Exam 1 ATI Targeted Review Assignments (Fluid/Electrolytes & Acid-Base, Perioperative Management, Central Venous Access Devices)

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect? A. Confusion B. Peripheral edema C. Facial flushing and warmth D. Hyperreflexia

A. Confusion Rationale: A client who has respiratory acidosis will experience confusion from a lack of cerebral perfusion. If acidosis is not reversed, the client's level of consciousness will decrease, and coma can occur.

A nurse is assessing a client who is recovering from spinal anesthesia. Which of the following sensations should the nurse expect to return to the client first? A. Pain B. Cold C. Touch D. Warmth

C. Touch

A nurse is developing a teaching plan for a client who had a thyroidectomy and takes a thyroid hormone replacement. Which of the following instructions should the nurse plan to include? A. "Take this medication on an empty stomach." B. "Take this medication with an antacid." C. "Change position slowly while taking this medication." D. "Limit your fluid intake while taking this medication."

A. "Take this medication on an empty stomach."

A nurse is receiving evening shift report on four clients who returned from the PACU that morning. Which of the following clients should the nurse assess first? A. A client who is postoperative following a thoracotomy and has a chest tube with 150 mL of bright-red blood in the collection chamber from the past 1 hr. B. A client who is postoperative following a small bowel resection and has a temporary colostomy along with absent bowel sounds in all four quadrants. C. A client who is postoperative following a tonsillectomy and has had one episode of coffee-ground emesis. D. A client who is postoperative following a total knee arthroplasty and is reporting a pain level of 7 on a scale from 0 to 10.

A. A client who is postoperative following a thoracotomy and has a chest tube with 150 mL of bright-red blood in the collection chamber from the past 1 hr.

A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Administer IV fluids to the client evenly over 24 hr. B. Provide the client with a salt substitute. C. Assess the client for pitting edema. D. Encourage the client to rise slowly when standing up. E. Weigh the client every 8 hr.

A. Administer IV fluids to the client evenly over 24 hr. D. Encourage the client to rise slowly when standing up. E. Weigh the client every 8 hr.

A nurse is managing the care of a client who is postoperative and has acute adrenal insufficiency. Which of the following actions should the nurse take? A. Administer IV hydrocortisone sodium. B. Give oral spironolactone. C. Infuse 1 unit of platelets. D. Restrict daily fluid intake.

A. Administer IV hydrocortisone sodium. Rationale: Hydrocortisone sodium is necessary to replace the cortisol deficiency that occurs with adrenal insufficiency. Administering a potassium-sparing diuretic, such as spironolactone, will further increase the client's potassium level, worsening the hyperkalemia.

A nurse is monitoring a client who received succinylcholine during a surgical procedure. Which of the following actions should the nurse take if the client develops manifestations of malignant hyperthermia? A. Administer dantrolene. B. Institute seizure precautions. C. Remove the endotracheal tube. D. Administer IV atropine.

A. Administer dantrolene.

A nurse is caring for a client who has a central venous catheter. When flushing the catheter, the nurse should use a 10 mL syringe to prevent which of the following complications associated with central vascular access devices? A. Catheter rupture B. Catheter migration C. Pneumothorax D. Phlebitis

A. Catheter rupture Rationale: When injecting fluid through a catheter, a smaller syringe generates more pressure than a larger syringe does. Therefore, to reduce the risk of catheter rupture, syringes that are 10-mL or larger are recommended for flushing or injecting fluid into a central venous catheter.

A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect? A. Decreased muscle strength B. Decreased gastric motility C. Increased heart rate D. Increased blood pressure

A. Decreased muscle strength

A nurse is caring for a client who has a pheochromocytoma. Which of the following actions should the nurse take? A. Elevate the head of the client's bed. B. Palpate the client's abdomen. C. Monitor the client for hypotension. D. Check the client's urine specific gravity.

A. Elevate the head of the client's bed. Rationale: The nurse should elevate the head of the client's bed to reduce blood pressure and abdominal pressure. The nurse should not palpate the abdomen of a client who has a pheochromocytoma, because this can cause release of catecholamines and increase blood pressure.

A nurse is monitoring the laboratory values of a client who has diabetes mellitus and is taking insulin. Which of the following results indicates a therapeutic outcome of insulin therapy? A. Fasting blood glucose 96 mg/dL B. Postprandial blood glucose 195 mg/dL C. Random blood glucose 210 mg/dL D. Preprandial blood glucose 60 mg/dL

A. Fasting blood glucose 96 mg/dL

A nurse is caring for a client who is 12 hr postoperative from a gastrectomy and has an NG tube set to continuous low suction. Which of the following findings requires intervention by the nurse? A. Gastric distention B. Absent bowel sounds C. Urine output of 150 mL over the last 4 hr D. Yellow drainage in the NG tube

A. Gastric distention

A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? A. Hyperactive deep-tendon reflexes B. Increased bowel sounds C. Drowsiness D. Decreased blood pressure

A. Hyperactive deep-tendon reflexes

While reviewing a client's laboratory results, a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions should the nurse take? A. Implement seizure precautions. B. Administer phosphate. C. Initiate diuretic therapy. D. Prepare the client for hemodialysis.

A. Implement seizure precautions.

A nurse is monitoring a client who is 24 hr postoperative after a total thyroidectomy. Which of the following findings should the nurse report to the provider? A. Laryngeal stridor B. Productive cough C. Pain with hyperextension of the neck D. Hoarse, weak voice

A. Laryngeal stridor Rationale: Laryngeal stridor is a harsh, high-pitched sound with inspiration that indicates respiratory obstruction. The nurse should take immediate action to preserve the client's airway.

A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurse include in the teaching as containing the lowest amount of magnesium? A. One large hard-boiled egg B. 1 cup bran cereal C. 1/2 cup almonds D. 1 cup cooked spinach

A. One large hard-boiled egg

A nurse is teaching a client who has an autoimmune disease about the adverse effects of long-term corticosteroid therapy. Which of the following adverse effects should the nurse include? (Select all that apply.) A. Osteoporosis B. Moon-shaped face C. Increased risk of infection D. Hearing loss E. Weight loss

A. Osteoporosis B. Moon-shaped face C. Increased risk of infection

A nurse is reviewing the medical record for a client who has a prescription for general anesthesia prior to surgery. Which of the following findings should the nurse report to the provider? A. Potassium 2.8 mEq/L B. Sodium 140 mEq/L C. INR 1.5 D. BUN 12 mg/dL

A. Potassium 2.8 mEq/L

A nurse has administered propranolol by IV bolus to a client who is having a thyroid storm. Which of the following findings indicates that the client is having a therapeutic response? A. Reduction of the effects of thyroid hormone on the heart B. Blockage of the release of thyroid hormone from the thyroid gland C. Increase in the heart's sensitivity to thyroid hormone D. Increase in the uptake of thyroid hormone by the thyroid gland

A. Reduction of the effects of thyroid hormone on the heart

A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mm Hg, PaCO2 56 mm Hg and HCO3- 26 mEq/L. The nurse should interpret these laboratory values as which of the following imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A. Respiratory acidosis Rationale: Status asthmaticus causes inadequate gas exchange, resulting in a low pH and PaO2, an elevated PaCO2, and an HCO3- within the expected reference range. These laboratory values indicate respiratory acidosis.

A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse report to the provider? A. Sodium 110 mEq/L B. 2+ deep-tendon reflexes C. Potassium 3.7 mEq/L D. Urine specific gravity 1.025

A. Sodium 110 mEq/L

A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following laboratory values should the nurse report to the provider? A. Sodium 128 mEq/L B. Potassium 4.8 mEq/L C. Calcium 9.1 mg/dL D. Magnesium 2.0 mEq/L

A. Sodium 128 mEq/L

A surgical nurse enters a surgical suite to ensure surgical asepsis is maintained. For which of the following findings should the nurse intervene? A. The scrub technologist is wearing a watch under their scrubs. B. The circulating nurse opens dressing packages before applying sterile gloves. C. The surgeon has their hands folded 5 cm (2 in) above their waist. D. The holding area nurse is performing client education.

A. The scrub technologist is wearing a watch under their scrubs.

A nurse is assessing a patient who is 2 hr postoperative following an appendectomy. Which of the following findings should the nurse report to the provider? A. Urine output of 20 mL/hr B. Temperature of 36.5° C (97.7° F) C. A 2 cm x 2 cm (0.79 in x 0.79 in) area of bloody drainage on the dressing D. WBC count 9,000 mm3

A. Urine output of 20 mL/hr

A nurse is reviewing laboratory values for a client who has diabetic ketoacidosis (DKA). Which of the following results should the nurse expect? A. pH 7.32, PaCO2 36 mm Hg, HCO3- 14 mEq/L B. pH 7.38, PaCO2 55 mm Hg, HCO3- 22 mEq/L C. pH 7.44, PaCO2 40 mm Hg, HCO3- 24 mEq/L D. pH 7.50, PaCO2 42 mm Hg, HCO3- 30 mEq/L

A. pH 7.32, PaCO2 36 mm Hg, HCO3- 14 mEq/L

A nurse is caring for a client who requires nasogastric suctioning. Which of the following sets of laboratory results indicate that the client has metabolic alkalosis? A. pH 7.51, PaO2 94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L B. pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 26 mEq/L C. pH 7.31, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 23 mEq/L D. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L

A. pH 7.51, PaO2 94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L

A nurse is assessing a client who has a phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect? A. Hepatic failure B. Abdominal pain C. Slow peripheral pulses D. Increase in cardiac output

C. Slow peripheral pulses

A nurse is providing discharge teaching to a client who has diabetes insipidus and a new prescription for desmopressin nasal spray. Which of the following instructions should the nurse include in the teaching? A. "Depress the pump once before using the nasal spray for the first time." B. "Blow your nose gently prior to using the nasal spray." C. "Administer the nasal spray while in a side-lying position." D. "Notify the provider if you develop numbness or tingling around the mouth."

B. "Blow your nose gently prior to using the nasal spray." Rationale: The nurse should instruct the client to blow his nose gently prior to using the spray. This action prevents dilution of the medication with nasal secretions.

A nurse is teaching a client who is in the immediate postoperative period about the use of a PCA pump. Which of the following statements should the nurse include in the teaching? A. "You will receive a dose of medication every time you push the button." B. "Do not allow visitors to push the PCA button if you are sleeping." C. "You cannot receive too much medication by pushing the button." D. "Do not push the PCA button until your pain reaches a severe level."

B. "Do not allow visitors to push the PCA button if you are sleeping."

A nurse is providing discharge instructions for a client who is postoperative following abdominal surgery. Which of the following client statements indicates an understanding of the teaching? A. "I will have an increase in yellow-colored drainage from my incision for 2 weeks." B. "I will eat foods that are high in protein and vitamin C during my recovery." C. "I should avoid taking over-the-counter pain medication if my pain is not severe." D. "I will remain on bed rest until my follow-up appointment with my doctor."

B. "I will eat foods that are high in protein and vitamin C during my recovery."

A nurse is teaching a client about glycosylated hemoglobin (HbA1c) testing. Which of the following statements indicates an understanding of the teaching? A. "I need to fast after midnight the night before the test." B. "This test's result is a good indicator of my average blood glucose levels." C. "A level of 8 to 10 percent suggests adequate blood glucose control." D. "I will use my hemoglobin A1c level to adjust my daily insulin doses."

B. "This test's result is a good indicator of my average blood glucose levels."

A nurse is providing preoperative teaching for a client who is scheduled to have a below-the-knee amputation. Which of the following instructions should the nurse include? A. "You should avoid lying on your abdomen after surgery." B. "Your surgeon might prescribe an antibiotic before surgery." C. "It is important for you to sit in a chair at the bedside for several hours every day to reduce the risk of pneumonia." D. "To promote wound healing, it is important to reduce your intake of carbohydrates once you return home."

B. "Your surgeon might prescribe an antibiotic before surgery."

A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medications should the nurse prepare to administer? A. Sodium polystyrene sulfonate 30 g/day B. 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr C. Bumetanide 8 mg/day D. 100 mL of dextrose 10% in water with 10 units of insulin

B. 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr Rationale: This IV solution will provide adequate fluid and potassium replacement to offset the losses from vomiting. The typical amount of potassium chloride to administer IV is 5 to 10 mEq/hr, not to exceed 20 mEq/hr. The dilution should be 1 mEq of potassium chloride to 10 mL of 0.9% sodium chloride.

A nurse is providing dietary teaching to a client who has heart failure and is receiving furosemide. Which of the following foods should the nurse recommend as containing the greatest amount of potassium? A. 1/2 cup chopped celery B. 1 cup plain yogurt C. One slice whole grain bread D. 1/2 cup cooked tofu

B. 1 cup plain yogurt

A nurse is caring for a client who requires long-term central venous access and is an avid swimmer. Which of the following central venous access devices is the best choice for this client? A. A tunneled central catheter B. An implanted port C. A nontunneled percutaneous central catheter D. A peripherally inserted central catheter

B. An implanted port Rationale: Because the entire device lies beneath the skin, the client can be immersed in water when the device is not in use without any increased risk for infection. This is the best choice for clients who wish to continue aquatic activities.

A nurse is caring for a client following a thyroidectomy. The nurse should assess for which of the following findings as an indication of hypocalcemia? A. Strong, bounding pulse B. Decreased bowel sounds C. Tingling and numbness of the hands and feet D. Diminished deep-tendon reflexes

C. Tingling and numbness of the hands and feet

A nurse is caring for a client who is preoperative and is asking multiple questions about the risks of the procedure. Which of the following actions should the nurse take? A. Explain the risks and benefits of the surgery to the client. B. Ask the surgeon to speak to the client for clarification. C. Reassure the client that the procedure is necessary for recovery. D. Notify the circulating nurse that the client has questions about the procedure.

B. Ask the surgeon to speak to the client for clarification.

A nurse is assessing a client who has a calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess? A. Deep-tendon reflexes B. Cardiac rhythm C. Peripheral sensation D. Bowel sounds

B. Cardiac rhythm Rationale: When using the airway, breathing, circulation approach to client care, the nurse should first assess the client's cardiac rhythm because this total serum calcium level is below the expected reference range. Hypocalcemia can cause ECG changes, bradycardia, or tachycardia.

A nurse is assessing a client who has diabetes mellitus and reports feeling anxious. Which of the following findings should the nurse expect if the client is hypoglycemic? A. Rapid, deep respirations B. Cool, clammy skin C. Abdominal cramping D. Orthostatic hypotension

B. Cool, clammy skin

A nurse is creating a plan of care for a client who is preoperative for a total hip arthroplasty. The client informs the nurse that they practice Judaism and adhere to a kosher diet. Which of the following interventions is the nurse's priority? A. Listen and allow the client to express feelings about the surgery. B. Determine if the client's faith conflicts with the treatment plan. C. Ensure the client's meal plan serves only kosher food following surgery. D. Teach the client how to perform various relaxation exercises.

B. Determine if the client's faith conflicts with the treatment plan.

A nurse is assessing a client who is 2 days postoperative following a total prostatectomy. The nurse notes that the client's right calf is red, edematous and warm to the touch. Which of the following actions should the nurse take? A. Apply an ice pack to the client's right calf. B. Elevate the client's right extremity. C. Administer testosterone to the client. D. Gently massage the client's right calf.

B. Elevate the client's right extremity.

A nurse is reviewing the laboratory report of a client who has fluid volume excess. Which of the following laboratory values should the nurse expect? A. Hgb 20 g/dL B. Hct 34% C. BUN 25 mg/dL D. Urine specific gravity 1.050

B. Hct 34% Rationale: The nurse should identify that a client who has fluid volume excess can have a Hct level that is below the expected reference range of 37% to 47% for females or 42% to 52% for males. Fluid volume excess can cause hemodilution and a decreased hematocrit level.

A nurse is assessing a client who has diabetes insipidus. The nurse should expect which of the following findings? A. Decreased heart rate B. Increased hematocrit C. High urine specific gravity D. Low BUN level

B. Increased hematocrit Rationale: Increased hematocrit is an expected finding of diabetes insipidus due to dehydration.

A nurse is planning teaching for a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse plan to include? A. Consume no more than three servings of alcohol per day. B. Ingest food with alcohol to reduce alcohol-induced hypoglycemia. C. Increase insulin dosage before planned exercise. D. Rest for 3 days between periods of vigorous exercise.

B. Ingest food with alcohol to reduce alcohol-induced hypoglycemia.

A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary edema. Which of the following actions should the nurse take first? A. Assist with intubation. B. Initiate high-flow oxygen therapy. C. Administer a rapid-acting diuretic. D. Provide cardiac monitoring.

B. Initiate high-flow oxygen therapy.

A nurse is caring for a client who is 2 days postoperative following a cholecystectomy. The client has been vomiting for the past 24 hr and reports a pain level of 8 on a 0 to 10 scale. The nurse notes a hard, distended abdomen and absent bowel sounds. After conferring with the provider, which of the following actions should the nurse take first? A. Draw the client's blood for electrolytes. B. Insert an NG tube. C. Administer pain medication. D. Initiate intake and output.

B. Insert an NG tube.

A nurse is assessing a client who is preoperative. The nurse should identify that which of the following factors reported by the client increases the risk for a postoperative wound infection? A. Frequent use of echinacea B. Long-term use of corticosteroids C. History of osteoporosis D. Diet high in vitamin C

B. Long-term use of corticosteroids

A nurse is caring for a client who has diabetes mellitus and has developed peripheral neuropathy. Which of the following measures should the nurse recommend to prevent injuries to the client's feet? A. Examine the skin of the feet feet weekly for alterations in skin integrity. B. Monitor the temperature of bath water with a thermometer. C. Shop for shoes early in the day. D. Round the edges of toenails when trimming them.

B. Monitor the temperature of bath water with a thermometer.

A nurse is assessing a client who received a preoperative IV dose of metoclopramide 1 hr ago. For which of the following findings should the nurse notify the provider? A. Dry mouth B. Muscle rigidity C. Tinnitus D. Diarrhea

B. Muscle rigidity

A nurse is caring for a client who has a central venous catheter and suddenly develops dyspnea, tachycardia and dizziness. The nurse suspects an air embolism and clamps the catheter immediately. The nurse should reposition the client into which of the following positions? A. Supine with a pillow beneath the knees B. On their left side in Trendelenburg position C. Upright and leaning over the overbed table D. On their right side with the head of the bed elevated 15°

B. On their left side in Trendelenburg position Rationale: This action is called Durant's maneuver/position. This position helps trap the air in the apex of the right atrium rather than allowing it to enter the right ventricle and, from there, move to the pulmonary arterial system.

A nurse is planning care for a client who has a potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings? A. Hyperactive deep-tendon reflexes B. Orthostatic hypotension C. Rapid, deep respirations D. Strong, bounding pulse

B. Orthostatic hypotension Rationale: The nurse should plan to monitor the client for orthostatic hypotension, which places them at risk for falls. Orthostatic hypotension is a manifestation of hypokalemia.

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate of 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis? A. PaO2 B. PaCO2 C. Sodium D. Bicarbonate

B. PaCO2

A nurse is evaluating a client who is receiving IV fluids to treat dehydration. Which of the following laboratory findings that the fluid therapy has been effective? A. BUN 26 mg/dL B. Sodium 142 mEq/L C. Hct 56% D. Urine specific gravity 1.035

B. Sodium 142 mEq/L

A nurse is caring for a client who has a surgical wound with a Penrose drain in place. Which of the following interventions should the nurse plan to perform? A. Cut a slit in a 4-inch square gauze pad to place around the drain. B. Use the sterile technique when performing dressing changes. C. Establish a clamping schedule prior to removal. D. Apply negative pressure when emptying the drain.

B. Use the sterile technique when performing dressing changes.

A nurse is teaching a client who has type 1 diabetes mellitus about how to prevent complications during illness. Which of the following statements by the client indicates an understanding of the teaching? A. "I should stop taking my insulin if I feel nauseous." B. "I will test my urine for protein when I start to feel ill." C. "I will call my doctor if my blood sugar is more than 250." D. "I should check my blood sugar level every 8 hours."

C. "I will call my doctor if my blood sugar is more than 250."

A nurse is providing discharge teaching for a client who is postoperative following a rhinoplasty using general anesthesia. Which of the following instructions should the nurse include? A. "Lie on your side when resting for the first week after surgery." B. "Limit intake to clear liquids for the first 24 hours after surgery." C. "Use cool compresses on your eyes, nose, and face." D. "Close your mouth when you are about to sneeze."

C. "Use cool compresses on your eyes, nose, and face."

A nurse is providing teaching to a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching? A. "If my stockings feel tight, I'll just roll them down for a while." B. "I'll put on my elastic stockings at the first sign of swelling." C. "When I sit down to watch television, I'll be sure to put my feet up." D. "It's okay to cross my legs as long as it's for less than an hour."

C. "When I sit down to watch television, I'll be sure to put my feet up."

A nurse in the ED is caring for a client who was in a motor-vehicle crash. The provider determines that the client needs immediate central venous access for fluid and blood replacement. Which of the following central venous access devices should the nurse anticipate being inserted? A. A tunneled central catheter B. An implanted port C. A nontunneled percutaneous central catheter D. A peripherally inserted central catheter

C. A nontunneled percutaneous central catheter Rationale: This type of central catheter is ideal for emergency situations where short-term (less than 6 weeks) central venous access is required for multiple therapies. This is the appropriate choice for this client. A PICC is a type of central catheter is designed for longer term therapy, such as lengthy courses of chemotherapy or parenteral nutrition. There is no indication that this client will require prolonged central venous access.

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following interventions should the nurse perform to prevent respiratory complications? A. Instruct the client to exhale into the incentive spirometer every 1 to 2 hr. B. Minimize the amount of pain medication the client receives to prevent sedation. C. Advise the client to splint the surgical incision when coughing and deep breathing. D. Reposition the client every 8 hr for the first 48 hr.

C. Advise the client to splint the surgical incision when coughing and deep breathing.

A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs." Which of the following actions should the nurse take first? A. Monitor the client's bowel sounds. B. Review the client's daily laboratory results. C. Auscultate the client's lungs. D. Palpate the client's peripheral pulses.

C. Auscultate the client's lungs. Rationale: An adverse effect of many diuretics, including furosemide, is hypokalemia. When using the airway, breathing, circulation approach to client care, the nurse should first auscultate the client's lungs to assess for respiratory changes due to weakness of the respiratory muscles.

A nurse is caring for a client who has dehydration and is receiving IV fluids. When assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload? A. Increased urine specific gravity B. Hypoactive bowel sounds C. Bounding peripheral pulses D. Decreased respiratory rate

C. Bounding peripheral pulses

A nurse is assessing a client who has adrenal insufficiency. Which of the following findings should the nurse expect? A. Moon-shaped face B. Weight gain C. Calcium 12.8 mg/dL D. Sodium 150 mEq/L

C. Calcium 12.8 mg/dL

A nurse is caring for a client who has a central venous access device in place. Which of the following routine interventions should the nurse use to prevent lumen occlusion? A. Apply a skin securement device to the catheter. B. Remove the dressing from the insertion site slowly and carefully. C. Clamp the tubing before removing a syringe from the positive pressure end cap. D. Have the client lie flat when changing administration sets or injection caps.

C. Clamp the tubing before removing a syringe from the positive pressure end cap. Rationale: When flushing a catheter through a positive pressure end cap, the nurse should remove the syringe prior to clamping the line. This action maintains the positive pressure of the cap and prevents air from entering the line.

A nurse is planning care for a client who is postoperative and has a closed-wound drainage system in place. Which of the following interventions should the nurse plan to include? A. Check the patency of the drain every 12 hr. B. Clamp the drain while the client is ambulating. C. Cleanse the drain plug with alcohol after emptying. D. Secure the drain to the client's bed sheet.

C. Cleanse the drain plug with alcohol after emptying.

A nurse is teaching a client who has diabetes mellitus about insulin injections. The client's prescription includes evening doses of insulin glargine and regular insulin. Which of the following instructions should the nurse include? A. Inject the insulins intramuscularly. B. Shake the insulins vigorously prior to administration. C. Draw up the insulins into separate syringes. D. Expect the insulins to appear cloudy.

C. Draw up the insulins into separate syringes. Rationale: The nurse should instruct the client to draw up the insulins into separate syringes because insulin glargine is not compatible with other insulins. The nurse should instruct the client to expect both insulins to appear clear and to discard any that appear cloudy. Gently mix the insulin vials prior to administration to prevent altering the chemistry of the medication.

A nurse is caring for a client who is receiving moderate (conscious) sedation with midazolam. The client's respiratory rate decreases from 16/min to 6/min, and their oxygen saturation decreases from 92% to 85%. Which of the following medications should the nurse administer? A. Atropine B. Acetylcysteine C. Flumazenil D. Protamine sulfate

C. Flumazenil

A nurse is assessing a client who has a new diagnosis of Cushing's disease. Which of the following findings should the nurse expect? A. Decreased blood pressure B. Weight loss C. Hirsutism D. Increased skin thickness

C. Hirsutism Rationale: Increased hair growth, or hirsutism, is an expected finding of Cushing's disease due to increased androgen production. Elevated BP, weight gain and thinning of the skin are all expected findings of Cushing's disease.

A nurse is assessing a client who has been taking propylthiouracil. The nurse should identify which of the following findings as an indication that the medication has been effective? A. Increased ability to sweat B. Increased bowel movements C. Increased body weight D. Increased libido

C. Increased body weight Rationale: Propylthiouracil suppresses the production of thyroid hormones and allows for weight gain. However, excessive weight gain could indicate that the dose of propylthiouracil is too high.

A circulating nurse is monitoring the temperature in a surgical suite. The nurse should identify that cool temperatures reduce a client's risk for which of the following potential complications of surgery? A. Malignant hyperthermia B. Blood clots C. Infection D. Hypoxia

C. Infection

A nurse in the PACU is assessing a client who is postoperative. Which of the following findings should the nurse report to the provider? A. Blood pressure 10% lower than baseline B. Pain level of 4 on a 0 to 10 scale C. Presence of inspiratory stridor D. Small amount of sanguineous drainage on dressing

C. Presence of inspiratory stridor

A nurse is assessing a client who is using PCA following a thoracotomy. The client is short of breath, appears restless, and has a respiratory rate of 28/min. The client's ABG results are pH 7.52, PaO2 89 mm Hg, PaCO2 28 mm Hg and HCO3- 24 mEq/L. Which of the following actions should the nurse take? A. Instruct the client to cough forcefully. B. Assist the client with ambulation. C. Provide calming interventions. D. Discontinue the PCA.

C. Provide calming interventions. Rationale: The client's respiratory rate is above the expected reference range of 12 to 20/min. The nurse should instruct the client to breathe slowly. Calming the client should decrease the respiratory rate, which will cause the client's carbon dioxide levels to increase to expected levels of 35 to 45 mm Hg and lower the pH to expected levels of 7.35 to 7.45.

A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving regular insulin by continuous IV infusion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider? A. Urine output 30 mL/hr B. Blood glucose 180 mg/dL C. Serum potassium 3.0 mEq/L D. BUN 18 mg/dL

C. Serum potassium 3.0 mEq/L Rationale: This serum potassium level is below the expected reference range. Hypokalemia is a serious complication that can occur when a client who has diabetic ketoacidosis is receiving insulin to treat the condition. The nurse should report this finding to the provider.

A nurse is admitting a client who has hyperthyroidism. When assessing the client, the nurse should expect which of the following findings? A. Cold intolerance B. Lethargy C. Tremors D. Sunken eyes

C. Tremors

A nurse is preparing to administer oral potassium to a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first? A. Administer a hypertonic solution. B. Repeat the potassium level. C. Withhold the medication. D. Monitor for paresthesia.

C. Withhold the medication.

A nurse is providing teaching for a client who is scheduled to undergo moderate sedation for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching? A. "I will need to complete a bowel prep the day before the procedure." B. "I will drink plenty of fluids the morning of the procedure." C. "I can eat as soon as the procedure is over." D. "I can expect to feel sleepy for several hours after the procedure."

D. "I can expect to feel sleepy for several hours after the procedure."

A nurse is teaching nutritional strategies to a client who has a low calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching? A. "I will eat more cheese because I can't drink milk." B. "I need to avoid foods with vitamin D because I am allergic to milk." C. "I will stop taking my calcium supplements if they irritate my stomach." D. "I will add broccoli and kale to my diet."

D. "I will add broccoli and kale to my diet."

A nurse in an outpatient clinic is teaching a client who has a diabetic foot ulcer about foot care. Which of the following statements by the client indicates an understanding of the teaching? A. "I will let my feet air dry after washing." B. "I will wear sandals to allow air to circulate around my feet." C. "I will buy over-the-counter medicine to treat the calluses on my feet." D. "I will apply lotion to the dry areas of my feet but not between my toes."

D. "I will apply lotion to the dry areas of my feet but not between my toes."

A nurse is providing preoperative teaching to a client who is scheduled to have a mastectomy with reconstructive surgery. Which of the following statements by the client indicates an understanding of the teaching? A. "I should wait to take my pain medication until after I have completed my range-of-motion exercises." B. "I should wait until a week after surgery to start my hand-strengthening exercises." C. "I will be able to lift an object that weighs 10 pounds 2 weeks after my surgery." D. "I will be able to shower after the doctor removes the drain."

D. "I will be able to shower after the doctor removes the drain."

A nurse is providing care to a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates an understanding of the teaching? A. "I should conserve energy by limiting my physical activity." B. "I will wait until my pain is at least 6 out of 10 before I use the PCA." C. "I will limit my daily fluid intake to two to three glasses." D. "I will use the incentive spirometer every hour."

D. "I will use the incentive spirometer every hour."

A nurse is preparing a teaching plan for a client who has diabetes insipidus and requires intranasal desmopressin. Which of the following information should the nurse include? A. "Drink at least 3 liters of fluid per day." B. "Weigh yourself weekly while wearing similar clothing at the same time of day." C. "Notify the provider of a weight loss of 1 pound or more per week." D. "Report nocturia because it requires a dosage adjustment."

D. "Report nocturia because it requires a dosage adjustment."

A nurse is teaching a client who is schedule for a vanillylmandelic acid test to screen for pheochromocytoma. Which of the following statements should the nurse include in the teaching? A. "Start fasting at midnight prior to the day of the test." B. "Begin the 24-hour urine collection with the first morning urination." C. "Take low-dose aspirin for pain during the testing period." D. "Restrict coffee intake 2 to 3 days prior to the test."

D. "Restrict coffee intake 2 to 3 days prior to the test."

A nurse is caring for a client who has a sodium level of 155 mEq/L. Which of the following IV fluids should the nurse anticipate the provider to prescribe? A. Dextrose 5% in 0.9% sodium chloride B. Dextrose 5% in lactated Ringer's C. 3% sodium chloride D. 0.45% sodium chloride

D. 0.45% sodium chloride Rationale: A sodium level of 155 mEq/L is an indication of hypernatremia. The nurse should anticipate a prescription for a hypotonic solution. The 0.45% sodium chloride is a hypotonic solution used to provide free water and treat cellular dehydration, which promotes waste elimination by the kidneys.

A nurse is teaching a client about the adrenocorticotropic (ACTH) stimulation test. The nurse should explain that the purpose of the test is to assess for which of the following disorders? A. Diabetes insipidus B. Hyperthyroidism C. Pheochromocytoma D. Addison's disease

D. Addison's disease Rationale: The nurse should instruct the client that the ACTH stimulation test is the standard test for Addison's disease. It measures the cortisol response to ACTH. The response is absent or very decreased in clients who have primary adrenal insufficiency.

A nurse is teaching a client who has diabetes mellitus. Which of the following should the nurse include as an expected finding of diabetic ketoacidosis (DKA)? A. Decreased urine output B. Weight gain of 0.45 kg (1 lb) in 24 hr C. Rapid, shallow respirations D. Blood glucose levels above 300 mg/dL

D. Blood glucose levels above 300 mg/dL

A nurse is caring for a client who has an implanted port that needs to be accessed for an infusion. Which of the following actions should the nurse take? A. Use a standard medium-gauge needle to access the port. B. Insert the primed needle into the port at a 45° angle. C. Withdraw the needle after insertion, leaving the needle's sheath in place for the infusion. D. Cover the device and the needle with a sterile transparent dressing.

D. Cover the device and the needle with a sterile transparent dressing. Rationale: Once the implanted port has been accessed, the needle must be supported and anchored. The needle should be covered with a transparent dressing to secure the needle.

A nurse is caring for a client who has bradycardia following a surgical procedure using spinal anesthesia. The nurse should plan to administer which of the following medications to the client? A. Amiodarone B. Propranolol C. Methyldopa D. Epinephrine

D. Epinephrine

A nurse is reviewing the laboratory results of a client undergoing screening for primary Cushing's disease. The nurse should expect an elevation in which of the following laboratory findings? A. Lymphocyte count B. Potassium C. Calcium D. Glucose

D. Glucose

A home health nurse is assessing a client who requires lifelong hormone replacement therapy for the treatment of hypothyroidism. The client has not been taking the medication regularly. Which of the following findings should the nurse expect? A. Increased urine output B. Persistent diarrhea C. Tachycardia D. Hypotension

D. Hypotension

A nurse is assessing a client who has dehydration. Which of the following assessments is the priority? A. Skin turgor B. Urine output C. Weight D. Mental status

D. Mental status

A nurse is caring for a client who had an open transverse colectomy 5 days ago. The nurse enters the client's room and recognizes that the wound has eviscerated. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take? A. Go to the nurses' station to seek assistance. B. Reinsert the organs into the abdominal cavity. C. Place the client in a reverse Trendelenburg position. D. Obtain vital signs to assess for shock.

D. Obtain vital signs to assess for shock.

A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports this finding? A. Sodium 152 mEq/L B. Chloride 102 mEq/L C. Magnesium 1.8 mEq/L D. Potassium 6.1 mEq/L

D. Potassium 6.1 mEq/L Rationale: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, can cause a prolonged PR interval, a wide QRS complex, flat or absent P waves, and tall, peaked T waves.

A nurse is providing preoperative teaching to a client who is scheduled for a gastrectomy in 1 week. The client expresses anxiety about the upcoming surgery. Which of the following actions should the nurse take? A. Sympathize with the client's feelings. B. Reassure the client that the surgery will go fine. C. Change the topic of discussion. D. Provide concise, factual information.

D. Provide concise, factual information.

A nurse is caring for a client who has type 2 diabetes mellitus and is experiencing a hyperglycemic-hyperosmolar state (HHS). Which of the following laboratory findings should the nurse expect? A. Serum pH 7.32 B. Blood glucose 250 mg/dL C. Blood glucose 425 mg/dL D. Serum pH 7.45

D. Serum pH 7.45 Rationale: A client who is experiencing HHS produces enough insulin to prevent ketosis but not enough to prevent hyperglycemia. Therefore, the serum pH is within the expected reference range. Glucose levels will be above 600 mg/dL.

A nurse is preparing to obtain a blood sample from a client who has a triple-lumen central catheter in place. Which of the following actions should the nurse take? A. Discard the first 35 mL of aspirated blood before collecting the sample. B. Place the client in Trendelenburg position while withdrawing the blood sample. C. Withdraw the blood sample from the lumen that has the smallest diameter. D. Turn off the distal infusions for 1 to 5 min before obtaining the blood sample.

D. Turn off the distal infusions for 1 to 5 min before obtaining the blood sample. Rationale: To help ensure that the laboratory results will not be altered by the solutions infusing through the central access device, it is recommended that the nurse stop the distal infusions and clamp the tubing for 1 to 5 min before obtaining the blood sample. How long to stop the infusion varies with the type of infusion. The lumen with the largest diameter is generally the best choice for blood sampling.

A client is transferred from the surgical suite to the PACU following oral surgery. While monitoring the client's vital signs, the nurse finds that the client's tongue has become swollen and is obstructing the airway. Which of the following actions should the nurse take first? A. Contact the anesthesiologist. B. Assist with endotracheal intubation. C. Increase the client's flow of oxygen. D. Use the head-tilt, chin-lift method to open the airway.

D. Use the head-tilt, chin-lift method to open the airway.

A nurse is reviewing the medical record of a client who is scheduled for an elective surgery. Which of the following medications should the nurse expect the provider to discontinue prior to surgery to minimize the risk for complications? A. Cefazolin B. Digoxin C. Ondansetron D. Warfarin

D. Warfarin

A nurse is reviewing the ABG results for four clients. Which of the following should the nurse identify as metabolic acidosis? A. pH 7.51, PaO2 94 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L B. pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 24 mEq/L C. pH 7.36, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 26 mEq/L D. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L

D. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L