Questions and Verified Answers for Exam Success
Dietary teaching for DM - CORRECT ANSWER>>>>- ask client to ID types of food
they prefer
Expected findings for a client with DM1 and blood glucose of 48 mg/dL - CORRECT
ANSWER>>>>Weakness, diaphoresis, hunger, nausea, shakiness & confusion
Expected findings of hyperglycemia - CORRECT ANSWER>>>>Dehydration,
decreased skin turgor, kussmaul respiration & ketonuria
Nursing actions for 72 post-op above the knee amputation - CORRECT
ANSWER>>>>-evaluate and assess residual limb 72 hrs after amputation
- assist client to prone for 20-30 minutes q3-4 hrs
- apply dressing distal-to-proximal
Prevention of uric acid stones - CORRECT ANSWER>>>>- take allopurinol
as prescribed
- exercise several times a day
- limit intake of foods high in purine
- increase fluid intake 2-3 L/day
- increase intake of citrus juices
Indication of Basilar skull fracture - CORRECT ANSWER>>>>Clear fluid coming
from the nares or ears
Indication of cerebral hemisphere injury - CORRECT ANSWER>>>>Motor loss on
1 side of the body
Indication of breast cancer - CORRECT ANSWER>>>>- non-tender hard lump
palpated in 1 breast
Education on improving gas exchange in a client with Emphysema -
CORRECT ANSWER>>>>- pursed-lip breathing during dyspnea periods
- drink 2,000-3,000 mL of fluids/day
- practice diaphragmatic breathing
- maintain O2 sat of at least 88% w/ home O2
Nursing actions PRIOR to initiating transfusion of RBC - CORRECT
ANSWER>>>>-assess & document vs
- ensure patient has 20-gauge or larger needle
- verify with another nurse blood type & Rh is correct
- change IV tubing to a set that has a filter on it
, Precautions when caring for a client w AIDS - CORRECT ANSWER>>>>Standard
- gown, gloves
Priority nursing action when a patient starts to have a seizure sitting in a chair
- CORRECT ANSWER>>>>Lower pt to the floor
Purpose of abduction pillows - CORRECT ANSWER>>>>Prevent dislocation of the
hip during position changes or movement
Risk for plantar flexion resulting in foot drop nurse uses ... -
CORRECT ANSWER>>>>Foot cradle at the foot of the bed
To keep patient's heels off the bed and prevent shearing and skin break down the
nurse uses.... - CORRECT ANSWER>>>>Regular bed pillow
Regular pillows & rolled blankets are used too - CORRECT
ANSWER>>>>Position patient off the operative side while in bed
Nursing assessment of a patient with fruity breath odor, dry mouth & extreme thirst ...
- CORRECT ANSWER>>>>Blood glucose level - findings indicate hyperglycemia and
DKA
Priority nursing action when preparing to irrigate a wound -
CORRECT ANSWER>>>>Check the client's pain levels
Purpose of 2 chest tubes - CORRECT ANSWER>>>>Upper tube removes air
from pleural space & lower drains blood and fluid from pleural spaced
Education regarding stomatitis r/t chemo - CORRECT ANSWER>>>>- oral care with
a soft toothbrush
- AVOID use of lemon and glycerine swabs after meals
- remove dentures except when eating
- frequent mouth rinses w/ hydrogen peroxide, warm saline or baking soda q2-3 hours
Discharge teaching on a new permanent pacemaker - CORRECT
ANSWER>>>>-check HR at the same time each day & document
- maintains a regular HR but doesn't lower or control HTN
- avoid applying pressure over the generator
- avoid being in close proximity to older microwaves that don't have shielding
PH 7.5, PaCO2 32 and HCO3 24 indicates - CORRECT
ANSWER>>>>Respiratory Alkalosis
Expected range for PaCO2 - CORRECT ANSWER>>>>35-45
Expected finding of BPH - CORRECT ANSWER>>>>Dysuria