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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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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.
Select below the 5 findings that are most concerning.
- A. The client comes to the emergency department with fatigue, shortness of breath, dry cough, and exertional dyspnea for 1 week;
- B. the client is homeless;
- C. Vital signs: RR 22, SpOz 88% on room air; the client is dyspneic but can speak in full sentences;
- D. the client reports smoking 1 pack of cigarettes per day for 35 years;
- E. S1, S2, and S3 are heard on auscultation;
- F. continuous cardiac monitor shows sinus rhythm with occasional premature ventricular contractions;
Correct Answer: B,D,E
Rationale: The client comes to the emergency department with fatigue, shortness of breath, dry cough, and
exertional dyspnea for 1 week; the client is homeless; medical history includes chronic heart
failure, uncontrolled hypertension, coronary artery disease, and type 2 diabetes mellitus
Vital signs: RR 22, SpOz 88% on room air; the client is dyspneic but can speak in full
sentences; lung auscultation reveals decreased breath sounds at the lung bases and bilateral
crackles; the client reports smoking 1 pack of cigarettes per day for 35 years; the client was
hospitalized for pneumonia 6 months ago
Vital signs: T 99 F (37.2 C), P 90, BP 170/100; continuous cardiac monitor shows sinus rhythm
with occasional premature ventricular contractions; S1, S2, and S3 are heard on auscultation;
bilateral lower extremity pitting edema is noted
Drag words from the choices below to fill in the blank/blanks.The nurse recognizes that furosemide was effective as evidenced by------------,-----------------, and ------------------
- A. 2+ peripheral edema
- B. Increased urine output
- C. Reduced urinary hesitancy
- D. Reduced cholesterol level
- E. Reduced work of breathing
Correct Answer: A,B,E
Rationale: Loop diuretics (eg, furosemide) block renal reabsorption of sodium, chloride, and potassium, which increases fluid excretion
in the urine (ie, diuresis). Diuresis decreases intravascular volume, resulting in decreased peripheral edema (eg, from 3+ to
2+). In addition, as fluid volume decreases, pulmonary congestion improves, thereby resulting in improved oxygen exchange
and reduced work of breathing
The client is diagnosed with hyperemesis gravidarum and is planning care with the registered nurse. For each potential intervention, click to specify if the intervention is indicated or contraindicated for the care of the client.
- A. Give clear liquids
- B. Weigh the client daily
- C. Obtain a 12-lead ECG
- D. Administer enteral nutrition
- E. Initiate a large-bore peripheral IV
- F. Document strict intake and output
- G. Auscultate the fetal heart rate intermittently
Correct Answer:
Rationale: When caring for clients with hyperemesis gravidarum (HG), the primary goal is to alleviate vomiting, replenish fluids, and correct electrolyte
and nutritional imbalances. Once completed, resumption of oral intake can be attempted. Interventions that are indicated at this time
include:
• Weighing the client daily to monitor for additional weight loss
• Obtaining a 12-lead ECG to monitor for cardiac changes related to electrolyte imbalances (eg, hypokalemia)
• Initiating a large-bore peripheral IV (eg, 18-gauge) to allow for administration of fluids and medications
• Documenting strict intake and output (eg, emesis, urinary output) to monitor hydration status and kidney function
• Auscultating the fetal heart rate intermittently (eg, twice daily, once per shift) to verify fetal status. (Continuous fetal heart rate
monitoring is not indicated at this gestational age.)
Many clients with HG cannot tolerate anything by mouth and are typically placed on a short period of gut rest (ie, NPO status), if hospitalized.
Therefore, giving clear liquids is contraindicated during the initial treatment phase of HG but should be offered once nausea and vomiting
have stopped. For the same reasons, administering enteral nutrition (eg, tube feeding) is contraindicated initially for this client and is not
anticipated unless feedings by mouth and other treatment measures fail.
Select below the 6 findings that require follow-up.
- A. enuresis at night
- B. recently relocated to a new home and school
- C. fatigue, irritability, and multiple
behavioral outbursts - D. frequently reports feeling
thirsty - E. weight in the 20th percentile
- F. Dry mucous membranes
- G. frequently requests to use
the bathroom while at school
Correct Answer: A,C,D,E,F,G
Rationale: The nurse should follow up on the following findings:
irritability may manifest as behavioral outbursts.
• Frequent urination and nocturnal enuresis: Frequent urination and involuntary voiding in a child who was previously
toilet trained for at least 6 months indicate excessive urination (ie, polyuria), which is a characteristic finding of multiple
medical conditions (eg, diabetes mellitus [DM], diabetes insipidus).
• Increased thirst and dry mucous membranes: Increased thirst (ie, polydipsia) and dry mucous membranes are signs
of dehydration. Dehydration in the presence of polyuria and weight loss is concerning for DM.
• Weight loss: Weight loss is a common finding in clients with DM because the body is unable to use glucose and instead
breaks down protein and fat stores for energy.
• Fatigue, irritability, and multiple behavioral outbursts: Fatigue and irritability in a client with polydipsia and polyuria
may indicate an energy deficit from altered glucose metabolism related to DM. In a 6-year-old client, fatigue and