Exam (elaborations)
Nurs 1220 Exam 3 Questions With Complete Solutions
- Course
- Institution
Nurs 1220 Exam 3 Questions With Complete Solutions
[Show more]
Content preview
Nurs 1220 Exam 3 Questions With Complete Solutions1. A nurse assesses a client who is admitted for treatment of
FLUID OVERLOAD. Which signs and symptoms does the
nurse expect to find? (Select all that apply.)
a. Increased pulse rate
b. Distended neck veins
c. Decreased blood pressure
d. Warm and pink skin
e. Skeletal muscle weakness
f. Visual disturbances Correct Answer ANS: A, B, E, F
Signs and symptoms of fluid overload include increased pulse
rate, distended neck veins, increased blood pressure, pale and
cool skin, skeletal muscle weakness, and visual disturbances.
Decreased blood pressure would be seen in dehydration. Warm
and pink skin is a normal finding
1. The nurse is caring for a client who has possible
hypothyroidism. What possible risk factors can cause this health
problem? (Select all that apply.)
a. Lithium drug therapy
b. Thyroid cancer
c. Autoimmune thyroid disease
d. Iodine deficiency
e. Laryngitis
f. Pituitary tumors Correct Answer ANS: A,B,C,D,F
All of these factors place a client at risk for hypothyroidism
except for laryngitis which is an inflammation of the larynx.
,1. The nurse is planning health teaching for a client starting on
levothyroxine. What health teaching about this drug would the
nurse include?
a. The need to take the drug when the client feels fatigued and
weak.
b. The need to report chest pain and dyspnea when starting the
drug.
c. The need to check blood pressure and pulse every day.
d. The need to rotate injection sites when giving self the drug.
Correct Answer ANS: B
Levothyroxine is a replacement hormone for clients who have
hypothyroidism and is taken orally for life. Vital signs do not
have to be checked every day, but the client should report any
chest pain and dyspnea when first starting the drug.
15 min rule IF SYMPTOMS DON'T IMPROVE Correct
Answer CHECK glucose levels
-Give 15g of carbs
If blood sugar is still low
GIVE 15 MORE CARBS (GRAHAM CRACKERS,
HONEY ,SALTINE CRACKERS,)
FASTING GLUCOSE
1/2 CUP OF JUICE
4 TO 5 HARD CANDY
3 TABS OF GLUCOSE
15. The nurse is planning teaching for a client who is starting
exenatide extended release (ER) for diabetes mellitus type 2.
Which statement will the nurse include in the teaching?
a. "Be sure to take the drug once a day before breakfast."
,b. "Take the drug every evening before bedtime."
c. "Give your drug injection the same day every week."
d. "Take the drug with dinner at the same time each day Correct
Answer ANS: C
Exenatide ER is an incretin mimetic (GLP-1 agonist) that works
with insulin to lower blood glucose levels by reducing
pancreatic glucagon secretion, reducing liver glucose
production, and delaying gastric emptying. As an extended-
release drug, it is given only once a week by injection.
16. A nurse is caring for an older adult client who is admitted
with moderate dehydration. Which INTERVENTION will the
nurse implement to PREVENT injury while in the hospital?
a. Ask family members to speak quietly to keep the client calm.
b. Assess urine color, amount, and specific gravity each day.
c. Encourage the client to drink at least 1 L of fluids each shift.
d. Dangle the client on the bedside before ambulating. Correct
Answer ANS: D
An older adult with moderate dehydration may experience
orthostatic hypotension. The client needs to dangle on the
bedside before ambulating. Although dehydration in an older
adult may cause confusion, speaking quietly will not help the
client remain calm or decrease confusion. Assessing the client's
urine may assist with the diagnosis of dehydration but would not
prevent injury. Clients are encouraged to drink fluids, but 1 L of
fluid each shift for an older adult may cause respiratory distress
and symptoms of fluid overload, especially if the client has heart
failure or renal insufficiency.
2. A nurse assesses a client who is prescribed a medication that
INHIBITS aldosterone secretion and release. For which
, potential complications will the nurse assess? (Select all that
apply.)
a. Urine output of 25 mL/hr
b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L)
c. Urine specific gravity of 1.02 g/mL
d. Serum sodium level of 128 mEq/L (128 mmol/L)
e. Blood osmolality of 250 mOsm/kg (250 mmol/kg) Correct
Answer ANS: B, E
Aldosterone is a naturally occurring hormone of the
mineralocorticoid type that increases the reabsorption of water
and sodium in the kidney at the same time that it promotes
excretion of potassium. Any drug or condition that disrupts
aldosterone secretion or release increases the client's risk for
excessive water loss (increased urine output), increased
potassium reabsorption, decreased blood osmolality, and
increased urine specific gravity. The client would not be at risk
for sodium imbalance.
2. A nurse is caring for an older client who exhibits dehydration-
induced confusion. Which intervention by the nurse is best?
a. Measure intake and output every 4 hours.
b. Assess client further for fall risk.
c. Increase the IV flow rate to 250 mL/hr.
d. Place the client in a high-Fowler position. Correct Answer
ANS: B
Dehydration most frequently leads to poor cerebral perfusion
and cerebral hypoxia, causing confusion. The client with
dehydration is at risk for falls because of this confusion,
orthostatic hypotension, dysrhythmia, and/or muscle weakness.
The nurse's best response is to do a more thorough evaluation of
the client's risk for falls. Measuring intake and output may need
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Classroom. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $17.99. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
82871 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now