Select all that apply, with every option explained

Question 1

A 24-year-old client with type 1 diabetes who uses insulin glargine at bedtime and insulin lispro with meals tells the nurse about plans to drink beer at a friend's wedding on Saturday evening. Which of the following instructions should the nurse include?

Accepted Answer

B: Check the capillary glucose at bedtime and again during the night; D: Eat a meal or snack containing carbohydrate while drinking alcohol. Type 1 diabetes is an autoimmune disease in which the body's immune system destroys the cells in the pancreas that make insulin.

Alcohol lowers the glucose in a way students often miss. The liver normally releases glucose between meals to keep the level up. While the liver is breaking down alcohol, it stops making and releasing glucose. In a client who takes insulin, that can cause hypoglycemia during drinking and for many hours afterward, often overnight while the client is asleep.

The client drinks only with food that contains carbohydrate, checks the glucose before bed and during the night, and eats a snack if the glucose is low. Hypoglycemia causes confusion, slurred speech, and unsteadiness, which look like being drunk, so friends and emergency staff may not recognize it.

Question 2

At 0630, the nurse is caring for a client with end-stage kidney disease and hypertension who is scheduled for hemodialysis at 0800. The client has an arteriovenous (AV) graft in the left upper arm. The morning medications include lisinopril 20 mg by mouth. Which of the following should the nurse include in the predialysis care?

Accepted Answer

A: Weigh the client on the same scale used after the last session; B: Hold the morning dose of lisinopril as prescribed for dialysis days; C: Palpate the graft for a thrill and auscultate it for a bruit; E: Measure the blood pressure on the right arm. End-stage kidney disease (ESKD) is the last stage of chronic kidney disease, when the kidneys have failed and the client needs dialysis or a kidney transplant to survive.

The predialysis weight is compared with the client's last postdialysis weight and target weight to decide how much fluid to remove, so the same scale is used each time. Antihypertensive medications are commonly held before dialysis, as prescribed, because fluid removal lowers the blood pressure and the combination can cause severe hypotension during the session. The graft is checked for a thrill and a bruit to confirm it is open. Blood pressure is measured on the arm without the access, because cuff pressure can damage or clot the graft.

Question 3

The nurse has taught a 66-year-old client who was newly diagnosed with pernicious anemia about vitamin B12 replacement. Which of the following statements by the client indicate understanding of the teaching?

Accepted Answer

A: "I will need vitamin B12 replacement for the rest of my life."; E: "I will report it if the tingling in my hands or feet gets worse.". In pernicious anemia, the stomach does not make intrinsic factor, which is needed to absorb vitamin B12 in the small intestine. The disease cannot be cured, so replacement is lifelong, most often with intramuscular injections given frequently at first and then monthly. Nasal B12, or high-dose oral B12 of 1,000 to 2,000 mcg a day, can work for some clients because a small amount is absorbed without intrinsic factor, but levels must be checked. Worsening numbness, tingling, balance problems or memory changes need to be reported, because nerve damage can become permanent if replacement is not enough.

Question 4

The nurse is preparing a 69-year-old client for discharge 4 days after a minor ischemic stroke. The nurse teaches the client and spouse how to respond to warning signs of another stroke. Which of the following statements by the spouse would indicate a correct understanding of the teaching?

Accepted Answer

A: "I will check the clock and tell the paramedics the time he was last normal."; B: "If one side of his face droops or an arm suddenly gets weak, I will call 911 immediately."; D: "Sudden loss of vision in one eye or sudden loss of balance is also a warning sign.". A client who has had one stroke has a higher risk of another, so the family needs to know the signs and exactly what to do. The warning signs come on suddenly and include facial droop, weakness or numbness of an arm or leg, trouble speaking or understanding, loss of vision in one or both eyes, and loss of balance or coordination.

The right response is to call emergency services immediately and note the time the client was last normal, because that time decides which treatments are still possible. Paramedics can start the assessment on the way and alert the hospital, so the stroke team is ready when the client arrives.

Question 5

The nurse is observing an unlicensed assistive personnel (UAP) feeding lunch to a 91-year-old client with advanced dementia who is prescribed a mechanical soft diet and has a history of aspiration pneumonia. Which of the following actions by the UAP would require the nurse to intervene?

Accepted Answer

A: Lowers the head of the bed flat right after the meal so that the client can rest; C: Feeds the client with the head of the bed raised to 30 degrees; D: Offers the next spoonful before the client has swallowed the last one. Aspiration is food or fluid entering the airway instead of the esophagus. Clients with advanced dementia are at high risk because they swallow more slowly, forget to chew, and may not cough well when food goes the wrong way. Safe feeding is built around gravity and time.

The client should sit fully upright, ideally at 90 degrees in a chair or as high as possible in bed, during the meal and for at least 30 minutes after it. Feeding at 30 degrees and lowering the bed flat right after the meal both let food and stomach contents run back toward the airway. Offering the next spoonful before the last one is swallowed overloads the mouth and is one of the commonest causes of choking in assisted feeding. The nurse stops each of these actions, corrects them on the spot, and reviews safe feeding with the UAP.

Question 6

The nurse is teaching a client at 10 weeks gestation about weight gain. Which statements should the nurse include? Select all that apply.

Accepted Answer

C: "About 3 pounds over the whole first trimester is what we expect."; E: "After that, gaining about a pound a week is the usual pattern.". Weight gain in pregnancy follows an uneven pattern. Very little weight is gained in the first trimester, usually about 1 to 4 pounds (0.5 to 2 kg) and sometimes none if nausea is severe. After that, the gain becomes steady at about 1 pound (0.5 kg) a week.

For a client who starts at a healthy weight, the usual goal is 25 to 35 pounds (11 to 16 kg) in total. A client who starts underweight aims higher, and a client who starts overweight aims lower, so the goal is set at the first visit. Even for an underweight client the goal is 28 to 40 pounds, so 45 to 50 pounds is too much for any client.

Three of the statements are wrong, and two of them are common beliefs. "Eating for two" doubles the amount of food, but no extra calories are needed in the first trimester, and the extra need later is only about 340 calories a day in the second trimester and about 450 in the third. Aiming to gain nothing in the first trimester encourages restricting food while the fetus is forming.

Question 7

A client at high risk for falls was found on the floor beside the bed at 0300 and sustained a hip fracture. The family has filed a lawsuit for negligence. Which of the following entries in the client's medical record would help show that the nurse met the standard of care?

Accepted Answer

A: "Fall risk reassessed at 2000; bed in lowest position, wheels locked, bed alarm on and tested at 2000."; B: "Hourly rounds documented 2200 to 0200; toileting offered at each round and accepted at 0100."; D: "Call light and urinal placed within reach at 0200; client repeated back how to use the call light.". Negligence is proved when a duty existed, the nurse breached the standard of care, harm was foreseeable, the breach caused the harm, and the client was injured. Here the injury and the duty are clear, so the record has to show that the nurse did what a reasonably prudent nurse would do for a client at high risk for falls.

Entries that refute negligence are specific, timed and objective, and they show that the expected precautions were in place: a current fall risk assessment, a low bed with locked wheels and a working alarm, regular rounding with toileting, and a call light within reach with evidence that the client understood it.

Question 8

The nurse is teaching a 61-year-old client who had shingles 2 years ago about the recombinant zoster vaccine (Shingrix). Which of the following should the nurse include in the teaching?

Accepted Answer

B: The vaccine is given as 2 doses, 2 to 6 months apart; D: The vaccine is recommended even after a past episode of shingles. The recombinant zoster vaccine is recommended for all adults 50 and older and for adults 19 and older who are immunocompromised. It is given as 2 doses, 2 to 6 months apart. A past episode of shingles does not prevent another one, so the client should still get the vaccine once the rash has healed. Soreness at the site, muscle aches, fever and fatigue for 2 to 3 days are common and are not a reason to skip the second dose.

Question 9

A 78-year-old client with atrial fibrillation who takes warfarin is admitted after a routine clinic check finds an INR of 4.8. The nurse completes the admission assessment. Select the 3 findings that require immediate follow-up.

Accepted Answer

B: Brown emesis that looks like coffee grounds in the bedside basin; E: A black, tarry stool passed during the assessment; F: A headache that began this morning, with new expressive aphasia. Warfarin lowers the liver's production of vitamin K-dependent clotting factors. An INR of 4.8 is well above the usual target of 2 to 3 for atrial fibrillation, so the blood takes much longer to clot and the risk of serious bleeding is high, especially in an older adult.

A new headache with expressive aphasia suggests bleeding inside the skull, the most feared complication of warfarin, and it is reported immediately because the client may need emergency imaging and reversal. Black, tarry stool (melena) is digested blood from the upper gastrointestinal tract, and coffee-ground emesis is blood that has been partly digested in the stomach. Both mean active gastrointestinal bleeding.

Question 10

A nurse is assessing a client whose international normalized ratio is 6.4. Which of the following findings should the nurse report immediately? Select all that apply.

Accepted Answer

A: A new headache that has come on this afternoon; C: Blood in the urine passed this morning; D: New abdominal pain with a distended abdomen. A client this anticoagulated will bleed from small insults, so the assessment has to separate the trivial from the dangerous.

The three to report are all bleeding into places where it cannot be seen or compressed. A new headache is bleeding into the brain until proved otherwise and it is the most dangerous finding on the list. Blood in the urine means bleeding somewhere in the urinary tract. New abdominal pain with distension can be bleeding into the abdomen, which can take a great deal of blood before anything shows on the outside.

The other two are expected in a client with a ratio this high. A bruise at a cannula site and gums that ooze a little with brushing are worth documenting, worth mentioning on the round, and not worth a telephone call on their own.

The rule that sorts them is where the bleeding is going. Into a place with room to fill and no way to compress it is urgent. Onto a surface that can be seen and pressed is not.

Select all that apply, with every option explained.