Nurse Zeny is caring for a client in an acute Addisonian crisis. Which laboratory data would the nurse expect to find? A. Hyperkalemia B. Reduced blood urea nitrogen (BUN) C. Hypernatremia D. Hyperglycemia Correct Answer: A. Hyperkalemia In adrenal insufficiency, the client has hyperkalemia due to reduced… Read More »
The LPN/LVN, under your supervision, is providing nursing care for a patient with GBS. What observation would you instruct the LPN/LVN to report immediately? A. Complaints of numbness and tingling. B. Facial weakness and difficulty speaking. C. Rapid heart rate of 102 beats per minute. D. Shallow respirations and decreased breath sounds.… Read More »
An 18-year-old male client admitted with heat stroke begins to show signs of disseminated intravascular coagulation (DIC). Which of the following laboratory findings is most consistent with DIC? A. Low platelet count B. Elevated fibrinogen levels C. Low levels of fibrin degradation products D. Reduced prothrombin time Correct Answer:… Read More »
A female client tells nurse Nikki that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client’s efforts, the nurse should check: A. Urine glucose level. B. Fasting blood glucose level. C. Serum fructosamine… Read More »
A nurse is caring for a patient with a platelet count of 20,000/microliter. Which of the following is an important intervention? A. Observe for evidence of spontaneous bleeding. B. Limit visitors to family only. C. Give aspirin in case of headaches. D. Impose immune precautions. Correct Answer:… Read More »
The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside? A. A tracheostomy set B. A padded tongue blade C. An endotracheal tube D. An airway Correct Answer: A. A tracheotomy set The client who has recently… Read More »
George, who has undergone thoracic surgery has a chest tube connected to a water-seal drainage system attached to suction. Presence of excessive bubbling is identified in the water-seal chamber, the nurse should: A. “Strip” the chest tube catheter B. Check the system for air leaks C. Recognize the system is functioning correctly… Read More »
A nurse caring for several patients in the cardiac unit is told that one is scheduled for implantation of an automatic internal cardioverter-defibrillator. Which of the following patients is most likely to have this procedure? A. A patient admitted for myocardial infarction without cardiac muscle damage. B. A postoperative coronary bypass patient, recovering on schedule.… Read More »
Nurse Michelle should know that the drainage is normal four (4) days after a sigmoid colostomy when the stool is: A. Green liquid B. Solid formed C. Loose, bloody D. Semiformed Correct Answer: C. Loose, bloody Normal bowel function and soft-formed stool usually do not occur until… Read More »
The client is admitted with right-sided congestive heart failure. In assessing the client for edema, the nurse should check the: A. Feet B. Neck C. Hands D. Sacrum Correct Answer: B. Neck The jugular veins in the neck should be assessed for distension. Increased blood volume, which… Read More »