Answers and Ration Ali Ties

Endocrine and Metabolic Disorders TestQuestion 1 of 5

A nurse is about to administer a client's morning dosage of insulin. The client's order is for 5 U of regular and 10 U of NPH given as a basal dose. He also is to receive an amount prescribed from his medium-dose sliding scale (shown below), based on his morning blood glucose level. The nurse performs a bedside blood glucose measurement and the result is 264 mg/dl. How many total units of insulin should the nurse administer to the client?

Plasma glucose (mg/dl)

Low dose (Regular insulin)

Medium dose (Regular insulin)

High dose (Regular insulin)

Very high dose (Regular insulin)

< 70 Call physician

Call physician Call physician

Call physician

71-140 0 U 0 U 0 U 0 U

141-180 1 U 2 U 4 U 10 U

181-240 2 U 4 U 8 U 15 U

241-300 4 U 6 U 12 U 20 U

301-400 6 U 9 U 16 U 25 U

> 400 8 U and call physician

12 U and call physician



Answer:

Correct Answer: 21 Your Answer: 4u

RATIONALES: The basal dosage for this client is 5 U of regular insulin and 10 U of NPH insulin. Using the medium-dose sliding scale and the client's blood glucose reading of 264 mg/dl, the nurse should determine that an additional 6 U of regular insulin are required, totalling 21 U (5 U + 10 U + 6 U = 21 U).

NURSING PROCESS STEP: Implementation

CLIENT NEEDS CATEGORY: Physiological integrity

CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies

COGNITIVE LEVEL: Application

The nurse is feeding an average-size client when the client suddenly begins choking on his food. According to the American Heart Association, the nurse should intervene using the actions listed below. List the actions in the sequence in which the nurse should perform them.

1. Administer abdominal thrusts until effective or until client becomes unresponsive.2. Activate the emergency response team.3. Ask the client if he can speak.4. Perform a tongue-jaw lift.5. Open the airway and attempt to ventilate the client.6. Give up to five abdominal thrusts.

RATIONALES: According to the American Heart Association, the nurse should ask the client if he's choking and if he can speak. Next, the nurse should administer abdominal thrusts or chest thrusts (if the client is obese or pregnant). The nurse should continue thrusts until they are effective or until the client becomes unresponsive. When the latter occurs, the nurse should activate the emergency response team and then perform a tongue-jaw left. Next, the nurse should open the airway and try to ventilate the client. If the airway is still obstructed, the nurse should reposition the head and try to ventilate again. Then, the nurse should give up to five abdominal thrusts.

4u

Cardiovascular Disorders TestQuestion 4 of 5

The nurse is interpreting a client's telemetry strip. If the QT interval is 0.52 second and the R-R interval is 1.72 seconds, how many seconds is the QTc interval (the QT interval corrected for the heart rate)?

Answer:

Correct Answer: 0.39 Your Answer: 50

RATIONALES: To correct the QT interval for variations in heart rate, divide the measured QT interval by the square root of the measured R-R interval.

Square root of 1.72 = 1.31 0.52 ÷ 1.31 = 0.39 second

The QTc should be less than 0.44 seconds in men, and less than 0.46 seconds in women.

NURSING PROCESS STEP: Analysis


CLIENT NEEDS SUBCATEGORY: Reduction of risk potential


Endocrine and Metabolic Disorders PretestQuestion 12 of 75

When assessing a client with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, the nurse is most likely to detect:

1. a blood pressure of 130/70 mm Hg.

2. a blood glucose level of 130 mg/dl.

020168 4 2 0.39 1

false test 5 true

50

028149 1 3 180,36;190,45 0

false test 5 false 191,30

010051 4 1 2,3,4,5 3

true test 5 false 2,3,4,5

025049 12 0 4 11

true pretest 75 false 4

3. bradycardia.

4. a blood pressure of 176/88 mm Hg.

Correct Answer: 4 Your Answer: 4

RATIONALES: Pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, causes hypertension, tachycardia, hyperglycemia, hypermetabolism, and weight loss. It isn't associated with the other options.

NURSING PROCESS STEP: Assessment


CLIENT NEEDS SUBCATEGORY: Physiological adaptation

COGNITIVE LEVEL: Analysis

Genitourinary Disorders PretestQuestion 14 of 75

During a routine examination, the nurse notes that the client seems unusually anxious. Anxiety can affect the genitourinary system by:

1. slowing the glomerular filtration rate.

2. increasing sodium resorption.

3. decreasing potassium excretion.

4. stimulating or hindering micturition.


RATIONALES: Anxiety may stimulate or hinder micturition. Its most noticeable effect is to cause frequent voiding and urinary urgency. However, when anxiety leads to generalized muscle tension, it may hinder urination because the perineal muscles must relax to complete micturition. Anxiety doesn't slow the glomerular filtration rate, increase sodium resorption, or decrease potassium excretion.




COGNITIVE LEVEL: Knowledge

RATIONALES: Vesicles are elevated, sharply defined lesions that are usually less than 1 cm in diameter and contain serous fluid. Common examples of vesicles include blisters and the lesions caused by chickenpox and herpes simplex. Bullae are elevated, fluid-filled lesions greater than 1 cm in diameter; an example is a second-degree burn wound. Cysts, such as sebaceous cysts, are elevated, thick-walled lesions containing fluid or semisolid matter. Pustules are elevated lesions less than 1 cm in diameter, and containing purulent material; examples include impetigo and acne lesions.

NURSING PROCESS STEP: Evaluation

CLIENT NEEDS CATEGORY: Health promotion and maintenance

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http://198.146.4.5/nclexrn3500/review.do;jsessionid=E685DE630E56513720CE7182395CF11C


http://198.146.4.5/nclexrn3500/results.do;jsessionid=E685DE630E56513720CE7182395CF11C

http://198.146.4.5/nclexrn3500/mainMenu.do;jsessionid=E685DE630E56513720CE7182395CF11C

CLIENT NEEDS SUBCATEGORY: None


Oncologic Disorders PretestQuestion 16 of 75

The nurse is developing a care plan for marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?

1. 24 hours

2. 2 to 4 days

3. 7 to 14 days

4. 21 to 28 days


RATIONALES: Bone marrow suppression becomes noticeable 7 to 14 days after floxuridine administration. Bone marrow recovery occurs in 21 to 28 days.





Gastrointestinal Disorders PretestQuestion 21 of 75

Indicate the location of an ostomy for which the client could eventually not need to wear an ostomy bag?

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022134 21 3 206,257;216,271 20

true pretest 75 false 133,196









The green rectangle shows the correct answer.

RATIONALES: With a sigmoid colostomy, the feces are solid; therefore, the client may eventually gain enough control that he would not need to wear a colostomy bag. With a descending colostomy, the feces are semi-mushy. With a transverse colostomy, the feces are mushy. With an ascending colostomy, the feces are fluid. In these three latter cases, it is unlikely that the client could gain control of elimination; consequently, wearing an ostomy bag would be necessary.

NURSING PROCESS STEP: Planning


CLIENT NEEDS SUBCATEGORY: Basic care and comfort


Basic Physical Assessment PretestQuestion 22 of 75

A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?

1. Place a tongue blade on the front of the tongue and ask the client to say "ah."

2. Place a tongue blade lightly on the posterior aspect of the tongue.

004032 22 0 2 21






3. Place a tongue blade on the middle of the tongue and ask the client to cough.

4. Place a tongue blade on the uvula.


RATIONALES: To assess a client's gag reflex, the nurse should gently touch the posterior aspect of the tongue with a tongue blade, which should elicit gagging. Having the client say "ah" evaluates cranial nerves IX and X. However, a tongue blade isn't necessary to hold down the tongue; the client need only stick out the tongue. Placing a tongue blade on the middle of the tongue and asking the client to cough has no value. Placing a tongue blade on the uvula may traumatize the area and harm the client.





Medication and I.V. Administration PretestQuestion 24 of 75

A client begins taking haloperidol (Haldol). After a few days, he experiences severe tonic contractures of muscles in the neck, mouth, and tongue. The nurse should recognize this as:

1. psychotic symptoms.

2. parkinsonism.

3. akathisia.

4. dystonia.


RATIONALES: These symptoms describe dystonia, which commonly occurs after a few days of treatment with haloperidol. The symptoms may be confused with psychotic symptoms and misdiagnosed. Parkinsonism results in muscle rigidity, shuffling gait, stooped posture, flat-faced affect, tremors, and drooling. Signs and symptoms of akathisia are restlessness, pacing, and inability to sit still.





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Basic Physical Care PretestQuestion 25 of 75

The nurse-manager of a home health facility includes which item in the capital budget?

1. Salaries and benefits for her staff

2. A $1,200 computer upgrade

3. Office supplies

4. Client education materials costing $300


RATIONALES: Capital budgets generally include items valued at more than $500. Salaries and benefits are part of the personnel budget. Office supplies and client education materials are part of the operating budget.


CLIENT NEEDS CATEGORY: Safe, effective care environment

CLIENT NEEDS SUBCATEGORY: Management of care



A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client's hypertension is caused by excessive hormone secretion from which gland?

1. Adrenal cortex

2. Pancreas

3. Adrenal medulla

4. Parathyroid

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RATIONALES: Excessive secretion of aldosterone in the adrenal cortex is responsible for the client's hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium and excretion of potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel metabolism. The adrenal medulla secretes the catecholamines — epinephrine and norepinephrine. The parathyroids secrete parathyroid hormone.





Psychotic Disorders PretestQuestion 27 of 75

Drug therapy with thioridazine (Mellaril) shouldn't exceed a daily dose of 800 mg to prevent which adverse reaction?

1. Hypertension

2. Respiratory arrest

3. Tourette syndrome

4. Retinal pigmentation


RATIONALES: Retinal pigmentation may occur if the thioridazine dosage exceeds 800 mg per day. The other options don't occur as a result of exceeding this dose.





Respiratory Disorders PretestQuestion 29 of 75

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A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

1. Nausea or vomiting

2. Abdominal pain or diarrhea

3. Hallucinations or tinnitus

4. Light-headedness or paresthesia


RATIONALES: The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.





Medication and I.V. Administration PretestQuestion 30 of 75

The physician prescribes heparin 25,000 U in 250 ml of normal saline solution to infuse at 600 U/hour for a client who suffered an acute myocardial infarction. After 6 hours of heparin therapy, the client's partial thromboplastin time is subtherapeutic. The physician orders an increase in the infusion to 800 U/hour. The nurse should set the infusion pump to deliver how many milliliters per hour?

Answer:


RATIONALES: The following formula is used to calculate drug dosages:

Dose on hand/Quantity on hand = Dose desired/X

The nurse should use the following equations:

25,000 U/250 ml = 800 U/hour/X.

Cross-multiply to solve for X and divide each side of the equation by 25,000 U

X = 8 ml/hour.




003143 30 2 8 29

true pretest 75 false

8







What is an appropriate nursing intervention for a client with an arm restraint?

1. Applying the restraint loosely to prevent pressure on the skin

2. Tying the restraint to the side rail

3. Positioning the restrained arm in full extension

4. Monitoring circulatory status every 2 hours


RATIONALES: The nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow slight joint movement without reducing the effectiveness of the restraint.



CLIENT NEEDS SUBCATEGORY: Safety and infection control


Cardiovascular Disorders PretestQuestion 32 of 75

After coronary artery bypass graft surgery, a client is admitted to the surgical intensive care unit and connected to a cardiac monitor. The nurse can't detect a pulse or blood pressure and observes the following pattern on the electrocardiogram (ECG) monitor. What does this pattern show?

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1. Artifact

2. Ventricular tachycardia

3. Ventricular fibrillation

4. Electromechanical dissociation


RATIONALES: This ECG shows ventricular fibrillation as indicated by undetectable P waves; no discernible heart rate; a chaotic, completely irregular rhythm; and a wavy baseline. Artifact is distortion on the ECG caused by interference or loose connections. In ventricular tachycardia, P waves seldom are discernible; the ventricular rate is above 100 beats/minute; and QRS complexes are wide, bizarre, and regular. In electromechanical dissociation, the ECG shows electrical activity with no mechanical contraction; the client lacks a pulse.




COGNITIVE LEVEL: Comprehension


To follow standard precautions, the nurse should carry out which measure?

1. Recapping needles after use

2. Wearing a gown when bathing a client

3. Wearing gloves when administering I.M. medication

4. Wearing gloves for all client contact


001015 33 0 3 32






RATIONALES: To follow standard precautions, caregivers must place used, uncapped needles and syringes in a puncture-resistant container; wear gloves when anticipating contact with the blood, body fluid, mucous membranes, or nonintact skin of any client (such as when administering an I.M. injection); and wear a gown during procedures that are likely to generate splashes of blood or body fluids. Standard precautions don't call for caregivers to wear a gown or gloves when bathing a client because this activity isn't likely to cause contact with blood or body fluids.





Basic Physical Assessment PretestQuestion 39 of 75

A client reports abdominal pain. Which action would aid the nurse's investigation of this complaint?

1. Using deep palpation

2. Assessing the painful area last

3. Assessing the painful area first

4. Checking for warmth in the painful area


RATIONALES: Assessing the painful area last allows the nurse to obtain the maximal amount of information with minimal client discomfort. To prepare the client, the nurse should always let the client know when the painful area will be assessed. Pressure resulting from deep palpation may cause rupture of an underlying mass. Checking for warmth in the painful area offers no real information about the client's pain.




COGNITIVE LEVEL: Comprehension

Immune and Hematologic Disorders PretestQuestion 40 of 75

The nurse is planning care for a client with human immunodeficiency virus (HIV). She's being assisted by a licensed practical nurse

004012 39 0 2 38


024082 40 1 4,5 39

true pretest 75 false 3,4,5









(LPN). Which statements by the LPN indicate her understanding of HIV transmission?

1. "I'll wear a gown, mask, and gloves for all client contact."

2. "I don't need to wear any personal protective equipment because nurses have a low risk of occupational exposure."

3. "I'll wear a mask if the client has a cough caused by an upper respiratory infection."

4. "I'll wear a mask, gown, and gloves when splashing of body fluids is likely."

5. "I'll wash my hands after client care."

Correct Answer: 4,5 Your Answer: 3,4,5

RATIONALES: Standard precautions include wearing gloves for any known or anticipated contact with blood or other body fluids, tissue, mucous membranes, or nonintact skin. If the task may result in splashing or splattering of blood or body fluids to the face, a mask and goggles or face shield should be worn. If the task may result in splashing or splattering of blood or body fluids to the body, a fluid-resistant gown or apron should be worn. Hands should be washed before and after client care and after removing gloves. A gown, mask, and gloves aren't necessary for client care unless contact with body fluids, tissue, mucous membranes, or nonintact skin is expected. Nurses have an increased, not decreased, risk of occupational exposure to blood-borne pathogens. HIV isn't transmitted in sputum unless blood is present.





Cardiovascular Disorders PretestQuestion 41 of 75

The nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize?

1. Repeat the dose of sublingual nitroglycerin every 15 minutes for three doses.

2. Store the drug in a cool, well-lit place.

3. Lie down or sit in a chair for 5 to 10 minutes after taking the drug.

020136 41 0 3 40






4. Restrict alcohol intake to two drinks per day.


RATIONALES: Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which makes the client dizzy and weak. Nitrates are taken at the first sign of chest pain and before activities that might induce chest pain. Sublingual nitroglycerin is taken every 5 minutes for three doses. If the pain persists, the client should seek medical assistance immediately. Nitrates must be stored in a dark place in a closed container. Sunlight causes the medication to lose its effectiveness. Alcohol is prohibited because nitrates may enhance the effects of the alcohol.






When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function?

1. Jaundice

2. Pruritus of the arms and legs

3. Fatigue during ambulation

4. Irritability and drowsiness


RATIONALES: Although all the options are associated with hepatitis B, the onset of irritability and drowsiness suggests a decrease in hepatic function. To detect signs and symptoms of disease progression, the nurse should observe for disorientation, behavioral changes, and a decreasing level of consciousness and should monitor the results of liver function tests, including the blood ammonia level. If hepatic function is decreased, the nurse should take safety precautions.





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Postpartum Period PretestQuestion 49 of 75

A mother with a past history of varicose veins has just delivered her first baby. The nurse suspects that the mother has developed a pulmonary embolus. Which data below would lead to this nursing judgment?

1. Sudden dyspnea

2. Chills, fever

3. Diaphoresis

4. Hypertension

5. Confusion

Correct Answer: 1,3,5 Your Answer: 5

RATIONALES: Sudden dyspnea with diaphoresis and confusion are classic signs and symptoms of dislodgment of a thrombus (stationary blood clot) from a varicose vein becoming an embolus (moving clot) that lodges itself into the pulmonary circulation. Chills and fever would indicate an infection. A client with an embolus could be hypotensive, not hypertensive.





Antepartum Period PretestQuestion 50 of 75

During routine preconception counseling, a client asks how early a pregnancy can be diagnosed. What is the nurse's best response?

1. "8 days after conception"

2. "When the woman misses a menstrual period"

3. "2 to 3 weeks after fertilization"

016023 50 0 1 49







4. "As soon as hormone levels decline"


RATIONALES: Based on human chorionic gonadotropin (hCG) levels in the blood and urine, pregnancy can be diagnosed as early as 8 days after conception, when the syncytiotrophoblast produces hCG. Sensitive and specific pregnancy tests can detect hCG in the blood and urine even before the first missed menstrual period. A missed period may also be related to other factors, such as poor nutrition, strenuous athletic activity, and certain drugs. Levels of hCG rise rapidly until about the 20th week of gestation. By the 20th week, they decline gradually and stay low for the remainder of gestation. Other hormones, such as human placental lactogen, estrogen, and progesterone, increase during pregnancy.






Following a transsphenoidal hypophysectomy, the nurse should assess the client carefully for which condition?

1. Hypocortisolism

2. Hypoglycemia

3. Hyperglycemia

4. Hypercalcemia


RATIONALES: The nurse should assess for hypocortisolism. Abrupt withdrawal of endogenous cortisol may lead to severe adrenal insufficiency. Steroids should be given during surgery to prevent hypocortisolism from occurring. Signs of hypocortisolism include vomiting, increased weakness, dehydration and hypotension. After the corticotropin-secreting tumor is removed, the client shouldn't be at risk for hyperglycemia. Calcium imbalance shouldn't occur in this situation.





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A client's attorney must prove which elements for a professional negligence action?

1. Duty, breach of duty, damages, and causation

2. Duty, damages, and causation

3. Duty, breach of duty, and damages

4. Breach of duty, damages, and causation


RATIONALES: Any professional negligence action must meet four demands — commonly known as the four D's — to be considered negligence and result in legal action: a duty for the health care professional to provide care to the person making the claim, a dereliction (breach) of that duty, the breach of duty resulted in damages and the damages were caused by a direct result of the negligence, (causation).





Intrapartum Period PretestQuestion 58 of 75

A client in labor is attached to an electronic fetal monitor (EFM). Which of the following data provided by an EFM most reliably indicates adequate uteroplacental and fetal perfusion?

1. Fetal heart rate variability within 5 to 10 beats/minute

2. Persistent fetal bradycardia

3. Late decelerations

4. Variable decelerations and sinusoidal pattern


RATIONALES: Fetal heart rate variability most reliably indicates uteroplacental and fetal perfusion; an average variability of 5 to 10 beats per minute is considered

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acceptable. Persistent fetal bradycardia may signal hypoxia, arrhythmias, or fetal cord compression. Late decelerations indicate decreased blood flow and oxygen to the intervillous spaces during uterine contractions — a nonreassuring pattern. Variable decelerations suggest umbilical cord compression; a sinusoidal pattern signals severe fetal anemia or asphyxiation.





Substance Abuse, Eating Disorders, Impulse Control Disorders PretestQuestion 60 of 75

The nurse is assisting in the discharge planning for a client with alcoholism. Which of the following should be included in the discharge plan?

1. Strongly encourage participation in Alcoholics Anonymous (AA).

2. Provide nutritional information and counseling.

3. Establish an exercise program.

4. Discuss relapse prevention.

5. Have the client introduce himself slowly to people from his former lifestyle.

Correct Answer: 1,2,3,4 Your Answer: 2,3,4

RATIONALES: AA is an outpatient support group for recovering alcoholics. It allows clients to share their problems and gain support from members of the group to avoid further alcohol abuse. Strongly encourage participation in this support group. Provide the client with nutritional information and counseling, particularly if the client is underweight or malnourished. Establish an exercise program appropriate for the client's physical health. Discourage the client from reestablishing relationships with former "drinking friends," because this could lead to relapse.





015092 60 1 1,2,3,4 59

true pretest 75 false 2,3,4

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When planning care for a client with a small-bowel obstruction, the nurse should consider the primary goal to be:

1. reporting pain relief.

2. maintaining body weight.

3. maintaining fluid balance.

4. reestablishing a normal bowel pattern.


RATIONALES: Because a client with a small-bowel obstruction can't tolerate oral intake, fluid volume deficit may occur and can be life-threatening. Therefore, maintaining fluid balance is the primary goal. The other options are secondary; pain relief and maintaining body weight don't reflect life-threatening conditions, and the client's normal bowel pattern can be reestablished after fluid volume is stabilized.





Immune and Hematologic Disorders PretestQuestion 68 of 75

A client with a myocardial infarction is admitted to an acute care facility. During the admission history, the nurse learns that the client also has hypertension and progressive systemic sclerosis. For a client with this disease, the nurse is most likely to formulate which nursing diagnosis?

1. Risk for impaired skin integrity

2. Constipation

3. Ineffective thermoregulation

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4. Risk for imbalanced nutrition: More than body requirements


RATIONALES: Progressive systemic sclerosis is a connective tissue disease characterized by fibrosis and degenerative changes of the skin, synovial membranes, and digital arteries. Therefore, the nurse is most likely to formulate a nursing diagnosis of Risk for impaired skin integrity. Because clients with the disease are prone to diarrhea from GI tract hypermotility (caused by pathologic changes), Constipation is an unlikely nursing diagnosis. Progressive systemic sclerosis doesn't cause ineffective thermoregulation. GI hypermotility may lead to malabsorption, and esophageal dysfunction may cause dysphagia; these conditions put the client with the disease at risk for inadequate nutrition, making Risk for imbalanced nutrition: More than body requirements an improbable nursing diagnosis.





Respiratory Disorders PretestQuestion 70 of 75

The nurse is performing a respiratory assessment on a client with left lower lobe atelectasis. Identify the area where the nurse may hear fine crackles associated with this condition.

The green rectangle shows the correct answer.

RATIONALES: To auscultate the left lower lobe from the anterior chest, use the landmarks of the left anterior axillary line, between the fifth and sixth intercostal spaces.





028150 70 3 208,130;220,150 69

true pretest 75 false 218,187





Musculoskeletal Disorders PretestQuestion 71 of 75

A home care nurse visits a client with muscular dystrophy. Which comment by the client indicates the he needs more information about an advance directive?

1. "I'm going to the doctor to get a new brace next week."

2. "I've got a sore on my heel where my wheelchair rubs."

3. "My dog is my best friend. I really don't have anyone who can make decisions for me when I no longer can."

4. "I love apple pie. I don't ever want a feeding tube when the time comes that I can't eat."


RATIONALES: Option 4 indicates that the client needs information about advance directives. In this statement, the client is voicing his wish not to have a feeding tube when his condition deteriorates. However, he doesn't explain that he's outlined these wishes in an advance directive. Options 1 and 2 are statements about the client's condition and his care plan. They don't indicate that the client requires more information about advance directives. Option 3 indicates that the client needs information about obtaining a health care power of attorney.






After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent arrhythmias.

1. Serum potassium level

2. Serum calcium level

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3. Serum sodium level

4. Serum chloride level


RATIONALES: During periods of acidosis, potassium leaves the cell causing hyperkalemia. As blood glucose levels normalize with treatment, potassium reenters the cell causing hypokalemia if levels aren't monitored closely. Hypokalemia places the client at risk for cardiac arrhythmias such as ventricular tachycardia. DKA has a lesser affect on serum calcium, sodium, and chloride levels. Changes in these levels don't typically cause cardiac arrhythmias.





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