client is familiar with the correct medical terms to promote understanding of what is happening. - Answer- B Rationale: Anxiety is a subjective feeling of apprehension, uneasiness, or dread. The appropriate intervention is to address the client's feelings related to the anxiety. Administering a sedative is not the most appropriate intervention and does not address the source of the client's anxiety. The nurse should not ignore the client's anxious feelings. Anxiety needs to be managed before meaningful client education can occur. The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? A. "I will stop taking my insulin if I'm too sick to eat." B. "I will decrease my insulin dose during times of illness." C. "I will adjust my insulin dose according to the level of glucose in my urine." D. "I will notify my primary health care provider (PHCP) if my blood glucose level is higher than 250 mmol/L." - Answer- D Rationale: During illness, the client with type 1 diabetes mellitus is at increased risk of diabetic ketoacidosis, due to hyperglycemia associated with the stress response and due to a typically decreased caloric intake. As part of sick day management, the client with diabetes should monitor blood glucose levels and should notify the PHCP if the level is higher than 250 mg/dL (13.9 mmol/L). Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the PHCP's advice and are usually adjusted on the basis of blood glucose levels, not urinary glucose readings. A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (52.9 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.3 mmol/L). The nurse would next prepare to administer which medication? A. An ampule of 50% dextrose B. NPH insulin subcutaneously C. IV fluids containing dextrose D. Phenytoin for the prevention of seizures - Answer- C Rationale: Emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing the serum glucose level. If the corrections occur too quickly, serious consequences, including hypoglycemia and cerebral edema, can occur. During management of DKA, when the blood glucose level falls to 250 to 300 mg/dL (13.9 to 16.7 mmol/L), the IV infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL (13.9 mmol/L), or until the client recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin is not a usual treatment measure for DKA. The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if frequently exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed?....... [Show More]
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