Tiêu đề RECALLS 8 - NP4 - SC ✅

14. The client is admitted to the intensive care department and diagnosed with myxedema coma. Which assessment data warrant immediate intervention by the nurse? A. Serum blood glucose level of 74 mg/dL. B. Pulse oximeter reading of 90%. C. Telemetry reading showing sinus bradycardia. D. The client is lethargic and sleeps all the time. 15. Propylthiouracil (PTU) is prescribed for a client diagnosed with hyperthyroidism. The client asks the nurse, “Why do I have to take this medication if I am going to get the atomic cocktail? ” The nurse explains that the medication is being prescribed because it decreases the: A. vascularity of the thyroid gland. B. production of thyroid hormones. C. need for thyroid iodine supplements. D. amount of already formed thyroid hormones. 16. A 21-year-old patient with hyperthyroidism complains of her “ugly” appearance and ask, “Will I always look so terrible?” What is the nurse best response? A. Makeup can help your protruding eyes seem less noticeable. B. “Your appearance doesn’t matter. It’s what’s inside that counts.” C. “With treatment, the fluid buildup behind your eyes will decrease.” D. “If you cut back the fluids, the swelling behind your eyes will go down.” 17. The patient with hyperparathyroidism should have extremities handled gently because: A. Decreased calcium bone deposits can lead to pathologic fractures. B. Edema causes stretched tissues to tear easily. C. hypertension can lead to stroke with residual paralysis D. Polyuria leads to dry skin and mucous membranes that can break down 18. Which medication should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy? A. sodium phosphate B. calcium gluconate C. echothiophate iodide D. sodium bicarbonate 19. A client with hyperthyroidism is to take saturated solution of potassium iodide (SSKI). What should the nurse do when administering this drug? A. Pour the solution over ice chips, popsicle, or ice cream. B. Mix the solution with an antacid after the patient’s last meal. C. Dilute the solution with carbonated drink and have the client drink it with a straw. D. Disguise the solution in a pureed fruit or vegetable and let the patient enjoy their meal. 20. A nurse is caring for a patient diagnosed with hypoparathyroidism. Laboratory tests reveal hypocalcemia. Which statement best describes the role of calcitonin in this patient’s condition? A. Calcitonin increases serum calcium levels by stimulating osteoclast activity. B. Calcitonin decreases serum calcium levels by inhibiting bone resorption. C. C. Calcitonin has no effect on calcium regulation in hypoparathyroidism. D. D. Calcitonin increases parathyroid hormone secretion to maintain calcium balance. Situation: A 56-year-old patient has been diagnose to have type 2 Diabetes Mellitus and has been admitted due to headache and blurring of vision. She had been on insulin therapy for almost 10 years now. 21. Which of the following diagnostic test do you expect to be ordered by the diabetologist as an indicator that the patient is compliant to her prescribed diet? A. Oral glucose tolerance test B. Glycosated hemoglobin level C. Fasting blood glucose level D. Finger glucose findings for one day 22. Before supper, an adult client who has type 2 diabetes and requires insulin tells the nurse about having tremors and being weak and anxious. What should the nurse do next? A. Tell the client to lie down for 30 minutes. B. Have the client drink a glass of milk or orange juice. C. Administer IM glucagon D. Administer the next dose of insulin. 23. Which nursing intervention should be done first when managing a pediatric client admitted to the emergency department with severe diabetic ketoacidosis (DKA)? A. Begin an insulin drip to lower the client’s blood glucose level. B. Correct any fluid deficit using an isotonic saline solution. C. Draw a blood glucose level and serum electrolyte panel. D. Secure the client’s airway to ensure adequate ventilation. 24. A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which finding has the greatest effect on fluid loss? A. hypotension B. decreased serum potassium level C. rapid, deep respirations D. warm, dry skin 25. A nurse enters the comfort room and finds a client with Diabetes Mellitus sitting on the floor, appearing confused and disoriented. Which action should the nurse take first? A. Obtain a capillary blood glucose reading B. Administer a prescribed insulin dose C. Administer intramuscular glucagon D. Inform the attending physician immediately 26. The nurse is performing discharge teaching for a client diagnosed with Cushing’s disease. Which statement by the client demonstrates an understanding of the instructions? A. “I will be sure to notify my health-care provider if I start to run a fever.” B. “Before I stop taking the prednisone, I will be taught how to taper it off.” C. “If I get weak and shaky, I need to eat some hard candy or drink some juice.” D. “It is fine if I continue to participate in weekend games of tackle football.” 27. The client diagnosed with Addison’s disease is admitted to the emergency department after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention should the nurse implement? A. Start an IV with an 18-gauge needle and infuse NS rapidly. B. Have the client stay in the waiting room until a bed is available. C. Obtain a permit for the client to receive a blood transfusion. D. Collect urinalysis and blood samples for a CBC and calcium level. 28. The nurse is instructing a college student with Addison’s disease how to adjust the dose of glucocorticoids. The nurse should explain that the patient may need an increased dosage of glucocorticoids in which situation? A. completing course work. B. gaining 4 lb (1.8 kg) C. becoming engaged D. having wisdom teeth extracted 29. Which goal is the priority for a client in addisonian crisis? A. controlling hypertension B. preventing irreversible shock C. preventing infection D. relieving anxiety 30. Which of the following patient statements would indicate that no further teaching is needed for a client newly diagnosed with Addison’s disease who will be taking corticosteroids? A. "I know I need to watch for signs of high blood sugar while I’m on this medication." B. "I will adjust my steroid dose depending on how much I eat or how much exercise I do." C. "If my blood pressure suddenly gets very high, I will notify my health care provider right away." D. "If I’m under a lot of stress, I should lower my corticosteroid dose to avoid side effects." 2 | Page
31. When teaching a client about taking oral glucocorticoids, how should the nurse instruct the client to take the medication? A. with a full glass of water B. on an empty stomach C. at bedtime to increase absorption D. with meals or with an antacid 32. Which indicator is best for determining whether a client with Addison’s disease is receiving the correct amount of glucocorticoid replacement? A. skin turgor B. temperature C. thirst D. daily weight 33. A client diagnosed with Cushing’s syndrome is admitted to the hospital and scheduled for a dexamethasone suppression test. What should the nurse do during this test? A. Collect a 24-hour urine specimen to measure serum cortisol levels. B. Administer 1 mg of dexamethasone orally at night and obtain serum cortisol levels the next morning. C. Draw blood samples before and after exercise to evaluate the effect of exercise on serum cortisol levels. D. Administer an injection of adrenocorticotropic hormone (ACTH) 30 minutes before drawing blood to measure serum cortisol levels. 34. Bone resorption is a possible complication of Cushing’s disease. To help the client prevent this complication, what should the nurse recommend to the client? A. Increase the amount of potassium in the diet. B. Maintain a regular program of weight-bearing exercise. C. Limit dietary vitamin D intake. D. Perform isometric exercises. 35. A client has an adrenal tumor and is scheduled for a bilateral adrenalectomy. During preoperative teaching, the nurse teaches the client how to do deep-breathing exercises after surgery. What should the nurse tell the client to do? A. “Sit in an upright position, and take a deep breath.” B. “Hold your abdomen firmly with a pillow, and take several deep breaths.” C. “Tighten your stomach muscles as you inhale, and breathe normally.” D. “Raise your shoulders to expand your chest.” 36. The client is admitted to the medical department with a diagnosis of rule-out (R/O) acute pancreatitis. Which laboratory values should the nurse monitor to confirm this diagnosis? A. Creatinine and blood urea nitrogen (BUN) B. Troponin and creatine kinase-MB (CK-MB) C. Serum amylase and lipase D. Serum bilirubin and calcium 37. Which client problem has priority for the client diagnosed with acute pancreatitis? A. Risk for fluid volume deficit B. Alteration in comfort C. Imbalanced nutrition: less than body requirements D. Knowledge deficit 38. The nurse is preparing to administer morning medications to clients. Which medication should the nurse question before administering? A. Pancreatic enzymes to the client who has finished breakfast B. The pain medication, morphine, to the client who has a respiratory rate of 20 C. The loop diuretic to the client who has a serum potassium level of 3.9 mEq/L D. The beta blocker to the client who has an apical pulse of 68 bpm 39. The nurse is administering a pancreatic enzyme to the client diagnosed with chronic pancreatitis. Which statement best explains the rationale for administering this medication? A. It is an exogenous source of protease, amylase, and lipase B. This enzyme increases the number of bowel movements C. This medication breaks down in the stomach to help with digestion D. Pancreatic enzymes help break down fat in the small intestine 40. The nurse is completing discharge teaching to the client diagnosed with acute pancreatitis. Which instruction should the nurse discuss with the client? A. Instruct the client to decrease alcohol intake B. Explain the need to avoid all stress C. Discuss the importance of stopping smoking D. Teach the correct way to take pancreatic enzymes 41. Which laboratory value should be monitored by the nurse for the client diagnosed with diabetes insipidus? A. Serum sodium B. Serum calcium C. Urine glucose D. Urine white blood cells 42. The nurse is discharging a client diagnosed with diabetes insipidus. Which statement made by the client warrants further intervention? A. “I will keep a list of my medications in my wallet and wear a Medic Alert bracelet.” B. “I should take my medication in the morning and leave it refrigerated at home.” C. “I should weigh myself every morning and record any weight gain.” D. “If I develop a tightness in my chest, I will call my health-care provider.” 43. The client is admitted to the medical unit with a diagnosis of rule-out diabetes insipidus (DI). Which instructions should the nurse teach regarding a fluid deprivation test? A. The client will be asked to drink 100 mL of fluid as rapidly as possible and then will not be allowed fluid for 24 hours. B. The client will be administered an injection of antidiuretic hormone (ADH), and urine output will be measured for 4 to 6 hours. C. The client will have nothing by mouth (NPO), and vital signs and weights will be done hourly until the end of the test. D. An IV will be started with normal saline, and the client will be asked to try to hold the urine in the bladder until a sonogram can be done. 44. The nurse is caring for a client diagnosed with diabetes insipidus (DI). Which intervention should be implemented? A. Administer sliding-scale insulin as ordered B. Restrict caffeinated beverages C. Check urine ketones if blood glucose is >250 D. Assess tissue turgor every four (4) hours 45.A client with central diabetes insipidus is prescribed desmopressin (DDAVP) nasal spray. Which statement by the client indicates the need for further teaching? A. “I will weigh myself daily and report sudden weight gain.” B. “If I notice swelling in my hands or feet, I should contact my health-care provider.” C. “I should blow my nose just before taking the nasal spray.” D. “If I miss a dose, I can double the next one to make up for it.” 46. Which recommendation should the nurse suggest to an elderly client who lives alone when discussing normal developmental changes of the olfactory organs? A. Suggest installing multiple smoke alarms in the home B. Recommend using a night-light in the hallway and bathroom C. Discuss keeping a high-humidity atmosphere in the bedroom D. Encourage the client to smell food prior to eating it 47. The elderly male client tells the nurse, “My wife says her cooking hasn’t changed, but it is bland and tasteless.” Which response by the nurse is most appropriate? A. “Would you like me to talk to your wife about her cooking?” B. “Taste buds change with age, which may be why the food seems bland.” C. “This happens because the medications sometimes cause a change in taste.” D. “Why don’t you barbecue food on a grill if you don’t like your wife’s cooking?” 3 | Page
48. Which situation makes the nurse suspect the client has glaucoma? A. An automobile accident because the client did not see the car in the next lane B. The cake tasted funny because the client could not read the recipe C. The client has been wearing mismatched clothes and socks D. The client ran a stoplight and hit a pedestrian walking in the crosswalk 49. The client has undergone a bilateral stapedectomy. Which action by the client warrants immediate intervention by the nurse? A. The client is ambulating without assistance B. The client is sneezing with the mouth open C. There is some slight serosanguineous drainage D. The client reports hearing popping in the affected ear 50. The client is diagnosed with glaucoma. Which symptom should the nurse expect the client to report? A. Loss of peripheral vision B. Floating spots in the vision C. A yellow haze around everything D. A curtain coming across vision 51. The nurse is administering eyedrops to the client. You know that no further teaching is needed when the patient states: A. “I will wash my hands before and after using the eye drops.” B. “I will tilt my head back and place the drops directly on my cornea.” C. “I will gently press on the inner corner of my eye after putting in the drops.” D. “I will share my eye drops with my spouse if we have the same symptoms.” 52. The client has had an enucleation of the left eye. Which intervention should the nurse implement? A. Discuss the need for special eyeglasses B. Refer the client for an ocular prosthesis C. Help the client obtain a seeing-eye dog D. Teach the client how to instill eyedrops 53. The client comes to the emergency department after splashing chemicals into the eyes. Which intervention should the nurse implement first? A. Have the client move the eyes in all directions B. Administer a broad-spectrum antibiotic C. Irrigate the eyes with normal saline solution D. Determine when the client had a tetanus shot 54. The client is scheduled for laser-assisted in situ keratomileusis (LASIK) surgery. Which instruction should the nurse discuss prior to the client’s discharge from day surgery? A. Wear bilateral eye patches for three (3) days B. Wear corrective lenses until the follow-up visit C. Do not read any material for at least one (1) week D. Teach the client how to instill corticosteroid ophthalmic drops 55. The nurse is placing patches on both eyes of a client with retinal detachment. What is the expected outcome of patching? A. Reduced rapid eye movements B. Decreased irritation caused by light entering the damaged eye C. Protection of the injured eye from infection D. Minimized eye strain on the uninvolved eye 56. Which statement indicates to the nurse the client is experiencing some hearing loss? A. “I clean my ears every day after I take a shower.” B. “I keep turning up the sound on my television.” C. “My ears hurt, especially when I yawn.” D. “I get dizzy when I get up from the chair.” 57. The client is diagnosed with Ménière’s disease. Which statement indicates the client understands the medical management for this disease? A. “After intravenous antibiotic therapy, I will be cured.” B. “I will have to use a hearing aid for the rest of my life.” C. “I must adhere to a low-sodium diet, 2,000 mg/day.” D. “I should sleep with the head of my bed elevated.” 58. The client is complaining of ringing in the ears. Which data are most appropriate for the nurse to document in the client’s chart? A. Complaints of vertigo B. Complaints of otorrhea C. Complaints of tinnitus D. Complaints of presbycusis 59. The nurse is preparing to administer otic drops into an adult client’s right ear. Which intervention should the nurse implement? A. Grasp the earlobe and pull back and out when putting drops in the ear B. Insert the eardrops without touching the outside of the ear C. Instruct the client to close the mouth and blow prior to instilling drops D. Pull the auricle down and back prior to instilling drops 60. Which ototoxic medication should the nurse recognize as potentially life-altering or threatening to the client? A. An oral calcium channel blocker B. An intravenous aminoglycoside antibiotic C. An intravenous glucocorticoid D. An oral loop diuretic 61. The client has ingested a corrosive solution containing lye. Which intervention should the nurse implement? A. Administer syrup of ipecac to induce vomiting B. Insert a nasogastric tube and connect to wall suction C. Assess for airway compromise D. Immediately administer water or milk 62. The male client was found in a parked car with the motor running. The paramedics brought the client to the ED with complaints of headache, nausea, and dizziness. The client is unable to recall his name or address. On assessment, the nurse notes the buccal mucosa is cherry-red. Which intervention should the nurse implement first? A. Check the client’s oxygenation level with a pulse oximeter B. Apply oxygen via nasal cannula at 100% C. Obtain a psychiatric consult to determine if this was a suicide attempt D. Prepare the client for transfer to a facility with a hyperbaric chamber 63. The nurse is providing first aid to a victim of a poisonous snake bite. Which intervention should be the nurse’s first action? A. Apply a tourniquet to the affected limb B. Cut an “X” across the bite and suck out the venom C. Administer a corticosteroid medication D. Have the client lie still and remove constrictive items 64. A patient was rushed to the OR. The patient’s mother said, “I saw her lying on the floor and I think she took all the Tylenol in the bottle.” As a nurse, you know that the antidote for Tylenol poisoning is: A. N-acetylcysteine (Mucomyst) B. Naloxone (Narcan) C. Flumazenil (Romazicon) D. Activated charcoal 65. The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical unit. Which nursing task cannot be delegated to the UAP? A. Obtaining the intake and output on a client diagnosed with food poisoning B. Performing a dressing change on a client with a chemical burn C. Assisting a client who overdosed on morphine to the bedside commode D. Helping a client with carbon monoxide poisoning turn, cough, and deep breathe 66. The female client presents to the emergency department with facial lacerations and contusions. The spouse will not leave the room during the assessment interview. Which intervention should be the nurse’s first action? A. Call the security guard to escort the spouse away B. Discuss the injuries while the spouse is in the room C. Tell the spouse the police will want to talk to him D. Escort the client to the bathroom for a urine specimen 67. The nurse is teaching a class about rape prevention to a group of women at a community center. Which information is not a myth about rape? 4 | Page