Select 5 findings that require further investigation.

A. unable to lie flat and sleeps in a chair at night
B. 6-1b (2.7-kg) weight
gain in 1 week
C. increased urinary hesitancy and urgency
D. SpO2 88% on room air
E. crackles in bilateral lung
bases;

Correct Answer: A,B,D,E

Rationale: A client with chronic heart failure (HF) who reports worsening fatigue, dyspnea, orthopnea, and peripheral edema is likely
experiencing declining oxygenation due to fluid volume overload. Assessment findings that require further investigation
include:
• Orthopnea: Labored breathing in the supine position is a common manifestation in clients with HF due to pulmonary
edema. Clients with orthopnea often sleep on a chair or on propped-up pillows to decrease work of breathing.
Paroxysmal nocturnal dyspnea, which is waking up in the middle of the night with suffocation due to dyspnea, is another
characteristic finding in HF.
• Crackles on auscultation: Crackles are a manifestation of pulmonary edema caused by fluid in the alveoli. Pulmonary
edema is concerning for worsening HF and impaired gas exchange.
• Peripheral edema and rapid weight gain (ie, >5 Ib/week [2.3 kg/week]): These symptoms are concerning for fluid
volume overload
• Hypoxemia: Decreased capillary oxygen saturation (SpO, <95%) is a sign of inadequate gas exchange. This is most
likely related to pulmonary edema from HF exacerbation.

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

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.

The nurse has reviewed the information from the Prescriptions. The nurse is reinforcing education on heart failure management. Which of the following client statements indicate a correct understanding of the teaching? Select all that apply.

A. I am going to join a cardiac rehabilitation program
B. I should take my furosemide at bedtime."
C. I will check my blood pressure before each dose of carvedilol.
D. I will notify my health care provider if I develop muscle cramps.
E. I will weigh myself once a week.

Correct Answer: A,C,D

Rationale: Pharmacological management of heart failure (HF) focuses on reducing cardiac workload and improving cardiac output. Beta
blockers (eg, carvedilol) reduce cardiac workload by inhibiting the action of catecholamines (eg, epinephrine, norepinephrine)
on beta-adrenergic receptors in the heart. Beta blockers decrease myocardial oxygen demand by decreasing blood
pressure (BP) and heart rate (HR). Therefore, clients prescribed antihypertensive medications (eg, carvedilol) should be
instructed to check BP and HR before each dose to monitor for hypotension and bradycardia
Loop diuretics (eg, furosemide, bumetanide) are potassium-wasting, which increases the client's risk of hypokalemia
Angiotensin system inhibitors (eg, sacubitril-valsartan) and potassium supplements cause hyperkalemia. Clients should be
taught symptoms of hypo- or hyperkalemia (eg, muscle cramps) and instructed to notify the health care provider if they occur
(Option 4).

Which of the following findings are consistent with a tension pneumothorax? Select all that apply.

A. Diminished breath sounds on one side
B. Dyspnea
C. Hypotension
D. Recent thoracic trauma
E. Tracheal deviation
F. Unilateral chest wall expansion

Correct Answer: A,B,C,D,E,F

Rationale: A pneumothorax is characterized by air inside the pleural space, which disrupts the negative pressure that maintains lung expansion. This
causes the lung to collapse either partially or completely, leading to unilateral, diminished breath sounds; unilateral chest wall
expansion; and dyspnea. A pneumothorax often occurs from blunt thoracic trauma (eg, during a motor vehicle collision). Air can also ent
the pleural space through the chest wall and parietal pleura (open pneumothorax) during or after an invasive procedure on or near the chest
wall (eg, thoracentesis, paracentesis, central line insertion) (Options 1, 2, 4, and 6).

The nurse has reviewed the information from the Laboratory Results.Three days later, the school nurse is called to the play area because the client is diaphoretic and becomes unconscious. The school nurse notices the clients medical alert bracelet and obtains a blood glucose level. Which action should the school nurse take after reading the blood glucose level?

A. Administer subcutaneous glucagon
B. Administer subcutaneous regular insulin
C. Encourage the client to take sips of an electrolyte drink
D. Provide the client with a snack containing 15 g of simple carbohydrates

Correct Answer: A

Rationale: Rapid growth and unpredictable eating patterns place a child with diabetes mellitus at high risk for hypoglycemia.
Hypoglycemia can occur rapidly and can be life-threatening. Clinical manifestations primarily result from lack of glucose to the
brain (and other vital organs) followed by rapid activation of the sympathetic nervous system:
• Pallor and diaphoresis
• Tremors
• Palpitations and tachycardia
• Altered mental status, irritability, slurred speech, confusion
• Dizziness
If hypoglycemia is suspected, the nurse should immediately obtain a blood glucose level. Clients with hypoglycemia who are
unconscious cannot tolerate oral carbohydrates. Therefore, the nurse should rapidly administer glucagon by injection (eg.
subcutaneous, IM) or apply a glucose paste to the gums. Glucagon increases blood glucose levels by rapidly converting
stored glycogen in the liver into glucose, a process known as glycogenolysis