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Complete the following sentence/sentences by choosing from the list of options. The nurse recognizes that the client is most likely experiencing ----------interventions to prevent ---------
- A. Pleural effusion
- B. Systemic emboli
- C. Cardiac tamponade
- D. pneumonia
- E. pericarditis
- F. Infective endocarditis
Correct Answer: F,B
Rationale: The nurse recognizes that the client is most likely experiencing infective endocarditis (lE) and should prioritize interventions
to prevent systemic emboli.
The client is most likely experiencing IE based on the history of a recent dental procedure and clinical findings of infection (eg,
fever, flu-like symptoms), microemboli (eg, splinter hemorrhages, Janeway lesions), and cardiac murmur. In addition to
microemboli, larger pieces of vegetation can break off the heart valve and embolize to various organs, causing life-threatening
complications (eg, stroke, spleen/kidney infarction).
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For each finding below, click to specify if the finding is consistent with the disease process of chronic heart failure or chronic obstructive pulmonary disease. Each finding may support more than one disease process.
- A. Fatigue
- B. Dyspnea
- C. S3 heart tone
- D. Rapid weight gain
- E. Pink, frothy sputum
- F. Barrel-shaped chest
Correct Answer:
Rationale: Chronic heart failure (HF) is a progressive condition characterized by impaired ventricular function that leads to decreased
cardiac output and inadequate tissue perfusion as blood backs up into the lungs and systemic circulation. Common clinical
manifestations of HF include:
• Fatigue and dyspne secondary to impaired gas exchange
• An S3 (eg, ventricular gallop) heart tone, characteristic of HF, occurs during early diastole when blood from the atria
enters the ventricle and hits the less compliant (stiff) ventricular wall, creating an audible vibration
• Rapid weight gain (>5 lb/week [2.3 kg/week]) due to fluid volume overload
• Blood-tinged (ie, pink), frothy sputum due to mixing of blood from the ruptured high-pressured pulmonary veins with
transudative (clear alveolar fluid (pulmonary edema)
Chronic obstructive pulmonary disease (COPD) is a progressive, irreversible respiratory tract condition characterized by
chronic airway inflammation, alveolar destruction and enlargement, and/or increased mucus production. Clients with COPD
have the following:
• Fatigue and dyspnea related to impaired gas exchange
• Appearance of a barrel-shaped chest due to the increased anteroposterior-to-transverse diameter ratio from
hyperinflation of the lungs
Which of the following statements by the client's parent indicates a correct understanding of the teaching about management for type 1 diabetes mellitus? Select all that apply
- A. I may need to administer insulin more frequently when my child is ill
- B. Insulin requirements will change as my child grows
- C. Insulin should be injected deeply enough to reach the muscle
- D. Overnight social events should be avoided to prevent changes in my child's routine
- E. Proper diet and exercise can eliminate the need for insulin during adulthood.
Correct Answer: A,B
Rationale: Clients with type 1 diabetes mellitus (DM) have impaired insulin production due to autoimmune destruction of pancreatic beta
cells. Because clients with type 1 DM do not produce insulin, lifelong insulin replacement is required. Insulin requirements
will change with growth and development
Insulin requirements may increase because stressful events (eg, illness) cause blood glucose levels to rise. When the
client is ill, the parent should be instructed to notify the health care provider, monitor blood glucose levels closely, test the urine
for ketones, increase insulin administration per sliding scale, and monitor for signs of dehydration
One hour after chest tube insertion, the client becomes agitated and knocks over the chest tube collection device. The device is damaged. and the tubing becomes disconnected. Which action should the nurse perform first?
- A. Adjust the head of the bed to semi- or high-Fowler position
- B. Notify the health care provider
- C. Obtain a new chest tube collection device
- D. Place the distal end of the chest tube into a bottle of sterile saline
Correct Answer: D
Rationale: If a chest tube becomes disconnected from a damaged drainage system, the priority is to restore the water seal, according to facility policy. A
safe, temporary way to accomplish this is to immerse the distal end of the tube (ie, farthest from the client) into a bottle of sterile saline
or sterile water while someone obtains a new water seal collection device. Some facilities may use shodded (rubber-tipped) hemostats to
temporarily clamp the tube until a new water seal device is obtained. However, clamping the tube can quickly cause a pneumothorax and
should be done only very briefly (Option 4).
The nurse has reviewed the information from the Laboratory Results. Complete the following sentence/sentences by choosing from the list/lists of options. Complete the following sentence by choosing from the lists of options . The client is most likely experiencing---------- and requires ------------- to prevent-------------
- A. Behavior Therapy
- B. Diabetes Mellitus
- C. Urinary Tract Infection
- D. Blood glucose managment
- E. Urosepsis
- F. Hyperglycemia
Correct Answer: B,D,F
Rationale: The client is most likely experiencing diabetes mellitus (DM) and requires blood glucose management to prevent
hyperglycemia.
A urinalysis positive for glucose and ketones are manifestations that should raise suspicion of DM. Ketones are produced
when the body cannot use glucose for energy and breaks down fat stores instead. Ketonuria is a sign of diabetic ketoacidosis
(DKA), a life-threatening complication of DM. Clients with new-onset type 1 DM often present with DKA. Blood glucose
management in those with type 1 DM will require insulin administration.
Complete the following sentence/sentences by choosing from the list/lists of options.This client is most likely experiencing gastrointestinal bleeding related to ----------
- A. Diverticulosis
- B. Ulcerative colitis
- C. Peptic Ulcer disease
Correct Answer: C
Rationale: The client is most likely experiencing gastrointestinal GI) bleeding related to peptic ulcer disease (PUD).
The clients symptoms are most consistent with upper Gl bleeding. PUD is one of the most common causes of upper GI
bleeding due to erosion and ulceration of the protective layers (ie, mucosa) of the upper Gl tract (eg, esophagus, stomach,
duodenum). Impaired mucosa allows digestive enzymes and stomach acid to break down underlying tissues, leading to GI
bleeding and perforation. The client has multiple risk factors for PUD, including history of Helicobacter pylori infection, chronic
NSAID use, smoking, and daily alcohol consumption.