NUR 265 Exam 2 Review

A client with a diagnosis if diabetes ketoacidosis (DKA) is being treated in the ER. Which
of the following clinical manifestations support this diagnosis? (Select all that Apply)

• Increase in pH

• Hyperactive

• Deep, rapid breathing

• Decreased urine output

• Elevated blood glucose

The nurse is preparing a plan of care for a client with diabetes mellitus who has
hyperglycemia. Which of the following Nursing diagnosis is a priority?

• Lack of Knowledge

• Inadequate fluid volume

• Compromised family coping

• Inadequate consumption of nutrients

The nurse is caring for a client after a nasal hypophysectomy and notes some clear
drainage coming for the clients left nostril. Which of the following nursing interventions
should the nurse take initially?

• Lower the head of the bead

• Test the drainage for glucose

• Obtain a culture of the drainage

• Continue to observe the drainage

The nurse is completing as assessment on a client who is being admitted for a diagnostic
workup for primary hyperparathyroidism. Which of the following clinical manifestations
would support this medical diagnosis?

• Polyuria

• Headache

• Bone pain

• Nervousness

• Weight gain

The nurse is caring for a client admitted to the intensive care unit with a diagnosis of
Addisonian crisis. Which of the following findings will the interdisciplinary care team
focus on?

• Hypotension

• Leukocytosis

• Hyperkalemia

• Hypercalcemia

• Hypernatremia

The nurse is performing an assessment on a client with a diagnosis of
pheochromocytoma. Which of the following assessment data would indicate a potential
complication associated with this disorder?

• A urinary output of 50 mL/hour

• A coagulation time of 5 minutes

• A heart rate that is 90 bpm and irregular

• A BUN level of 20 mg/dL (7.1 mmol/L)

The nurse is caring for a client who was admitted to the nursing unit following a
thyroidectomy. Which of the following assessment is the priority for this client?

• Hypoglycemia

• Level of hoarsness

• Respiratory distress

• Edema at the surgical site

The nurse has become aware of the following client situations. It would be a priority for
the nurse to follow up with the client who...

• has diabetes insipidus and continues to have a low urine specific gravity

• had a subtotal thyroidectomy 12 hours ago and complaining of mild pain

• has hyperparathyroidism and scheduled to receive prescribed desmopression

• has DKA and is reporting the last bowel movement was three days ago.

The nurse is admitting a client from the ER with a diagnosis of myxedema coma is made.
Which of the following would the nurse do first?

• Warm the client

• Maintain patent airway

• Administer thyroid hormone

• Administer fluid replacement

The nurse is admitting a client who is diagnosed with syndrome of inappropriate
antidiuretic hormone secretion (SIADH) and has a serum sodium of 113 mE/L. Which of
the following HCP prescriptions should the nurse anticipate? (Select all that apply).

• Initiate an infusion of 3% NaCl

• Administer IV furosemide

• Restrict fluids to 800 mLs/24hours

• Elevate the head of bed to high fowlers

• Administer a vasopressin antagonist