MS P2 Compilation

APPENDICITIS
In addition, he says that the pain is worst on

the right lower quadrant. The patient points
to his abdomen at a location which is about
1. True or False: The appendix is found on a one-third distance between the anterior
the left lower side of the abdomen and is superior iliac spine and umbilicus. This area
connected to the cecum of the large is known as what?
intestine.
 A. Rovsing's Point
 True
 B. Hamman's Point
 False
 C. McBurney's Point
The answer is FALSE: The appendix is found
 D. Murphy's Point
on the RIGHT (not left) lower side of the
abdomen and is connected to the cecum The answer is C. This is known as McBurney's
of the large intestine. Point and is a classic sign and symptom in
patients with appendicitis.
4. Thinking back to the scenario in question

2. Select all the following options that are
3, what other signs and symptoms are
NOT causes of appendicitis:
associated with appendicitis. SELECT-ALL-
 A. Fecalith THAT-APPLY:
 A. Increased red blood Cells

 B. Routine usage of NSAIDs  B. Patient has the desire to be
 C. Infection due to Helicobacter positioned in the prone position to
relieve pain
pylori  C. Umbilical pain that extends in the
 D. Lymph node enlargement due to
right lower quadrant
viral or bacterial infection  D. Abdominal rebound
 E. Diet low in fiber tenderness
The answers are: B, C, and E. These options

are NOT causes of appendicitis. Routine  E. Abdominal Flaccidity
usage of NSAIDS and infection due H. pylori The answers are: C and D. These are classic
are causes of peptic ulcers. While a diet low signs and symptoms found in patients with
in fiber is thought to be the cause of appendicitis. Option A is wrong because the
diverticulosis. Fecalith and lymph node patient may have increased WHITE blood
enlargement due to viral or bacterial cells (not red). Option B is wrong because
infection (such as mononucleosis etc.) can the patient may have the desire to be in the
cause appendicitis. fetal position (side-lying with the knees bent)
3. A 23 year old patient is admitted with to relieve the pain. The prone position would
suspected appendicitis. The patient states increase the pain. Option E is wrong
he is having pain around the umbilicus that because the patient would have
extends into the lower part of his abdomen. abdominal RIGIDITY (not flaccidity).
5. An 18 year old patient is admitted with  D. "It is normal for some patients to
appendicitis. Which statement by the have shoulder pain after a
patient requires immediate nursing laparoscopic appendectomy.”
intervention?
The answer is B. This statement by the nursing
 A. "The pain hurts so much it is student requires re-education because heat
making me nauseous." should NEVER be applied to abdomen if
appendicitis is suspected or known. Heat
 B. "I have no appetite."
application can increase the risk of
 C. "The pain seems to be gone appendix perforation. Ice application is
recommended, if warranted. However, the
now." side-lying position can help relieve the
patient’s pain and is recommended. All the
 D. "If I position myself on my right other options are correct.
side, it makes the pain less intense."
7. Your patient is 4 days post-opt from an
The answer is C. It is important that the nurse appendectomy. Which assessment finding
monitors the patient's pain level. If the requires further evaluation?
patient reports that the pain has suddenly
decreased or is gone, this is a warning sign  A. The patient reports their last bowel
that the appendix may have perforated movement was the day before
(ruptured). If the appendix has ruptured, the surgery.
sudden decrease in pain will be followed by  B. The patient reports incisional pain.
more pain due to peritonitis (which is life-
threatening). Therefore, the nurse should  C. The patient coughs and deep
notify the doctor immediately. breathes while splinting the
abdominal incision.
6. You're providing education to a group of
nursing students about the care of a patient
with appendicitis. Which statement by a  D. Options A and C
nursing student requires re-education about
The answer is A. If the patient has not had a
your teaching?
bowel movement 2-3 days after surgery it
 A. "After an appendectomy the requires further evaluation such as listening
patient may have a nasogastric to bowel sounds and asking the patient if
tube to remove stomach fluids and they are passing gas. If the patient has no
swallowed air." bowel sounds or does NOT report passing
gas, the doctor should be notified. Options B
 B. "Non-pharmacological techniques
and C are normal findings.
for a patient with appendicitis
include application of heat to the 8. A patient is recovering after having an
abdomen and the side-lying appendectomy. The patient is 48 hours post-
opt from surgery and is tolerating full liquids.
position." The physician orders for the patient to try
solid foods. What types of foods should the
 C. "The nurse should monitor the patient incorporate in their diet?
patient for signs and symptoms of
peritonitis which includes increased
heart rate, respirations, temperature,  A. Foods high in fiber
abdominal distention, and intense
 B. Foods low in fiber
abdominal pain."
 C. Foods high in carbohydrates C. CT (with contrast depending on body
habitus)
 D. Foods low in protein
D. CT (helpful if perforation is suspected
The answer is A. It is best for the patient to to diagnose periappendiceal
follow a diet high in fiber to prevent straining abscess)
during bowel movements.
RATIO: Low grade fever less than 100.4F/38C
, B. Moderate leukocytosis (10,000-20,000) , C.
Ultrasound , D. CT (with contrast depending
9. A patient is scheduled for appendectomy on body habitus) , E. CT (helpful if perforation
at noon. While performing your morning is suspected to diagnose periappendiceal
assessment, you note that the patient has a abscess)
fever of 103.8 'F and rates abdominal pain 9
on 1-10. In addition, the abdomen is 2) What best explains what happens to the
distended and the patient states, "I was appendix when it is obstructed?
feeling better last night but it seems the pain
A. the inflamed tissue becomes infected
has become worst." The patient is having
and dies from lack of blood supply
tachycardia and tachypnea. Based on the
and eventually bursts
scenario, what do you suspect the patient is
B. the inflamed tissue dies from lack of
experiencing?
blood supply causing the appendix
 A. Pulmonary embolism to burst
C. the obstruction causes pressure to
 B. Colon Fistulae build up and eventually causes the
appendix to burst
D. the obstruction hardens the
 C. Peritonitis
appendix eventually causing it to
 D. Hemorrhage burst
The answer is C. Based on the patient's 3) Roxy is admitted to the hospital with a
presenting symptoms, the patient is most possible diagnosis of appendicitis. On
likely experiencing peritonitis because the physical examination, the nurse should be
appendix has ruptured. The key clues in this looking for tenderness on palpation at
scenario are the classic signs and symptoms McBurney’s point, which is located in the
of peritonitis (tachycardia, tachypnea, high
A. left lower quadrant
temperature, and abdominal
B. left upper quadrant
pain/distension) along with the patient's
C. right lower quadrant
statement that they were feeling better last
D. right upper quadrant
night (hence probably the time the
appendix ruptured) which periodically RATIO: C. right lower quadrant . To be exact,
relieved the pain at the appendix but the appendix is anatomically located at the
allowed for the contents of the appendix to Mc Burney’s point at the right iliac area of the
leak into the peritoneal cavity....hence right lower quadrant.
causing peritonitis.
4) The celiac artery supplies blood to which
1) What are diagnostic features of acute part of the GI tract?
appendicitis? click all that apply
A. duodenum
A. Low grade fever less than 100.4F/38C B. jejunum
B. Moderate leukocytosis (10,000- C. small intestine and proximal colon
20,000) Ultrasound D. mid-transverse colon to rectum
E. cecum fiber- fecaliths, parasites,and
neoplasms
5) During defecation, movement of feces into
D. suppositories, FB, neoplams,
the rectum initiates (click all that apply)
undigested fiber and calcium salts,
A. rectoanal inhibitory reflex calcium salts or undigested fiber-
B. voluntary relaxation of the pelvic floor fecaliths, infection, fecal stasis,
and external sphincter mechanism parasites
C. voluntary increase in intra-abdominal
9) What is the blind sac that is in the RLQ
pressure
below the ileocecal valve?
D. voluntary contraction of external
sphincter A. cecum
B. appendix
RATIO: B. voluntary relaxation of the pelvic
C. transverse colon
floor and external sphincter mechanism, C.
D. ascending colon
voluntary increase in intra-abdominal
pressure 10) The middle rectal artery supplies blood to
which part of the rectum?
6) What is the primary cause of appendicitis?
A. The lower rectum
A. obstruction of the lumen between the
B. The middle rectum
cecum and appendix
C. The anal sphincters
B. inflammation due to an immune
D. upper and middle rectum
response
C. constipation 11) Situation: Mr. Gerald Liu, 19 y/o, is being
D. overuse of antibiotics admitted to a hospital unit complaining of
severe pain in the lower abdomen.
7) Jerry has diagnosed with appendicitis. He
Admission vital signs reveal an oral
develops a fever, hypotension and
temperature of 101.2 0F. Signs and symptoms
tachycardia. The nurse suspects which of the
include pain in the RLQ of the abdomen that
following complications?
may be localize at McBurney’s point. To
A. Intestinal obstruction relieve pain, Mr. Liu should assume which
B. Peritonitis position?
C. Bowel ischemia
A. Prone
D. Deficient fluid volume
B. Supine, stretched out
RATIO: B. Peritonitis . Complications of acute C. Sitting
appendicitis are peritonitis, perforation and D. Lying with legs drawn up
abscess development.
RATIO: D. Lying with legs drawn up . Posturing
8) What are some possible causes of an by lying with legs drawn up can relax the
obstructed appendix? abdominal muscle thus relieve pain.
A. inflammatory bowel disease, 12) A patient presents with periumbilical pain

infection, fecal stasis, calcium salts or that moves to the RLQ over 24 hrs. the pain is
undigested fiber- fecaliths, parasites, exacerbated by walking, coughing, or a car
fb, and neoplasms ride. The patient presents with nausea,
B. infection, fecal stasis, calcium salts or vomiting, and a low grade fever of less than
undigested fiber-fecaliths, parasites, 38C or 100.4. What is the suspected
FB, and neoplasms, diarrhea diagnosis?
C. fecal stasis, fecaliths, FB, gastric ulcer,
infection, calcium salts or undigested
A. Acute appendicitis abdomen, Ernie jerks even on slight pressure.
B. Ovarian cyst Blood test was ordered. Diagnosis is acute
C. Volvulus appendicitis. Stat appendectomy was
D. Acute pancreatitis indicated. Pre op care would include all of
E. Acute cholecystitis the following except?
13) What type of tissue is the appendix made A. Consent signed by the father
up of? B. Enema STAT
C. Skin prep of the area including the
A. lymphatic
pubis
B. connective
D. Remove the jewelries
C. fibrinous
D. intestinal mucosa 17) Situation: A 20 year old college student
was rushed to the ER of PGH after he fainted
14) The inferior mesenteric artery supplies
during their ROTC drill. Complained of severe
blood to which part of the GI tract?
right iliac pain. Upon palpation of his
A. mid-transverse colon to rectum abdomen, Ernie jerks even on slight pressure.
B. colon and anal canal Blood test was ordered. Diagnosis is acute
C. descending colon and rectum appendicitis. Pre-anesthetic med of Demerol
D. colon and rectum and atrophine sulfate were ordered to :
E. colon, cecum, and rectum
A. Allay anxiety and apprehension
15) Situation : Mr. Gerald Liu, 19 y/o, is being B. Reduce pain
admitted to a hospital unit complaining of C. Prevent vomiting
severe pain in the lower abdomen. D. Relax abdominal muscle
RATIO: A. Allay anxiety and apprehension .
temperature of 101.2 0F. Which of the
Pain is not reduced in appendicits. Clients
following would confirm a diagnosis of
are not given pain medication as to assess
appendicitis?
whether the appendix ruptured. A sudden
A. The pain is localized at a position relief of pain indicates the the appendix has
halfway between the umbilicus and ruptured and client will have an emergency
the right iliac crest. appendectomy and prevent peritonitis.
B. Mr. Liu describes the pain as Demerol and Atropine are used to allay
occurring 2 hours after eating client’s anxiety pre operatively.
C. The pain subsides after eating
18) Which condition is most likely to have a
D. The pain is in the left lower quadrant
nursing diagnosis of fluid volume deficit?
RATIO: A. The pain is localized at a position
A. Appendicitis
halfway between the umbilicus and the right
B. Pancreatitis
iliac crest. Pain over McBurney’s point, the
C. Cholecystitis
point halfway between the umbilicus and
D. Gastric ulcer
the iliac crest, is diagnosis for appendicitis.
Options b and c are common with ulcers; RATIO: B. Pancreatitis . Hypovolemic shock
option d may suggest ulcerative colitis or from fluid shifts is a major factor in acute
diverticulitis. pancreatitis. The other conditions are less
likely to exhibit fluid volume deficit.
16) Situation: A 20 year old college student
was rushed to the ER of PGH after he fainted 19) Post op care for appendectomy include
during their ROTC drill. Complained of severe the following except
A. Early ambulation D. Infection of the appendix diminishes
B. Diet as tolerated after fully conscious necrotic arterial blood flow and
C. Nasogastric tube connect to suction increases venous drainage.
D. Deep breathing and leg exercise
RATIO: B. Obstruction of the appendix
RATIO: B. Diet as tolerated after fully reduces arterial flow, leading to ischemia,
conscious. Client’s peristalsis will return in 48 inflammation, and rupture of the appendix.
to 72 hours post-op therefore, Fluid and food A client with appendicitis is at risk for infection
are witheld until the bowel sounds returns. related to inflammation, perforation, and
Remember that ALL PROCUDURES requiring surgery because obstruction of the appendix
GENERAL and SPINAL anesthesia above the causes mucus fluid to build up, increasing
nerves that supply the intestines will cause pressure in the appendix and compressing
temporary paralysis of the bowel. Specially venous outflow drainage. The pressure
when the bowels are traumatized during the continues to rise with venous obstruction;
procedure, it may take longer for the arterial blood flow then decreases, leading
intestinal peristalsis to resume. to ischemia from lack of perfusion.
Inflammation and bacterial growth follow,
20) Other condition/s that could produce
and swelling continues to raise pressure
pain similar to appendicitis include
within the appendix, resulting in gangrene
A. Inflammation of gall bladder and rupture. Geriatric, not middle-aged,
B. Stone in ureter clients are especially susceptible to
C. Inflammation of right colon appendix rupture.
D. All of the above
22) The superior rectal artery supplies blood
RATIO: D. All of the above . Other conditions to which part of the GI tract?
like gall stones, inflammation of gall bladder,
A. The rectum
stone in the ureter, ruptured ovarian follicle,
B. The upper and middle rectum
a ruptured tubal pregnancy, perforation of
C. lower rectum
stomach or duodenal ulcer, and
D. anal sphincters and rectum
inflammation of the right colon can produce
E. anal sphincters only
pain similar to appendicitis.
23) Typical signs and symptoms of
21) When preparing a male client, age 51, for
appendicitis include:
surgery to treat appendicitis, the nurse
formulates a nursing diagnosis of Risk for A. Nausea
infection related to inflammation, B. Left lower quadrant pain
perforation, and surgery. What is the rationale C. Pain when pressure is applied to the
for choosing this nursing diagnosis? right lower quadrant of the
abdomen.
A. Obstruction of the appendix may
D. High fever
increase venous drainage and cause
the appendix to rupture. RATIO: Nausea is typically associated with
B. Obstruction of the appendix reduces appendicitis with or without vomiting. Pain is
arterial flow, leading to ischemia, generally felt in the right lower quadrant.
inflammation, and rupture of the Rebound tenderness, or pain felt with release
appendix. of pressure applied to the abdomen, may be
C. The appendix may develop present with appendicitis. Low-grade fever is
gangrene and rupture, especially in a associated with appendicitis.
middle-aged client.
24) What stimulates the contraction of D. contracts, relaxes
propulsive waves that move stool distally
28) While examining a patient with suspected
from the cecum?
appendicitis, you would expect to find pain
A. distention of the colonic wall (with or without) gaurding, (with or without)
B. distention of the small intestinal wall rebound tenderness, pain (with or without)
C. the fermenting vat located in the passive flexion of R hip, pain (with or without)
cecum passive flexion of L hip, and a postitive or
D. distention of the cecum wall negative obturator sign?
25) The superior mesenteric artery supplies A. Pain: with gaurding, with rebound
blood to which part of the GI tract? tenderness, with passive flexion of R
hip, without passive flexion of L hip,
A. small intestine (other than
and a positive obturator sign
duodenum) and proximal colon
B. Pain: without gaurding, with rebound
B. mid-transverse colon to rectum
tenderness, with passive flexion of R
C. duodenum
hip, without passive flexion of L hip,
D. cecum
and a postivie obturator sign
E. rectum only
C. Pain: without gaurding, with rebound
26) Situation: Mr. Gerald Liu, 19 y/o, is being tenderness, with passive flexion of R
admitted to a hospital unit complaining of hip, with passive flexion of L hip, and
severe pain in the lower abdomen. a positive obturator sign
Admission vital signs reveal an oral D. Pain: with gaurding, with rebound
temperature of 101.2 0F. After a few minutes, tenderness, with passive flexion of R
the pain suddenly stops without any hip, with passive flexion of L hip, and
intervention. Nurse Ray might suspect that: a positive obturator sign
A. the appendix is still distended 29) The __________ extends from the
B. the appendix may have ruptured rectosigmoid junction to the anal canal and
C. an increased in intrathoracic pressure is composed of insensitive columnar
will occur epithelium.
D. signs and symptoms of peritonitis
A. Anal Canal
occur
B. Rectum
RATIO: B. the appendix may have ruptured . C. Colon
If a confirmed diagnosis is made and the D. Large bowel
pain suddenly without any intervention, the
30) Surgery is the definitive treatment for
appendix may have ruptured; the pain is
appendicitis.
lessened because the appendix is no longer
distended thus surgery is still needed. A. True
B. False
27) During the rectoanal inhibitory reflex, the
internal sphincter ________ allowing the RATIO: A. True. Surgery is the definitive
contents into the anal canal, then the treatment for appendicitis. It may be
external sphincter ____________ and contents performed as an open surgery or through a
are pushed back into the rectum. This occurs laparoscope. Antibiotics are also useful in
up to 7 times daily. treating appendicitis, but usually require to
be followed by surgery due to recurrence.
A. relaxes, relaxes
B. contracts, contracts 31) If after surgery the patient’s abdomen
C. relaxes, contracts becomes distended and no bowel sounds
appreciated, what would be the most
suspected complication? [1]
1. Hypovolemia, electrolyte imbalance
A. Intussusception 2. Elevated temperature, weakness
B. Paralytic Ileus and diaphoresis
C. Hemorrhage 3. Nausea and vomiting, rigidity of the
D. Ruptured colon abdominal wall
4. Pallor and eventually shock
RATIO: B. Paralytic Ileus . Paralytic Ileus is a
A. 1 and 2
mechanical bowel obstruction where in, the
B. 2 and 3
patients intestine fails to regain its motility. It is
C. 1,2,3
usually caused by surgery and anesthesia.
D. All of the above
Intusussusception, Appendicitis and
Peritonitis also causes paralytic ileus. RATIO: D. All of the above . Peritonitis will
cause all of the above symptoms. The
32) The _____________ is 3-4 cm long, starts at
peritoneum has a natural tendency to
the dentate line, is supported by the internal
GUARD and become RIGID as to limit the
and external anal sphincters, and composed
infective exudate exchange inside the
of sensitive squamous epithelium.
abdominal cavity. Hypovolemia and F&E
A. Rectum imbalance are caused by severe nausea
B. Anal Canal and vomiting in patients with peritonitis
C. Colon because of acute pain. As inflammation and
D. Anal sphincter canal infection spreads, fever and chills will
become more apparent causing elevation in
33) The inferior rectal artery supplies blood to temperature, weakness and sweating. If
which part of the rectum? peritonitis is left untreated, Client will become
severely hypotensive leading to shock and
A. the internal and external anal
death.
sphincters
B. the lower rectum 37) Situation : Mr. Gerald Liu, 19 y/o, is being
C. the upper, middle, and lower rectum admitted to a hospital unit complaining of
D. the external sphincter only severe pain in the lower abdomen.
E. the internal sphincter only Admission vital signs reveal an oral
temperature of 101.2 0F. Which of the
34) What percentage of people have
following complications is thought to be the
appendicitis in their lifetime?
most common cause of appendicitis?
A. 10%
A. A fecalith
B. 20%
B. Internal bowel occlusion
C. 30%
C. Bowel kinking
D. 50%
D. Abdominal wall swelling
35) The appendix is located on the _____
RATIO: A fecalith is a hard piece of stool
lower side of the abdomen.
which is stone like that commonly obstructs
A. Right the lumen. Due to obstruction, inflammation
B. Left and bacterial invasion can occur. Tumors or
foreign bodies may also cause obstruction.
36) Peritonitis may occur in ruptured
appendix and may cause serious problems 38) What part of the colon propels retrograde
which are waves of contraction to allow the cecum to
retain liquid feces and act as a ‘fermenting C. The appendix may develop
vat’? gangrene and rupture, especially in a
middle-aged client.
A. mid-transverse colon
D. Infection of the appendix diminishes
B. entire transverse colon
necrotic arterial blood flow and
C. ascending colon
increases venous drainage.
D. descending colon
E. ileum RATIO: B. Obstruction of the appendix
reduces arterial flow, leading to ischemia,
39) Situation: A 20 year old college student
inflammation, and rupture of the appendix.
was rushed to the ER of PGH after he fainted
A client with appendicitis is at risk for infection
during their ROTC drill. Complained of severe
related to inflammation, perforation, and
surgery because obstruction of the appendix
abdomen, Ernie jerks even on slight pressure.
causes mucus fluid to build up, increasing
Blood test was ordered. Diagnosis is acute
pressure in the appendix and compressing
appendicitis. Which result of the lab test will
venous outflow drainage. The pressure
be significant to the diagnosis?
continues to rise with venous obstruction;
A. RBC : 4.5 TO 5 Million / cu. mm. arterial blood flow then decreases, leading
B. Hgb : 13 to 14 gm/dl. to ischemia from lack of perfusion.
C. Platelets : 250,000 to 500,000 cu.mm. Inflammation and bacterial growth follow,
D. WBC : 12,000 to 13,000/cu.mm and swelling continues to raise pressure
within the appendix, resulting in gangrene
RATIO: D. WBC : 12,000 to 13,000/cu.mm . and rupture. Geriatric, not middle-aged,
WBC increases with inflammation and clients are especially susceptible to
infection. appendix rupture.
40) Worms do not cause appendicitis. 42) What 3 major branches of the aorta
supply blood to the intestines?
A. True
B. False A. celiac artery, superior mesenteric
artery, inferior mesenteric artery
RATIO: B. False . Worms can block the
B. celiac artery, superior mesenteric
opening of the appendix resulting in
artery, and right and left gastric artery
appendicitis. In addition, fecaliths, infection
C. superior mesenteric artery, inferior
or inflammation can also block the opening
mesenteric artery, and internal and
of the appendix leading to appendicitis.
external iliac arteries
41) When preparing a male client, age 51, for D. common iliac artery, superior
surgery to treat appendicitis, the nurse mesenteric artery, inferior mesenteric
formulates a nursing diagnosis of Risk for arteries
infection related to inflammation,
43) What is the treatment for appendicitis?
perforation, and surgery. What is the rationale
for choosing this nursing diagnosis? A. surgical removal of inflamed
appendix before it ruptures
A. Obstruction of the appendix may
B. pain control and antibiotics
increase venous drainage and cause
C. pain control
the appendix to rupture.
D. antibiotics and observation
B. Obstruction of the appendix reduces
arterial flow, leading to ischemia, 44) What vein carries venous blood from the
inflammation, and rupture of the intestines to the liver?
appendix.
10, 000/mm3. Other options are normal
values.
A. portal vein
B. iliac veins 48) Diet does not influence the development
C. middle colic vein of appendicitis.
D. inferior mesenteric vein
A. True
E. superior mesenteric vein
B. False
45) McBurney Point is located ________
RATIO: B. False . Diet lacking in fiber is a risk
A. Around the umbilicus factor for appendicitis.
B. In the right lower abdomen
49) Symptoms of appendicitis include ______
C. In the left lower abdomen
D. In the upper abdomen A. Abdominal pain
B. Nausea
RATIO: B. In the right lower abdomen. Pain in
C. Constipation
appendicitis normally starts around the
D. All of the above
umbilicus but later settles in the right lower
abdomen near the appendix. This point is RATIO: D. All of the above . Symptoms of
called the McBurney Point and is located appendicitis include abdominal pain,
midway between the umbilicus and the top nausea, vomiting, loss of appetite, low grade
of the right pelvic bone. fever, constipation, diarrhea and an inability
to pass gas. A swelling may subsequently
46) Perforation is not a complication of
appear in the abdomen overlying the
appendicitis.
appendix.
A. True
50) Common anesthesia for appendectomy
B. False
is
RATIO: B. False. The inflamed appendix can
A. Spinal
burst resulting in inflammation of the lining of
B. General
the abdomen (peritoneum), the condition
C. Caudal
being called peritonitis.
D. Hypnosis
47) Situation : Mr. Gerald Liu, 19 y/o, is being
RATIO: A. Spinal . Spinal anesthesia is the most
admitted to a hospital unit complaining of
common method used in appendectomy.
severe pain in the lower abdomen.
Using this method, Only the area affected is
anesthetized preventing systemic side
temperature of 101.2 0F. The doctor ordered
effects of anesthetics like dizziness,
for a complete blood count. After the test,
hypotension and RR depression.
Nurse Ray received the result from the
laboratory. Which laboratory values will 51. The nurse would increase the comfort of
confirm the diagnosis of appendicitis? the patient with appendicitis by:
A. RBC 5.5 x 106/mm3 "a. Having the patient lie prone
B. Hct 44 %
C. WBC 13, 000/mm3 b. Flexing the patient's right knee
D. Hgb 15 g/dL
c. Sitting the patient upright in a chair
RATIO: C. WBC 13, 000/mm3 . Increase in
d. Turning the patient onto his or her left side
WBC counts is suggestive of appendicitis
because of bacterial invasion and RATIO: Correct answer: B"
inflammation. Normal WBC count is 5, 000 –
The patient with appendicitis usually prefers d. hypertension."
to lie still, often with the right leg flexed to
RATIO: Acute pancreatitis can cause
decrease pain.
decreased urine output, which results from
52. "The nurse is caring for a patient in the the renal failure that sometimes
emergency department with complaints of accompanies this condition. Intracranial
acute abdominal pain, nausea, and pressure neither increases nor decreases in a
vomiting. When the nurse palpates the client with pancreatitis. Tachycardia, not
patient's left lower abdominal quadrant, the bradycardia, usually is associated with
patient complains of pain in the right lower pulmonary or hypovolemic complications of
quadrant. The nurse will document this as pancreatitis. Hypotension can be caused by
which of the following diagnostic signs of a hypovolemic complication, but
appendicitis? hypertension usually isn't related to acute
pancreatitis."
a. Rovsing sign
55. "When preparing a male client, age 51,
b. referred pain
for surgery to treat appendicitis, the nurse
c. Chvostek's sign formulates a nursing diagnosis of Risk for
d. rebound tenderness perforation, and surgery. What is the rationale
for choosing this nursing diagnosis?"
RATIO: In patients with suspected
appendicitis, Rovsing sign may be elicited by a. Obstruction of the appendix may increase
palpation of the left lower quadrant, causing venous drainage and cause the appendix to
pain to be felt in the right lower quadrant. rupture.
53. Which of the following position should the b. Obstruction of the appendix reduces
client with appendicitis assume to relieve arterial flow, leading to ischemia,
pain? inflammation, and rupture of the appendix.
A. Prone c. The appendix may develop gangrene and
rupture, especially in a middle-aged client.
B. Sitting
d. Infection of the appendix diminishes
C. Supine
necrotic arterial blood flow and increases
D. Lying with legs drawn up venous drainage."
RATIO: Lying still with legs drawn up tow RATIO: A client with appendicitis is at risk for
Cards chest helps relive tension on the infection related to inflammation,
abdominal muscle, which helps to reduce perforation, and surgery because
the amount of discomfort felt. Lying flat or obstruction of the appendix causes mucus
sitting may increase the amount of pain fluid to build up, increasing pressure in the
experienced appendix and compressing venous outflow
drainage. The pressure continues to rise with
54. "When evaluating a male client for venous obstruction; arterial blood flow then
complications of acute pancreatitis, the decreases, leading to ischemia from lack of
nurse would observe for: perfusion. Inflammation and bacterial
"a. increased intracranial pressure. growth follow, and swelling continues to raise
pressure within the appendix, resulting in
b. decreased urine output. gangrene and rupture. Geriatric, not middle-
c. bradycardia.
aged, clients are especially susceptible to 4. Heat should never be applied to the
appendix rupture. abdomen of a patient suspected of having
peritonitis because of the risk of rupture."
56. "A client is admitted with a diagnosis of
acute appendicitis. When assessing the 58. A client is admitted with right lower
abdomen, the nurse would expect to find quadrant pain, anorexia, nausea, low-grade
rebound tenderness at which location? fever, and elevated white blood cell count.
Which complication is most likely the cause?
a) Left lower quadrant
1. A. fecalith
b) Left upper quadrant
2. Bowel Kinking
c) Right upper quadrant
3. Internal blowel occlusion
d) Right lower quadrant
4. Abdominal wall swelling
RATIO: The pain of acute appendicitis
localizes in the right lower quadrant (RLQ) at RATIO: The client is experiencing
McBurney's point, an area midway between appendicitis. A. fecalith is a fecal calculus, or
the umbilicus and the right iliac crest. Often, stone, that occludes the lumen of the
the pain is worse when manual pressure near appendix and is the most common cause of
the region is suddenly released, a condition appendicitis. Bowel wall swelling, kinking of
called rebound tenderness. the appendix, and external occlusion not
internal occlusion, of the bowel by adhesions
57. The nurse is monitoring a client diagnosed
can also be cause of appendicitis."
with appendicitis who is scheduled for
surgery in 2 hours. The client begins to 59. "When preparing a male client, age 51,
complain of increased abdominal pain and for surgery to treat appendicitis, the nurse
begns to vomit. On assessment, the nurse formulates a nursing diagnosis of Risk for
notes that the abdomen is distended and infection related to inflammation,
bowel sounds are diminished. Which is the perforation, and surgery. What is the rationale
appropriate nursing intervention? " for choosing this nursing diagnosis?"
1. Notify the Physician a. Obstruction of the appendix may increase

venous drainage and cause the appendix to
2. Administer the prescribed pain medication
rupture.
3. Call and ask the operating room team to
b. Obstruction of the appendix reduces
perform the surgery as soon as possible
arterial flow, leading to ischemia,
4. Reposition the client and apply a heating inflammation, and rupture of the appendix.
pad on warm setting to the client's abdomen
c. The appendix may develop gangrene and
RATIO: 1. Based on the assessment rupture, especially in a middle-aged client.
information the nurse should suspect
peritonitis, a complication that is associated
with appendicitis, and notify the physician.
venous drainage."
2. Administering pain medication is not an
RATIO: A client with appendicitis is at risk for
appropriate intervention
3. Scheduling surgical time is not within the perforation, and surgery because
scope of practice of an RN. obstruction of the appendix causes mucus
fluid to build up, increasing pressure in the
appendix and compressing venous outflow b. Obstruction of the appendix reduces
drainage. The pressure continues to rise with arterial flow, leading to ischemia,
venous obstruction; arterial blood flow then inflammation, and rupture of the appendix.
decreases, leading to ischemia from lack of
perfusion. Inflammation and bacterial
growth follow, and swelling continues to raise
pressure within the appendix, resulting in d. Infection of the appendix diminishes
gangrene and rupture. Geriatric, not middle- necrotic arterial blood flow and increases
aged, clients are especially susceptible to venous drainage."
appendix rupture."
RATIO: A client with appendicitis is at risk for
60. "A client with acute appendicitis infection related to inflammation,
develops a fever, tachycardia, and perforation, and surgery because
hypotension. Based on these assessment obstruction of the appendix causes mucus
findings, the nurse should further assess the fluid to build up, increasing pressure in the
client for which of the following appendix and compressing venous outflow
complications? drainage. The pressure continues to rise with
venous obstruction; arterial blood flow then
1. Deficient fluid volume.
2. Intestinal obstruction. perfusion. Inflammation and bacterial
growth follow, and swelling continues to raise
3. Bowel ischemia.
pressure within the appendix, resulting in
4. Peritonitis gangrene and rupture. Geriatric, not middle-
aged, clients are especially susceptible to
RATIO: "Complications of acute appendicitis appendix rupture.
are perforation, peritonitis, and abscess
development. Signs of the development of 62. The nurse is monitoring a client admitted
peritonitis include abdominal pain and to the hospital with a diagnosis of
distention, tachycardia, tachypnea, nausea, appendicitis who is scheduled for surgery in
vomiting, and fever. Because peritonitis can 2 hours. The client begins to complain of
cause hypovolemic shock, hypotension can increased abdominal pain and begins to
develop. Deficient fluid volume would not vomit. On assessment, the nurse notes that
cause a fever. Intestinal obstruction would the abdomen is distended and bowel sounds
cause abdominal distention, diminished or are diminished. Which is the appropriate
absent bowel sounds, and abdominal pain. nursing intervention? Saunders
Bowel ischemia has signs and symptoms Comprehensive Review for the NCLEX-RN
similar to those found with intestinal Examination 5th ed.
obstruction."
1. Notify the physician
2. Administer the prescribed pain medication
formulates a nursing diagnosis of Risk for 3. Call and ask the operating room team to
infection related to inflammation, perform the surgery as soon as possible
4. Reposition the client and apply a heating
for choosing this nursing diagnosis?
pad on warm setting to the clien't abdomen
a. Obstruction of the appendix may increase
RATIO: Based on the signs and symptoms
presented in the question, the nurse shoudl
rupture.
suspect peritonitis and notify the physician.
Administering pain medication is not an 64. "The client diagnosed with appendicitis
appropriate intervention. Heat should never has undergone an appendectomy. At two
be applied to the abdomen of a client wiht hours postoperative, the nurse takes the vital
suspected appendicitis because of the risk of signs and notes T 102.6 F, P 132, R 26, and BP
rupture. Scheduling surgical time is not within 92/46. Which interventions should the nurse
the scope of nursing practice, although the implement? List in order of priority.
physician probably would perform the
1. Increase the IV rate.
surgery earlier than the prescheduled time.
2. Notify the health care provider.
63. When preparing a male client, age 51, for
surgery to treat appendicitis, the nurse 3. Elevate the foot of the bed.
formulates a nursing diagnosis of Risk for
infection related to inflammation, 4. Check the abdominal dressing.
5. Determine if the IV antibiotics have been
for choosing this nursing diagnosis?"
administered.
Order of priority: 1, 3, 4, 5, 2."
rupture. RATIO: "1. The nurse should increase the IV
rate to maintain the circulatory system
function until further orders can be obtained.
inflammation, and rupture of the appendix. 3. The foot of the bed should be elevated to
help treat shock, the symptoms of which
include elevated pulse and decreased BP.
Those signs and an elevated temperature
d. Infection of the appendix diminishes indicate an infection may be present and
necrotic arterial blood flow and increases the client could be developing septicemia.
venous drainage."
4. The dressing should be assessed to
RATIO: A client with appendicitis is at risk for determine if bleeding is occurring.
5. The nurse should administer any IV
perforation, and surgery because
antibiotics ordered after addressing
obstruction of the appendix causes mucus
hypovolemia. The nurse will need this
information when reporting to the HCP.
appendix and compressing venous outflow
drainage. The pressure continues to rise with 2. The HCP should be notified when the nurse
venous obstruction; arterial blood flow then has the needed information."
perfusion. Inflammation and bacterial 65. "A client is admitted with right lower
growth follow, and swelling continues to raise quadrant pain, anorexia, nausea, low-grade
pressure within the appendix, resulting in fever, and an elevated white blood cell
gangrene and rupture. Geriatric, not middle- count. Which complication is most likely the
aged, clients are especially susceptible to cause?"
appendix rupture. 1. A fecalith
2. Bowel kinking
3. Internal bowel occlusion
4. Abdominal wall swelling"

RATIO: The client is experiencing c. The appendix may develop gangrene and
appendicitis. A fecalith is a fecal calculus, or rupture, especially in a middle-aged client.
stone, that occludes the lumen of the
appendix and is the most common cause of
appendicitis. Bowel wall swelling, kinking of
venous drainage."
the appendix, and external occlusion, not
internal occlusion, of the bowel by adhesions RATIO: A client with appendicitis is at risk for
can also be causes of appendicitis. infection related to inflammation,
perforation, and surgery because
66. "During the assessment of a patient with
obstruction of the appendix causes mucus
acute abdominal pain, the nurse should:
a. perform deep palpation before appendix and compressing venous outflow
auscultation drainage. The pressure continues to rise with
venous obstruction; arterial blood flow then
b. obtain blood pressure and pulse rate to
determine hypervolemic changes
perfusion. Inflammation and bacterial
c. auscultate bowel sounds because growth follow, and swelling continues to raise
hyperactive bowel sounds suggest paralytic pressure within the appendix, resulting in
ileus gangrene and rupture. Geriatric, not middle-
aged, clients are especially susceptible to
d. measure body temperature because an appendix rupture.
elevated temperature may indicate an
inflammatory or infectious process. 68. A client complains of severe pain in the
right lower quadrant of the abdomen. To
RATIO: for the patient complaining of acute assist with pain relief, the nurse should take
abdominal pain, nurse should take vital signs which of the following actions? "
immediately. Increased pulse and
decreasing blood pressure are indicative of 1. Encourage the client to change positions
hypovolemia. An elevated temperature frequently in bed
suggests an inflammatory infectious process.
2. Massage the right lower quadrant fo the
Intake and output measurements provide
abdomen
essential information about the adequate of
vascular volume. Inspect abdomen first and 3. Apply warmth to the abdomen with a
then auscultate bowel sounds. Palpation is heating pad
performed next and should be gentle.
4. Use comfort measures and pillows to
67. When preparing a male client, age 51, for position the client"
surgery to treat appendicitis, the nurse
RATIO: "1. ""Encourage the client..."" -
unnecesary movement will increase pain
and should be avoided
for choosing this nursing diagnosis?" 2. ""Massage the lower..."" - if appendicitis is
suspected, massorge or palpation should
never be performed as thes actions may
cause the appendix to rupture
rupture.
3. ""Apply warmth..."" - if pain is casused by
appendicitis, increased circulation from the
heat may cause appendix to rupture
inflammation, and rupture of the appendix.
4. ""Use comfort measures..."" - CORRECT: 72. "A nurse is caring for a client admitted to
non-pharmacological methods of pain relief" the hospital with a suspected diagnosis of
acute appendicitis. Which of the following
laboratory results would the nurse expect to
note if the client does have appendicitis?
infection related to inflammation, 1. Leukopenia with a shift to the right
2. Leukocytosis with a shift to the right
for choosing this nursing diagnosis?
3.Leukocytosis with a shift to the left
venous drainage and cause the appendix to 4. Leukopenia with a shift to the left"
rupture.
73. The nurse is monitoring a client admitted
b. Obstruction of the appendix reduces to the hospital with a dx of appendicitis who
arterial flow, leading to ischemia, is scheduled for surgery in 2 hours. The client
inflammation, and rupture of the appendix. begins to complain of increased abdominal
pain and begins to vomit. On assessment, the
nurse notes that the abdomen is distended
and bowel sounds are diminished. Which is
d. Infection of the appendix diminishes appropriate nursing intervention?
A. Notify the physician
venous drainage."
B. Administer the prescribe pain medication
70. "A client is admitted with a diagnosis of
acute appendicitis. When assessing the C. Call and ask the operating room team to
abdomen, the nurse would expect to find perform the surgery as soon as possible
rebound tenderness at which location?
D. Reposition the client and apply a heating
A) Left lower quadrant pad on warm setting to the clients abdomen"
B) Left upper quadrant 74. The health-care provider should be
notified when the nurse has the needed
C) Right upper quadrant
information. An 18 yr old is admitted with an
D) Right lower quadrant" acute onset of right lower quadrant pain.
Appendicitis is suspected. For which clinical
71. A client is admitted with complaints of
indicator should the nurse assess the client to
severe pain in the lower right quadrant of the
determine if the pain is secondary to
abdomen. To assist with pain relief, the nurse
appendicitis
should take which of the following actions?
A) urinary retention
1. Encourage the patient to change positions
frequently. B) gastric hyperacidity
2. Administer Demerol 50 mg IM q4hrs and C) rebound tenderness

PRN.
D) increased lower bowel motility
3. Apply warmth to abdomen with a heating
RATIO: rebound tenderness is a classic
pad.
subjective sign of appendicitis
4. Use comfort measures and pillows to
position the patient.
"1. Contact the surgeon to request an order
for a narcotic for the pain.
75. "The health care team is assessing a
patient for acute pancreatitis after he 2. Maintain the client in a recumbent
presented to the emergency department position.
with severe abdominal pain. Which
3. Place the client on nothing-by-mouth
laboratory value is the best diagnostic
(NPO) status.
indicator of acute pancreatitis?
4. Apply heat to the abdomen in the area of
A. Gastric pH
the pain."
B. Blood glucose
78. "A client with appendicitis is experiencing
C. Serum amylase excruciating abdominal pain. An abdominal
X-ray film reveals intraperitoneal air. The
D. Serum potassium
nurse should prepare the client for:
RATIO: Serum amylase levels indicate
a) colonoscopy.
pancreatic function, and they are used to
diagnose acute pancreatitis. Blood glucose, b) surgery.
gastric pH, and potassium levels are not
c) nasogastric (NG) tube insertion.
direct indicators of acute pancreatic
dysfunction. d) barium enema."
76. Which client requires immediate nursing RATIO: The client should be prepared for
intervention? "The client who: surgery because his signs and symptoms
indicate bowel perforation. Appendicitis is
a) complains of epigastric pain after eating.
the most common cause of bowel
b) complains of anorexia and periumbilical perforation in the United States. Because
pain. perforation can lead to peritonitis and sepsis,
surgery wouldn't be delayed to perform
c) presents with ribbonlike stools.
other interventions, such as colonoscopy, NG
d) presents with a rigid, boardlike abdomen. tube insertion, or a barium enema. These
procedures aren't necessary at this point."
RATIO: A rigid, boardlike abdomen is a sign of
peritonitis, a possibly life-threatening 79. A client has surgery for a perforated
condition. Epigastric pain occurring 90 appendix with localized peritonis. In which
minutes to 3 hours after eating indicates a position should the nurse place the client?
duodenal ulcer. Anorexia and periumbilical
A) Sims position
pain are characteristic of appendicitis. Risk of
rupture is minimal within the first 24 hours, but B) trendelenburg
increases significantly after 48 hours. A client
C) semi-fowlers
with a large-bowel obstruction may have
ribbonlike stools. D)dorsal recumbant
77. "The nurse is admitting a client with acute RATIO: Semi-fowlers aids in drainage and
appendicitis to the emergency department. prevents spread of infection throughout the
The client has abdominal pain of 10 on a pain abodominal cavity.
scale of 1 to 10. The client will be going to
surgery as soon as possible. The nurse should:
79. A nurse is making a home health visit and RATIO: Monitor for peritonitis because if the
finds the client experiencing right lower appendix ruptures, bacteria can enter the
quadrant abdominal pain, which has peritoneum. Pain will be managed with
decreased in intensity over the last day. The analgesics, and pt should be NPO for surgery.
client also has a rigid abdomen and a Discharge is not done at this time
temperature of 103.6 F. The nurse should
82. A client with complaints of right lower
intervene by:
quadrant pain is admitted to the emergency
a) administer Tylenol (acetaminophen) for department. Blood specimens are drawn
the elevated temperature and sent to the laboratory. Which laboratory
finding should be reported to the physician
b) advising the client to increase oral fluids
immediately?
c) asking the client when she last had a
a) Hematocrit 42%
bowel movement
b) Serum potassium 4.2 mEq/L
d) notifying the physician
c) Serum sodium 135 mEq/L
RATIO: The client symptoms indicate
appendicitis which requires immediate d) White blood cell (WBC) count 22.8/mm3.
attention
RATIO: The nurse should report the elevated
80. The nurse is admitting a client with the WBC count. This finding, which is a sign of
diagnosis of appendicitis to the surgical unit. infection, indicates that the client's appendix
Which question is essential to ask? might have ruptured. Hematocrit of 42%,
serum potassium of 4.2 mEq/L, and serum
A."When did you last eat?"
sodium of 135 mEq/L are within normal limits.
B."Have you had surgery before?" Alterations in these levels don't indicate
appendicitis."
C."Have you ever had this type of pain
before?" 83. The doctor ordered for a complete blood
count. After the test, Nurse Ray received the
D."What do you usually take to relieve your result from the laboratory. Which laboratory
pain?" values will confirm the diagnosis of
appendicitis?
RATIO: When a person is admitted with
possible appendicitis, the nurse should a. RBC 5.5 x 106/mm3
anticipate surgery. It will be important to
know when she last ate when considering the b. Hct 44 %
type of anesthesia so that the chance of
c. WBC 13, 000/mm3
aspiration can be minimized. The other
inoformation is "nice to know", but not d. Hgb 15 g/dL"
essential.
RATIO: "Rationale: Increase in WBC counts is
81. Which of the nursing interventions should suggestive of appendicitis because of
be implemented to manage appendicitis? bacterial invasion and inflammation. Normal
WBC count is 5, 000 - 10, 000/mm3. Other
a. Assess pain
options are normal values."
b. encourage oral intake of clear fluids.
c. provide discharge teaching
D. assess for symptoms of peritonitis.

84. A client has an appendectomy. This is an 87. A nurse is caring for a child who had a
example of what kind of surgery? laproscopic appendectomy. What
interventions should the nurse document on
a. Diagnostic
the child's clinical record? Select all that
b. palliative apply.
c. ablative 1) Intake and Output
d. constructive 2) Measurement of Pain
RATIO: Appendectomy is an example of 3) Tolerance to low-residue diet

ablative surgery. Diagnostic confirms or
4) Frequency of dressing changes
establishes a diagnosis, palliative relieves or
reduces pain, and constructive restores 5) Auscultation of bowel sounds
function or appearance.
RATIO:
85. A school-aged child has an emergency
1) Assessment and documentation of fluid
appendectomy. The nurse should report
balance are critical aspects of all
which of the following to the HCP if notes in
postoperative care.
the immediate postoperative period.
2) Laparoscopic surgery involves insufflating
1. abdominal pain,
the abdominal cavity with air, which is painful
2. tugging at the incision line, until it is absorbed. The amount of pain should
be measured and documented with either a
3. thirst,
1-10 scale or the Wong's FACES for younger
4 a rigid abdomen children.
RATIO: A tense, rigid abdomen is an early 3) A special diet is not indicated after this
symptom of peritonitis. The other findings are surgery.
expected in the immediate postoperative
4) After a laparoscopic appendectomy
period.
there is little drainage and no dressings.
86. "A client has an appendectomy and
5) Auscultating for bowel sounds and
develops peritonitis. The nurse should asses
documenting their presennce or absence
the client for an elevated temperature and
evaluate the child's adaptation to the
which additional clinical indication
intestinal trauma caused by the surgery.
commonly associated with peritonitis?
88. The nurse is assessing an adolescent who
1. hyperactivity
is admitted to the hospital with appendicitis.
2. extreme hunger The nurse should report which of the following
to the HCP?
3. urinary retention
1) change in pain rating of 7 to 8 on a 10
4. local muscular rigidity point scale.
RATIO: muscular rigidity over the affected 2) sudden relief of sharp pain, shifting to
area is a classic sign of peritonitis diffuse pain.
3)shallow breathing with normal vital signs.
4) decrease of pain rating from 8 to 6 when

parents visit.
RATIO: The nurse notifies the HCP if the client d. Measure body temperature because an
has sudden relief of sharp pain and on elevated temperature may indicate an
presence of more diffuse pain. this change in inflammatory or infectious process"
the pain indicates the appendix has
RATIO: For the patient complaining of acute
ruprured. The diffuse pain is typically
abdominal pain, the nurse should take vital
accompanied by rigid guarding of the
signs immediately. Increased pulse and
abdomen, progressive abdominal distension,
decreasing blood pressure (BP) are
tachycardia, pallor, chills, and irritability. The
indicative of hypovolemia. An elevated
slight increase pain can be expected; the
temperature suggests an inflammatory or
decrease in pain when parents visit may be
infectious process. Intake and output
attributed to being distracted from the pain.
measurements provide essential information
shallow breathing is likely due to the pain and
about the adequacy of vascular volume.
is insignificant when other vital signs are
Inspect the abdomen first and then
normal
auscultate bowel sounds. Palpation is
89. Bobby, a 13 year old is being seen in the performed next and should be gentle."
emergency room for possible appendicitis.
91. "A nurse is providing wound care to a
An important nursing action to perform when
client 1 day after the client underwent an
preparing Bobby for an appendectomy is to:
appendectomy. A drain was inserted into the
a) administer saline enemas to cleanse the incisional site during surgery. Which action
bowels should the nurse perform when providing
wound care?
b) apply heat to reduce pain
1. Remove the dressing and leave the
c) measure abdominal girth
incision open to air. 2. Remove the drain if
d) continuously monitor pain wound drainage is minimal.
RATIO: Pain is closely monitored in 3. Gently irrigate the drain to remove

appendicitis. In most cases, pain medication exudate.
is not given until prior to surgery or until the
4. Clean the area around the drain moving
diagnosis is confirmed to be able to closely
away from the drain.
monitor the progression of the disease. A
sudden change in the character of pain may RATIO: The nurse should gently clean the
indicate rupture or bowel perforation. area around the drain by moving in a circular
Administering an enema or applying heat motion away from the drain. Doing so
may cause perforation and abdominal girth prevents the introduction of microorganisms
may not change with appendicitis. to the wound and drain site. The incision
cannot be left open to air as long as the drain
90. "During the assessment of a patient with
is intact. The nurse should note the amount
acute abdominal pain, the nurse should:
and character of wound drainage, but the
a. Perform deep palpation before surgeon will determine when the drain should
ascultation be removed. Surgical wound drains are not
irrigated.
b. Obtain blood pressure and pulse rate to
determine hypervolemic changes
c. Ascultate bowel sounds because

hyperactive bowel sounds suggest paralytic
ileus
92. which statement made by the client who likely not order narcotic medication prior to
is postoperative abdominal surgery indicates surgery. The nurse can place the client in a
the discharge teaching has been effective? position that is most comfortable for the
client. Heat is contraindicated because it
1. "i will take my temp each week and report
may lead to perforation of the appendix
any elevation."
94. Which of the following would confirm a
2. "i will not need any pain meds when i go
diagnosis of appendicitis?
home."
a. The pain is localized at a position halfway
3. i will take all of my antibiotics until they are
between the umbilicus and the right iliac
gone."
crest.
4. i will not take a shower until my three month
b. Mr. Liu describes the pain as occurring 2
check up.
hours after eating
RATIO:
c. The pain subsides after eating
1. the client should check the temp twice a
d. The pain is in the left lower quadrant"
day.
RATIO: "Pain over McBurney's point, the point
2. it is not realistic to expect the client to
halfway between the umbilicus and the iliac
experience no pain after surgery.
crest, is diagnosis for appendicitis. Options b
3 (CORRECT): this statement about taking all and c are common with ulcers; option d may
the antibiotics ordered indicates the suggest ulcerative"
teaching is effective.
95. Which of the following would indicate that
4. clients may shower after surgery, but not Bobby's appendix has ruptured? "
taking a tub bath for three months after
a) diaphoresis
surgery is too long a time.
b) anorexia
93. The nurse is admitting a client with acute
appendicitis to the emergency department. c) pain at Mc Burney's point
The client has abdominal pain of 10 on a pain
d) relief from pain
scale of 1 to 10. The client will be going to
surgery as soon as possible. The nurse should: RATIO: all are normal signs of having
appendicits and once you have relief from
1. Contact the surgeon to request an order
pain means you could have a rupture.
for a narcotic for the pain.
96. Which of the following complications is
2. Maintain the client in a recumbent
thought to be the most common cause of
position.
appendicitis?
3. Place the client on nothing-by-mouth
a. A fecalith
(NPO) status.
b. Internal bowel occlusion
4. Apply heat to the abdomen in the area of
the pain." c. Bowel kinking
RATIO: The nurse should place the client on d. Abdominal wall swelling"
NPO status in anticipation of surgery. The
nurse can initiate pain relief strategies, such RATIO: A fecalith is a hard piece of stool
as relaxation techniques, but the surgeon will which is stone like that commonly obstructs
the lumen. Due to obstruction, inflammation
and bacterial invasion can occur. Tumors or
foreign bodies may also cause obstruction."
99. The nurse is caring for the following clients
97. The client with sever abdominal pain is on a surgical unit. Which client would the
being evaluated for appendicitis. What is the nurse assess first?
most common cause of appendicistis?
1.The client who had an inguinal hernia
http://nursing.slcc.edu/nclexrn3500/
repair and has not voided in four (4) hours.
1. Rupture of the appendix
2.The client who was admitted with
2.Obstruction of the appendix abdominal pain who suddenly has no pain.
3 A high-fat diet 3.The client four (4) hours postoperative

abdominal surgery with no bowel sounds.
4. A duodenal ulcer
4.The client who is one (1) day postoperative
RATIO: Appendicitis most commonly results
appendectomy who is being discharged"
from obstruction of the appendix, which may
lead to rupture. A high-fat diet or duodenal RATIO:
ulcer doesn't cause appendicitis; however, a
1. A client who has not voided within four (4)
client may require dietary restrictions after an
hours after any surgery would not be priority.
appendectomy
This is an acceptable occurrence, but if the
98. "A client with acute appendicitis client hasn't voided for eight (8) hours, then
develops a fever, tachycardia, and the nurse would assess further.
hypotension. Based on these assessment
2. This could indicate a ruptured appendix,
findings, the nurse should further assess the
which could lead to peritonitis, a life-
client for which of the following
threatening complication; therefore,
complications?"
thenurse should assess this client first.
1. Deficient fluid volume.
3. Bowel sounds should return within 24
2. Intestinal obstruction. hoursafter abdominal surgery. Absent bowel
soundsat four (4) hours postoperative would
3. Bowel ischemia.
not beof great concern to the nurse
4. Peritonitis.
4. The client being discharged would be
RATIO: Complications of acute appendicitis stableand not a priority for the nurse"
are perforation, peritonitis, and abscess
development. Signs of the development of
peritonitis include abdominal pain and 100. "The nurse is caring for a patient
distention, tachycardia, tachypnea, nausea, following an appendectomy. The patient
vomiting, and fever. Because peritonitis can takes a deep breath, coughs, and then
cause hypovolemic shock, hypotension can winces in pain. Which of the following
develop. Deficient fluid volume would not statements, if made by the nurse to the
cause a fever. Intestinal obstruction would patient, is BEST?
cause abdominal distention, diminished or
A.) "Take three deep breaths, hold your
absent bowel sounds, and abdominal paIn.
incision, and then cough."
Bowel ischemia has signs and symptoms
similar to those found with intestinal B.) "That was good. Do that again and soon
obstruction. it won't hurt as much."
C.) "It won't hurt as much if you hold your not to apply heat to the abdomen because
incision when you cough." heat could encourage the appendix to
rupture.
D.) "Take another deep breath, hold it, and
then cough deeply." 102. Which clinical manifestation does the
nurse expect with acute appendicitis?
RATIO:
A. High fever
(1) correct-most effective way of deep
breathing and coughing, dilates airway and B. Nausea and vomiting
expands lung surface area
C. Rebound tenderness
(2) should splint incision before coughing to
D. Pain relieved with ambulation
reduce discomfort and increase efficiency
RATIO: One manifestation of acute
(3) partial answer, should take three deep
appendicitis is localized and rebound
breaths before coughing
tenderness of McBurney point upon
(4) implies coughing routine is adequate, palpation. A high fever is a manifestation of
incision needs to be splinted" a perforated appendix. Nausea and
vomiting are generalized symptoms and are
101. A client telephones the health clinic
not present exclusively with appendicitis.
with complaints of generalized abdominal
Ambulation increases pain in appendicitis.
pain which is aggravated by moving or
walking. The client has not been able to eat 103. Which condition may occur if the client
for a day and is nauseated. Which advice does not seek medication attention for
should the nurse provide to this client? acute appendicitis within 24dash36 hours?
(Select all that apply.)
A. "Take a warm shower and apply a
heating pad to the abdomen." A. Seizure
B. "Rest in bed and drink warm fluids." B. Constipation
C. "Seek immediate medical attention." C. Nausea
D. "Take an over-the-counter laxative." D. Peritonitis
RATIO: The initial characteristic E. Perforation

manifestation of acute appendicitis is
RATIO: If treatment is not initiated, tissue
continuous, mild, generalized or upper
necrosis and gangrene result within 24-36
abdominal pain. Over the next 4 hours, the
hours, leading to perforation (rupture).
pain intensifies and localizes in the right
Perforation allows the contents of the
lower quadrant of the abdomen. Pain
gastrointestinal (GI) tract to flow into the
associated with appendicitis is aggravated
peritoneal space of the abdomen, resulting
by moving, walking, or coughing. If medical
in peritonitis. Appendicitis does not cause
attention is not provided, gangrene can
seizures, nausea, or constipation.
develop within 24dash36 hours. The client
should be instructed to seek immediate 104. A teenage boy presents with suspected
medical attention. Resting in bed and appendicitis. The caregiver asks, "Why did
drinking warm fluids is not going to prevent my son get this?" Which response by the
the appendix from developing gangrene. nurse is the most appropriate?
When appendicitis is suspected, the client
should be instructed to avoid laxatives and
A. "Your son has been eating too much such as fresh fruits and vegetables,
fiber." decreases the incidence of appendicitis.
B. "Your son is eating too many fruits and 107. Which assessment finding leads the
vegetables." nurse to suspect that an older client may
have appendicitis? (Select all that apply.)
C. "Your son has not been getting enough
exercise." A. Pain migrating from the lower left to the
upper right quadrant
D. "Your adolescent son is in a risk group."
B. Tenderness when pressing McBurney point
RATIO: Adolescent boys are at greatest risk
for appendicitis. Appendicitis cannot be C. Confusion
prevented, but certain dietary habits may
reduce the risk of developing this condition. D. No abdominal pain
Eating foods that contain high fiber content, E. Internal rotation of the left hip increases
such as fresh fruits and vegetables, pain
decreases the incidence of appendicitis.
RATIO: Fewer than 30% of older adults who
105. Appendicitis almost always results from have appendicitis present with classic
an obstruction in the appendiceal lumen. symptoms. Classic signs of acute
Which problem should the nurse identify as appendicitis are pain that is aggravated by
the cause of this obstruction? moving or walking, rebound tenderness of
A. Monolith McBurney point, and extension or internal
rotation of the right hip that increases pain
B. Fecalith and confusion. A little less than half
demonstrate no rebound or involuntary
C. Tonsillolith
guarding. Pain typically migrates down to
D. Ptyalith the lower right quadrant in appendicitis.
RATIO: The obstruction is often caused by a 108. A teenage girl is being assessed for the
hard mass of feces (fecalith). Ptyalith is a possibility of appendicitis. Which other
calculus in the salivary gland. Tonsillolith is a condition should the nurse consider? (Select
calculus in the tonsil. A monolith is a large all that apply.)
stone used in sculpture.
A. Pelvic inflammatory disease
106. Which statement by a client diagnosed
B. Ovulation
with acute appendicitis leads the nurse to
believe the client needs teaching about C. Menstruation
dietary interventions?
D. Urinary tract infection
A. "I eat raw vegetables for a snack several
days per week." E. Ruptured ectopic pregnancy
B. "I don't like fruits and vegetables." Answer: A, B, E
C. "I prefer to have meat with each meal." RATIO: In adolescent and young women,
symptoms must be differentiated from those
D. "I eat fruit with breakfast every day." associated with ovulation, ruptured ectopic
pregnancy and pelvic inflammatory
RATIO: Certain dietary habits may reduce
disease. Although a urinary tract infection
the risk of developing acute appendicitis.
may cause abdominal pain, it typically does
Eating foods that contain high fiber content,
not present in the same way as appendicitis. B. A low-fat, high-calorie diet
Menstruation does not have the same
C. Passive range of motion
symptoms as appendicitis.
D. Fluid resuscitation
109. Appendicitis in a pregnant woman is a
complex problem. Which statement is true E. Surgery
based on the given premise?
RATIO: Clinical therapies for the treatment of
A. Appendicitis is the most common surgical peritonitis include removal of the ruptured
presentation in pregnant women. appendix, antibiotics, and fluid resuscitation.
A low-fat, high-calorie diet and passive
B. Appendicitis does not occur in pregnant
range of motion are not therapies used to
women.
treat peritonitis after a ruptured appendix.
C. Appendicitis will cause fetal death.
112. The nurse is caring for a client admitted
D. A pregnant woman will have surgery for a ruptured appendix. Which information
postpartum. should the nurse expect to provide to this
client? (Select all that apply.)
RATIO: Acute appendicitis is the most
common surgical presentation in pregnant A. A laparotomy will be performed.
women. It can be successfully managed by
B. Intravenous fluids will be provided.
the surgical and obstetrical teams. A recent
study has found that appendicitis during C. Antibiotic medication will be provided
pregnancy can be managed successfully before and after the surgery.
without any dangerous fetal outcomes.
D. Pain medication will be provided after the
110. A client presents with suspected surgery.
appendicitis. The nurse should prepare the
client for which collaborative intervention? E. A laparoscopic appendectomy will be
performed.
A. Chest x-ray
RATIO: For a ruptured appendix, a
B. Abdominal ultrasound laparotomy will be performed. The client will
receive antibiotics before and after the
C. Electrolytes
surgery to prevent the development of
D. Complete blood count (CBC) infection from fecal contents, which have
spilled into the abdominal cavity.
RATIO: Abdominal ultrasound is the most
Intravenous fluids will be provided to
effective test for diagnosing acute
maintain fluid and electrolyte balance. Pain
appendicitis. Electrolyte testing provides
medication will be provided after the
information relating to the mineral balance
surgery. A laparoscopic appendectomy is
in the body. A CBC would be drawn, but it is
performed for clients whose appendix has
not a definitive test to diagnose acute
not ruptured.
appendicitis. Chest x-rays are not used to
diagnose abdominal conditions. 113. Which condition prompts the nurse to
recommend a clear liquid diet to a post
111. For which collaborative therapy for
appendectomy client?
peritonitis following a ruptured appendix
should the nurse prepare the client? (Select A. Client denies any nausea
all that apply.)
B. Client no longer reports pain
A. Antibiotics
C. Client is afebrile 116. A client with acute appendicitis asks
the nurse, "Why don't you give me a heating
D. Client's bowel sounds have returned
pad? I think that will help me with my pain."
RATIO: Once bowel sounds return, a client The nurse's response should be based on
can begin taking clear fluids. The which reason?
postoperative client is expected to be
A. It increases the need for fluids.
afebrile. Pain will subside as healing
continues. Nausea would be subsided for B. It increases the spread of infection.
the client to resume a PO diet, but it is the
C. It reduces white blood cell count.
presence of bowel sounds that would
indicate the gastrointestinal tract's ability to D. It encourages perforation.
handle digestion.
RATIO: Heat should not be applied to the
114. A client had a laparoscopic abdomen since this increases circulation to
appendectomy last night. Which assessment the appendix and could cause perforation.
finding should concern the nurse? It is not true that heat is avoided in acute
appendicitis because it increases the need
A. Dry wound
for fluids, increases the spread of infection,
B. Adequate fluid intake or reduces white blood cell count.
C. Pain 117. A client is admitted with acute

appendicitis. Which nursing diagnosis may
D. Fever
be appropriate for this client? (Select all that
RATIO: possible infection. Postoperative pain apply.)
is expected. Adequate fluid intake and a
A. Nutrition, Imbalanced: Less than Body
dry wound are positive recovery signs.
Requirements
115. For which intervention are African
B. Fluid Volume: Deficit, Risk for
American children with appendicitis less
likely to receive in the emergency C. Tissue Perfusion: Peripheral, Ineffective
department?
D. Infection, Risk for
A. IV fluids
E. Pain, Acute
B. Adequate pain medication
RATIO: A client with acute appendicitis
C. Postoperative teaching would experience pain at the site. Any
patient who has undergone surgery is at risk
D. Surgical intervention
for fluid depletion and infection of the
RATIO: African American children are less wound. Nutritional status and change in
likely to receive adequate medication in peripheral perfusion are not nursing
emergency departments for pain during problems appropriate for the client with
episodes of appendicitis. Nurses should appendicitis.
advocate for appropriate pain
118. The nurse is providing discharge
management for all clients.
teaching to a client who is recovering from
an uncomplicated appendectomy. Which
information should the nurse include?
A. Caring for the wound

B. Recognizing manifestations of infection need for more pain medication and
ingesting a less-than-nutritious snack.
C. Increasing physical activity
120.The nurse is preparing to conduct a
D. Notifying the healthcare provider with
physical examination on a client diagnosed
changes
with appendicitis. Which intervention should
E. Avoiding nonsteroidal anti-inflammatory the nurse include in this assessment? (Select
drugs (NSAID) all that apply.)
RATIO: The client with uncomplicated A. Characteristics of bowel sounds

appendectomy is often discharged home
B. Presence of abdominal pain on palpation
the day of the surgery or the day after.
Postoperative teaching includes wound C. Presence of blood in the stool
care, including hand hygiene and dressing
D. Contour of the abdomen
changes as indicated; to report to the
healthcare provider fever, increased E. Current body temperature
abdominal pain, swelling, redness,
drainage, bleeding, or warmth of the RATIO: When conducting the physical
operative site; activity limitations (e.g., assessment on a client with appendicitis, the
lifting); and return to work if appropriate. The nurse should include abdominal contour,
client can take NSAIDs for pain. current body temperature, characteristics of
bowel sounds, and whether the client is
119. The nurse is evaluating a client experiencing tenderness to light palpation.
recovering at home after an emergency Blood in the stool is not an area to assess in
appendectomy. Which observation the client with appendicitis.
indicates that self-care has been effective?
(Select all that apply.) 121. A 16-year-old presents at the
emergency department complaining of right
A. The client snacks on pretzels and club lower quadrant pain and is subsequently
soda during the visit. diagnosed with appendicitis. When planning
this patients nursing care, the nurse should
B. The client plans to recover at home until
prioritize what nursing diagnosis?
cleared by the surgeon.
A) Imbalanced Nutrition: Less Than Body
C. The client uses a pillow to splint the
Requirements Related to Decreased Oral
incision before coughing.
Intake
D. The client performs abdominal wound
B) Risk for Infection Related to Possible
care appropriately.
Rupture of Appendix
E. The client requests a prescription for more
C) Constipation Related to Decreased
pain medication.
Bowel Motility and Decreased Fluid Intake
RATIO: Observations that indicate that the
D) Chronic Pain Related to Appendicitis
client is appropriately providing self-care
after an appendectomy include using a Ans: B
pillow to splint the incision before coughing,
performing wound care appropriately, and Feedback:
planning to recover at home until cleared
The patient with a diagnosis of appendicitis
by the surgeon. Observations that indicate
has an acute risk of infection related to the
that self-care could improve include the
possibility of rupture. This immediate
physiologic risk is a priority over nutrition and
constipation, though each of these concerns
1. Presence of abdominal pain on palpation
should be addressed by the nurse. The pain
associated with appendicitis is acute, not 2. Contour of the abdomen
chronic.
3. Characteristics of bowel sounds
122. The nurse is evaluating teaching
provided to a client with chronic 4. Current body temperature
appendicitis. Which observation indicates
RATIO: When conducting the physical
that teaching has been effective?
assessment on a client with appendicitis, the
Client eats fruit with breakfast and a salad for nurse should include abdominal contour,
lunch current body temperature, characteristics of
bowel sounds, and whether the client is
RATIO: Chronic appendicitis has periods of experiencing tenderness to light palpation.
exacerbation. Ingesting foods with high fiber Blood in the stool is not an area to assess in
content, such as fresh fruits and vegetables, the client with appendicitis.
can help to decrease the incidence of
fecaliths and subsequent bouts of acute 125. A 16-year-old female client is brought to
appendicitis. Exercise, sleep, and social the emergency department experiencing
activities will not help reduce the risk of severe right lower quadrant abdominal pain.
developing acute appendicitis. In addition to appendicitis, which other
health problems will the nurse also assess for
123. A client with severe right lower quadrant during the examination?
abdominal pain says that the pain has
suddenly stopped. Which nursing
interventions are appropriate for this client?
1. Ectopic Pregnancy
2. Mittelschmerz (one sided, lower

1. Anticipate IV fluid administration abdominal pain associated with ovulation)
2. Notify the physician 3. Pelvic Inflammatory disease
3. Expect orders for IV antibiotics RATIO: In adolescent and young adult

females, the symptoms of appendicitis must
4. Prepare the client for surgery be differentiated from the pain of ovulation
or mittelschmerz, possible ruptured ectopic
RATIO: A sudden reduction in abdominal
pregnancy, and pelvic inflammatory
pain in appendicitis could indicate that the
disease. A fecalith is one cause for
appendix has ruptured. The nurse needs to
appendicitis. A kidney stone will not cause
anticipate care for a ruptured appendix and
severe right lower quadrant abdominal pain.
potential peritonitis by notifying the
physician, preparing the client for surgery to 126. The nurse is identifying goals of care with
remove the appendix, expecting a client seeking treatment for appendicitis.
intravenous antibiotics to be prescribed, and Which outcomes are appropriate for the
expect intravenous fluids to be prescribed for nurse to include in the plan of care?
fluid resuscitation.
1. Abdominal pain will be relieved with pain
124. The nurse is preparing to conduct a meds
physical examination on a client
experiencing vague abdominal pain. What 2. The abdominal wound will heal without
should the nurse include in this assessment? infection
3. Questions about surgical procedure will be
maintained
4. Fluid and electrolyte balance will be

maintained.
RATIO: Goals of care for a client with

appendicitis should focus on treatment
approaches and the client's response. For
appendicitis, surgery will most likely be
performed, so goals should focus on
answering questions about the surgical
procedure, healing of the wound without
infection, maintaining fluid and electrolyte
balance, and relieving abdominal pain with
medication. Perfusion status is not a priority
problem for the client with appendicitis.
127. The nurse is caring for a client is admitted

for a burst appendix. Which information is
appropriate for the nurse to provide to this
client?
1. a laparotomy will be performed
2. Antibiotic medication will be provided

before and after the surgery
3. IV fluids will be provided
4. Pain meds will be provided after surgery
RATIO: For a burst appendix, a laparotomy

will be performed. The client will receive
antibiotics before and after the surgery to
prevent the development of infection from
fecal contents, which have spilled into the
abdominal cavity. Intravenous fluids will be
provided to maintain fluid and electrolyte
balance. Pain medication will be provided
after the surgery.
PEPTIC ULCER 3. You're educating a group of patients at an
1. In the stomach lining, the parietal cells outpatient clinic about peptic ulcer
release _________ and the chief cells release formation. Which statement is correct about
__________ which both play a role in peptic how peptic ulcers form?
ulcer disease.
 A. "An increase in gastric acid is the
 A. pepsin, hydrochloric acid sole cause of peptic ulcer formation."
 B. pepsinogen, pepsin  B. "Peptic ulcers can form when acid

penetrates unprotected stomach
 C. pepsinogen, gastric acid mucosa. This causes histamine to be
released which signals to the parietal
 D. hydrochloric acid, and
cells to release more hydrochloric
acid which erodes the stomach lining
pepsinogen
The answer is D. In the stomach lining, the further."
parietal cells release HYDROCHLORIC ACID
 C. "Peptic ulcers form when acid
and the chief cells release PEPSINOGEN
penetrates unprotected stomach
which both plays a role in peptic ulcer
mucosa. This causes pepsin to be
disease. Pepsinogen then mixes with the
released which signals to the parietal
hydrochloric acid and turns into pepsin.
cells to release more pepsinogen
which erodes the stomach lining
further."
2. A patient has developed a duodenal ulcer.
 D. "The release of prostaglandins
As the nurse, you know that which of the
cause the stomach lining to
following plays a role in peptic ulcer
breakdown which allows ulcers to
formation. Select ALL that apply:
form."
The answer is B. Ulcers form when acid
 A. Spicy foods penetrates unprotected stomach mucosa.
This causes histamine to be released which
signals to the parietal cells to release more
 B. Helicobacter pylori hydrochloric acid which erodes the stomach
lining further
 C. NSAIDs 4. Your patient is diagnosed with peptic ulcer

 D. Milk disease due to h.pylori. This bacterium has a
unique shape which allows it to penetrate the
stomach mucosa. You know this bacterium
 E. Zollinger-Ellison Syndrome is:
The answers are B, C, and E. Helicobacter
 A. Rod shaped
pylori and NSAIDS are the most common
causes for peptic ulcer formation. Zollinger-  B. Spherical shaped
Ellison Syndrome can cause peptic ulcers but
it is not as common as H. pylori or NSAIDS.
Foods and stress are no longer thought to  C. Spiral shaped
cause ulcers. Certain foods and stress can
 D. Filamentous shaped
irritate ulcers or prolong healing but there is
no evidence to suggest they cause them. The answer is C. Helicobacter pylori (h. pylori)
are spiral shaped which all them to
penetrate down into the stomach lining to
reside.  A. Duodenal
 B. Gastric
5. Helicobacter pylori can live in the  C. Esophageal

stomach's acidic conditions because it  D. Refractory
secretes ___________which neutralizes the
acid. The answer is A. The patient signs and
symptoms describe a duodenal ulcer.
 A. ammonia Gastric ulcer tend to not cause pain in the
middle of the night and epigastric pain in
worst with food.
 B. urease
 C. carbon dioxide
8. A patient with chronic peptic ulcer disease
 D. bicarbonate
underwent a gastric resection 1 month ago
The answer is B. H. pylori can live in the acidic and is reporting nausea, bloating, and
conditions of the stomach because it diarrhea 30 minutes after eating. What
secretes urease which produces ammonia to condition is this patient most likely
neutralize the acid. experiencing?
 A. Gastroparesis
6. The physician orders a patient with a  B. Fascia dehiscence

duodenal ulcer to take a UREA breath test.
Which lab value will the test measure to
determine if h. pylori is present?  C. Dumping Syndrome
 D. Somogyi effect
 A. Ammonia
The answer is C. After a gastric resection the
 B. Urea stomach is not able to regulate the
movement of food due to the removal of
 C. Hydrochloric acid
sections of the stomach (usually the pyloric
valve and duodenum). Therefore, the food
 D. Carbon dioxide enters into the small intestine too fast before
the stomach can finish digesting it. The
The answer is D. If h. pylori are present, the partially digested food will act hypertonically
bacteria will release urease which produces and cause water from the blood to enter
ammonia and carbon dioxide. For the test, jejunum. This will cause a fluid shift leading to
the patient will ingest a urea tablet and bowel swelling, diarrhea, and nausea etc.
breath samples will be analyzed for carbon
dioxide levels.
7. A patient arrives to the clinic for evaluation 9. Thinking back to the patient in question 8,
of epigastric pain. The patient describes the select ALL the correct statements on how to
pain to be relieved by food intake. In educate this patient about decreasing their
addition, the patient reports awaking in the symptoms:
middle of the night with a gnawing pain in the
stomach. Based on the patient's description  A. "It is best to eat 3 large meals a day
this appears to be what type of peptic ulcer? rather than small frequent meals."
 B. "After eating a meal lie down for 30  A. "H2 blockers block histamine which
causes the chief cells to decrease the
minutes." secretion of hydrochloric acid."
 C. "Eat a diet high in protein, fiber, and  B. "Ranitidine and Famotidine are two
types of histamine-receptor blocker
low in carbs." medications."
 D. "Be sure to drink at least 16 oz. of milk  C. "Antacids and H2 blockers should
with meals." not be given together."
The answers are B and C. The patient in  D. All the statements are CORRECT.
question 8 is exhibiting signs and symptoms of The answer is A. This statement is false. H2
dumping syndrome. The patient should eat blockers block histamine which causes the
small but frequent meals (NOT 3 large meals PARTIETAL (not chief) cells to decrease the
a day), lie down for 30 minutes after meals, secretion of hydrochloric acid.
avoid sugary drinks and foods, and follow a
high protein, high fiber, and low-carb diet,
and avoid consuming drinks while eating but
afterwards. 12. You are providing discharge teaching to
a patient taking Sucralfate (Carafate). Which
statement by the patient demonstrates they
understand how to take this medication?
10. A patient is recovering from discomfort

 A. "I will take this medication at the
from a peptic ulcer. The doctor has ordered
same time I take Ranitidine."
to advance the patient’s diet to solid foods.
The patient's lunch tray arrives. Which food  B. "I will always take this medication on
should the patient avoid eating? an empty stomach."
 C. "It is best to take this medication with
 A. Orange
antacids."
 B. Milk
 D. "I will take this medication once a
 C. White rice week."
 D. Banana The answer is B. This statement is the only

correct statement about how to take
The answer is A. When an ulcer is actively Carafate. It should always be taken on an
causing signs and symptoms, the patient empty stomach without food so it can coat
should avoid acidic foods like tomatoes or the site of ulceration. This medication should
citric fruits/juices, chocolate, alcohol, fried NOT be taken with H2 blockers (Ranitidine) or
foods and caffeine. These foods can irritate antacids because these drugs affect the
the ulcer site. Instead the patient should absorption of Carafate.
consume alkalotic or bland foods like milk,
white rice or bananas.
13. Select all the medications a physician
may order to treat a H. Pylori infection that is
11. Which statement is INCORRECT about causing a peptic ulcer?
Histamine-receptor blockers?
 A. Proton-Pump Inhibitors
The answer is B. This patient is most likely
 B. Antacids experiencing an upper GI bleeding. Signs
and symptoms of a possible GI bleeding with
 C. Anticholinergics a peptic ulcer include: vomiting coffee
ground emesis along with bloating, and
abdominal mass.
 D. 5-Aminosalicylates
16. A nurse is caring for a patient who just has
been diagnosed with a peptic ulcer. When
 E. Antibiotics teaching the patient about his new diagnosis,
how should the nurse best describe a peptic
ulcer?
 F. H2 Blockers
A) Inflammation of the lining of the stomach
 G. Bismuth Subsalicylates B) Erosion of the lining of the stomach or

intestine
The answers are: A, E, F, and G. All these
medications can be used to treat an h. pylori C) Bleeding from the mucosa in the stomach
infection that is causing a peptic ulcer.
D) Viral invasion of the stomach wall
Ans: B
14. A physician prescribes a Proton-Pump Feedback:

Inhibitor to a patient with a gastric ulcer.
A peptic ulcer is erosion of the lining of the
Which medication is considered a PPI?
stomach or intestine. Peptic ulcers are often
accompanied by bleeding and inflammation,
but these are not the definitive characteristics.
 A. Pantoprazole
17. A patient comes to the clinic complaining
 B. Famotidine of pain in the epigastric region. What
 C. Magnesium Hydroxide assessment question during the health
interview would most help the nurse
 D. Metronidazole determine if the patient has a peptic ulcer?
The answer is A. Pantoprazole is the only PPI A) Does your pain resolve when you have
listed. Remember PPIs tend to end with the
something to eat?
letters "prazole".
B) Do over-the-counter pain medications
help your pain?
15. A patient with a peptic ulcer is suddenly C) Does your pain get worse if you get up
vomiting dark coffee ground emesis. On
and do some exercise?
assessment of the abdomen you find
bloating and an epigastric mass in the D) Do you find that your pain is worse when
abdomen. Which complication may this you need to have a bowel movement?
patient be experiencing?
Ans: A
 A. Obstruction of pylorus
Feedback:
 B. Upper gastrointestinal bleeding
Pain relief after eating is associated with
 C. Perforation duodenal ulcers. The pain of peptic ulcers is
generally unrelated to activity or bowel
 D. Peritonitis
function and may or may not respond to Ans: B
analgesics.
Feedback:
18. A patient with a diagnosis of peptic ulcer
Most peptic ulcers result from infection with
disease has just been prescribed
the gram-negative bacteria H. pylori, which
omeprazole (Prilosec). How should the nurse
may be acquired through ingestion of food
best describe this medications therapeutic
and water. The organism is endemic to all
action?
areas of the United States. Genetic factors
A) This medication will reduce the amount of have not been identified.
acid secreted in your stomach.
20. A patient presents to the walk-in clinic
Test Bank - Brunner & Suddarth's Textbook of complaining of vomiting and burning in her
Medical-Surgical Nursing 14e (Hinkle 2017) mid-epigastria. The nurse knows that in the
875 process of confirming peptic ulcer disease,
the physician is likely to order a diagnostic
B) This medication will make the lining of your
test to detect the presence of what?
stomach more resistant to damage.
A) Infection with Helicobacter pylori
C) This medication will specifically address
the pain that accompanies peptic ulcer Test Bank - Brunner & Suddarth's Textbook of
disease. Medical-Surgical Nursing 14e (Hinkle 2017)
879
D) This medication will help your stomach
lining to repair itself. B) Excessive stomach acid secretion
Ans: A C) An incompetent pyloric sphincter
Feedback: D) A metabolic acidbase imbalance
Proton pump inhibitors like Prilosec inhibit the Ans: A

synthesis of stomach acid. PPIs do not
Feedback:
increase the durability of the stomach lining,
relieve pain, or stimulate tissue repair. H. pylori infection may be determined by
endoscopy and histologic examination of a
19. A nurse is assessing a patient who has
tissue specimen obtained by biopsy, or a
peptic ulcer disease. The patient requests
rapid urease test of the biopsy specimen.
more information about the typical causes of
Excessive stomach acid secretion leads to
Helicobacter pylori infection. What would it
gastritis; however, peptic ulcers are caused
be appropriate for the nurse to instruct the
by colonization of the stomach by H. pylori.
patient?
Sphincter dysfunction and acidbase
A) Most affected patients acquired the imbalances do not cause peptic ulcer
infection during international travel. disease.
B) Infection typically occurs due to ingestion 21. A patient with a peptic ulcer disease has
of contaminated food and water. had metronidazole (Flagyl) added to his
current medication regimen. What health
C) Many people possess genetic factors
education related to this medication should
causing a predisposition to H. pylori infection.
the nurse provide?
D) The H. pylori microorganism is endemic in
A) Take the medication on an empty
warm, moist climates.
stomach.
B) Take up to one extra dose per day if (Cytotec). What would the nurse be most
stomach pain persists. accurate in informing the patient about the
drug?
C) Take at bedtime to mitigate the effects of
drowsiness. A) It reduces the stomachs volume of
hydrochloric acid
D) Avoid drinking alcohol while taking the
drug. B) It increases the speed of gastric emptying
Ans: D C) It protects the stomachs lining
Feedback: D) It increases lower esophageal sphincter

pressure
Alcohol must be avoided when taking Flagyl
and the medication should be taken with Ans: C
food. This drug does not cause drowsiness
Feedback:
and the dose should not be adjusted by the
patient. Misoprostol is a synthetic prostaglandin that,
like prostaglandin, protects the gastric
mucosa. NSAIDs decrease prostaglandin
22. A patient is receiving education about his production and predispose the patient to
upcoming Billroth I procedure peptic ulceration. Misoprostol does not
(gastroduodenostomy). This patient should reduce gastric acidity, improve emptying of
be informed that he may experience which the stomach, or increase lower esophageal
of the following adverse effects associated sphincter pressure.
with this procedure?
24. Diagnostic imaging and physical
A) Persistent feelings of hunger and thirst assessment have revealed that a patient with
peptic ulcer disease has suffered a
B) Constipation or bowel incontinence
perforated ulcer. The nurse recognizes that
C) Diarrhea and feelings of fullness emergency interventions must be performed
as soon as possible in order to prevent the
D) Gastric reflux and belching development of what complication?
Ans: C A) Peritonitis
Feedback: B) Gastritis
Following a Billroth I, the patient may have C) Gastroesophageal reflux
problems with feelings of fullness, dumping
syndrome, and diarrhea. Hunger and thirst, D) Acute pancreatitis
constipation, and gastric reflux are not
Ans: A
adverse effects associated with this
procedure. Feedback:
Perforation is the erosion of the ulcer through

23. A nurse is providing patient education for the gastric serosa into the peritoneal cavity
a patient with peptic ulcer disease without warning. Chemical peritonitis
secondary to chronic nonsteroidal anti- develops within a few hours of perforation
inflammatory drug (NSAID) use. The patient and is followed by bacterial peritonitis.
has recently been prescribed misoprostol Gastritis, reflux, and pancreatitis are not
acute complications of a perforated ulcer.
25. A patient has been diagnosed with peptic 28. When HP is the cause of PUD, the ulcer
ulcer disease and the nurse is reviewing his disease can be eradicated with
prescribed medication regimen with him.
A. Treatment
What is currently the most commonly used
drug regimen for peptic ulcers? B. Medicine
A) Bismuth salts, antivirals, and histamine-2 C. Meditation
(H2) antagonists
D. None
B) H2 antagonists, antibiotics, and
bicarbonate salts 29. The lifetime risk of ulcer disease is
C) Bicarbonate salts, antibiotics, and ZES A. 40 to 50 percent
D) Antibiotics, proton pump inhibitors, and B. 30 to 40 percent

bismuth salts
C. 5 to 10 percent
Ans: D
D. 10 to 30 percent
Feedback:
30. Both gastric ulcers and H.pylori infection
Currently, the most commonly used therapy are highly associated with _________.
for peptic ulcers is a combination of
A. C. Diff
antibiotics, proton pump inhibitors, and
bismuth salts that suppress or eradicate H. B. Gastric malignancy
pylori. H2 receptor antagonists are used to
treat NSAID-induced ulcers and other ulcers C. Uveitis
not associated with H. pylori infection, but D. Esophageal Neoplasms
they are not the drug of choice. Bicarbonate
salts are not used. ZES is the Zollinger-Ellison 31. Ulcerations typically occur in regions
syndrome and not a drug. bathed with acid/pepsin, such as the
26. Which of the following is NOT a causative A. Jejunum

agent for a peptic ulcer?
B. Cecum
A. NSAIDS
C. Duodenum
B. Helicobactor pylori
D. McBurney's point
C. Physiological Stress
32. What often describes the pain of PUD?
D. Augmentin
A. Sharp, knife-like. Radiates to the right
27. What are the complications of a Peptic shoulder
Ulcer?
B. Dull, achy. Localized to the stomach.
A. Barrett's
C. Diffuse, joint arthralgia.
B. GI bleedPerforation
D. Burning or gnawing. Radiates to the back.
C. Dysphagia
33. Complications of PUD include bleeding,
D. A & D perforation, and penetration. 1.) Bleeding
typically manifests as _________________. 2.)
E. B & C
PUD is the most common cause of stomach pain should be assessed first by the
nonhemorrhagic GI bleeds/ nurse. The sudden onset of stomach pain
could be indicative of a perforated ulcer,
A. Melena
which would require immediate medical
B. Clots attention. It is also important for the nurse to
thoroughly assess the nature of the client's
C. Coffee Grounds pain. The client with the fractured jaw is
experiencing pain and should be assessed
D. Loose, runny stools
next. The nurse should then assess the client
34. What is best used for detecting small or who is NPO for tests to ensure NPO status and
healing ulcers? comfort. Last, the nurse can assess the client
before surgery.
A. Endoscopy
37. The nurse is caring for a client who has just
B. Barium had an upper GI endoscopy. The client's vital
C. Radiography signs must be taken every 30 minutes for 2
hours after the procedure. The nurse assigns
D. Urea Breath Test an unlicensed nursing personnel (UAP) to
take the vital signs. One hour later, the UAP
E. Abdominal CT
reports the client, who was previously
35. What is the treatment for PUD in addition afebrile, has developed a temperature of
to discontinuing irritating factors? 101.8 ° F (38.8 ° C). What should the nurse do
in response to this reported assessment data?
A. PPI
1. Promptly assess the client for potential
B. Amoxicillin perforation.
C. Bismuth subsalicylate plus tetracycline 2. Tell the assistant to change thermometers
D. Combination therapy and retake the temperature.
36. The nurse has been assigned to provide 3. Plan to give the client acetaminophen
care for four clients at the beginning of the (Tylenol) to lower the temperature.
day shift. In what order should the nurse 4. Ask the assistant to bathe the client with
assess these clients? tepid water.
1. The client awaiting hiatal hernia repair at RATIO: A sudden spike in temperature
11 am. following an endoscopic procedure may
2. A client with suspected gastric cancer who indicate perforation of the GI tract. The nurse
is on nothing-by-mouth (NPO) status for tests. should promptly conduct a further
assessment of the client, looking for further
3. A client with peptic ulcer disease indicators of perforation, such as a sudden
experiencing sudden onset of acute onset of acute upper abdominal pain; a
stomach pain. rigid, boardlike abdomen; and developing
signs of shock. Telling the assistant to change
4. A client who is requesting pain medication
thermometers is not an appropriate action
2 days after surgery to repair a fractured jaw.
and only further delays the appropriate
3, 4, 2, 1 action of assessing the client. The nurse
would not administer acetaminophen
RATIO: The client with peptic ulcer disease without further assessment of the client or
who is experiencing a sudden onset of acute without a physician's order; a suspected
perforation would require that the client be are most likely to complain of a burning
placed on nothing-by-mouth status. Asking epigastric pain that occurs about 1 hour after
the assistant to bathe the client before any eating. Eating frequently aggravates the
assessment by the nurse is inappropriate. pain. Clients with duodenal ulcers are more
likely to complain about pain that occurs
38. A client is admitted to the hospital after
during the night and is frequently relieved by
vomiting bright red blood and is diagnosed
eating.
with a bleeding duodenal ulcer. The client
develops a sudden, sharp pain in the 40. The nurse is caring for a client who has
midepigastric region along with a rigid, had a gastroscopy. Which of the following
boardlike abdomen. These clinical signs and symptoms may indicate that the
manifestations most likely indicate which of client is developing a complication related
the following? to the procedure? Select all that apply.
1. An intestinal obstruction has developed. 1. The client has a sore throat.
2. Additional ulcers have developed. 2. The client has a temperature of 100 ° F (37.8
° C).
3. The esophagus has become inflamed.
3. The client appears drowsy following the
4. The ulcer has perforated.
procedure.
RATIO: The body reacts to perforation of an
4. The client has epigastric pain.
ulcer by immobilizing the area as much as
possible. This results in boardlike abdominal 5. The client experiences hematemesis.
rigidity, usually with extreme pain. Perforation
RATIO: Following a gastroscopy, the nurse
is a medical emergency requiring immediate
should monitor the client for complications,
surgical intervention because peritonitis
which include perforation and the potential
develops quickly after perforation. An
for aspiration. An elevated temperature,
intestinal obstruction would not cause
complaints of epigastric pain, or the vomiting
midepigastric pain. The development of
of blood (hematemesis) are all indications of
additional ulcers or esophageal
a possible perforation and should be
inflammation would not cause a rigid,
reported promptly. A sore throat is a
boardlike abdomen.
common occurrence following a
39. When obtaining a nursing history on a gastroscopy. Clients are usually sedated to
client with a suspected gastric ulcer, which decrease anxiety and the nurse would
signs and symptoms should the nurse expect anticipate that the client will be drowsy
to assess? Select all that apply. following the procedure.
1. Epigastric pain at night. 41. A client with peptic ulcer disease tells the
nurse that he has black stools, which he has
2. Relief of epigastric pain after eating.
not reported to his physician. Based on this
3. Vomiting. information, which nursing diagnosis would
be appropriate for this client?
4. Weight loss.
1. Ineffective coping related to fear of
5. Melena. diagnosis of chronic illness.
RATIO: Vomiting and weight loss are 2. Deficient knowledge related to
common with gastric ulcers. The client may unfamiliarity with significant signs and
also have blood in the stools (melena) from symptoms.
gastric bleeding. Clients with a gastric ulcer
3. Constipation related to decreased gastric 5. Stay away from crowded areas.
motility.
RATIO: The nurse should encourage the client
4. Imbalanced nutrition: Less than body to reduce stimulation that may enhance
requirements related to gastric bleeding. gastric secretion. The nurse can also advise
the client to utilize health practices that will
RATIO: Black, tarry stools are an important
prevent recurrences of ulcer pain, such as
warning sign of bleeding in peptic ulcer
avoiding fatigue and elimination of smoking.
disease. Digested blood in the stool causes it
Eating small, frequent meals helps to prevent
to be black. The odor of the stool is very
gastric distention if not actively bleeding and
offensive. Clients with peptic ulcer disease
decreases distension and release of gastrin.
should be instructed to report the incidence
Medications should be administered
of black stools promptly to their primary
promptly to maintain optimum levels. After
health care provider. The data do not
awakening during the night, the client should
support the other diagnoses.
eat a small snack and return to bed, keeping
42. A client with peptic ulcer disease is taking the head of the bed elevated for an hour
ranitidine (Zantac). What is the expected after eating. It is not necessary to stay away
outcome of this drug? from crowded areas.
1. Heal the ulcer. 44. A client with peptic ulcer disease reports
that he has been nauseated most of the day
2. Protect the ulcer surface from acids. and is now feeling light-headed and dizzy.
Based upon these findings, which nursing
3. Reduce acid concentration.
actions would be most appropriate for the
4. Limit gastric acid secretion. nurse to take? Select all that apply.
RATIO: Histamine-2 (H2) receptor antagonists, 1. Administering an antacid hourly until

such as ranitidine, reduce gastric acid nausea subsides.
secretion. Antisecretory, or proton-pump
2. Monitoring the client's vital signs.
inhibitors, such as omeprazole (Prilosec), help
ulcers heal quickly in 4 to 8 weeks. 3. Notifying the physician of the client's
Cytoprotective drugs, such as sucralfate symptoms.
(Carafate), protect the ulcer surface against
acid, bile, and pepsin. Antacids reduce acid 4. Initiating oxygen therapy.
concentration and help reduce symptoms.
5. Reassessing the client in an hour.
43. A client with a peptic ulcer reports
RATIO: The symptoms of nausea and dizziness
epigastric pain that frequently awakens her
in a client with peptic ulcer disease may be
during the night. The nurse should instruct the
indicative of hemorrhage and should not be
client to do which activities? Select all that
ignored. The appropriate nursing actions at
apply.
this time are for the nurse to monitor the
1. Obtain adequate rest to reduce client's vital signs and notify the physician of
stimulation. the client's symptoms. To administer an
antacid hourly or to wait 1 hour to reassess
2. Eat small, frequent meals throughout the the client would be inappropriate; prompt
day. intervention is essential in a client who is
potentially experiencing a gastrointestinal
3. Take all medications on time as ordered.
hemorrhage. The nurse would notify the
4. Sit up for one hour when awakened at physician of assessment findings and then
night.
initiate oxygen therapy if ordered by the client is upset and argumentative. Not
physician. keeping up with his job will probably increase
the client's stress level, but the nurse's
45. The nurse is preparing to teach a client
response is best if it is based on the fact that
with a peptic ulcer about the diet that should
a relaxed environment is an essential
be followed after discharge. The nurse should
component of ulcer healing. Nurses cannot
explain that the diet will most likely consist of
set limits on a client's behavior; clients must
which of the following?
make the decision to make lifestyle changes.
1. Bland foods.
47. A client with a peptic ulcer has been
2. High-protein foods. instructed to avoid intense physical activity
and stress. Which strategy should the client
3. Any foods that are tolerated. incorporate into the home care plan?
4. Large amounts of milk. 1. Conduct physical activity in the morning so
that he can rest in the afternoon.
RATIO: Diet therapy for ulcer disease is a
controversial issue. There is no scientific 2. Have the family agree to perform the
evidence that diet therapy promotes necessary yard work at home.
healing. Most clients are instructed to follow
a diet that they can tolerate. There is no 3. Give up jogging and substitute a less
need for the client to ingest only a bland or demanding hobby.
high-protein diet. Milk may be included in the
4. Incorporate periods of physical and
diet, but it is not recommended in excessive
mental rest in his daily schedule.
amounts.
RATIO: It would be most effective for the
46. The nurse finds a client who has been
client to develop a health maintenance plan
diagnosed with a peptic ulcer surrounded by
that incorporates regular periods of physical
papers from his briefcase and arguing on the
and mental rest in the daily schedule.
telephone with a coworker. The nurse's
Strategies should be identified to deal with
response to observing these actions should
the types of physical and mental stressors
be based on knowledge that:
that the client needs to cope with in the
1. Involvement with his job will keep the client home and work environments. Scheduling
from becoming bored. physical activity to occur only in the morning
would not be restful or practical. There is no
2. A relaxed environment will promote ulcer need for the client to avoid yard work or
healing. jogging if these activities are not stressful.
3. Not keeping up with his job will increase the 48. A client is to take one daily dose of
client's stress level. ranitidine (Zantac) at home to treat her
peptic ulcer. The client understands proper
4. Setting limits on the client's behavior is an
drug administration of ranitidine when she
important nursing responsibility.
says that she will take the drug at which of the
RATIO: A relaxed environment is an essential following times?
component of ulcer healing. Nurses can help
1. Before meals.
clients understand the importance of
relaxation and explore with them ways to 2. With meals.
balance work and family demands to
promote healing. Being involved with his 3. At bedtime.
work may prevent boredom; however, this
4. When pain occurs.
RATIO: Ranitidine blocks secretion of 1. "I should take my antacid before I take my
hydrochloric acid. Clients who take only one other medications."
daily dose of ranitidine are usually advised to
2. "I need to decrease my intake of fluids so
take it at bedtime to inhibit nocturnal
that I don't dilute the effects of my antacid."
secretion of acid. Clients who take the drug
twice a day are advised to take it in the 3. "My antacid will be most effective if I take
morning and at bedtime. It is not necessary it whenever I experience stomach pains."
to take the drug before meals. The client
should take the drug regularly, not just when 4. "It is best for me to take my antacid 1 to 3
pain occurs. hours after meals."
49. A client has been taking aluminum RATIO: Antacids are most effective if taken 1
hydroxide (Amphojel) 30 mL six times per to 3 hours after meals and at bedtime. When
day at home to treat his peptic ulcer. He tells an antacid is taken on an empty stomach,
the nurse that he has been unable to have a the duration of the drug's action is greatly
bowel movement for 3 days. Based on this decreased. Taking antacids 1 to 3 hours after
information, the nurse would determine that a meal lengthens the duration of action, thus
which of the following is the most likely cause increasing the therapeutic action of the
of the client's constipation? drug. Antacids should be administered
about 2 hours after other medications to
1. The client has not been including enough decrease the chance of drug interactions. It
fiber in his diet. is not necessary to decrease fluid intake
when taking antacids. If antacids are taken
2. The client needs to increase his daily
more frequently than recommended, the
exercise.
likelihood of developing adverse effects
3. The client is experiencing an adverse increases. Therefore, the client should not
effect of the aluminum hydroxide. take antacids as often as desired to control
pain.
4. The client has developed a gastrointestinal
obstruction. 51. Which of the following would be an
expected outcome for a client with peptic
RATIO: It is most likely that the client is
ulcer disease? The client will:
experiencing an adverse effect of the
antacid. Antacids with aluminum salt 1. Demonstrate appropriate use of
products, such as aluminum hydroxide, form analgesics to control pain.
insoluble salts in the body. These precipitate
2. Explain the rationale for eliminating
and accumulate in the intestines, causing
alcohol from the diet.
constipation. Increasing dietary fiber intake
or daily exercise may be a beneficial lifestyle 3. Verbalize the importance of monitoring
change for the client but is not likely to relieve hemoglobin and hematocrit every 3 months.
the constipation caused by the aluminum
hydroxide. Constipation, in isolation from 4. Eliminate contact sports from his or her
other symptoms, is not a sign of a bowel lifestyle.
obstruction.
RATIO: Alcohol is a gastric irritant that should
50. A client is taking an antacid for treatment be eliminated from the intake of the client
of a peptic ulcer. Which of the following with peptic ulcer disease. Analgesics are not
statements best indicates that the client used to control ulcer pain; many analgesics
understands how to correctly take the are gastric irritants. The client's hemoglobin
antacid? and hematocrit typically do not need to be
monitored every 3 months, unless
gastrointestinal bleeding is suspected. The D. Gastric acid stimulation.
client can maintain an active lifestyle and
RATIO: The esophagogastroduodenoscopy
does not need to eliminate contact sports as
(EGD) is an invasive diagnostic test which
long as they are not stress-inducing.
visualizes the esophagus, stomach, and
52. Which assessment data indicate to the duodenum to accurately diagnose an ulcer
nurse the clients gastric ulcer has perforated? and evaluate the effectiveness of the clients
treatment.
A. Complaints of sudden, sharp, substernal
pain 55. Which specific data should the nurse
obtain from the client who is suspected of
B. Rigid, boardlike abdomen with rebound
having peptic ulcer disease?
tenderness
A. History of side effects experienced from all
C. Frequent, clay-colored, liquid stool
medications
D. Complaints of vague abdominal pain in
B. Use of non steroidal anti inflammatory
the right upper quadrant
drugs (NSAIDs)
RATIO: B. A rigid, boardlike abdomen with
C. Any known allergies to drugs and
rebound tenderness is the classic
environmental factors
sign/symptom of peritonitis, which is a
complication of a perforated gastric ulcer D. Medical histories of at lease 3 generations
53. Which assessment data support to the RATIO: B. Use of NSAIDs places the client at
nurse the clients diagnosis of gastric ulcer? risk for peptic ulcer and hemorrhage. NSAIDs
suppress the production of prostaglandin in
A. Presence of blood in the clients stool for
the stomach, which is a protective
the past month.
mechanism to prevent damage from
B. Reports of a burning sensation moving like hydrochloric acid.
a wave.
56. Which physical examination should the
C. Sharp pain in the upper abdomen after nurse implement first when assessing the
eating a heavy meal. client diagnosed with peptic ulcer disease?
D. Complaints of epigastric pain 30-60 A. Auscultate the clients bowel sounds in all
minutes after ingesting food. four quadrants
RATIO: D. The client diagnosed with a gastric B. Palpate the abdominal area for
ulcer, pain usually occurs 30 to 60 minutes tenderness
after eating, but not at night. In contrast,no
C. Percuss the abdominal borders to identify
client with a duodenal ulcer has pain during
organs
the night often relieved by eating food. Pain
occurs 1-3 hours after meals. D. Assess the tender area progressing to
nontender
54. The nurse is caring for a client diagnosed
with rule out peptic ulcer disease. Which test RATIO: A. Auscultation should be used prior to
confirms this diagnosis? palpitation or percussion when assessing the
abdomen. Manipulation of the abdomen
A. Esophagogastroduodenoscopy
can alter bowel sounds and give false
B. Magnetic resonance imaging information
C. Occult blood test

57. Which problems should the nurse include C. The client has no signs and symptoms of
in the plan of care for the client diagnosed hemoptysis
with peptic ulcer disease to observe for
D. The client take s antacids with each meal
physiological complications?
RATIO: B. Maintaining lifestyle changes such
A. Alteration in bowel elimination patterns
as following an appropriate diet and
B. Knowledge deficit in the causes of ulcers reducing stress indicate the client is
complying with the medical regimen.
C. Inability to cope with changing family roles
Compliance is the goal of treatment to
D. Potential for alteration in gastric emptying prevent complications.
RATIO: D. Potential for alteration in gastric 60. The nurse has been assigned to care for a
emptying is caused by edema or scarring client diagnosed with peptic ulcer disease.
associated with an ulcer, which may cause a Which assessment data require further
feeling of "fullness", vomiting of undigested intervention?
food or abdominal distention
A. Bowel sour s auscultated 15 times in 1
58. The nurse is caring for a client diagnosed minute
with hemorrhage get duodenal ulcer. Which
B. Belching after eating a heavy and fatty
collaborative interventions shoulder nurse
meal late at night
implement? Select all that apply.
C. A decrease in systolic BP of 20 mm Hg from
lying to sitting
A. Perform a complete pain assessment
D. A decreased frequency of distress located
B. Assess the clients vital signs frequently in the epigastric region
C. Administer a proton pump inhibitor 61. The nurse is caring for a client diagnosed
intravenously with rule out peptic ulcer disease. Which test
confirms this diagnosis?
D. Obtain permission and administer blood
products A. Esophagogastroduodenoscopy
E. Monitor the intake of a soft, bland diet B. Magnetic resonance imaging
RATIO: C. This is a collaborative intervention C. Occult blood test

the nurse should implement. It requires an
D. Gastric acid stimulation.
order from the HCP. D. Administering blood
products is collaborative, requiring an order RATIO: The esophagogastroduodenoscopy
from the HCP. (EGD) is an invasive diagnostic test which
visualizes the esophagus, stomach, and
59. Which expected outcome should the
duodenum to accurately diagnose an ulcer
nurse include for a client diagnosed with
and evaluate the effectiveness of the clients
peptic ulcer disease?
treatment.
62. Which specific data should the nurse

A. The clients pain is controlled with the use obtain from the client who is suspected of
of NSAIDs having peptic ulcer disease?
B. The client maintains lifestyle modifications

A. History of side effects experienced from all associated with an ulcer, which may cause a
medications feeling of "fullness", vomiting of undigested
food or abdominal distention
B. Use of non steroidal anti inflammatory
drugs (NSAIDs) 65. The nurse is caring for a client diagnosed
with hemorrhage get duodenal ulcer. Which
C. Any known allergies to drugs and
collaborative interventions shoulder nurse
environmental factors
implement? Select all that apply.
D. Medical histories of at lease 3 generations
A. Perform a complete pain assessment
RATIO: Use of NSAIDs places the client at risk
B. Assess the clients vital signs frequently
for peptic ulcer and hemorrhage. NSAIDs
suppress the production of prostaglandin in C. Administer a proton pump inhibitor
the stomach, which is a protective intravenously
mechanism to prevent damage from
D. Obtain permission and administer blood
hydrochloric acid.
products
63. Which physical examination should the
E. Monitor the intake of a soft, bland diet
nurse implement first when assessing the
client diagnosed with peptic ulcer disease? RATIO: C. This is a collaborative intervention
the nurse should implement. It requires an
A. Auscultate the clients bowel sounds in all
order from the HCP.
four quadrants
D. Administering blood products is
B. Palpate the abdominal area for
collaborative, requiring an order from the
tenderness
HCP.
C. Percuss the abdominal borders to identify
66. Which expected outcome should the
organs
nurse include for a client diagnosed with
D. Assess the tender area progressing to peptic ulcer disease?
nontender
A. The clients pain is controlled with the use
RATIO: Auscultation should be used prior to of NSAIDs
palpitation or percussion when assessing the
B. The client maintains lifestyle modifications
abdomen. Manipulation of the abdomen
can alter bowel sounds and give false C. The client has no signs and symptoms of
information hemoptysis
64. Which problems should the nurse include D. The client take s antacids with each meal
in the plan of care for the client diagnosed
with peptic ulcer disease to observe for RATIO: Maintaining lifestyle changes such as
physiological complications? following an appropriate diet and reducing
stress indicate the client is complying with the
A. Alteration in bowel elimination patterns medical regimen. Compliance is the goal of
treatment to prevent complications.
B. Knowledge deficit in the causes of ulcers
67. The nurse has been assigned to care for a
C. Inability to cope with changing family roles
client diagnosed with peptic ulcer disease.
D. Potential for alteration in gastric emptying Which assessment data require further
intervention?
RATIO: D. Potential for alteration in gastric
emptying is caused by edema or scarring
A. Bowel sour s auscultated 15 times in 1 70. The client with a history of peptic ulcer
minute disease is admitted into the intensive care
unit with frank gastric bleeding. Which priority
B. Belching after eating a heavy and fatty
intervention should the nurse implement?
meal late at night
A. Maintain a strict record of intake and
C. A decrease in systolic BP of 20 mm Hg from
output
lying to sitting
B. Insert a nasogastric tube and begin saline
D. A decreased frequency of distress located
lavage
in the epigastric region
C. Assist the client with keeping a detailed
RATIO: C. A decrease of 20 mm Hg in blood
calorie count
pressure after changing position from lying,
to sitting, to standing is orthostatic D. Provide a quiet environment to promote
hypotension. This could indicate client is rest
bleeding.
RATIO: B. Inserting a nasogastric tube and
68. Which oral medication should the nurse lavaging the stomach with saline is the most
question before administering to the client important intervention because this directly
with peptic ulcer disease? stops the bleedingIC. A decrease of 20 mm
Hg in blood pressure after changing position
A. E-mycin, an antibiotic
from lying, to sitting, to standing is orthostatic
B. Prilosec, a proton pump inhibitor hypotension. This could indicate client is
bleeding.
C. Flagyl, an anti microbial agent
71. The client with peptic ulcer disease (PUD)
D. Tylenol, a nonnarcotic analgesic asks the nurse whether licorice and slippery
elm might be useful in managing the disease.
RATIO: A. E-mycinis irritating to stomach, and
What is the nurse's best response?
it's use in a client with peptic ulcer disease
should be questioned A. "No, they probably won't be useful. You
should use only prescription medications in
69. The nurse has administered an antibiotic,
your treatment plan."
a proton pump inhibitor, and Pepto- Bismol
for peptic ulcer disease secondary to H. B. "These herbs could be helpful. However,
pylori. Which data would indicate to the you should talk with your physician before
nurse the medications are effective? adding them to your treatment regimen."
A. A decrease in alcohol intake C. "Yes, these are known to be effective in
managing this disease, but make sure you
B. Maintaining a bland diet
research the herbs thoroughly before taking
C. A return to previous activities them."
D. A decrease in gastric distress D. "No, herbs are not useful for managing this
disease. You can use any type of over-the-
RATIO: D. Antibiotics, proton pump inhibitors, counter drugs though. They have been
and Pepto-Bismol are administered to shown to be safe."
decrease the irritation of the ulcerative area
and cure the ulcer. A decrease in gastric RATIO: B. Although these herbs may be
distress indicates the medication is effective helpful in managing PUD, the client should
consult his or her physician before making a
change in the treatment regimen.
72. The nurse is caring for an older adult male mucosal barrier. These medications increase
client who reports stomach pain and the risk of ulcer development. Misoprostol,
heartburn. Which syndrome is most bethanechol, and metoclopramide are
significant in determining whether the client's used in gastroesophageal reflux disease and
ulceration is gastric or duodenal in origin? peptic ulcer drug therapy. pp. 905-906
A. Pain occurs 1 1/2 to 3 hours after a meal, 75.Which drug increases production of
usually at night. gastric mucus?
B. Pain is worsened by the ingestion of food. Tofranil
C. The client has a malnourished Sucralfate

appearance.
Cimetidine
D. The client is a man older than 50 years.
Misoprostol
RATIO: A key symptom characteristic of
RATIO: Misoprostol, a synthetic prostaglandin
duodenal ulcers is that pain usually awakens
analog prescribed to prevent gastric ulcers
the client between 1 AM and 2 AM,
caused by nonsteroidal antiinflammatory
occurring 1 1/2 to 3 hours after a meal.
drugs (NSAIDs), increases production of
73. The client is experiencing bleeding gastric mucus and mucosal secretion of
related to peptic ulcer disease (PUD). Which bicarbonate.
nursing intervention is the highest priority?
Sucralfate forms a protective layer and
A. Starting a large-bore intravenous (IV) serves as a barrier against acids, bile salts,
and enzymes.
B. Administering intravenous (IV) pain
medication Tofranil is a tricyclic antidepressant that
provides pain relief in peptic ulcer disease.
C. Preparing equipment for intubation
Cimetidine is a histamineblocker that
D. Monitoring the client's anxiety level
provides ulcer healing. Misoprostol is
RATIO: A large-bore IV should be placed as prescribed to prevent gastric ulcers caused
requested, so that blood products can be by NSAIDs.
administered.
76. The patient with peptic ulcer disease is
74. Which medications increase the risk of taking sucralfate. Which outcome would the
ulcer development? Select all that apply. nurse anticipate?
Some correct answers were not selected Healing of ulcer

Aspirin
Reduction in acid secretion
Misoprostol
Protection of ulcer from acids
Bethanechol
Neutralization of gastric acid secretion
Corticosteroids
Sucralfate acts by forming a protective layer
Metoclopramide around an ulcer that serves as a barrier
against acid, bile salts, and enzymes in the
RATIO: Aspirin and corticosteroids are stomach. Histamine blockers are used to
ulcerogenic drugs that inhibit the synthesis of promote ulcer healing. Proton pump
prostaglandins, increase gastric acid inhibitors such as omeprazole reduce gastric
secretion, and reduce the integrity of the
acid secretion. Antacids increase gastric pH Bilious
and neutralize gastric acid secretion.
"Coffee ground"
77. Which entries in a patient’s list of current
Undigested food
medications would indicate specific
treatment for Helicobacter pylori ( H. pylori)? RATIO: The appearance of blood exposed to
Select all that apply. hydrochloric acid and other digestive
enzymes in the stomach is dark brown with a
Cimetidine
coffee-ground consistency. This should be
Amoxicillin reported by the nurse. Fecal vomitus would
be experienced with a total bowel
Famotidine
obstruction. Bilious vomitus or undigested
Omeprazole food may be seen with various
gastrointestinal disturbances, such as
Clarithromycin gallbladder disease, gastroenteritis, or
gastritis.
Antibiotics such as amoxicillin and
clarithromycin are used to treat H. pylori 80. Which histamine-receptor blocker is
infection, which is a common cause of available only for oral administration?
peptic and duodenal ulcers. Cimetidine and
famotidine are histamine-receptor blockers Nizatidine
that decrease acid production. Omeprazole
Ranitidine
reduces gastric secretion. Test-Taking Tip: Be
alert for details about what you are being Cimetidine
asked to do. In this question type, you are
Famotidine
asked to select all options that apply to a
given situation or patient. All options likely RATIO: Nizatidine is available only for oral
relate to the situation, but only some of the administration but not for IV administration;
options may relate directly to the situation. the medication is used to promote ulcer
healing. Ranitidine, cimetidine, and
78. Two days after a patient has had gastric
famotidine are histamine (H 2) blockers that
surgery, the nurse suspects that the patient’s
can be given orally or through IV. p. 898
nasogastric tube is not in the correct position.
Which action would the nurse take?
Remove the tube and insert a new

nasogastric tube.
Notify the health care provider immediately.
Monitor for evidence of local inflammation

and edema.
Irrigate the nasogastric tube with normal

saline solution.
79. A patient with a peptic ulcer begins

vomiting. Which type of vomitus is associated
with bleeding in the stomach?
Fecal
DKA AND HHNS
4. This condition happens gradually and is
more likely to affect older adults?
1. This complication is found mainly in Type

2 diabetics?  A. HHNS
 A. Diabetic Ketoacidosis  B. DKA
 B. Hyperglycemic Hyperosmolar The answer is A.
5. A patient has an infection and reports not

Nonketotic Syndrome checking their blood glucose or regularly
taking Metformin. What condition is this
The answer is B.
patient MOST at risk for?
2. A patient is found to have a blood
glucose of 375 mg/dL, positive ketones in
the urine, and blood pH of 7.25. Which  A. HHNS
condition is this?  B. DKA
 C. Metabolic alkalosis
 A. Diabetic Ketoacidosis
 B. Hyperglycemic Hyperosmolar  D. Metabolic acidosis

Nonketotic Syndrome
The answer is A.
The answer is A.
6. Which patient population is most at risk for
3. Hyperglycemic Hyperosmolar Nonketotic DKA?
Syndrome would have all of the following
signs and symptoms EXCEPT?  A. Middle-aged adults who are
obese
 A. Dry mucous membranes
 B. Older-adults with Type 2 diabetes
 B. Polyuria
 C. Blood glucose >600 mg/dL  C. Newly diagnosed diabetes
 D. None of the options

 D. Kussmaul breathing
The answer is C.
The answer is D. Kussmaul breathing is found
in DKA due to the compensatory 7. True or False: Osmotic diuresis is present in
mechanism of the respiratory system. HHNS and DKA due to the kidney's inability
Remember that in DKA there are excessive to reabsorb the excessive glucose which
ketones (none are present in HHNS) which causes glucose to leak into the urine which
are acids and this causes metabolic in turn causes extra water and electrolytes
acidosis. Therefore, the respiratory system to be excreted.
tries to "blow off" extra acid (carbon
dioxide) to try to make the blood more
 True
alkalotic.
 False
The answer is TRUE

8. Which of the following is NOT a medical 11. A patient is being discharged home after
treatment for DKA and HHNS? recovering from HHNS. Which statement by
the patient requires patient re-education
 A. IV regular insulin
about this condition?
 B. Isotonic fluids
 A. "I will monitor my blood glucose
 C. Bicarbonate levels regularly."
 B. "This condition happens suddenly

 D. IV potassium Solution
without any warning signs."
The answer is C.
 C. "If I become sick I will monitor my
9. Which of the following is not a sign or blood glucose more frequently and
symptom of Diabetic Ketoacidosis?
 A. Positive Ketones in the urine drink lots of fluids."
 B. Polydipsia  D. "It is important I take my

medication as prescribed."
The answer is B. HHNS tends to happen

 C. Oliguria
GRADUALLY rather than suddenly. DKA
tends to occurs suddenly. Therefore, the
 D. Abdominal Pain patient should be re-educated about how
signs and symptoms will appear gradually
The answer is C. Oliguria means low urinary and how to detect them before the disease
output...in DKA there is POLYURIA (high process advances.
urinary output)
12. The elderly patient with type 2 diabetes
10. You are providing care to a patient mellitus presents to the clinic with a fever and
experiencing diabetic ketoacidosis. The productive cough. The diagnosis of
patient is on an insulin drip and their current pneumonia is made. You notice tenting skin,
glucose level is 300. In addition, to the deep tongue furrows, and vital signs of
insulin drip the patient also has 5% Dextrose 110/80 mm Hg, 120 beats/minute, and 24
0.45% NS infusing in the right antecubital breaths/minute. What assessment is
vein. Which of the following patient important for you to obtain?
signs/symptoms causes concern?
A. Blood glucose
 A. Patient has a potassium level of
B. Orthostatic blood pressures
2.3
C. Urine ketones
D. Temperature
 B. Patient complains of thirst.
RATIO: A. Blood glucose
 C. Patient is nauseous.
HHS is typically seen in patients with type 2
 D. Patient's skin and mucous
diabetes and infection, such as pneumonia.
The main presenting sign is a glucose level
membranes are dry. above 600 mg/dL. Enough evidence of
The answer is A. dehydration already exists that orthostatic
vital sign assessments are not a priority, and C. Ketone bodies higher than 4+ in urine
they are often inaccurate in the elderly due
D. Signs and symptoms of diabetes insipidus
to poor vascular tone. Patients with HHS do
not have elevated ketone levels, which is a RATIO: B. Slow onset resulting in a blood
key distinction between HHS and DKA. glucose level greater than 600 mg/dL
Temperature will eventually be taken but is
often blunted in the elderly and diabetics. An HHS has a slower onset than diabetic
infectious diagnosis has already been made. ketoacidosis. HHS is often related to impaired
The glucose level for appropriate fluid and thirst sensation, inadequate fluid intake, or
insulin treatment is the priority. functional inability to replace fluids. Because
of the slower onset, the blood glucose levels
13. The patient with HHS presented with a can be quite high (more than 600 mg/dL)
glucose level of 800 mg/dL and is started on before diagnosis. HHS is seen in type 2
IV fluids and insulin. What action do you diabetics, and there is enough circulating
anticipate when the patient's glucose insulin to prevent ketoacidosis. Diabetes
reaches 250 mg/dL? insipidus is related to inadequate antidiuretic
hormone secretion or kidney response with
A. Administer an intravenous (IV) solution
dilute, frequent urination. It is not related to
with 5% dextrose.
HHS.
B. Administer sodium polystyrene sulfate
15. A diabetic patient has a serum glucose
(Kayexalate).
level of 824 mg/dL (45.7 mmol/L) and is
C. Slow the IV infusion rate to 40 mL/hour. unresponsive. After assessment of the
patient, you suspect DKA rather than HHS
D. Assess cardiac monitoring for peaked T
based on the finding of
waves.
A. polyuria.
RATIO: A. Administer an intravenous (IV)
solution with 5% dextrose. B. severe dehydration.
When blood glucose levels fall to C. rapid, deep respirations.

approximately 250 mg/dL, IV fluids
D. decreased serum potassium.
containing glucose are administered to
prevent hypoglycemia. Kayexalate (for RATIO: C. rapid, deep respirations.
cation exchange) is used in the treatment of
hyperkalemia, which causes peaked T waves Rapid, deep respirations are Kussmaul's and
on cardiac monitoring. In HHS hypokalemia are are the body's attempt to reverse
may result from insulin moving the potassium metabolic acidosis through exhalation of
intracellularly. Fluid replacement remains a excess carbon dioxide. Symptoms of DKA
priority, but it is given with dextrose. The include manifestations of dehydration, such
infusion rate of 40 mL/hour keeps the vein as poor skin turgor, dry mucous membranes,
open, but it is not the appropriate tachycardia, and orthostatic hypotension.
replacement rate. Kussmaul respirations (rapid, deep breathing
associated with dyspnea) are the body's
14. What is a typical finding of hyperosmolar attempt to reverse metabolic acidosis
hyperglycemic syndrome (HHS)? through exhalation of excess carbon dioxide.
Acetone is detected on the breath as a
A. Occurs in type 1 diabetes as the
sweet, fruity odor.
presenting symptom
B. Slow onset resulting in a blood glucose

level greater than 600 mg/dL
16. What is a finding in DKA that is not seen mg/dL, ketone result of 2+, and rapid
in hyperosmolar hyperglycemic syndrome respirations with a fruity odor. What finding
(HHS)? do you anticipate?
A. Glucose level above 400 mg/dL A. pH below 7.30
B. Hyperkalemia B. Urine specific gravity below 1.005
C. Ketones in blood C. High sodium bicarbonate levels
D. Urine output of 30 mL/hr D. Low blood urea nitrogen (BUN) level
RATIO: C. Ketones in blood RATIO: A. pH below 7.30
The main difference between the two The patient is in metabolic acidosis, which is
conditions is that ketone bodies are absent a pH below 7.35. Dehydration results in a high
or minimal in HHS because the body has urine specific gravity (at the upper end of the
enough insulin to prevent ketoacidosis. Both normal range, or above 1.025 to 1.030).
have high glucose levels, although the level Sodium bicarbonate levels are low in
in HHS tends to be higher (above 600 mg/dL). metabolic acidosis. The dehydration that
Hypokalemia is possible in both, although it is occurs with DKA elevates the BUN level.
more likely and serious in DKA. Urine output of
19. The patient in the emergency department
30 mL/hr is normal obligatory output; both
is diagnosed with diabetic ketoacidosis.
conditions are likely to have dehydration and
Which laboratory value is essential for you to
decreased output.
monitor?
17. Which assessment is the most sensitive
A. Magnesium (Mg)
indicator that the IV fluid administration may
be too rapid when treating a patient with B. Hemoglobin (Hb)
DKA and a history of renal disease?
C. White blood cells (WBCs)
A. Pedal edema
D. Potassium (K)
B. Tachypnea
RATIO: D. Potassium (K)
C. Urine output of 40 mL/hour
Even if the patient has normal potassium
D. Change in the level of consciousness levels, there can be significant hypokalemia
when insulin is administered as it pushes the
RATIO: D. Change in the level of
serum potassium intracellularly. This can lead
consciousness
to life-threatening hypokalemia. The other
Too rapid fluid replacement can lead to options are not as significant.
hyponatremia and cerebral edema. Pedal
20. The patient with type 1 diabetes arrives in
edema is a later and relatively insignificant
the emergency department with a glucose
sign. In a bedridden patient, edema is more
level of 390 mg/dL and positive result for
evident in the sacral area. The Kussmaul
ketones. Vital signs are 110/70 mm Hg, 120
respirations are expected; crackles
beats/minute, and 28 deep, sighing
auscultated in the lungs are a more sensitive
respirations/minute. What is the priority need
indicator. The desired urine output for
for the patient?
adequate hydration is 30 to 60 mL/hr.
A. Oxygen
18. The patient presents to the emergency
department with a glucose level of 400 B. Intravenous (IV) fluids
C. Albuterol (Ventolin) A. Administer a second bolus of glucose
solution.
D. Metformin (Glucophage)
B. Administer regular insulin per sliding scale.
RATIO: B. Intravenous (IV) fluids
C. Have the patient eat peanut butter and
A patient in diabetic ketoacidosis (DKA)
toast.
needs IV fluids and insulin to stop the tissue
breakdown resulting in ketone bodies and D. Obtain a serum glucose level.
acidosis. The initial goal is fluid and
RATIO: C. Have the patient eat peanut
electrolyte balance. Kussmaul respirations
butter and toast.
indicate the body is attempting to
compensate by blowing off the carbon The patient has had an appropriate response
dioxide, but it is ineffective as long as the to the glucose. Now a complex
body continues to break down the ketone carbohydrate is needed to prevent
bodies and remains in metabolic acidosis. hypoglycemia from reoccurring. There is no
need for a second bolus of glucose because
21. The patient has type 1 diabetes mellitus
the result is within normal range. Insulin is not
and is found unresponsive with cool and
given, even though the glucose level is
clammy skin. What action is a priority?
slightly elevated. The short-acting glucose is
A. Obtain a serum glucose level. metabolized and insulin administration can
increase the risk of a second hypoglycemic
B. Give hard candy under the tongue.
reaction. A serum confirmation of the level
C. Administer glucagon per standing order. can be obtained but is not the priority.
D. Notify the health care provider. 23. The patient is managed with NPH and
regular insulin injections before breakfast
C. Administer glucagon per standing order. and before dinner. When is the patient most
likely to have a hypoglycemic reaction?
RATIO: The patient has signs and symptoms of
hypoglycemia for which treatment should be A. After breakfast
the priority. Glucagon stimulates a strong
hepatic response to convert glycogen to B. Before lunch
glucose and therefore makes glucose rapidly
C. During lunch
available. Waiting for a serum result (up to an
hour) is improper because brain cells D. After lunch
continue to die from a lack of glucose.
RATIO: B. Before lunch
Nothing solid should be placed in the mouth
when the patient has an altered level of The regular insulin peak occurs about 2 to 3
consciousness and can aspirate. With hours with a duration of 5 to 6 hours. If too
obvious symptoms, emergent treatment much insulin or not enough food is given, the
takes priority over notifying the health care most likely time of hypoglycemia is before
provider. lunch, when the regular insulin is still present,
the NPH has its onset, and the breakfast food
22. The patient had a hypoglycemic episode
has been metabolized.
and is treated with a concentrated glucose
oral tablet. Fifteen minutes later the capillary
glucose level (Accu-Check) is 150 mg/dL.
What action should you take?
24. Which symptoms reported by a patient annually thereafter for early detection and
with diabetes mellitus are most important to treatment.
follow-up?
26. You are beginning to teach a diabetic
A. "My vision has been getting fuzzier over patient about the vascular complications of
the past year." diabetes. Which information is appropriate
for you to include?
B. "I cannot read the small print anymore."
A. Macroangiopathy does not occur in type
C. "There is something like a veil of blackness
1 diabetes but does affect type 2 diabetics
coming across my vision."
who have severe disease.
D. "I have yellow discharge from one eye."
B. Microangiopathy is specific to diabetes
RATIO: C. "There is something like a veil of and most commonly affects the capillary
blackness coming across my vision." membranes of the eyes, kidneys, and skin.
Diabetic retinopathy, particularly C. Renal damage resulting from changes in

proliferative retinopathy, can cause retinal large and medium-sized blood vessels can
detachment, which has the classic new be prevented by careful glucose control.
symptom of a veil coming across the field of
D. Macroangiopathy causes slowed gastric
vision. This requires emergency treatment.
emptying and the sexual impotency
Chronic blurry vision can be cataracts and is
experienced by most patients with diabetes.
not emergent. Change in the ability to read
things near to the eye (presbyopia or RATIO: B. Microangiopathy is specific to
farsightedness) is an age-related change diabetes and most commonly affects the
and not emergent. Conjunctivitis needs capillary membranes of the eyes, kidneys,
treatment but is not as emergent as retinal and skin.
detachment.
Microangiopathy occurs in type 1 and type 2
25. What is the best teaching for a patient diabetes mellitus. When it affects the eyes, it
who is newly diagnosed with diabetes is called diabetic retinopathy. When kidneys
mellitus type 2? are affected, the patient has nephropathy.
When the skin is affected, it can lead to
A. Read a Snellen chart yearly.
diabetic foot ulcers. Sexual impotency and
B. Be checked out for presbycusis. slowed gastric emptying result from
microangiopathy.
C. Notify the doctor if your vision has color
distortion. 27. Laboratory results are available for a 54-
year-old patient with a 15-year history of
D. See an ophthalmologist for a dilated eye diabetes. Which result follows the expected
examination yearly. pattern accompanying macrovascular
disease as a complication of diabetes?
RATIO: D. See an ophthalmologist for a
dilated eye examination yearly. A. Increased triglyceride levels
The earliest and most treatable stages of B. Decreased low-density lipoprotein levels
diabetic retinopathy often produce no
changes in the vision. Because of this, the C. Increased high-density lipoprotein levels
patient with type 2 diabetes should have a
D. Decreased very-low-density lipoprotein
dilated eye examination by an
levels
ophthalmologist at the time of diagnosis and
RATIO: A. Increased triglyceride levels
Macrovascular complications of diabetes pressure is well-controlled. What is your
include changes in medium- and large-sized response?
blood vessels. They include cerebrovascular,
A. It helps prevent hypertension as diabetics
cardiovascular, and peripheral vascular
are prone to it.
disease. Increased triglyceride levels are
associated with these macrovascular B. ACE inhibitors delay the progression of
changes. For this reason, the patient should nephropathy in patients with diabetes.
limit the amount of fat in the diet.
C. ACE inhibitors prevent macrovascular
28. What therapies are appropriate for complications.
patients with diabetes mellitus (select all
that apply)? D. ACE inhibitors help prevent atherosclerosis.
A. Use of statins to treat dyslipidemia RATIO: B. ACE inhibitors delay the progression
of nephropathy in patients with diabetes.
B. Use of diuretics to treat nephropathy
ACE inhibitors and angiotensin II receptor
C. Use of angiotensin-converting enzyme antagonists (ARBs) are used to treat
(ACE) inhibitors to treat nephropathy hypertension and delay the progression of
nephropathy in patients with diabetes. ACE
D. Use of laser photocoagulation to treat
inhibitors are not used prophylactically. ACE
retinopathy
inhibitors do not affect macrovascular
E. Use of protein restriction in patients with complications. Nephropathy is a
early signs of nephropathy microvascular complication.
RATIO: A. Use of statins to treat dyslipidemia 30. What is most helpful in the prevention of
nephropathy in a patient with diabetes
C. Use of angiotensin-converting enzyme
mellitus?
(ACE) inhibitors to treat nephropathy
A. Acid-ash diet
D. Use of laser photocoagulation to treat
retinopathy B. Ensuring adequate fluid intake for renal
perfusion
In patients with diabetes who have
microalbuminuria or macroalbuminuria, ACE C. Preventing obstruction from benign
inhibitors (-prils) or angiotensin II receptor prostatic hyperplasia (BPH)
antagonists (ARBs) (-sartans) should be used.
D. Stopping smoking
Both of these drug classes are used to treat
hypertension. The statin drugs are the most RATIO: D. Stopping smoking
widely used lipid-lowering drugs. Laser
photocoagulation therapy is indicated to Risk factors for diabetic nephropathy include
reduce the risk of vision loss in patients with hypertension, genetic predisposition,
proliferative retinopathy, macular edema, smoking, and chronic hyperglycemia.
and in some cases of nonproliferative Diabetic nephropathy is an intrarenal
retinopathy. microvascular complication in which the
glomeruli of the kidney are damaged. The
29. The patient has diabetes mellitus and kidney receives about 25% of the cardiac
macroalbuminuria. The patient asks you why output, and inadequate fluids or shock
the physician is prescribing the angiotensin- resulting in adequate perfusion is a prerenal
converting enzyme (ACE) inhibitor lisinopril cause. BPH is a postrenal cause of kidney
(Zestril) for him even though his blood pathology.
31. Which elevated laboratory finding is the The patient asks you why the primary health
best indication of potential diabetic care provider prescribed the selective
nephropathy? serotonin reuptake inhibitor (SSRI) duloxetine
(Cymbalta). What is the best response?
A. Blood urea nitrogen (BUN) level
A. The doctor thought the discomfort was
B. Urine albumin-to-creatinine ratio
causing the patient to be depressed.
C. Urine specific gravity
B. The drug is known to improve patients'
D. Chloride (Cl-) level moods and enhance coping.
RATIO: B. Urine albumin-to-creatinine ratio C. It regulates pain by affecting

neurotransmitters that transmit pain through
Screening for nephropathy depends on the the spine.
urinary albumin-to-creatinine ratio and a
serum creatinine level. BUN alone, without D. It deadens the sensitivity to peripheral
correction to creatinine, can indicate many nerve endings.
other issues, including dehydration and liver
RATIO: C. It regulates pain by affecting
function. Unless there is renal failure, urine
neurotransmitters that transmit pain through
specific gravity is more indicative of
the spine.
dehydration.
SSRI drugs work by inhibiting the reuptake of
32. The patient with diabetes and shortness of
norepinephrine and serotonin, which are
breath is brought from the nursing home to
neurotransmitters that are believed to play a
the hospital emergency department. The
role in the transmission of pain through the
electrocardiogram (ECG) shows evidence of
spinal cord. Duloxetine is thought to relieve
a myocardial infarction (MI), but the patient
pain by increasing the levels of serotonin and
denied ever having chest pain. Which is the
norepinephrine, which improves the body's
best explanation of what happened?
ability to regulate pain.
A. The patient had a "silent" MI related to
34. The male patient with diabetes and heart
autonomic neuropathy.
disease confides to you that he can no
B. The patient had chest pain but forgot longer have an erection. What is the reason
because of dementia. for these changes?
C. The patient minimized the chest pain A. It is a normal part of aging and is relieved
because he was worried about costs. with sildenafil (Viagra).
D. The patient has the psychologic defense B. It usually is related to emotions and is a
mechanism of denial. temporary problem.
RATIO: A. The patient had a "silent" MI related C. It is often the first sign of diabetic
to autonomic neuropathy. autonomic neuropathy.
Cardiovascular abnormalities associated D. It indicates that the patient has

with autonomic neuropathy include painless developed a neurogenic bladder.
myocardial infarction. Shortness of breath
RATIO: C. It is often the first sign of diabetic
related to decreased cardiac functioning
autonomic neuropathy.
can be the first overt sign or symptom.
Erectile dysfunction (ED) is common and
33. The patient with diabetes reports tingling
often is the first manifestation of autonomic
and burning in the lower extremities at night.
failure. ED is a common long-term
complication of diabetes. Neurogenic
bladder is related to urinary retention.
1. This result is below normal levels.
35. Which lower extremity or foot finding is a
2. This result is within acceptable levels.
sign of sensory neuropathy in a patient with
diabetes mellitus? 3. This result is above recommended levels.
A. Dusky when legs are dependent 4. This result is dangerously high.
B. Pitting pedal edema RATIO: 3. This result parallels a serum blood
glucose level of approximately 180 to200
C. Intermittent claudication
mg/dL. An A1c is a blood test reflecting
D. Strong pedal pulse average blood glucose levels over a period
of three (3) months; clients with elevated
RATIO: C. Intermittent claudication
blood glucose levels are at risk for
Peripheral arterial disease (PAD) is caused by developing long-term complications.
a reduction of blood flow to the lower
38. The nurse administered 28 units of Humulin
extremities. Classic signs include intermittent
N, an intermediate-acting insulin, to a client
claudication, pain at rest, cold feet, loss of
diagnosed with type 1 diabetes at 1600.
hair, delayed capillary filling, and dependent
Which intervention should the nurse
rubor. Dusky legs when they are dependent,
implement?
pitting pedal edema, and a strong pedal
pulse are signs of peripheral venous disease. 1. Ensure the client eats the bedtime snack.
36. An 18-year-old female client, 5′4′′tall, 2. Determine how much food the client ate
weighing 113 kg, comes to the clinic for a at lunch.
non healing wound on her lower leg, which
3. Perform a glucometer reading at 0700.
she has had for two (2) weeks. Which disease
process should the nurse suspect the client 4. Offer the client protein after administering
has developed? insulin.
1. Type 1 diabetes.' RATIO: 1. Humulin N peaks in 6 to 8 hours,
making the client at risk for hypoglycemia
2. Type 2 diabetes.
around midnight, which is why the client
3. Gestational diabetes. should receive a bedtime snack.This snack
will prevent nighttime hypoglycemia.
4. Acanthosis nigricans.
39. The client diagnosed with type 1 diabetes
RATIO: 2. Type 2 diabetes is a disorder usually
is receiving Humalog, a rapid-acting
occurring around the age of 40, but it is now
insulin,by sliding scale. The order reads blood
being detected in children and young adults
glucose level: <150, zero (0) units; 151 to
as a result of obesity and sedentary lifestyles.
200,three (3) units; 201 to 250, six (6) units;
Non healing wounds are a hallmark sign of
>251, contact health-care provider. The UAP
type 2 diabetes.This client weighs 248.6
reports to the nurse the client's glucometer
pounds and is short.
reading is 189. How much insulin should the
37. The client diagnosed with type 1 diabetes nurse administer to the client?
has a glycosylated hemoglobin (A1c) of
Three (3) units.
8.1%. Which interpretation should the nurse
make based on this result? RATIO: The client's result is 189, which is
between151 and 200, so the nurse should
administer3 units of Humalog insulin 1. Assess the client's ability to read small print.
subcutaneously
2. Monitor the client's serum PT level.
40. The nurse is discussing the importance of
3. Teach the client how to perform a
exercising with a client diagnosed with type
hemoglobin A1c test daily.
2 diabetes whose diabetes is well controlled
with diet and exercise. Which information 4. Instruct the client to check the feet weekly.
should the nurse include in the teaching
about diabetes? RATIO: 1. Age-related visual changes and
diabetic retinopathy could cause the client
1. Eat a simple carbohydrate snack before to have difficulty in reading and drawing up
exercising. insulin dosage accurately.
2. Carry peanut butter crackers when 43. The client with type 2 diabetes controlled
exercising. with biguanide oral diabetic medication is
scheduled for a (CT) scan with contrast of the
3. Encourage the client to walk 20 minutes
abdomen to evaluate pancreatic function.
three (3) times a week.
Which intervention should the nurse
4. Perform warm up and cool-down implement?
exercises.
1. Provide a high-fat diet 24 hours prior to test.
RATIO: 4. All clients who exercise should
2. Hold the biguanide medication for 48
perform warmup and cool-down exercises to
hours prior to test.
help prevent muscle strain and injury.
3. Obtain an informed consent form for the
41. The nurse is assessing the feet of a client
test
with long-term type 2 diabetes. Which
assessment data warrant immediate .4. Administer pancreatic enzymes prior to
intervention by the nurse? the test.
1. The client has crumbling toenails. RATIO: 2. Biguanide medication must be held
for a test with contrast medium because it
2. The client has athlete's foot.
increases the risk of lactic acidosis,which
3. The client has a necrotic big toe. leads to renal problems.
4. The client has thickened toenails. 44. The diabetic educator is teaching a class
on diabetes type 1 and is discussing sick-day
RATIO: 3.A necrotic big toe indicates "dead"
rules. Which interventions should the
tis-sue. The client does not feel pain, does not
diabetes educator include in the discussion?
realize the injury, and does not seek
Select all that apply.
treatment. Increased blood glucose levels
decrease the oxygen supply needed to heal 1. Take diabetic medication even if unable
the wound and increase the risk for to eat the client's normal diabetic diet.
developing an infection
2. If unable to eat, drink liquids equal to the
42. The home health nurse is completing the client's normal caloric intake.
admission assessment for a 76-year-old
3. It is not necessary to notify the health-care
client diagnosed with type 2 diabetes
provider if ketones are in the urine.
controlled with 70/30 insulin. Which
intervention should be included in the plan of 4. Test blood glucose levels and test urine
care? ketones once a day and keep a record.
5. Call the health-care provider if glucose 1. Ask the client if he has somewhere he can
levels are higher than 180 mg/dL. go and live.
1, 2, 5 2. Arrange for someone to give him insulin at

a local homeless shelter.
RATIO: 1.The most important issue to
teachclients is to take insulin even if they 3. Notify Adult Protective Services about the
areunable to eat. Glucose levels are in- client's situation.
creased with illness and stress.
4. Ask the HCP to take the client off insulin
2.The client should drink liquids such asregular because he is homeless.
cola or orange juice, or eat regular gelatin,
RATIO: 2.Client advocacy focuses support
which provide enoughglucose to prevent
on theclient's autonomy. Even if the
hypoglycemia whenreceiving insulin.
nursedisagrees with his living on the street,it is
5.The HCP should be notified if the the client's right. Arranging for someone to
bloodglucose level is this high. Regular give him his insulin provides for his needs and
insulinmay need to be prescribed to keep allows hischoices
theblood glucose level within
47. The nurse is developing a care plan for
acceptablerange
the client diagnosed with type 1 diabetes.The
45. The client received 10 units of Humulin R, nurse identifies the problem "high risk for
a fast-acting insulin, at 0700. At 1030 the UAP hyperglycemia related to non compliance
tells the nurse the client has a headache and with the medication regimen." Which
is really acting "funny." Which intervention statement is an appropriate short-term goal
should the nurse implement first? for the client?
1. Instruct the UAP to obtain the blood 1. The client will have a blood glucose level
glucose level. between 90 and 140 mg/dL.
2. Have the client drink eight (8) ounces of 2. The client will demonstrate appropriate
orange juice. insulin injection technique.
3. Go to the client's room and assess the 3. The nurse will monitor the client's blood
client for hypoglycemia. glucose levels four (4) times a day.
4. Prepare to administer one (1) ampule 50% 4. The client will maintain normal kidney
dextrose intravenously. function with 30-mL/hr urine output.
RATIO: 3. Regular insulin peaks in 2 to 4 RATIO: 1.The short-term goal must address
hours.Therefore, the nurse should think about the response part of the nursing diagnosis,
the possibility the client is having a which is "high risk for hyperglycemia," and this
hypoglycemic reaction and should assess blood glucose level is within acceptable
the client. The nurse should not delegate ranges for a client who is non compliant.
nursing tasks to a UAP if the client is unstable.
46. The nurse at a free standing health care is admitted to the intensive care unit with
clinic is caring for a 56-year-old male client hyperosmolar hyperglycemic nonketonic
who is homeless and is a type 2 diabetic syndrome (HHNS) coma. Which assessment
controlled with insulin. Which action is an data should the nurse expect the client to
example of client advocacy? exhibit?
1. Kussmaul's respirations.
2. Diarrhea and epigastric pain. 51. The client diagnosed with HHNS was
admitted yesterday with a blood glucose
3. Dry mucous membranes.
level of 780 mg/dL. The client's blood glucose
4. Ketone breath odor. level is now 300 mg/dL. Which intervention
should the nurse implement?
RATIO: 3. Dry mucous membranes are a result
of the hyperglycemia and occur with both 1. Increase the regular insulin IV drip.
HHNS and DKA.
2. Check the client's urine for ketones.
49. The elderly client is admitted to the
3. Provide the client with a therapeutic
intensive care department diagnosed with
diabetic meal.
severe HHNS. Which collaborative
intervention should the nurse include in the 4. Notify the HCP to obtain an order to
plan of care? decrease insulin.
1. Infuse 0.9% normal saline intravenously. RATIO: 4. When the glucose level is
decreased to around 300 mg/dL, the regular
2. Administer intermediate-acting insulin.
insulin infusion therapy is decreased.
3. Perform blood glucometer checks daily. Subcutaneous insulin will be administered per
sliding scale.
4. Monitor arterial blood gas results.
RATIO: 1. The initial fluid replacement is is found lying unconscious on the floor of the
0.9%normal saline (an isotonic solution) bathroom. Which intervention should the
intravenously, followed by 0.45% saline.The nurse implement first?
rate depends on the client's fluid volume
status and physical health, especially of the 1. Administer 50% dextrose IVP.
heart.
2. Notify the health-care provider.
50. Which electrolyte replacement should
3. Move the client to the ICU.
the nurse anticipate being ordered by
thehealth-care provider in the client 4. Check the serum glucose level.
diagnosed with DKA who has just been
RATIO: 1. The nurse should assume the client
admitted tothe ICU?
is hypoglycemic and administer IVP dextrose,
1. Glucose. which will rouse the client immediately. If the
collapse is the result of hyperglycemia, this
2. Potassium.
additional dextrose will not further injure the
3. Calcium. client.
4. Sodium 53. Which assessment data indicate the

client diagnosed with diabetic ketoacidosis
RATIO: 2.The client in DKA loses potassium is responding to the medical treatment?
fromincreased urinary output, acidosis, cata-
bolic state, and vomiting. Replacementis 1. The client has tented skin turgor and dry
essential for preventing cardiac dys- mucous membranes.
rhythmias secondary to hypokalemia
2. The client is alert and oriented to date,
time, and place.
3. The client's ABG results are pH 7.29, PaCO2

44, HCO315.
4. The client's serum potassium level is 3.3 56. The nurse is discussing ways to prevent
mEq/L. diabetic keto acidosis with the client
diagnosed with type 1 diabetes. Which
RATIO: 2. The client's level of consciousness
instruction is most important to discuss with
can be altered because of dehydration and
the client?
acidosis. If the client's sensorium is intact, the
client is getting better and responding to the 1. Refer the client to the American Diabetes
medical treatment. Association.
54. The UAP on the medical floor tells the 2. Do not take any over-the-counter
nurse the client diagnosed with DKA wants medications.
something else to eat for lunch. Which
3. Take the prescribed insulin even when
intervention should the nurse implement?
unable to eat because of illness.
1. Instruct the UAP to get the client additional
4. Explain the need to get the annual flu and
food.
pneumonia vaccines.
2. Notify the dietitian about the client's
RATIO: 3. Illness increases blood glucose
request.
levels;therefore, the client must take
3. Request the HCP increase the client's insulinand consume high-carbohydrate
caloric intake. foodssuch as regular Jell-O, regular popsi-
cles, and orange juice
4. Tell the UAP the client cannot have
anything else. 57. The charge nurse is making client
assignments in the intensive care unit. Which
RATIO: 2. The client will not be compliant with
client should be assigned to the most
the diet if he or she is still hungry.Therefore,
experienced nurse?
the nurse should request the dietitian talk to
the client to try to adjust the meals so the 1. The client with type 2 diabetes who has a
client will adhere to the diet. blood glucose level of 348 mg/dL.
55. The emergency department nurse is 2. The client diagnosed with type 1 diabetes
caring for a client diagnosed with HHNS who who is experiencing hypoglycemia.
has a blood glucose of 680 mg/dL. Which
3. The client with DKA who has multifocal
question should the nurse ask the client to
premature ventricular contractions.
determine the cause of this acute
complication? 4. The client with HHNS who has a plasma
osmolarity of 290 mOsm/L.
1. "When is the last time you took your insulin?"
RATIO: 3. Multifocal PVCs, which are
2. "When did you have your last meal?"
secondary to hypokalemia and can occur in
3. "Have you had some type of infection clients with DKA, are a potentially life-
lately?" threatening emergency. This client needs an
experienced nurse.
4. "How long have you had diabetes?"
58. Which arterial blood gas results should the
RATIO: 3. The most common precipitating
nurse expect in the client diagnosed with
factoris infection. The manifestations may
diabetic ketoacidosis?
beslow to appear, with onset rangingfrom 24
hours to 2 weeks 1. pH 7.34, PaO299, PaCO2 48, HCO324.
2. pH 7.38, PaO295, PaCO240, HCO322.

3. pH 7.46, PaO285, PaCO230, HCO326. mechanical ventilation are not required to
treat HHS.
4. pH 7.30, PaO290, PaCO230, HCO318.
61. A client with a diagnosis of diabetic
RATIO: 4. This ABG indicates metabolic
ketoacidosis (DKA) is being treated in the
acidosis,which is expected in a client
emergency department. Which findings
diagnosedwith diabetic ketoacidosis.
would the nurse expect to note as confirming
59. The client is admitted to the ICU this diagnosis? Select all that apply.
diagnosed with DKA. Which interventions
1 Increase in pH
shouldthe nurse implement? Select all that
apply. 2.Comatose state
1. Maintain adequate ventilation. 3.Deep, rapid breathing
2. Assess fluid volume status. 4.Decreased urine output
3. Administer intravenous potassium. 5.Elevated blood glucose level
4. Check for urinary ketones. 6.Low plasma bicarbonate level
5. Monitor intake and output. 356
1, 2, 3, 4, 5 RATIO: In DKA, the arterial pH is lower than

7.35, plasma bicarbonate is lower than 15
60. A client is brought to the emergency
mEq/L, the blood glucose level is higher than
department in an unresponsive state, and a
250 mg/dL, and ketones are present in the
diagnosis of hyperglycemic hyperosmolar
blood and urine. The client would be
state (HHS) is made. The nurse would
experiencing polyuria, and Kussmaul's
immediately prepare to initiate which
respirations (deep and rapid breathing
anticipated health care provider's
pattern) would be present. A comatose state
prescription
may occur if DKA is not treated, but coma
1.Endotracheal intubation would not confirm the diagnosis.
2.100 units of NPH insulin 62. The nurse teaches a client with diabetes
mellitus about differentiating between
3.Intravenous infusion of normal saline hypoglycemia and ketoacidosis. The client
demonstrates an understanding of the
4.Intravenous infusion of sodium bicarbonate
teaching by stating that a form of glucose
RATIO: The primary goal of treatment in should be taken if which symptoms develop?
hyperglycemic hyperosmolar state (HHS) is to Select all that apply
rehydrate the client to restore fluid volume
1.Polyuria
and to correct electrolyte deficiency.
Intravenous fluid replacement is similar to 2.Shakiness
that administered in diabetic ketoacidosis
(DKA) and begins with IV infusion of normal 3.Palpitations
saline. Regular insulin, not NPH insulin, would
4.Blurred vision
be administered. The use of sodium
bicarbonate to correct acidosis is avoided 5.Lightheadedness
because it can precipitate a further drop in
6.Fruity breath odor
serum potassium levels. Intubation and
236
RATIO: Shakiness, palpitations, and
lightheadedness are signs of hypoglycemia
and would indicate the need for food or
glucose. Polyuria, blurred vision, and a fruity
breath odor are signs of hyperglycemia.
63. A client is admitted to a hospital with a

diagnosis of diabetic ketoacidosis (DKA). The
initial blood glucose level was 950 mg/dL. A
continuous intravenous infusion of short-
acting insulin is initiated, along with
intravenous rehydration with normal saline.
The serum glucose level is now 240 mg/dL.
The nurse would next prepare to administer
which item?
1.Ampule of 50% dextrose
2.NPH insulin subcutaneously
3.Intravenous fluids containing dextrose
4.Phenytoin (Dilantin) for the prevention of

seizures
RATIO: During management of DKA, when

the blood glucose level falls to 250 to 300
mg/dL, the infusion rate is reduced and a
dextrose solution is added to maintain a
blood glucose level of about 250 mg/dL, or
until the client recovers from ketosis. Fifty
percent dextrose is used to treat
hypoglycemia. NPH insulin is not used to treat
DKA. Phenytoin (Dilantin) is not a usual
treatment measure for DKA
ACUTE KIDNEY e. urine with high
INJURY specific gravity
Which descriptions If a patient is in the

characterize AKI? Select diuretic phase of AKI,
all that apply the nurse must monitor
for which serum
a. primary cause of death electrolyte imbalances?
is infection
b. it almost always
affects older people a. hyperkalemia and
c. disease course is hyponatremia
potentially reversible
b. hyperkalemia and
d. most common cause is
diabetic nephropathy hypernatremia
e. cardiovascular disease c. hypokalemia and
is most common cause of hyponatremia
death
d. hypokalemia and
hypernatremia
During the oliguric phase
of AKI, the nurse
monitors the patient The nurse is caring for a
for Select all that apply 68-yr-old man who had
a. hypotension coronary artery bypass
b. ECG changes surgery 3 weeks ago.
c. hypernatremia During the oliguric phase
d. pulmonary edema
of acute kidney disease,
which action would be
1
appropriate to include in d. Restrict fluids
the plan of care? according to previous
daily loss
a. Provide foods high in

potassium. Which patient diagnosis
b. Restrict fluids based or treatment is most
on urine output. consistent with prerenal
acute kidney injury
c. Monitor output from (AKI)?
peritoneal dialysis.
d. Offer high-protRein
snacks between meals. a. IV tobramycin
b. Incompatible blood
transfusion
When caring for a patient
during the oliguric phase c. Poststreptococcal
of acute kidney injury glomerulonephritis
(AKI), which nursing d. Dissecting abdominal
action is appropriate? aortic aneurysm
a. Weigh patient three

times weekly. The patient has rapidly
b. Increase dietary progressing glomerular
sodium and potassium. inflammation. Weight
c. Provide a low-protein, has increased and urine
high-carbohydrate diet. output is steadily
2
declining. What is the c. Hypernatremia
priority nursing d. BUN increases
intervention?
e. Urine output increases
An unlicensed assistive
a. Monitor the patient's personnel (UAP) reports
cardiac status. to the RN that a patient
b. Teach the patient about with acute kidney failure
hand washing. had a urine output of 350
c. Obtain a serum mL over the past 24
specimen for electrolytes. hours after receiving
furosemide 40 mg IV
d. Increase direct push. The UAP asks the
observation of the nurse how this can
patient. happen. What is the
nurse's best response?
Which assessment
findings would alert the a. "During the oliguric
nurse that the patient has phase of acute kidney
entered the diuretic phase failure, patients often do
of acute kidney injury not respond well to either
(AKI)? Select all that fluid challenges or
apply diuretics."
b. "There must be some
a. Dehydration sort of error. Someone
b. Hypokalemia must have failed to
record the urine output."
3
c. "A patient with acute b. Instruct patients to
kidney failure retains drink extra fluids during
sodium and water, which periods of strenuous
counteracts the action of exercise.
the furosemide." c. Immediately report a
d. "The gradual urine output of less than
accumulation of 2 mL/kg/hr.
nitrogenous waste d. Record intake and
products results in the output and weigh patients
retention of water and daily.
sodium."
e. Monitor laboratory
values that reflect kidney
The RN supervising a function.
senior nursing student is
discussing methods for
preventing acute kidney For which patient is the
injury (AKI). Which nurse most concerned
points would the RN be about the risk for
sure to include in this developing kidney
discussion? Select all that disease?
apply
a. A 25-year-old patient
a. Encourage patients to who developed a urinary
avoid dehydration by tract infection (UTI)
drinking adequate fluids. during pregnancy
4
b. A 55-year-old patient nurse will plan care to
with a history of kidney meet the goal of
stones
c. A 63-year-old patient a. replacing fluid volume.
with type 2 diabetes b. preventing
d. A 79-year-old patient hypertension.
with stress urinary c. maintaining cardiac
incontinence output.
d. diluting nephrotoxic
A patient with acute substances.
kidney injury (AKI) has
an arterial blood pH of
7.30. The nurse will A patient who has acute
assess the patient for glomerulonephritis is
hospitalized with acute
a. vasodilation. kidney injury (AKI) and
b. poor skin turgor. hyperkalemia. Which
c. bounding pulses. information will the
nurse obtain to evaluate
d. rapid respirations. the effectiveness of the
prescribed calcium
A patient with severe gluconate IV?
heart failure develops
elevated blood urea a. Urine output
nitrogen (BUN) and
creatinine levels. The b. Calcium level
5
c. Cardiac rhythm placing a catheter in the
d. Neurologic status left femoral vein. Which
intervention will be
included in the plan of
Which information will care?
be most useful to the
nurse in evaluating
improvement in kidney a. Place the patient on
function for a patient bed rest.
who is hospitalized with b. Start continuous pulse
acute kidney injury oximetry.
(AKI)? c. Discontinue the
retention catheter.
a. Blood urea nitrogen d. Restrict the patients
(BUN) level oral protein intake.
b. Urine output
c. Creatinine level Which information about
d. Calculated glomerular a patient who was
filtration rate (GFR) admitted 10 days
previously with acute
kidney injury (AKI)
In a patient with acute caused by dehydration
kidney injury (AKI) who will be most important
requires hemodialysis, a for the nurse to report to
temporary vascular the health care provider?
access is obtained by
6
a. The blood urea nitrogen (BUN) and
nitrogen (BUN) level is creatinine levels.
67 mg/dL. d. Check the chart for the
b. The creatinine level is most recent blood
3.0 mg/dL. potassium level.
c. Urine output over an 8-
hour period is 2500 mL. When caring for a
d. The glomerular dehydrated patient with
filtration rate is <30 acute kidney injury who
mL/min/1.73m2. is oliguric, anemic, and
hyperkalemic, which of
the following prescribed
After noting lengthening actions should the nurse
QRS intervals in a patient take first?
with acute kidney injury
(AKI), which action
should the nurse take a. Insert a urinary
first? retention catheter.
b. Place the patient on a
a. Document the QRS cardiac monitor.
interval. c. Administer epoetin
b. Notify the patients alfa (Epogen, Procrit).
health care provider. d. Give sodium
c. Look at the patients polystyrene sulfonate
current blood urea (Kayexalate).
7
What are intrarenal a. anaphylaxis
causes of AKI? Select all b. renal calculi
that apply
c. hypovolemia
d. nephrotoxic drugs
a. anaphylaxis
e. decreased cardiac
b. renal stones output
c. nephrotoxic drugs
d. acute ATN is the most
glomerulonephritis common cause of
e. tubular obstruction by intrarenal AKI. Which
myoglobin patient is most likely to
develop ATN?
An 83 year old female

patient was found lying a. patient with DM
on the bathroom floor. b. patient with
She said she fell 2 days hypertensive crisis
ago and has not been able
to take her heart c. patient who tried to
medicine or eat or drink overdose on
anything since then. acetaminophen
What conditions could be d. patient with major
causing prerenal AKI in surgery who required a
this patient? Select all blood transfusion
that apply
8
What indicates to the c. conservation of
nurse that a patient with potassium
oliguria has prerenal d. excretion of hydrogen
oliguria? ions
a. urine testing reveals a What indicates to the

low specific gravity nurse that a patient with
b. causative factor is AKI is in the recovery
malignant hypertension phase?
c. urine testing reveals a
high sodium a. a return to normal
concentration weight
d. reversal of oliguria b. a urine output of 3,700
occurs with fluid mL/day
replacement
c. decreasing sodium and
potassium levels
Metabolic acidosis d. decreasing BUN and
occurs in the oliguric creatinine levels
phase of AKI as a result
of impairment of
a. excretion of sodium
b. excretion of
bicarbonate While caring for the
patient in the oliguric
9
phase of AKI, the nurse irreversible metabolic
monitors the patient for acidosis
associated collaborative b. during the oliguric
problems. When should phase, daily fluid intake
the nurse notify the is limited to 1,000 ml
HCP? plus the prior day's
measured fluid loss
a. urine output is 300 c. dietary sodium and
ml/day potassium during the
b. edema occurs in the oliguric phase of AKI are
feet, legs, and sacral area managed according to the
patient's urinary output
c. cardiac monitor reveals
a depressed T wave and d. one of the most
elevated ST segment important nursing
measures in managing
d. the patient experiences fluid balance in the
increasing muscle patient with AKI is
weakness and abdominal taking accurate daily
cramping weights
In caring for the patient A 68 year old man with a

with AKI, of what should history of HF resulting
the nurse be aware? from HTN has AKI as a
result of the effects of
a. the most common nephrotoxic diuretics.
cause of death is Currently his serum
10
potassium is 6.2 with recognizes that treatment
cardiac changes, BUN is of the acid-base problem
108, serum creatinine with sodium bicarbonate
4.1, and serum HCO3 13. would cause a decrease
He is somnolent and in which value?
disoriented. Which
treatment should the
nurse expect to be used a. pH
for him? b. potassium level
c. bicarbonate level
d. carbon dioxide level
a. loop diuretics
b. renal replacement A patient with AKI is a
therapy candidate for continuous
c. insulin and sodium renal replacement
bicarbonate therapy (CRRT). What is
the most common
d. sodium polystyrene indication for use of
sulfonate (kayexalate) CRRT?
A patient with AKI has a a. pericarditis

serum potassium level of
6.7 and the following b. hyperkalemia
ABG results: pH: 7.28, c. fluid overload
PaCO2: 30, PaO2: 86, d. hypernatremia
HCO3: 18. The nurse
11
A nurse is planning care the nurse expect? Select
for a client who has all that apply
prerenal AKI following
abdominal aortic
aneurysm repair. Urinary a. reduced BUN
output is 60 ml in the b. elevated cardiac
past 2 hours, and BP is enzymes
92/58. The nurse should c. reduced urine output
expect which of the
following interventions? d. elevated blood
creatinine
e. elevated blood calcium
a. prepare the client for a
CT scan with contrast
dye A client has been
b. plan to administer admitted with acute renal
nitroprusside failure. What should the
nurse do? Select all that
c. prepare to administer a apply
fluid challenge
d. plan to position the
client in Trendelenburg a. elevate the HOB 30-45
degrees
b. take vital signs
A nurse is assessing a
client who has prerenal c. establish an IV site
AKI. Which of the d. call the admitting
following findings should healthcare provider for
prescriptions
12
e. contact the
hemodialysis unit A client with acute renal
failure has an increase in
Which initial the serum potassium
manifestation of acute level. The nurse should
renal failure is most monitor the client for
common?
a. dysuria a. cardiac arrest
b. anuria b. pulmonary edema
c. hematuria c. circulatory collapse
d. oliguria d. hemorrhage
The client who is in acute A high-carbohydrate,

renal failure has an low-protein diet is
elevated BUN. What is prescribed for the client
the likely cause of this with acute renal failure.
finding? The intended outcome of
this diet is to
a. fluid retention
b. hemolysis of RBCs a. act as a diuretic
c. below-normal b. reduce demands on the

metabolic rate liver
d. reduced renal blood c. help maintain urine

flow acidity
13
d. prevent the d. hypokalemia
development of ketosis
The client in acute renal

The client with acute failure has an external
renal failure asks the cannula inserted in the
nurse for a snack. forearm for hemodialysis.
Because the client's Which nursing measure
potassium level is is appropriate for the care
elevated, which snack is of this client?
most appropriate?
a. use the unaffected arm

a. a gelatin dessert for blood pressure
b. yogurt measurements
c. an orange b. draw blood from the

cannula for routine
d. peanuts laboratory work
c. percuss the cannula for
In the oliguric phase of bruits each shift
acute renal failure, the d. inject heparin into the
nurse should assess the cannula each shift
client for
During dialysis, the client

a. pulmonary edema has disequilibrium
b. metabolic alkalosis syndrome. The nurse
c. hypotension should first
14
my kidneys ever function
a. administer oxygen per normally again?" The
nasal cannula nurse's response is based
on the knowledge that the
b. slow the rate of client's renal status will
dialysis most likely
c. reassure the client that
the symptoms are normal
a. continue to improve
d. place the client in over a period of weeks
Trendelenburg's position
b. result in the need for
permanent hemodialysis
Which abnormal blood c. improve only if the
value would not be client receives a renal
improved by dialysis transplant
treatment?
d. result in end-stage
a. elevated serum renal failure
creatinine level
b. hyperkalemia
A client with AKI has a
c. decreased hemoglobin serum potassium level of
concentration 7.0. The nurse should
d. hypernatremia plan which actions as a
priority? Select all that
apply
The client with acute
renal failure is recovering
and asks the nurse, "will
15
a. place the client on a d. Thrombocytopenia
cardiac monitor
b. notify the HCP Which patient has the
c. put the client on NPO greatest risk for prerenal
status except for ice chips AKI?
d. review the client's
medications to determine a. The patient who is
if any contain or retain hypovolemic because of
potassium hemorrhage.
e. allow an extra 500 ml b. The patient who relates
of IV fluid intake to a history of chronic
dilute the electrolyte urinary tract obstruction.
concentration
c. The patient with
vascular changes related
to coagulopathies.
Which assessment d. The patient receiving
finding is commonly antibiotics such as
found in the oliguric gentamicin.
phase of acute kidney
injury (AKI)?
Important nursing
interventions for the
a. Hypovolemia patient with AKI are
b. Hyperkalemia Select all that apply
c. Hypernatremia
16
a. careful monitoring of A. Specific gravity of
intake and output. urine at 3 different times
b. daily patient weights. is 1.010.
c. meticulous aseptic A urinalysis may show

technique. casts, red blood cells
(RBCs), white blood
d. increase intake of cells (WBCs), a specific
vitamin A and D. gravity fixed at about
e. frequent mouth care. 1.010, and urine
osmolality at about 300
mOsm/kg.
How do you determine
that a patient's oliguria is
associated with acute
renal failure (ARF)? When caring for a patient
A. Specific gravity of during the oliguric phase
urine at 3 different times of acute kidney injury,
is 1.010. what would be an
B. The serum creatinine appropriate nursing
level is normal. intervention?
C. The blood urea A. Weigh patient three

nitrogen (BUN) level is times weekly
normal or below. B. Increase dietary
D. Hypokalemia is sodium and potassium
identified. C. Provide a low-protein,
high-carbohydrate diet
17
D. Restrict fluids
according to the previous
day's fluid loss
Which assessment
D. Restrict fluids finding is commonly
according to the previous found in the oliguric
day's fluid loss phase of acute kidney
Patients in the oliguric injury (AKI)?
phase of acute kidney A. Hypovolemia
injury have fluid volume
excess with potassium B. Hyperkalemia
and sodium retention. C. Hypernatremia
They will need to have D. Thrombocytopenia
dietary sodium,
potassium, and fluids B. Hyperkalemia
restricted. Daily fluid In AKI, the serum
intake is based on the potassium levels increase
previous 24-hour fluid because the normal
loss (measured output ability of the kidneys to
plus 600 mL for excrete potassium is
insensible loss). The diet impaired. Sodium levels
also needs to provide are typically normal or
adequate, not low, diminished, whereas fluid
protein intake to prevent volume is normally
catabolism. The patient increased due to
should also be weighed decreased urine output.
daily, not just three times Thrombocytopenia is not
per week. a consequence of AKI,
18
although altered platelet kidneys. These factors
function may occur in reduce systemic
AKI. circulation, causing a
reduction in renal blood
flow, and they lead to
decreased glomerular
Which patient has the perfusion and filtration of
greatest risk for prerenal the kidneys.
AKI?
A. The patient is
hypovolemic because of
hemorrhage.
B. The patient relates a
history of chronic urinary The patient admitted to
tract obstruction. the intensive care unit
C. The patient has after a motor vehicle
vascular changes related accident has been
to coagulopathies. diagnosed with AKI.
Which finding indicates
D. The patient is the onset of oliguria
receiving antibiotics such resulting from AKI?
as gentamicin.
A. Urine output less than
A. The patient is 1000 mL for the past 24
hypovolemic because of hours
hemorrhage.
Prerenal causes of AKI
are factors external to the
19
B. Urine output less than appropriate calculations,
800 mL for the past 24 you determine that for
hours the next 24 hours the
C. Urine output less than patient's fluid allocation
600 mL for the past 24 is
hours A. 600 mL.
D. Urine output less than B. 800 mL.
400 mL for the past 24 C. 1000 mL.
hours
D. 1200 mL.
D. Urine output less than
400 mL for the past 24 C. 1000 mL.
hours Fluid intake must be
The most common initial closely monitored during
manifestation of AKI is the oliguric phase. The
oliguria, a reduction to rule for calculating the
urine output to less than fluid restriction is to add
400 mL/day. all losses for the previous
24 hours to 600 mL for
insensible losses.
The patient in the

oliguric phase of AKI
excreted 300 mL of urine Your plan for care of a
in addition to 100 mL of patient with AKI includes
other losses during the which goal of dietary
past 24 hours. With management?
20
A. Provide sufficient nitrogen and wastes in
calories while preventing blood).
nitrogen excess.
B. Deliver adequate
calories while restricting
fat and protein intake. For the patient with AKI,
which laboratory result
C. Replace protein intake would cause you the
with enough fat intake to greatest concern?
sustain metabolism.
A. Potassium level of 5.9
D. Restrict fluids, mEq/L
increase potassium
intake, and regulate B. BUN level of 25
sodium intake. mg/dL
A. Provide sufficient C. Sodium level of 144

calories while preventing mEq/L
nitrogen excess. D. pH of 7.5
The challenge of A. Potassium level of 5.9
nutrition management in mEq/L
AKI is to provide Hyperkalemia is one of
adequate calories to the most serious
prevent catabolism complications in AKI
despite the restrictions because it can cause life-
required to prevent threatening cardiac
electrolyte and fluid dysrhythmias.
disorders and azotemia
(accumulation of
21
Observing and recording
Important nursing accurate intake and
interventions for the output are essential.
patient with AKI are Measure daily weights
(select all that apply) with the same scale at the
same time each day to
A. careful monitoring of assess excessive gains or
intake and output. losses of body fluids.
B. daily patient weights. Mouth care is important
C. meticulous aseptic to prevent stomatitis,
technique. which develops when
ammonia (produced by
D. increase intake of bacterial breakdown of
vitamin A and D. urea) in saliva irritates
E. frequent mouth care. the mucous membrane.
A. careful monitoring of
intake and output.
B. daily patient weights. What characterizes AKI
C. meticulous aseptic (select all that apply)?
technique. A. Primary cause of
E. frequent mouth care. death is infection.
You have an important B. It usually affects older
role in managing fluid people.
and electrolyte balance C. The disease course is
during the oliguric and potentially reversible.
diuretic phases of AKI.
22
D. The most common because the number of
cause is diabetic functioning nephrons
nephropathy. decreases with age.
E. Cardiovascular disease
is the most common
cause of death.
During the oliguric phase
A. Primary cause of of AKI, you monitor the
death is infection. patient for (select all that
C. The disease course is apply)
potentially reversible. A. hypertension.
AKI is potentially B. electrocardiographic
reversible. It has a high (ECG) changes.
mortality rate, and the
primary cause of death is C. hypernatremia.
infection; the primary D. pulmonary edema.
cause of death for E. urine with high
chronic kidney failure is specific gravity.
cardiovascular disease.
AKI commonly follows A. hypertension.
severe, prolonged B. electrocardiographic
hypotension or (ECG) changes.
hypovolemia or exposure D. pulmonary edema.
to a nephrotoxic agent.
You monitor the patient
Although it can occur at
in the oliguric phase of
any age, the older adult is
AKI for hypertension and
more susceptible to AKI
pulmonary edema. When
23
urinary output decreases, D. Hypokalemia and
fluid retention occurs. hypernatremia
The severity of the C. Hypokalemia and
symptoms depends on the hyponatremia
extent of the fluid
overload. In the case of In the diuretic phase of
reduced urine output AKI, the kidneys have
(anuria and oliguria), the recovered their ability to
neck veins may become excrete wastes but not to
distended and have a concentrate the urine.
bounding pulse. Hypovolemia and
hypotension can result
from massive fluid
losses. Because of the
If a patient is in the large losses of fluid and
diuretic phase of AKI, electrolytes, the patient
you must monitor for must be monitored for
which serum electrolyte hyponatremia,
imbalances? hypokalemia, and
dehydration.
A. Hyperkalemia and
hyponatremia
B. Hyperkalemia and
hypernatremia You are preparing to
C. Hypokalemia and administer a dose of
hyponatremia PhosLo to a patient with
chronic kidney disease
(CKD). This medication
24
should have a beneficial condition is characterized
effect on which by
laboratory value? A. Progressive
A. Sodium irreversible destruction of
B. Potassium the kidneys
C. Magnesium B. A rapid decrease in

urinary output with an
D. Phosphorus elevated BUN level
D. Phosphorus C. Increasing creatinine
Phosphorus and calcium clearance with a decrease
have inverse or reciprocal in urinary output
relationships, meaning D. Prostration,
that when phosphorus somnolence, and
levels are high, calcium confusion with coma and
levels tend to be low. imminent death
Administration of
calcium should help to A. Progressive
reduce a patient's irreversible destruction of
abnormally high the kidneys
phosphorus level, as seen CKD involves
in CKD. progressive, irreversible
loss of kidney function.
A patient is admitted to
the hospital with CKD. Nurses need to educate
You understand that this patients at risk for CKD.
25
Which individuals are hypertension, age older
considered to be at than 60 years,
increased risk (select all cardiovascular disease,
that apply)? family history of CKD,
A. Older African exposure to nephrotoxic
Americans drugs, and ethnic
minorities (e.g., African
B. Individuals older than American, Native
60 years American).
C. Those with a history
of pancreatitis
D. Those with a history
of hypertension Patients with CKD have
an increased incidence of
E. Those with a history cardiovascular disease
of type 2 diabetes related to (select all that
A. Older African apply)
Americans A. hypertension.
B. Individuals older than B. vascular calcifications.
60 years
C. a genetic
D. Those with a history predisposition.
of hypertension
D. hyperinsulinemia
E. Those with a history causing dyslipidemia.
of type 2 diabetes
E. increased high-density
Risk factors for CKD lipoproteins levels.
include diabetes mellitus,
A. hypertension.
26
B. vascular calcifications. CKD. Calcium deposits
D. hyperinsulinemia in the vascular medial
causing dyslipidemia. layer are associated with
stiffening of the blood
Traditional vessels. The mechanisms
cardiovascular risk involved are
factors, such as multifactorial and
hypertension and incompletely understood,
elevated lipid levels, are but they include (1)
common in CKD vascular smooth muscle
patients. cells that change into a
Hyperinsulinemia chondrocyte or
stimulates hepatic osteoblast-like cell, (2)
production of high total body calcium
triglycerides. Most and phosphate levels due
patients with uremia to abnormal bone
develop dyslipidemia. metabolism, (3) impaired
Much of the renal excretion, and (4)
cardiovascular disease drug therapies to treat the
may be related to bone disease (e.g.,
nontraditional risk factors calcium phosphate
such as vascular binders).
calcification and arterial
stiffness. Vascular
calcification and arterial
stiffness are major Measures indicated in the
contributors to conservative therapy of
cardiovascular disease in CKD include
27
A. decreased fluid intake, those receiving
carbohydrate intake, and hemodialysis, as their
protein intake. urinary output
B. increased fluid intake; diminishes, fluid
decreased carbohydrate restrictions are enhanced.
intake and protein intake. Intake depends on the
daily urine output.
C. decreased fluid intake Generally, 600 mL (from
and protein intake; insensible loss) plus an
increased carbohydrate amount equal to the
intake. previous day's urine
D. decreased fluid intake output is allowed for a
and carbohydrate intake; patient receiving
increased protein intake. hemodialysis. Patients
C. decreased fluid intake are advised to limit fluid
and protein intake; intake so that weight
increased carbohydrate gains are no more than 1
intake. to 3 kg between dialyses
(interdialytic weight
Water and any other gain). For the patient who
fluids are not routinely is undergoing dialysis,
restricted in the pre-end- protein is not routinely
stage renal disease restricted. The beneficial
(ESRD) stages. Patients role of protein restriction
on hemodialysis have a in CKD stages 1 through
more restricted diet than 4 as a means to reduce
patients receiving the decline in kidney
peritoneal dialysis. For function is being studied.
28
Historically, dietary A. remove fluid without
counseling often the use of a dialysate.
encouraged restriction of B. remove fluid in less
protein for CKD patients. than 24 hours.
Although there is some
evidence that protein C. allow the patient to
restriction has benefits, receive the therapy at the
many patients find these work site.
diets difficult to adhere D. be administered
to. For CKD stages 1 through a peripheral line.
through 4, many A. remove fluid without
clinicians encourage a the use of a dialysate.
diet with normal protein
intake. However, you Several features of
should teach patients to continuous replacement
avoid high-protein diets therapy are different from
and supplements because those of hemodialysis.
they may overstress the Solute removal can occur
diseased kidneys. by convection (no
dialysate required) in
addition to osmosis and
diffusion. The process
The advantage of can take days or weeks.
continuous replacement The patient cannot
therapy over receive the therapy at
hemodialysis is its ability work and a vascular
to access device is required.
29
bloody or blood tinged, a
You are caring for a possible rupture in the
patient receiving filter membrane should
continuous replacement be suspected, and
therapy and notice that treatment is suspended
the filtrate is blood immediately to prevent
tinged. What is your blood loss and infection.
priority action?
A. Place the patient in
Trendelenburg position. A patient with a history
B. Initiate a peripheral of end-stage renal disease
intravenous line. (ESRD) resulting from
C. Suspend treatment diabetes mellitus has
immediately. presented to the
outpatient dialysis unit
D. Administer vitamin K for his scheduled
(Aquamephyton) per hemodialysis. Which
order. assessment should you
C. Suspend treatment prioritize before, during,
immediately. and after his treatment?
The ultrafiltrate should A. Level of
be clear yellow, and consciousness
specimens may be B. Blood pressure and
obtained for evaluation of fluid balance
serum chemistries. If the
ultrafiltrate becomes C. Temperature, heart
rate, and blood pressure
30
D. Assessment for signs technique to prevent
and symptoms of peritonitis."
infection B. "You will be allowed
B. Blood pressure and a more liberal protein
fluid balance diet after you complete
Although all of the CAPD."
assessments are relevant C. "It is important for
to the care of a patient you to maintain a daily
receiving hemodialysis, written record of blood
the nature of the pressure and weight."
procedure indicates a D. "You must continue
particular need to regular medical and
monitor blood pressure nursing follow-up visits
and fluid balance. while performing
CAPD."
A. "It is essential that you
Which statement maintain aseptic
regarding continuous technique to prevent
ambulatory peritoneal peritonitis."
dialysis (CAPD) is of Peritonitis is a potentially
highest priority when fatal complication of
teaching a patient new to peritoneal dialysis, and it
this procedure? is imperative to teach the
A. "It is essential that you patient methods to
maintain aseptic prevent it from occurring.
Although the other
31
teaching statements are neurovascular status
accurate, they do not distal to the graft.
address the potential for C. Listen with a
mortality by peritonitis, stethoscope over the graft
making that nursing for presence of a bruit.
action the highest
priority. A thrill can be felt by
palpating the area of
anastomosis of the
arteriovenous graft, and a
How should you assess bruit can be heard with a
the patency of a newly stethoscope. The bruit
placed arteriovenous and thrill are created by
graft for dialysis? arterial blood rushing
into the vein.
A. Irrigate the graft daily
with low-dose heparin.
B. Monitor for any
increase in blood What are the main
pressure in the affected advantages of peritoneal
arm. dialysis compared to
C. Listen with a hemodialysis?
stethoscope over the graft A. No medications are
for presence of a bruit. required because of the
D. Frequently monitor enhanced efficiency of
the pulses and the peritoneal membrane
in removing toxins.
32
B. The diet is less approximately 24 hours
restricted and dialysis can earlier. What is an
be performed at home. expected assessment
C. The dialysate is finding for this patient
biocompatible and causes during the early stage of
no long-term recovery?
consequences. A. Hypokalemia
D. High glucose B. Hyponatremia
concentrations of the C. Large urine output
dialysate cause a
reduction in appetite, D. Leukocytosis with
promoting weight loss. cloudy urine output
B. The diet is less C. Large urine output

restricted and dialysis can Patients frequently
be performed at home. experience diuresis in the
Advantages of peritoneal hours and days
dialysis include fewer immediately after kidney
dietary restrictions and transplantation.
home dialysis is possible. Electrolyte imbalances
and signs of infection are
unexpected findings that
warrant prompt
A patient is recovering in intervention.
the intensive care unit
(ICU) after receiving a
kidney transplant
33
An ESRD patient D. Hemodialysis replaces
receiving hemodialysis is the normal functions of
considering asking a the kidneys, and patients
relative to donate a do not have to live with
kidney for the continual fear of
transplantation. In rejection.
assisting the patient to A. Successful
make a decision about transplantation usually
treatment, what do you provides better quality of
tell the patient? life than that offered by
A. Successful dialysis.
transplantation usually Kidney transplantation is
provides better quality of extremely successful,
life than that offered by with 1-year graft survival
dialysis. rates of about 90% for
B. If rejection of the deceased donor
transplanted kidney transplants and 95% for
occurs, no further live donor transplants.
treatment for the renal An advantage of kidney
failure is available. transplantation compared
C. The with dialysis is that it
immunosuppressive reverses many of the
therapy that is required pathophysiologic changes
after transplantation associated with renal
causes fatal malignancies failure when normal
in many patients. kidney function is
restored. It also
34
eliminates the common after
dependence on dialysis transplantation.
and the accompanying D. Notify the
dietary and lifestyle nephrologist that the
restrictions. patient has developed
Transplantation is also symptoms of acute
less expensive than rejection.
dialysis after the first
year.
The nurse is caring for a
client with acute kidney
injury (AKI). Which
A kidney transplant condition should the
recipient complains of nurse recognize as a
fever, chills, and dysuria possible cause for this
over the past 2 days. disease? (Select all that
What is the first action apply.)
that you should take?
A. Assess temperature A. Severe heart failure
and initiate a workup to
rule out infection. B. Major trauma
B. Provide warm covers C. Radiologic contrast

for the patient and give 1 media
gram of acetaminophen D. Hemorrhage
orally. E. Cerebrovascular
C. Reassure the patient disease
and let him know this is
35
injury (AKI) should the
The nurse preceptor is nurse consider the
teaching a new graduate priority?
about conditions that can
cause damage to the renal
parenchyma and A. Fluid overload
nephrons resulting in B. Hyperperfusion
acute kidney injury C. Urinary obstruction
(AKI). Which condition
should the nurse D. Diminished cardiac
preceptor include? output
The nurse is describing to
A. Glomerulonephritis a colleague how the
accumulation of
B. Hemolysis metabolites in the blood
C. Dehydration from renal failure affects
D. Hypertension the body. Which effect
should the nurse include?
E. Vasculitis
critically-ill client who A. Decreased levels of
experienced significant nitrogenous wastes in
blood loss during blood
surgery. Which concern B. Increased pain
related to the client's risk C. Altered electrolyte
for prerenal acute kidney balance
36
D. Bradycardia Which diet instruction
should the nurse include?
A nurse is caring for a
pregnant woman. Which
physiologic condition A. Eat high-calcium
may occur during foods.
pregnancy and is related B. Eat foods low in
to the development of saturated fat.
acute kidney injury
(AKI) that should C. Eat foods high in
concern the nurse? potassium.
(Select all that apply.) D. Eat low-phosphorus
foods.
A. Preeclampsia E. Eat foods low in

potassium.
B. Hypoglycemia
C. Hypertension
D. Hyperemesis
gravidarum The nurse is discussing
management of acute
E. Hydronephrosis kidney injury (AKI) with
the client. Which would
The nurse is reviewing describe the key goal to
discharge instructions managing this condition?
with a client with acute
renal injury (AKI).
37
A. Maintaining fluid and D. Avoid taking iron
electrolyte balance supplementation.
B. Avoiding the use of
diuretics
C. Eating more The nurse describes the
vegetables that are low in increased risk of
iron gastrointestinal bleeding
D. Drinking more fluids to a client with AKI.
Which factor should the
nurse inform the client
The nurse is discussing about with regard to
medications with a client medication? (Select all
with acute kidney injury that apply.)
(AKI) upon discharge.
Which should be
included in the teaching? A. "Avoid magnesium-
based antacids."
A. Avoid taking B. "Regular doses of

acetaminophen (Tylenol). antacids are indicated."
B. Avoid taking C. "Take antacids at

NSAIDS. bedtime."
C. Avoid taking blood D. "Over-the-counter

pressure medication at calcium carbonate
night. (Tums) is helpful."
38
E. "Drink milk to coat the
stomach prior to taking A client diagnosed with
medication." acute kidney injury
(AKI) is experiencing
A 63-year-old man is hyperkalemia. Which
admitted with postrenal medication should the
acute kidney injury nurse anticipate being
(AKI) because of a prescribed to this client?
kidney stone. Vascular (Select all that apply.)
volume and renal
perfusion have been A. Angiotensin-
restored and he is on converting enzyme
fluid restriction. During (ACE) inhibitors
the past 24 hours, he has
voided 250 mL of urine. B. Glucose
He has not had any other C. Insulin
type of output. How D. Sodium bicarbonate
much fluid should the
client receive over the E. Calcium chloride
next 24 hours?
A client experiencing
A. 2750 mL hyperkalemia is
scheduled for dialysis.
B. 1250 mL The nurse anticipates an
C. 750 mL order for insulin to help
D. 3000 mL lower the serum
potassium level. Which
39
beneficial action does B. H2-receptor antagonist
this medication have for C. Calcium chloride
this client?
D. Lactated Ringer
A. Pulls fluid from the

cells A client is being
discharged following the
B. Lowers the blood placement of an AV
glucose rate fistula. The nurse is
C. Drives the potassium providing discharge
back into the cells instructions to the client
D. Acts as an regarding the fistula.
anticoagulant Which should the nurse
share during this session?
The nurse is treating a

client with a serum A. "The fistula will not
potassium level of be functional for dialysis
6.7mEq/L who is already for a month."
on restricted potassium B. "The fistula will heal
intake. Which medication within a week."
may be ordered to reduce C. "This is temporary
the neuromuscular effects access for dialysis."
of this increased serum
level? D. "This fistula is created
by joining two arteries
together."
A. Antibiotic
40
A. Recent exposure to
Which data should the nephrotoxic medications
nurse collect when B. Reports of weight loss
completing a physical C. Reports of anorexia
examination on a client
experiencing acute D. Previous transfusion
kidney injury (AKI)? reactions
(Select all that apply.) E. Chronic diseases
A. Weight The nurse is providing

B. Reports of edema discharge instructions to
a client going home on
C. Lung sounds 80mg of furosemide
D. History of diabetes (Lasix), a loop diuretic,
mellitus twice a day. Which
E. Skin color teaching should be
included in these
instructions? (Select all
The nurse is completing a that apply.)
health history on a client
admitted with acute renal
failure. Which A. Take with water
information should the only."
nurse collect? (Select all B. "Avoid using
that apply.) nonsteroidal anti-
inflammatory drugs
(NSAIDs)."
41
C. "Rise slowly from E. Because chair scales
lying or sitting position." are the most accurate
D. "Do not take at the
same time as other
medications."
The nurse notes that the
E. "Take in the morning plan of care for a client
and at bedtime." with acute kidney injury
(AKI) instructs them to
For which reason did the reposition the client
nurse place a chair scale every 2 hours while in
in the room of a client bed. Which is the
who has been admitted rationale behind this
with acute kidney injury instruction?
(AKI)? (Select all that
apply.) A. To avoid skin
breakdown
A. Because equipment B. To keep skin dry
calibration can vary C. To avoid bone
B. To ensure an accurate fractures
weight D. To keep the client
C. Limited availability of awake
equipment
D. To utilize standard
technique
42
medicine or eat or drink
ACUTE KIDNEY anything since then.
INJURY & CHRONIC What conditions could be
KIDNEY INJURY causing prerenal AKI in
this patient (select all that
apply)?
What are intrarenal a. Anaphylaxis
causes of acute kidney
injury (AKI) (select all b. Renal calculi
that apply)? c. Hypovolemia
a. Anaphylaxis d. Nephrotoxic drugs
b. Renal stones e. Decreased cardiac
c. Bladder cancer output
d. Nephrotoxic drugs
e. Acute Acute tubular necrosis
glomerulonephritis (ATN) is the most
common cause of
f. Tubular obstruction by intrarenal AKI. Which
myoglobin patient is most likely to
develop ATN?
An 83-year-old female a. Patient with diabetes
patient was found lying mellitus
on the bathroom floor.
She said she fell 2 days b. Patient with
ago and has not been able hypertensive crisis
to take her heart
43
c. Patient who tried to What indicates to the
overdose on nurse that a patient with
acetaminophen oliguria has prerenal
d. Patient with major oliguria?
surgery who required a a. Urine testing reveals a
blood transfusion low specific gravity.
Priority Decision: A b. Causative factor is
dehydrated patient is in malignant hypertension.
the Injury stage of the c. Urine testing reveals a
RIFLE staging of AKI. high sodium
What would the nurse concentration.
first anticipate in the
treatment of this patient? d. Reversal of oliguria
occurs with fluid
a. Assess daily weight replacement.
b. IV administration of
fluid and furosemide
(Lasix) In a patient with AKI,
which laboratory
c. IV administration of urinalysis result indicates
insulin and sodium tubular damage?
bicarbonate
a. Hematuria
d. Urinalysis to check for
sediment, osmolality, b. Specific gravity fixed
sodium, and specific at 1.010
gravity treatment. c. Urine sodium of 12
mEq/L (12 mmol/L)
44
d. Osmolality of 1000 c. Decreasing sodium and
mOsm/kg (1000 potassium levels
mmol/kg) d. Decreasing blood urea
nitrogen (BUN) and
Metabolic acidosis creatinine levels
occurs in the oliguric
phase of AKI as a result While caring for the
of impairment of patient in the oliguric
a. ammonia synthesis. phase of AKI, the nurse
b. excretion of sodium. monitors the patient for
associated collaborative
c. excretion of problems. When should
bicarbonate. the nurse notify the
d. conservation of health care provider?
potassium. a. Urine output is 300
mL/day.
What indicates to the b. Edema occurs in the
nurse that a patient with feet, legs, and sacral area.
AKI is in the recovery c. Cardiac monitor
phase? reveals a depressed T
a. A return to normal wave and elevated ST
weight segment.
b. A urine output of 3700 d. The patient
mL/day experiences increasing
45
muscle weakness and taking accurate daily
abdominal cramping. weights.
In caring for the patient A 68-year-old man with a

with AKI, what should history of heart failure
the nurse be aware of? resulting from
a. The most common hypertension has AKI as
cause of death in AKI is a result of the effects of
irreversible metabolic nephrotoxic diuretics.
acidosis. Currently his serum
potassium is 6.2 mEq/L
b. During the oliguric (6.2 mmol/L) with
phase of AKI, daily fluid cardiac changes, his
intake is limited to 1000 BUN is 108 mg/dL (38.6
mL plus the prior day's mmol/L), his serum
measured fluid loss. creatinine is 4.1 mg/dL
c. Dietary sodium and (362 mmol/L), and his
potassium during the serum HCO3− is 14
oliguric phase of AKI are mEq/L (14 mmol/L). He
managed according to the is somnolent and
patient's urinary output. disoriented. Which
d. One of the most treatment should the
important nursing nurse expect to be used
measures in managing for him?
fluid balance in the a. Loop diuretics
patient with AKI is
46
b. Renal replacement d. A 64-year-old woman
therapy with chronic heart failure
c. Insulin and sodium admitted with bloody
bicarbonate stools
d. Sodium polystyrene e. A 58-year-old man

sulfonate (Kayexalate) with prostate cancer
undergoing preoperative
workup for
Prevention of AKI is prostatectomya, b, c, d, e.
important because of the High-risk patients
high mortality rate. include those exposed
Which patients are at
increased risk for AKI
(select all that apply)? Priority Decision: A
patient on a medical unit
a. An 86-year-old woman has a potassium level of
scheduled for a cardiac 6.8 mEq/L. What is the
catheterization priority action that the
b. A 48-year-old man nurse should take?
with multiple injuries a. Place the patient on a
from a motor vehicle cardiac monitor.
accident
b. Check the patient's
c. A 32-year-old woman blood pressure (BP).
following a C-section
delivery for abruptio c. Instruct the patient to
placentae avoid high-potassium
foods.
47
d. Call the lab and seriousness of her
request a redraw of the chronic kidney disease
lab to verify results. (CKD), the nurse knows
that
A patient with AKI has a the stage of CKD is

serum potassium level of based on what?
6.7 mEq/L (6.7 mmol/L) a. Total daily urine
and the following arterial output
blood gas results: pH b. Glomerular filtration
7.28, PaCO20 mm Hg, rate
PaO286 mm Hg,
HCO3−18 mEq/L (18 c. Degree of altered
mmol/L). The nurse mental status
recognizes that treatment d. Serum creatinine and
of the acid-base problem urea levels
with sodium bicarbonate
would cause a decrease
in which value? The patient with CKD is
receiving dialysis, and
a. pH the nurse observes
b. Potassium level excoriations on the
c. Bicarbonate level patient's skin. What
pathophysiologic changes
d. Carbon dioxide level in CKD can contribute to
this finding (select all
In replying to a patient's that apply)?
questions about the a. Dry skin
48
b. Sensory neuropathy binders, and limited fluid
c. Vascular calcifications intake
d. Calcium-phosphate
skin deposits The patient with CKD is
e. Uremic crystallization brought to the emergency
from high BUN department with
Kussmaul respirations.
a, b, d. Pruritus is What does the nurse
common in patients know about CKD that
receiving dialysis. could cause this patient's
Kussmaul respirations?
What causes the a. Uremic pleuritis is
gastrointestinal (GI) occurring.
manifestation of b. There is decreased
stomatitis in the patient pulmonary macrophage
with CKD? activity.
a. High serum sodium c. They are caused by
levels respiratory compensation
b. Irritation of the GI for metabolic acidosis.
tract from creatinine d. Pulmonary edema
c. Increased ammonia from heart failure and
from bacterial breakdown fluid overload is
of urea occurring.
d. Iron salts, calcium-
containing phosphate
49
Which serum laboratory related to alterations in
value indicates to the calcium and phosphorus
nurse that the patient's metabolism. What is the
CKD is getting worse? pathologic process
a. Decreased BUN directly related to the
increased risk for
b. Decreased sodium fractures?
c. Decreased creatinine a. Loss of aluminum
d. Decreased calculated through the impaired
glomerular filtration rate kidneys
(GFR) b. Deposition of calcium
phosphate in soft tissues
What is the most serious of the body
electrolyte disorder c. Impaired vitamin D
associated with kidney activation resulting in
disease? decreased GI absorption
a. Hypocalcemia of calcium
b. Hyperkalemia d. Increased release of

parathyroid hormone in
c. Hyponatremia response to decreased
d. Hypermagnesemia calcium levels
For a patient with CKD Priority Decision: What

the nurse identifies a is the most appropriate
nursing diagnosis of risk snack for the nurse to
for injury: fracture
50
offer a patient with stage a. anemia.
4 CKD? b. hypertension.
a. Raisins c. hyperkalemia.
b. Ice cream d. mineral and bone
c. Dill pickles disorder.
d. Hard candy
Which drugs will be used
Which complication of to treat the patient with
chronic kidney disease is CKD for mineral and
treated with bone disorder (select all
erythropoietin (EPO)? that apply)?
a. Anemia a. Cinacalcet (Sensipar)
b. Hypertension b. Sevelamer (Renagel)
c. Hyperkalemia c. IV glucose and insulin
d. Mineral and bone d. Calcium acetate

disorder (PhosLo)
e. IV 10% calcium
gluconate
The patient with CKD
asks why she is receiving
nifedipine (Procardia) What accurately
and furosemide (Lasix). describes the care of the
The nurse understands patient with CKD?
that these drugs are being a. A nutrient that is
used to treat the patient's commonly supplemented
51
for the patient on dialysis a. angina.
because it is dialyzable is b. asthma.
iron.
c. hypertension.
b. The syndrome that
includes all of the signs d. rheumatoid arthritis.
and symptoms seen in the
various body systems in The patient with chronic
CKD is azotemia. kidney disease is
c. The use of morphine is considering whether to
contraindicated in the use peritoneal dialysis
patient with CKD (PD) or hemodialysis
because accumulation of (HD). What are
its metabolites maycause advantages of PD when
seizures. compared to HD (select
d. The use of calcium- all that apply)?
based phosphate binders a. Less protein loss
in the patient with CKD b. Rapid fluid removal
is contraindicated when
serum calciumlevels are c. Less cardiovascular
increased. stress
During the nursing d. Decreased

assessment of the patient hyperlipidemia
with renal insufficiency, e. Requires fewer dietary
the nurse asks the patient restrictions
specifically about a
history of
52
What does the dialysate c. Continuous
for PD routinely contain? venovenous
a. Calcium in a lower hemofiltration (CVVH)
concentration than in the d. Continuous
blood ambulatory peritoneal
b. Sodium in a higher dialysis (CAPD)
concentration than in the
blood To prevent the most
c. Dextrose in a higher common serious
concentration than in the complication of PD, what
blood is important for the nurse
d. Electrolytes in an to do?
equal concentration to a. Infuse the dialysate
that of the blood slowly.
b. Use strict aseptic
In which type of dialysis technique in the dialysis
does the patient dialyze procedures.
during sleep and leave c. Have the patient empty
the fluid in the abdomen the bowel before the
during the day? inflow phase.
a. Long nocturnal d. Reposition the patient
hemodialysis frequently and promote
b. Automated peritoneal deep breathing.
dialysis (APD)
53
A patient on arteriovenous fistula
hemodialysis develops a (AVF). What should the
thrombus of a nurse explain to him that
subcutaneous will occur during
arteriovenous (AV) graft, dialysis?
requiring its removal. a. He will be able to visit,
While waiting for a read, sleep, or watch TV
replacement graft or while reclining in a chair.
fistula, the patient is most
likely to have what done b. He will be placed on a
for treatment? cardiac monitor to detect
any adverse effects that
a. Peritoneal dialysis might occur.
b. Peripheral vascular c. The dialyzer will
access using radial artery remove and hold part of
c. Silastic catheter his blood for 20 to 30
tunneled subcutaneously minutes to remove the
to the jugular vein waste products.
d. Peripherally inserted d. A large catheter with
central catheter (PICC) two lumens will be
line inserted into inserted into the fistula to
subclavian vein send blood to and return
A man with end-stage it from the dialyzer.
kidney disease is
scheduled for What is the primary way
hemodialysis following that a nurse will evaluate
healing of an the patency of an AVF?
54
a. Palpate for pulses A patient rapidly
distal to the graft site. progressing toward end-
b. Auscultate for the stage kidney disease asks
presence of a bruit at the about the possibility of a
site. kidney transplant. In
responding to the patient,
c. Evaluate the color and the nurse knows that
temperature of the what is a contraindication
extremity. to kidney
d. Assess for the presence transplantation?
of numbness and tingling a. Hepatitis C infection
distal to the site.
b. Coronary artery
disease
A patient with AKI is a c. Refractory
candidate for continuous hypertension
renal replacement
therapy (CRRT). What is d. Extensive vascular
the most common disease
indication for use of Priority Decision: During

CRRT? the immediate
postoperative care of a
a. Azotemia recipient of a kidney
b. Pericarditis transplant, what should
c. Fluid overload the nurse expect to do?
d. Hyperkalemia a. Regulate fluid intake

hourly based on urine
output.
55
b. Monitor urine-tinged The nurse is caring for a
drainage on abdominal 68-year-old man who had
dressing. coronary artery bypass
c. Medicate the patient surgery 3 weeks ago. If
frequently for incisional the patient is now is in
flank pain. the oliguric phase of
acute kidney disease,
d. Remove the urinary which action would be
catheter to evaluate the appropriate to include in
ureteral implant. the plan of care?
A.Provide foods high in
A patient received a potassium.
kidney transplant last B.Restrict fluids based on
month. Because of the urine output.
effects of
immunosuppressive C.Monitor output from
drugs and CKD, what peritoneal dialysis
complication of D.Offer high protein
transplantation should the snacks between meals.
nurse be assessing the
patient for to decrease the
risk of mortality?
a. Infection
b. Rejection
c. Malignancy A 52-year-old man with
stage 2 chronic kidney
d. Cardiovascular disease disease is scheduled for
56
an outpatient diagnostic A.fatigue.
procedure using contrast B. flank tenderness.
media. Which action
should the nurse take? C.cardiac dysrhythmias.
A.Assess skin turgor to D.elevated triglycerides.

determine hydration
status. A frail 72-year-old
B.Insert a urinary woman with stage 3
catheter for the expected chronic kidney disease is
diuresis. cared for at home by her
C.Evaluate the patient's family. The patient has a
lower extremities for history of taking many
edema over-the-counter
medications. Which over-
D. Check the patient's the-counter medications
urine for the presence of should the nurse teach
ketones the patient to avoid?
A.Aspirin
A 56-year-old woman B. Acetaminophen
with type 2 diabetes (Tylenol)
mellitus and chronic
kidney disease has a C. Diphenhydramine
serum potassium level of (Benadryl)
6.8 mEq/L. The nurse D.Aluminum hydroxide
should assess the patient (Amphogel)
for
57
to a patient with chronic
kidney disease (CKD)
should know that this
The home care nurse medication should have a
visits a 34-year-old beneficial effect on
woman receiving which laboratory value?
peritoneal dialysis.
Which statement, if made A.Sodium
by the patient, indicates a B.Potassium
need for immediate C. Magnesium
follow-up by the nurse?
D. Phosphorus
A. "Drain time is faster if
I rub my abdomen."
B."The fluid draining Which statement by the
from the catheter is nurse regarding
cloudy." continuous ambulatory
peritoneal dialysis
C."The drainage is (CAPD) would be of
bloody when I have my highest priority when
period." teaching a patient new to
D."I wash around the this procedure?
catheter with soap and A. "It is essential that you
water." maintain aseptic
technique to prevent
The nurse preparing to peritonitis.
administer a dose of B. "You will be allowed
calcium acetate (PhosLo) a more liberal protein
58
diet once you complete B. Blood pressure and
CAPD." fluid balance
C."It is important for you C.Temperature, heart
to maintain a daily rate, and blood pressure
written record of blood D.Assessment for signs
pressure and weight." and symptoms of
D."You will need to infection
continue regular medical
and nursing follow-up
visits while performing A patient is recovering in
CAPD." the intensive care unit
(ICU) after receiving a
kidney transplant
approximately 24 hours
A patient with a history ago. What is an expected
of end-stage kidney assessment finding for
disease secondary to this patient during this
diabetes mellitus has early stage of recovery?
presented to the A.Hypokalemia
outpatient dialysis unit B. Hyponatremia
for his scheduled
hemodialysis. Which C.Large urine output
assessments should the D. Leukocytosis with
nurse prioritize before, cloudy urine output
during, and after his
treatment?
A.Level of consciousness
59
Which assessment The patient has a form of
finding is a consequence glomerular inflammation
of the oliguric phase of that is progressing
AKI? rapidly. She is gaining
A. Hypovolemia weight, and the urine
output is steadily
B. Hyperkalemia declining. What is the
C. Hypernatremia priority nursing
D.Thrombocytopenia intervention?
A.Monitor the patient's
cardiac status.
The patient was
diagnosed with prerenal B.Teach the patient about
AKI. The nurse should hand washing.
know that what is most C.Obtain a serum
likely the cause of the specimen for electrolytes.
patient's diagnosis? D. Increase direct
A.IV tobramycin observation of the
(Nebcin) patient.
B.Incompatible blood
transfusion The nurse knows the
C.Poststreptococcal patient with AKI has
glomerulonephritis entered the diuretic phase
D.Dissecting abdominal when what assessments
aortic aneurysm. occur (select all that
apply)?
60
A.Dehydration C.Watermelon and ice
B.Hypokalemia cream with chocolate
sauce
C.Hypernatrimia
D.Bran cereal with ½
D.BUN increases banana and milk and
E.Serum Creatinine orange juice
Increases Which patient should be
Dehydration, taught preventive
Hypokalemia measures for CKD by the
nurse because this patient
is most likely to develop
A 78-year-old patient has CKD?
Stage 3 CKD and is
being taught about a low A.A 50-year-old white
potassium diet. The nurse female with hypertension
knows the patient B.A 61-year-old Native
understands the diet American male with
when the patient selects diabetes
which foods to eat? C.A 40-year-old Hispanic
A.Apple, green beans, female with
and a roast beef sandwich cardiovascular disease
B.Granola made with D.A 28-year-old African
dried fruits, nuts, and American female with a
seeds urinary tract infection
61
Diffusion, osmosis, and A.Administer hypertonic
ultrafiltration occur in saline.
both hemodialysis and B.Administer a blood
peritoneal dialysis. The transfusion
nurse should know that
ultrafiltration in C.Decrease the rate of
peritoneal dialysis is fluid removal.
achieved by which D.administer antiemetic
method? medications.
A.Increasing the pressure
gradient A 24-year-old female
B.Increasing osmolality donated a kidney via a
of the dialysate laparoscopic donor
C.Decreasing the glucose nephrectomy to a non-
in the dialysate related recipient. The
patient is experiencing a
D.Decreasing the lot of pain and refuses to
concentration of the get up to walk. How
dialysate should the nurse handle
this situation?
During hemodialysis, the A.Have the transplant
patient develops light- psychologist convince
headedness and nausea. her to walk.
What should the nurse do B. Encourage even a
for the patient? short walk to avoid
complications of surgery.
62
C.Tell the patient that no D. Continuous
other patients have ever ambulatory peritoneal
refused to walk. dialysis (CAPD)
D.Tell the patient she is
lucky she did not have an ______________ is
open nephrectomy. solely filtered from the
bloodstream via the
The physician has glomerulus and is NOT
decided to use renal reabsorbed back into the
replacement therapy to bloodstream but is
remove large volumes of excreted through the
fluid from a patient who urine.
is hemodynamically A. Urea
unstable in the intensive B. Creatinine
care unit. The nurse
should expect which C. Potassium
treatment to be used for D. Magnesium
this patient? The answer is B.
A.Hemodialysis (HD) 3 Creatinine is a waste
times per week product from muscle
B.Automated peritoneal breakdown and is
dialysis (APD) removed from the
bloodstream via the
C.Continuous glomerulus of the
venovenous nephron. It is the only
hemofiltration (CVVH) substance that is solely
63
filtered out of the blood rate indicates how well
but NOT reabsorbed back the glomerulus is filtering
into the system. It is the blood. A normal GFR
excreted out through the tends to be 90 mL/min or
urine. This is why a higher. A GFR of 40
creatinine clearance test mL/min indicates that the
is used as an indicator for kidney's ability to filter
determining renal the blood is decreased.
function and for Therefore, the kidneys
calculating the will be unable to remove
glomerular filtration rate. waste and excessive
A patient with acute renal water from the
injury has a GFR blood...hence
(glomerular filtration hypervolemia and an
rate) of 40 mL/min. increased BUN level will
Which signs and present in this patient.
symptoms below may The patient will
this patient present with? experience
Select all that apply: HYPERkalemia (not
hypo) because the
A. Hypervolemia kidneys are unable to
B. Hypokalemia remove potassium from
C. Increased BUN level the blood. In addition, an
INCREASED creatinine
D. Decreased Creatinine level (not decreased) will
level present because the
The answers are A and C. kidneys cannot remove
The glomerular filtration
64
excessive waste products, minute that contain no
such as creatinine. amounts of creatinine in
it. Remember creatinine
is a waste product of
You're assessing morning muscle breakdown.
lab values on a female Therefore, the kidneys
patient who is recovering should be able to remove
from a myocardial excessive amounts of it
infraction. Which lab from the bloodstream. A
value below requires you patient who has
to notify the physician? experienced a myocardial
A. Potassium level 4.2 infraction is at risk for
mEq/L pre-renal acute injury due
B. Creatinine clearance to decreased cardiac
35 mL/min output to the kidneys
from a damaged heart
C. BUN 20 mg/dL muscle (the heart isn't
D. Blood pH 7.40 able to pump as
The answer is B. A efficiently because of
normal creatinine ischemia). All the other
clearance level in a labs values are normal.
female should be 85-125
mL/min (95-140 mL/min A 55-year-old male
males). A creatinine patient is admitted with a
clearance level indicates massive GI bleed. The
the amount of blood the patient is at risk for what
kidneys can make per
65
type of acute kidney
injury? Select all the patients
A. Post-renal below that are at risk for
B. Intra-renal acute intra-renal injury?
C. Pre-renal A. A 45 year old male

with a renal calculus.
D. Intrinsic renal
B. A 65 year old male
The answer is C. Pre- with benign prostatic
renal injury is due to hyperplasia.
decreased perfusion to
the kidneys secondary to C. A 25 year old female
a cause (massive GI receiving chemotherapy.
bleeding...patient is D. A 36 year old female
losing blood volume). with renal artery stenosis.
This leads to a major E. A 6 year old male with
decrease in kidney acute glomerulonephritis.
function because the
kidneys are deprived of F. An 87 year old male
nutrients to function and who is taking an
the amount of blood it aminoglycoside
can filter. Pre-renal medication for an
injury can eventually lead infection.
to intrarenal damage The answers are: C, E,
where the nephrons and F. These patients are
become damaged. at risk for an intra-renal
injury, which is where
there is damage to the
66
nephrons of kidney. The findings, what stage of
patients in options A and AKI is this patient in?
B are at risk for POST- A. Initiation
RENAL injury because
there is an obstruction B. Diuresis
that can cause back flow C. Oliguric
of urine into the kidney, D. Recovery
which can lead to
decreased function of the The answer is D. This
kidney. The patient in patient is in the recovery
option D is at risk for stage of AKI. The
PRE-RENAL injury patient's labs and urinary
because there is an issue output indicate the renal
with perfusion to the function has returned to
kidney. normal. Remember the
recovery stages starts
when the GFR
(glomerular filtration
A patient with acute rate) has returned to
kidney injury has the normal (normal GFR 90
following labs: GFR 92 mL/min or higher),
mL/min, BUN 17 mg/dL, which will allow waste
potassium 4.9 mEq/L, levels and electrolyte
and creatinine 1 mg/dL. levels to be maintained.
The patient's 24 hour
urinary output is 1.75
Liters. Based on these
67
amount of urea in the
filtrate (because the
nephrons can filter the
A 36-year-old male urea out of the blood) and
patient is diagnosed with this causes osmotic
acute kidney injury. The diuresis. Urinary output
patient is voiding 4 L/day will be excessive (3 to 6
of urine. What L/day). Therefore, the
complication can arise patient is at risk for
based on the stage of hypotension, diluted
AKI this patient is in? urine (low urine specific
Select all that apply: gravity), and
A. Water intoxication hypokalemia (waste
B. Hypotension potassium in the urine).
The patient is not at risk
C. Low urine specific for water intoxication and
gravity will not have a normal
D. Hypokalemia GFR until the recovery
E. Normal GFR stage.
The answers are: B, C,
and D. This patient is in
the DIURESIS stage of True or False: All
AKI. The nephrons are patients with acute renal
now starting to filter out injury will progress
waste but cannot through the oliguric stage
concentrate the urine. of AKI but not all
There is now a high patients will progress
68
through the diuresis hyperkalemia, improving
stage. GFR, resolving edema,
True and urinary output 4
L/day.
False
D. A 78 year old female
with respiratory acidosis,
Which patient below with increased GFR,
acute kidney injury is in decreased
the oliguric stage of AKI: BUN/creatinine,
A. A 56 year old male hypokalemia, and urinary
who has metabolic output 550 mL/day.
acidosis, decreased GFR, The answer is A. During
increased the oliguric stage of AKI
BUN/Creatinine, the patient will have a
hyperkalemia, edema, urinary output of 400
and urinary output 350 mL/day or LESS. This is
mL/day. due to a decreased GRF
B. A 45 year old female (glomerular filtration
with metabolic alkalosis, rate), which will lead to
hypokalemia, normal increased amounts of
GFR, increased waste in the blood
BUN/creatinine, edema, (increased
and urinary output 600 BUN/Creatinine),
mL/day. metabolic acidosis
(decreased excretion of
C. A 39 year old male hydrogen ions),
with metabolic acidosis, hyperkalemia,
69
hypervolemia must monitor the patient's
(edema/hypertension), electrolyte levels,
and urinary output of especially potassium
<400 mL/day. (hypokalemia).
You're developing a
nursing care plan for a While educating a group
patient in the diuresis of nursing students about
stage of AKI. What the stages of acute kidney
nursing diagnosis would injury, a student asks
you include in the care how long the oliguric
plan? stage lasts. You explain
A. Excess fluid volume to the student this stage
B. Risk for electrolyte can last?
imbalance A. 1-2 weeks
C. Urinary retention B. 1-3 days
D. Acute pain C. Few hours to 2 weeks
The answer is B. During D. 12 months
the diuresis stage of AKI, The answer is A. The
the patient will be losing oliguric stage can last 1-2
an excessive amount of weeks. Regarding the
urine (3-6 Liters/day) and other stages of AKI:
is at risk for fluid volume Initiation: few hours to
deficient and electrolyte several days, diuresis: 1-
imbalance. The nurse
70
3 weeks, and recovery:
12 months or more. which descriptions
characterize acute kidney
A patient with AKI has a injury (SATA)?
urinary output of 350
mL/day. In addition, a. primary cause of death
morning labs showed an is infection
increased BUN and
creatinine level along b. it almost always
with potassium level of 6 affects older people
mEq/L. What type of diet c. disease course is
ordered by the physician potentially reversible
is most appropriate for d. most common cause is
this patient? diabetic nephropathy
A. Low-sodium, high- e. cardiovascular disease
protein, and low- is most common cause of
potassium death
B. High-protein, low- RIFLE defines three
potassium, and low- stages of AKI based on
sodium changes in
C. Low-protein, low-
potassium, and low-
sodium a. BP and urine
osmolality
D. High-protein and
high-potassium b. fractional excretion of
urinary sodium
71
c. estimation of GFR the nurse must monitor
with the MDRD equation for which serum
d. serum creatinine or electrolyte imbalance?
urine output from
baseline a. hyperkalemia and
hyponatremia
During the oliguric phase b. hyperkalemia and
of AKI, the nurse hypernatremia
monitors the patient for c. hypokalemia and
(SATA). hyponatremia
d. hypokalemia and
a. hypotension hypernatremia
b. ECG changes
c. hypernatremia
d. pulmonary edema a patient is admitted to
e. urine with high the hospital with chronic
specific gravity kidney disease. the nurse
understands that this
b. ECG changes condition is characterized
d. pulmonary edema by
a. progressive irreversible
If a patient is in the destruction of the kidneys
diuretic phase of AKI,
72
b. a rapid decrease in e. those with a history of
urine output with an type 2 diabetes
elevated BUN
c. an increasing
creatinine clearance with
a decrease in urine output patients with CKD
experience an increased
d. prostration, incidence of
somnolence, and cardiovascular disease
confusion with coma and related to (SATA)
imminent death
a. hypertension
nurses must teach
patients at risk for b. vascular calcification
developing chronic c. a genetic
kidney disease. predisposition
individuals considered to d. hyperinsulinemia
be at increased risk causing dyslipidemia
include (SATA)
e. increased HDLs
a. older AA
b. patients > 60 years old
Nutritional support and
c. those with a history of management are essential
pancreatitis across the entire
d. those with a history of continuum of CKD.
hypertension Which statements would
73
be considered true related patient receiving
to nutritional therapy hemodialysis
(SATA)?
An ESRD patient
a. fluid is not usually receiving hemodialysis is
restricted for patients considering asking a
receiving peritoneal relative to donate a
dialysis kidney for
b. sodium and potassium transplantation. In
may be restricted in assisting the patient to
someone with advanced make a decision about
CKD. treatment, the nurse
informs the patient that
c. decreased fluid intake
and a low-potassium diet
are hallmarks of the diet a. successful
for a patient receiving transplantation usually
hemodialysis provides better quality of
d. decreased fluid intake life than that offered by
and a low-potassium diet dialysis
are hallmarks of the diet b. if rejection of the
for a patient receiving transplant occurs, no
peritoneal dialysis further treatment for the
e. decreased fluid intake renal failure is available
and a diet with c. hemodialysis replaces
phosphate-rich foods are the normal functions of
hallmarks of the diet for a the kidneys, and patients
74
do not have to live with d. listen with a
continual fear of rejection stethoscope over the graft
d. the to detect a bruit
immunosuppressive e. frequently monitor the
therapy following pulses and neurovascular
transplant makes teh status distal to the graft
person ineligible to
receive other forms of
treatment if the kidney a major advantage of
fails. peritoneal dialysis is
to assess the patency of a a. the diet is less

newly place AV graft for restricted and dialysis can
dialysis, the nurse should be performed at home
(SATA) b. the dialysate is
biocompatible and causes
no long-term
a. monitor the BP in the consequences
affected arm
c. high glucose
b. irrigate the graft daily concentrations of the
with low-dose heparin dialysate cause a
c. palpate the area of the reduction in appetite,
graft to feel a normal promoting weight loss
thrill d. no medications are
requires because of the
enhanced efficacy of the
75
peritoneal membrane in a client with AKI has a
removing toxins serum potassium level of
6. the nurse should plan
which action as a
a kidney transplant priority?
recipient complains of
having fever, chills, and
dysuria over the past 2 a. check the sodium level
days. what is the first b. place the client on a
action that the nurse cardiac monitor
should take?
c. encourage increased
vegetables in the diet
a. assess temperature and d. allow an extra 500 mL
initiate workup to rule of fluid intake to dilute
out infection the electrolyte
b. reassure the patient concentration
that this is common after
transplant
a client being
c. provider warm cover hemodialyzed suddenly
for the patient and give 1 becomes short of breath
g tylenol orally and complains of chest
d. notify the nephrologist pain. the client is
that the patient has tachycardic, pale, and
developed symptoms of anxious, and the nurse
acute rejection suspects air embolism.
76
what is the priority b. reposition the client to
nursing action? his or her side
c. contact the HCP
a. monitor VS every 15 d. place the client in good
minutes for the next hour body alignment
b. discontinue dialysis e. check the peritoneal
and notify the HCP dialysis system for kinks
c. continue dialysis at a f. increase the flow rate
slower rate after checking of the peritoneal dialysis
the lines for air solution
d. bolus the client with
500 mL of normal saline a hemodialysis client
to break up the air with a left arm fistula is
embolism at risk for arterial steal
syndrome. the nurse
the nurse monitoring a should assess the client
client receiving for which manifestations
peritoneal dialysis notes of this complication?
that the client's outflow is
less than the inflow. a. warmth, redness, and
Which actions should the pain in the left hand
nurse take? (SATA)
b. aching pain, pallor,
and edema of the left arm
a. check the level of the
drainage bag
77
c. edema and reddish
discoloration of the left
arm
d. pallor, diminished
pulse, and pain in the left
hand
The nurse is performing
a client with CKD returns an assessment on a client
to the nursing unit who has returned from
following a hemodialysis the dialysis unit
treatment. On following hemodialysis.
assessment, the nurse The client complaining of
notes tht the client's headache and nausea is
temperature is 100.2. extremely restless. Which
which nursing action is is the most appropriate
most appropriate? nursing action?
a. encourage fluids a. monitor the client
b. notify the HCP b. elevate the head of the

bed
c. continue to monitor VS
c. medicate the client for
d. monitor the site of the nausea
shunt for infection
d. notify the HCP
78
a client newly diagnosed dialysis because of the
with CKD has just been risk for which
started on peritoneal complication?
dialysis. During the
infusion of the dialysat,
the client complains of a. infection
abdominal pain. Which b. hyperglycemia
action by the nurse is c. hypophosphatemia
most appropriate?
d. disequilibrium
syndrome
a. stop the dialysis
b. slow the infusion a week after kidney
c. decrease the amount to transplant, a client
be infused develops a temperature of
d. explain that the pain 101F, the blood pressure
will subside after the first is elevated, and the
few exchanges kidney is tender. The x-
ray indicates that the
transplanted kidney is
the nurse is instructing a enlarged. Based on those
client with DM about assessment findings, the
peritoneal dialysis. The nurse suspects which
nurse tells the client that complication?
it is important to
maintain the prescribed
dwell time for the a. acute rejection
79
b. kidney infection d. headache, deteriorating
c. chronic rejection level of consciousness,
and twitching
d. kidney obstruction
During hemodialysis, the

the client newly patient develops light-
diagnosed with CKD headedness and nausea.
recently has begun What should the nurse do
hemodialysis. knowing first?
that the client is at risk
for disequilibrium
syndome, the nurse a. Administer hypertonic
should assess the client saline.
during dialysis for which b. Administer a blood
associated transfusion.
manifestations?
c. Decrease the rate of
fluid removal.
a. hypertension, d. Administer antiemetic
tachycardia, and fever medications.
b. hypotension,
bradycardia, and
hypothermia
c. restlessness, The nurse is caring for a
irritability, and 68-yr-old man who had
generalized weakness coronary artery bypass
surgery 3 weeks ago.
80
During the oliguric phase when the patient selects
of acute kidney disease, which foods to eat?
which action would be
appropriate to include in
the plan of care? a. Apple, green beans,
and a roast beef sandwich
b. Granola made with
a. Provide foods high in dried fruits, nuts, and
potassium. seeds
b. Restrict fluids based c. Watermelon and ice
on urine output. cream with chocolate
c. Monitor output from sauce
peritoneal dialysis. d. Bran cereal with ½
d. Offer high-protein banana and milk and
snacks between meals. orange juice
b. Restrict fluids based
on urine output. When caring for a patient
during the oliguric phase
of acute kidney injury
(AKI), which nursing
A 78-yr-old patient has action is appropriate?
stage 3 CKD and is being
taught about a low-
potassium diet. The nurse a. Weigh patient three
knows the patient times weekly.
understands the diet
81
b. Increase dietary c. Continuous
sodium and potassium. venovenous
c. Provide a low-protein, hemofiltration (CVVH)
high-carbohydrate diet. d. Continuous
d. Restrict fluids ambulatory peritoneal
according to previous dialysis (CAPD)
daily loss. c. Continuous
The physician has venovenous
decided to use renal hemofiltration (CVVH)
replacement therapy to
remove large volumes of
fluid from a patient who
is hemodynamically A frail 72-yr-old woman
unstable in the intensive with stage 3 chronic
care unit. The nurse kidney disease is cared
should expect which for at home by her
treatment to be used for family. The patient has a
this patient? history of taking many
over-the-counter
medications. Which over-
a. Hemodialysis (HD) the-counter medications
three times per week should the nurse teach
b. Automated peritoneal the patient to avoid?
dialysis (APD)
a. aspirin
b. acetaminophen
82
c. diphenhydramine an outpatient diagnostic
d. aluminum hydroxide. procedure using contrast
media. Which priority
action should the nurse
The home care nurse perform?
visits a 34-yr-old woman
receiving peritoneal
dialysis. Which statement a. assess skin turgor to
indicates a need for determine hydration
immediate follow-up by status
the nurse? b. insert a urinary
catheter for the expected
diuresis
a. drain time is faster if i
rub my abdomen c. evaluate the patient's
lower extremities for
b. the fluid draining from edema
the catheter is cloudy
d. check the patient's
c. the drainage is bloody urine for the presence of
when i have my period ketones
d. i was around the
catheter with soap and
water Which findings will the
nurse expect when caring
for a patient with chronic
A 52-yr-old man with kidney disease (CKD)
stage 2 chronic kidney (select all that apply.)?
disease is scheduled for
83
a. anemia b. hyponatremia
b. dehydration c. large urine output
c. hypertension d. leukocytosis with
d. hypercalcemia cloudy urine output
e. increased risk for

fractures A patient with end-stage
f. elevated WBCs renal disease (ESRD)
secondary to diabetes
mellitus has arrived at the
outpatient dialysis unit
for hemodialysis. Which
assessments should the
nurse perform as a
priority before, during,
and after the treatment?
A patient is recovering in
the intensive care unit a. level of consciousness
(ICU) 24 hours after b. blood pressure and
receiving a kidney fluid balance
transplant. What is an
expected assessment c. temperature, heart rate,
finding during the earliest and blood pressure
stage of recovery? d. assessment for signs
and symptoms of
infection
a. hypokalemia
84
priority nursing
Which patient diagnosis intervention?
or treatment is most
consistent with prerenal a. monitor the patient's
acute kidney injury cardiac status
(AKI)?
b. teach the patient about
hand washing
a. IV tobramycin c. obtain a serum
b. incompatible blood specimen for electrolytes
transfusion d. increase direct
c. poststreptococcal observation of the patient
glomerulonephritis
d. dissecting abdominal Which assessment
aortic aneurysm findings would alert the
nurse that the patient has
entered the diuretic phase
of acute kidney injury
(AKI) (select all that
apply.)?
The patient has rapidly
progressing glomerular a. dehydration
inflammation. Weight
has increased and urine b. hypokalemia
output is steadily c. hypernatremia
declining. What is the d. BUN increases
85
e. urine output increases peritoneal dialysis.
f. serum creatinine Which strategy is used to
increases achieve ultrafiltration in
peritoneal dialysis?
A patient with a 25-year

history of type 1 diabetes a. increasing the pressure
mellitus is reporting gradient
fatigue, edema, and an b. increasing osmolality
irregular heartbeat. On of the dialysate
assessment, the nurse c. decreasing the glucose
notes newly developed in the dialysate
hypertension and
uncontrolled blood d. decreasing the
sugars. Which diagnostic concentration of the
study is most indicative dialysate
of chronic kidney disease
(CKD)? Which patient has the
most significant risk
a. serum creatinine factors for CKD?
b. serum potassium
c. microalbuminuria a. a 50-yr-old white
woman with
d. calculated GFR hypertension
Diffusion, osmosis, and
ultrafiltration occur in
both hemodialysis and
86
b. a 61-yr-old Native
American man with
diabetes
Which statement
c. a 40-yr-old Hispanic regarding continuous
woman with ambulatory peritoneal
cardiovascular disease dialysis (CAPD) would
d. a 28-yr-old African be most important when
American woman with a teaching a patient new to
urinary tract infection the treatment?
The nurse preparing to a. maintain a daily

administer a dose of written record of blood
calcium acetate to a pressure and weight
patient with chronic b. it is essential that you
kidney disease (CKD). maintain aseptic
Which laboratory result technique to prevent
will the nurse monitor to peritonitis
determine if the desired
effect was achieved? c. you will be allowed a
more liberal protein diet
once you complete
a. sodium CAPD
b. potassium d. continue regular
c. magnesium medical and nursing
follow-up visits while
d. phosphorus performing CAPD
87
blood pH of 7.30, the
After the insertion of an nurse will expect an
arteriovenous graft assessment finding of
(AVG) in the right
forearm, a patient a. persistent skin tenting
complains of pain and
coldness of the right b. rapid, deep
fingers. Which action respirations.
should the nurse take? c. hot, flushed face and
neck.
a. Teach the patient about d. bounding peripheral

normal AVG function. pulses.
b. Remind the patient to The nurse is planning

take a daily low-dose care for a patient with
aspirin tablet. severe heart failure who
has developed elevated
c. Report the patient's blood urea nitrogen
symptoms to the health (BUN) and creatinine
care provider. levels. The primary
d. Elevate the patient's treatment goal in the plan
arm on pillows to above will be
the heart level.
a. augmenting fluid
When a patient with volume.
acute kidney injury b. maintaining cardiac
(AKI) has an arterial output.
88
c. diluting nephrotoxic d. "I need to take
substances. erythropoietin to boost
d. preventing systemic my immune system and
hypertension. help prevent infection."
b. maintaining cardiac
output. Sodium polystyrene
sulfonate (Kayexalate) is
ordered for a patient with
Which statement by a hyperkalemia.
patient with stage 5
chronic kidney disease Before administering the
(CKD) indicates that the medication, the nurse
nurse's teaching about should assess the
management of CKD has
been effective? a. bowel sounds.
b. blood glucose.
a. "I need to get most of c. blood urea nitrogen
my protein from low-fat (BUN).
dairy products."
d. level of consciousness
b. "I will increase my (LOC).
intake of fruits and
vegetables to 5 per day." A patient will need
vascular access for
c. "I will measure my hemodialysis. Which
urinary output each day statement by the nurse
to help calculate the
amount I can drink."
89
accurately describes an a. Auscultate for a bruit
advantage of a fistula at the fistula site.
over a graft? b. Assess the quality of
the left radial pulse.
a. A fistula is much less c. Compare blood
likely to clot. pressures in the left and
b. A fistula increases right arms.
patient mobility. d. Irrigate the fistula site
c. A fistula can with saline every 8 to 12
accommodate larger hours.
needles.
d. A fistula can be used A patient who has had
sooner after surgery. progressive chronic
kidney disease (CKD) for
several years has just
begun regular
When caring for a patient hemodialysis. Which
with a left arm information about diet
arteriovenous fistula, will the nurse include in
which action will the patient teaching?
nurse include in the plan
of care to maintain the
patency of the fistula? a. Increased calories are
needed because glucose
is lost during
hemodialysis.
90
b. More protein is b. The patient plans 30 to
allowed because urea and 60 minutes for a dialysate
creatinine are removed exchange.
by dialysis. c. The patient cleans the
catheter while taking a
c. Dietary potassium is bath each day.
not restricted because the d. The patient slows the
level is normalized by inflow rate when
dialysis. experiencing abdominal
d. Unlimited fluids are pain.
allowed because retained
fluid is removed during Which information in a
dialysis. patient's history indicates
to the nurse that the
Which action by a patient patient is not an
who is using peritoneal appropriate candidate for
dialysis (PD) indicates kidney transplantation?
that the nurse should
provide more teaching a. The patient has type 1
about PD? diabetes.
b. The patient has
a. The patient leaves the metastatic lung cancer.
catheter exit site without c. The patient has a
a dressing. history of chronic
hepatitis C infection.
91
d. The patient is infected reported by the patient
with human indicates that patient
immunodeficiency virus. teaching is required?
Which assessment a. Acetaminophen

finding may indicate that b. Magnesium hydroxide
a patient is experiencing
adverse effects to c. Calcium phosphate
a corticosteroid d. Multivitamin w/ iron

prescribed after kidney
transplantation? Before administration of
captopril to a patient with
a. Postural hypotension stage 2 chronic kidney
disease (CKD), the nurse
b. Recurrent tachycardia will check the patient's
c. Knee and hip joint pain
d. Increased serum a. glucose.
creatinine
b. creatinine.
c. potassium.
The nurse in the dialysis
clinic is reviewing the d. phosphate.
home medications of a
patient with chronic A 55-yr-old patient with
kidney disease (CKD). end-stage kidney disease
Which medication (ESKD) is scheduled to
92
receive a prescribed dose a. Start continuous pulse
of epoetin alfa (Procrit). oximetry.
Which information b. Restrict physical
should the nurse report to activity to bed rest.
the health care provider
before giving the c. Restrict the patient's
medication? oral protein intake.
d. Discontinue the
urethral retention
a. Creatinine 1.6 mg/dL catheter.
b. Oxygen saturation
89%
c. Hemoglobin level 13
g/dL A 72-yr-old patient with
a history of benign
d. Blood pressure 98/56 prostatic hyperplasia
mm Hg (BPH) is admitted with
acute urinary retention
Which intervention will and elevated blood urea
be included in the plan of nitrogen (BUN) and
care for a patient with creatinine levels. Which
acute kidney injury prescribed therapy should
(AKI) who has a the nurse implement
temporary vascular first?
access catheter in the left
femoral vein? a. Insert urethral catheter.
93
b. Obtain renal d. Check the medical
ultrasound. record for the most recent
c. Draw a complete blood potassium level.
count.
d. Infuse normal saline at A 62-yr-old female
50 mL/hour patient has been
hospitalized for 4 days
with acute kidney
A patient with acute injury(AKI) caused by
kidney injury (AKI) has dehydration. Which
longer QRS intervals on information will be most
the electrocardiogram important for the nurse to
(ECG) than were noted report to the health care
on the previous shift. provider?
Which action should the
nurse take first?
a. The creatinine level is
3.0 mg/dL.
a. Notify the patient's
health care provider. b. Urine output over an
8-hour period is 2500
b. Document the QRS mL.
interval measurement.
c. The blood urea
nitrogen (BUN) level is
c. Review the chart for 67 mg/dL.
the patient's current
creatinine level.
94
d. The glomerular
filtration rate is less than
30 mL/min/1.73 m2
A female patient with

A 42-yr-old patient chronic kidney disease
admitted with acute (CKD) is receiving
kidney injury due to peritoneal dialysis with
dehydration has oliguria, 2-L inflows. Which
anemia, and information should the
hyperkalemia. Which nurse report promptly to
prescribed action should the health care provider?
the nurse take first?
a. The patient has an

a. Insert a urinary outflow volume of 1800
retention catheter. mL.
b. Place the patient on a b. The patient's peritoneal
cardiac monitor. effluent appears cloudy.
c. Administer epoetin c. The patient's abdomen
alfa (Epogen, Procrit). appears bloated after the
d. Give sodium inflow.
polystyrene sulfonate d. The patient has
(Kayexalate). abdominal pain during
the inflow phase.
95
The nurse is assessing a a. Slow down the rate of
patient 4 hours after a dialysis.
kidney transplant. Which b. Check the blood
information is most pressure (BP).
important to
communicate to the c. Review the hematocrit
health care provider? (Hct) level.
a. The urine output is 900 d. Give prescribed PRN

to 1100 mL/hr. antiemetic drugs.
b. The patient's central

venous pressure (CVP) is
decreased. The nurse is titrating the
c. The patient has a level IV fluid infusion rate
7 (0- to 10-point scale) immediately after a
incisional pain. patient has had kidney
d. The blood urea transplantation. Which
nitrogen (BUN) and parameter will be most
creatinine levels are important for the nurse to
elevated. consider?
During routine a. Heart rate

hemodialysis, a patient b. Urine output
complains of nausea and c. Creatinine clearance
dizziness. Which action
should the nurse take d. Blood urea nitrogen
first? (BUN) level
96
After receiving change-
A patient complains of of-shift report, which
leg cramps during patient should the nurse
hemodialysis. The nurse assess first?
should
a. Patient who is
a. massage the patient's scheduled for the drain
legs. phase of a peritoneal
dialysis exchange
b. reposition the patient
supine. b. Patient with stage 4
chronic kidney disease
c. give acetaminophen who has an elevated
(Tylenol). phosphate level
d. infuse a bolus of c. Patient with stage 5
normal saline. chronic kidney disease
who has a potassium
Muscle cramps during level of 3.4 mEq/L
dialysis are caused by d. Patient who has just
rapid removal of sodium returned from having
and water. Treatment hemodialysis and has a
includes infusion of heart rate of 124/min
normal saline. The other The patient who has
actions do not address the tachycardia after
reason for the cramps. hemodialysis may be
bleeding or excessively
hypovolemic and should
97
be assessed immediately e. Have several servings
for these complications. of dairy products daily.
The other patients also
need assessments or
interventions but are not The nurse teaches a
at risk for life-threatening patient with chronic
complications. kidney disease about
prevention of
complications. What
Which information will should the nurse include
be included when the in the teaching plan?
nurse is teaching self-
management to a patient
who is receiving A. Monitor for
peritoneal dialysis (select proteinuria daily with a
all that apply)? urine dipstick.
B. Perform self-
catheterization every 4
a. Avoid commercial salt hours to measure urine.
substitutes.
C. Take calcium-based
b. Restrict fluid intake to phosphate binders on an
1000 mL daily. empty stomach.
c. Take phosphate D. Check weight daily
binders with each meal. and report a gain of
d. Choose high-protein greater than 4 pounds
foods for most meals.
98
A. Observe for signs of a
A client in kidney failure secondary infection.
is to have a serum blood B. Provide a high-
urea nitrogen level protein, low-
determined. What will carbohydrate diet.
this diagnostic test C. n and out
measure? catheterization for
residual urine
A. Concentration of the D. Encourage fluids to
urine osmolarity and 2000 mL in 24 hours
electrolytes
B.Serum level of the end A client with Acute
products of protein Kidney Injury is being
metabolism assessed to determine if
C.Ability of the kidneys the cause is prerenal, or
to concentrate urine post renal. If the cause is
D.Levels of C-reactive pre-renal, which
protein to determine condition is most likely
inflammation the cause?
What nursing measure A. Heart failure

would be included in the B. Glomerular Nephritis
plan of care for a client C. Kidney stone
with acute kidney injury?
99
D. Aminoglycoside D. Hyperkalemia
toxicity 3. A 65 year old male
patient has a glomerular
filtration rate of 55
mL/min. The patient has
a history of uncontrolled
1. A 55 year old male hypertension and
patient is diagnosed with coronary artery disease.
chronic kidney disease. You're assessing the new
The patient's recent GFR medication orders
was 25 mL/min. What received for this patient.
stage of chronic kidney Which medication
disease is this known ordered by the physician
as?* will help treat the
A. Stage 1 patient's hypertension
along with providing a
B. Stage 3 protective mechanism to
C. Stage 4 the kidneys?*
D. Stage 5 A. Lisinopril
2. A patient with CKD B. Metoprolol
has a low erythropoietin C. Amlodipine
(EPO) level. The patient
is at risk for? D. Verapamil
A. Hypercalcemia 4. Which patient below is

NOT at risk for
B. Anemia developing chronic
C. Blood clots kidney disease?*
100
A. A 58 year old female 6. Your patient with
with uncontrolled chronic kidney disease is
hypertension. scheduled for dialysis in
B. A 69 year old male the morning. While
with diabetes mellitus. examining the patient's
telemetry strip, you note
C. A 45 year old female tall peaked T-waves. You
with polycystic ovarian notify the physician who
disease. orders a STAT basic
D. A 78 year old female metabolic panel (BMP).
with an intrarenal injury. What result from the
5. A patient with Stage 5 BMP confirms the EKG
CKD is experiencing abnormality?*
extreme pruritus and has A. Phosphate 3.2 mg/dL
several areas of B. Calcium 9.3 mg/dL
crystallized white
deposits on the skin. As C. Magnesium 2.2
the nurse, you know this mg/dL
is due to excessive D. Potassium 7.1 mEq/L
amounts of what 7. You are providing
substance found in the education to a patient
blood?* with CKD about calcium
A. Calcium acetate. Which statement
B. Urea by the patient
demonstrates they
C. Phosphate understood your teaching
D. Erythropoietin
101
about this medication? B. Low
Select-all-that-apply:* C. Normal
A. "This medication will D. Same as the
help keep my calcium phosphate level
level normal."
9. A patient with stage 4
B. "I will take this chronic kidney disease
medication with meals or asks what type of diet
immediately after." they should follow. You
C. "It is important I explain the patient should
consume high amounts of follow a:*
oatmeal, poultry, fish, A. Low protein, low
and dairy products while sodium, low potassium,
taking this medication." low phosphate diet
D. "This medication will B. High protein, low
help prevent my sodium, low potassium,
phosphate level from high phosphate diet
increasing."
C. Low protein, high
8. While assessing sodium, high potassium,
morning labs on your high phosphate diet
patient with CKD. You
note the patient's D. Low protein, low
phosphate level is 6.2 sodium, low potassium,
mg/dL. As the nurse, you high phosphate diet
expect to find the 10. The kidneys are
calcium level to be?* responsible for
A. Elevated performing all the
102
following functions D. tachypnea, low pH,
EXCEPT?* and low serum
A. Activating Vitamin D bicarbonate.
B. Secreting Renin
C. Secreting A patient with diabetes
Erythropoietin has had many renal
calculi over the past 20
D. Maintaining cortisol years and now has
production chronic renal failure.
Which substance must be
Signs and symptoms of reduced in this patient’s
acute renal failure diet?
include: *
A. Carbohydrates
A. bradycardia, with B. Fats
decreased respiration, C. Protein
low serum bicarbonate,
and elevated pH. D. Vitamin C
B. lethargy, tachypnea,
and elevated serum A major sensitive
bicarbonate. indicator of kidney
C. slowed respirations disease is:
and low pH.
A. BUN level.
103
B. Creatinine clearance most important for the
level. nurse evaluate before
C. Serum potassium teaching begins?
level.
D. Uric acid level. A. Family Hx
B. Attention span
Polystyrene sulfonate C Uric Acid level
(Kayexalate) is used in
renal failure to: D. Support system
A. Correct acidosis Which sign indicated the

second phase of acute
B. Reduce serum renal failure?
phosphate levels
C. Exchange potassium
for sodium A. Daily doubling of
urine output (4 to 5
D. Prevent constipation L/day)
from sorbitol use
B. Urine output less than
400 ml/day
Nurse Angelo is C. Urine output less than
preparing to teach the 100 ml/day
patient with CRF about
dietary modifications. D. Stabilization of renal
Which of the following function
aspects of the patient is
104
You are teaching the D. "I should call
patient with chronic renal immediately if I see
failure about what swelling at my dialysis
symptoms to report to the port"
doctor when outside of
the hospital. Which
statement, if made by the Your patient with chronic
patient, indicates correct renal failure reports
understanding? pruritus. Which
instruction should you
include in this patient’s
A. "I should call my teaching plan?
doctor if my stomach
starts feeling sick or my
breath smells funny like A. Rub the skin
pea" vigorously with a towel
B. "Muscle weakness and B. Take frequent baths

abdominal cramps are a
sign of worsening C. Apply alcohol-based
condition and I should emollients to the skin
report this to my doctor" D. Keep fingernails short
C. "My doctor wants me and clean
to call him if I feel a
vibrating or buzzing Which cause of
sensation over my hypertension is the most
hemodialysis graft. common in acute renal
failure?
105
A. Pulmonary edema B. Infuse normal saline
B. Hypervolemia solution
C. Hypovolemia C. Administer a 5%
dextrose solution
D. Anemia
D. Encourage active
ROM exercises
Acute renal failure is
potentially reversible in
the: Your 60 y.o. patient with
A. convalescent phase. pyelonephritis and
possible septicemia has
B. initiation phase. had five UTIs over the
C. maintenance phase. past two years. She is
D. recovery phase fatigued from lack of
sleep, has lost weight,
and urinates frequently
Your patient is even in the night. Her
complaining of muscle labs show: sodium, 154
cramps while undergoing mEq/L; osmolarity 340
hemodialysis. Which mOsm/L; glucose, 127
intervention is effective mg/dl; and potassium, 3.9
in relieving muscle mEq/L. Which nursing
cramps? diagnosis is priority? *
A. Increase the rate of A. Fluid volume deficit

dialysis related to osmotic
106
diuresis induced by
hyponatremia A. Excess fluid volume
B. Fluid volume deficit related to the kidney’s
related to inability to inability to maintain fluid
conserve water balance.
C. Altered nutrition: Less B. Ineffective tissue
than body requirements perfusion related to
related to hypermetabolic interrupted arterial blood
state flow.
D. Altered nutrition: Less C. Ineffective therapeutic
than body requirements Regimen Management
related to catabolic related to lack of
effects of insulin knowledge about therapy.
deficiency D. Increased cardiac
output related to fluid
The nurse assesses the overload.
client who has chronic
renal failure and notes You are administering
the following: crackles in erythropoietin to the
the lung bases, elevated patient with Chronic
blood pressure, and Renal Failure. Which of
weight gain of 2 pounds the following would be a
in one day. Based on sign of adverse reaction?
these data, which of the Select all that apply. *
following nursing
diagnoses is appropriate?
107
A. Seizure B. Reposition the client
B. Hypertension onto the side that is not
experiencing flank pain.
C. Decreased urinary
output C. Educate the patient on
the importance of fluid
D. Improved exercise intake.
tolerance
D. Administer morphine
E. Head ache sulfate 2 mg IV.
F. Flushed skin
G. Increased urinary 1) The cause of
output ___________ failure is
H. Hematuria impaired blood supply to
the kidney (Fluid Volume
Deficit, hemorrhage,
What is the priority heart failure, shock)
action when a patient
A. prerenal
presents to the
B. Intrarenal
emergency room
C. Postrenal
suffering from nausea, D. perirenal
vomiting, and flank pain 2) What electrolytes are
as a result of renal in urine?
calculi?
A. Na
A. Schedule a surgical B. K
consult. C. Cl
D. HCO3-
E. All of the above
108
3) Which diagnostic test urine because they
would be monitored to signify renal failure.
evaluate glomerulat A. True
filtration rate B. False
and renal function? 6) The nurse is reviewing
A. Sreum laboratory results on a
creatinine and client with
BUN acute renal failure.
B. Urinalysis Which one of the
C. Kidney biopsy following should be
D. creatinine reported immediately?
clearance A. Blood urea
4) Marina with nitrogen 50 mg/dl
acute renal failure moves B. Hemoglobin
into the diuretic phase of 10.3 mg/dl
after one week of C. Venous
therapy. During this blood pH 7.30
phase the client must be D. Serum
assessed for signs of potassium 6
developing: mEq/L
A. Hypovolemia 7)Nurse Liza is assigned
B. renal failure to care for a client who
C. metabolic has returned to the
acidosis nursing unit after left
D. hyperkalemia nephrectomy. Nurse
5) true or false? Liza’s highest priority
Creatinine, phosphate, would be…
sulfates, and uric acid
should not be present in A. Hourly urine
output
109
B. Temperature excess,malnutrition
C. Able to turn side and fluid volume excess
to side or malnutrition ?
D. Able to sips
clear liquidQ. A. Increase
8) The charge nurse B. Decrease
assigned in the care for a 10) The most serious
client with electrolyte disorder
acute renal failure and associated with kidney
hypernatremia to you, a disease is
newly graduated RN. A. hypermagnesem
Which actions can you ia
delegate to the nursing B. hyponatremia
assistant? C. hyperkalemia
D. metabolic
A. Provide oral acidosis
care every 3-4 11) A client in
hours acute renal failure is a
B. Monitor for candidate for
indications of continuous renal placeme
dehydration nt therapy (CRRT). The
C. Administer most common indication
0.45% saline by for use of CRRT is
IV line A. azotemia
D. Assess daily B. pericarditis
weights for trends C. hyperkalemia
D. fluid overload
9) __________ in 12) A history of infection
BUN/Creatinine ratio specifically caused by
indicate fluid volume group A beta-hemolytic
110
streptococci is associated A. acute tubular
with which of the necrosis or tubular
following disorders? necrosis
B. acute
A. Acute glomerulonephriti
glomerulonephriti s
s C. chronic renal fai
B. Acute renal failu lure
re D. UTI
C. Chronic renal fai 15) What controls the
lure amount of water
D. Nephrotic absorption?
syndrome
13) The leading cause of A. antidiuretic
ESRD is the client with a hormone
history of (Vasopressin)
B. melanin
A. hypotension C. thyroxine
B. anemia D. prolactin
C. prostate cancer 16) What does urine
D. diabetes mostly consist of?
Mellitus
14) The risk for A. H2O (Water)
__________________ is B. NaCl (Salt)
particularly high when C. Urea
ischemia and exposure to D. KCl
a nephrotoxin occur at 17) How much water do
the same time. normal kidneys excrete
each day?
A. 3-4 liters
111
B. 5-6 liters D. BUN
C. 1-2 liters 20) For a male client in
D. 7-8 liters the oliguric phase of
18) Chronic kidney acute renal failure (ARF),
disease is defined by which nursing
Kidney Disease intervention is most
Outcomes Quality important?
Initiative (K/DOQI) as A. Encouraging
evidence of structural or coughing and
functional kidney deep breathing
abnormalities (abnormal B. Promoting
urinalysis, imaging carbohydrate
studies, or histology) that intake
persists for at least ___ C. Limiting fluid
months, with or without a intake
decreased GFR. D. Providing pain-
relief measures
A. 1 21) How much salt do
B. 2 normal kidneys excrete
C. 3 each day?
D. 6
E. 12 A. 1-2 mg
19) What is the # B. 5 g
1 renal function test? C. 3-4 g
A. Renal Clearance D. 6-8 g
/Creatinine 22) Which is a normal
Clearance value of Blood Urea
B. Osmolarity Nitrogen (BUN)?
C. Serum
Creatinine A. 0.5-1.1 mg/dL
B. 5-20 mg/dL
112
C. 40-70 mg/dL B. Administering
D. 250-500 mg/dL narcotics as
23) When the kidneys needed
cannot effectively C. Testing serial
regulate fluid and samples iwth
electrolyte balance and dipsticks for
eliminate metabolic occult blood
waste products, intake of D. Ambulating the
these substances must be client in the room
regulated. Fluid and and hall for short
Sodium intake are distances
________. 25) A female client is
admitted with a diagnosis
A. encouraged of acute renal failure. She
B. limited is awake, alert, oriented,
C. restricted and complaining of
24) The nurse is caring severe back pain, nausea
for the client who has had and vomiting and
a renal biopsy. Which of abdominal cramps. Her
the following vital signs are blood
interventions would the pressure 100/70 mm Hg,
nurse avoid in the care of pulse 110, respirations
the client after this 30, and oral temperature
procedure? 100.4°F (38°C). Her
A. Encourage electrolytes are sodium
fluids to at least 120 mEq/L, potassium
3L in the first 24 5.2 mEq/L; her urinary
hours output for the first 8
hours is 50 ml. The client
is displaying signs of
113
which electrolyte and oral yeast
imbalance? infections
A. Hyponatremia 28)
B. Hyperkalemia ________ renal failure is
C. Hyperphosphate a slow, insidious process
mia of kidney destruction. It
D. Hypercalcemia may go unrecognized for
26) how many ml/hr of years as nephrons are
urine output is the normal destroyed and renal mass
minimum? is reduced.
A. Chronic
A. 30 B. Acute
B. 35 29) The client
C. 40 with renal failure should
D. 45 be on which type of diet?
27) Signs and symptoms A. high protein,
of acute kidney rejection high
that the nurse should carbohydrate, low
teach the patient to calorie
observe for include B. adequate calorie
A. tachycardia and intake, high
headache carbohydrate,
B. fever and limited protein
painful transplant C. Limited protein,
site low carbohydrate,
C. severe adequate calorie
hypotension and intake
weight loss D. Low calorie,
D. recurrent urinary limited protein,
tract infections low carbohydrate
114
30) A client suffering complication during
from acute renal failure hemodialysis.
has an unexpected
increase in urinary output A. hypertension
to 150ml/hr. The nurse B. bleeding
assesses that the client C. Infection
has entered the second D. Dialysis
phase of dementia
acute renal failure. 32) After 1 week a client
Nursing actions with acute renal failure
throughout this phase moves, into the diuretic
include observation for phase. During this phase
signs and symptoms of the client must be
A. Hypervolemia, carefully assessed for
hypokalemia, and signs of:
hypernatremia. A. Hypovolemia
B. Hypervolemia, B. Hyperkalemia
hyperkalemia, and C. Metabolic
hypernatremia. acidosis
C. Hypovolemia, D. Chronic renal fai
wide fluctuations lure
in serum sodium 33) What is the #1 cause
and potassium of death when kidneys
levels. fail?
D. Hypovolemia, A. hyperkalemia
no fluctuation in B. hypokalemia
serum sodium and C. hypernatremia
potassium levels. D. hyponatremia
31) _________ is the 34) The nurse is
most frequent reviewing laboratory
115
results on a client with C. acute tubular
acute renal failure. necrosis
Which one of the D. dialysis
following should be 36)
reported _________ renal Failure
IMMEDIATELY? is a rapid decline
A. Blood urea in renal function with an
nitrogen 50 mg/dl abrupt onset
B. Hemoglobin of A. acute
10.3 mg/dl B. chronic
C. Venous blood 37) How do kidneys
pH 7.30 control Na+ levels and
D. Serum K+ levels?
potassium 6
mEq/L A. The kidneys
35) When the kidneys release renin,
have too few nephrons to which controls
excrete metabolic wastes angiotensin. The
and regulate fluid and angiotensin
electrolyte balance controls
adequately, the client is aldosterone.
said to have , the final Aldosterone
stage of controls the levels
Chronic Renal Failure. of Na+ and K+
A. End- B. Kidneys release
stage renal disease aldosterone which
(ESRD) controls renin.
B. renal insufficien Renin causes the
cy release of
angiotensin.
116
Angiotensin and solutes to empty into
controls the levels a collecting device. Fluid
of Na+ and K+ may be replaced with a
C. The kidneys balanced electrolyte
release renin solution as needed during
which controls treatment.
K+. The kidneys A. Hemodialysis
release B. Continuous
angiotensin which ambulatory
causes Na+ peritoneal dialysis
realease. C. Continuous
38) Anti-hypertensive cyclic peritoneal
therapy in patients with dialysis
chronic renal disease is D. Continuous Ren
for? al Replacement
A. Renal protection Therapy
B. Cardiovascular 40) __________ failure is
protection caused by obstruction of
C. Both renal and urine flow. (urethral
cardiovascular obstruction by enlarged
protection prostate or tumor;
D. None of the ureteral or kidney pelvis
above obstruction by calculi)
39) ____________ is a
treatment for renal failure A. p
in which blood id rerenal
continuously circulated B. i
(artery to vein or vein to ntrarenal
vein) and filtered, C. p
allowing excess water ostrenal
117
D. pto the patient, the nurse
erirenal knows that
41) Agents that damage contraindications to
the kidney tissue are kidney transplantation
called: include
A. nephrons A. hepatitis C
B. nephrotoxins infection
C. antibodies B. extensive
D. enterotoxins vascular disease
42) Which phase of C. coronary artery
Acute Renal Failure disease
results in FVE and edema D. refractory
due to salt and water hypertension
retention, hypertension, 44) Which of the
Azotemia, hyperkalemia, following medications
muscle weakness, does not interfere with
nausea, diarrhea, and either creatinine secretion
high serum creatinine and or the assay used to
BUN levels? measure the serum
A. initiation phase creatinine?
B. maintenance
phase A. Ibuprofen
C. recovery phase B. Cimetidine
D. intrarenal phase C. Trimethoprim
43) A patient rapidly D. Cefoxitin
progressing toward E. Flucytosine
ESRD asks about the 45) A female client with
possibility of a kidney acute renal failure is
transplant. In responding undergoing dialysis for
the first time. The nurse
118
in charge monitors the B. gain of 2 pounds
client closely for dialysis over a 2 day
equilibrium syndrome, a period
complication that is most C. loss of 5 pounds
common during the first over a 5 day
few dialysis sessions. period
Typically, dialysis D. gain of 5 pounds
equilibrium syndrome over a 2 day
causes: period
A. confusion, 47) Nurse Tristan is
headache, and caring for a male client in
seizures. acute renal failure. The
B. acute bone pain nurse should expect
and confusion. hypertonic glucose,
C. weakness, insulin infusions, and
tingling, and sodium bicarbonate to be
cardiac used to treat:
arrhythmias. A. hypernatremia.
D. hypotension, B. hypokalemia.
tachycardia, and C. hyperkalemia.
tachypnea. D. hypercalcemia.
46) Clients with 48) The client with
chronic renal failure ESRD tells the nurse that
should notify the she hates the thought of
physician of any weight: being tied to the machine,
A. loss of 2 pounds but is also glad to start
over a 5 day dialysis because she will
period be able to eat and drink
what she wants. Based on
this information, the nuse
119
identifies the nursing A. 100 times more
diagnosis of acidic
B. 200 times less
A. self-esteem acidic
disturbance C. 1000 times more
related to acidic
dependence on D. 2000 times more
dialysis acidic
B. anxiety related 50) Impaired metabolic
to perceived threat processes such as
to health status Hyperkalemia, Acidosis,
and role Hyperlipidemia,
functioning Hyperuricemia, and
C. ineffective malnutrition are some
management of effects of ___________.
therapeutic
regimen related to A. hematuria
lack of knowledge B. oliguria
of treatment plan C. uremia
D. risk for D. nephrotoxins
imbalanced 51) ________ failure is
nutrition: more caused by Acute damage
than body to renal tissue and
requirements, nephrons or acute tubular
related to necrosis: abrupt decline
increased dietary in tubular and glomerular
intake function due to either
49) How acidic is urine prolonged ischemia
compared to blood? and/or exposure to
nephrotoxins. (Acute
120
glomerulonephritis, D. Platelet
malignant hypertension, dysfunction
ischemia; nephrotoxic 54) The nurse is
drugs or substances; red performing an
blood cell destruction; assessment on a client
muscle tissue breakdown who has returned from
due to trauma, the dialysis unit
heatstroke) following hemodialysis.
A. Prerenal The client is complaining
B. Intrarenal of a headache and nausea
C. Postrenal and is extremely restless.
D. Perirenal Which of the following is
52) Common early the most appropriate
manifestation of kidney nursing action?
disease are loss of
concentration and dilute A. Notify the
urine and loss of ability physician
to concentrate and dilute B. Monitor the
urine . client
C. Elevate the head
A. True of the bed
B. False D. Medicate the
53) A client with client for nausea
acute renal failure is 55) How much KCL do
aware that the most normal kidneys excrete
serious complication of each day?
this condition is:
A. Constipation A. 6-8 g
B. Anemia B. 1g
C. Infection C. 6-8 mg
D. 3 mg
121
56) Clients on continuous B. Polydypsia
ambulatory peritoneal C. Oliguria
dialysis (CAPD) must D. Anuria
empty their peritoneal 59) A client on peritoneal
cavity and replace the dialysis notices that the
dialysate every collecting bag of
__________ hours. dialysate is cloudy, what
is this an indication of?
A. 24
B. 6-8 A. The client needs
C. 4-6 to change their
D. 48 dialysate
57) Which of these drugs B. The patient
is nephrotoxic? needs a kidney
transplant
A. Diuretics C. Medication was
B. ACE inhibitors added to the
C. NSAIDs dialysate
D. Sodium D. The patient is
bicarbonate/ infected and
Potassium experiencing
bicarbonate peritonitis
58) A client is admitted 60) End-
to the hospital and has a stage renal disease is
diagnosis of early stage defined as GFR less than
chronic renal failure. ml/min per 1.73m2.
Which of the following A. 45
would the nurse expect to B. 30
note on assessment of the C. 15
client? D. 10
A. Polyuria
122
E. 5 63) Which of the
61) During the following are abnormal
_________ phase of to be found in the urine?
Acute Renal Failure,
Oliguria develops and the A. K
kidneys cannot B. Amino acids
efficiently eliminate C. Glucose
metabolic wastes, water, D. all of the above
electrolytes, and acids. E. Amino acids and
A. maintenance glucose
B. initiation 64) ESRD occurs when
C. recovery the GFR is less than ___
62) What tests and results per minute.
prove the presence of A. 5 ml
dilute urine? B. 10 ml
A. Fixed Specific C. 15 ml
Gravity (1.010), D. 25 ml
and/or Fixed 65) “urine in the blood”
osmolality (300 A. uremia
mOsm/l) B. uticaria
B. GFR (100 C. urethritis
ml/min), and/or D. urethrorrhea
Specific Gravity
(1.030) 1. Dialysis allows for the
C. Serum exchange of particles
Creatinine (1.5 across a semipermeable
mg/dl) membrane by which of
the following actions?
123
A. Osmosis and C. There will be a
diffusion few changes in
B. Passage of fluid your lifestyle.
toward a solution D. Use alcohol on
with a lower the skin and clean
solute it due to
concentration integumentary
C. Allowing the changes.
passage of blood 3. A client is undergoing
cells and protein peritoneal dialysis. The
molecules through dialysate dwell time is
it. completed, and the dwell
D. Passage of clamp is opened to allow
solute particles the dialysate to drain.
toward a solution The nurse notes that the
with a higher drainage has stopped and
concentration. only 500 ml has drained;
2. A client is the amount the dialysate
diagnosed with chronic instilled was 1,500 ml.
renal failure and told she Which of the following
must start hemodialysis. interventions would be
Client teaching would done first?
include which of the
following instructions? A. Change the
client’s position.
A. Follow a high B. Call the
potassium diet physician.
B. Strictly follow C. Check the
the hemodialysis catheter for kinks
schedule or obstruction.
124
D. Clamp the D. Prepare the
catheter and instill client for
more dialysate at hemodialysis.
the next exchange 5. A client has a history
time. of chronic renal failure
4. A client receiving and received
hemodialysis treatment hemodialysis treatments
arrives at the hospital three times per week
with a blood pressure of through an arteriovenous
200/100, a heart rate of (AV) fistula in the left
110, and a respiratory arm. Which of the
rate of 36. Oxygen following interventions is
saturation on room air is included in this client’s
89%. He complains of plan of care?
shortness of breath, and
+2 pedal edema is noted. A. Keep the AV
His last hemodialysis fistula site dry.
treatment was yesterday. B. Keep the AV
Which of the following fistula wrapped in
interventions should be gauze.
done first? C. Take the blood
pressure in the left
A. Administer arm
oxygen D. Assess the AV
B. Elevate the foot fistula for a bruit
of the bed and thrill
C. Restrict the 6. Which of the following
client’s fluids factors causes the nausea
associated with renal
failure?
125
A. Oliguria B. Serum calcium
B. Gastric ulcers level of 5 mEq/L
C. Electrolyte C. Increased blood
imbalances coagulation
D. Accumulation of D. Diarrhea
waste products 9. A nurse is assessing
7. Which of the following the patency of an
clients is at greatest risk arteriovenous fistula in
for developing acute the left arm of a client
renal failure? who is receiving
hemodialysis for the
A. A dialysis client treatment of chronic renal
who gets failure. Which finding
influenza indicates that the fistula
B. A teenager who is patent?
has an
appendectomy A. Absence of bruit
C. A pregnant on auscultation of
woman who has a the fistula.
fractured femur B. Palpation of a
D. A client with thrill over the
diabetes who has fistula
a heart C. Presence of a
catherization radial pulse in the
8. In a client in renal left wrist
failure, which assessment D. Capillary refill
finding may indicate time less than 3
hypocalcemia? seconds in the nail
beds of the fingers
A. Headache on the left hand.
126
10. The client with syndrome, the nurse
chronic renal failure is at assesses the client during
risk of developing dialysis for:
dementia related to
excessive absorption of A. Hypertension,
aluminum. The nurse tachycardia, and
teaches that this is the fever
reason that the client is B. Hypotension,
being prescribed which bradycardia, and
of the following hypothermia
phosphate binding C. restlessness,
agents? irritability, and
generalized
A. Alu-cap weakness
(aluminum D. Headache,
hydroxide) deteriorating level
B. Tums (calcium of consciousness,
carbonate) and twitching.
C. Amphojel 12. A client with chronic
(aluminum renal failure has
hydroxide) completed a
D. Basaljel hemodialysis treatment.
(aluminum The nurse would use
hydroxide) which of the following
11. The client newly standard indicators to
diagnosed with chronic evaluate the client’s
renal failure recently has status after dialysis?
begun hemodialysis.
Knowing that the client is A. Potassium level
at risk for disequilibrium and weight
127
B. BUN and Which of the following
creatinine levels would the nurse expect to
C. VS and BUN note on assessment of the
D. VS and weight. client?
13. The hemodialysis
client with a left arm A. Polyuria
fistula is at risk for steal B. Polydipsia
syndrome. The nurse C. Oliguria
assesses this client for D. Anuria
which of the following 15. The client with
clinical manifestations? chronic renal failure
returns to the nursing unit
A. Warmth, following a hemodialysis
redness, and pain treatment. On assessment
in the left hand. the nurse notes that the
B. Pallor, client’s temperature is
diminished pulse, 100.2. Which of the
and pain in the following is the most
left hand. appropriate nursing
C. Edema and action?
reddish
discoloration of A. Encourage
the left arm fluids
D. Aching pain, B. Notify the
pallor, and edema physician
in the left arm. C. Monitor the site
14. A client is admitted of the shunt for
to the hospital and has a infection
diagnosis of early stage D. Continue to
chronic renal failure. monitor vital
signs
128
16. The nurse is understanding of this
performing an dietary restriction?
assessment on a client
who has returned from A. Cantaloupe
the dialysis unit B. Spinach
following hemodialysis. C. Lima beans
The client is complaining D. Strawberries
of a headache and nausea 18. The nurse is
and is extremely restless. reviewing a list of
Which of the following is components contained in
the most appropriate the peritoneal dialysis
nursing action? solution with the client.
The client asks the nurse
A. Notify the about the purpose of the
physician glucose contained in the
B. Monitor the solution. The nurse bases
client the response knowing
C. Elevate the head that the glucose:
of the bed
D. Medicate the A. Prevents excess
client for nausea glucose from
17. The nurse is assisting being removed
a client on a low- from the client.
potassium diet to select B. Decreases risk
food items from the of peritonitis.
menu. Which of the C. Prevents
following food items, if disequilibrium
selected by the client, syndrome
would indicate an D. Increases
osmotic pressure
129
to produce complains of abdominal
ultrafiltration. pain. Which action by the
19. The nurse is nurse is most
preparing to care for a appropriate?
client receiving
peritoneal dialysis. A. Slow the
Which of the following infusion
would be included in the B. Decrease the
nursing plan of care to amount to be
prevent the major infused
complication associated C. Explain that the
with peritoneal dialysis? pain will subside
after the first few
A. Monitor the exchanges
clients level of D. Stop the dialysis
consciousness 21. The nurse is
B. Maintain strict instructing a client with
aseptic technique diabetes mellitus about
C. Add heparin to peritoneal dialysis. The
the dialysate nurse tells the client that
solution it is important to
D. Change the maintain the dwell time
catheter site for the dialysis at the
dressing daily prescribed time because
20. A client newly of the risk of:
diagnosed with renal
failure is receiving A. Infection
peritoneal dialysis. B. Hyperglycemia
During the infusion of C. Fluid overload
the dialysate the client D. Disequilibrium
syndrome
130
22. The client with acute should plan to administer
renal failure has a serum this medication:
potassium level of 5.8
mEq/L. The nurse would A. Just before
plan which of the dialysis
following as a priority B. During dialysis
action? C. On return from
dialysis
A. Allow an extra D. The day after
500 ml of fluid dialysis
intake to dilute 24. The client with
the electrolyte chronic renal failure has
concentration. an indwelling catheter for
B. Encourage peritoneal dialysis in the
increased abdomen. The client
vegetables in the spills water on the
diet catheter dressing while
C. Place the client bathing. The nurse
on a cardiac should immediately:
monitor
D. Check the A. Reinforce the
sodium level dressing
23. The client with B. Change the
chronic renal failure who dressing
is scheduled for C. Flush the
hemodialysis this peritoneal dialysis
morning is due to receive catheter
a daily dose of enalapril D. Scrub the
(Vasotec). The nurse catheter with
providone-iodine
131
25. The client being client about self-
hemodialyzed suddenly monitoring between
becomes short of breath hemodialysis treatments.
and complains of chest The nurse determines that
pain. The client is the client best
tachycardic, pale, and understands the
anxious. The nurse information given if the
suspects air embolism. client states to record the
The nurse should: daily:
A. Continue the A. Pulse and
dialysis at a respiratory rate
slower rate after B. Intake, output,
checking the lines and weight
for air C. BUN and
B. Discontinue creatinine levels
dialysis and notify D. Activity log
the physician 27. The client with an
C. Monitor vital arteriovenous shunt in
signs every 15 place for hemodialysis is
minutes for the at risk for bleeding. The
next hour nurse would do which of
D. Bolus the client the following as a
with 500 ml of priority action to prevent
normal saline to this complication from
break up the air occurring?
embolism.
26. The nurse has A. Check the
completed client teaching results of the PT
with the hemodialysis time as they are
ordered.
132
B. Observe the site D. Check the
once per shift peritoneal dialysis
C. Check the shunt system for kinks
for the presence E. Reposition the
of a bruit and client to his or her
thrill side.
D. Ensure that 29. The nurse assesses
small clamps are the client who has
attached to the chronic renal failure and
AV shunt notes the following:
dressing. crackles in the lung
28. The nurse is bases, elevated blood
monitoring a client pressure, and weight gain
receiving peritoneal of 2 pounds in one day.
dialysis and nurse notes Based on these data,
that a client’s outflow is which of the following
less than the inflow. nursing diagnoses is
Select actions that the appropriate?
nurse should take.
A. Excess fluid
A. Place the volume related to
client in good the kidney’s
body alignment inability to
B. Check the maintain fluid
level of the balance.
drainage bag B. Increased
C. Contact the cardiac output
physician related to fluid
overload.
133
C. Ineffective C. Activity
tissue perfusion Intolerance
related to D. Impaired Gas
interrupted Exchange
arterial blood E. Pain.
flow. 31. What is the primary
D. Ineffective disadvantage of using
therapeutic peritoneal dialysis for
Regimen long term management of
Management chronic renal failure?
related to lack of
knowledge about A. The danger of
therapy. hemorrhage is
30. The nurse is caring high.
for a hospitalized client B. It cannot correct
who has chronic renal severe
failure. Which of the imbalances.
following nursing C. It is a time
diagnoses are most consuming
appropriate for this method of
client? Select all that treatment.
apply. D. The risk of
contacting
A. Excess Fluid hepatitis is high.
Volume 32. The dialysis solution
B. Imbalanced is warmed before use in
Nutrition; Less peritoneal dialysis
than Body primarily to:
Requirements
134
A. Encourage the B. Bleeding
removal of serum indicates
urea. abdominal blood
B. Force potassium vessel damage
back into the C. Bleeding can
cells. indicate kidney
C. Add extra damage.
warmth into the D. Bleeding is
body. caused by too-
D. Promote rapid infusion of
abdominal muscle the dialysate.
relaxation. 34. Which of the
33. During the client’s following nursing
dialysis, the nurse interventions should be
observes that the solution included in the client’s
draining from the care plan during dialysis
abdomen is consistently therapy?
blood tinged. The client
has a permanent A. Limit the
peritoneal catheter in client’s visitors
place. Which B. Monitor the
interpretation of this client’s blood
observation would be pressure
correct? C. Pad the side
rails of the bed
A. Bleeding is D. Keep the client
expected with a NPO.
permanent 35. Aluminum
peritoneal catheter hydroxide gel
(Amphojel) is prescribed
135
for the client with A. “I’ll take it
chronic renal failure to every 4 hours
take at home. What is the around the clock.”
purpose of giving this B. “I’ll take it
drug to a client with between meals
chronic renal failure? and at bedtime.”
C. “I’ll take it
A. To relieve the when I have a
pain of gastric sour stomach.”
hyperacidity D. “I’ll take it with
B. To prevent meals and
Curling’s stress bedtime snacks.”
ulcers 37. The client with
C. To bind chronic renal failure tells
phosphorus in the the nurse he takes
intestine magnesium hydroxide
D. To reverse (milk of magnesium) at
metabolic home for constipation.
acidosis. The nurse suggests that
36. The nurse teaches the client switch to
the client with chronic psyllium hydrophilic
renal failure when to take mucilloid (Metamucil)
the aluminum hydroxide because:
gel. Which of the
following statements A. MOM can cause
would indicate that the magnesium
client understands the toxicity
teaching? B. MOM is too
harsh on the
bowel
136
C. Metamucil is material as
more palatable needed.
D. MOM is high in 39. The nurse helps the
sodium client with chronic renal
38. In planning teaching failure develop a home
strategies for the client diet plan with the goal of
with chronic renal helping the client
failure, the nurse must maintain adequate
keep in mind the nutritional intake. Which
neurologic impact of of the following diets
uremia. Which teaching would be most
strategy would be most appropriate for a client
appropriate? with chronic renal
failure?
A. Providing all
needed teaching A. High
in one extended carbohydrate,
session. high protein
B. Validating B. High calcium,
frequently the high potassium,
client’s high protein
understanding of C. Low protein,
the material. low sodium, low
C. Conducting a potassium
one-on-one D. Low protein,
session with the high potassium
client. 40. A client with chronic
D. Using renal failure has asked to
videotapes to be evaluated for a home
reinforce the continuous ambulatory
137
peritoneal dialysis standard
(CAPD) program. The peritoneal dialysis
nurse should explain that is a more effective
the major advantage of technique.”
this approach is that it: B. “Diet
restrictions are the
A. Is relatively low same for both
in cost CAPD and
B. Allows the standard
client to be more peritoneal
independent dialysis.”
C. Is faster and C. “Diet
more efficient restrictions with
than standard CAPD are fewer
peritoneal dialysis than with standard
D. Has fewer peritoneal dialysis
potential because dialysis is
complications constant.”
than standard D. “Diet
peritoneal dialysis restrictions with
41. The client asks CAPD are fewer
whether her diet would than with standard
change on CAPD. Which peritoneal dialysis
of the following would because CAPD
be the nurse’s best works more
response? quickly.”
A. “Diet 42. Which of the
restrictions are following is the most
more rigid with significant sign of
CAPD because peritoneal infection?
138
A. Cloudy dialysate 45. When caring for Mr.
fluid Roberto’s AV shunt on
B. Swelling in the his right arm, you should:
legs
C. Poor drainage of A. Cover the entire
the dialysate fluid cannula with an
D. Redness at the elastic bandage
catheter insertion B. Notify the
site physician if a
43. The main indicator of bruit and thrill are
the need for hemodialysis present
is: C. User surgical
aseptic technique
A. Ascites when giving shunt
B. Acidosis care
C. Hypertension D. Take the blood
D. Hyperkalemia pressure on the
44. To gain access to the right arm instead
vein and artery, an AV
shunt was used for Mr.
Roberto. The most SPINAL CORD
serious problem with INJURY
regards to the AV shunt
is: A patient with a spinal
cord injury at the T1
A. Septicemia level complains of a
B. Clot formation severe headache and an
C. Exsanguination "anxious feeling." Which
D. Vessel sclerosis is the most appropriate
139
initial reaction by the 4. Explain to the patient
nurse? that this could be a
1. Try to calm the patient common, temporary
and make the problem.
environment soothing.
2. Assess for a full
bladder. The nurse is caring for a
3. Notify the healthcare patient with increased
provider. intracranial pressure
4. Prepare the patient for (IICP). The nurse realizes
diagnostic radiography. that some nursing actions
are contraindicated with
A hospitalized patient IICP. Which nursing
with a C7 cord injury action should be
begins to yell "I can't feel avoided?
my legs anymore."
Which is the most 1. Reposition the patient
appropriate action by the every two hours.
nurse? 2. Position the patient
with the head elevated 30
1. Remind the patient of degrees.
her injury and try to 3. Suction the airway
comfort her. every two hours per
2. Call the healthcare standing orders.
provider and get an order 4. Provide continuous
for radiologic evaluation. oxygen as ordered.
3. Prepare the patient for
surgery, as her condition
is worsening. A patient with a spinal
cord injury (SCI) is
140
admitted to the unit and 3. respiratory wheezes
placed in traction. Which and stridor
of the following actions 4. diarrhea
is the nurse responsible 5. fecal impaction
for when caring for this
patient?
Select all that apply. An unconscious patient
receiving emergency care
1. modifying the traction following an automobile
weights as needed crash accident has a
2. assessing the patient's possible spinal cord
skin integrity injury. What guidelines
3. applying the traction for emergency care will
upon admission be followed?
4. administering pain Select all that apply.
medication
5. providing passive 1. Immobilize the neck
range of motion using rolled towels or a
cervical collar.
A patient has 2. The patient will be
manifestations of placed in a supine
autonomic dysreflexia. position
Which of these 3. The patient will be
assessments would placed on a ventilator.
indicate a possible cause 4. The head of the bed
for this condition? will be elevated.
Select all that apply. 5. The patient's head will
be secured with a belt or
1. hypertension tape secured to the
2. kinked catheter tubing stretcher.
141
4. 35-year-old male who
A patient with a spinal coaches a soccer team
cord injury is recovering
from spinal shock. The The nurse understands
nurse realizes that the that when the spinal cord
patient should not is injured, ischemia
develop a full bladder results and edema occurs.
because what emergency How should the nurse
condition can occur if it explain to the patient the
is not corrected quickly? reason that the extent of
injury cannot be
1. autonomic dysreflexia determined for several
2. autonomic crisis days to a week?
3. autonomic shutdown
4. autonomic failure 1. "Tissue repair does not
begin for 72 hours."
2. "The edema extends
Which patient is at the level of injury for two
highest risk for a spinal cord segments above and
cord injury? below the affected level."
3. "Neurons need time to
1. 18-year-old male with regenerate so stating the
a prior arrest for driving injury early is not
while intoxicated (DWI) predictive of how the
2. 20-year-old female patient progresses."
with a history of 4. "Necrosis of gray and
substance abuse white matter does not
3. 50-year-old female occur until days after the
with osteoporosis injury."
142
3. Teach the patient to
A patient with a spinal grasp the side rail to turn.
cord injury (SCI) has 4. Use the log roll to turn
complete paralysis of the the patient to the side.
upper extremities and
complete paralysis of the
lower part of the body. The patient is admitted
The nurse should use with injuries that were
which medical term to sustained in a fall. During
adequately describe this the nurse's first
in documentation? assessment upon
1. hemiplegia admission, the findings
2. paresthesia are: blood pressure 90/60
3. paraplegia (as compared to 136/66
4. quadriplegia in the emergency
Which of the following department), flaccid
nursing actions is paralysis on the right,
appropriate for absent bowel sounds,
preventing skin zero urine output, and
breakdown in a patient palpation of a distended
who has recently bladder. These signs are
undergone a consistent with which of
laminectomy? the following?
1. paralysis
1. Provide the patient 2. spinal shock
with an air mattress. 3. high cervical injury
2. Place pillows under 4. temporary
patient to help patient hypovolemia
turn.
143
While caring for the patient's BP is 83/49, and
patient with spinal cord his pulse is 39 beats/min,
injury (SCI), the nurse and he remains orally
elevates the head of the intubated. The nurse
bed, removes identifies this
compression stockings, pathophysiologic
and continues to assess response as caused by
vital signs every two to
three minutes while a. increased vasomotor
searching for the cause in tone after injury
order to prevent loss of b. a temporary loss of
consciousness or death. sensation and flaccid
By practicing these paralysis below the level
interventions, the nurse is of injury
avoiding the most c. loss of
dangerous complication parasympathetic nervous
of autonomic dysreflexia, system innervation
which is which of the resulting in
following? vasoconstriction
d. loss of sympathetic
1. hypoxia nervous system
2. bradycardia innervation resulting in
3. elevated blood peripheral vasodilation
pressure
4. tachycardia A nurse is caring for a
client with a spinal cord
A patient is admitted to injury who reports a
the hospital with a CD4 severe headache and is
spinal cord injury after a sweating profusely. vital
motorcycle collision. The signs include BP
144
220/110, apical heart rate
of 54/min. Which of the An initial incomplete
following acctions should spinal cord injury often
the nurse take first? results in complete cord
damage because of
a. notify the provider a. edematous
b. sit the client upright in compression of the cord
bed above the level of the
c. check the client's injury
urinary catheter for b. continued trauma to
blockage the cord resulting from
d. administer damage to stabilizing
antihypertensive ligaments
medication c. infarction and necrosis
B. sit the client upright in of the cord caused by
bed edema, hemorrhage, and
metabolites
d. mecheanical
Following a T2 spinal transection of the cord by
cord injury, the patient sharp vertebral bone
develops paralytic ileus. fragments after the initial
While this condition is injury
present, the nurse
anticipates that the Two days following a
patient will need spinal cord injury, a
a. IV fluids patient asks continually
b. tube feedings about the extent of
c. parenteral nutrition impairment that will
d. nasogastric suctioning result from the injury.
145
The best response by the function. The nurses' best
nurse is, response to the patient is,
a. you will have more a. it is really still too soon

normal function when to know if you will have
spinal shock resolves and a return of function
the reflex arc returns b. the could be a really
b. the extent of your positive finding. can you
injury cannot be show me the movement
determined until the c. that's wonderful. we
secondary injury to the will start exercising your
cord is resolved legs more frequently now
c. when your condition is d. im sorry, but the
more stable, an MRI will movement is only a
be done that can reveal reflex and does not
the extent of the cord indicate normal function
damage
d. because long-term
rehabilitation can affect Urinary function during
the return of tunction, it the acute phase of spinal
will be years before we cord injury is maintained
can tell when the with
complete effect will be a. an indwelling catheter
b. intermittent
A week following a catheterization
spinal cord injury at T2, a c. insertion of a
patient experiences suprapubic catheter
movement in his leg and d. use of incontinent pads
tells the nurse he is to protect the skin
recovering some
146
A nurse is caring for a c. assess lung sounds and
client who has a C4 respiratory rate and depth
spinal cord injury. which d. prepare the patient for
of the following should endotracheal intubation
the nurse recognize the and mechanical
client as being at the ventilation
greatest risk for?
a. neurogenic shock The healthcare provider

b. paralytic ileus has ordered IV dopamine
c. stress ulcer (Intropin) for a patient in
d. respiratory the emergency
compromise deparement with a spinal
cord injury.
The nurse determines that
During assessment of a the drug is having the
patient with a spinal cord desired effect when
injury, the nurse assessment findings
determines that the include
patient has a poor cough
with diaphragmatic a. pulse rate of 68
breathing. Based on this b. respiratory rate of 24
finding, the nurses' first c. BP of 106/82
action should be to d. temperature of 96.8
a. initiate frequent A patient is admitted to

turning and repositioning the emergency
b. use tracheal suctioning department with a spinal
to remove secretions cord injury at the level of
T2. Which of the
147
following findings is of shock. The nurse plans
most concern to the care for the patient based
nurse? on the knowledge that
a. SpO2 of 92% a. rehabilitation measures

b. HR of 42 beats/min cannot be initiated until
c. BP of 88/60 spinal shock has resolved
d. loss of motor and b. the patient will need
sensory function in arms continuous monitoring
and legs for hypotension,
tachycardia, and
hypoxemia
Without surgical c. resolution of spinal
stabilization, shock is manifested by
immobilization and spasticity, hyperreflexia,
traction of the patient and reflex emptying of
with a cervical spinal the bladder
cord injury most d. the patient will have
frequently requires the complete loss of motor
use of and sensory functions
a. kinetic beds below the level of the
b. hard cervical collars injury, but autonomic
c. skeletal traction with functions are not affected
skull tongs
d. sternal-occipital-
mandibular immobilizer A patient with a C7
(SOMI) brace spinal cord injury
undergoing rehabilitation
A patient with a spinal tells the nurse he must
cord injury has spinal have the flu because he
148
has a bad headache and possible cervical spinal
nausea. The initial action cord injury following an
of the nurse is to automobile crash. During
a. call the physician the admission of the
b. check the patient's patient, the nurse places
temperature the highest priority on
c. take the patient's BP
d. elevate the HOB to 90 a. maintaining a patent
degrees airway
b. assessing the patient
One indication for for head and other
surgical therapy of the injuries
patient with a spinal cord c. maintaining
injury is when immobilization of the
cervical spine
a. there is incomplete d. assessing the patient's
cord lesion involvement motor and sensory
b. the ligaments that function
support the spine are torn
c. a high cervical injury
causes loss of respiratory A nurse is planning care
function for a client who suffered
d. evidence of continued a spinal cord injury (SCI)
compression of the cord involving a T12 fracture
is apparent 1 week ago. The client
has no muscle control of
the lower limbs, bowel,
A patient is admitted to or bladder. which of the
the emergency following should be the
department with a nurses' greatest priority?
149
a. prevention of further A nurse is caring for a
damage to the spinal cord client who experienced a
b. prevention of cervical spine injury 3
contractures of the lower months ago. Which of the
extremities following types of
c. prevention of skin bladder management
breakdown of areas that methods should the nurse
lack sensation use for this client?
d. prevention of postural
hypotension when a. condom catheter
placing the client in a b. intermittent urinary
wheelchair catheterization
Goals of rehabilitation c. crede's method
for the patient with an d. indwelling urinary
injury at the C6 level catheter
include (select all that a. condom catheter
apply)
a. stand erect with leg A patient is admitted

brace with a spinal cord injury
b. feed self with hand at the C7 level. During
devices assessment the nurse
c. drive an electric identifies the presence of
wheelchair spinal shock on finding
d. assist with transfer a. paraplegia with flaccid
activities paralysis
e. drive adapted van from b. tetraplegia with total
wheelchair sensory loss
150
c. total hemiplegia with the patient is discharged
sensory and motor loss from rehabilitation
d. spastic tetraplegia with
loss of pressure sensation
In planning community
During the patient's education for prevention
process of grieving for of spinal cord injuries,
the losses resulting from the nurse targets
spinal cord injury, the a. elderly men
nurse b. teenage girls
c. elementary school-age
a. helps the patient children
understand that working d. adolescent and young
through the grief will be adult men
a lifelong process
b. should assist the In counseling patient
patient to move through with spinal cord lesions
all stages of the regarding sexual
mourning process to function, the nurse
acceptance advises a male patient
c. lets the patient know with a complete lower
that anger directed at the motor neuron lesion that
staff or the family is not a he
positive coping
mechanism a. is most likely to have
d. facilitates the grieving reflexogenic erections
process so that it is and may experience
completed by the time orgasm if ejaculation
occurs
151
b. may have uncontrolled pressure in coordination
reflex erections, but that with reflex voiding
orgasm and ejaculation patterns
are usually not possible d. that a urinary
c. has a lesion with the diversion, such as an ileal
greatest possibility of conduit, is the easiest
successful psychogenic way to handle urinary
erection with ejaculation elimination
and orgasm
d. will probably be A nurse is caring for a
unable to have either client who experienced a
psychogenic or cervical spine injury 24
reflexogenic erections hours ago. which of the
with no ejaculation or following types of
orgasm prescribed medications
should the nurse clarify
A patient with paraplegia with the provider?
has developed an irritable
bladder with reflex a. glucocorticoids
emptying. The nurse b. plasma expanders
teaches the patient c. H2 antagonists
d. muscle relaxants
a. hygiene care for an
indwelling urinary
catheter 27. When caring for a
b. how to perform patient who was admitted
intermittent self- 24 hours previously with
catheterization a C5 spinal cord injury,
c. to empty the bladder which nursing action has
with manual pelvic the highest priority?
152
b. tell the patient that
a. Continuous cardiac sildenafil (Viagra) helps
monitoring for to decrease erectile
bradycardia dysfunction in patients
b. Administration of with spinal cord injury.
methylprednisolone c. inform the patient that
(Solu-Medrol) infusion most patients with upper
c. Assessment of motor neuron injuries
respiratory rate and depth have reflex erections.
d. Application of d. suggest that the patient
pneumatic compression and his wife work with a
devices to both legs nurse specially trained in
sexual counseling.
22. A 26-year-old patient
with a C8 spinal cord
injury tells the nurse, 13. A patient with a neck
"My wife and I have fracture at the C5 level is
always had a very active admitted to the intensive
sex life, and I am worried care unit (ICU) following
that she may leave me if I initial treatment in the
cannot function emergency room. During
sexually." The most initial assessment of the
appropriate response by patient, the nurse
the nurse to the patient's recognizes the presence
comment is to of spinal shock on
finding
a. advise the patient to
talk to his wife to a. hypotension,
determine how she feels bradycardia, and warm
about his sexual function. extremities.
153
b. involuntary, spastic e. Retention catheter care
movements of the arms f. Administration of H2
and legs. receptor blockers
c. the presence of
hyperactive reflex
activity below the level 16. A patient with a T1
of the injury. spinal cord injury is
d. flaccid paralysis and admitted to the intensive
lack of sensation below care unit (ICU). The
the level of the injury. nurse will teach the
patient and family that
a. use of the shoulders
1. When caring for a will be preserved.
patient who experienced b. full function of the
a T1 spinal cord patient's arms will be
transsection 2 days ago, retained.
which collaborative and c. total loss of respiratory
nursing actions will the function may occur
nurse include in the plan temporarily.
of care? (Select all that d. elevations in heart rate
apply.) are common with this
type of injury.
a. Endotracheal
suctioning 1. In which order will the
b. Continuous cardiac nurse perform the
monitoring following actions when
c. Avoidance of cool caring for a patient with
room temperature possible cervical spinal
d. Nasogastric tube cord trauma who is
feeding
154
admitted to the once initial assessment
emergency department? and stabilization is
a. Administer O2 using a accomplished.
non-rebreathing mask.
b. Monitor cardiac
rhythm and blood
pressure. 14. When caring for a
c. Immobilize the patient who had a C8
patient's head, neck, and spinal cord injury 10
spine. days ago and has a weak
d. Transfer the patient to cough effort, bibasilar
radiology for spinal CT. crackles, and decreased
Correct Answer: C, A, B, breath sounds, the initial
D intervention by the nurse
Rationale: The first should be to
action should be to
prevent further injury by a. administer oxygen at 7
stabilizing the patient's to 9 L/min with a face
spinal cord. Maintenance mask.
of oxygenation by b. place the hands on the
administration of 100% epigastric area and push
O2 is the second priority. upward when the patient
Because neurogenic coughs.
shock is a possible c. encourage the patient
complication, continuous to use an incentive
monitoring of heart spirometer every 2 hours
rhythm and BP is during the day.
indicated. CT scan to d. suction the patient's
determine the extent and oral and pharyngeal
level of injury is needed airway.
155
a. Teaching the patient
20. The nurse discusses how to self-catheterize
long-range goals with a b. Assisting the patient to
patient with a C6 spinal the toilet q2-3hr
cord injury. An c. Use of the Credé
appropriate patient method to empty the
outcome is bladder
d. Catheterization for
a. transfers independently residual urine after
to a wheelchair. voiding
b. drives a car with
powered hand controls.
c. turns and repositions Which is most important
self independently when to respond to in a patient
in bed. presenting with a T3
d. pushes a manual spinal injury?
wheelchair on flat,
smooth surfaces. A. Blood pressure of
88/60 mm Hg, pulse of
56 beats/minute
18. A patient with a B. Deep tendon reflexes
paraplegia resulting from of 1+, muscle strength of
a T10 spinal cord injury 1+
has a neurogenic reflex C. Pain rated at 9
bladder. When the nurse D. Warm, dry skin
develops a plan of care
for this problem, which
nursing action will be
most appropriate? The patient arrives in the
emergency department
156
from a motor vehicle C. The heel has a
accident, during which reddened, nonblanchable
the car ran into a tree. area.
The patient was not D. Reflux bowel
wearing a seat belt, and emptying.
the windshield is
shattered. What action is Which clinical
most important for you to manifestation do you
do? interpret as representing
neurogenic shock in a
A. Determine if the patient with acute spinal
patient lost cord injury?
consciousness.
B. Assess the Glasgow A. Bradycardia
Coma Scale (GCS) score. B. Hypertension
C. Obtain a set of vital C. Neurogenic spasticity
signs. D. Bounding pedal pulses
D. Use a logroll
technique when moving
the patient. 17. A male client with a
spinal cord injury is
One month after a spinal prone to experiencing
cord injury, which automatic dysreflexia.
finding is most important The nurse would avoid
for you to monitor? which of the following
measures to minimize the
A. Bladder scan indicates risk of recurrence?
100 mL.
B. The left calf is 5 cm a. Strict adherence to a
larger than the right calf. bowel retraining program
157
b. Keeping the linen
wrinkle-free under the
client
c. Preventing During rehabilitation, a
unnecessary pressure on patient with spinal cord
the lower limbs injury begins to ambulate
d. Limiting bladder with long leg braces.
catheterization to once Which level of injury
every 12 hours does the nurse associate
with this degree of
recovery?
A client with a spinal
cord injury is prone to
experiencing autonomic a. L1-2
dysreflexia. The nurse
should avoid which b. T6-7
measure to minimize the c. T1-2
risk of recurrence?
d. C7-8
1. strict adherence to a A patient with a T4
bowel retraining program spinal cord injury
2. keeping the linen experiences neurogenic
wrinkle free under the shock as a result of SNS
client dysfunction. What would
3. avoiding unnecessary the nurse recognize as
pressure on the lower
characteristic of this
limbs
condition?
4. limiting bladder
catheterization to once
every 12 hours
158
a. Tachycardia A patient with a C7 SCI
b. Hypotension undergoing rehabilitation
tells the nurse he must
c. Increased urine output have the flu because he
d. Peripheral has a bad headache and
vasoconstriction nausea. The nurse's first
priority is to
A patient with spinal

cord injury is a. call the HCP
experiencing severe b. check the patient's
neurologic deficits. What temperature
is the most likely
mechanism of injury for c. take the patient's blood
this patient? pressure
d. elevate the HOB to 90
degrees
a. compression

b. hyperextension patient with a halo vest
after cervical spine
c. flexion-rotation injury. Which care
instructions should the
nurse include in the
d. extension-rotation patient's discharge plan?
159
a. Keep a wrench close or b. "A reflex erection may
attached to the vest. cause an unsafe drop in
b. Use the frame and vest blood pressure."
to assist in positioning. c. "If I develop a severe
c. Clean around the pins headache, I will lie down
using betadine swab for 15 to 20 minutes."
sticks. d. "I can avoid this
d. Loosen both sides of problem by taking
the vest to provide skin medications to prevent
care leg spasms."
The nurse performs A 22-yr-old woman with

discharge teaching for a paraplegia after a spinal
34-yr-old male patient cord injury tells the home
with a thoracic spinal care nurse she
cord injury (T2) from a experiences bowel
construction accident. incontinence two or three
Which patient statement times each day. Which
indicates teaching about action by the nurse is
autonomic dysreflexia is most appropriate?
successful?
a. Insert a rectal stimulant
a. "I will perform self- suppository.
catheterization at least six
times per day."
160
b. Teach the patient to b. Spinal shock syndrome
gradually increase intake c. Anterior cord
of high-fiber foods. syndrome
c. Assess bowel d. Brown-Séquard
movements for syndrome
frequency, consistency,
and volume.
d. Instruct the patient to Which clinical
avoid all caffeinated and manifestation would the
carbonated beverages. nurse interpret as a
manifestation of
neurogenic shock in a
The nurse is caring for a patient with acute spinal
patient admitted with a cord injury?
spinal cord injury after a
motor vehicle accident.
The patient exhibits a a. Bradycardia
complete loss of motor, b. Hypertension
sensory, and reflex c. Neurogenic spasticity
activity below the injury
level. The nurse d. Bounding pedal pulses
recognizes this condition
as which of the When planning care for a
following? patient with a cervical
spinal cord injury (C5),
a. Central cord syndrome which nursing diagnosis
has the highest priority?
161
a. Impaired urinary b. Irregular respirations
elimination related to and shortness of breath
tetraplegia c. Decreased level of
b. Risk for impaired consciousness or
tissue integrity related to hallucinations
paralysis d. Abdominal distention
c. Disabled family coping and absence of bowel
related to the extent of sounds
trauma
d. Ineffective airway Which intervention
clearance related to should the nurse perform
cervical spinal cord first in the acute care of a
injury patient with autonomic
dysreflexia?
Which manifestations in a. Urinary catheterization

a patient with a thoracic
spinal cord injury (T4)
should alert the nurse to b. Check for bowel
possible autonomic impaction
dysreflexia? c. Elevate the head of the
bed
a. Headache and rising d. Administer

blood pressure intravenous hydralazine
162
A 25-yr-old male patient short time ago.
who is a professional Assessment of the client
motocross racer has reveals increased blood
anterior spinal cord pressure (168/94 mm Hg)
syndrome at T10. His and decreased heart rate
history is significant for (48 beats/min),
tobacco, alcohol, and diaphoresis, and flushing
marijuana use. What is of the face and neck.
the nurse's priority when What action should the
planning for nurse take first?
rehabilitation?
a. Administer the ordered

a. Prevent urinary tract acetaminophen.
infection. b. Check the Foley tubing
b. Monitor the patient for kinks or obstruction.
every 15 minutes. c. Adjust the temperature
c. Encourage him to in the client's room.
verbalize his feelings. d. Notify the health care
d. Teach him about using provider about the
the gastrocolic reflex. change in status.
A client with a spinal The nurse is helping a

cord injury (SCI) reports client with a spinal cord
sudden severe throbbing injury to establish a
headache that started a bladder retraining
163
program. Which (ED). What is the priority
strategies may stimulate nursing assessment?
the client to void? Select
all that apply.
a. Determine the level at
which the client has
a. Stroking the client's intact sensation.
inner thigh b. Assess the level at
b. Pulling on the client's which the client has
pubic hair retained mobility.
c. Initiating intermittent c. Check blood pressure
straight catheterization and pulse for signs of
d. Pouring warm water spinal shock.
over the client's perineum d. Monitor respiratory
e. Tapping the bladder to effort and oxygen
stimulate the detrusor saturation level.
muscle
f. Reminding the client to Which nursing action
void in a urinal every will the home health
hour while awake nurse include in the plan
of care for a patient with
paraplegia in order to
A client with a spinal prevent autonomic
cord injury at level C3 to dysreflexia?
C4 is being cared for by
the nurse in the
emergency department
164
a. Assist with selection of c. hyperactive reflex
a high protein diet. activity below the level
b. Use quad coughing to of the injury.
assist cough effort. d. lack of movement or
c. Discuss options for sensation below the level
sexuality and fertility. of the injury.
d. Teach the purpose of a

prescribed bowel A patient with a T1
program. spinal cord injury is
admitted to the intensive
care unit. The nurse will
A patient with a neck teach the patient and
fracture at the C5 level is family that
care unit. During initial
assessment of the patient, a. use of the shoulders
the nurse recognizes the will be preserved.
presence of neurogenic b. full function of the
shock on finding patients arms will be
retained.
a. hypotension, c. total loss of respiratory
bradycardia, and warm function may occur
extremities. temporarily.
b. involuntary, spastic d. elevations in heart rate
movements of the arms are common with this
and legs. type of injury.
165
A patient with paraplegia a. transfer independently
resulting from a T10 to a wheelchair.
spinal cord injury has a b. drive a car with
neurogenic reflex powered hand controls.
bladder. Which action
will the nurse include in c. turn and reposition
the plan of care? independently when in
bed.
d. push a manual
a. Educate on the use of wheelchair on flat,
the Cred method. smooth surfaces.
b. Teach the patient how
to self-catheterize.
A patient who sustained a
c. Catheterize for residual spinal cord injury a week
urine after voiding. ago becomes angry,
d. Assist the patient to telling the nurse I want to
the toilet every 2 hours. be transferred to a
When the nurse is hospital where the nurses
developing a know what they are
rehabilitation plan for a doing! Which reaction by
patient with a C6 spinal the nurse is best?
cord injury, an
appropriate patient goal a. Ask for the patients
is that the patient will be input into the plan for
able to care.
166
b. Clarify that abusive a. tell the spouse that the
behavior will not be patient can perform
tolerated. activities independently.
c. Reassure the patient b. remind the patient
about the competence of about the importance of
the nursing staff. independence in daily
d. Continue to perform activities.
care without responding c. develop a plan to
to the patients comments. increase the patients
independence in
consultation with the
After a 25-year-old patient and the spouse.
patient has returned home
following rehabilitation d. recognize that it is
for a spinal cord injury, important for the spouse
the home care nurse to be involved in the
notes that the spouse is patients care and support
performing many of the the spouses participation.
activities that the patient
had been managing When caring for a patient
during rehabilitation. The who was admitted 24
most appropriate action hours previously with a
by the nurse at this time C5 spinal cord injury,
is to which nursing action has
the highest priority?
167
a. Assessment of b. administer oxygen at 7
respiratory rate and depth to 9 L/min with a face
b. Continuous cardiac mask.
monitoring for c. place the hands on the
bradycardia epigastric area and push
c. Application of upward when the patient
pneumatic compression coughs.
devices to both legs d. encourage the patient
d. Administration of to use an incentive
methylprednisolone spirometer every 2 hours
(Solu-Medrol) infusion during the day.
When caring for a patient

who had a C8 spinal cord A patient with a history
injury 10 days ago and of a T2 spinal cord injury
has a weak cough effort tells the nurse, I feel
and loose-sounding awful today. My head is
secretions, the initial throbbing, and I feel sick
intervention by the nurse to my stomach. Which
should be to action should the nurse
take first?
a. suction the patients

oral and pharyngeal a. Assess for a fecal
airway. impaction.
168
b. Give the prescribed sexuality after spinal cord
antiemetic. injury.
c. Check the blood d. Penile injection,
pressure (BP). prostheses, or vacuum
d. Notify the health care suction devices are
provider. possible options.
A 26-year-old patient When caring for a patient

with a T3 spinal cord who experienced a T1
injury asks the nurse spinal cord transsection 2
about whether he will be days ago, which
able to be sexually active. collaborative and nursing
Which initial response by actions will the nurse
the nurse is best? include in the plan of
care? Select all that apply
a. Reflex erections
frequently occur, but a. Urinary catheter care
orgasm may not be
possible. b. Nasogastric (NG) tube
b. Sildenafil (Viagra) is feeding
used by many patients
with spinal cord injury.
c. Continuous cardiac
c. Multiple options are monitoring
available to maintain
169
d. Avoidance of cool What causes an initial
room temperature SCI to result in complete
cord damage?
e. Administration of H2
receptor blockers a. edematous
compression of the cord
above the level of injury
A 70 year old patient is
admitted after falling b. continued trauma to
from his roof. He has a the cord resulting from
spinal cord injury at the damage to stabilizing
C7 level. What findings ligaments
during the assessment c. infarction and necrosis
identify the presence of of the cord caused by
spinal shock? edema, hemorrhage, and
metabolites
a. paraplegia with a d. mechanical transection

flaccid paralysis of the cord by sharp
vertebral bone fragments
b. tetraplegia with total after the initial injury
sensory loss
c. total hemiplegia with
sensory and motor loss
d. spastic tetraplegia with c
loss of pressure sensation A patient with SCI has
spinal shock. The nurse
plans care for the patient
170
based on what impairment that will
knowledge? result from the injury.
What is the best response
by the nurse?
a. rehabilitation measures
cannot be initiated until
spinal shock has resolved a. "you will have more
b. the patient will need normal function when
continuous monitoring spinal shock resolves and
for hypotension, the reflux arc returns"
tachycardia, and b. "the extent of your
hypoxemia injury cannot be
c. resolution of spinal determined until the
shock is manifested by secondary injury to the
spasticity, reflex return, cord is resolved"
and neurogenic bladder c. "when your condition
d. patient will have is more stable, MRI will
complete loss of motor be done to reveal the
and sensory functions extent of the cord
below the level of the damage"
injury, but autonomic d. "because long-term
functions are not affected rehabilitation can affect
the return of function, it
will be years before we
Two days following SCI, can tell what the
a patient asks continually complete affect will be"
about the extent of
171
The patient was in a b. heart rate of 42 bpm
traffic collision and is c. BP of 88/60
experiencing loss of
function below C4. d. loss of motor and
Which effect must the sensory function in the
nurse be aware of to arms and legs
provide priority care for
the patient? What is one indication
for early surgical therapy
a. respiratory of the patient with SCI?
diaphragmatic breathing
b. loss of all respiratory a. there is incomplete
muscle function cord lesion involvement
c. decreased response of b. the ligaments that
the SNS support the spine are torn
d. GI hypomobility with c. a high cervical causes
paralytic ileus and gastric loss of respiratory
distention function
A patient is admitted to d. evidence of continued
the ED with SCI at the compression of the cord
level of T2. Which is apparent
clinical finding is of most
concern by the nurse?
A patient is admitted to
the ED with a possible
a. SpO2 of 92% cervical SCI following an
172
automobile crash. During
admission of the patient, a. kinetic beds
what is the highest
priority for the nurse? b. hard cervical collar
c. skeletal traction with
skull tongs
a. maintaining a patent
airway d. sternal-occipital-
mandibular immobilizer
b. assessing the patient brace
for head and other
injuries
c. maintaining The HCP has prescribed
immobilization of the IV norepinephrine for the
cervical spine patient in the ED with
SCI. The nurse
d. assessing the patient's determines that the drug
motor and sensory is having the desired
function effect when what is
observed in patient
assessment?
Before surgical
stabilization, what a. HR of 68 bpm
method of b. respiratory rate of 24
immobilization for the
patient with a cervical c. temperature of 96.8
SCI should the nurse d. BP 106/82
expect to be used?
173
During assessment of the anticipate that the patient
patient with SCI, the will need?
nurse determines that the
patient has a poor cough
with diaphragmatic a. IV fluids
breathing. Based on this b. tube feedings
finding, what should be c. parenteral nutrition
the nurse's first action?
d. nasogastric suctioning
a. institute frequent
turning and repositioning How is urinary function
maintained during the
b. use tracheal suctioning acute phase of SCI?
to remove secretions
c. assess lung sounds and
respiratory rate and depth a. an indwelling catheter
d. prepare the patient for b. intermittent

ET intubation and catheterization
mechanical ventilation c. insertion of a
suprapubic catheter
d. use of incontinent pads
to protect the skin
Following a T2 SCI, the
patient develops paralytic
ileus. While this A week following SCI at
condition is present, what T2, a patient experiences
should the nurse movement in his legs and
174
tells the nurse that he is emptying. Along with
recovering some possible use of
function. What is the medications, what will be
nurse's best response? most helpful for the nurse
to teach the patient?
a. "it is really still too

soon to know if you will a. hygiene care for an
have a return of function" indwelling urinary
b. "that could be a really catheter
positive finding. Can you b. how to perform
show me the movement?" intermittent self-
c. "that's wonderful. We catheterization
will start exercising your c. to empty the bladder
legs more frequently with manual pelvic
now" pressure in coordination
d. "I'm sorry but the with reflex voiding
movement is only a patterns
reflex and does not d. that a urinary
indicate normal function" diversion, such as an ileal
conduit, is the easiest
way to handle urinary
elimination
A patient with paraplegia In counseling patients

has developed an irritable with SCI regarding
bladder with reflux
175
sexual function, how and no ejaculation or
should the nurse advise a orgasm
male patient with a
complete lower motor
neuron lesion?
a. he may have
uncontrolled reflex During the patient's
erections, but orgasm and process of grieving for
ejaculation are usually the losses resulting from
not possible SCI, what should the
b. he is most likely to nurse do?
have reflex erections and
may experience orgasm if a. help the patient to
S2-S4 nerve pathways understand that working
are intact through the grief will be
c. he has a lesion with the a lifelong process
greatest possibility of b. assist the patient to
successful pyschogenic move through all stages
erection with ejaculation of the mourning and grief
and orgasm process to acceptance
d. he will probably be c. let the patient know
unable to have either that anger directed at the
psychogenic or staff or the family is not a
reflexogenic erections positive coping
mechanism
176
d. facilitate the grieving d. prevention of postural
process so that it is hypotension when
completed by the time placing the client in a
the patient is discharged wheelchair
from rehabilitation

A nurse is planning care client who has a SCI who
for a client who has a reports severe headache
SCI involving a T12 and is sweating
fracture 1 week ago. The profusely. Vital signs
client has no muscle include BP 220/110 and
control of the lower apical HR of 54. Which
limbs, bowel, or bladder. of the following actions
Which of the following should the nurse take
should be the nurse's first?
highest priority?
a. examine the skin for

a. prevention of further irritation or pressure
damage to the spinal cord
b. prevention of b. sit the client upright in
contractures of the lower bed
extremities
c. check the urinary
c. prevention of skin catheter for blockage
breakdown of areas that
lack sensation
177
d. administer
antihypertensive a. anticoagulant
medication
b. plasma expanders
c. H2 antagonists
client who has a C4 SCI. d. muscle relaxants
The nurse should
recognize the client is at A nurse is caring for a
greatest risk for which of client who experienced a
the following cervical spine injury 3
complications? months ago. The nurse
should plan to implement
a. neurogenic shock which of the following
types of bladder
b. paralytic ileus management methods?
c. stress ulcer
d. respiratory a. condom catheter
compromise
b. intermittent urinary
catheterization
A nurse is caring for a c. Crede's method
client who experiences a
cervical spine injury 24 d. indwelling urinary
hours ago. Which of the catheter
following prescriptions
should the nurse clarify A client with a SCI is
with the provider? prone to experiencing
178
autonomic dysreflexia. The nurse is evaluating
The nurse should include the neurologic signs of a
which measures in the client in spinal shock
plan of care to minimize following SCI. Which
the risk of this observation indicates that
occurrence? Select all spinal shock persists?
that apply
a. hyperreflexia
a. keeping the linens b. positive reflexes
wrinkle-free under the
client c. flaccid paralysis
b. preventing d. reflex emptying of the

unnecessary pressure on bladder
the lower limbs
c. limiting bladder The nurse is caring for a
catheterization to once patient admitted 1 week
every 12 hours ago with an acute spinal
d. turning and cord injury. Which of the
repositioning the client at following assessment
least every 2 hours findings would alert the
nurse to the presence of
e. ensuring that the client autonomic dysreflexia?
has a bowel movement at
least once a week A) Tachycardia
B) Hypotension
C) Hot, dry skin
179
D) Throbbing headache C) Altered family and
Correct Answer(s): D individual coping caused
by the extent of trauma
Autonomic dysreflexia is
related to reflex D) Ineffective airway
stimulation of the clearance caused by high
sympathetic nervous cervical spinal cord
system reflected by injury
hypertension, Correct Answer(s): D
bradycardia, throbbing Maintaining a patent
headache, and airway is the most
diaphoresis. important goal for a
patient with a high
When planning care for a cervical fracture.
patient with a C5 spinal Although all of these are
cord injury, which appropriate nursing
nursing diagnosis is the diagnoses for a patient
highest priority? with a spinal cord injury,
respiratory needs are
A) Risk for impairment always the highest
of tissue integrity caused priority. Remember the
by paralysis ABCs.
B) Altered patterns of
urinary elimination
caused by quadriplegia Which of the following
signs and symptoms in a
patient with a T4 spinal
cord injury should alert
180
the nurse to the
possibility of autonomic Which of the following
dysreflexia? interventions should the
A) Headache and rising nurse perform in the
blood pressure acute care of a patient
B) Irregular respirations with autonomic
and shortness of breath dysreflexia?
C) Decreased level of A) Urinary

consciousness or catheterization
hallucinations B) Administration of
D) Abdominal distention benzodiazepines
and absence of bowel C) Suctioning of the
sounds patient's upper airway
Correct Answer(s): A D) Placement of the
Among the patient in the
manifestations of Trendelenburg position
autonomic dysreflexia Correct Answer(s): A
are hypertension (up to Because the most
300 mm Hg systolic) and common cause of
a throbbing headache. autonomic dysreflexia is
Respiratory bladder irritation,
manifestations, decreased immediate catheterization
level of consciousness, to relieve bladder
and gastrointestinal distention may be
manifestations are not necessary. The patient
characteristic.
181
should be positioned spinal cord injury
upright. Benzodiazepines includes analyzing the -
are contraindicated and vital sign, plantar
suctioning is likely reflexes, bilatereal hand
unnecessary. grasp, description of
trauma.
Nurse is assessing a Romberg test must be

patient who has a spinal performed while standing
cord injury?Which therefore not suitable for
should the nurse include unstable patient
in the nervous system
assessment to determine A patient has
the extent of the patient's impairments from a SCI
injury? at C4 classified as
select all that apply. incomplete C on the
a. vital sign American Spinal Injury
Association, (ASIA)
b. romberg test Impairment Sclae. Which
c. plantar reflexes patient assessment is the
d. bilatereal hand grasps nurse likely to observe in
this patient?
e. description of trauma
A. poor propricopetor in
Correct Answer (s): a, c, the legs
d, e
B. poor peristalsis in the
the assessment to intestines
determine the level of
182
C. Absent gag and Medrol) as a continous
blinking reflexes IV fusion to a male
D. Absent bladder patient who has fractures
fulness sensation of the cervical vertebrae.
Which intervention
Answer is B would prevent or detect
A patient who has a SCI adverse effects of the
has neurologic medication?
impairment to all A. record pt baseline
extremities and the weight
diaphragm. However,
because the injury is C on B. adminster PPI( proton
the ASIA impairment pump inhibitor)
Scale, sensory function C. Check the hear rate for
can be intact but motor bradycardia
function will be impaired D. suction the patient's
significantly or absent.the oropharynx
patient can lose moderate
to complete peristatlic Correct Answer(s): B
action in the intestines the nurse should
but should reatine the adminster PPI because
ability to sense bladder they are at high risk for
fulnessand the position of Gi erosion and bleeding.
the legs. from the steroid.
The nurse admnisters A male patient has a

methylprenisone(Solu- pinal cord injury at L 1-2
183
. Which clinical A female nurse is injured
manifestation of the in an automobile accident
patient's injury is the and suffers acute
nurse likely to observe compresssion of the
before spinal shock anterior apinal cord at
resolves? T8-10 Which nursing rols
A. opoiod analgesic Iv is a potential source of
for foot pain employment for the
patients after completing
B. able to blance in rehabilitation ?
sitting position
A. Certified nurse
C. unresponsive practioner
quadriceps muscle
B. Community health
D. requites asssist control nursing
ventilation
C. Hospital case
Correct Answer(s) : C mangement
during spinal shock D. Inpatient behavioral
neuromuscular function health
is lost below the level of
the injury along with Correct C. Hospital case
hyporeflexia and loss of management(s)
sensation. So the pt will the nurse in most likely
not be able to sit until the to have an anterior cord
pinal shock resolves. syndrome resulting in the
loss of neuromuscular
and pain and temp
sensation below t8. Pt
184
will have full use of Weakness of thoracic
upper extremities , upper muscle is most likely to
back, and resp cause life-threatening
muscles.thus she will be complications because
in a wheel chair. affects patients
oxygentation and
ventilation.
A 70 yr old patient who
has a spinal cord injury at
C8 resulting in central A patient with a neck
cord syndrome. Which fracture at the C5 level is
effect of the patient's admitted to the intensive
most likely to be life care unit (ICU) following
threatening after initial treatment in the
completeing emergency room. During
rehabiliation? initial assessment of the
A. increased bone density patient, the nurse
loss recognizes the presence
of spinal shock on
B. higher tisk for tissue finding
hpoxia
a. hypotension,
C. vasomotor bradycardia, and warm
compensation lost extremities.
D. Weakness of thoracic b. involuntary, spastic
muscles movements of the arms
Correct Answer(s): D and legs.
185
c. the presence of When caring for a patient
hyperactive reflex who had a C8 spinal cord
activity below the level injury 10 days ago and
of the injury. has a weak cough effort,
d. flaccid paralysis and bibasilar crackles, and
lack of sensation below decreased breath sounds,
the level of the injury. the initial intervention by
the nurse should be to
Correct Answer(s): D
a. administer oxygen at 7
Rationale: Clinical to 9 L/min with a face
manifestations of spinal mask.
shock include decreased
reflexes, loss of b. place the hands on the
sensation, and flaccid epigastric area and push
paralysis below the area upward when the patient
of injury. Hypotension, coughs.
bradycardia, and warm c. encourage the patient
extremities are evidence to use an incentive
of neurogenic shock. spirometer every 2 hours
Involuntary spastic during the day.
movements and d. suction the patient's
hyperactive reflexes are oral and pharyngeal
not seen in the patient at airway.
this stage of spinal cord
injury. Correct Answer(s): B
Rationale: The nurse has
identified that the cough
effort is poor, so the
186
initial action should be to admitted to the intensive
use assisted coughing care unit (ICU). The
techniques to improve the nurse will teach the
ability to mobilize patient and family that
secretions. a. use of the shoulders
Administration of oxygen will be preserved.
will improve
oxygenation, but the data b. full function of the
do not indicate patient's arms will be
hypoxemia, and oxygen retained.
will not help expel c. total loss of respiratory
respiratory secretions. function may occur
The use of the spirometer temporarily.
may improve respiratory d. elevations in heart rate
status, but the patient's are common with this
ability to take deep type of injury.
breaths is limited by the
loss of intercostal muscle Correct Answer(s): B
function. Suctioning may Rationale: The patient
be needed if the patient is with a T1 injury can
unable to expel secretions expect to retain full
by coughing but should motor and sensory
not be the nurse's first function of the arms. Use
action. of only the shoulders is
associated with cervical
spine injury. Total loss of
A patient with a T1 respiratory function
spinal cord injury is occurs with injuries
187
above the C4 level and is Correct Answer(s): C
permanent. Bradycardia Rationale: The purpose
is associated with injuries of methylprednisolone
above the T6 level. administration is to help
preserve neurologic
The health care provider function; therefore, the
orders administration of nurse will assess this
IV methylprednisolone patient for lower-
(Solu-Medrol) for the extremity function.
first 24 hours to a patient Sympathetic nervous
who experienced a spinal system dysfunction
cord injury at the T10 occurs with injuries at or
level 3 hours ago. When above T6, so monitoring
evaluating the of BP and heart rate will
effectiveness of the not be useful in
medication the nurse will determining the
assess effectiveness of the
medication. Respiratory
a. blood pressure and and GI function will not
heart rate. be impaired by a T10
b. respiratory effort and injury, so assessments of
O2 saturation. these systems will not
c. motor and sensory provide information
function of the legs. about whether the
medication is effective.
d. bowel sounds and
abdominal distension.
188
A patient with a appropriate method is to
paraplegia resulting from avoid incontinence by
a T10 spinal cord injury emptying the bladder at
has a neurogenic reflex regular intervals through
bladder. When the nurse intermittent
develops a plan of care catheterization. Assisting
for this problem, which the patient to the toilet
nursing action will be will not be helpful
most appropriate? because the bladder will
a. Teaching the patient not empty. The Credé
how to self-catheterize method is more
appropriate for a bladder
b. Assisting the patient to that is flaccid, such as
the toilet q2-3hr occurs with a reflexic
c. Use of the Credé neurogenic bladder.
method to empty the Catheterization after
bladder voiding will not resolve
d. Catheterization for the patient's incontinence.
residual urine after
voiding A patient with a history
Correct Answer(s): A of a T2 spinal cord tells
Rationale: Because the the nurse, "I feel awful
patient's bladder is today. My head is
spastic and will empty in throbbing, and I feel sick
response to to my stomach." Which
overstretching of the action should the nurse
bladder wall, the most take first?
189
a. Notify the patient's dysreflexia is ruled out as
health care provider. the cause of the nausea.
b. Check the blood The nurse may assess for
pressure (BP). a fecal impaction, but this
should be done after
c. Give the ordered checking the BP and
antiemetic. lidocaine jelly should be
d. Assess for a fecal used to prevent further
impaction. increases in the BP.
Correct Answer(s): B The nurse discusses long-
Rationale: The BP should range goals with a patient
be assessed immediately with a C6 spinal cord
in a patient with an injury injury. An appropriate
at the T6 level or higher patient outcome is
who complains of a a. transfers independently
headache to determine to a wheelchair.
whether autonomic b. drives a car with
dysreflexia is causing the powered hand controls.
symptoms, including
hypertension. c. turns and repositions
Notification of the self independently when
patient's health care in bed.
provider is appropriate d. pushes a manual
after the BP is obtained. wheelchair on flat,
Administration of an smooth surfaces.
antiemetic is indicated Correct Answer(s): D
after autonomic
190
Rationale: The patient the patient's behavior is
with a C6 injury will be to
able to use the hands to a. ask for the patient's
push a wheelchair on flat, input into the plan for
smooth surfaces. Because care.
flexion of the thumb and
fingers is minimal, the b. clarify that abusive
patient will not be able to behavior will not be
grasp a wheelchair during tolerated.
transfer, drive a car with c. reassure the patient
powered hand controls, that the anger will pass
or turn independently in and rehabilitation will
bed. then progress.
d. ignore the patient's
A patient who sustained a anger and continue to
T1 spinal cord injury a perform needed
week ago refuses to assessments and care.
discuss the injury and Correct Answer(s): A
becomes verbally abusive Rationale: The patient is
to the nurses and other demonstrating behaviors
staff. The patient consistent with the anger
demands to be transferred phase of the mourning
to another hospital, process, and the nurse
where "they know what should allow expression
they are doing." The best of anger and seek the
response by the nurse to patient's input into care.
Expression of anger is
191
appropriate at this stage a. advise the patient to
and should be tolerated talk to his wife to
by the nurse. Refusal to determine how she feels
acknowledge the patient's about his sexual function.
anger by telling the b. tell the patient that
patient that the anger is sildenafil (Viagra) helps
just a phase is to decrease erectile
inappropriate. Continuing dysfunction in patients
to perform needed with spinal cord injury.
assessments and care is
appropriate, but the nurse c. inform the patient that
should seek the patient's most patients with upper
input into what care is motor neuron injuries
needed. have reflex erections.
d. suggest that the patient
and his wife work with a
A 26-year-old patient nurse specially trained in
with a C8 spinal cord sexual counseling.
injury tells the nurse,
"My wife and I have Correct Answer(s): D
always had a very active Rationale: Maintenance
sex life, and I am worried of sexuality is an
that she may leave me if I important aspect of
cannot function rehabilitation after spinal
sexually." The most cord injury and should be
appropriate response by handled by someone with
the nurse to the patient's expertise in sexual
comment is to counseling. Although the
192
patient should discuss and parents are
these issues with his performing many of the
wife, open activities of daily living
communication about (ADLs) that the patient
this issue may be difficult had been managing
without the assistance of during rehabilitation. The
a counselor. Sildenafil most appropriate action
does assist with erectile by the nurse at this time
dysfunction after spinal is to
cord injury, but the a. tell the family
patient's sexuality is not members that the patient
determined solely by the can perform ADLs
ability to have an independently.
erection. Reflex erections
are common after upper b. remind the patient
motor neuron injury, but about the importance of
these erections are independence in daily
uncontrolled and cannot activities.
be maintained during c. recognize that it is
coitus. important for the patient's
A 25-year-old patient has family to be involved in
returned home following the patient's care and
extensive rehabilitation support their activities.
for a C8 spinal cord d. develop a plan to
injury. The home care increase the patient's
nurse visits and notices independence in
that the patient's spouse consultation with the
193
with the patient, spouse,
and parents. When caring for a patient
Correct Answer((s): D who was admitted 24
Rationale: The best hours previously with a
action by the nurse will C5 spinal cord injury,
be to involve all the which nursing action has
parties in developing an the highest priority?
optimal plan of care. a. Continuous cardiac
Because family members monitoring for
who will be assisting bradycardia
with the patient's ongoing b. Administration of
care need to feel that methylprednisolone
their input is important, (Solu-Medrol) infusion
telling the family that the
patient can perform c. Assessment of
ADLs independently is respiratory rate and depth
not the best choice. d. Application of
Reminding the patient pneumatic compression
about the importance of devices to both legs
independence may not Correct Answer(s): C
change the behaviors of
the family members. Rationale: Edema around
Supporting the activities the area of injury may
of the spouse and parents lead to damage above the
will lead to ongoing C4 level, so the highest
dependency by the priority is assessment of
patient. the patient's respiratory
194
function. The other Correct Answer(s): C, A,
actions are also B, D
appropriate but are not as Rationale: The first
important as assessment action should be to
of respiratory effort. prevent further injury by
stabilizing the patient's
In which order will the spinal cord. Maintenance
nurse perform the of oxygenation by
following actions when administration of 100%
caring for a patient with O2 is the second priority.
possible cervical spinal Because neurogenic
cord trauma who is shock is a possible
admitted to the complication, continuous
emergency department? monitoring of heart
rhythm and BP is
a. Administer O2 using a indicated. CT scan to
non-rebreathing mask. determine the extent and
b. Monitor cardiac level of injury is needed
rhythm and blood once initial assessment
pressure. and stabilization is
c. Immobilize the accomplished.
patient's head, neck, and
spine. The nurse is caring for a
d. Transfer the patient to man who has experienced
radiology for spinal CT. a spinal cord injury.
Throughout his recovery,
the client expects to gain
195
control of his bowels. defecation is a spinal
The nurse's best response reflex involving the
to this client would be parasympathetic nerve
which of the following? fibers. Normally, the
a. "Over time, the nerve external anal sphincter is
fibers will regrow new maintained in a state of
tracts, and you can have tonic contraction. With a
bowel movements again." spinal cord injury, the
client no longer has this
b. "Wearing an nervous system control
undergarment will and is often incontinent.
become more
comfortable over time."
c "Having a bowel For a 65-year-old woman
movement is a spinal who has lived with a T1
reflex requiring intact spinal cord injury for 20
nerve fibers. Yours are years, which health
not intact." teaching instructions
should the nurse
d "It is not going to emphasize?
happen. Your nerve cells
are too damaged." a. A mammogram is
needed every year.
Correct Answer(s: ) C
b. Bladder function tends
Having a bowel to improve with age.
movement is a spinal
reflex requiring intact c. Heart disease is not
nerve fibers. Yours are common in people with
not intact The act of spinal cord injury.
196
d. As a person ages, the b. assess the gag reflex
need to change body and respiratory rate and
position is less important. depth.
c. lightly palpate the
6. The most common affected side of the face
early symptom of a for edema.
spinal cord tumor is d. test for temperature
a. urinary incontinence. and sensation perception
on the face.
b. back pain that worsens
with activity. e. ask the patient to
describe factors that
c. paralysis below the initiate an episode.
level of involvement.
d. impaired sensation of
pain, temperature, and 8. During routine
light touch. assessment of a patient
with Guillain-Barré
syndrome, the nurse finds
7. During assessment of the patient is short of
the patient with breath. The patient's
trigeminal neuralgia, the respiratory distress is
nurse should (select all caused by
that apply) a. elevated protein in the
a. inspect all aspects of CSF.
the mouth and teeth. b. immobility resulting
from ascending paralysis.
197
c. degeneration of motor approximately eight
neurons in the brainstem weeks."
and spinal cord. d. "You should be able to
d. paralysis ascending to walk without help within
the nerves that stimulate three months."
the thoracic area
1. A patient has a spinal

9. A nurse is caring for a cord injury at T4. Vital
patient newly diagnosed signs include falling
with chronic blood pressure with
inflammatory bradycardia. The nurse
demyelinating recognizes that the
polyneuropathy (CIDP). patient is experiencing
Which statement can the a. a relative
nurse accurately use to hypervolemia.
teach the patient about
CIDP? b. an absolute
hypovolemia.
a. "Corticosteroids have
little effect on this c. neurogenic shock from
disease." low blood flow.
b. "Maintenance therapy d. neurogenic shock from

will be needed to prevent massive vasodilation.
relapse."
c. "You will go into A patient has been
remission in admitted to the hospital
with a T3-level complete
198
spinal cord injury. The E. Patient will be able to
nurse has to plan the have effective coughing
home-based ability.
rehabilitation for this
patient. When creating Rationale
the care plan, the nurse
considers the activities The patient with a T3-
that the patient is able to level spinal cord injury
do independently. What will have full innervation
activities should the of the upper extremities,
nurse consider to make back, essential intrinsic
maximum use of patient's muscles of the hands, full
abilities? Select all that strength and dexterity of
apply. grasp, decreased trunk
stability, and decreased
respiratory reserve.
A. Independent self-care Therefore, the patient
is possible. may have the following
B. Independent potentials: full
wheelchair mobility is independence in self-care
possible. and in a wheelchair,
ability to drive a car with
C. Patient may be able to hand controls,
drive with hand controls. independent standing in a
D. Patient will be able to standing frame.
climb stairs Abdominal muscles are
independently. affected, so the ability to
cough is lost. The patient
199
may also not be able to C. The patient is
climb stars due to the constipated and is
injury. passing hard stools with
straining.
D. The sensation of a full
bowel is perceived by the
A patient has been patient, and fecal
admitted to the hospital incontinence is present.
with a spinal cord injury.
Following the E. The sensation of a full
assessment, the health bowel is not perceived by
care provider concludes the patient, and fecal
that the injury is above incontinence is present.
T12. What signs and Rationale
symptoms related to the An injury above T12
gastrointestinal system leads to development of a
would indicate an injury reflexic bowel, wherein
above T12? Select all nervous interactions
that apply. between the colon (large
intestine) and the brain
A. The patient has an are interrupted. As a
absence of bowel sounds. result, the person may not
feel the need to have a
B. There is excess gastric bowel movement.
distention, and the However, stool is still
stomach is hard. building up in the rectum.
The build-up triggers a
200
reflex, causing the nursing interventions
rectum and colon to would be appropriate for
react, leading to a bowel this patient if the nurse
movement without suspects autonomic
warning. When the dysreflexia? Select all
sensation of a full bowel that apply.
is perceived by the
patient and the patient
has fecal incontinence, it A. Lower the head of the
is a lower-level spinal bed.
cord injury (below T12). B. Monitor blood
In spinal cord injury, it is pressure regularly.
usually incontinence that C. Make the patient lie
occurs. When the injury flat on the bed.
is above T5, paralytic
ileus may be present and D. Notify the primary
bowel sounds may be health care provider.
absent. E. Check for the presence
of bowel impaction.
A nurse is assessing a F. Remove the kink in

patient with a T2-level the catheter and drain the
spinal cord injury. The bladder.
nurse notices that there is
a kink in the catheter, the Rationale
bladder is distended, and
A sudden rise in blood
the blood pressure is
pressure for a spinal cord
220/100 mm Hg. What
201
injury patient above the most important nursing
level of T6 is generally intervention in this case
indicative of autonomic is elevating the head of
dysreflexia. Nursing the bed 45 degrees or
interventions in a serious higher to make the
emergency like patient sit upright; this
autonomic dysreflexia would lower the blood
include notifying the pressure.
primary health care While assessing a
provider and determining patient's level of spinal
the cause. The blood injury, the nurse observes
pressure should be that the patient has
regularly monitored; sensation and movement
administration of an in the neck and the region
alpha-adrenergic blocker above, and can breathe
or an arteriolar without a ventilator.
vasodilator is required. What is the potential for
Contractions of the rehabilitation that the
rectum are also a cause; nurse can expect?
therefore, the nurse
should check for bowel
impaction and treat it A. Ability to feed self
accordingly. The most with setup
common cause is bladder B. Ability to drive an
distension. If a catheter is electric wheelchair
present, the presence of
any kinks or folds should
be checked. However, the
202
C. Attendant care stick and head wand.
required for 10 hours in a Hence independent use of
day a computer is not
D. Independent computer possible.
use with adaptive
equipment
Rationale What type of blunt
A patient with sensation trauma can lead to a
and movement in the spinal cord injury?
neck and the region A. Stab wound
above the neck can drive
an electric wheelchair by B. Diving accident
using chin control of a C. Gunshot wound
mouth stick. Self-feeding D. Torn spinal cord
is not possible for the
patient because the Rationale
ability of movement is A diving accident is a
limited to the neck. The blunt trauma caused by a
patient requires complete physical injury that can
assistance with daily lead to spinal cord injury.
living activities; therefore Stab wound, gunshot
attendant care is required wounds, and a torn spinal
24 hours a day. Due to cord are instances of
paralysis in the arms and penetrating traumas that
hands, the patient can can injure the spinal cord.
access the computer only
with the help of a mouth
203
Which syndrome of paralysis of the lower
incomplete spinal cord limbs and areflexic bowel
lesion is described as and bladder
cord damage common in b. Spinal cord damage
the cervical region resulting in ipsilateral
resulting in greater motor paralysis and
weakness in upper contralateral loss of pain
extremities than lower? and sensation below the
a. Central cord syndrome level of the lesion
b. Anterior cord c. Rare cord damage
syndrome resulting in loss of
c. Posterior cord proprioception below the
syndrome lesion level with
retention of motor control
d. Cauda equina and and temperature and pain
conus medullaris sensation
syndromes
d. Often caused by
The patient is diagnosed flexion injury with acute
with Brown-Séquard compression of cord
syndrome after a knife resulting in complete
wound to the spine. motor paralysis and loss
Which description of pain and temperature
accurately describes this sensation below the level
syndrome? of injury
a. Damage to the most
distal cord and nerve
roots, resulting in flaccid
204
The patient's spinal cord b. The ligaments that
injury is at T4. What is support the spine are
the highest-level goal of torn.
rehabilitation that is c. A high cervical injury
realistic for this patient causes loss of respiratory
to have? function.
a. Indoor mobility in d. Evidence of continued
manual wheelchair compression of the cord
b. Ambulate with is apparent.
crutches and leg braces
c. Be independent in self- The health care provider
care and wheelchair use has ordered IV dopamine
d. Completely (Intropin) for a patient in
independent ambulation the emergency
with short leg braces and department with a spinal
canes cord injury. The nurse
determines that the drug
is having the desired
What is one indication effect when what is
for early surgical therapy observed in patient
of the patient with a assessment?
spinal cord injury? a. Heart rate of 68 bpm
a. There is incomplete b. Respiratory rate of 24
cord lesion involvement.
c. Blood pressure of
106/82 mm Hg
205
d. Temperature of 96.8°F d. He will probably be
(36.0°C) unable to have either
psychogenic or
reflexogenic erections
In counseling patients and no ejaculation or
with spinal cord lesions orgasm
regarding sexual
function, how should the
nurse advise a male A patient with a
patient with a complete metastatic tumor of the
lower motor neuron spinal cord is scheduled
lesion? for removal of the tumor
a. He is most likely to by a laminectomy. In
have reflexogenic planning postoperative
erections and may care for the patient, what
experience orgasm if should the nurse
ejaculation occurs. recognize?
b. He may have a. Most cord tumors

uncontrolled reflex cause autodestruction of
erections but orgasm and the cord as in traumatic
ejaculation are usually injuries.
not possible. b. Metastatic tumors are
c. He has a lesion with commonly extradural
the greatest possibility of lesions that are treated
successful psychogenic palliatively.
erection with ejaculation c. Radiation therapy is
and orgasm. routinely administered
206
following surgery for all D. Administer
malignant spinal cord 100mg of
tumors. pentobarbital IV
as ordered.
d. Because complete 2) A client with a
removal of subarachnoid hemorrhage
intramedullary tumors is is prescribed a 1,000-mg
not possible, the surgery loading dose of Dilantin
is considered palliative. IV. Which consideration
is most important when
administering this dose?
1) An 18-year-old client
is admitted with a closed A. Therapeutic
head injury sustained in a drug levels should
MVA. His intracranial be maintained
pressure (ICP) shows an between 20 to 30
upward trend. Which mg/ml.
intervention should the B. Rapid dilantin
nurse perform first? administration can
cause cardiac
A. Reposition the arrhythmias.
client to avoid C. Dilantin should
neck flexion be mixed in
B. Administer 1 g dextrose in water
Mannitol IV as before
ordered administration.
C. Increase the D. Dilantin should
ventilator’s be administered
respiratory rate to through an IV
20 breaths/minute
207
catheter in the following responses best
client’s hand. describes this result?
3) A client with head A. Appropriate;
trauma develops a urine lowering carbon
output of 300 ml/hr, dry dioxide (CO2)
skin, and dry mucous reduces
membranes. Which of the intracranial
following nursing pressure (ICP).
interventions is the most B. Emergent; the
appropriate to perform client is poorly
initially? oxygenated.
C. Normal
A. Evaluate urine D. Significant; the
specific gravity client has alveolar
B. Anticipate hypoventilation.
treatment for renal 5) A client who had a
failure transsphenoidal
C. Provide hypophysectomy should
emollients to the be watched carefully for
skin to prevent hemorrhage, which may
breakdown be shown by which of the
D. Slow down the following signs?
IV fluids and
notify the A. Bloody drainage
physician from the ears
4) When evaluating an B. Frequent
ABG from a client with a swallowing
subdural hematoma, the C. Guaiac-positive
nurse notes the PaCO2 is stools
30 mm Hg. Which of the D. Hematuria
208
6) After a interventions should be
hypophysectomy, done first?
vasopressin is given IM
for which of the A. Assess full
following reasons? ROM to
determine extent
A. To treat growth of injuries
failure B. Call for an
B. To prevent immediate chest
syndrome of x-ray
inappropriate C. Immobilize the
antidiuretic client’s head and
hormone neck
(SIADH) D. Open the airway
C. To reduce with the head-tilt
cerebral edema chin-lift maneuver
and lower 8) A client with a C6
intracranial spinal injury would most
pressure likely have which of the
D. To replace following symptoms?
antidiuretic
hormone (ADH) A. Aphasia
normally secreted B. Hemiparesis
by the pituitary. C. Paraplegia
7) A client comes into the D. Tetraplegia
ER after hitting his head 9) A 30-year-old was
in an MVA. He’s alert admitted to the
and oriented. Which of progressive care unit with
the following nursing a C5 fracture from a
motorcycle accident.
Which of the following
209
assessments would take has limited movement of
priority? his upper extremities.
A. Bladder medications would be
distension used to control edema of
B. Neurological the spinal cord?
deficit
C. Pulse ox A. Acetazolamide
readings (Diamox)
D. The client’s B. Furosemide
feelings about the (Lasix)
injury C. Methylprednisol
10) While in the ER, a one (Solu-
client with C8 tetraplegia Medrol)
develops a blood pressure D. Sodium
of 80/40, pulse 48, and bicarbonate
RR of 18. The nurse 12) A 22-year-old client
suspects which of the with quadriplegia is
following conditions? apprehensive and
flushed, with a blood
A. Autonomic pressure of 210/100 and a
dysreflexia heart rate of 50 bpm.
B. Hemorrhagic Which of the following
shock nursing interventions
C. Neurogenic should be done first?
shock
D. Pulmonary A. Place the client
embolism flat in bed
11) A client is admitted B. Assess patency
with a spinal cord injury of the indwelling
at the level of T12. He urinary catheter
210
C. Give one SL A. Insert an
nitroglycerin indwelling urinary
tablet catheter to straight
D. Raise the head drainage
of the bed B. Schedule
immediately to 90 intermittent
degrees catherization
13) A client with a every 2 to 4 hours
cervical spine injury has C. Perform a
Gardner-Wells tongs straight
inserted for which of the catherization
following reasons? every 8 hours
while awake
A. To hasten D. Perform Crede’s
wound healing maneuver to the
B. To immobilize lower abdomen
the surgical spine before the client
C. To prevent voids.
autonomic 15) A client is admitted
dysreflexia to the ER for head trauma
D. To hold bony is diagnosed with an
fragments of the epidural hematoma. The
skull together underlying cause of
14) Which of the epidural hematoma is
following interventions usually related to which
describes an appropriate of the following
bladder program for a conditions?
client in rehabilitation for
spinal cord injury?
211
A. Laceration of D. Insert nasal and
the middle ear packing with
meningeal artery sterile gauze
B. Rupture of the 17) When discharging a
carotid artery client from the ER after a
C. Thromboemboli head trauma, the nurse
sm from a carotid teaches the guardian to
artery observe for a lucid
D. Venous bleeding interval. Which of the
from the following statements best
arachnoid space described a lucid
16) A 23-year-old client interval?
has been hit on the head
with a baseball bat. The A. An interval
nurse notes clear fluid when the client’s
draining from his ears speech is garbled
and nose. Which of the B. An interval
following nursing when the client is
interventions should be alert but can’t
done first? recall recent
events
A. Position the C. An interval
client flat in bed when the client is
B. Check the fluid oriented but then
for dextrose with becomes
a dipstick somnolent
C. Suction the nose D. An interval
to maintain when the client
airway patency has a “warning”
symptom, such as
212
an odor or visual D. Urinary
disturbance. continence
18) Which of the 20) A nurse assesses a
following clients on the client who has episodes
rehab unit is most likely of autonomic dysreflexia.
to develop autonomic Which of the following
dysreflexia? conditions can cause
autonomic dysreflexia?
A. A client with a
brain injury A. Head
B. A client with a ache
herniated nucleus B. Lumb
pulposus ar spinal cord
C. A client with a injury
high cervical C. Neuro
spine injury genic shock
D. A client with a D. Noxio
stroke us stimuli
19) Which of the 21) During an episode of
following conditions autonomic dysreflexia in
indicates that spinal which the client becomes
shock is resolving in a hypertensive, the nurse
client with C7 should perform which of
quadriplegia? the following
interventions?
A. Absence of pain
sensation in chest A. Elevate the
B. Spasticity client’s legs
C. Spontaneous B. Put the client
respirations flat in bed
213
C. Put the client in anticipate during
the the acute phase?
Trendelenburg’s A. Absent corneal
position reflex
D. Put the client in B. Decerebate
the high-Fowler’s posturing
position C. Movement of
22) A client with a T1 only the right or
spinal cord injury arrives left half of the
at the emergency body
department with a BP of D. The need for
82/40, pulse 34, dry skin, mechanical
and flaccid paralysis of ventilation
the lower extremities. 24) A client with C7
Which of the following quadriplegia is flushed
conditions would most and anxious and
likely be suspected? complains of a pounding
headache. Which of the
A. Autonomic following symptoms
dysreflexia would also be
B. Hypervolemia anticipated?
C. Neurogenic
shock A. Decreased urine
D. Sepsis output or oliguria
23) A client has a B. Hypertension
cervical spine injury at and bradycardia
the level of C5. Which of C. Respiratory
the following conditions depression
would the nurse D. Symptoms of
shock
214
25) A 40-year-old B. “Expect profuse
paraplegic must perform vomiting for 24
intermittent catherization hours after the
of the bladder. Which of injury.”
the following instructions C. “Wake him
should be given? every hour and
assess his
A. “Clean the orientation to
meatus from back person, time, and
to front.” place.”
B. “Measure the D. “Notify the
quantity of urine.” physician
C. “Gently rotate immediately if he
the catheter has a headache.”
during removal.” 27) Which
D. “Clean the neurotransmitter is
meatus with soap responsible for may of
and water.” the functions of the
26) An 18-year-old frontal lobe?
client was hit in the head
with a baseball during A. Dopamine
practice. When B. GABA
discharging him to the C. Histamine
care of his mother, the D. Norepinephrine
nurse gives which of the 28) The nurse is
following instructions? discussing the purpose of
an electroencephalogram
A. “Watch him for (EEG) with the family of
keyhole pupil the a client with massive
next 24 hours.” cerebral hemorrhage and
215
loss of consciousness. It B. Subarachnoid
would be most accurate hemorrhage
for the nurse to tell C. Epidural
family members that the hematoma
test measures which of D. Contusion
the following conditions? 30) After falling 20’, a
36-year-old man sustains
A. Exte a C6 fracture with spinal
nt of intracranial cord transaction. Which
bleeding other findings should the
B. Sites nurse expect?
of brain injury
C. Acti A. Quadriplegia
vity of the brain with gross arm
D. Perc movement and
ent of functional diaphragmic
brain tissue breathing
29) A client arrives at B. Quadriplegia
the ER after slipping on a and loss of
patch of ice and hitting respiratory
her head. A CT scan of function
the head shows a C. Paraplegia with
collection of blood intercostal muscle
between the skull and loss
dura mater. Which type D. Loss of bowel
of head injury does this and bladder
finding suggest? control
31) A 20-year-old client
A. Subdural who fell approximately
hematoma 30’ is unresponsive and
216
breathless. A cervical client reports a severe,
spine injury is suspected. pounding headache.
How should the first- Which of the following
responder open the nursing interventions
client’s airway for rescue would be appropriate for
breathing? this client? Select all that
apply.
A. By A. Elevate the
inserting a HOB to 90
nasopharyngeal degrees
airway B. Loosen
B. By constrictive
inserting a clothing
oropharyngeal C. Use a fan to
airway reduce
C. By diaphoresis
performing a jaw- D. Assess for
thrust maneuver bladder distention
D. By and bowel
performing the impaction
head-tilt, chin-lift E. Administer
maneuver antihypertensive
32) The nurse is caring medication
for a client with a T5 F. Place the client in
complete spinal cord a supine position
injury. Upon assessment, with legs elevated
the nurse notes flushed 33) The client with a
skin, diaphoresis above head injury has been
the T5, and a blood urinating copious
pressure of 162/96. The amounts of dilute urine
217
through the Foley A. Skull fracture
catheter. The client’s B. Concussion
urine output for the C. Subdural
previous shift was 3000 hematoma
ml. The nurse D. Epidural
implements a new hematoma
physician order to 35) The nurse is caring
administer: for a client who suffered
a spinal cord injury 48
A. Desmopressin hours ago. The nurse
(DDAVP, monitors for GI
stimate) complications by
B. Dexamethasone assessing for:
(Decadron)
C. Ethacrynic acid A. A flattened
(Edecrin) abdomen
D. Mannitol B. Hematest
(Osmitrol) positive
34) The nurse is caring nasogastric tube
for the client in the ER drainage
following a head injury. C. Hyperactive
The client momentarily bowel sounds
lost consciousness at the D. A history of
time of the injury and diarrhea
then regained it. The 36) A client with a
client now has lost spinal cord injury is
consciousness again. The prone to experiencing
nurse takes quick action, autonomic dysreflexia.
knowing this is The nurse would avoid
compatible with: which of the following
218
measures to minimize the and during
risk of recurrence? position changes
B. Using
A. Strict adherence vasopressor
to a bowel medications as
retraining prescribed
program C. Moving the
B. Limiting bladder client quickly as
catherization to one unit
once every 12 D. Applying
hours Teds or
C. Keeping the compression
linen wrinkle-free stockings.
under the client 38) The nurse is caring
D. Preventing for a client admitted with
unnecessary spinal cord injury. The
pressure on the nurse minimizes the risk
lower limbs of compounding the
37) The nurse is injury most effectively
planning care for the by:
client in spinal shock.
Which of the following A. Keeping the
actions would be least client on a
helpful in minimizing the stretcher
effects of vasodilation B. Logrolling the
below the level of the client on a firm
injury? mattress
C. Logrolling the
A. Monitoring client on a soft
vital signs before mattress
219
D. Placing the number 5 being the last
client on a Stryker priority).
frame
39) The nurse is A. Check for
evaluating neurological bladder distention
signs of the male client in B. Raise the head
spinal shock following of the bed
spinal cord injury. Which C. Contact the
of the following physician
observations by the nurse D. Loosen tight
indicates that spinal clothing on the
shock persists? client
E. Administer an
A. Positive reflexes antihypertensive
B. Hyperreflexia medication
C. Inability to elicit 41) A client is at risk for
a Babinski’s increased ICP. Which of
reflex the following would be a
D. Reflex emptying priority for the nurse to
of the bladder monitor?
40) A client with a
spinal cord injury A. Unequal pupil
suddenly experiences an size
episode of autonomic B. Decreasing
dysreflexia. After systolic blood
checking the client’s vital pressure
signs, list in order of C. Tachycardia
priority, the nurse’s D. Decreasing body
actions (Number 1 being temperature
the first priority and 42) Which of the
following respiratory
220
patterns indicate deterioration in the
increasing ICP in the client’s condition?
brain stem? A. Widening pulse
pressure
A. Slow, irregular B. Decrease in the
respirations pulse rate
B. Rapid, shallow C. Dilated, fixed
respirations pupil
C. Asymmetric D. Decrease in
chest expansion LOC
D. Nasal flaring 45) A client who is
43) Which of the regaining consciousness
following nursing after a craniotomy
interventions is becomes restless and
appropriate for a client attempts to pull out her
with an ICP of 20 mm IV line. Which nursing
Hg? intervention protects the
A. Give the client a client without increasing
warming blanket her ICP?
B. Administer low- A. Place her in a
dose barbiturate jacket restraint
C. Encourage the B. Wrap her hands
client to in soft “mitten”
hyperventilate restraints
D. Restrict fluids C. Tuck her arms
44) A client has signs of and hands under
increased ICP. Which of the draw sheet
the following is
an early indicator of
221
D. Apply a wrist breathing after recent
restraint to each intracranial occipital
arm bleeding. Which action
46) Which of the would be most
following describes appropriate?
decerebrate posturing?
A. Count the rate to
A. Internal rotation be sure the
and adduction of ventilations are
arms with flexion deep enough to be
of elbows, wrists, sufficient
and fingers B. Call the
B. Back hunched physician while
over, rigid flexion another nurse
of all four checks the vital
extremities with signs and
supination of ascertains the
arms and plantar patient’s Glasgow
flexion of the feet Coma score.
C. Supination of C. Call the
arms, dorsiflexion physician to
of feet adjust the
D. Back arched; ventilator settings.
rigid extension of D. Check deep
all four tendon reflexes to
extremities. determine the best
47) A client receiving motor response
vent-assisted mode 48) In planning the care
ventilation begins to for a client who has had a
experience cluster posterior fossa
222
(infratentorial) D. Absent corneal
craniotomy, which of the reflex
following is
contraindicates when 50) Shortly after
positioning the client? admission to an acute
care facility, a male client
A. Keeping with a seizure disorder
the client flat on develops status
one side or the epilepticus. The
other physician orders
B. Elevating diazepam (Valium) 10
the head of the mg I.V. stat. How soon
bed to 30 degrees can the nurse administer
C. Log rolling a second dose of
or turning as a diazepam, if needed and
unit when turning prescribed?
D. Keeping
the head in neutral A. In
position 30 to 45 seconds
49) A client has been B. In
pronounced brain dead. 10 to 15 minutes
Which findings would C. In
the nurse assess? Check 30 to 45 minutes
all that apply. D. In
1 to 2 hours
A. Decerebrate
posturing
B. Dilated non 1. Which patient below is
reactive pupils at MOST risk for
C. Deep tendon developing a condition
reflexes
223
called autonomic
dysreflexia? 2. Your patient, who has
A. A 24-year-old male a spinal cord injury at T3,
patient with a traumatic states they are
brain injury. experiencing a throbbing
B. A 15-year-old female headache. What is your
patient with a spinal cord NEXT nursing action?
injury at C7. A. Perform a bladder
C. A 35-year-old male scan
patient with a spinal cord B. Perform a rectal
injury at L6. digital examination
D. A 42-year-old male C. Assess the patient's
patient recovering from a blood pressure
hemorrhagic stroke. D. Administer a PRN
The answer is B. Patients medication to alleviate
who are at MOST risk for pain and provide a dark,
developing autonomic calm environment.
dysreflexia are patients The answer is C. This is
who've experienced a the nurse's NEXT action.
spinal cord injury at T6 The patient is at risk for
or higher...this includes developing autonomic
C7. L6 is below T6, and dysreflexia because of
traumatic brain injury their spinal cord injury at
and hemorrhagic stroke T3 (remember patients
does not increase a who have a SCI at T6 or
patient risk of AD. higher are at MOST risk).
224
If a patient with this type blood pressure is 106/76
of injury states they have and heart rate is 72. What
a headache, the nurse action should the nurse
should NEXT assess the take FIRST?
patient's blood pressure. A. Reassess the patient’s
If it is elevated, the nurse blood pressure.
would take measures to
check the bladder (a B. Check the patient's
bladder issue is the most blood glucose.
common cause of AD), C. Position the patient at
bowel, and skin for 90 degrees and lower the
breakdown. legs.
D. Provide cooling
blankets for the patient.
3. You're performing a The answer is C. Based

head-to-toe assessment on the patient findings
on a patient with a spinal and how the patient has a
cord injury at T6. The spinal cord injury at T6,
patient is restless, sweaty, they are experiencing
and extremely flushed. autonomic dysreflexia.
You assess the patient's Patients with this
blood pressure and heart condition may have a
rate. The patient’s blood blood pressure that is 20-
pressure is 140/98 and 40 mmHg higher than
heart rate is 52. You look their baseline and may
at the patient's chart and experience bradycardia
find that their baseline (heart rate less than 60).
225
The FIRST action the A. Hypoglycemia
nurse should take when B. Distended bladder
AD is suspected is to
position the patient at 90 C. Sacral pressure injury
degree (high Fowler's) D. Fecal impaction
and lower the legs. This E. Urinary tract infection
will allow gravity to
cause the blood to pool in The answers are B, C, D,
the lower extremities and and E. Anything that can
help decrease the blood cause an irritating
pressure. Then the nurse stimulus below the site of
should try to find the the spinal injury (T6 or
cause of the autonomic higher) can lead to
dysreflexia, which could autonomic dysreflexia,
be a full bladder, which causes an
impacted bowel, or skin exaggerated sympathetic
break down. reflex response and the
parasympathetic system
is unable to oppose it.
This will lead to severe
4. You’re providing an hypertension. The most
in-service to a group of common cause of AD is a
new nurse graduates on bladder issue
the causes of autonomic (full/distended bladder,
dysreflexia. Select all the urinary tract infection
most common causes you etc). Other common
will discuss during the causes are due to a bowel
in-service: issue like fecal impaction
226
or skin break down
(pressure injury/ulcer,
cut, infection etc.).
6. The physician orders
Nitropaste for a patient
who has developed
5. After taking all the autonomic dysreflexia.
necessary steps for a Which finding would
patient who has require the nurse to hold
developed autonomic the ordered dose of
dysreflexia, what should Nitropaste and notify the
the nurse assess FIRST physician?
as a possible cause of this A. The patient’s blood
condition? pressure is 130/80.
A. Skin break down B. The patient reports a
B. Blood glucose throbbing headache.
C. Possible bladder C. The patient’s lower

irritant extremities are pale and
cool.
D. Last bowel movement
D. The patient states they
The answer is C. A took Sildenafil 12 hours
bladder issue is usually ago.
the most common cause
of AD. If this isn’t the The answer is D. A
issue the nurse should patient should not receive
assess the bowel and then a dose of Nitropaste if
the skin for break down. they have taken a
227
phosphodiesterase A. Headache
inhibitor within the past B. Low blood glucose
24 hours (Sildenafil or
Tadalafil). This will C. Sweating
cause major vasodilation D. Flushed below site of
and severe hypotension injury
that will not respond to E. Pale and cool above
medication. Another site of injury
medication should be
used. All the other F. Hypertension
findings are expected G. Slow heart rate
with autonomic H. Stuffy nose
dysreflexia.
The answers are A, C, F,
G and H. All of these are
signs and symptoms of
7. A patient is receiving autonomic dysreflexia.
treatment for a complete The patient will have
spinal cord injury at T4. flushing above site of
As the nurse you know to injury due to vasodilation
educate the patient on the from parasympathetic
signs and symptoms of activity, BUT will be
autonomic dysreflexia pale and cool below site
What signs and of injury due to
symptoms will you vasoconstriction
educate the patient occurring below the site
about? Select all that of injury for the
apply:
228
sympathetic response 9. In autonomic
reflex. dysreflexia, the nurse
would expect what
finding below the site of
the spinal cord injury?
8. What is the BEST A. Flushed lower body
position for a patient
experiencing autonomic B. Pale and cool lower
dysreflexia? extremities
A. High Fowler's with C. Low blood pressure

legs lowered D. Absent reflexes
B. Low Fowler's with The answer is B. The
legs lowered lower extremities would
C. Semi-Fowler's with be cool and pale due to
legs at heart level vasconstriction caused by
the exaggerated reflex
D. Prone response of the
The answer is A. The sympathetic nervous
patient should be in high system from an irritating
Fowler's (90 degrees) stimulus. The
with the legs lowered. sympathetic reflex can
This will allow gravity to NOT be unopposed by
cause blood to pool in the the parasympathetic
lower extremities and nervous system due to
help decrease blood the spinal injury, which is
pressure. blocking the nerve
impulse. The areas found
229
ABOVE the site of injury has experienced a lumbar
would be flushed due to injury."
vasodilation from D. "The first-line of
parasympathetic treatment for autonomic
stimulation. dysreflexia is an
antihypertensive
medication."
10. Which statements are The answers are B and C.

TRUE about autonomic Option A is false, it
dysreflexia? Select all should say: Autonomic
that apply: dysreflexia is an
exaggerated reflex
A. "Autonomic response by the
dysreflexia is an SYMPATHETIC (NOT
exaggerated reflex parasympathetic) nervous
response by the system that results in
parasympathetic nervous severe hypertension due
system that results in to a spinal cord injury.
severe hypertension due Option D is false because
to a spinal cord injury." medications are used
B. "Autonomic only if the blood pressure
dysreflexia causes a slow is not decreasing or the
heart rate and severe cause cannot be
hypertension." determined.
C. "Autonomic
dysreflexia is less likely
to occur in a patient who
230
11. The nurse is about to also important prior to
assess for bowel catheterization to check
impaction in a patient the bladder for urine.
who has developed
autonomic dysreflexia.
The nurse makes it 1. A nurse explains that
priority to? the spinal cord extends
from the brainstem to the
A. Avoid using lubricants level of which vertebra?
B. Stimulate the bowel a. Last thoracic
with rectal manipulation
b. Second lumbar
C. Slowly administer a
saline solution prior to c. First sacral
assessment d. Coccygeal
D. Instill an anesthetic ANS: B
jelly prior to assessment The cord starts at the
The answer is D. To brainstem and extends to
avoid increasing the second lumbar
autonomic dysreflexia vertebra.
symptoms by increasing 2. On admission to the
the sympathetic reflex emergency department, a
due to an irritating patient with a C5
stimulus, the nurse compression fracture can
should instill an move only his head and
anesthetic jelly before has flaccid paralysis of
assessing the rectum for all extremities. The
hardened stool. This is distraught family asks if
231
the paralysis is 3. Which assessment
permanent. What would indicate the
is the best response by resolution of spinal
the nurse? shock?
a. “Yes. In all likelihood, a. Extension and rigidity

the paralysis is probably in affected limbs
permanent.” b. Spastic involuntary
b. “No. Significant movements in affected
recovery of function limbs
should occur in a few c. Tingling and burning
days.” in affected limbs
c. “It is too early to tell. d. Voluntary purposeful
When the spinal shock movements of affected
subsides, we will know limbs
more.” ANS: B
d. “You should talk to 4. Which assessment
your physician about leads the emergency
things of that nature.” department nurse to
ANS: C suspect that a patient’s
Spinal shock caused by spinal cord injury (SCI)
swelling may last from a is below C4?
few days to months, a. Voluntary eye
clouding the issue of the movement
true extent of the injury.
b. Ability to blink the
eyelids
232
c. Unlabored respiration The muscle group that
d. Ability to make a controls the feet is at L5.
facial grimace 6. What technique should
ANS: C the nurse implement to
move the impaired legs
The phrenic nerve, which of a patient with an SCI
is at C1 to C4, controls to avoid stimulation
the diaphragm and muscle spasm?
intercostal function for
ventilation. a. Firmly grasping the
calf muscle and the thigh
5. During a neurologic muscle
assessment, a nurse asks
a patient to dorsiflex the b. Manipulating the limb
foot against the resistance by supporting the knee
of the nurse’s hand. The and ankle joints
patient is unable to c. Holding the foot
perform this action. upright and slowly
Where does this dragging the limb into
assessment confirm that position
cord damage has d. Requesting assistance
occurred? to support the calf and
a. C4 to C5 thigh
b. L2 to L4 ANS: B
c. L5 Undue muscle
d. S1 stimulation can cause
spasticity. Using the joint
ANS: C
233
locations to support limbs 8. Which technique of
when repositioning them opening the airway in the
reduces likelihood of newly admitted patient
spasticity. with an SCI is the most
7. When recording the appropriate?
findings of muscle a. Chin lift
strength, a nurse records b. Head tilt
a 2 for the right arm.
How should his score be c. Jaw thrust
interpreted? d. Neck flexion
a. Weak contraction ANS: C
b. Muscle movement The jaw thrust does not
when supported require spinal movement.
c. Active muscle 9. Brown-Séquard
movement without syndrome results in
support which neurologic deficit?
d. Full, active range-of- a. Bilateral loss of pain
motion exercises against sensation below the level
resistance of injury
ANS: B b. Bilateral loss of
A 2 on the muscle- temperature and motor
grading scale means that function below the level
muscular movement is of injury
observed when the limb
is supported.
234
c. Motor and sensory loss b. Manage a mechanical
in the upper extremities wheelchair with hand
only control.
d. Ipsilateral loss of c. Manage a specially
motor function and equipped wheelchair.
contralateral loss of pain d. Manage an ordinary
sensation and wheelchair.
temperature
ANS: D
ANS: D
Upper extremity mobility
Brown-Séquard and enhanced hand grip
syndrome is a allow the use of an
hemisection of the cord ordinary wheelchair by
resulting in ipsilateral an individual with a C8
motor loss and level SCI.
contralateral loss of pain
and temperature. 11. A paraplegic patient
excitedly reports seeing
10. Which level of his foot move when he
independence is an was being turned. How is
appropriate nursing care this phenomenon best
plan goal for a patient explained?
with a C8 transection?
a. Reflexive movement
a. Manage a mechanical
wheelchair with a b. Return of motor
joystick. function
c. Early symptom of
autonomic dysreflexia
235
d. Result of hypertonicity bladder causes
of the muscle spontaneous emptying.
ANS: A 13. A distressed family
Reflexive action is a member asks about the
movement that does not purpose of the Gardner-
require communication to Wells tongs. Which is the
the brain via the spinal most helpful
cord. explanation by the nurse
12. After spinal shock regarding the action of
has been resolved, an Gardner-Wells tongs?
indwelling catheter is a. Compress the cervical
removed. What way vertebrae.
should the nurse expect b. Immobilize the head.
this patient to empty the
bladder? c. Allow the patient to be
moved out of bed.
a. Manual expression
(Credé method) d. Align the cervical
vertebrae.
b. Spontaneous reflexive
action ANS: D
c. Normal voluntary The Gardner-Wells tongs

control are secured to the skull to
separate and align the
d. Self-catheterization cervical vertebrae, but
ANS: B they do not immobilize
After spinal shock the head. When the tongs
resolves, spasticity of the
236
are in place, the patient is 15. A patient is receiving
bedridden. methylprednisolone.
14. What is the major What purpose should the
advantage of the halo nurse explain this drug
device over the Gardner- has in treating
Wells tongs? a patient with an SCI?
a. Separates the cervical a. Reduces spinal cord
vertebrae cellular damage
b. Allows the patient out b. Counteracts spinal
of bed shock
c. Aligns the cervical c. Increases blood supply
spine to the injured cord
d. Relieves pain d. Enhances sexual
ANS: B function
The halo device and the ANS: A

Gardner-Wells tongs do Methylprednisolone, if
exactly the same thing in given within the first 8
terms of separation and hours of the injury, can
alignment. significantly reduce
The only advantage of cellular damage to the
the halo device is the cord.
mobility it allows. 16. A patient with an SCI
Neither traction modality begins to have seizures,
specifically relieves pain. and the blood pressure
(BP) rises rapidly to
237
210/160 mm Hg. Which c. Raise the head of the
is the third indicator of bed to at least 45 degrees.
the syndrome of d. Administer oxygen per
autonomic dysreflexia? mask.
a. Profuse vomiting ANS: C
b. Hives on face and neck Raising the head of the
c. Excessive urine output bed reduces the BP.
d. Bradycardia Flexed legs, cooling, and
oxygen will not alleviate
ANS: D the syndrome.
Bradycardia, 18. Which intervention
hypertension, and seizure by a nurse is effective in
are the three signs of the prevention of
autonomic dysreflexia. autonomic dysreflexia in
17. What should be the the patient with an SCI?
immediate intervention a. Ensure patency of the
when a nurse recognizes urinary catheter.
autonomic dysreflexia in
the patient with an SCI? b. Give warm baths to the
patient to stimulate
a. Flex the patient’s legs vasodilation.
using the knee gatch of
the bed. c. Keep lighting at a
minimum to reduce
b. Cool the patient with stimulation.
alcohol solution.
d. Offer the patient four
or five small meals daily.
238
ANS: A c. Not absorbed well
A distended bladder, below the level of the
constipation, and sudden injury
jarring can all set off d. Too small a dose to be
autonomic dysreflexia. effective
Vagal stimulation retards ANS: C
vasodilation. The number
and size of meals have no A patient with
affect on preventing this quadriplegia has a high
syndrome. cervical lesion, which
causes nearly the entire
19. A nurse tells a patient vascular tree to have poor
with quadriplegia that he perfusion. This condition
is being treated with would make absorption
intravenous (IV) drugs of medications from the
because this method is tissues unpredictable.
more effective than
intramuscularly (IM). 20. The family members
What explanation should of a patient with an SCI,
the nurse provide about who is in the
IM medications to rehabilitation phase,
explain to the patient wants to take the patient
why they are less outdoors for a visit. It is
effective than IV? 90° F outside and very
humid. What should the
a. Too concentrated nurse suggest?
b. Too irritating to poorly
perfused tissue
239
a. Do not go outside at all b. Inform the charge
but remain in the nurse.
hospital. c. Perform intermittent
b. Take a spray bottle to catheterizations.
spray water to cool the d. Turn the patient to the
patient by evaporation. right side.
c. Take a light sweater to ANS: A
insulate the patient.
The nurse should
d. Have the patient drink continue to monitor the
at least 32 oz of water patient for urine output.
during the outing. Two hours is too soon to
ANS: B expect a continent patient
Water will evaporate and to void. Informing the
cool the patient, similar charge nurse and
to perspiration. catheterization are not
necessary. Turning this
21. A nurse notes that no patient to the side is
urinary output has contraindicated.
occurred in a patient who
underwent a 22. Which statement
laminectomy 2 hours made by a male patient
earlier. What action with an SCI could be
should the nurse assessed as a positive
implement? adaptation to the nursing
diagnosis of “Sexual
a. Continue to monitor. dysfunction, related to
altered body function”?
240
a. “I know I will never all possibilities of a
have a sexual relationship sexual relationship are
again.” defeatist remarks and are
b. “I need some not positive. However, a
suggestions as to how to patient should realize that
direct my sexual energy his or her sexual
into gardening or relationships will alter as
painting . . . or just a result of the SCI.
anything.” 23. What should a nurse
c. “Can you arrange an emphasize regarding the
appointment with a sex rehabilitation of the
counselor so I can begin patient with an SCI?
to examine alternative a. Rehabilitation is
methods of sexual usually achieved within a
activity?” few months after
d. “I think that after a stabilization.
while I will be able to b. Rehabilitation will
have sexual relationships return the patient with an
just like I had before my SCI to the preaccident
accident.” functional level.
ANS: C c. Rehabilitation focuses
Seeking help from a on adjustments necessary
counselor indicates an to reenter society and the
acceptance of learning workplace.
alternative techniques.
Remarks eliminating
241
d. Rehabilitation d. Apply splints to the
completely targets self- limbs.
care. ANS: D
ANS: C Applying splints will
The goals of reduce contractures. Cold
rehabilitation are application, agitation of
modification of lifestyle, the limb with ROM
as well as expectations exercises too frequently,
and adjustments, and tactile stimuli
necessary to attain the increase spasticity.
highest level of 25. The family of a
independence possible. patient with an SCI is
24. What should a nurse concerned with the lack
include in a patient’s plan of bowel function 2 days
of care when considering after the injury. What is
interventions for the the best response by the
outcome of prevention of nurse?
contractures in a patient a. “Because of his injury,
with an SCI? he will always need to
a. Apply cold wraps to have enemas for bowel
the limbs twice a day. evacuation.”
b. Perform full ROM b. “Medical management
exercises every 2 hours. is delaying bowel action
c. Use significant tactile because it places pressure
stimuli each shift. on the injury.”
242
c. “Bowel function b. Marks will be placed
should return in on either side of the
approximately 3 days injury to mark the area.
after the accident.” c. A cone-shaped wedge
d. “We’ll just have to of bone will be placed
wait and see if bowel between the vertebrae.
action returns this week.” d. A detailed
ANS: C radiographic image will
Bowel action usually be taken of the spinal
returns with peristalsis on injury.
the third day after the ANS: D
accident. The bowel A cone-down
responds to dilation from radiographic image
the content in the bowel provides a very detailed
and moves without picture of the lesion.
voluntary action from the
patient. 27. What should a nurse
encourage a patient with
26. What should a nurse an SCI to do after a
explain when a patient computed tomography
with an SCI inquires (CT) scan?
what the physician means
by a conedown? a. Sit up at a 30-degree
angle.
a. A cone is surgically
placed over the spine to b. Prevent chilling.
protect the cord. c. Drink plenty of water.
d. Avoid bearing down.
243
ANS: C all increased the potential
Fluids are pushed after a for rehabilitation.
CT scan to flush the Rehabilitation personnel
contrast media through and health insurance are
the kidneys. not new.
28. What has occurred in 29. What changes occur

the past 10 years to with the intervertebral
enhance rehabilitation of disks in older adults that
individuals with SCIs? increase the risk of
(Select all that apply.) injury? (Select all that
apply.)
a. Technologically
advanced assistive aids a. Fill with calcium
deposits
b. Rehabilitation
personnel b. Are less shock
absorbent
c. Development of
trauma centers c. Are herniated
d. Health insurance d. Enlarge and swell
e. Rapid transport of e. Lose water

victims ANS: B, E
ANS: A, C, E Age affects the water
New assistive aids, the content in intervertebral
development of disks, which makes them
decentralized trauma less able to absorb shock.
centers, and the rapid Herniation and swelling
transport of victims have can occur at any age.
244
Disks do not fill with The magnetic field will
calcium. deactivate the batteries in
30. Before taking a a pacemaker and will
magnetic resonance also attract any metal
image (MRI), a patient object into the
asks why metal objects 31. A nurse is caring for
and the MRI machine are a despondent young
such concerns. What is female patient with an
the best explanation by SCI at C5. The patient
the nurse regarding the verbalizes concern
MRI machine? (Select all regarding sexual
that apply.) dysfunction. What should
a. Causes metal objects to the nurse assure this
spark, similar to a patient she can still
microwave experience? (Select all
that apply.)
b. Deactivates the battery
in a pacemaker a. Vaginal sensation
c. Causes metal to heat b. Vaginal orgasm

up and burn the patient c. Normal menses
d. Does not transmit clear d. Intercourse
data if metal is present e. Children
e. Attracts any metal into ANS: C, D, E
the MRI chamber
Intercourse, normal
ANS: B, E menses, and childbirth
are all possible for a
245
woman with a C5 lesion, e. Slap the patient on
but no vaginal sensation upper back while the
occurs. Orgasm is patient is in the prone
possible but not vaginally position.
stimulated. ANS: D
32. A home health nurse To assist the patient with
encourages the family of an SCI to cough, the
a patient with an SCI to caregiver applies
use the assisted cough pressure on the
technique. What does this diaphragm as the patient
technique require the attempts to cough after
caregiver to do? (Select having taken a deep
all that apply.) breath.
a. Assist the patient to
inhale a bronchodilator
spray and then cough. DIABETES
MELLITUS
b. Forcefully press on
patient’s back below the An 18 year old female
rib cage while the patient client, 5'4" tall, weighing
is in the prone position. 113 kg, comes to the
clinic for a non healing
c. Assist the patient to wound on her lower leg,
lean forward, breathe which she has had for
deep, and then cough. two (2) weeks. Which
d. Apply pressure to disease process should
diaphragm as the patient the nurse suspect the
coughs. client has developed?
246
2. Type 2 diabetes insulin, to a client
3. Gestational diabetes diagnosed with type 1
diabetes at 1600. Which
4. Acanthosis nigricans intervention should the
nurse implement?
2. The client diagnosed 1. Ensure the client eats
with type 1 diabetes has a the bedtime snack
glycosylated hemoglobin 2. Determine how much
(A1c) of 8.1%.Which food the client ate at
interpretation should the lunch
nurse make based on this
result? 3. Perform a glucometer
reading at 0700
1. This result is below
normal levels 4. Offer the client protein
after administering
2. This resul tis within insulin
acceptable levels
3. This result is above
recommended levels 4. The client diagnosed
with type 1 diabetes is
4. This result is receiving Humalog, a
dangerously high rapid-acting insulin, by
sliding scale. The order
3. The nurse reads blood glucose
administered 28 units of level: <150, zero (0)
Humulin N, an units; 151-200, three (3)
intermediate-acting units; 201-250, six (6)
units; >251, contact
247
health-care provider. The 3. Encourage the client to
unlicensed assistive walk 20 minutes the (3)
personnel (UAP) reports times a week
to the nurse the client's 4. Perform warmup and
glucometer reading is cool-down exercises
189. How much insulin
should the nurse
administer to the client? 6. The nurse is assessing
3 units the feet of a client with
long-term type 2
diabetes. Which
assessment data warrant
5. The ruse is discussing immediate intervention
the importance of by the nurse?
exercising with a client 1. The client has
diagnosed with type 2 crumbling toenails
diabetes whose diabetes 2. The client has athlete's
is well controlled with foot
diet and exercise. Which
information should the 3. The client has a
nurse include in the necrotic big toe
teaching about diabetes? 4. The client has
1. Eat a simple thickened toenails
carbohydrate snack
before exercising
2. Carry peanut butter
crackers when exercising
248
fo are computed
7. The home health nurse tomography (CT) scan
is completing the with contrast of the
admission assessment for abdomen to evaluate
a 76-year old client pancreatic function.
diagnosed with type 2 Which intervention
diabetes controlled with should the nurse
70/30 insulin. Which implement?
intervention should be 1. Provide a high-fat diet
included in the plan of 24 hours prior to test
care? 2. Hold the biguanide
1. Assess the client's medication for 48 hours
ability to read small print prior to test
2. Monitor the client's 3. Obtain an informed
serum PT level consent form for the test
3. Teach the client how 4. Administer pancreatic
to perform a hemoglobin enzymes prior to the test
A1ctest daily
4. Instruct the client to 9. The diabetic educator
check the feet weekly is teaching a class on
diabetes type 1 and is
8. The client with type 2 discussing sick-day rules.
diabetes controlled with Which interventions
biguanide oral diabetic should the diabetes
medication is scheduled educator include in the
249
discussion? Select all that fast-acting insulin,at
apply: 0700. At 1030 the
1. Take diabetic unlicensed assistive
medication even I unable personnel (UAP) tells the
to eat the client's normal nurse the client has a
diabetic diet headache and is really
acting "funny." Which
2. If unable to eat, drink intervention should the
liquids equal to the nurse implement first?
client's normal caloric
intake 1. Instruct the UAP to
obtain the blood glucose
3. It is not necessary to level
notify the health-care
provider if ketones are in 2. Have the client drink
the urine eight (8) ounces of
orange juice
4. Test blood glucose
levels and test urine 3. Go to the client's room
ketones once a day and and assess the client for
keep a record hypoglycemia
5. Call the health-care 4. Prepare to administer

provider if glucose levels one (1) ampule 50%
are higher than 180 dextrose intravenously
mg/dL
11. The nurse at a
10. The client received freestanding health care
10 units of Humulin R, a clinic is caring for a 56-
year-old male client who
250
is homeless and is a type medication regimen."
2 diabetic controlled with Which statement is an
insulin. Which action is appropriate short-term
an example of client goal for the client?
advocacy? 1. The client will have a
1. Ask the client if he has blood glucose level
somewhere he can go and between 90 and 140
live mg/dL
2. Arrange for someone 2. The client will
to give him insulin at a demonstrate appropriate
local homeless shelter insulin injection
3. Notify Adult technique
Protective Services about 3. The nurse will monitor
the clients situation the client's blood glucose
4. Ask the HCP to take levels four (4) times a
the client off insulin day.
because he is homeless 4. The client will
maintain normal kidney
function with 30 mL/hr
12. The nurse is urine output
developing a care plan
for the client diagnosed
with type diabetes. The 13. The client diagnosed
nurse identifies the with type 2 diabetes is
problem "high risk for admitted to the intensive
hyperglycemia related to care unit with
noncompliance with the hyperosmolar
251
hyperglycemic nonkeonic 3. Perform blood
syndrome (HHNS) coma. glucometer checks daily.
Which assessment data 4. Monitor arterial blood
should the nurse expect gas results.
the client to exhibit?
1. Kussmaul's
respiration's 15. Which electrolyte
replacement should the
2. Diarrhea and epigastric nurse anticipate being
3. Dry mucous ordered by the health-
membranes care provider in the client
4. Ketone breath odor diagnosed with DKA
who has just been
admitted to the ICU?
14. The elderly client is 1. Glucose
care department 2. Potassium
diagnosed with severe 3. Calcium
HHNS. Which 4. Sodium
collaborative intervention
should the nurse include
in the plan of care? 16. The client diagnosed
1. Infuse 0.9% normal with HHNS was admitted
saline intravenously. yesterday with a blood
glucose level of 780
2. Administer mg/dL. The client's blood
intermediate-acting glucose level is now 300
insulin. mg/dL. Which
252
intervention should the 3. Move the client to the
nurse implement? ICU
1. Increase the regular 4. Check the serum
insulin IV drip. glucose level
2. Check the client's urine
for urinary ketones.
3. Provide the client with
a therapeutic diabetic
meal. 18. Which assessment
data indicate the client
4. Notify the HCP to diagnosed with diabetic
obtain an order to keto acidosis is
decrease insulin therapy. responding to the medical
treatment?
17. The client diagnosed 1. The client has tented
with type 1 diabetes is skin turbor and dry
found lying unconscious mucous membranes
on the floor of the 2. The client is alert and
bathroom. Which oriented to date, time,
intervention should the and place
nurse implement first?
3. The client's ABG
1. Administer 50% results are pH-7.29,
dextrose IVP PaCO2-44, HCO3-15
2. Notify the health-care 4. The client's serum
provider potassium level is 3.3
mEq/L
253
19. The UAP on the determine the cause of
medical floor tells the this acute complication?
nurse the client 1. "When is the last time
diagnosed with DKA you took your insulin?"
wants something else to
eat for lunch. Which 2. "When did you have
intervention should the your last meal?"
nurse implement? 3. "Have you had some
1. Instruct the UAP to get type of infection lately?"
the client additional food 4. "How long have you
2. Notify the dietician had diabetes?"
about the client's request
3. Request the HCP
increase the client's 21. The nurse is
caloric intake discussing ways to
4. Tell the UAP the client prevent diabetic keto
cannot have anything else acidosis with the client
diagnosed with type 1
diabetes. Which
20. The emergency instruction is most
department nurse is important to discuss with
caring for a client the client?
diagnosed with HHNS
who has a blood glucose 1. Refer the client to the
of 680 mg/dL. Which American Diabetes
question should the nurse Association
ask the client to
254
2. Do not take any over- 3. The client with DKA
the-counter medications who has multi focal
3. Take the prescribed premature ventricular
insulin even when unable contractions
to eat because of illness 4. The client with HHNS
4. Explain the need to get who has a plasma
the annual flu and osmolarity of 290
pneumonia vaccines mOsm/L
23. Which arterial blood

gas results should the
22. The charge nurse is nurse expect in the client
making client diagnosed with diabetic
assignments in the keto acidosis?
intensive care unit.
Which client should be 1. pH-7.34, PaO2-99,
assigned to the most PaCO2-48, HCO3-24
experienced nurse? 2. pH-7.38, PaO2-95,
1. The client with type 2 PaCO2-40, HCO3-22
diabetes who has a blood 3. pH-7.46, PaO2-85,
glucose level of 348 PaCO2-30, HCO3-26
mg/dL 4. pH-7.30, PaO2-90,
2. The client diagnosed PaCO2-30, HCO3-18
with type 1 diabetes who
is experiencing
hypoglycemia 24. The client is admitted
to the ICU diagnosed
255
with DKA. Which C. Try to avoid stressful
interventions should the situations during the
nurse implement? Select collection period.
all that apply. D. Complete at least 30
1. Maintain adequate minutes of strenuous
ventilation exercise before collecting
2. Asses fluid volume the urine sample.
status C. Try to avoid stressful
3. Administer situations during the
intravenous potassium collection period.
4. Check for urinary

ketones Which of the following
5. Monitor intake and assessment parameters is
output of highest priority when
caring for a patient
undergoing a water
When instructing a deprivation test?
patient regarding a urine A. Serum glucose
study for free cortisol, it
is most important for the B. Patient weight
nurse to tell the patient to C. Arterial blood gases
A. Save the first voided D. Patient temperature
urine in the am.
B. Maintain a high- A patient has sought care
sodium diet 3 days before because of a loss of 25 lb
collection.
256
over the past 6 months, A. Calcium levels
during which the patient B. Potassium levels
claims to have made no
significant dietary C. Blood glucose levels
changes. The nurse D. Sodium and chloride
should assess the patient levels
for potential A. Calcium levels
A. Thyroid disorders.
B. Diabetes insipidus. A patient's recent medical
C. Pituitary dysfunction. history is indicative of
D. Parathyroid diabetes insipidus. The
dysfunction. nurse would perform
patient education related
A. Thyroid disorders. to which of the following
diagnostic tests?
The surgeon was unable A. Thyroid scan
to save a patient's B. Fasting glucose test
parathyroid gland during
a radical thyroidectomy. C. Oral glucose tolerance
The nurse should D. Water deprivation test
consequently pay
particular attention to
which of the following A 54-year-old patient
components of the admitted with type 2
patient's laboratory diabetes, asks the nurse
values? what "type 2" means.
Which of the following is
257
the most appropriate information on the
response by the nurse? patient's past glucose
A. "With type 2 diabetes, control?
the body of the pancreas A. Prealbumin level
becomes inflamed." B. Urine ketone level
B. "With type 2 diabetes, C. Fasting glucose level
insulin secretion is
decreased and insulin D. Glycosylated
resistance is increased." hemoglobin level
C. "With type 2 diabetes,

the patient is totally The nurse has been
dependent on an outside teaching a patient with
source of insulin." diabetes how to perform
D. "With type 2 diabetes, self-monitoring of blood
the body produces glucose. During
autoantibodies that evaluation of the patient's
destroy b-cells in the technique, the nurse
pancreas." identifies a need for
additional teaching when
the patient does which of
The nurse caring for a the following?
54-year-old patient A. Chooses a puncture
hospitalized with site in the center of the
diabetes mellitus would finger pad
look for which of the
following laboratory test
results to obtain
258
B. Washes hands with
soap and water to cleanse The nurse is assigned to
the site to be used the care of a 64-year-old
C. Warms the finger patient diagnosed with
before puncturing to type 2 diabetes. In
obtain a drop of blood formulating a teaching
D. Tells the nurse that the plan that encourages the
result of 120 mg/dl patient to actively
indicates good control of participate in
diabetes management of the
diabetes, which of the
following should be the
The nurse is teaching a nurse's initial
54-year-old patient with intervention?
diabetes about proper A. Assess patient's
composition of the daily perception of what it
diet. The nurse explains means to have diabetes.
that the guideline for
carbohydrate intake is B. Ask the patient to
which of the following? write down current
knowledge about
A. 80% of daily intake diabetes.
B. Minimum of 80 g/day C. Set goals for the
C. Minimum of 130 patient to actively
g/day participate in managing
D. Maximum of 130 his diabetes.
g/day
259
D. Assume responsibility large- and medium-sized
for all of the patient's blood vessels can be
care to decrease stress prevented by careful
level. glucose control.
D. Macroangiopathy
The nurse is beginning to causes slowed gastric
teach a diabetic patient emptying and the sexual
about vascular impotency experienced
complications of by a majority of patients
diabetes. Which of the with diabetes.
following information
would be appropriate for The nurse is evaluating a
the nurse to include? 45-year-old patient
A. Macroangiopathy does diagnosed with type 2
not occur in type 1 diabetes mellitus. Which
diabetes but rather in of the following
type 2 diabetics who symptoms reported by
have severe disease. the patient is considered
B. Microangiopathy is one of the classic clinical
specific to diabetes and manifestations of
most commonly affects diabetes?
the capillary membranes A. Excessive thirst
of the eyes, kidneys, and B. Gradual weight gain
skin.
C. Overwhelming fatigue
C. Renal damage
resulting from changes in
260
D. Recurrent blurred urine. As the nurse
vision assesses for signs of
ketoacidosis, which of
the following respiratory
A 54-year-old patient patterns would the nurse
with diabetes mellitus is expect to find?
scheduled for a fasting
blood glucose level at A. Central apnea
8:00 am. The nurse B. Hypoventilation
instructs the patient to C. Kussmaul respirations
only drink water after
what time? D. Cheyne-Stokes
respirations
A. 6:00 pm on the
evening before the test
B. 4:00 am on the day of The nurse is assisting a
the test diabetic patient to learn
dietary planning as part
C. Midnight before the of initial management of
test diabetes. The nurse
D. 7:00 am on the day of would encourage the
the test patient to limit intake of
which of the following
foods to help reduce the
A patient is admitted percent of fat in the diet?
with diabetes mellitus,
has a glucose level of 380 A. Cheese
mg/dl, and a moderate B. Broccoli
level of ketones in the C. Chicken
261
D. Oranges The nurse evaluates that
the patient understands
the principles of foot care
Lab results are back for a if the patient makes
54-year-old patient with a which of the following
15-year history of statements?
diabetes. Which of the
following lab results A. "I should only walk
follows the expected barefoot in nice dry
pattern accompanying weather."
macrovascular disease as B. "I should look at the
a complication of condition of my feet
diabetes? every day."
A. Increased triglyceride C. "I am lucky my shoes
levels fit so nice and tight
B. Decreased low-density because they give me
lipoproteins firm support."
C. ncreased high-density D. "When I am allowed

lipoproteins up out of bed, I should
check the shower water
D. Decreased very-low- with my toes."
density lipoproteins
The nurse has taught a A patient is admitted
patient admitted with with diabetes mellitus,
diabetes, cellulitis, and malnutrition, and
osteomyelitis about the cellulitis. The patient's
principles of foot care. potassium level is 5.6
262
mEq/L. The nurse The patient received
considers that which of regular insulin 10 units
the following could be a subcutaneously at 8:30
contributing factor for pm for a blood glucose
this lab result (SELECT level of 253 mg/dl. The
ALL THAT APPLY)? nurse plans to monitor
A. The level may be this patient for signs of
increased as a result of hypoglycemia at which
dehydration that of the following peak
accompanies action times?
hyperglycemia. A. 9:00 pm to 10:30 pm
B. The patient may be B. 10:30 pm to 11:30 pm
excreting extra sodium C. 12:30 am to 1:30 am
and retaining potassium
because of malnutrition. D. 2:30 am to 4:30 am
C. The level is consistent

with renal insufficiency A nurse is caring for a
that can develop with client who has blood
renal nephropathy. glucose of 52 mg/dL. The
D. The level may be client is lethargic but
raised as a result of arousable. Which of the
metabolic ketoacidosis following actions should
caused by the nurse perform first?
hyperglycemia. A. Recheck blood
glucose in 15 min.
263
B. Provide a C. Hold breakfast for 1 hr
carbohydrate and protein after insulin
food. administration.
C. Provide 4 oz grape D. Clarify the
juice. prescription because
D. Report findings to the insulin should not be
provider. administered at this time.
A nurse is preparing to A nurse is preparing to

administer a morning administer the morning
dose of rapid acting doses of glargine
insulin (NovoLog) to a (Lantus) insulin and
client who has type 1 regular (Humulin R)
diabetes mellitus. Which insulin to a client who
of the following is an has a blood glucose of
appropriate action by the 278 mg/dL. Which of the
nurse? following is an
appropriate nursing
A. Check the client's action?
blood glucose
immediately after A. Draw up the regular
breakfast. insulin and then the
glargine insulin in the
B. Administer the insulin same syringe.
when breakfast arrives.
B. Draw up the glargine
insulin then the regular
264
insulin in the same C. Increase daily fiber
syringe. intake.
C. Draw up and D. Limit saturated fat
administer regular and intake to 15% of daily
glargine insulin in caloric intake.
separate syringes. E. Include omega-3 fatty
D. Administer the regular acids in the diet.
insulin, wait 1 hr, and
then administer the
glargine insulin. A nurse is teaching foot
care to a client who has
diabetes mellitus. Which
A nurse is presenting of the following
information to a group of information should the
clients about nutrition nurse include in the
habits that prevent type 2 teaching? (Select all that
diabetes mellitus. Which apply.)
of the following should A. Remove calluses
the nurse include in the using over-the-counter
information? (Select all remedies.
that apply.)
B. Apply lotion between
A. Eat less meat and toes.
processed foods.
C. Perform nail care after
B. Decrease intake of bathing.
saturated fats.
D. Trim toenails straight
across.
265
E. Wear closed-toe shoes. A. Weight gain
B. Fruity odor of breath
A nurse is reviewing the C. Abdominal pain
health record of a client D. Kussmaul respirations
who has hyperglycemic-
hyperosmolar state E. Metabolic acidosis
(HHS). Which of the
following data confirms A nurse is reviewing
this diagnosis? (Select all laboratory reports of a
that apply.) client who has
A. Evidence of recent hyperglycemic-
myocardial infraction hyperosmolar state
B. BUN 35 mg/dL (HHS). Which of the
following is an expected
C. Takes a calcium finding?
channel blocker
A. Serum pH 7.2
D. Age 77 years
B. Serum osmolarity 350
E. No insulin production mOsm/L
C. Serum potassium 3.8
A nurse is assessing a mg/dL
client who has diabetic D. Serum creatinine 0.8
ketoacidosis and ketones mg/dL
in the urine. Which of the
following are expected
findings? (Select all that A nurse is preparing to
apply.) administer IV fluids to a
266
client who has diabetic A. Drink 3 L of fluids
ketoacidosis. Which of daily.
the following is an B. Monitor blood glucose
appropriate nursing every 4 hr when ill.
action?
C. Administer insulin as
A. Administer an IV prescribed when ill.
infusion of regular
insulin at 0.3 unit/kg/hr. D. Notify the provider
when blood glucose is
B. Administer an IV 200 mg/dL.
infusion of 0.45%
sodium chloride. E. Report ketones in the
urine after 24 hr of
C. Rapidly administer an illness.
IV infusion of 0.9%
sodium chloride.
D. Add glucose to the IV Emma Martin, 76 has
infusion when serum type 2 diabetes and was
glucose is 350 mg/dL. been admitted to the floor
for compulsive gambling.
Patient takes Glyburide 5
A nurse is providing mg per day and
discharge teaching to a Metformin 1000 twice
client who experienced daily. She is consuming
diabetic ketoacidosis. ¾ of the food on her plate
Which of the following as observed by her
should the nurse include nurses.
in the teaching? (Select
all that apply.)
267
You observe that she had mg per day and
had multiple Metformin 1000 twice
hypoglycemic incidents daily. She is consuming
over the previous week. ¾ of the food on her plate
What factor is probably as observed by her
most responsible for the nurses.
hypoglycemia?
What is the best way to

a. Patient isn't eating all manage Emma's blood
of her food. sugars moving forward?
b. Patient is in renal
failure and may have a a. Transition to a
prolonged hypoglycemia basal/bolus insulin
because the Glyburide is regimen immediately.
working in her body for a
long time. b. Provide hydration in
an effort to lower
c. Patient has elevated creatinine and raise GFR,
creatinine which then restart Glyburide.
contraindicates use of
metformin. c. Stop oral anti-diabetes
agents while carefully
monitoring blood sugars.
Emma Martin, 76 has Order A1c, BMP and
type 2 diabetes and was develop treatment plan
been admitted to the floor based on results.
for compulsive gambling.
Patient takes Glyburide 5
268
b. Bolus insulin can be
Your patient is NPO and calculated using a
the MD has ordered correction scale
Humalog using the Very c. Lantus is an example
Insulin Sensitive of bolus insulin
Correction Scale. When
should you check her d. Humalog is an
blood sugars? example of bolus insulin
a. Before meals and Emma Martin, 76 has

bedtime type 2 diabetes and was
been admitted to the floor
b. Every 4 hours for compulsive gambling.
c. Every 6 hours Patient takes Glyburide 5
d. There is not enough mg per day and
information to answer the Metformin 1000 twice
question daily. She is consuming
¾ of the food on her plate
as observed by her
Which Statement about nurses.
bolus insulin is false?
You are meeting Mrs.

a. Bolus insulin provides Jones for the first time
mealtime coverage tonight. Which of the
following attributes about
Mrs. Jones makes you
269
think she may be at risk His serum creatinine is
for hypoglycemia? 0.9 mg/dL.
a. Mrs. Jones takes 50 a. Jackie's serum

units of Lantus at creatinine is at an
bedtime acceptable level so he
b. Mrs. Jones has had may restart the
blood sugars in the 50's at Metformin immediately.
bedtime for the past 2 b. The glimepiride should
nights and her insulin be held for 48 hours so
regimen hasn't changed the contrast dye can clear
c. Mrs. Jones has peanut the kidneys first.
butter and crackers for a c. The metformin should
bedtime snack be held for 48 hours so
d. Mrs. Jones has had the contrast dye can clear
type 1 diabetes for 50 the kidneys first.
years d. The glimepiride and
metformin should both be
held for 48 hours so the
Jackie Dubuque, 58 is contrast dye can clear the
scheduled for an MRI kidneys first.
with contrast dye today.
Jackie takes Metformin
1000 mg BID and John Bellegarde, 22 - is
glimepiride 4 mg BID. newly diagnosed type 1
diabetes. He's asking
270
questions whenever you them with his medical
enter his room. You are team.
using your "cheat sheets" c. A and B
to guide conversations.
However, some of his d. Let him know that you
questions are out of your aren't an expert in type 1
realm of expertise. diabetes and spend as
What's the best way to little time in his room as
proceed? you can get away with.
a. Advise John you are Which statement best

asking the Hospitalist for describes why a patient
referrals to an with type 1 diabetes may
endocrinologist, CDE develop DKA in the
and visiting nurses to hospital?
help answer his a. The patient doesn't feel
questions. Let John know like eating, skips sliding
that the hospital has a scale, but continues to
medical library that take Lantus.
patients are welcome to b. The patient is eating
utilize. with mealtime sliding
b. Advise John that you scale ordered and he has
want to help him, but started to take Lantus at
don't know the answers bedtime.
to his questions. Write c. The patient is
his questions down share transitioning from IV
271
dextrose to food, is on a history of hypoglycemia
sliding scale and NPH unawareness who was
twice daily. hospitalized after an
d. The patient isn't eating automobile accident
much, the sliding scale involving low blood
starts at >200 and no long sugars? (SELECT ALL
acting insulin has been THAT APPLY)
ordered.
a. Keep an emergency
In which case would the glucagon kit at home for
patient be more likely to family members to
have DKA or HHS? administer
b. Purchase a medical
identification bracelet
a. Positive ketones that says patient has
b. Blood sugars >600 diabetes
mg/dL c. Avoiding
c. Symptoms developed hypoglycemia over
quickly over 24 hours several weeks can help
improve the
hyperglycemia
unawareness
Which of the following d. It is important to avoid
should be a component of over-treatment because
hypoglycemia education then the patient will have
for your patient with a
272
to contend with a diabetes who ambulates
rebound hyperglycemia in a walker?
Which would not be a. Start jogging for 10-15

included in your foot care minutes per day
education plan for the b. Eat 3 meals per day,
patient with diabetes? add protein to each meal
a. Look for cuts and sign c. There is no need to test
of infection daily. blood sugars because you
b. Soak feet in hot water only have type 2 diabetes
for at least an hour every d. There is no need to
day. continue the chair
c. Do not go barefoot. exercises suggested by
d. A Podiatrist should your Physical Therapist
trim toe nails. after discharge
e. All of the information

listed above should be Ann Boyd, 60 was
included. admitted with COPD.
She was placed on a
predisone taper this
What lifestyle morning. Her A1c is 10.5
intervention suggestion is and blood sugars are in
appropriate for the 85- the 200's. She is 60
year old patient with inches tall and weighs
newly diagnosed type 2 250#. Which statement
273
best describes the Danny Hildreth is 55. He
situation? has type 2 diabetes and
peripheral neuropathy
with right foot cellulitis
a. Ann's has steroid- and is on IV
induced diabetes due to Vancomycin. Danny
today's predisone taper takes his oral medications
and her sugars will go properly and tests blood
back to normal levels as sugars as ordered by his
soon as the taper has physician. What will be
been discontinued. your diabetes educational
b.Ann has had type 2 focus?
diabetes for a while as a. Neuropathy, foot care
evidenced by the elevated and complications.
A1c. The COPD
exacerbation has caused a b. Insulin management -
further rise in blood he will be on insulin
sugars. The predisone sooner than later.
will cause sugars to go up c. Review oral
even further. medications and blood
c.Ann has type 1 diabetes glucose monitoring.
d.There is not enough d. No teaching necessary

information to determine - he seems to have
if Ann has diabetes mastered the basics.
Mary Barretto, 34 is on
an insulin pump. Mary
has type 1 diabetes and
274
was admitted in DKA. bolus of insulin may be
What information is false caused by a kink in the
and will not help her tubing. Change the
prevent future DKA infusion set under those
hospitalizations? conditions to prevent
a. Illness causes blood DKA.
sugars to go up - so a
person with type 1 A nurse is teaching a
diabetes will need patient with Type 1
additional insulin during Diabetes who is
an illness. Call your beginning a complex
physician for assistance regimen of glycemic
with insulin pump control about the
adjustments when you properties and actions of
get sick. the various types of
b. Purchase ketostix and insulin. The nurse should
test urine if blood sugars explain that the type of
>250, or if you have insulin that has an onset
nausea or vomiting. of 60 - 120 minutes,
c. Suspend insulin peaks in 6 - 14 hours, and
delivery on the pump if has a duration of 16 - 24
you aren't going to eat hours is known as:
d. Unexpected blood
sugar elevations that do A. Regular Insulin
not decrease when you (Humilin)
have administered a
275
B. Insulin Glargine D. The tubing could
(Lantus) become occluded
C. NPH Insulin D. Malfunctioning of the
D. Insulin Detemir pump from low battery
power, occlusion of
C. NPH has an onset of tubing or needles, or lack
60 - 120 minutes, peaks of insulin in the pump
in 6 - 14 hours, and has a increases the risk of
duration of 16 - 24 hours DKA.
A nurse is instructing a
A nurse instructing a patient newly diagnosed
patient about the use of with type 2 DM about the
an insulin pump should biguanide she has been
explain that the risk of prescribed, which is
DKA increases with the Metformin. The nuse
use of a pump because: should explain that this
type of medication acts
by:
A. The pump must be
removed for bathing
B. Insulin is injected A. Reducing hepatic
continuously glucose production
C. The pump uses B. Delaying carbohydrate

intermediate acting digestion
insulin
276
C. Increasing the cellular B. Store pens with needle
response to insulin pointing upward
D. Increasing insulin C. Insert needle slowly
secretion by the pancreas D. Keep pen at room
A. Biguanides reduce temperature for a few
hepatic glucose minutes
production while D. Injecting cold insulin
increasing insulin action can be painful
on muscle glucose uptake
The nurse is reviewing

results of a lab test
A nurse is reviewing self performed as part of a
administration of insulin 50yo woman's annual
using a prefilled pen physical. The nurse notes
administration system a blood glucose level of
with a patient who started 120 mg/dl. The nurse
using it the previous should determine this as
week. The patient asks an abnormal result for a:
what he can do to reduce
discomfort. The nurse
teaches: A. Casual bg
measurement
B. Fasting bg
A. Agitate the syringe measurement
slightly before injection
277
C. Glycosylated d. systematically rotate
Hemoglobin insulin injections within
measurement one anatomic site
D. 2 hour measurement D. systematically rotate
for oral glucose insulin injections within
one anatomic site
A newly diagnosed DM
Type I client has been
stabilized with daily A client with a diagnosis
insulin injections. A of DKA is being treated
nurse prepares a in an emergency room.
discharge teaching plan Which finding would a
regarding the insulin and nurse expect to note as a
plans to reinforce which confirming diagnosis?
of the following
concenpts? a. comatose state
a. always keep insulin b. decreased urine output

vials refrigerated c. increased respiration
b. ketones in the urine and increased pH
singnify a need for less d. elevated blood glucose
insulin levels and low plasma
c. increase the amount of bicarbonate level
insulin before unusual D. elevated blood
exercise glucose level and low
plasma bicarb level
278
A nurse teaches a client
A client with DM with DM about
demonstrates acute differentiating between
anxiety when first hypoglycemia and
admitted for treatment of ketoacidosis. The client
hyperglycemia. The demonstrates an
appropriate intervention understanding of the
to decrease the client's teaching by stating that
anxiety is to: glucose will be taken if
which symptom
a. administer a sedative develops?
b. convey empathy, trust, a. polyuria
and respect towards the
client b. shakiness
c. ignore the signs and c. blurred vision

symptoms of anxiety so d. fruity breath odor
that they will soon B. shakiness
disappear
A client is admitted with
d. make sure that the a diagnosis of DKA. The
client knows all the initial blood glucose level
correct medical terms was 950 mg/dL. An IV
B. convey empathy, trust, infusion of regular
and respect toward the insulin is initiated, along
client with IV rehydration with
normal saline. The serum
279
glucose level is now 240 a. "I will stop taking my
mg/dL. The nurse would insulin if I'm too sick to
next prepare to eat"
administer which of the b. "I will decrease my
following? insulin dose during times
a. ampule 50% dextrose of illness"
b. NPH insulin subcut c. "I will adjust my
c. IV fluids 5% dextrose insulin dose according to
the level of glucose in my
d. Phenytoin (Dilantin) urine"
for prevention of seizures
d. "I will notify my
C. IV fluids with 5% physician if my blood
dextrose glucose level is higher
than 250 mg/dL"
D. "I will notify my
A nurse provides physician if my blood
instructions to a client glucose level is higher
newly diagnosed with than 250 mg/dL"
Type I. The nurse
recognizes accurate
understanding of
measures to prevent A home health nurse
ketoacidosis when the visits a client with a
client says: diagnosis of Type I DM.
The client relates a
history of vomiting and
280
diarrhea and tells the blood glucose of 280
nurse that no food has mg/dL. The priority
been consumed for 36 nursing diagnosis would
hours. Which statement be:
by the client indicates a a. fluid volume deficit
need for further teaching?
b. dysfunctional family
a. "I need to stop my processes
insulin"
c. nutrition: less than
b. "I need to increase my body requirements
fluid intake"
d. knowledge deficit:
c. "I need to monitor my disease process and
blood glucose every 3-4 treatment
hours"
A. fluid volume deficit
d. "I need to call the
physician because of
these symptoms"
A. "I need to stop my The nurse is caring for a
insulin" client with a blood
glucose of 550 mg/dL
diagnosed with DKA
who has just begun fluid
A nurse is preparing a resuscitation. In this
plan of care for a diabetic acute phase, the next
patient with priority nursing action is
hyperglycemia with to prepare to:
polyuria, polydipsia, and a. correct the acidosis
281
b. apply a monitor for an c. "The best time for me
ECG to exercise is mid-late
c. administer 5% afternoon"
dextrose IV d. "The best time for me
d. administer a to exercise is after my
continuous regular morning snack"
insulin infusion C. "The best time for me
D. administer a to exercise is mid-late
continuous regular afternoon"
insulin infusion
A client is taking NPH
A client with Type I calls insulin daily every
the nurse to report morning. The RN
recurrent episodes of instructs the client that
hypoglycemia with the most likely time for a
exercising. Which hypoglycemic reaction to
statement by the client occur is:
indicates an inadequate a. 2-4 hours after
understanding of the peak administration
action of NPH insulin? b. 4-12 hours after
a. "The best time for me administration
to exercise is after I eat" c. 16-18 hours after
b. "The best time for me administration
to exercise is after d. 18-24 hours after
breakfast" administration
282
B. 4-12 hours after c. Changes in diet and
administration exercise may control
blood glucose levels in
type 2 diabetes.
Which statement by a
nurse to a patient newly
diagnosed with type 2 For some patients with
diabetes is correct? type 2 diabetes, changes
in lifestyle are sufficient
to achieve blood glucose
a. Insulin is not used to control. Insulin is
control blood glucose in frequently used for type 2
patients with type 2 diabetes, complications
diabetes. are equally severe as for
b. Complications of type type 1 diabetes, and type
2 diabetes are less serious 2 diabetes is usually
than those of type 1 diagnosed with routine
diabetes. laboratory testing or after
c. Changes in diet and a patient develops
exercise may control complications such as
blood glucose levels in frequent yeast infections.
type 2 diabetes.
d. Type 2 diabetes is
usually diagnosed when A 48-year-old male
the patient is admitted patient screened for
with a hyperglycemic diabetes at a clinic has a
coma. fasting plasma glucose
283
level of 120 mg/dL (6.7 implement additional
mmol/L). The nurse will teaching?
plan to teach the patient a. The patient always
about carries hard candies when
engaging in exercise.
a. self-monitoring of b. The patient goes for a
blood glucose. vigorous walk when his
b. using low doses of glucose is 200 mg/dL.
regular insulin. c. The patient has a
c. lifestyle changes to peanut butter sandwich
lower blood glucose. before going for a bicycle
ride.
d. effects of oral
hypoglycemic d. The patient increases
medications. daily exercise when
ketones are present in the
c. lifestyle changes to urine.
lower blood glucose.
d. The patient increases
daily exercise when
A 28-year-old male ketones are present in the
patient with type 1 urine.
diabetes reports how he
manages his exercise and
glucose control. Which The nurse is assessing a
behavior indicates that 22-year-old patient
the nurse should experiencing the onset of
symptoms of type 1
284
diabetes. Which question a. Urine dipstick for
is most appropriate for glucose
the nurse to ask? b. Oral glucose tolerance
test
a. "Are you anorexic?" c. Fasting blood glucose
b. "Is your urine dark level
colored?" d. Glycosylated
c. "Have you lost weight hemoglobin level
lately?" d. Glycosylated
d. "Do you crave sugary hemoglobin level
drinks?"
c. "Have you lost weight
lately?" A 55-year-old female
patient with type 2
A patient with type 2 diabetes has a nursing
diabetes is scheduled for diagnosis of imbalanced
a follow-up visit in the nutrition: more than body
clinic several months requirements. Which goal
from now. Which test is most important for this
will the nurse schedule to patient?
evaluate the effectiveness
of treatment for the a. The patient will reach
patient? a glycosylated
hemoglobin level of less
than 7%.
285
b. The patient will follow a. check glucose level
a diet and exercise plan before, during, and after
that results in weight swimming.
loss. b. delay eating the noon
c. The patient will choose meal until after the
a diet that distributes swimming class.
calories throughout the c. increase the morning
day. dose of neutral protamine
d. The patient will state Hagedorn (NPH) insulin.
the reasons for d. time the morning
eliminating simple sugars insulin injection so that
in the diet. the peak occurs while
a. The patient will reach swimming.
a glycosylated a. check glucose level
hemoglobin level of less before, during, and after
than 7%. swimming.
A 38-year-old patient The nurse determines a

who has type 1 diabetes need for additional
plans to swim laps daily instruction when the
at 1:00 PM. The clinic patient with newly
nurse will plan to teach diagnosed type 1 diabetes
the patient to says which of the
following?
286
in moderate daily
a. "I can have an exercise, which action is
occasional alcoholic most important for the
drink if I include it in my nurse to take?
meal plan."
b. "I will need a bedtime a. Determine what type
snack because I take an of activities the patient
evening dose of NPH enjoys.
insulin." b. Remind the patient that
c. "I can choose any exercise will improve
foods, as long as I use self-esteem.
enough insulin to cover c. Teach the patient about
the calories." the effects of exercise on
d. "I will eat something at glucose level.
meal times to prevent d. Give the patient a list
hypoglycemia, even if I of activities that are
am not hungry." moderate in intensity.
c. "I can choose any a. Determine what type
foods, as long as I use of activities the patient
enough insulin to cover enjoys.
the calories."
Which statement by the

In order to assist an older patient indicates a need
diabetic patient to engage
287
for additional instruction Which patient action
in administering insulin? indicates good
understanding of the
nurse's teaching about
a. "I need to rotate administration of aspart
injection sites among my (NovoLog) insulin?
arms, legs, and abdomen
each day."
b. "I can buy the 0.5 mL a. The patient avoids
syringes because the line injecting the insulin into
markings will be easier to the upper abdominal
see." area.
c. "I should draw up the b. The patient cleans the

regular insulin first after skin with soap and water
injecting air into the NPH before insulin
bottle." administration.
d. "I do not need to c. The patient stores the

aspirate the plunger to insulin in the freezer after
check for blood before administering the
injecting insulin." prescribed dose.
a. "I need to rotate d. The patient pushes the

injection sites among my plunger down while
arms, legs, and abdomen removing the syringe
each day." from the injection site.
b. The patient cleans the
skin with soap and water
288
before insulin
administration. a. The patient programs
the pump for an insulin
bolus after eating.
A patient receives aspart b. The patient changes

(NovoLog) insulin at the location of the
8:00 AM. Which time insertion site every week.
will it be most important c. The patient takes the
for the nurse to monitor pump off at bedtime and
for symptoms of starts it again each
hypoglycemia? morning.
d. The patient plans for a
a. 10:00 AM diet that is less flexible
when using the insulin
b. 12:00 AM pump.
c. 2:00 PM a. The patient programs
d. 4:00 PM the pump for an insulin
a. 10:00 AM bolus after eating.
Which patient action A 32-year-old patient

indicates a good with diabetes is starting
understanding of the on intensive insulin
nurse's teaching about the therapy. Which type of
use of an insulin pump? insulin will the nurse
289
discuss using for release from the
mealtime coverage? pancreas.
c. Glyburide should be
a. Lispro (Humalog) taken even if the morning
blood glucose level is
b. Glargine (Lantus) low.
c. Detemir (Levemir) d. Glyburide should not
d. NPH (Humulin N) be used for 48 hours after
a. Lispro (Humalog) receiving IV contrast
media.
b. Glyburide stimulates
insulin production and
Which information will release from the
the nurse include when pancreas.
teaching a 50-year-old
patient who has type 2
diabetes about glyburide
(Micronase, DiaBeta, The nurse has been
Glynase)? teaching a patient with
type 2 diabetes about
managing blood glucose
a. Glyburide decreases levels and taking
glucagon secretion from glipizide (Glucotrol).
the pancreas. Which patient statement
b. Glyburide stimulates indicates a need for
insulin production and additional teaching?
290
allergic rash from an
a. "If I overeat at a meal, unknown cause, the
I will still take the usual health care provider
dose of medication." prescribes prednisone
(Deltasone). The nurse
b. "Other medications will anticipate that the
besides the Glucotrol patient may
may affect my blood
sugar."
c. "When I am ill, I may a. need a diet higher in
have to take insulin to calories while receiving
control my blood sugar." prednisone.
d. "My diabetes won't b. develop acute

cause complications hypoglycemia while
because I don't need taking the prednisone.
insulin." c. require administration
d. "My diabetes won't of insulin while taking
cause complications prednisone.
because I don't need d. have rashes caused by
insulin." metformin-prednisone
interactions.
c. require administration
of insulin while taking
When a patient who takes prednisone.
metformin (Glucophage)
to manage type 2
diabetes develops an
291
A hospitalized diabetic d. request that if testing is
patient received 38 U of further delayed, the
NPH insulin at 7:00 AM. patient be returned to the
At 1:00 PM, the patient unit to eat.
has been away from the
nursing unit for 2 hours,
missing the lunch
delivery while awaiting a The nurse identifies a
chest x-ray. To prevent need for additional
hypoglycemia, the best teaching when the patient
action by the nurse is to who is self-monitoring
blood glucose
a. save the lunch tray for

the patient's later return a. washes the puncture
to the unit. site using warm water
b. ask that diagnostic and soap.
testing area staff to start a b. chooses a puncture site
5% dextrose IV. in the center of the finger
c. send a glass of milk or pad.
orange juice to the c. hangs the arm down
patient in the diagnostic for a minute before
testing area. puncturing the site.
d. request that if testing is d. says the result of 120
further delayed, the mg indicates good blood
patient be returned to the sugar control.
unit to eat.
292
b. chooses a puncture site capillary blood glucose
in the center of the finger monitoring.
pad. d. Discuss the need for
the patient to actively
participate in diabetes
management.
The nurse is preparing to
teach a 43-year-old man b. Assess the patient's
who is newly diagnosed perception of what it
with type 2 diabetes means to have diabetes
about home management mellitus.
of the disease. Which
action should the nurse
take first?
An unresponsive patient
with type 2 diabetes is
a. Ask the patient's brought to the emergency
family to participate in department and
the diabetes education diagnosed with
program. hyperosmolar
b. Assess the patient's hyperglycemic syndrome
perception of what it (HHS). The nurse will
means to have diabetes anticipate the need to
mellitus.
c. Demonstrate how to a. give a bolus of 50%
check glucose using dextrose.
293
b. insert a large-bore IV
catheter. a. use only the lispro
c. initiate oxygen by insulin until the
nasal cannula. symptoms are resolved.
d. administer glargine b. limit intake of calories
(Lantus) insulin. until the glucose is less
b. insert a large-bore IV than 120 mg/dL.
catheter. c. monitor blood glucose
every 4 hours and notify
the clinic if it continues
to rise.
A 26-year-old female d. decrease intake of
with type 1 diabetes carbohydrates until
develops a sore throat glycosylated hemoglobin
and runny nose after is less than 7%.
caring for her sick
toddler. The patient calls c. monitor blood glucose
the clinic for advice every 4 hours and notify
about her symptoms and the clinic if it continues
a blood glucose level of to rise.
210 mg/dL despite taking
her usual glargine
(Lantus) and lispro
(Humalog) insulin. The The health care provider
nurse advises the patient suspects the Somogyi
to effect in a 50-year-old
patient whose 6:00 AM
294
blood glucose is 230
mg/dL. Which action will a. Assess the patient for
the nurse teach the symptoms of
patient to take? hyperglycemia.
b. Give the patient a
a. Avoid snacking at snack of peanut butter
bedtime. and crackers.
b. Increase the rapid- c. Have the patient drink
acting insulin dose. a glass of orange juice or
c. Check the blood nonfat milk.
glucose during the night d. Administer a
d. Administer a larger continuous infusion of
dose of long-acting 5% dextrose for 24 hours.
insulin. b. Give the patient a
c. Check the blood snack of peanut butter
glucose during the night and crackers.
Which action should the Which question during

nurse take after a 36- the assessment of a
year-old patient treated diabetic patient will help
with intramuscular the nurse identify
glucagon for autonomic neuropathy?
hypoglycemia regains
consciousness?
295
a. "Do you feel bloated a. Choose flat-soled
after eating?" leather shoes.
b. "Have you seen any b. Set heating pads on a
skin changes?" low temperature.
c. "Do you need to c. Use callus remover for
increase your insulin corns or calluses.
dosage when you are d. Soak feet in warm
stressed?" water for an hour each
d. "Have you noticed any day.
painful new ulcerations a. Choose flat-soled
or sores on your feet?" leather shoes.
a. "Do you feel bloated
after eating?"
Which finding indicates a

need to contact the health
Which information will care provider before the
the nurse include in nurse administers
teaching a female patient metformin
who has peripheral (Glucophage)?
arterial disease, type 2
diabetes, and sensory
neuropathy of the feet a. The patient's blood
and legs? glucose level is 174
mg/dL.
296
b. The patient has gained a. Amitriptyline
2 lb (0.9 kg) since decreases the depression
yesterday. caused by your foot pain.
c. The patient is b. Amitriptyline helps
scheduled for a chest x- prevent transmission of
ray in an hour. pain impulses to the
d. The patient's blood brain.
urea nitrogen (BUN) c. Amitriptyline corrects
level is 52 mg/dL. some of the blood vessel
d. The patient's blood changes that cause pain.
urea nitrogen (BUN) d. Amitriptyline
level is 52 mg/dL. improves sleep and
makes you less aware of
nighttime pain.
b. Amitriptyline helps
A diabetic patient who prevent transmission of
has reported burning foot pain impulses to the
pain at night receives a brain.
new prescription. Which
information should the
nurse teach the patient
about amitriptyline Which information is
(Elavil)? most important for the
nurse to report to the
health care provider
before a patient with type
297
2 diabetes is prepared for
a coronary angiogram? a. The patient administers
the glargine 30 minutes
a. The patient's most before each meal.
recent HbA1C was 6.5%. b. The patient's family
b. The patient's prefills the syringes with
admission blood glucose the mix of insulins
is 128 mg/dL. weekly.
c. The patient took the c. The patient draws up

prescribed metformin the regular insulin and
(Glucophage) today. then the glargine in the
same syringe.
d. The patient took the
prescribed captopril d. The patient disposes of
(Capoten) this morning. the open vials of glargine
and regular insulin after 4
c. The patient took the weeks.
prescribed metformin
(Glucophage) today. d. The patient disposes of
the open vials of glargine
and regular insulin after 4
weeks.
Which action by a patient
indicates that the home
health nurse's teaching
about glargine and A 26-year-old patient
regular insulin has been with diabetes rides a
successful? bicycle to and from work
298
every day. Which site a. The patient's blood
should the nurse teach pressure is 154/92.
the patient to administer b. The patient has a
the morning insulin? history of emphysema.
c. The patient's blood
a. thigh. glucose is 86 mg/dL.
b. buttock. d. The patient has chest
c. abdomen. pressure when walking.
d. upper arm. d. The patient has chest

pressure when walking.
c. abdomen.
The nurse is taking a

The nurse is interviewing health history from a 29-
a new patient with year-old pregnant patient
diabetes who receives at the first prenatal visit.
rosiglitazone (Avandia) The patient reports no
through a restricted personal history of
access medication diabetes but has a parent
program. What is most who is diabetic. Which
important for the nurse to action will the nurse plan
report immediately to the to take first?
health care provider?
299
a. Teach the patient about mEq/L. Which action
administering regular prescribed by the health
insulin. care provider should the
b. Schedule the patient nurse take first?
for a fasting blood
glucose level. a. Place the patient on a
c. Discuss an oral glucose cardiac monitor.
tolerance test for the b. Administer IV
twenty-fourth week of potassium supplements.
pregnancy.
c. Obtain urine glucose
d. Provide teaching about and ketone levels.
an increased risk for fetal
problems with gestational d. Start an insulin
diabetes. infusion at 0.1
units/kg/hr.
b. Schedule the patient
for a fasting blood a. Place the patient on a
glucose level. cardiac monitor.
A 27-year-old patient A 54-year-old patient is

admitted with diabetic admitted with diabetic
ketoacidosis (DKA) has a ketoacidosis. Which
serum glucose level of admission order should
732 mg/dL and serum the nurse implement
potassium level of 3.1 first?
300
should the nurse take
a. Infuse 1 liter of normal first?
saline per hour.
b. Give sodium a. Infuse dextrose 50%
bicarbonate 50 mEq IV by slow IV push.
push. b. Administer 1 mg
c. Administer regular glucagon subcutaneously.
insulin 10 U by IV push. c. Obtain a glucose
d. Start a regular insulin reading using a finger
infusion at 0.1 stick.
units/kg/hr. d. Have the patient drink
a. Infuse 1 liter of normal 4 ounces of orange juice.
saline per hour. c. Obtain a glucose
reading using a finger
stick.
A patient who was

admitted with diabetic
ketoacidosis secondary to A female patient is
a urinary tract infection scheduled for an oral
has been weaned off an glucose tolerance test.
insulin drip 30 minutes Which information from
ago. The patient reports the patient's health
feeling lightheaded and history is most important
sweaty. Which action for the nurse to
301
communicate to the
health care provider? a. Bedtime glucose of
140 mg/dL
a. The patient uses oral b. Noon blood glucose of
contraceptives. 52 mg/dL
b. The patient runs c. Fasting blood glucose
several days a week. of 130 mg/dL
c. The patient has been d. 2-hr postprandial
pregnant three times. glucose of 220 mg/dL
d. The patient has a b. Noon blood glucose of
family history of 52 mg/dL
diabetes.
a. The patient uses oral
contraceptives.
When a patient with type
2 diabetes is admitted for
a cholecystectomy, which
Which laboratory value nursing action can the
reported to the nurse by nurse delegate to a
the unlicensed assistive licensed
personnel (UAP) practical/vocational nurse
indicates the most urgent (LPN/LVN)?
need for the nurse's
assessment of the a. Communicate the
patient? blood glucose level and
302
insulin dose to the An active 28-year-old
circulating nurse in male with type 1 diabetes
surgery. is being seen in the
b. Discuss the reason for endocrine clinic. Which
the use of insulin therapy finding may indicate the
during the immediate need for a change in
postoperative period. therapy?
c. Administer the
prescribed lispro a. Hemoglobin A1C level
(Humalog) insulin before 6.2%
transporting the patient to b. Blood pressure 146/88
surgery. mmHg
d. Plan strategies to c. Heart rate at rest 58
minimize the risk for beats/minute
hypoglycemia or
hyperglycemia during the d. High density
postoperative period. lipoprotein (HDL) level
65 mg/dL
c. Administer the
prescribed lispro b. Blood pressure 146/88
(Humalog) insulin before mmHg
transporting the patient to
surgery.
A 34-year-old has a new

diagnosis of type 2
diabetes. The nurse will
discuss the need to
303
schedule a dilated eye b. "I will not need to
exam worry about
hypoglycemia with the
Byetta."
a. every 2 years.
c. "I should take my daily
b. as soon as possible. aspirin at least an hour
c. when the patient is 39 before the Byetta."
years old. d. "I will take the pill at
d. within the first year the same time I eat
after diagnosis. breakfast in the
b. as soon as possible. morning."
c. "I should take my daily
aspirin at least an hour
After the nurse has before the Byetta."
finished teaching a
patient who has a new
prescription for exenatide
(Byetta), which patient A few weeks after an 82-
statement indicates that year-old with a new
the teaching has been diagnosis of type 2
effective? diabetes has been placed
on metformin
a. "I may feel hungrier (Glucophage) therapy
than usual when I take and taught about
this medicine." appropriate diet and
exercise, the home health
nurse makes a visit.
304
Which finding by the should the nurse take
nurse is most important next?
to discuss with the health
care provider?
a. Give the patient 4 to 6
oz more orange juice.
a. Hemoglobin A1C level b. Administer the PRN
is 7.9%. glucagon (Glucagon) 1
b. Last eye exam was 18 mg IM.
months ago. c. Have the patient eat
c. Glomerular filtration some peanut butter with
rate is decreased. crackers.
d. Patient has questions d. Notify the health care
about the prescribed diet. provider about the
c. Glomerular filtration hypoglycemia.
rate is decreased. a. Give the patient 4 to 6
oz more orange juice.
The nurse has

administered 4 oz of Which nursing action can
orange juice to an alert the nurse delegate to
patient whose blood unlicensed assistive
glucose was 62 mg/dL. personnel (UAP) who are
Fifteen minutes later, the working in the diabetic
blood glucose is 67 clinic?
mg/dL. Which action
305
recent blood glucose
a. Measure the ankle- reading was 230 mg/dL
brachial index. c. 60-year-old with
b. Check for changes in hyperosmolar
skin pigmentation. hyperglycemic syndrome
who has poor skin turgor
c. Assess for unilateral or and dry oral mucosa
bilateral foot drop.
d. 68-year-old with type
d. Ask the patient about 2 diabetes who has
symptoms of depression. severe peripheral
a. Measure the ankle- neuropathy and
brachial index. complains of burning
foot pain
c. 60-year-old with
hyperosmolar
After change-of-shift hyperglycemic syndrome
report, which patient will who has poor skin turgor
the nurse assess first? and dry oral mucosa
a. 19-year-old with type 1

diabetes who was
admitted with possible After change-of-shift
dawn phenomenon report, which patient
should the nurse assess
b. 35-year-old with type first?
1 diabetes whose most
306
a. 19-year-old with type 1 in the diabetic clinic
diabetes who has a schedule at least annually
hemoglobin A1C of 12% (select all that apply)?
b. 23-year-old with type
1 diabetes who has a a. Chest x-ray
blood glucose of 40
mg/dL b. Blood pressure
c. 40-year-old who is c. Serum creatinine

pregnant and whose oral d. Urine for
glucose tolerance test is microalbuminuria
202 mg/dL e. Complete blood count
d. 50-year-old who uses (CBC)
exenatide (Byetta) and is f. Monofilament testing
complaining of acute of the foot
abdominal pain
BCDF
b. 23-year-old with type
1 diabetes who has a
blood glucose of 40 b. Blood pressure
mg/dL c. Serum creatinine
d. Urine for
microalbuminuria
To monitor for f. Monofilament testing
complications in a patient of the foot
with type 2 diabetes,
which tests will the nurse
307
In which order will the B. Hunger
nurse take these steps to C. Blood glucose <60
prepare NPH 20 units mg/dL
and regular insulin 2
units using the same D. Glycosuria
syringe? (Put a comma The answer is C.
and a space between each
answer choice [A, B, C,
D, E]). 2. Type 1 diabetics
typically have the
following clinical
a. Rotate NPH vial. characteristics:
b. Withdraw regular A. Thin, young with
insulin. ketones present in the
c. Withdraw 20 units of urine
NPH. B. Overweight, young
d. Inject 20 units of air with no ketones present
into NPH vial. in the urine
e. Inject 2 units of air into C. Thin, older adult with

regular insulin vial. glycosuria
D. Overweight, adult-
aged with ketones present
1. Which of the following in the urine
symptoms do NOT
present in The answer is A.
hyperglycemia?
A. Extreme thirst
308
3. A patient with diabetes C. A 76 year old female
has a morning glucose of with a history of cardiac
50. The patient is sweaty, disease.
cold, and clammy. Which D. None of the options
of the following nursing provided.
interventions is the
MOST important? The answer is B.
Remember Type 2
A. Recheck the glucose diabetes risk factors are
level related to lifestyle.being
B. Give the patient ½ cup obese is a risk factor
(4 oz) of fruit juice (BMI >30 in males is
C. Call the doctor considered obese). So,
the 28 year old male with
D. Keep the patient a BMI of 49 is most at
nothing by mouth risk for Type 2.
The answer is B .
5. The _____ ______

4. Which of the following secrete insulin which are
patients is at most risk for located in the _______.
Type 2 diabetes? A. Alpha cells, liver
A. A 6 year old girl B. Alpha cells, pancreas
recovering from a viral
infection with a family C. Beta cells, liver
history of diabetes. D. Beta cells, pancreas
B. A 28 year old male The answer is D.
with a BMI of 49.
309
A. Insulin and oral
6. A 36-year-old male is diabetic medications are
newly diagnosed with administered routinely in
Type 2 diabetes. Which the treatment of Type 2
of the following diabetes.
treatments do you expect B. Insulin may be needed
the patient to be started during times of surgery
on initially? or illness.
A. Diet and exercise C. Insulin is never taken
regime by the Type 2 diabetic.
B. Metformin BID by D. Oral medications are
mouth the first line of treatment
C. Regular insulin for newly diagnosed
subcutaneous Type 2 diabetics.
D. None, monitoring at The answer is B.

this time is sufficient
enough 8. What statement or
The answer is A. statements are
INCORRECT regarding
Diabetic Ketoacidosis?
A. DKA occurs mainly in
7. Which of the following Type 1 diabetics.
statements are true
regarding Type 2 B. Ketones are present in
diabetes treatment? the urine in DKA.
310
C. Cheyne-stokes D. None, this is a normal
breathing will always blood glucose reading
present in DKA. The answer is A. This
D. Severe hypoglycemia question requires critical
is a hallmark sign in thinking because the
DKA. patient is NPO for
E. Options C & D surgery and can NOT eat
but is experiencing
The answer is E. hypoglycemia. Normally,
you could give the
9. A patient who has patient 15 grams of a
diabetes is nothing by simple carbohydrate like
mouth as prep for 4 oz of fruit juice or soda,
surgery. The patient glucose tablets, gel etc.
states they feel like their per hypoglycemia
blood sugar is low. You protocol However, the
check the glucose and patient can NOT eat due
find it to be 52. The next to surgery prep.
nursing intervention Therefore the nurse
would be to: would need to administer
Dextrose 50% IV per
A. Administer Dextrose protocol to help increase
50% IV per protocol the blood glucose and
B. Continue to monitor recheck the glucose level.
the glucose
C. Give the patient 4 oz 10. A Type 2 diabetic
of fruit juice may have all the
311
following signs or 2. A patient is admitted
symptoms EXCEPT: with Diabetic
A. Blurry vision Ketoacidosis. The
physician orders
B. Ketones present in the intravenous fluids of
urine 0.9% Normal Saline and
C. Glycosuria 10 units of intravenous
D. Poor wound healing regular insulin IV bolus
and then to start an
The answer is B. insulin drip per protocol.
The patient’s labs are the
DIABETIC following: pH 7.25,
KETOACIDOSIS Glucose 455, potassium
2.5. Which of the
following is the most
1. Which of the following appropriate nursing
is not a sign or symptom intervention to perform
of Diabetic Ketoacidosis? next?
A. Positive Ketones in A. Start the IV fluids and

the urine administer the insulin
B. Oliguria bolus and drip as ordered
C. Polydipsia B. Hold the insulin and
notify the doctor of the
D. Abdominal Pain
potassium level of 2.5
312
C. Hold IV fluids and
administer insulin as 4. Which of the following
ordered statements are
D. Recheck the glucose INCORRECT about
level Diabetic Ketoacidoisis?
A. Extreme
3. Which patient is Hyperglycemia that
MOST likely to develop presents with blood
Diabetic Ketoacidosis? glucose >600 mg/dL
A. A 25 year old female B. Ketones are present in

newly diagnosed with the urine.
Cushing’s Disease taking C. Metabolic acidosis is
glucocorticoids. present with Kussmaul
B. A 36 year old male breathing.
with diabetes mellitus D. Potassium levels
who has been unable to should be at least 3.3 or
eat the past 2 days due to higher during treatment
a gastrointestinal illness of DKA with insulin
and has not been taking therapy.
insulin.
C. A 35 year old female
newly diagnosed with
Type 2 diabetes.
D. None of the options
are correct.
313
5. True or False: When A. Patient has a
priming the tubing for an potassium level of 2.3
Insulin infusion it is best B. Patient complains of
practice to waste 50cc to thirst.
100cc of insulin prior to
starting the infusion c. Patient is nauseous.
because insulin absorbs D. Patient’s skin and
into the plastic lining of mucous membranes are
the tubing. TRUE dry.
6. You are providing care 7. What type of insulin

to a patient experiencing do you expect the doctor
diabetic ketoacidosis. to order for treatment of
The patient is on an DKA?
insulin drip and their
current glucose level is
300. In addition to this, A. IV NPH
the patient also has 5% B. IV Novolog
Dextroxe 0.45% NS C. IV Levemir
infusing in the right
D. IV Regular Insulin
antecubital vein. Which
of the following patient
signs/symptoms causes 8. A patient diagnosed
concern? with diabetes mellitus is
being discharged home
and you are teaching
them about preventing
314
DKA. What statement by Knowing that
the patient demonstrates gluconeogenesis helps to
they understood your maintain blood glucose
teaching about this levels, a nurse should:
condition?
A. Document weight
A. “I will hold off taking changes because of fatty
my insulin while I’m acid mobilization.
sick.” B. Evaluate the patient’s
B. “It is normal for my sensitivity to low room
blood sugar to be 250- temperatures because of
350 mg/dL while I’m decreased adipose tissue
sick.” insulation.
C. “It is important I C. Protect the patient
check my blood glucose from sources of infection
every 3-4 hours when because of decreased
I’m sick and consume cellular protein deposits.
liquids.” D. Do all of the above.
D. “I should not be
alarmed if ketones are
present in my urine The nurse is admitting a
because this is expected patient diagnosed with
during illness.” type 2 diabetes mellitus.
The nurse should expect
the following symptoms
315
during an assessment, D. >5.6%
except:
Rotation sites for insulin

A. Hypoglycemia injection should be
B. Frequent bruising separated from one
another by 2.5 cm (1
C. Ketonuria inch) and should be used
D. Dry mouth only every:
A. Third day
B. Every other day
Glycosylated hemoglobin C. 1-2 weeks
(HbA1C) test measures D. 2-4 weeks
the average blood
glucose control of an
individual over the A clinical feature that
previous three months. distinguishes a
Which of the following hypoglycemic reaction
values is considered a from a ketoacidosis
diagnosis of pre- reaction is:
diabetes?
A. Blurred vision
A. 6.5-7% B. Diaphoresis
B. 5.7-6.4% C. Nausea
C. 5-5.6%
316
D. Weakness in the arteries of the
lower extremities
Clinical nursing
assessment for a patient The nurse expects that a
with microangiopathy type 1 diabetic may
who has manifested receive how much of his
impaired peripheral or her morning dose of
arterial circulation insulin preoperatively?
includes all of the
following, except:
A. 10-20%
B. 25-40%
A. Integumentary
inspection for the C. 50-60%
presence of brown spots D. 85-90%
on the lower extremities
B. Observation for Albert, a 35-year-old
paleness of the lower insulin-dependent
extremities diabetic, is admitted to
C. Observation for the hospital with a
blanching of the feet after diagnosis of pneumonia.
the legs are elevated for He has been febrile since
60 seconds admission. His daily
D. Palpation for insulin requirement is 24
increased pulse volume units of NPH. Every
morning Albert is given
NPH insulin at 0730.
317
Meals are served at 0830, A. 6-8 hours
1230, and 1830. The B. 10-14 hours
nurse expects that the
NPH insulin will reach C. 14-18 hours
its maximum effect D. 24-28 hours
(peak) between the hours
of:
A nurse went to a
patient’s room to do
A. 1130 and 1330 routine vital signs
B. 1330 and 1930 monitoring and found out
that the patient’s bedtime
C. 1530 and 2130 snack was not eaten. This
D. 1730 and 2330 should alert the nurse to
check and assess for:
A male nurse is A. Elevated serum

providing a bedtime bicarbonate and
snack for his patient. This decreased blood pH
is based on the B. Signs of
knowledge that hypoglycemia earlier
intermediate-acting than expected
insulins are effective for C. Symptoms of
an approximate duration hyperglycemia during the
of: peak time of NPH insulin
D. Sugar in the urine
318
response on the
A client is taking NPH information that the
insulin daily every pump:
morning. The nurse
instructs the client that A. Gives a small
the most likely time for a continuous dose of
hypoglycemic reaction to regular insulin
occur is: subcutaneously, and the
client can self-administer
A. 2-4 hours after a bolus with an additional
administration dosage from the pump
before each meal.
B. 6-14 hours after
administration B. It is timed to release
programmed doses of
C. 16-18 hours after regular or NPH insulin
administration into the bloodstream at
D. 18-24 hours after specific intervals.
administration C. It is surgically
attached to the pancreas
and infuses regular
insulin into the pancreas,
An external insulin pump which in turn releases the
is prescribed for a client insulin into the
with DM. The client asks bloodstream.
the nurse about the
functioning of the pump. D. It continuously
The nurse bases the infuses small amounts of
319
NPH insulin into the admitted for the
bloodstream while treatment of
regularly monitoring hyperglycemia. The most
blood glucose levels. appropriate intervention
to decrease the client’s
anxiety would be to:
A client with a diagnosis
of diabetic ketoacidosis
(DKA) is being treated in A. Administer a sedative
the ER. Which finding B. Make sure the client
would a nurse expect to knows all the correct
note as confirming this medical terms to
diagnosis? understand what is
happening
A. Elevated blood C. Ignore the signs and
glucose level and a low symptoms of anxiety so
plasma bicarbonate that they will soon
B. Decreased urine disappear
output D. Convey empathy,
C. Increased respiration trust, and respect toward
and an increase in pH the client
D. Comatose state
A nurse is preparing a
plan of care for a client
A client with DM with diabetes mellitus
demonstrates acute who has hyperglycemia.
anxiety when first
320
The priority nursing C. Correct the acidosis
diagnosis would be: D. Apply an
electrocardiogram
A. High risk for monitor
deficient fluid volume
B. Deficient knowledge: A nurse performs a
disease process and physical assessment on a
treatment client with type 2
C. Imbalanced nutrition: diabetes mellitus.
less than body Findings include fasting
requirements blood glucose of
120mg/dl, temperature of
D. Disabled family 101ºF, pulse of 88 bpm,
coping: compromised respirations of 22 bpm,
and a BP of 140/84
A nurse is caring for a mmHg. Which finding
client admitted to the ER would be of most
with DKA. In the acute concern to the nurse?
phase the priority nursing
action is to prepare to: A. Pulse
B. Blood pressure
A. Administer regular C. Respiration
insulin intravenously
D. Temperature
B. Administer 5%
dextrose intravenously
321
A client with type 1 A client with diabetes
diabetes mellitus calls the mellitus visits a health
nurse to report recurrent care clinic. The client’s
episodes of diabetes previously had
hypoglycemia with been well controlled with
exercise. Which glyburide (Diabeta), 5
statement by the client mg PO daily, but
indicated an inadequate recently, the fasting
understanding of the peak blood glucose has been
action of NPH insulin running 180-200 mg/dl.
and exercise? Which medication, if
added to the clients
regimen, may have
A. “The best time for me contributed to the
to exercise is every hyperglycemia?
afternoon.”
A client with diabetes
B. “The best time for me mellitus visits a health
to exercise is right after I care clinic. The client’s
eat.” diabetes previously had
C. “The best time for me been well controlled with
to exercise is after glyburide (Diabeta), 5
breakfast.” mg PO daily, but
D. “The best time for me recently, the fasting
to exercise is after my blood glucose has been
morning snack.” running 180-200 mg/dl.
Which medication, if
added to the clients
322
regimen, may have
contributed to the When a client is first
hyperglycemia? admitted with
hyperglycemic
A. prednisone hyperosmolar nonketotic
(Deltasone) syndrome (HHNS), the
nurse’s priority is to
B. atenolol (Tenormin) provide:
C. phenelzine (Nardil)
D. allopurinol A. Oxygen
(Zyloprim)
B. Carbohydrates
C. Fluid replacement
D. Dietary instruction
Glucose is an important
molecule in a cell
because this molecule is The nurse is admitting a
primarily used for: client with
hypoglycemia. Identify
the signs and symptoms
A. Extraction of energy the nurse should expect.
B. Synthesis of protein Select all that apply.
C. Building of genetic A. Thirst
material B. Palpitations
D. Formation of cell C. Diaphoresis
membranes
D. Slurred speech
323
E. Hyperventilation who is learning
alternative site testing
(AST) for glucose
When a client is monitoring says:
experiencing diabetic
ketoacidosis, the insulin
that would be A. “I need to rub my
administered is: forearm vigorously until
When a client is warm before testing at
experiencing diabetic this site.”
ketoacidosis, the insulin B. “The fingertip is
that would be preferred for glucose
administered is: monitoring if
hyperglycemia is
suspected.”
A. Human NPH insulin
C. “I have to make sure
B. Human regular that my current glucose
insulin monitor can be used at an
C. Insulin lispro alternate site.”
injection D. “Alternate site testing
D. Insulin glargine is unsafe if I am
injection experiencing a rapid
change in glucose
levels.”
The nurse recognizes that
additional teaching is
necessary when the client
324
A 44-year-old woman following symptoms
with type 1 diabetes would you anticipate the
comes to the emergency client to exhibit? Select
department due to all that apply.
abdominal pain
accompanied by nausea
and vomiting. The patient A. Fruity odor breath
had a history of chronic B. Deep and labored
back pain due to a motor respirations
accident 20 years ago. C. Blurred vision
Her situation renders her
unable to work and pay D. Increased urination
for the increasing price of E. Increased thirst
insulin, which has F. Fatigue
doubled during the last
G. glucose level of 60
five years. The patient
mg/dL
doesn’t have medical
coverage or insurance; H. Dehydration
therefore, she rations her I. Respiratory rate of 8
insulin intake, making bpm
her unable to follow her
J. Hypernatremia Blood
prescribed therapeutic
regimen for her diabetes. K. Metabolic alkalosis
Because of her situation,
the client is at high risk
Nurse Robedee is
of developing diabetic
teaching an underweight
ketoacidosis. As her
and emaciated client
nurse, which of the
325
about the proper C. Increased PCO2
methods/techniques when D. Decreased HCO3
giving insulin. Which
one of the following
shows a proper The nurse knows that
technique? glucagon may be given in
the treatment of
hypoglycemia because it:
A. Pinch the skin up and
use a 90-degree angle
B. Use a 45-degree angle A. Inhibits
with the skin pinched up gluconeogenesis
C. Massage the area of B. Stimulates the release

injection after injecting of insulin
the insulin C. Increases blood
D. Warm the skin with a glucose levels
warm towel or washcloth D. Provides more
prior to the injection storage of glucose.
A client’s blood gases A client with type 1

reflect diabetic acidosis. diabetes mellitus has a
The nurse should expect: fingerstick glucose level
of 258mg/dl at bedtime.
An order for sliding scale
A. Increased pH insulin exists. The nurse
B. Decreased PO2 should:
326
A. Call the physician A client with diabetes
B. Encourage the intake mellitus states, “I cannot
of fluids eat big meals; I prefer to
snack throughout the
C. Administer the insulin day.” The nurse should
as ordered carefully explain that:
D. Give the client 1/2 c.
of orange juice
A. Regulated food intake
is basic to control
The nurse is teaching a B. Salt and sugar
client regarding the restriction is the main
administration of insulin concern
as part of the discharge
plan. Which of the C. Small, frequent meals
following insulin has the are better for digestion
most rapid onset of D. Large meals can
action? contribute to a weight
problem
A. insulin regular A client with diabetes

(Humulin R) mellitus has an above-
knee amputation because
B. lispro (Admelog) of severe peripheral
C. glargine (Toujeo) vascular disease, Two
D. insulin NPH days following surgery,
(Humulin N) when preparing the client
327
for dinner, it is the nausea and vomits one
nurse’s primary hour after taking his
responsibility to: glyburide (DiaBeta)?
A. Check the client’s A. Give glyburide again

serum glucose level B. Give subcutaneous
B. Assist the client out insulin and monitor blood
of bed to the chair glucose
C. Place the client in a C. Monitor blood
High-Fowler's position glucose closely, and look
D. Ensure that the for signs of
client’s residual limb is hypoglycemia
elevated D. Monitor blood
glucose, and assess for
signs of hyperglycemia
nursing interventions
should be taken for a Which of the following
client who complains of chronic complications is
nausea and vomits one associated with diabetes?
hour after taking his
glyburide (DiaBeta)?
A. Dizziness, dyspnea
Which of the following on exertion, and coronary
nursing interventions artery disease
should be taken for a
client who complains of
328
B. Retinopathy, administration would be
neuropathy, and coronary used in the initial
artery disease treatment of
C. Leg ulcers, cerebral hyperglycemia in a client
ischemic events, and with diabetic
pulmonary infarcts ketoacidosis?
D. Fatigue, nausea,
vomiting, muscle A. Subcutaneous
weakness, and cardiac B. Intramuscular
arrhythmias
C. IV bolus only
Rotating injection sites
when administering D. IV bolus, followed by
insulin prevents which of continuous infusion
the following
complications? Insulin forces which of
the following electrolytes
A. Insulin edema out of the plasma and
into the cells?
B. Insulin lipodystrophy
C. Insulin resistance
A. Calcium
D. Systemic allergic
reactions B. Magnesium
C. Phosphorus
Which of the following D. Potassium

methods of insulin
329
causes of A. Kussmaul’s
Hyperglycaemic respirations and a fruity
Hyperosmolar Non- odor on the breath
Ketotic Syndrome
(HHNS) is most B. Shallow respirations
common? and severe abdominal
pain
C. Decreased respiration
A. Insulin overdose and increased urine
B. Removal of the output
adrenal gland D. Cheyne-stokes
C. Undiagnosed, respirations and foul-
untreated smelling urine
hyperpituitarism
D. Undiagnosed, Clients with type 1
untreated diabetes diabetes may require
mellitus which of the following
changes to their daily
A client is in diabetic routine during periods of
ketoacidosis (DKA) infection?
secondary to infection. Clients with type 1
As the condition diabetes may require
progresses, which of the which of the following
following symptoms changes to their daily
might the nurse see?
330
routine during periods of C. "Without insulin, you
infection? will develop ketoacidosis
(DKA)."
A. No changes D. "The endocrine

function of your pancreas
B. Less insulin is to secrete insulin."
C. More insulin E. "It means your
D. Oral antidiabetic pancreas cannot secrete
agents insulin."
Marlisa has been Dr. Shrunk orders

diagnosed with diabetes intravenous (IV) insulin
mellitus type 1. She asks for Rita, a client with a
Nurse Errol what this blood sugar of 563.
means. What is the best Nurse AJ administers
response by the nurse? insulin lispro (Humalog)
Select all that apply. intravenously (IV). What
does the best evaluation
of the nurse reveal?
A. "Your alpha cells Select all that apply.
should be able to secrete
insulin, but cannot."
B. "The exocrine A. The nurse could have
function of your pancreas given the insulin
is to secrete insulin." subcutaneously.
331
B. The nurse should D. The client will have
have contacted the moist clammy skin.
physician.
C. The nurse should A clinical instructor
have used regular insulin teaches a class for the
(Humulin R). public about diabetes
D. The nurse used the mellitus. Which
correct insulin. individual does the nurse
E. The nurse could have assess as being at the
given the insulin highest risk for
intramuscularly. developing diabetes?
Ben injects his insulin as A. The 50-year-old

prescribed, but then gets client who does not get
busy and forgets to eat. any physical exercise
What will the best B. The 56-year-old client
assessment of the nurse who drinks three glasses
reveal? of wine each evening
C. The 42-year-old client
A. The client will be who is 50 pounds
very thirsty. overweight
B. The client will D. The 38-year-old

complain of nausea. client who smokes one
pack of cigarettes per day
C. The client will need
to urinate.
332
A patient was recently B. It must be taken with
diagnosed with type 1 meals.
diabetes mellitus and C. It decreases sugar
received insulin. Which production in the liver.
laboratory test will the
nurse assess? D. It inhibits the
absorption of
carbohydrates.
A. Potassium E. It reduces insulin
B. AST (aspartate resistance.
aminotransferase)
C. Serum amylase Serge who has diabetes
D. Sodium mellitus is taking oral
agents and is scheduled
for a diagnostic test that
Jansen is receiving requires him to be NPO.
metformin (Glucophage). What is the best plan of
What will be the best the nurse with regard to
plan of the nurse with giving the client his oral
regard to patient medications?
education with this drug?
Select all that apply.
A. Administer the oral
agents immediately after
A. It stimulates the the test.
pancreas to produce more
insulin.
333
B. Notify the diagnostic D. "I know it is tough,
department and request but you will get used to
orders. the shots soon."
C. Notify the physician
and request orders. Nurse Andy has finished
D. Administer the oral teaching a client with
agents with a sip of water diabetes mellitus how to
before the test. administer insulin. He
evaluates the learning has
occurred when the client
take pills instead. What is makes which statement?
the best response by the
nurse?
A. "I should check my
blood sugar immediately
A. "Insulin must be prior to the
injected because it needs administration."
to work quickly."
B. "I should provide
B. "Insulin can't be in a direct pressure over the
pill because it is site following the
destroyed in stomach injection."
acid."
C. "I should use the
C. "Have you talked to abdominal area only for
your doctor about taking insulin injections."
pills instead?"
334
D. "I should only use a
calibrated insulin syringe Dr. Wijangco orders
for the injections." insulin lispro (Humalog)
10 units for Alicia, a
Genevieve has diabetes client with diabetes
type 1 and receives mellitus. When will the
insulin for glycemic nurse administer this
control. She tells the medication?
nurse that she likes to
have a glass of wine with A. When the client is
dinner. What will the best eating
plan of the nurse for
client education include? B. Thirty minutes before
meals
C. Fifteen minutes
A. The alcohol could before meals
cause pancreatic disease.
D. When the meal trays
B. The alcohol could arrive on the floor
cause serious liver
disease.
C. The alcohol could Nurse Matt makes a
predispose you to home visit to the client
hypoglycemia. with diabetes mellitus.
During the visit, Nurse
D. The alcohol could Matt notes the client’s
predispose you to additional insulin vials
hyperglycemia. are not refrigerated. What
335
is the best action by the validate with the
nurse at this time? physician?
A. Instruct the client to A. Use Humalog insulin

label each vial with the for sliding scale
date when opened. coverage.
B. Tell the client there is B. Metformin
no need to keep (Glucophage) 1000 mg
additional vials. per day in divided doses.
C. Have the client place C. Administer regular
the insulin vials in the insulin 30 minutes prior
refrigerator. to meals.
D. Have the client D. Lantus insulin 20U
discard the vials. BID.
During the morning Gary has diabetes type 2.

rounds, Nurse AJ Nurse Martha has taught
accompanied the him about the illness and
physician in every evaluates learning has
patient’s room. The occurred when the client
physician writes orders makes which statement?
for the client with
order would the nurse A. "My cells have
increased their receptors,
336
but there is enough
insulin." Which of the following is
B. "My peripheral cells accurate pertaining to
have increased sensitivity physical exercise and
to insulin." type 2 diabetes mellitus?
C. "My beta cells cannot
produce enough insulin A. Physical exercise can
for my cells." slow the progression of
D. "My cells cannot use type 2 diabetes mellitus.
the insulin my pancreas B. Strenuous exercise is
makes." beneficial when blood
glucose is high.
The principal goals of C. Patients who take
therapy for older patients insulin and engage in
who have poor glycemic strenuous physical
control are: exercise might
experience
hyperglycemia.
A. Enhancing the quality
of life. D. Adjusting insulin
regimen allows for safe
B. Decreasing the participation in all forms
chance of complications. of exercise.
C. Improving self-care
through education.
Harry is a diabetic patient
D. All of the above. who is experiencing a
337
reaction to alternating Dr. Hugo has prescribed
periods of nocturnal sulfonylureas for
hypoglycemia and Rebecca in the
hyperglycemia. The management of diabetes
patient might be mellitus type 2. As a
manifesting which of the nurse, you know that the
following? primary purpose of
Harry is a diabetic patient sulfonylureas, such as
who is experiencing a long-acting glyburide
reaction to alternating (Micronase), is to:
periods of nocturnal
hypoglycemia and A. Induce hypoglycemia
hyperglycemia. The by decreasing insulin
patient might be sensitivity.
manifesting which of the
following? B. Improve insulin
sensitivity and decrease
hyperglycemia.
A. Uncontrolled diabetes C. Stimulate the beta
B. Somogyi cells of the pancreas to
phenomenon secrete insulin.
C. Brittle diabetes D. Decrease insulin
D. Diabetes insipidus sensitivity by enhancing
glucose uptake.
338
Rosemary has been A 50-year-old widower is
taking glargine (Lantus) admitted to the hospital
to treat her condition. with a diagnosis of
One of the benefits of diabetes mellitus and
glargine (Lantus) insulin complaints of rapid-onset
is its ability to: weight loss, elevated
blood glucose levels, and
polyphagia. The
A. Release insulin gerontology nurse should
rapidly throughout the anticipate which of the
day to help control basal following secondary
glucose. medical diagnoses?
B. Release insulin A 50-year-old widower is
evenly throughout the admitted to the hospital
day and control basal with a diagnosis of
glucose levels. diabetes mellitus and
C. Simplify the dosing complaints of rapid-onset
and better control blood weight loss, elevated
glucose levels during the blood glucose levels, and
day. polyphagia. The
D. Cause hypoglycemia gerontology nurse should
with other manifestations anticipate which of the
of other adverse following secondary
reactions. medical diagnoses?
A. Impaired glucose
tolerance
339
B. Gestational diabetes for him? Select all that
mellitus apply.
C. Pituitary tumor
D. Pancreatic tumor A. Fasting Plasma
An older woman with Glucose (FPG)
diabetes mellitus visits B. Two-hour Oral
the clinic concerning her Glucose Tolerance Test
condition. Which of the (OGTT)
following symptoms C. Glycosylated
might an older woman hemoglobin (HbA1C)
with diabetes mellitus
complain? D. Fingerstick glucose
three times daily
E. Urinalysis and urine
A. Anorexia culture
B. Pain intolerance
C. Weight loss According to the
D. Perineal itching National Diabetes
Statistics Report, diabetes
remains one of the
Gregory is a 52-year-old leading causes of death in
man identified as high- the United States since
risk for diabetes mellitus. 2010. Which of the
Which laboratory test following factors are
should a nurse anticipate risks for the development
a physician would order
340
of diabetes mellitus? A. Caucasian woman.
Select all that apply. B. Asian woman.
C. African-American
A. Age over 45 years woman.
B. Overweight with a D. Hispanic male.
waist/hip ratio >1
C. Having a consistent An ailing 70-year-old
HDL level above 40 woman with a diagnosis
mg/dl of type 2 diabetes
D. Maintaining a mellitus has been ill with
sedentary lifestyle pneumonia. The client’s
E. Polycystic ovary intake has been very
syndrome poor, and she is admitted
to the hospital for
observation and
During a visit to the management as needed.
hospital, the student What is the most likely
nurses are asked which of problem with this
the following persons patient?
would most likely be
diagnosed with diabetes
mellitus. They are correct A. Insulin resistance has
if they answered a 44- developed.
year-old: B. Diabetic ketoacidosis
is occurring.
341
C. Hypoglycemia D. Mix the drug in 50 ml
unawareness is of dextrose 5% in water
developing. and infuse over 30
D. Hyperglycemic minutes.
hyperosmolar nonketotic E. Be aware that the
syndrome. drug is not compatible
with morphine.
After suffering an acute

MI, a client with a When reviewing the
history of type 1 diabetes urinalysis report of a
is prescribed metoprolol client with newly
(Lopressor) I.V. Which diagnosed diabetes
nursing interventions are mellitus, the nurse would
associated with I.V. expect which urine
administration of characteristics to be
metoprolol? Select all abnormal? Select all that
that apply. apply.
A. Amount.
A. Monitor glucose B. Odor.
levels closely. C. pH.
B. Monitor for heart D. Specific gravity.
block and bradycardia.
E. Glucose level.
C. Monitor blood
pressure closely. F. Ketone bodies.
342
B. The client with
A nurse has a four- diabetes insipidus.
patient assignment in the C. The client with
medical step-down unit. diabetic ketoacidosis.
When planning care for D. The client with
the clients, which client syndrome of
would have the following inappropriate antidiuretic
treatment goals: fluid hormone (SIADH)
replacement, vasopressin secretion.
replacement, and
correction of underlying
intracranial pathology? During the lecture, the
A nurse has a four- clinical instructor tells
patient assignment in the the students that 50% to
medical step-down unit. 60% of daily calories
When planning care for should come from
the clients, which client carbohydrates. What
would have the following should the nurse say
treatment goals: fluid about the types of
replacement, vasopressin carbohydrates that can be
replacement, and eaten?
correction of underlying
intracranial pathology? A. Try to limit simple
sugars to between 10%
A. The client with and 20% of daily
diabetes mellitus. calories.
343
B. Simple carbohydrates B. Atherosclerosis
are absorbed more C. Glycosuria
rapidly than complex
carbohydrates. D. Acidosis
C. Simple sugars cause a

rapid spike in glucose Joko has recently been
levels and should be diagnosed with type 1
avoided. Diabetes Mellitus and
D. Simple sugars should asks nurse Jessica for
never be consumed by help formulating a
someone with diabetes. nutrition plan. Which of
the following
recommendations would
At the time Cherrie Ann the nurse make to help
found out that the the client increase calorie
symptoms of diabetes consumption to offset
were caused by high absorption problems?
levels of blood glucose,
she decided to break the
habit of eating A. Eat small meals with
carbohydrates. With this, two or three snacks
the nurse would be aware throughout the day to
that the client might keep blood glucose levels
develop which of the steady
following complications? B. Increase the
consumption of simple
carbohydrates
A. Retinopathy
344
C. Eating small meals Nurse Shey is educating
with two or three snacks a pregnant client who has
may be more helpful in gestational diabetes.
maintaining blood Which of the following
glucose levels than three statements should the
large meals. nurse make to the client?
D. Skip meals to help Select all that apply.
lose weight
A. Cakes, candies,
Billy is being asked cookies, and regular soft
concerning his health in drinks should be avoided.
the emergency B. Gestational diabetes
department. When increases the risk that the
obtaining a health history mother will develop
from a patient with acute diabetes later in life.
pancreatitis, the nurse C. Gestational diabetes
asks the patient usually resolves after the
specifically about the baby is born.
history of:
D. Insulin injections may
be necessary.
A. Alcohol use
B. Cigarette smoking E. The mother should
C. Diabetes mellitus strive to gain no more
D. High-protein diet weight during pregnancy.
345
F. The baby will likely B. Unlimited intake of
be born with diabetes total fat, saturated fat,
and cholesterol
The goal of preprandial C. Including adequate

blood glucose for those servings of fruits,
with type 1 diabetes vegetables, and the dairy
mellitus is: group
D. Applicable to with
either Type 1 or Type 2
A. <80 mg/dl diabetes mellitus
B. <130 mg/dl
C. <180 mg/dl
D. >8%
The guidelines for The nurse working in the

carbohydrate counting as physician’s office is
medical nutrition therapy reviewing lab results on
for diabetes mellitus the clients seen that day.
includes all of the One of the clients who
following, except: has classic diabetic
symptoms had an eight-
A. Flexibility in types hour fasting plasma
and amounts of foods glucose (FPG) test done.
consumed The nurse realizes that
diagnostic criteria
346
developed by the type 1 diabetes mellitus
American Diabetes and would be most
Association for diabetes suggestive and require
include classic diabetic follow-up investigation?
symptoms plus which of
the following fasting
plasma glucose levels? A. Excessive intake of
calories, rapid weight
gain, and difficulty losing
A. Higher than 106 weight
mg/dl B. An increase in three
B. Higher than 126 areas: thirst, intake of
mg/dl fluids, and hunger
C. Higher than 140 C. Poor circulation,
mg/dl wound healing, and leg
D. Higher than 160 ulcers
mg/dl D. Lack of energy,
weight gain, and
depression
When taking a health
history, the nurse screens
for manifestations The nurse is working
suggestive of diabetes with an overweight client
type 1. Which of the who has a high-stress job
following manifestations and smokes. This client
are considered the has just received a
primary manifestations of diagnosis of type 2
347
diabetes mellitus and has five minutes five times a
just been started on an day for at least five
oral hypoglycemic agent. months
goals for the client which
if met, would be most During a visit to a
likely to lead to an community, the nurse
improvement in insulin will recommend routine
efficiency to the point the screening for diabetes
client would no longer when the person has one
require oral or more of seven risk
hypoglycemic agents? criteria. Which of the
following persons that
the nurse comes in
A. Comply with contact with most needs
medication regimen to be screened for
100% for 6 months diabetes based on the
B. Quit the use of any seven risk criteria?
tobacco products by the
end of three months A. A client with an HDL
C. Lose a pound a week cholesterol level of 40
until the weight is within mg/dl and a triglyceride
the normal range for level of 300 mg/dl
height and exercise 30 B. A woman who is at
minutes daily 90% of standard body
D. Practice relaxation weight after delivering an
techniques for at least eight-pound baby
348
C. A middle-aged A. 10% dextrose in
Caucasian male water (D10W)
D. An older client who is B. 0.9% normal saline
hypotensive solution
C. 5% dextrose in water
(D5W)
D. 0.45% normal saline
solution
You are doing some

A client was brought to teaching with a client
the emergency room with who is starting on a
complaints of slurring of sulfonylurea antidiabetic
speech, vomiting, dry agent. The client
mucosa, and dry skin mentions that he usually
turgor. Lab tests showing has a couple of beers
serum sodium 125 each night and takes an
mEq/L and serum blood aspirin each day to
glucose of 350 mg/dL. prevent heart attacks
Nurse Sophie will and/or strokes. Which of
anticipate the physician the following responses
to initially order which of would be best on the part
the following intravenous of the nurse?
solutions?
349
A. As long as you only A. “This syndrome
drink two beers and take occurs mainly in people
one aspirin, this should with type 1 diabetes.”
not be a problem B. “It has a higher
B. The aspirin is alright mortality rate than
but you need to give up diabetic ketoacidosis.”
drinking any alcoholic C. “The client with
beverages HHNS is in a state of
C. Taking alcohol and/or overhydration.”
aspirin with a D. “This condition
sulfonylurea drug can develops very rapidly.”
cause the development of
hypoglycemia
D. Aspirin and alcohol Nurse Robedee is
will cause the stomach to teaching an underweight
bleed more when on a and emaciated client
sulfonylurea drug about the proper
methods/techniques when
giving insulin. Which
Which of the following, one of the following
if stated by the nurse, is shows a proper
correct about technique?
Hyperglycemic Nurse Robedee is
Hyperosmolar teaching an underweight
Nonketotic Syndrome and emaciated client
(HHNS)? about the proper
methods/techniques when
350
giving insulin. Which C. Obesity
one of the following D. Smoking
shows a proper
technique?
A. Pinch the skin up and

use a 90-degree angle
B. Use a 45-degree angle Blood sugar is well
with the skin pinched up controlled when
C. Massage the area of Hemoglobin A1C is:
injection after injecting Blood sugar is well
the insulin controlled when
D. Warm the skin with a Hemoglobin A1C is:
warm towel or washcloth
prior to the injection A. Below 5.7%
Nurse Pira is explaining B. Between 12%-15%
to the client about type 2
diabetes mellitus. Risk C. Less than 180 mg/dL
factors of such condition D. Between 90 and 130
include all of the mg/dL
following, except:
A. Advanced age diabetes drugs acts by
B. Physical inactivity decreasing the amount of
351
glucose produced by the C. Give 4 to 6 oz (118 to
liver? 177 mL) of orange juice
D. Give the client four to
A. Alpha-glucosidase six glucose tablets
inhibitors Which insulin can be
B. Biguanides administered through
continuous intravenous
C. Meglitinides infusion?
D. Sulfonylureas
A. insulin glargine
A 39-year-old company (Lantus)
driver presents with B. insulin aspart
shakiness, sweating, (Novolog)
anxiety, and palpitations
and tells the nurse he has C. insulin detemir
type 1 diabetes mellitus. (Levemir)
Which of the following D. insulin Afrezza
actions should the nurse E. regular insulin
do first? (Novolin R)
A. Inject 1 mg of A medication nurse is

glucagon subcutaneously about to give insulin to a
B. Administer 50 mL of patient with diabetes
50% glucose I.V mellitus. Upon reviewing
the medications of the
352
patient, which of the
following would cause a A. Insulin resistance
further decrease in the
blood glucose level of the B. Dawn phenomenon
patient? C. Insulin
lipohypertrophy
A. hydrochlorothiazide D. Somogyi
(Microzide) phenomenon
B. levothyroxine
(Synthroid) A nurse is caring for a
C. carvedilol (Coreg) client admitted with
diabetic retinopathy.
D. hydrocortisone Which of the following
(SoluCortef) would the nurse expect to
note on the assessment of
Tony is a night shift this client:
nurse who is assigned to
a patient whose glucose A. Blurred or distorted
levels remain normal at vision
bedtime but experiences
hypoglycemia at 3 am B. Flashes of lights or
and hyperglycemia at 7 floaters
am. The patient is likely C. Sudden loss of vision
experiencing what kind D. All of the above
of complication of insulin
therapy?
353
A patient received 6 units QID. When the nurse
of regular insulin three visits the patient at 5 pm,
(3) hours ago. The nurse the nurse observes the
would be most concerned man performing blood
if which of the following sugar analysis. The result
was observed? is 50 mg/dL. The nurse
would expect the patient
to be:
A. Kussmaul
respirations and
diaphoresis A. Anxiety, paleness,
B. Anorexia and lethargy and pulse of 110 bpm
C. Diaphoresis and B. Lethargic with hot

trembling dry skin and rapid deep
respirations
D. Headache and
polyuria C. Alert and cooperative
with BP of 130/80 mm
Hg and respirations of 12
Mr. Wesley is newly breaths per minute
diagnosed with Type I D. Short of breath, with
DM and is being seen by distended neck veins and
the home health nurse. bounding pulse of 96
The doctor’s orders bpm
include: 1200 calorie
ADA diet, 15 units NPH
insulin before breakfast, 1) Nurse Perry is caring
and check blood sugar for a female client with
type 1 diabetes mellitus
354
who exhibits confusion, C. Before lunch
light-headedness, and D. After dinner
aberrant behavior. The 3) The glycosylated
client is still conscious. hemoglobin of a 40-year-
The nurse should first old client with diabetes
administer: mellitus is 2.5%. The
nurse understands that:
A. I
.M. or A. The client can
subcutaneous have a higher-
glucagon. calorie diet.
B. I B. The client has
.V. bolus of good control of
dextrose 50%. her diabetes.
C. 1 C. The client
5 to 20 g of a fast- requires
acting adjustment in her
carbohydrate such insulin dose.
as orange juice. D. The client has
D. 1 poor control of
0 U of fast-acting her diabetes.
insulin. 4) A patient with severe
2) A client with diabetes hypoglycemia arrives at
mellitus has a the ED unconscious by
prescription for Glucotrol ambulance. The nurse
XL (glipizide). The client would first…
should be instructed to
take the medication: A. Giv
e regular insulin
A. At bedtime by IV
B. With breakfast
355
B. Giv A. Cerebral edema
e NPH by IV B. Arrhythmias
C. Giv C. Peptic ulcers
e 10-15 g CHO or D. Mucormycosis
Orange juice 7) Which of the
D. Giv following clinical
e 1 mg glucagon characteristics is
E. associated with Type 1
5) A male client with diabetes (previously
type 1 diabetes mellitus referred to as insulin-
asks the nurse about dependent diabetes
taking an oral mellitus [IDDM])?
antidiabetic agent. Nurse
Jack explains that these A. Presence of islet
medications are only cell antibodies
effective if the client: B. Obesity
C. Rare ketosis
A. prefers to take D. Requirement for
insulin orally. oral
B. has type 2 hypoglycemic
diabetes. agents
C. has type 1 8) What are the micro
diabetes. vascular complications of
D. is pregnant and uncontrolled diabetes?
has type 2
diabetes. A. Delayed gastric
6) Which of the emptying
following conditions is B. Diarrhea
not linked to diabetic C. Glomuerular
ketoacidosis? injury
356
D. Bleeding of 11) The newly diagnosed
retinal caplillaries diabetic patient asks the
E. Numbness of feet nurse why he needs to
F. Impotence check his feet every day.
9) What is the number The nurse’s best response
one complication of is….
diabetes?
A. To prevent leg
A. Diabetic amputation.
ketoacidosis B. To check for
B. Obesity any cuts, sores, or
C. Hypertension dry cracked skin
D. Cardiovascular so they can be
disease treated early to
10) Nurse Noemi prevent infection
administers glucagon to or gangrene.
her diabetic client, then C. To see if they
monitors the client for hurt.
adverse drug reactions D. You just need to
and interactions. Which do it.
type of drug interacts 12) What type of cells
adversely with glucagon? secrete glucagon?
A. Oral A. Beta cells
anticoagulants B. Alpha cells
B. Anabolic C. Plasma cells
steroids D. Acinar cells
C. Beta-adrenergic 13) Nurse John is
blockers assigned to care for a
D. Thiazide postoperative male client
diuretics who has diabetes
357
mellitus. During the A. Amputations
assessment interview, the (BKA)
client reports that he’s B. Cardiovascular
impotent and says he’s disease
concerned about its effect C. Edema
on his marriage. In D. Peripheral
planning this client’s neuropathy
care, the most E. Hyperthyroidism
appropriate intervention F. Retinopathy
would be to: G. Cardio
neuropathy
A. Encourage the H. Coma
client to ask I. Nephropathy
questions about J. Arteriosclerosis
personal K. Hypertension
sexuality. L. Obesity
B. Provide time for M. Infections
privacy. 15) Which of the
C. Provide support following is not an effect
for the spouse or of diabetes?
significant other.
D. Suggest referral A. Small vessel
to a sex counselor occlusion
or other B. Necrosis of
appropriate extremities
professional. C. Ketone Body
14) Which are potential production
complications of D. Decreased fat
diabetes? (Choose all that metabolism
applies)
358
16) Which of the B. “Glipizide may
following is not an cause a low serum
indicator of diabetic sodium level, so
ketoacidosis? make sure you
have your sodium
A. Hyperthermia level checked
B. Nausea/Vomitin monthly.”
g C. “You won’t
C. Slow and need to check
shallow breathing your blood
D. Psychosis glucose level after
leading to you start taking
dementia glipizide.”
17) Dr. Kennedy D. “Take glipizide
prescribes glipizide after a meal to
(Glucotrol), an oral prevent
antidiabetic agent, for a heartburn.”
male client with type 2 18) What type of cells
diabetes mellitus who has secrete insulin?
been having trouble
controlling the blood A. Beta cells
glucose level through diet B. Alpha cells
and exercise. Which C. Plasma cells
medication instruction D. Acinar cells
should the nurse provide? 19) A 65-year-old female
who has diabetes mellitus
A. “Be sure to take and has sustained a large
glipizide 30 laceration on her left
minutes before wrist asks the nurse,
meals.” “How long will it take for
359
my scars to disappear?” breath smell. This is
which statement would known as…
be the nurse’s best
response? A. Trousseau’s
B. Cullen’s
A. “The contraction C. Kussmaul’s
phase of wound D. Bitot’s
healing can take 2 21) The nurse is
to 3 years.” performing wound care
B. “Wound healing on a foot ulcer in a client
is very individual with type 1 diabetes
but within 4 mellitus. Which
months the scar technique demonstrates
should fade.” surgical asepsis?
C. “With your
history and the A. Putting on
type of location of sterile gloves then
the injury, it’s opening a
hard to say.” container of
D. “If you don’t sterile saline.
develop an B. Cleaning the
infection, the wound with a
wound should circular motion,
heal any time moving from
between 1 and 3 outer circles
years from now.” toward the center.
20) The nurse enters a C. Changing the
patient’s room and sees sterile field after
the patient breathing sterile water is
rapidly with a fruity spilled on it.
360
D. Placing a sterile be altered
dressing ½” (1.3 significantly.”
cm) from the edge 23) A male client has just
of the sterile field. been diagnosed with type
22) A male client with 1 diabetes mellitus.
type 1 diabetes mellitus When teaching the client
has a highly elevated and family how diet and
glycosylated hemoglobin exercise affect insulin
(Hb) test result. In requirements, Nurse Joy
discussing the result with should include which
the client, nurse guideline?
Sharmaine would be
most accurate in stating: A. “You’ll need
more insulin
A. “The test needs when you exercise
to be repeated or increase your
following a 12- food intake.”
hour fast.” B. “You’ll need
B. “It looks like less insulin when
you aren’t you exercise or
following the reduce your food
prescribed intake.”
diabetic diet.” C. “You’ll need
C. “It tells us about less insulin when
your sugar control you increase your
for the last 3 food intake.”
months.” D. “You’ll need
D. “Your insulin more insulin
regimen needs to when you exercise
361
or decrease your C. 18 to 20 g of a
food intake.” simple
24) An agitated, confused carbohydrate.
female client arrives in D. 25 to 30 g of a
the emergency simple
department. Her history carbohydrate.
includes type 1 diabetes 25) Acarbose (Precose),
mellitus, hypertension, an alpha-glucosidase
and angina pectoris. inhibitor, is prescribed
Assessment reveals for a female client with
pallor, diaphoresis, type 2 diabetes mellitus.
headache, and intense During discharge
hunger. A stat blood planning, nurse Pauleen
glucose sample measures would be aware of the
42 mg/dl, and the client client’s need for
is treated for an acute additional teaching when
hypoglycemic reaction. the client states:
After recovery, nurse
Lily teaches the client to A. “If I have
treat hypoglycemia by hypoglycemia, I
ingesting: should eat some
sugar, not
A. 2 to 5 g of a dextrose.”
simple B. “The drug
carbohydrate. makes my
B. 10 to 15 g of a pancreas release
simple more insulin.”
carbohydrate. C. “I should never
take insulin while
362
I’m taking this phosphorylated in
drug.” kidney
D. “It’s best if I 28) The physician has
take the drug with prescribed NPH insulin
the first bite of a for a client with diabetes
meal.” mellitus. Which
26) Which of the statement indicates that
following is not true the client knows when
about Type I DM? the peak action of the
insulin occurs?
A. May be linked
to autoimmunity A. “I will make
B. Onset usually sure I eat
prior to age 20 breakfast within 2
C. Beta islet cells hours of taking
destroyed my insulin.”
D. Does not require B. “I will need to
insulin injections carry candy or
27) Which of the some form of
following is caused by sugar with me all
insulin release? the time.”
C. “I will eat a
A. Increased snack around
breakdown of fats three o’clock each
B. Increase afternoon.”
breakdown of D. “I can save my
proteins dessert from
C. Decreased blood supper for a
sugar bedtime snack.”
D. Causes glucose
to be
363
29) Which of the mellitus and takes
following is not an insulin
accurate test for diabetes? 31) Which of the
following is not true
A. Glucose about Type II DM?
tolerance test
B. HbA A. Considered
C. Fasting adult onset
glucagon test diabetes
30) A home health nurse B. Cause unknown
is at the home of a client may be due to
with diabetes and genetics
arthritis. The client has C. Require insulin
difficulty drawing up 80% of cases
insulin. It would be most D. May take a drug
appropriate for the nurse that sensitize cells
to refer the client to or increase insulin
release
A. A social worker 32) Which of the
from the local following is not an
hospital indicator of a
B. An occupational hypoglycemic condition?
therapist from the
community center A. Fatigue
C. A physical B. Poor appetite
therapist from the C. Tachycardia
rehabilitation D. Confusion
agency 33) Glucagon increases
D. Another client blood levels of glucose
with diabetes by causing liver to
breakdown glycogen.
364
A. TRUE B. glucose and high
B. FALSE amounts of
34) A patient with a bilirubin in the
history of diabetes urine
mellitus is in the second C. ketones in the
post-operative day urine
following D. ketones and
cholecystectomy. She has adrenaline in the
complained of nausea urine
and isn’t able to eat solid 36) A client has a
foods. The nurse enters medical history of
the room to find the rheumatic fever, type 1
patient confused and (insulin dependent)
shaky. Which of the diabetes mellitus,
following is the most hypertension, pernicious
likely explanation for the anemia, and
patient’s symptoms? appendectomy. She’s
admitted to the hospital
A. Anesthesia and undergoes mitral
reaction. valve replacement
B. Hyperglycemia. surgery. After discharge,
C. Hypoglycemia. the client is scheduled for
D. Diabetic a tooth extraction. Which
ketoacidosis. history finding is a major
35) A urine test in an risk factor for infective
undiagnosed diabetic endocarditis?
may show……..
A. appendectomy
A. glucose and B. pernicious
ketones in the anemia
urine
365
C. diabetes mellitus the nurse expect the
D. valve physician to do?
replacement
A. Initiate insulin
therapy.
37) Of the following B. Switch the client
types of insulin, which is to a different oral
the most rapid acting? antidiabetic agent.
C. Prescribe an
A. Humalog additional oral
B. Regular antidiabetic agent.
C. NPH D. Restrict
D. Ultralente carbohydrate
38) The nurse’s first intake to less than
action upon finding a 30% of the total
patient with mild caloric intake.
hypoglycemia is to… 40) When caring for a
female client with a
A. Call the rapid history of hypoglycemia,
response team nurse Ruby should avoid
B. Give 1 mg of administering a drug that
glucagon may potentiate
C. Give 10-15 g of hypoglycemia. Which
CHO or Orange drug fits this description?
juice
D. Give insulin A. sulfisoxazole
39) After taking glipizide (Gantrisin)
(Glucotrol) for 9 months, B. mexiletine
a male client experiences (Mexitil)
secondary failure. Which C. prednisone
of the following would (Orasone)
366
D. lithium the client knows when
carbonate the peak action of the
(Lithobid) insulin occurs?
41) A male client with
diabetes mellitus is A. “I will make
receiving insulin. Which sure I eat
statement correctly breakfast within
describes an insulin unit? 10 minutes of
taking my
A. It’s a common insulin.”
measurement in B. “I will need to
the metric system. carry candy or
B. It’s the basis for some form of
solids in the sugar with me all
avoirdupois the time.”
system. C. “I will eat a
C. It’s the smallest snack around
measurement in three o’clock each
the apothecary afternoon.”
system. D. “I can save my
D. It’s a measure of dessert from
effect, not a supper for a
standard measure bedtime snack.”
of weight or 43) Which of the
quantity. following would not be
42) The physician has considered an acute
prescribed Novalog effect of diabetes
insulin for a client with mellitus?
statement indicates that A. Polyuria
B. Weight gain
367
C. Polydipsia after onset of Type I
D. Polyphagia Diabetes?
44) Which instruction
about insulin A. Torsemide
administration should B. Cyclosporine
nurse Kate give to a C. Clofibrate
client? D. Ceftriaxone
46) As blood glucose
A. “Always follow decreases glucagon is
the same order inhibited.
when drawing the
different insulins A. TRUE
into the syringe.” B. FALSE
B. “Shake the vials 47) Of the following
before categories of oral
withdrawing the antidiabetic agents,
insulin.” which exert their primary
C. “Store unopened action by directly
vials of insulin in stimulating the pancreas
the freezer at to secrete insulin?
temperatures well A. Sulfonylureas
below freezing.” B. Thiazolidinedio
D. “Discard the nes
intermediate- C. Biguanides
acting insulin if it D. Alpha
appears cloudy.” glucosidase
45) Which of the inhibitors
following drugs may be 48) The nurse enters a
given as an diabetic patient’s room at
immunosuppressant soon 11:30 and notices that the
368
patient is diaphoretic, performed
tachycardic, anxious, weekly.
states she is hungry, and C. Induction of
doesn’t remember where labor is begun at
she is. This patient is 34 weeks’
most likely showing gestation.
signs of what? D. Nonstress
testing is
A. hyperglycemic performed weekly
B. hypoglycemic until 32 weeks’
C. diabetic gestation
ketoacidosis 50) The diabetic patient’s
D. hyperosmolar lab work comes back
hyperglycemic with a pH of 7.4, serum
noketotic coma blood sugar of 950,
49) A client with type 1 serum osmolarity of 460,
diabetes mellitus who’s a pCO2 of 35, HCO3 of
multigravida visits the 25. The patient is
clinic at 27 weeks confused and dehydrated.
gestation. The nurse This patient is showing
should instruct the client signs and symptoms
that for most pregnant of….
women with type 1
diabetes mellitus: A. Diabetic
ketoacidosis
A. Weekly fetal B. hyperosmolar
movement counts hyperglycemic
are made by the noketotic coma
mother. C. Hypoglycemia
B. Contraction
stress testing is
369
D. diabetic D. Hypotension
neuropathy 53) During a class on
51) The nurse teaches the exercise for diabetic
patient about glargine clients, a female client
(Lantus), a “peakless” asks the nurse educator
basal insulin including how often to exercise.
which of the following The nurse educator
statements? advises the clients to
exercise how often to
A. Do not mix the meet the goals of planned
drug with other exercise?
insulins
B. Administer the A. At least once a
total daily dosage week
in two doses. B. At least three
C. Draw up the times a week
drug first, then C. At least five
add regular times a week
insulin. D. Every day
D. The drug is 54) For a diabetic male
rapidly absorbed client with a foot ulcer,
and has a fast the physician orders bed
onset of action rest, a wet-to-dry
52) Which of the dressing change every
following is not related to shift, and blood glucose
a chronic diabetes monitoring before meals
mellitus condition? and bedtime. Why are
wet-to-dry dressings used
A. Atherosclerosis for this client?
B. Neuropathy
C. Glaucoma
370
A. They contain subcutaneous insulin
exudate and therapy, the nurse would
provide a moist be accurate in telling him
wound the regimen includes the
environment. use of:
B. They protect the
wound from A. intermediate and
mechanical long-acting
trauma and insulins
promote healing. B. short and long-
C. They debride the acting insulins
wound and C. short-acting
promote healing only
by secondary D. short and
intention. intermediate-
D. They prevent the acting insulins
entrance of 56) Patients with Type 1
microorganisms diabetes mellitus may
and minimize require which of the
wound following changes to
discomfort. their daily routine during
55) A client with type 1 periods of infection?
diabetes mellitus has A. No changes.
been on a regimen of B. Less insulin.
multiple daily injection C. More insulin.
therapy. He’s being D. Oral diabetic
converted to continuous agents.
subcutaneous insulin 57) At a senior citizens
therapy. While teaching meeting a nurse talks
the client bout continuous with a client who has
371
diabetes mellitus Type 1. B. Insulin
Which statement by the C. Glucagon
client during the D. Somatostatin
conversation is most 59) A patient arrives at
predictive of a potential the ED with a blood
for impaired skin sugar of 578, serum
integrity? osmolarity of 300, pH of
7.3, severe thirst,
A. “I give my dehydration, and
insulin to myself confusion. The patient is
in my thighs.” breathing rapidly and has
B. “Sometimes a fruity breath smell. This
when I put my patient has symptoms
shoes on I don’t of……
know where my
toes are.” A. Diabetic
C. “Here are my up ketoacidosis
and down glucose B. hyperosmolar
readings that I hyperglycemic
wrote on my noketotic coma
calendar.” C. Hypoglycemia
D. “If I bathe more D. diabetic
than once a week neuropathy
my skin feels too 60) A 27-year-old
dry.” woman has Type I
58) Which of the diabetes mellitus. She
following is not and her husband want to
considered an endocrine have a child so they
hormone? consulted her
diabetologist, who gave
A. Renin
372
her information on C. Astigmatism
pregnancy and diabetes. D. Glaucoma
Of primary importance 62) Which of the
for the diabetic woman following is not an
who is considering adverse effect of
pregnancy should be glucagon?
A. a review of the A. Allergic reaction
dietary B. Vomiting
modifications that C. Nausea
will be necessary. D. Fever
B. early prenatal 63) Which of the
medical care. following is not an
C. adoption instead adverse effect of oral
of conception. hypoglycemics?
D. understanding
that this is a major A. Hypoglycemia
health risk to the B. Headache
mother. C. Rashes
61) Clients with diabetes D. Projectile
mellitus require frequent vomiting
vision assessment. The 64) A 25-year-old
nurse should instruct the woman is in her fifth
client about which of the month of pregnancy. She
following eye problems has been taking 20 units
most likely to be of NPH insulin for
associated with diabetes diabetes mellitus daily
mellitus? for six years. Her
diabetes has been well
A. Cataracts controlled with this
B. Retinopathy dosage. She has been
373
coming for routine diabetes mellitus. During
prenatal visits, during the assessment interview,
which diabetic teaching the client reports that
has been implemented. he’s impotent and says
Which of the following that he’s concerned about
statements indicates that its effect on his marriage.
the woman understands In planning this client’s
the teaching regarding care, the most
her insulin needs during appropriate intervention
her pregnancy? would be to:
A. “Are you sure A. Encourage the
all this insulin client to ask
won’t hurt my questions about
baby?” personal sexuality
B. “I’ll probably B. Provide time for
need my daily privacy
insulin dose C. Provide support
raised.” for the spouse or
C. “I will continue significant other
to take my regular D. Suggest referral
dose of insulin.” to a sex counselor
D. “These finger or other
sticks make my appropriate
hand sore. Can I professional
do them less 66) Patricia a 20 year old
frequently?” college student with
65) A nurse assigned to diabetes mellitus requests
care for a postoperative additional information
male client who has about the advantages of
374
using a pen like insulin B. Usually thin at
deliverydevices. The diagnosis
nurse explains that the C. Ketosis-prone
advantages of these D. Demonstrate
devices over syringes islet cell
includes: antibodies
68) The nurse teaches the
A. Accurate dose patient about diabetes
delivery including which of the
B. Shorter injection following statements?
time
C. Lower cost with A. Elevated blood
reusable insulin glucose levels
cartridges contribute to
D. Use of smaller complications of
gauge needle. diabetes, such as
67) Which of the diminished vision.
following clinical B. Sugar is found
characteristics is only in dessert
associated with Type 2 foods.
diabetes (previously C. The only diet
referred to as non- change needed in
insulin-dependent the treatment of
diabetes mellitus diabetes is to stop
[NIDDM])? eating sugar.
D. Once insulin
A. Can control injections are
blood glucose started in the
through diet and treatment of Type
exercise 2 diabetes, they
375
can never be temperatures
discontinued. because of
69) Glucagon causes decreased adipose
increased blood sugar tissue insulation
and causes slow C. Protect the
breakdown of glycogen patient from
in the liver. sources of
infection because
A. TRUE of decreased
B. FALSE cellular protein
70) Insulin inhibits the deposits
release of _______. D. Do all of the
A. Glucagon above
B. ADH
C. Beta cells Clinical manifestations
D. Somatostatin associated with a
diagnosis of type 1 DM
1. Knowing that include all of the
gluconeogenesis helps to following except:
maintain blood levels, a
nurse should: A. Hypoglycemia
B. Hyponatremia
A. Document C. Ketonuria
weight changes D. Polyphagia
because of fatty
acid mobilization
B. Evaluate the
patient’s 3. The lowest fasting
sensitivity to low plasma glucose level
room
376
suggestive of a diagnosis 6. Clinical nursing
of DM is: assessment for a patient
with microangiopathy
A. 90mg/dl who has manifested
B. 115mg/dl impaired peripheral
C. 126mg/dl arterial circulation
D. 180mg/dl includes all of the
following except:
4. Rotation sites for
insulin injection should A. Integumentary
be separated from one inspection for the
another by 2.5 cm (1 presence of brown
inch) and should be used spots on the lower
only every: extremities
B. Observation for
A. Third day paleness of the
B. Week lower extremities
C. 2-3 weeks C. Observation for
D. 2-4 weeks blanching of the
feet after the legs
are elevated for
5. A clinical feature that
60 seconds
distinguishes a
D. Palpation for
hypoglycemic reaction
increased pulse
from a ketoacidosis
volume in the
reaction is:
arteries of the
A. Blurred vision lower extremities
B. Diaphoresing
C. Nausea 7. The nurse expects that
D. Weakness a type 1 diabetic may
377
receive ____ of his or her D. 1730 and 2330
morning dose of insulin
preoperatively: 9. A bedtime snack is
provided for Albert. This
A. 10-20% is based on the
B. 25-40% knowledge that
C. 50-60% intermediate-acting
D. 85-90% insulins are effective for
an approximate duration
8. Albert, a 35-year-old of:
insulin dependent
diabetic, is admitted to A. 6-8 hours
the hospital with a B. 10-14 hours
diagnosis of pneumonia. C. 16-20 hours
He has been febrile since D. 24-28 hours
admission. His daily 10. Albert refuses his
insulin requirement is 24 bedtime snack. This
units of NPH. Every should alert the nurse to
morning Albert is given assess for:
NPH insulin at 0730.
Meals are served at 0830, A. Elevated serum
1230, and 1830. The bicarbonate and a
nurse expects that the decreased blood
NPH insulin will reach pH.
its maximum effect B. Signs of
(peak) between the hours hypoglycemia
of: earlier than
expected.
A. 1130 and 1330 C. Symptoms of
B. 1330 and 1930 hyperglycemia
C. 1530 and 2130 during the peak
378
time of NPH bases the response on the
insulin. information that the
D. Sugar in the pump:
urine
A. Gives small
11. A client is taking continuous dose
NPH insulin daily every of regular insulin
morning. The nurse subcutaneously,
instructs the client that and the client can
the most likely time for a self-administer a
hypoglycemic reaction to bolus with an
occur is: additional dosage
from the pump
A. 2-4 hours after before each meal.
administration B. Is timed to
B. 6-14 hours after release
administration programmed
C. 16-18 hours doses of regular
after or NPH insulin
administration into the
D. 18-24 hours bloodstream at
after specific intervals.
administration C. Is surgically
attached to the
12. An external insulin pancreas and
pump is prescribed for a infuses regular
client with DM. The insulin into the
client asks the nurse pancreas, which
about the functioning of in turn releases
the pump. The nurse
379
the insulin into
the bloodstream. 14. A client with DM
D. Continuously demonstrates acute
infuses small anxiety when first
amounts of NPH admitted for the
insulin into the treatment of
bloodstream while hyperglycemia. The most
regularly appropriate intervention
monitoring blood to decrease the client’s
glucose levels. anxiety would be to:
13. A client with a A. Administer a

diagnosis of diabetic sedative
ketoacidosis (DKA) is B. Make sure the
being treated in the ER. client knows all
Which finding would a the correct
nurse expect to note as medical terms to
confirming this understand what
diagnosis? is happening.
C. Ignore the signs
A. Elevated blood and symptoms of
glucose level and anxiety so that
a low plasma they will soon
bicarbonate disappear
B. Decreased urine D. Convey
output empathy, trust,
C. Increased and respect
respirations and toward the client.
an increase in pH
D. Comatose state
380
15. A nurse is preparing a nurse’s primary
plan of care for a client responsibility to:
with DM who has
hyperglycemia. The A. Check the
priority nursing diagnosis client’s serum
would be: glucose level
B. Assist the client
A. High risk for out of bed to the
deficient fluid chair
volume C. Place the client
B. Deficient in a high-fowlers
knowledge: position
disease process D. Ensure that the
and treatment client’s residual
C. Imbalanced limb is elevated.
nutrition: less
than body 67. Daniel is diagnosed
requirements of having
D. Disabled family hyperthyroidism (Graves’
coping: disease). Which of the
compromised. following is a drug of
choice for his condition?
32. A client with DM has
an above-knee A. Furosemide
amputation because of (Lasix)
severe peripheral B. Digoxin
vascular disease, Two (Lanoxin)
days following surgery, C. Propranolol
when preparing the client (Inderal)
for dinner, it is the D. Propylthiouracil
(PTU)
381
B. Electrocardiogra
68. Which of the phy
following medications C. Ultrasonography
are most likely to cause D. Venous duplex
hypothyroidism? (Select Doppler study
all that apply.)
A. Acetylsalicylic 70. Nurse Gil is caring
acid (aspirin) for a patient with a
B. Furosemide diagnosis of
(Lasix) hypothyroidism. Which
C. Docusate nursing diagnosis should
sodium (Colace) the nurse most seriously
D. Rifampin consider when analyzing
(Rifadin) the needs of the patient?
A. High risk for
69. After visiting the aspiration related
physician, Angela found to severe
out that she has a thyroid vomiting
problem. In line with her B. Diarrhea related
condition, which of the to increased
following diagnostic peristalsis
studies is done to C. Hypothermia
determine the size and related to slowed
composition of the metabolic rate
thyroid gland? D. Oral mucous
membrane, altered
A. Thyroid scan related to disease
with RAI 123I process
382
71. During lecture, the someone with
clinical instructor tells diabetes.
the students that 50% to
60% of daily calories 76. The goal for pre-
should come from prandial blood glucose
carbohydrates. What for those with Type 1
should the nurse say diabetes mellitus is:
about the types of
carbohydrates that can be A. <80 mg/dl
eaten? B. <130 mg/dl
C. <180 mg/dl
A. Try to limit D. <6%
simple sugars to 77. The guidelines for
between 10% and Carbohydrate Counting
20% of daily as medical nutrition
calories. therapy for diabetes
B. Simple mellitus includes all of
carbohydrates are the following EXCEPT:
absorbed more
rapidly than A. Flexibility in
complex types and
carbohydrates. amounts of foods
C. Simple sugars consumed
cause rapid spike B. Unlimited intake
in glucose levels of total fat,
and should be saturated fat and
avoided. cholesterol
D. Simple sugars C. Including
should never be adequate servings
consumed by of fruits,
383
vegetables and the C. Higher than 140
dairy group mg/dl
D. Applicable to D. Higher than 160
with either Type 1 mg/dl
or Type 2 diabetes 79. When taking a health
mellitus history, the nurse screens
78. The nurse working in for manifestations
the physician’s office is suggestive of Diabetes
reviewing lab results on Type I. Which of the
the clients seen that day. following manifestations
One of the clients who are considered the
has classic diabetic primary manifestations of
symptoms had an eight- Diabetes Type I and
hour fasting plasma would be most suggestive
glucose (FPG) test done. and require follow-up
The nurse realizes that investigation?
diagnostic criteria
developed by the A. Excessive intake
American Diabetes of calories, rapid
Association for diabetes weight gain, and
include classic diabetic difficulty losing
symptoms plus which of weight
the following fasting B. An increase in
plasma glucose levels? three areas: thirst,
intake of fluids,
A. Higher than 106 and hunger
mg/dl C. Poor circulation,
B. Higher than 126 wound healing,
mg/dl and leg ulcers,
384
D. Lack of energy, end of three
weight gain, and months
depression C. Lose a pound a
80. The nurse is working week until weight
with an overweight client is in normal range
who has a high-stress job for height and
and smokes. This client exercise 30
has just received a minutes daily
diagnosis of Type II D. Practice
Diabetes and has just relaxation
been started on an oral techniques for at
hypoglycemic agent. least five minutes
Which of the following five times a day
goals for the client which for at least five
if met, would be most months
likely to lead to an 81. During a visit in a
improvement in insulin community, the nurse
efficiency to the point the will recommend routine
client would no longer screening for diabetes
require oral when the person has one
hypoglycemic agents? or more of seven risk
criteria. Which of the
A. Comply with following persons that
medication the nurse comes in
regimen 100% for contact with most needs
6 months to be screened for
B. Quit the use of diabetes based on the
any tobacco seven risk criteria?
products by the A. A client with an
HDL cholesterol
385
level of 40 mg/dl A. As long as you
and a triglyceride only drink two
level of 300 mg/dl beers and take one
B. A woman who aspirin, this
is at 90% of should not be a
standard body problem
weight after B. The aspirin is
delivering an alright but you
eight-pound baby need to give up
C. A middle-aged drinking any
Caucasian male alcoholic
D. An older client beverages
who is C. Taking alcohol
hypotensive and/or aspirin
with a
83. You are doing some sulfonylurea drug
teaching with a client can cause
who is starting on a development of
sulfonylurea antidiabetic hypoglycemia
agent. The client D. Aspirin and
mentions that he usually alcohol will cause
has a couple of beers the stomach to
each night and takes an bleed more when
aspirin each day to on a sulfonylurea
prevent heart attack drug
and/or strokes. Which of 84. Which of the
the following responses following if stated by the
would be best on the part nurse is correct about
of the nurse? Hyperglycemic
Hyperosmolar
386
Nonketotic Syndrome B. Use a 45 degree
(HHNS)? angle with the
skin pinched up
A. This syndrome C. Massage the
occurs mainly in area of injection
people with Type after injecting the
I Diabetes insulin
B. It has a higher D. Warm the skin
mortality rate than with a warmed
Diabetic towel or
Ketoacidosis washcloth prior to
C. The client with the injection
HHNS is in a
state of
overhydration 87. Blood sugar is well
D. This condition controlled when
develops very Hemoglobin A1C is:
rapidly
A. Below 5.7%
85. Nurse Robedee is B. Between 12%-
teaching a thin client 15%
about the proper C. Less than 180
methods/techniques when mg/dL
giving insulin. Which D. Between 90 and
one of the following is 130 mg/dL
proper? 88. Which of the
following diabetes drugs
A. Pinch the skin acts by decreasing the
up and use a 90 amount of glucose
degree angle produced by the liver?
387
A. Alpha- 90. An external insulin
glucosidase pump is prescribed for a
inhibitors client with diabetes
B. Biguanides mellitus and the client
C. Meglitinides asks the nurse about the
D. Sulfonylureas functioning of the pump.
The nurse bases the
89. A 39-year-old response on the
company driver presents information that the
with shakiness, sweating, pump:
anxiety, and palpitations
and tells the nurse he has A. is timed to
Type I Diabetes Mellitus. release
Which of the follow programmed
actions should the nurse doses of regular
do first? or NPH insulin
into the
A. Inject 1 mg of bloodstream at
glucagon specific intervals
subcutaneously. B. gives a small
B. Administer 50 continuously dose
mL of 50% of regular insulin
glucose I.V. subcutaneously,
C. Give 4 to 6 oz and the client can
(118 to 177 mL) self-administer a
of orange juice. bolus with an
D. Give the client additional dose
four to six glucose from the pump
tablets. before each meal
388
C. continuously the nurse observes the
infuses small man performing blood
amounts of NPH sugar analysis. The result
insulin into the is 50 mg/dL. The nurse
bloodstream while would expect the patient
regularly to be
monitoring blood
glucose levels A. confused with
D. is surgically cold, clammy skin
attached to the and pulse of 110
pancreas and B. lethargic with
infuses regular hot dry skin and
insulin into the rapid deep
pancreas, which respirations
in turn releases C. alert and
the insulin into cooperative with
the bloodstream BP of 130/80 and
respirations of 12
D. short of breath,
95. Mr. Wesley is newly with distended
diagnosed with Type I neck veins and
DM and is being seen by bounding pulse of
the home health nurse. 96.
The doctors orders
include: 1200 calorie
ADA diet, 15 units NPH
insulin before breakfast,
and check blood sugar
qid. When the nurse
visits the patient at 5 pm,
389

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APPENDICITIS

In addition, he says that the pain is worst on

4. Thinking back to the scenario in question

 A. Increased red blood Cells

 E. Diet low in fiber tenderness

The answers are: B, C, and E. These options

A. inflammatory bowel disease, 12) A patient presents with periumbilical pain

1. Notify the Physician a. Obstruction of the appendix may increase

3. Internal bowel occlusion

4. Abdominal wall swelling"

2. Administer Demerol 50 mg IM q4hrs and C) rebound tenderness

c. provide discharge teaching

D. assess for symptoms of peritonitis.

c. ablative 1) Intake and Output

d. constructive 2) Measurement of Pain

RATIO: Appendectomy is an example of 3) Tolerance to low-residue diet

3)shallow breathing with normal vital signs.

4) decrease of pain rating from 8 to 6 when

RATIO: Pain is closely monitored in 3. Gently irrigate the drain to remove

c. Ascultate bowel sounds because

3 A high-fat diet 3.The client four (4) hours postoperative

B. "Rest in bed and drink warm fluids." B. Constipation

C. "Seek immediate medical attention." C. Nausea

D. "Take an over-the-counter laxative." D. Peritonitis

RATIO: The initial characteristic E. Perforation

B. "I don't like fruits and vegetables." Answer: A, B, E

C. Pain 117. A client is admitted with acute

A. Caring for the wound

RATIO: The client with uncomplicated A. Characteristics of bowel sounds

2. Mittelschmerz (one sided, lower

2. Notify the physician 3. Pelvic Inflammatory disease

3. Expect orders for IV antibiotics RATIO: In adolescent and young adult

4. Fluid and electrolyte balance will be

RATIO: Goals of care for a client with

127. The nurse is caring for a client is admitted

1. a laparotomy will be performed

2. Antibiotic medication will be provided

3. IV fluids will be provided

4. Pain meds will be provided after surgery

RATIO: For a burst appendix, a laparotomy

 B. pepsinogen, pepsin  B. "Peptic ulcers can form when acid

 C. NSAIDs 4. Your patient is diagnosed with peptic ulcer

5. Helicobacter pylori can live in the  C. Esophageal

6. The physician orders a patient with a  B. Fascia dehiscence

with meals." not be given together."

10. A patient is recovering from discomfort

 D. Banana The answer is B. This statement is the only

 G. Bismuth Subsalicylates B) Erosion of the lining of the stomach or

14. A physician prescribes a Proton-Pump Feedback:

Ans: A C) An incompetent pyloric sphincter

Feedback: D) A metabolic acidbase imbalance

Proton pump inhibitors like Prilosec inhibit the Ans: A

Ans: D C) It protects the stomachs lining

Feedback: D) It increases lower esophageal sphincter

Perforation is the erosion of the ulcer through

C) Bicarbonate salts, antibiotics, and ZES A. 40 to 50 percent

D) Antibiotics, proton pump inhibitors, and B. 30 to 40 percent

26. Which of the following is NOT a causative A. Jejunum

1. An intestinal obstruction has developed. 1. The client has a sore throat.

RATIO: Histamine-2 (H2) receptor antagonists, 1. Administering an antacid hourly until