A 67-year-old client develops acute shortness of breath and progressive hypoxia requiring right femur. The hypoxia was probably caused by which of the following conditions?
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Solution
Fat embolism
Option D: Long bone fractures are correlated with fat emboli, which cause shortness of breath and hypoxia.
Options A and C: It’s unlikely the client has developed asthma or bronchitis without a previous history.
Option B: He could develop atelectasis but it typically doesn’t produce progressive hypoxia.
Johnny a firefighter was involved in extinguishing a house fire and is being treated to smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. He most likely has developed which of the following conditions?
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Solution
Adult respiratory distress syndrome (ARDS)
Option A: Severe hypoxia after smoke inhalation is typically related to ARDS.
Options B, C, and D: The other conditions listed aren’t typically associated with smoke inhalation and severe hypoxia.
Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder?
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Solution
Calcium and phosphorous
Option B: In osteoporosis, bones lose calcium and phosphate salts, becoming porous, brittle, and abnormally vulnerable to fracture.
Option D: Sodium and potassium aren’t involved in the development of osteoporosis.
Patrick is treated in the emergency department for a Colles’ fracture sustained during a fall. What is a Colles’ fracture?
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Solution
Fracture of the distal radius
Option A: Colles’ fracture is a fracture of the distal radius, such as from a fall on an outstretched hand. It’s most common in women.
Options B, C, and D: Colles’ fracture doesn’t refer to a fracture of the olecranon, humerus, or carpal scaphoid.
For a client with Graves’ disease, which nursing intervention promotes comfort?
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Solution
Maintaining room temperature in the low-normal range
Option D: Graves’ disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client’s room temperature in the low-normal range.
Option A: To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids.
Option B: Placing extra blankets on the bed of a client with heat intolerance would cause discomfort.
Option C: To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.
Nurse Sarah expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?
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Solution
Below-normal serum potassium level
Option D: A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency.
Options A and B: An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis.
Option C: Metabolic acidosis, not serum alkalosis, may occur in HHNS.
Rico with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?v
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Solution
“Rotate injection sites within the same anatomic region, not among different regions.”
Option B: The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next.
Option A: Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other deviations.
Option C: Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn’t inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites systematically.
Option D: Exercise speeds drug absorption, so the client shouldn’t inject insulin into sites above muscles that will be exercised heavily.
The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?
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Solution
No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test
Option A: In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism.
Option B: A decreased TSH level indicates a pituitary deficiency of this hormone.
Option D: Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs.
Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Mariner should expect the dose’s:
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Solution
onset to be at 2:30 p.m. and its peak to be at 4 p.m.
Option C: Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.
A male client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by doing which of the following?
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Solution
Performing capillary glucose testing every 4 hours
Option D: The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance, placing the client at risk for hyperglycemia.
Option A: Urine ketone testing isn’t indicated because the client does secrete insulin and, therefore, isn’t at risk for ketosis.
Option B: Urine specific gravity isn’t indicated because although fluid balance can be compromised, it usually isn’t dangerously imbalanced.
Option C: Temperature regulation may be affected by excess cortisol and isn’t an accurate indicator of infection.