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Ati nur 213 lifespan 2 (fundamental exam)
Total Questions : 25
Showing 10 questions, Sign in for moreWhich nursing interventions should the RN implement when providing care for a patient with ascites related to Cirrhosis of the liver? Select all that apply.
Explanation
A. Administer furosemide as prescribed: Furosemide promotes diuresis in patients with ascites, thereby relieving abdominal distension and associated discomfort. It is used carefully alongside electrolyte monitoring to prevent complications such as hypokalemia or dehydration.
B. Encourage an increase in oral fluids: Increasing fluid intake is generally contraindicated in patients with ascites, especially if they also have dilutional hyponatremia. Fluid restriction is more appropriate to prevent worsening of fluid retention and further strain on liver function.
C. Prepare patient for a paracentesis: Paracentesis is an effective procedure for relieving severe ascites in cirrhosis. This intervention provides symptomatic relief and can improve respiratory function and comfort in advanced cases.
D. Maintain strict intake and output: Monitoring fluid balance is critical in managing ascites. Accurate intake and output records help evaluate the effectiveness of diuretic therapy and detect complications like fluid overload or electrolyte imbalance.
E. Ambulate in hallway three times daily: While it doesn’t directly reduce ascites, mobility improves circulation, reduces the risk of venous stasis and thromboembolism, and supports overall physical function.
A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client?
A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?
A nurse is providing teaching to a client who has hypothyroidism and has been prescribed levothyroxine. Which of the following medication instructions would the nurse include in the teaching?
A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider?
A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse identify as the primary cause of liver cirrhosis?
Which symptoms reported by the patient immediately following the surgical removal of the thyroid and parathyroid gland requires intervention by the RN? Select the "2" findings that require immediate follow-up.
Explanation
A. Dizziness: Dizziness may be due to anesthesia recovery, fluid shifts, or low blood pressure but is not specifically linked to complications following thyroid and parathyroid removal. While it should be monitored, it does not require immediate intervention unless accompanied by other symptoms.
B. Hand tremors: Hand tremors can be an early indicator of hypocalcemia, a serious complication after parathyroid gland removal. The parathyroids regulate calcium, and their removal can cause calcium levels to drop quickly, resulting in neuromuscular irritability, which must be addressed promptly.
C. Earache: Earache is not typically associated with thyroid or parathyroid surgery and is not an expected or urgent postoperative concern. It could be referred pain or unrelated, and although it may be documented, it doesn’t require immediate follow-up.
D. Foot cramps: Foot cramps are another classic sign of hypocalcemia following parathyroid gland removal. They result from increased neuromuscular excitability due to low calcium levels and can progress to tetany if untreated. Immediate evaluation and calcium replacement may be necessary.
E. Increased appetite: An increase in appetite is not a common complication of thyroid or parathyroid surgery and does not indicate an urgent issue. It is not typically associated with calcium imbalance or other immediate post-op concerns and does not require urgent follow-up.
A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take?
The nurse is assessing an adult patient with Type 1 diabetes mellitus. Which labs result should be reported to the physician immediately? Select the "3" findings that require immediate follow-up.
Explanation
A. Blood glucose 112 mg/dL: This glucose level is within the target fasting range for patients with Type 1 diabetes. It indicates good short-term glucose control and does not pose an immediate clinical concern, so it does not require urgent physician notification.
B. Hemoglobin A1C 6.0%: An A1C of 6.0% reflects strong long-term glycemic control. This value is below the ADA-recommended goal of <7% for most adults with diabetes, indicating stability and no need for immediate intervention.
C. Hemoglobin 10.2 g/dL: This indicates mild to moderate anemia, which could be due to chronic kidney disease a common diabetic complication. It may reflect decreased erythropoietin production from renal impairment and should be evaluated promptly to prevent worsening.
D. Creatinine 2.5 mg/dL: This level is significantly elevated, suggesting renal dysfunction, which is serious in a patient with diabetes. It may signal progression of diabetic nephropathy or acute kidney injury and warrants immediate medical evaluation and intervention.
E. Microalbuminuria 40 mg/24 hours: This indicates early kidney damage but is not an emergent finding. While it supports the diagnosis of diabetic nephropathy, it does not require urgent reporting unless accompanied by worsening renal function or other critical signs.
F. Positive ketones in the urine: Ketones in the urine suggest fat breakdown due to insufficient insulin and risk of diabetic ketoacidosis (DKA). This is an acute and potentially life-threatening complication of Type 1 diabetes that requires immediate physician notification and intervention.
For each client finding below, click to specify if the finding is consistent with the disease process
Explanation
- Heart rate is 54, patient has complained of constipation and poor appetite: Myxedema, a severe form of hypothyroidism, causes bradycardia due to decreased metabolism. Constipation and poor appetite occur as slowed metabolism reduces gastrointestinal motility and hunger.
- Patient is anxious and irritable with skin moist and warm: Graves Disease causes hyperthyroidism, increasing metabolic rate and sympathetic activity. This leads to anxiety, irritability, and warm, moist skin from increased blood flow and sweating. These findings show the hypermetabolic state of Graves.
- Nonpitting edema noted in the extremities with thinning hair: Nonpitting edema results from mucopolysaccharide buildup in hypothyroidism. Thinning hair occurs due to thyroid hormone deficiency affecting hair follicles. These are classic signs of advanced hypothyroidism.
- Patient has recently lost over 10 pounds in the last month and has noticed a fine tremor in the hands: Weight loss despite increased appetite is typical of Graves Disease due to elevated metabolism. Fine hand tremors result from increased beta-adrenergic stimulation. These symptoms indicate hyperthyroidism.
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