Drag words from the choices below to fill in the blank/blank...

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

Complete the following sentence by choosing from the lists of options. The nurse suspects that the client's current symptoms are due to -------------------------
and that the client is at increased risk for permanent vision loss due to--------------------------

A. Cataracts
B. Infection
C. Retinal detachment
D. Corneal ulcer
E. Angle-closure glaucoma
F. Optic nerve ischemia

Correct Answer: E,F

Rationale: Acute angle-closure glaucoma results from a significant increase in intraocular pressure (IOP) (>50 mm Hg) due to impaired aqueous
humor drainage. In susceptible individuals (eg, those with a narrow anterior chamber angle), dilation of the pupil causes the iris to press
against the lens, preventing flow of aqueous humor through the pupil. This causes the iris to bulge forward, closing the anterior chamber
angle and blocking drainage of aqueous humor through the trabecular meshwork. The rise in IOP leads to immediate optic nerve ischem
potentially resulting in permanent vision loss.

The nurse is contributing to the client's plan of care. For each potential intervention, click to specify if the intervention is indicated or not indicated for the care of the client.

A. Administer antiemetic
B. Insert a nasogastric tube
C. Place the client on a soft diet
D. Obtain an abdominal CT scan
E. Administer a stimulant laxative

Correct Answer:

Rationale: Small bowel obstruction (SBO) is an intestinal blockage that obstructs the flow of intestinal contents (eg, fluid, gas, fecal
material). The blockage may be due to mechanical (eg, surgical adhesions, hernias, tumors) or nonmechanical/functional (eg,
paralytic ileus) causes. As intestinal contents accumulate, clients develop abdominal distension, colicky abdominal pain,
bilious vomiting, and inability to pass flatus or stool.
Clients with SBO are at risk for fluid, electrolyte, and nutritional imbalances due to decreased intestinal absorption. Clients may
develop bowel necrosis and perforation due to impaired intestinal blood flow, which can lead to peritonitis and sepsis.
The practical nurse should anticipate assisting the registered nurse with the following interventions for a client with SBO:
• Inserting a nasogastric tube for gastrointestinal decompression to reduce abdominal distension and improve intestinal
blood flow
• Administering antiemetics (eg, ondansetron) to prevent further fluid and electrolyte imbalance from vomiting
• Preparing the client for abdominal CT scan to determine the size and location of intestinal obstruction
• Administering IV fluids to improve fluid volume status
In clients with SBO, bowel rest (ie, NPO status) with gastric decompression is prescribed; therefore, a soft diet is not
indicated. Stimulant laxatives increase intestinal motility and are not indicated for clients with intestinal obstruction due to
the risk for bowel perforation.

The nurse has reviewed the information from the Nurses' Notes, Vital Signs, and Laboratory Results.The nurse is reviewing the client's response to potassium-lowering therapies. Which finding is unexpected and requires follow-up by the
nurse?

A. Blood glucose level and diaphoresis
B. Blood pressure and heart rate
C. Crackles and peripheral edema
D. Serum potassium level

Correct Answer: A

Rationale: Treatment for hyperkalemia includes administration of calcium gluconate, furosemide, albuterol nebulizer, and insulin with dextrose. These
therapies may cause rapid shifts in fluid volume, blood glucose, and serum electrolytes. Insulin shifts available glucose and potassium into
the cell, lowering serum potassium levels; however, too much insulin and not enough dextrose cause hypoglycemia (eg, blood glucose 50
mg/dL [2.7 mmol/L]). Clients with kidney disease have an increased risk of hypoglycemia because insulin may accumulate.
The nurse should understand that a low blood glucose level and symptoms suspicious for hypoglycemia (eg, diaphoresis) require follow-u
to prevent seizures, coma, and death due to lack of circulating glucose (Option 1). This client requires an additional dose of dextrose.
(Option 2) This client's blood pressure is 146/88 mm Hg and heart rate is within normal limits. This is an improvement from the initial blood
pressure and represents a therapeutic response to furosemide administration. Blood pressure should be lowered slowly to avoid hypotensior

Select 5 findings that require immediate follow-up.

A. sore throat and nasal congestion for the past week
B. Pregnancy status is
unknown.
C. The abdomen is soft without rigidity or
rebound tenderness,
D. appears drowsy and is oriented to person and time on
E. Vital signs are T 98.8 F (37.1 C), V P 128, V RR 30, and BP 88/60 mm Hg
F. Finger-stick blood glucose level is 600 mg/dL (33.3 mmol/L) .

Correct Answer: B,D,E,F

Rationale: This client has findings of chronic hyperglycemia, including polydipsia (increased thirst) and polyuria (increased urination) which may indicate
untreated diabetes mellitus. Recent findings also indicate potential upper respiratory infection, hypovolemia, and an acute abdominal
condition. For this client, the following findings are the priority for follow-up:
• Delayed menstruation (time since last menstruation exceeds typical cycle length) could indicate that the client is pregnant, which
presents a risk for pregnancy-related complications (eg, ruptured ectopic pregnancy) and affects care provided to the client (eg, avoid x-
rays and teratogenic medications).
• Decreased level of consciousness (eg, drowsiness, disorientation) places the client at increased risk for injury and aspiration and
may indicate impaired brain perfusion. This may be due to hypotension or hyperglycemia-induced cerebral edema.
• Hypotension causes impaired organ perfusion that could be life threatening without immediate intervention.
• Tachycardia occurs to compensate for hypotension or can be the cause of hypotension and requires prompt attention to prevent
cardiovascular collapse.
• Tachypnea is concerning, particularly when associated with rapid, deep respirations (ie, Kussmaul breathing), because it may indicate a
compensatory response to an underlying metabolic acidosis (eg, ketoacidosis, hypotension-induced lactic acidosis).
• Severe hyperglycemia may indicate diabetic ketoacidosis (DKA), a life-threatening complication of diabetes mellitus. In addition,
hyperglycemia has a diuretic effect leading to fluid loss that worsens cardiovascular compromise.

The nurse has implemented the prescribed therapies and is now assisting the client to fill out the lunch menu. Which meal choice is best for this client?

A. Black beans and rice, sliced tomatoes, and a banana
B. Grilled chicken sandwich, corn on the cob, and applesauce
C. Hamburger patty on a whole wheat bun with avocado
D. Salmon, green peas, baked potato, and strawberries

Correct Answer: B

Rationale: This client is experiencing hyperkalemia and should reduce dietary intake of potassium. The preferred meal choice for this client would
include lean meat, such as chicken, that is grilled rather than cooked in oil, and side dishes consisting of fruits and vegetables low in
potassium, such as corn and applesauce (Option 2).
(Options 1, 3, and 4) Beans (a legume), salmon, tomatoes, bananas, potatoes, strawberries, whole wheat products, and avocados are all
high-potassium foods that the client should avoid at this time. Clients with cardiovascular disease should not consume red meat (eg,
hamburger patty) except in limited quantity because it is high in saturated fat.