ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 50 Questions
Question 1 of 5
A client with diabetes insipidus is extremely dehydrated and is unable to take oral fluids. Fluid therapy is prescribed. Which intervention would be most important for the client?
Correct Answer: A
Rationale: The nurse must measure the urine output every 30 minutes when administering prescribed fluid and drug therapy when the client is acutely ill or extremely dehydrated, fails to take oral fluids, or is beginning to receive medical treatment. Doing so ensures adequate kidney function. Although monitoring the rate of IV infusions, measuring fluid intake, and weighing the client daily are important, measuring the urine output every 30 minutes is the priority.
Question 2 of 5
A client sustained a head injury when falling from a ladder. While in the hospital, the client begins voiding large amounts of clear urine and reports being very thirsty. The client states feeling weak and having experienced an 8 pound weight loss since admission. What condition does the nurse expect the client to be tested for?
Correct Answer: A
Rationale: With diabetes insipidus, urine output may be as high as 20 L/24 hours. Urine is dilute, with a specific gravity of 1.002 or less. Limiting fluid intake does not control urine excretion. Thirst is excessive and constant. Activities are limited by the frequent need to drink and void. Weakness, dehydration, and weight loss develop. SIADH will have the opposite clinical manifestations. The client's symptoms are related to the trauma and not to a pituitary tumor. The thyroid gland does not cause these symptoms.
Question 3 of 5
The nurse is administering a medication to a client with hyperthyroidism to block the production of thyroid hormone. The client is not a candidate for surgical intervention at this time. What medication should the nurse administer to the client?
Correct Answer: C
Rationale: Antithyroid drugs, such as propylthiouracil and methimazole, are given to block the production of thyroid hormone preoperatively or for long-term treatment for clients who are not candidates for surgery or radiation treatment. Levothyroxine would increase the level of thyroid and be contraindicated in this client. Spironolactone is a diuretic and does not have the action of blocking production of thyroid hormone, and neither does propranolol, which is a beta-blocker.
Question 4 of 5
A client with Addison disease has a blood glucose level above 80 mg/dL 30 minutes after receiving 15 g of carbohydrates for symptoms of hypoglycemia. Which action would the nurse take next?
Correct Answer: B
Rationale: Milk and graham crackers contain forms of carbohydrates that take longer to absorb and tend to maintain the blood glucose level for an extended period. The physician should be informed if the client continues to be symptomatic and the blood glucose level is below 80 mg/dL. Maintaining bed rest protects the client from injuries from a fall but does not address the blood glucose issue. Assessing the client's blood glucose level provides a numeric assessment of the blood glucose level and would be performed in an ongoing fashion.
Question 5 of 5
A client with Addison disease is being discharged from the hospital and is being instructed about the dietary regimen. What type of diet should the nurse provide written and verbal instructions about?
Correct Answer: D
Rationale: A high-protein, moderate-carbohydrate diet that is low in refined carbohydrates is recommended to reduce the risk of hypoglycemia from excess insulin secretion. The risk of hypoglycemia is also lessened by consuming frequent meals and snacks, especially a substantial bedtime snack. The other dietary regimens are not effective in the management of Addison disease.