Question

A nurse is caring for a client who has type 1 diabetes mellitus. Which of the following conditions should the nurse monitor the client for due to the client's lack of insulin production?

Answer 1

Correct Answers:

Diabetic ketoacidosis (DKA)

Rationale :

✨ In type 1 diabetes, the pancreas produces little to no insulin, so glucose cannot enter cells for energy.

✨ The body responds by breaking down fat for fuel, producing ketones that accumulate and cause metabolic acidosis.

✨ This creates diabetic ketoacidosis (DKA), a life-threatening complication marked by dehydration, ketonemia, and acid-base imbalance.

✨ Without insulin, hyperglycemia worsens and triggers osmotic diuresis, leading to severe fluid and electrolyte losses.

✨ The nurse monitors for DKA because it directly results from absolute insulin deficiency.

Neuroglycopenia

✨ Neuroglycopenia occurs when the brain has too little glucose, usually from hypoglycemia (often due to excess insulin).

✨ Lack of insulin production primarily causes hyperglycemia and ketosis, not neuroglycopenic states.

Hypoglycemia

✨ Hypoglycemia in diabetes is most commonly related to insulin administration, missed meals, or excessive activity.

✨ A client lacking insulin production is more prone to hyperglycemia and ketone formation, not spontaneous hypoglycemia.

Increased glycogen storage

✨ Insulin promotes glycogen synthesis, so absent insulin reduces glycogen storage rather than increasing it.

✨ In insulin deficiency, the liver tends to break down glycogen and make new glucose, worsening hyperglycemia.

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Answer 2

Correct Answers:

Agitation

Rationale :

🌟 During an asthma attack, airway narrowing reduces ventilation and can cause hypoxemia.

🌟 Early hypoxemia often presents as restlessness, anxiety, and agitation due to decreased oxygen delivery to the brain.

🌟 Agitation is a key early warning sign that oxygenation is compromised and respiratory effort is increasing.

🌟 As hypoxemia worsens, the client may progress from agitation to confusion and decreased level of consciousness, signaling respiratory failure risk.

🌟 The nurse should treat agitation during asthma as a potential indicator of inadequate oxygenation.

Dysphagia

🌟 Dysphagia is not a typical manifestation of hypoxemia in asthma and more often relates to neurologic or esophageal issues.

🌟 Asthma-related hypoxemia primarily causes respiratory distress and neurologic changes (restlessness, confusion).

Hypotension

🌟 Hypotension is not an expected early finding of hypoxemia in asthma; it may occur late with shock or severe fatigue.

🌟 Early asthma distress usually causes tachycardia and increased work of breathing, not hypotension.

Nausea

🌟 Nausea is nonspecific and not a primary indicator of hypoxemia during asthma.

🌟 Respiratory compromise is better indicated by agitation, dyspnea, accessory muscle use, and falling oxygen saturation.

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Answer 3

Correct Answers:

"Take the medication with a meal."

Rationale :

💫 Metformin XR is best taken with food to reduce common gastrointestinal effects such as nausea, abdominal discomfort, and diarrhea.

💫 Taking it with a meal improves tolerance and supports consistent adherence.

💫 Extended-release formulations are designed to release medication gradually to maintain steadier drug levels.

💫 Correct administration helps optimize glucose control while minimizing side effects that can cause discontinuation.

💫 Food-associated dosing is a key teaching point for safe, effective use of metformin XR.

“This medication may cause an increase in perspiration.”

💫 Increased sweating is more associated with hypoglycemia, which metformin alone typically does not cause.

💫 Metformin’s common side effects are mainly gastrointestinal, not diaphoresis.

“This medication may turn your urine orange.”

💫 Orange urine is associated with medications like rifampin or phenazopyridine, not metformin.

💫 Metformin does not commonly change urine color.

“You may crush or chew the medication.”

💫 Extended-release tablets should not be crushed or chewed because it can cause dose dumping and increased side effects.

💫 XR products must be swallowed whole to preserve the controlled-release mechanism.

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Answer 4

Correct Answers:

Elevated trilodothyronine (T3)

Rationale :

🔷 Hyperthyroidism (elevated thyroid hormones such as T3) increases sympathetic stimulation and cardiac excitability.

🔷 Excess thyroid hormone raises heart rate and can trigger atrial irritability, making atrial fibrillation more likely.

🔷 Elevated T3 is a classic reversible contributor to new-onset or worsening atrial fibrillation.

🔷 Identifying thyroid imbalance is important because treating hyperthyroidism may reduce arrhythmia burden.

🔷 The nurse recognizes elevated T3 as a potential underlying etiology for atrial fibrillation.

Elevated erythrocyte sedimentation rate (ESR)

🔷 ESR is a nonspecific marker of inflammation and does not directly cause atrial fibrillation.

🔷 It may indicate an inflammatory condition, but it is not a typical primary trigger of AF.

Elevated C-reactive protein (CRP)

🔷 CRP indicates inflammation and cardiovascular risk, but it is not a direct physiologic cause of atrial fibrillation.

🔷 AF is more strongly linked to triggers like thyroid excess, structural heart disease, and electrolyte imbalance.

Elevated brain natriuretic peptide (BNP)

🔷 BNP reflects heart failure/stretch, which may coexist with AF but is not the classic “cause” lab finding in this list.

🔷 The most direct lab-linked cause here is thyroid hormone elevation.

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Answer 5

Correct Answers:

10 seconds or longer of breathing cessation 10 seconds or longer of breathing cessation
Daytime sleepiness
Loud snort after breathing cessation
Many episodes of apnea per night
Frequent, loud snoring

Rationale :

10 seconds or longer of breathing cessation

🟢 Obstructive sleep apnea is defined by repeated episodes of airflow cessation or reduction due to upper airway collapse.

🟢 Apneas typically last ≥10 seconds, causing intermittent hypoxemia and sleep disruption.

🟢 These repeated pauses are central diagnostic features measured during sleep studies.

Daytime sleepiness

🟢 Frequent nighttime arousals prevent restorative sleep, leading to excessive daytime sleepiness.

🟢 Clients may report fatigue, poor concentration, and falling asleep unintentionally.

🟢 Daytime sleepiness reflects chronic sleep fragmentation from repeated apneic events.

Loud snort after breathing cessation

🟢 After an apnea, the client often partially arouses and reopens the airway with a loud snort/gasp.

🟢 This is a common observation from bed partners and indicates obstructive airway reopening.

🟢 The snort occurs because airflow suddenly resumes after obstruction.

Many episodes of apnea per night

🟢 OSA typically involves recurrent episodes throughout the night rather than a single event.

🟢 Repetition increases cumulative hypoxemia burden and cardiovascular strain.

🟢 Multiple episodes are part of severity scoring (e.g., apnea-hypopnea index).

Frequent, loud snoring

🟢 Snoring results from turbulent airflow through a partially obstructed upper airway.

🟢 It is a classic symptom of OSA and often occurs with witnessed apneas.

🟢 Loud, habitual snoring strongly suggests ongoing airway obstruction during sleep.

Easily getting back to sleep after awakening

🟢 OSA commonly causes fragmented sleep with frequent arousals, but clients often do not feel rested afterward.

🟢 The hallmark is nonrestorative sleep and daytime fatigue, not “easy return to sleep” as a defining feature.

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Answer 6

Correct Answers:

Synchronized electrical cardioversion

Rationale :

🔴 Symptomatic atrial fibrillation with palpitations, lightheadedness, and shortness of breath suggests the rhythm may be causing hemodynamic compromise.

🔴 Synchronized cardioversion delivers a timed electrical shock to reset the heart rhythm safely by syncing with the R wave.

🔴 This reduces the risk of inducing ventricular fibrillation compared with unsynchronized shocks.

🔴 Cardioversion is commonly used to restore sinus rhythm when symptoms are significant or rate control is inadequate.

🔴 The nurse anticipates this procedure because it directly addresses the abnormal rhythm causing symptoms.

Pericardiocentesis

🔴 Pericardiocentesis removes fluid from the pericardial sac, typically for cardiac tamponade.

🔴 It does not treat atrial fibrillation as a primary rhythm management procedure.

Septal myectomy

🔴 Septal myectomy is a surgical procedure used for hypertrophic obstructive cardiomyopathy, not atrial fibrillation.

🔴 It is not an acute intervention for rhythm conversion.

Pericardial window

🔴 A pericardial window is created to drain recurrent pericardial effusions.

🔴 It is unrelated to restoring rhythm in atrial fibrillation.

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Answer 7

Correct Answers:

"I will take my bronchodilators after meals."

Rationale :

🔷 Clients with COPD should typically use bronchodilators before meals to improve airflow and reduce dyspnea while eating.

🔷 Eating increases oxygen demand and can worsen shortness of breath, so maximizing bronchodilation first supports safer intake.

🔷 Taking bronchodilators after meals can leave the client more fatigued and breathless during the meal, reducing nutritional intake.

🔷 Good nutrition is vital in COPD due to high energy expenditure from increased work of breathing.

🔷 The nurse identifies this statement as needing correction to support adequate nutrition and breathing comfort.

“I will rest for at least 30 minutes before eating.”

🔷 Resting conserves energy and reduces dyspnea prior to meals, supporting better intake.

🔷 This strategy improves tolerance for chewing and swallowing without excessive fatigue.

“I will eat five or six small meals each day.”

🔷 Small frequent meals prevent gastric distention that can impair diaphragmatic movement and worsen dyspnea.

🔷 This approach supports steady caloric intake without exhausting the client.

“I will choose foods that are not gas-forming.”

🔷 Gas-forming foods can cause bloating, limiting lung expansion and increasing breathing difficulty.

🔷 Avoiding these foods supports comfort and improves ventilation while eating.

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Answer 8

Correct Answers:

Regular insulin

Rationale :

💫 DKA requires rapid correction of hyperglycemia and ketone production using short-acting insulin that can be titrated.

💫 Regular insulin is used IV in DKA because it has a predictable onset and allows continuous infusion for precise control.

💫 IV regular insulin quickly reduces blood glucose while also stopping ketogenesis by restoring insulin availability.

💫 Long-acting insulins are not used initially for acute DKA correction because they cannot be titrated quickly.

💫 The nurse anticipates regular insulin as the standard insulin used for acute DKA management.

NPH insulin

💫 NPH is intermediate-acting and is not appropriate for rapid titration in acute DKA treatment.

💫 It does not provide the immediate controllable effect needed in emergencies.

Insulin glargine

💫 Glargine is long-acting basal insulin and is not used as the primary initial insulin to treat acute DKA.

💫 It cannot be adjusted rapidly to meet the changing needs in critical illness.

Insulin detemir

💫 Detemir is also long-acting and is intended for basal control rather than rapid correction.

💫 DKA requires short-acting insulin that can be titrated minute-to-minute.

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Answer 9

Correct Answers:

The client experiences sudden weakness of one arm and leg.

Rationale :

🌟 Sudden unilateral weakness is a hallmark of acute stroke, which is a life-threatening emergency.

🌟 Atrial fibrillation increases the risk of thromboembolic stroke due to clot formation in the atria.

🌟 Even while receiving heparin, the client can still develop a clot or bleeding complication, so neuro changes require immediate action.

🌟 The nurse must prioritize rapid assessment and activation of stroke protocols to preserve brain tissue and function.

🌟 This finding is the priority because it reflects possible cerebral ischemia and time-sensitive intervention.

The client has an aPTT of 80 seconds.

🌟 aPTT of 80 seconds may be therapeutic or high depending on facility range, but it is not as immediately life-threatening as stroke signs.

🌟 Abnormal coagulation values require provider notification and monitoring, yet acute neuro deficits take priority.

The client's ECG tracing shows irregular heart rate without P waves.

🌟 This is expected with atrial fibrillation and confirms the rhythm but does not indicate an immediate new emergency by itself.

🌟 Priorities shift when there are signs of organ compromise, such as neurologic deficits.

The client's urine output is cloudy and odorous.

🌟 This suggests a possible urinary infection, which is important but not immediately life-threatening in the moment.

🌟 Stroke symptoms require urgent intervention because delays can cause permanent disability.

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Answer 10

Correct Answers:

"Maintain stable blood glucose levels."

Rationale :

✨ Chronic hyperglycemia is the primary driver of microvascular damage that leads to retinopathy and nephropathy.

✨ Maintaining stable blood glucose levels reduces endothelial injury, slows basement membrane thickening, and prevents progressive capillary damage.

✨ Tight glucose control lowers the risk of proteinuria, declining GFR, and vision-threatening retinal changes over time.

✨ Teaching should emphasize consistent monitoring, medication adherence, meal planning, and recognizing patterns of high glucose.

✨ This instruction directly targets the root cause of these long-term complications: persistent elevated glucose exposure.

“Wear compression stockings daily.”

✨ Compression stockings are used for venous insufficiency and edema management, not prevention of diabetic nephropathy or retinopathy.

✨ They do not address microvascular glucose-related damage to kidneys or eyes.

“Examine your feet carefully every day.”

✨ Daily foot inspection helps prevent neuropathy-related injury and ulcer complications, not retinopathy or nephropathy.

✨ It is important diabetic teaching, but it does not primarily prevent kidney/eye microvascular disease.

“Have an eye examination once per year.”

✨ Annual eye exams support early detection of retinopathy, but they do not directly prevent nephropathy.

✨ The question asks about preventing both retinopathy and nephropathy; glycemic control impacts both.

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Custom: NRS 114 Exam #2_2026

No.

1 :
A nurse is caring for a client who has type 1 diabetes mellitus. Which of the following conditions should the nurse monitor the client for due to the client's lack of insulin production?

2 :
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

3 :
A nurse is teaching a client who is taking metformin XR for type II diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

4 :
A nurse is reviewing laboratory results for a client who has atrial fibrillation. Which of the following blood test results should the nurse identify as a possible cause of atrial fibrillation?

5 :
Which of the following are manifestations of obstructive sleep apnea? (Select all that apply.)

6 :
A nurse is planning care for a client who has atrial fibrillation and reports heart palpitations, lightheadedness, and shortness of breath. Which of the following procedures should the nurse anticipate for this client?

7 :
A nurse is teaching a client who has chronic obstructive pulmonary disease about ways to facilitate eating. Which of the following statements indicates a need for further teaching?

9 :
A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority?

10 :
A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

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Custom: NRS 114 Exam #2_2026

No.

1 : A nurse is caring for a client who has type 1 diabetes mellitus. Which of the following conditions should the nurse monitor the client for due to the client's lack of insulin production?

2 : A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

3 : A nurse is teaching a client who is taking metformin XR for type II diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

4 : A nurse is reviewing laboratory results for a client who has atrial fibrillation. Which of the following blood test results should the nurse identify as a possible cause of atrial fibrillation?

5 : Which of the following are manifestations of obstructive sleep apnea? (Select all that apply.)

6 : A nurse is planning care for a client who has atrial fibrillation and reports heart palpitations, lightheadedness, and shortness of breath. Which of the following procedures should the nurse anticipate for this client?

7 : A nurse is teaching a client who has chronic obstructive pulmonary disease about ways to facilitate eating. Which of the following statements indicates a need for further teaching?

9 : A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority?

10 : A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

1 :
A nurse is caring for a client who has type 1 diabetes mellitus. Which of the following conditions should the nurse monitor the client for due to the client's lack of insulin production?

2 :
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

3 :
A nurse is teaching a client who is taking metformin XR for type II diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

4 :
A nurse is reviewing laboratory results for a client who has atrial fibrillation. Which of the following blood test results should the nurse identify as a possible cause of atrial fibrillation?

5 :
Which of the following are manifestations of obstructive sleep apnea? (Select all that apply.)

6 :
A nurse is planning care for a client who has atrial fibrillation and reports heart palpitations, lightheadedness, and shortness of breath. Which of the following procedures should the nurse anticipate for this client?

7 :
A nurse is teaching a client who has chronic obstructive pulmonary disease about ways to facilitate eating. Which of the following statements indicates a need for further teaching?

9 :
A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority?

10 :
A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?