The nurse in the emergency department would arrange to transfer which burned clients to a burn center?

15% partial-thickness burn, Lightening injury, History of pulmonary edema, Healthy 67 year old, 4% partial-thickness burn to perineum

The nurse instructs a patient with type 1 diabetes mellitus to avoid which of the following drugs while taking insulin?

Aldactone (Spironolactone)

When a diabetic patient asks about maintaining adequate blood glucose levels, which of the following statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74 mg/dL?

The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel.

The nurse associates which assessment finding in the diabetic patient with decreasing renal function?

Protein in the urine during a random urinalysis

What is the nurse’s best response about developing diabetes to the patient whose father has type 1 diabetes mellitus?

You have a greater susceptibility for development of the disease because of your family history.

The nurse recognizes which patient as having the greatest risk for undiagnosed diabetes mellitus?

Middle-aged Native American woman

A diabetic patient is brought into the emergency department unresponsive. The arterial pH is 7.28. Besides the blood pH, which clinical manifestation is seen in uncontrolled diabetes mellitus and ketoacidosis?

Increased respiratory rate

Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction?

Tremors, nervousness, profuse perspiration

A nurse is teaching a client with diabetes mellitus who asks, Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL (3.3 mmol/L)?= How would the nurse respond?

Your brain needs a constant supply of glucose because it cannot store it.

After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations?

Diabetes can cause blindness, so I should see the ophthalmologist yearly.

A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. What action would the nurse take first?

Examine the client's feet for signs of injury.

A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement would the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications?

Maintain tight glycemic control and prevent hyperglycemia.

A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement would the nurse include in this client' s teaching?

Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs).

After teaching a patient with type 2 diabetes mellitus who is prescribed nateglinide, the nurse assesses the client's understanding. Which statement made by the patient indicates a correct understanding of the prescribed therapy?

I will take this medicine immediately before I eat.

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?

Give your drug injection the same day every week.

The nurse is planning teaching for a client who is starting acarbose for diabetes mellitus type 2. Which statement will the nurse include in the teaching?

Be sure to take the drug with each meal.

After teaching a client who has diabetes mellitus with retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching?

I should look into swimming or water aerobics to get my exercise.

The nurse assesses a client with diabetic ketoacidosis. Which assessment finding would the nurse correlate with this condition?

Increased rate and depth of respiration

A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values would the nurse identify as potential ketoacidosis in this client?

pH 7.28, HCO3 18 mEq/L (18 mmol/L), PCO2 28 mm Hg, PO2 98 mm Hg

A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take?

Administration of intravenous insulin

A nurse teaches a client with type 1 diabetes mellitus. Which statement would the nurse include in this client's teaching to decrease the client's insulin needs?

Walk at a moderate pace for 1 mile daily.

After teaching a client who is recovering from pancreas transplantation, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching?

If I develop an infection, I should stop taking my corticosteroid.

A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement would the nurse include in this client's teaching to prevent injury?

Use a bath thermometer to test the water temperature.

A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the client's diet would the nurse decrease?

Proteins

A nurse assesses a client who has diabetes mellitus and notes that the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of orange juice, the client's signs and symptoms have not changed. What action would the nurse take next?

Administer another half-cup (120 mL) of orange juice.

A nurse teaches a client with diabetes mellitus about sick-day management. Which statement would the nurse include in this client's teaching?

Monitor your blood glucose levels at least every 4 hours while sick.

The nurse is caring for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 7:00 a.m. (0700). At which time would the nurse assess the client for potential hypoglycemia related to the NPH insulin?

4:00 PM (1600)

After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for
additional teaching?

I should decrease my intake of protein and eliminate carbohydrates from my diet.

A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis:
Vital Signs and Assessment Laboratory Results Medications
Blood pressure: 90/62 mm Hg Serum potassium: 2.6 Potassium chloride 40, Pulse: 120 beats/min mEq/L (2.6 mmol/L) mEq/L (40 mmol/L) IV Respiratory rate: 28 breaths/min bolus STAT, Urine output: 20 mL/hr via Increase IV fluid to 100 catheter mL/hr

What action would the nurse take?

Increase the intravenous rate and then consult with the primary health care provider about the potassium prescription.

The nurse is caring for a newly admitted older adult who has a blood glucose of 300 mg/dL (16.7 mmol/L), a urine output of 185 mL in the past 8 hours, and a blood urea nitrogen (BUN) of 44 mg/dL (15.7 mmol/L). What diabetic complication does the nurse suspect?

Hyperglycemic-hyperosmolar state (HHS)

The nurse is caring for a newly admitted client who is diagnosed with
hyperglycemic-hyperosmolar state (HHS). What is the nurse's priority action at this time?

Establish intravenous access to provide fluids.

A nurse assesses adults at a health fair. Which adults would the nurse counsel to be tested for diabetes? (Select all that apply.)

56-year-old African-American male, A 48-year-old female with a sedentary lifestyle, A 50-year-old male with a body mass index greater than 25 kg/m2, A 28-year-old female who gave birth to a baby weighing 9.2 lb (4.2 kg)

A nurse assesses a patient who is experiencing diabetic ketoacidosis (DKA). For which assessment findings would the nurse monitor the client?

Deep and fast respirations, Tachycardia, Orthostatic hypotension

A nurse teaches a client with diabetes mellitus about foot care. Which statements would the nurse include in this client's teaching? (Select all that apply.)

Do not walk around barefoot.

Trim toenails straight across with a nail clipper.

A nurse provides diabetic education at a public health fair. Which disorders would the nurse include as complications of diabetes mellitus?

Stroke
Kidney failure
Blindness

The nurse is caring for a client who has severe hypoglycemia and is experiencing a seizure. What actions will the nurse take at this time?

Administer glucagon 1 mg subcutaneously.
Be sure the bed side rails are in the up position.
Notify the primary health care provider immediately.
Monitor the client's blood glucose level.

The nurse is caring for a client who has diabetes mellitus type 1 and is experiencing hypoglycemia. Which assessment findings will the nurse expect?

Nervousness, blurred vision

A nurse reviews the laboratory values of a client who returned from kidney transplantation 12 hours ago:
Sodium 136 mEq/L (135 mmol/L)
Potassium 5 mEq/L (5 mmol/L)
Blood urea nitrogen (BUN) 44 mg/dL (15.7 mmol/L)
Serum creatinine 2.5 mg/dL (221 mcmol/L)
What initial intervention would the nurse anticipate?

Increase the dose of immunosuppression.

A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, "I'm having right belly pain and have a temperature of 101° F (38.3° C)." How would the nurse respond?

You should go to the hospital immediately to get checked out.

When caring for a postpartum woman experiencing hypovolemic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is

decreased urinary output

What is a priority intervention in planning care for the child with disseminated intravascular coagulation (DIC)?

Management in the intensive care unit

Which action should be initiated to limit hypovolemic shock when uterine inversion occurs?

Increase the intravenous infusion rate.

The nurse gets the hand-off report on four clients. Which client would the nurse assess first?

Client with a blood pressure change of 128/74 to 110/88 mm Hg

A nurse is caring for a client who suffered massive blood loss after trauma. How does the nurse correlate the blood loss with the client' s mean arterial pressure (MAP)?

Lower blood volume lowers MAP.

A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since the client was last assessed 4 hours ago. What action by the nurse is best?

Assess using the MEWS score.

A nurse is caring for a client after surgery who is restless and apprehensive. The assistive personnel (AP) reports the vital signs and the nurse sees that they are only slightly different from previous readings. What action does the nurse delegate next to the AP?

Measure urine output from the catheter.

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL (11.6 mmol/L). The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best?

High glucose is common in shock and needs to be treated.

A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3 (3.8  109/L), blood glucose level 198 mg/dL (11 mmol/L), and temperature 96.2° F (35.6°C). What action by the nurse takes priority?

Notify the primary health care provider immediately.

A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock?

Drink fluids on a regular schedule.

A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority?

Ensure the client has a patent airway.

A client is receiving norepinephrine for shock. What assessment finding best indicates a therapeutic effect from this drug?

Alert and oriented, answering questions

A nurse is caring for a client who has a diagnosis of multiple organ dysfunction syndrome (MODS) who will be receiving sodium nitroprusside via IV infusion. What action by the nurse causes the charge nurse to intervene?

Removing the IV bag from the brown plastic cover

A nurse on the general medical-surgical unit is caring for a client in shock and assesses the following:
Respiratory rate: 10 breaths/min
Pulse: 136 beats/min
Blood pressure: 92/78 mm Hg
Level of consciousness: responds to voice
Temperature: 101.5° F (38.5° C)
Urine output for the last 2 hours: 40 mL/hr.
What action by the nurse is best?

Call the Rapid Response Team

A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the primary health care provider?

Lactate: 5.4 mg/dL (6 mmol/L)

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge?

I hope I can get my water turned back on when I get home.

A client with MODS has been started on dobutamine. What assessment finding requires the nurse to communicate with the primary health care provider immediately?

Report of chest heaviness

Which teaching will the nurse provide to a client who is being placed on a corticosteroid after a renal transplant?

Avoid events where there will be large crowds.

A nurse is caring for an adult female client who has arrived to the hospital after a motor vehicle accident. The client is unresponsive. Who will be contacted as the legal next of kin for medical decision making?

The mother who lives in another state.

Which finding will the nurse notice as a symptom of acute graft rejection in a liver transplant recipient?

Slight yellowing of skin and eyes.

A nurse is providing pre-operative care for a client who is asking about the risks and benefits of their scheduled transplant surgery shortly after the surgery was explained to them by the healthcare provider. Which action by the nurse is best?

Tell the surgeon that the client has more questions about the surgery.

A nurse working in a clinic is returning phone calls. Which client will be called first?

A client who had a transplant two months ago who is reporting a low grade fever

A client who is a registered organ donor in Kansas has been declared dead by neurological criteria. The next of kin has stated that they do not want anyone to call Midwest Transplant Network. Which action will the nurse take?

Notify Midwest Organ Transplant of the client death.

Which test will the nurse tell the new nurse is the most definitive test for brain death?

Apnea test

A nurse is conducting an assessment on a client who is on the waiting list for a kidney transplant. Which finding(s) will indicate a need to call the transplant team? Select all that apply.

A client has been skipping hemodialysis appointments every week.

A client has let their health insurance lapse.

A client with type 2 diabetes has been prescribed insulin. Which statement indicates they understood the teaching by the nurse?

"I will make sure the insulin I inject is not cold"

The client received lispro insulin at 0700. When is the most likely time for a hypoglycemic reaction to occur?

0800

What are the most common signs and symptoms of diabetes mellitus? Select all that Apply.

fatigue, polydipsia, polyphagia, polyuria

A nurse is receiving report on a group of clients. Which client will the nurse see first?

A client who is two days post compound femoral fracture whose vital signs are as follows: HR 110, BP 106/42, RR 22, T 97.2 F.

A nurse is caring for a client who was brought into the emergency room with dizziness after spending several hours doing yard work in the sun. Which findings will cause the nurse concern? Select all that Apply.

The client's potassium level is 5.4 mmol/L.

The client reports still being thirsty after having a glass of water.

The client's fingers are cool to the touch.

The client has had urinary output of 20 mL/hr over the last 2 hours.

Which action will the nurse ask the unlicensed assistive personnel to complete when caring for a client experiencing hypovolemic shock?

Remind the client to use the call light when wanting to get out of bed.

A nurse is caring for a client who has sepsis. Which finding(s) will the nurse report immediately? Select all that Apply.

Petechiae on the lower back.

Increasing anxiety and restlessness

A nurse is caring for a client who is experiencing septic shock. Which action will the nurse perform first?

Start Intravenous fluids.

A nurse is caring for a client who experienced a severe burn two hours ago. Which finding will cause the nurse the greatest concern?

Salivary drooling

A nurse is caring for an adult client who is alert and oriented after experiencing partial and deep full-thickness burn over 70% of their body during a house fire. Which action will the nurse perform first?

Administer IV narcotics for pain control.