Fluid and Electrolyte
The nurse is caring for a client admitted for cardiogenic shock. Which statement by the family should most concern the nurse immediately? Select all that apply. 1. "His lips look a little bluish." 2. "He has gained 5 pounds this week." 3. "I think his ankles look bigger." 4. "He has a very wet cough today." 5. "He's urinating a lot more today."
1. "His lips look a little bluish." 4. "He has a very wet cough today."
The nurse is caring for a client with a potassium level of 2.4 mEq/L. Which statement made by the client warrants a telephone call to the health-care provider (HCP)? 1. "I feel like my heart is skipping a beat." 2. "I woke up this morning feeling nauseated." 3. "My leg was cramping during the night." 4. "I feel a little sleepy today."
1. "I feel like my heart is skipping a beat."
The nurse is reinforcing education for a client being discharged on potassium supplements. Which statement made by the client indicates a need for further education? 1. "I will take my potassium on an empty stomach." 2. "I will keep my appointments to get my potassium level checked." 3. "I will take my potassium with a full glass of water." 4. "I will not crush my extended-release potassium"
1. "I will take my potassium on an empty stomach."
The nurse is teaching a client with hypernatremia about food options low in sodium. Which food choices indicate an understanding of the teaching? Select all that apply. 1. 1 small fresh orange 2. 3 ounces of canned corn 3. 2 ounces of fresh carrots 4. 1 regular corn dog 5. 2 slices of American cheese 6. 1 cup of brown rice
1. 1 small fresh orange 3. 2 ounces of fresh carrots 6. 1 cup of brown rice
The nurse is assisting in triage of clients in the emergency department. Which client should the nurse expect to be seen first? 1. 47-year-old client receiving chemotherapy with a temperature of 101.4° F (38.6° C) 2. 32-year-old client reporting painful urination and flank pain 3. 16-year-old client ambulatory with a bandaged cut on forehead 4. 40-year-old client reporting nausea and vomiting for the last 2 hours with no relief
1. 47-year-old client receiving chemotherapy with a temperature of 101.4° F (38.6° C)
The nurse is caring for four clients. Which client has the highest risk of septic shock? 1. 67-year-old client with a urinary tract infection (UTI) that tested positive for Escherichia coli 2. 37-year-old client diagnosed with pneumonia reporting chest pain 3. 75-year-old client postoperative hip replacement reporting pain in left hip 4. 21-year-old client diagnosed with tonsillitis with a fever of 101.1° F (38.4° C)
1. 67-year-old client with a urinary tract infection (UTI) that tested positive for Escherichia coli
The nurse is reviewing arterial blood gas (ABG) results for a client. Which pH value would the nurse expect to find in a client with acidosis? 1. 7.23 2. 7.38 3. 7.41 4. 7.49
1. 7.23
The nurse is screening clients at risk for sepsis. Which client has a higher risk for sepsis? Select all that apply. 1. 82-year-old client diagnosed with urinary tract infection (UTI) and confusion 2. 42-year-old client receiving chemotherapy admitted for pneumonia 3. 6-month-old infant admitted with severe burns on hands 4. 33-year-old client post-myocardial infarction 5. 21-year-old HIV-positive client admitted with an opportunistic infection
1. 82-year-old client diagnosed with urinary tract infection (UTI) and confusion 2. 42-year-old client receiving chemotherapy admitted for pneumonia 3. 6-month-old infant admitted with severe burns on hands 5. 21-year-old HIV-positive client admitted with an opportunistic infection
The nurse is caring for a group of clients. Which of the following clients is at high risk for developing hyponatremia? Select all that apply. 1. A client who is nothing by mouth (NPO) 2. A client with dry skin 3. A client taking diuretics 4. A client with constipation 5. A client who experienced a near-drowning in freshwater
1. A client who is nothing by mouth (NPO) 3. A client taking diuretics 4. A client with constipation 5. A client who experienced a near-drowning in freshwater
The nurse is caring for a group of clients. Which clients does the nurse recognize as being at risk for hypomagnesemia? Select all that apply. 1. A client with anorexia 2. A client with fluid volume excess 3. A client with hyperthermia 4. A client with kidney disease 5. A client with Crohn's disease 6. A client with chronic alcoholism
1. A client with anorexia 4. A client with kidney disease 5. A client with Crohn's disease 6. A client with chronic alcoholism
The nurse is caring for a group of clients. Which client is at highest risk for developing respiratory acidosis? 1. A client with chronic obstructive pulmonary disease (COPD) 2. A client with anorexia 3. A client with anxiety disorder 4. A client with a nasogastric tube connected to suction
1. A client with chronic obstructive pulmonary disease (COPD)
The nurse is reviewing lab values for a client and notes a magnesium level of 1.0 mEq/L. Which of the following interventions should the nurse expect to implement? 1. Administer magnesium sulfate intravenously (IV) per order 2. Insert an indwelling Foley catheter 3. Apply oxygen at 4 L/min via nasal cannula 4. Prepare the client for dialysis
1. Administer magnesium sulfate intravenously (IV) per order
Question 90. The nurse is caring for a client who just underwent a parathyroidectomy. What should the nurse have readily available for emergency use? 1. Calcium gluconate 2. Vitamin D 3. Loop diuretics 4. Isotonic intravenous (IV) fluid
1. Calcium gluconate
The nurse is reviewing lab results for a client with fluid volume deficit and notes a sodium level of 118 mEq/L. The nurse will expect the client to exhibit which of the following clinical manifestations? Select all that apply. 1. Confusion 2. Decreased body temperature 3. Changes in mental status 4. Increase in urine output 5. Weight gain 6. Excessive hunger
1. Confusion 3. Changes in mental status
The nurse is caring for a client diagnosed with cardiogenic shock. The nurse understands that which of the following are potential complications of shock? Select all that apply. 1. Disseminated intravascular coagulation (DIC) 2. Multiple organ dysfunction syndrome (MODS) 3. Paralytic ileus 4. Acute respiratory distress syndrome (ARDS) 5. Cerebral edema
1. Disseminated intravascular coagulation (DIC) 2. Multiple organ dysfunction syndrome (MODS) 3. Paralytic ileus 4. Acute respiratory distress syndrome (ARDS)
The nurse is caring for a client with fluid volume excess who has begun to feel short of breath. Which of the following interventions should the nurse implement? 1. Elevate the head of the bed 2. Instruct the client to lie on their left side 3. Apply oxygen at 4 L via nasal cannula 4. Teach the client to cough and deep breathe
1. Elevate the head of the bed
The nurse is caring for a client with fluid volume excess. Which of the following medications can the nurse expect to administer? 1. Furosemide 2. 0.9% normal saline 3. Clindamycin 4. Dexamethasone
1. Furosemide
The nurse is caring for a client in the compensated stage of shock. Which finding should the nurse expect? 1. Heart rate 112 beats/min 2. Systolic blood pressure of 87/55 mm Hg 3. Tachypnea with crackles 4. Urine output 15 mL/hr
1. Heart rate 112 beats/min
A client admitted with hypovolemia asks the nurse the cause of this condition. The nurse identifies which of the following as risk factors for hypovolemia? Select all that apply. 1. Hemorrhage 2. Vomiting 3. Constipation 4. Liver cirrhosis 5. Burns 6. Dry skin
1. Hemorrhage 2. Vomiting 4. Liver cirrhosis 5. Burns
A client presents to the hospital reporting diarrhea and vomiting for 3 days. The nurse notes the client also has a fever and tachycardia. The nurse suspects the client is experiencing which of the following? 1. Hyponatremia 2. Hypernatremia 3. Hyperkalemia 4. Hypokalemia
1. Hyponatremia
The nurse is caring for a hypotensive client with neurogenic shock who is unresponsive to intravenous (IV) crystalloid fluids. Which order should the nurse anticipate the health-care provider to prescribe next? 1. IV norepinephrine infusion 2. IV morphine administration 3. Continuous monitoring of urinary output 4. Obtain blood for ordered labs
1. IV norepinephrine infusion
The nurse is caring for a client diagnosed with cardiogenic shock. Which nursing diagnosis is a priority? 1. Ineffective tissue perfusion 2. Deficient knowledge 3. Ineffective grieving 4. Impaired skin integrity
1. Ineffective tissue perfusion
The nurse is explaining shock to an elderly client admitted to the unit. Which intervention should be included in the teaching? Select all that apply. 1. Involve family members/caregiver in instruction 2. Speak in high-pitched tones for hard-of-hearing clients 3. Provide larger print material 4. Allow time for questions 5. Use medical terminology
1. Involve family members/caregiver in instruction 3. Provide larger print material 4. Allow time for questions
The nurse is caring for a client who has developed fluid volume deficit. Which of the following interventions should the nurse expect to implement? 1. Monitor weight daily 2. Implement fluid restriction 3. Administer diuretics as ordered 4. Observe for edema
1. Monitor weight daily
The nurse is caring for a hypotensive client diagnosed with septic shock. Which orders by the health-care provider should the nurse consider priority? Select all that apply. 1. Obtain two sets of blood cultures 2. Administer ordered broad-spectrum antibiotics 3. Administer ordered stool softener 4. Turn client every 2 hr 5. Administer ordered crystalloid fluid bolus at 30 mL/kg
1. Obtain two sets of blood cultures 2. Administer ordered broad-spectrum antibiotics 5. Administer ordered crystalloid fluid bolus at 30 mL/kg
The nurse is caring for a client with dehydration. Which of the following clinical manifestations will the nurse expect the client to exhibit? Select all that apply. 1. Poor skin turgor 2. Increased urine output 3. Dark urine 4. Decreased body temperature 5. Constipation
1. Poor skin turgor 3. Dark urine 5. Constipation
The nurse is caring for a client diagnosed with distributive shock secondary to severe burns. The client's urinary output has decreased to 10 mL/hr. The nurse understands that this is a result of which physiological response? 1. Renin-angiotensin-aldosterone system 2. Parasympathetic nervous system 3. Epinephrine-cortisol-glucagon release 4. Anaerobic respiration
1. Renin-angiotensin-aldosterone system
The nurse is deciding whether to work at a facility that allows LPNs/LVNs to administer intravenous (IV) fluids. Which essential action should the nurse take to identify legal, safe standards of practice? 1. Review the state's Nurse Practice Act 2. Obtain the Infusion Nurses Society policy 3. Read the Institute for Healthcare Improvement guidelines 4. Examine the National Institute for Occupational Safety and Health procedures
1. Review the state's Nurse Practice Act
The nurse is caring for a client diagnosed with cardiogenic shock. The nurse notes new-onset crackles in the lower lungs and distended jugular veins. Which of these actions should the nurse anticipate the health-care provider to order next? Select all that apply. 1. Slow intravenous fluid infusion 2. Chest x-ray 3. 500 mL crystalloid fluid bolus 4. Obtain new set of vital signs 5. Obtain electrocardiogram
1. Slow intravenous fluid infusion 2. Chest x-ray 4. Obtain new set of vital signs 5. Obtain electrocardiogram
The nurse is preparing to administer intravenous (IV) norepinephrine to a client in septic shock. Which goal should the nurse expect the client to reach if treatment is effective? Select all that apply. 1. Systolic blood pressure above 100 mm Hg 2. SpO2 < 93% 3. Tachycardia 4. Decrease in white blood cell count 5. Bronchodilation
1. Systolic blood pressure above 100 mm Hg 3. Tachycardia
The nurse is caring for a client diagnosed with cardiogenic shock. Which finding indicates an improvement in client condition? Select all that apply. 1. Venous lactic acid level >2.2 mmol/L 2. Urinary output < 30 ml/hr 3. Addition of norepinephrine drip 4. Increased prothrombin time 5. Elevated pulmonary wedge pressure
1. Venous lactic acid level >2.2 mmol/L
The nurse is caring for a client who is in metabolic alkalosis. The client asks the nurse about the cause of the diagnosis. The nurse describes which of the following as a cause of metabolic alkalosis? Select all that apply. 1. vomiting 2.hypovolemia 3. anxiety 4. hypokalemia
1. vomiting 2. hypovolemia 4. hypokalemia
The nurse is caring for a group of clients. Which of the following clients is at high risk for developing hyponatremia? Select all that apply. 1. A client who is nothing by mouth (NPO) 2. A client with dry skin 3 .A client taking diuretics 4. A client with constipation 5. A client who experienced a near-drowning in fresh water 6. A client with a bowel obstruction connected to high intermittent suction
1.A client who is nothing by mouth (NPO) 3. a client taking diuretics 5. a client who experienced a near-drowning in fish water 6. client with a bowel obstruction connected to high intermittent suction
A client with hypokalemia is prescribed a second order for 1 L of 0.9% normal saline with 40 mEq of potassium per liter. The fluid is ordered to run for 8 hrs. At what rate will the nurse set the infusion pump? Enter the numeral only.
125
A client with dehydration has been prescribed 500 mL of 0.9% normal saline to run over 3 hrs using a microdrip set with a drip factor of 60 gtt/mL. Calculate the drip rate for the solution. Record your answer as a whole number. Enter the numeral only.
167
The nurse is caring for a 174-pound client diagnosed with septic shock. A bolus is ordered by the provider at 30 mL/kg. The nurse should expect to administer how many milliliters of fluid? Round to the nearest whole number. Enter the numeral only.
2,373
The nurse is preparing to discharge a client prescribed an epinephrine autoinjector. What statement by the client indicates that teaching has been successful? Select all that apply. 1. "I should wait to take my autoinjector until a doctor tells me to." 2. "I should go to the hospital after using my autoinjector." 3. "I should always carry my autoinjector with me." 4. "The epinephrine will open my airways if I'm having a reaction." 5. "Epinephrine takes a long time before it starts working."
2. "I should go to the hospital after using my autoinjector." 3. "I should always carry my autoinjector with me." 4. "The epinephrine will open my airways if I'm having a reaction."
A client asks the nurse what causes fluid volume excess. What is the nurse's best response? 1. "You may be experiencing this because you don't eat a diet high in sodium." 2. "You were diagnosed with heart failure last year, which can cause you to retain fluid." 3. "You may experience an increase in fluid if you have had diarrhea recently." 4. "Since you have been dehydrated, you will notice your feet swell."
2. "You were diagnosed with heart failure last year, which can cause you to retain fluid."
The nurse is teaching a client about options for food high in calcium. Which food choices made by the client indicate an understanding of the teaching? Select all that apply1. 1. 1 large orange 2. 8 ounces of plain yogurt 3. 1 cup of low-fat milk 4. 1 cup of canned pasta with meat sauce 5. 1 slice of white bread 6. 1 cup canned tomato juice
2. 8 ounces of plain yogurt 3. 1 cup of low-fat milk
A client in cardiogenic shock has a weak, thready radial pulse. What is the minimal systolic blood pressure (SBP) the nurse should expect? 1. 70 mm Hg 2. 80 mm Hg 3. 90 mm Hg 4. 100 mm Hg
2. 80 mm Hg
The nurse is caring for a group of clients. Which of the following clients is at highest risk for fluid volume excess? 1. A client who refuses to drink water 2. A client who has received six liters of intravenous (IV) fluid 3. A client who has been vomiting for 2 days. 4. A client who currently has diarrhea
2. A client who has received six liters of intravenous (IV) fluid
The nurse is caring for a client with a calcium level of 6 mg/dL. The nurse would expect the client to exhibit which clinical manifestation? 1. Increased blood pressure 2. Altered heart rhythm 3. Constipation 4. Increased heart rate
2. Altered heart rhythm
The nurse is caring for a 75-year-old client admitted with dehydration. The nurse knows that the following statements are true regarding dehydration and older adults. Select all that apply. 1. Older adults have an increase in thirst sensation 2. An older adult has a decrease in total body water from 60% to 50% 3. Older adults need to be encouraged to drink fluids often 4. Older adults exhibit the same clinical manifestations of dehydration as a younger adult 5. Older adults require 30 mL/kg/day of fluids to prevent dehydration
2. An older adult has a decrease in total body water from 60% to 50% 3. Older adults need to be encouraged to drink fluids often 5. Older adults require 30 mL/kg/day of fluids to prevent dehydration
Which of the following is an example of an electrolyte? 1. Neutrophil 2. Calcium 3. Hemoglobin 4. Glucose
2. Calcium
The nurse is caring for a client admitted for septic shock. Vital signs are pulse 131 beats/min, blood pressure 110/72 mm Hg, respirations 18 breaths/min, and lactate 4.4 mmol/L. Which of these options should the nurse anticipate the health-care provider to order? Select all that apply. 1. Intravenous (IV) dobutamine 2. Crystalloid fluid bolus 30 mL/kg 3. Intravenous (IV) broad-spectrum antibiotics within 3 hr of diagnosis 4. Two sets of blood cultures prior to intravenous (IV) antibiotics 5. Continuous urinary output monitoring
2. Crystalloid fluid bolus 30 mL/kg 4. Two sets of blood cultures prior to intravenous (IV) antibiotics 5. Continuous urinary output monitoring
The nurse is caring for a client presenting with obstructive shock. Which nursing diagnoses are priority? Select all that apply. 1. Knowledge deficit 2. Decreased cardiac output 3. Disturbed thought process 4. Ineffective breathing pattern 5. Ineffective tissue perfusion
2. Decreased cardiac output 4. Ineffective breathing pattern 5. Ineffective tissue perfusion
The nurse is caring for a client in the emergency department reporting severe chest pain. Which additional finding would indicate the client is in cardiogenic shock? Select all that apply. 1. Blood pressure 146/99 mm Hg 2. Distended jugular veins 3. Respirations 18 breaths/min 4. Pulse 126 beats/min 5. Coarse crackles in lower lobes of lungs
2. Distended jugular veins 4. Pulse 126 beats/min 5. Coarse crackles in lower lobes of lungs
The nurse is taking a medication history on a client admitted with hypokalemia. Which of the following medications would be of most concern to the nurse? 1. Spironolactone 2. Furosemide 3. Triamterene 4. Amiloride
2. Furosemide
The nurse is caring for a client admitted with kidney failure waiting to receive dialysis. Which of the following electrolyte imbalances should the nurse expect to see? 1. Hypocalcemia 2. Hyperkalemia 3. Hyponatremia 4. Hypomagnesemia
2. Hyperkalemia
The nurse is caring for a client diagnosed with hypovolemic shock after a fall. The client reports taking a stool-softener, a beta-blocker, and an 81-mg aspirin daily. Which abnormal assessment finding should the nurse expect in this client? Select all that apply. 1. Tachycardia 2. Hypotension 3. Thready peripheral pulses 4. Flat, nondistended peripheral veins 5. Distended jugular veins
2. Hypotension 3. Thready peripheral pulses 4. Flat, nondistended peripheral veins
The nurse is caring for a client who has returned from a magnetic resonance imaging (MRI) scan with contrast. Which of the following findings would indicate an anaphylactic reaction to the intravenous (IV) contrast? Select all that apply. 1. Bradycardia 2. Hypotension 3. Urticaria 4. Distended jugular veins 5. Pruritus
2. Hypotension 3. Urticaria 5. Pruritus
The nurse is caring for a client prescribed several intravenous (IV) medications. The nurse notes a pressure ulcer on the left posterior aspect of the foot. The nurse understands which medication increases risk for pressure-related injuries? Select all that apply. 1. IV vancomycin 2. IV vasopressin 3. IV diphenhydramine 4. IV norepinephrine 5. IV methylprednisolone
2. IV vasopressin 4. IV norepinephrine
The nurse is caring for a client with severe fluid volume excess. What clinical manifestations should the nurse expect to find on assessment? Select all that apply. 1. Decreased blood pressure 2. Increased respirations 3. Pitting edema in the feet 4. Decreased urine output 5. Weight gain 6. Crackles in the lungs
2. Increased respirations 3. Pitting edema in the feet 5. Weight gain 6. Crackles in the lungs
The nurse is caring for a client who has new-onset confusion and has been diagnosed with a thoracic tumor. Vital signs are pulse 141 beats/min, blood pressure 74/51 mmHg, SpO2 93% on room air, and respirations 28 breaths/min. Which type of shock should the nurse expect the health-care provider to diagnose? 1. Septic shock 2. Obstructive shock 3. Hypovolemic shock 4. Anaphylactic shock
2. Obstructive shock
The nurse is assisting in the care of a client suffering from septic shock. Which order should the nurse question? 1. Administer crystalloid intravenous (IV) fluids at 30 mL/kg 2. Place the client in the Trendelenburg position 3. Draw two sets of blood cultures 4. Prepare for administration of broad-spectrum antibiotics
2. Place the client in the Trendelenburg position
The nurse is caring for a client with a diagnosis of fluid volume excess (FVE). Which intervention should the nurse include in the plan of care? 1. Administer 0.9% normal saline intravenously 2. Restrict sodium in the diet 3. Encourage fluid intake 4. Prepare the client for dialysis
2. Restrict sodium in the diet
The nurse is reviewing lab values for a group of clients. Which lab value would be of most concern to the nurse? 1. Magnesium 1.6 mEq/L 2. Sodium 120 mEq/L 3. Potassium 4.0 mEq/L 4. Calcium 10mg/dL
2. Sodium 120 mEq/L
A client with dehydration is prescribed intravenous (IV) fluid of 0.9% normal saline solution. The order is for 1 L to run over 4 hrs. At what rate should the nurse set the infusion pump? Enter the numeral only.
250
Which intravenous fluid should be maintained for a client who is receiving blood? 1. 3% sodium chloride 2. 0.45% sodium chloride 3. 0.9% sodium chloride 4. 5% sodium chloride
3. 0.9% sodium chloride
The nurse is monitoring intake and output for a client with fluid volume excess. The client consumed 240 mL of orange juice, 1.5 L of water, 1 L of 0.9% normal saline, and 480 mL of chicken broth. How many milliliters will the nurse document for the client's intake? 1. 2220mL 2. 3000mL 3. 3220mL 4. 4000mL
3. 3220mL
The nurse is assigned to the following clients. Which client should the nurse see first? 1. A client post-acute myocardial infarction with a blood pressure of 102/68, pulse of 77 beats/min, and respirations of 14 breaths/min.. 2. A client diagnosed with a urinary tract infection (UTI) with a blood pressure of 155/87, pulse of 61 beats/min, and respirations of 16 breaths per minute 3. A client that fell off a ladder with a blood pressure of 84/55, pulse of 54 beats/min, and respirations of 14 breaths per minute. 4. A client with a migraine reporting dizziness and nausea
3. A client that fell off a ladder with a blood pressure of 84/55, pulse of 54 beats/min, and respirations of 14 breaths per minute.
The nurse is reviewing lab values for a group of clients and notes a potassium level of 7 mEq/L in a client. Which of the following clients is most at risk for developing this potassium imbalance? 1. A client taking furosemide for heart failure 2. A client who has been vomiting for 3 days 3. A client with chronic kidney failure 4. A client with Cushing's syndrome
3. A client with chronic kidney failure
The nurse is reviewing forms of shock. Which of the following are not forms of distributive shock? 1. Septic shock 2. Neurogenic shock 3. Cardiogenic shock 4. Anaphylactic shock
3. Cardiogenic shock
The nurse is reviewing the pathophysiology of shock with a colleague. The nurse understands that altered body fluid distribution without blood loss is a cause for which type of shock? 1. Cardiogenic shock 2. Obstructive shock 3. Distributive shock 4. Hypovolemic shock
3. Distributive shock
The nurse is caring for a client reporting urticaria, pruritus, wheezing, and apprehension. Which order from the provider should the nurse question? Select all that apply. 1. Intramuscular (IM) epinephrine 2. Diphenhydramine 3. Dobutamine drip 4. Methylprednisolone 5. Crystalloid fluid bolus
3. Dobutamine drip 5. Crystalloid fluid bolus
The nurse reviews the effects of epinephrine on the body with a colleague. Which statement indicates a need for further teaching? 1. Epinephrine increases the heart rate 2. Epinephrine can cause elevated glucose readings 3. Epinephrine causes decreased blood pressure 4. Epinephrine is released from the adrenal glands
3. Epinephrine causes decreased blood pressure
The nurse is caring for a client receiving multiple liters of intravenous (IV) fluid following surgery. For which complication should the nurse assess? 1. Fluid volume deficit 2. Liver failure 3. Fluid volume excess 4. New onset of seizures
3. Fluid volume excess
The nurse is assisting in blood draws for a client diagnosed with septic shock. The nurse should expect which acid/base disorder? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
3. Metabolic acidosis
The nurse is confused about a client's IV medication. Which of these is the best action the nurse should take? 1. Ask the unlicensed assistive personnel (UAP) for input 2. Consult another LPN/LVN 3. Notify the RN 4. Base decision on what the drug book said
3. Notify the RN
The nurse is caring for a client in the emergency department with a stab wound to the left lower leg. The wound is actively bleeding, and vital signs are: heart rate 110 beats/min, blood pressure 94/61 mm Hg, and SpO2 98% on room air. Which intervention should the nurse perform first? 1. Obtain intravenous (IV) access 2. Place the client on 2 L of oxygen 3. Place pressure dressing on wound 4. Obtain a rectal temperature
3. Place pressure dressing on wound
The nurse is caring for a client on a continuous electrocardiogram (ECG). The ECG shows a potential dysrhythmia, and the client reports increased shortness of breath and crushing chest pain. Vitals remain stable. Which action should the nurse anticipate the health-care provider will do next? 1. Administer intravenous (IV) norepinephrine 2. Administer crystalloid fluid bolus at 30 mL/kg 3. Prepare for potential coronary angioplasty 4. Obtain two sets of blood cultures
3. Prepare for potential coronary angioplasty
The nurse is caring for a client diagnosed with septic shock. The client's vitals are: blood pressure 84/64, heart rate 134, respiratory rate 20, and temperature 97.4° F (36.3° C). The nurse should understand the client is in which phase of shock? 1. Compensated 2. Irreversible 3. Progressive 4. Anaerobic metabolism
3. Progressive
The nurse is caring for a client diagnosed with septic shock. Which set of vital signs indicates treatment is successful? 1. Pulse 115 beats per minute, blood pressure 92/76 mm Hg, SpO2 86% on 2 L of oxygen per nasal cannula 2. Pulse 35 beats per minute, blood pressure 79/42 mm Hg, spO2 97% on room air 3. Pulse 88 beats per minute, blood pressure 110/77 mm Hg, spO2 94% on 4 L per nasal cannula 4. Pulse 155 beats per minute, blood pressure 55/35 mm Hg, spO2 91% on room air
3. Pulse 88 beats per minute, blood pressure 110/77 mm Hg, spO2 94% on 4 L per nasal cannula
The nurse is assessing a client presenting after a motor vehicle collision (MVC). Which assessment should the nurse consider top priority? 1. Medication allergies 2. Neurovascular checks on extremities 3. Pulse oximetry 4. Presence of peripheral edema
3. Pulse oximetry
The nurse is reviewing arterial blood gas (ABG) results for a client with chronic obstructive pulmonary disease (COPD) and notes a pH of 7.23. Which of the following imbalances is the client experiencing? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
3. Respiratory acidosis
Which type of fluid is found in synovial fluid in the joints? 1. Interstitial 2. Intravascular 3. Transcellular 4. Intracellular
3. Transcellular
The nurse is caring for a client in obstructive shock. Vital signs are blood pressure 77/46 mm Hg, pulse 166 beats/min, SpO2 96% on room air, respirations 22 breaths/min, and urinary output 20 mL/hr. Of the following objective findings, which indicates adequate perfusion? 1. Pulse 113 beats/min 2. Blood pressure 88/46 mm Hg 3. Urinary output 30 mL/hr 4. Respirations 18 breaths/min
3. Urinary output 30 mL/hr
The nurse expects a client to lose up to 2500 mL of sensible and insensible fluid each day. Which of the following is an example of sensible water loss? 1. Sweating 2. Breathing 3. Urination 4. Defecation
3. Urination
The nurse is assessing a client who is being treated for fluid volume excess. Which of the following situations warrants notifying the health-care provider (HCP)? 1. Lung sounds clear bilaterally 2. Neck veins nondistended 3. Urine output 10 mL/hr 4. Weight loss of 1 pound
3. Urine output 10 mL/hr
A client has a saline lock. Which technique is used when checking patency? 1. Scrub the hub for 5 seconds 2. Encourage fluid into lock 3. Use gentle pressure to insert fluid 4. Expect resistance during insertion of fluid
3. Use gentle pressure to insert fluid
The nurse is preparing to administer a beta-adrenergic agent to a client in cardiogenic shock. Which medication is a beta-adrenergic agent often used for cardiogenic shock? 1. epinephrine 2. phenylephrine hydrochloride 3. dobutamine 4. dexamethasone
3. dobutamine
The nurse is caring for a client reporting shortness of breath after a bee sting. Which medication is used to dilate the bronchioles during a severe allergic reaction? 1. diphenhydramine 2. hydrocortisone 3. epinephrine 4. norepinephrine
3. epinephrine
The nurse is reviewing laboratory values for a client and notes a calcium level of 13 mg/dL. The nurse can expect to see which of the following clinical manifestations? Select all that apply. 1. confusion 2.hyperactive deep tendon reflexes 3. increased heart rate 4. muscle weakness
3.Increased heart rate 4.Muscle weakness
The nurse is caring for a client who is prescribed furosemide. The nurse instructs the client on food choices for a diet high in potassium and low in sodium. Which food selection made by the client indicates an understanding of the teaching? 1. 1 cup of chicken noodle soup 2. 5 ounces of pork with barbecue sauce 3. 3 ounces of turkey breast luncheon meat 4. 1 plain baked potato
4. 1 plain baked potato
The nurse is caring for a 68-pound client diagnosed with septic shock. The provider orders a crystalloid fluid bolus for the client at 30 mL/kg. Which size bag should the nurse retrieve? 1. 100 mL 2. 250 mL 3. 500 mL 4. 1000 mL
4. 1000 mL
A client presents to the emergency room with multiple stab wounds to the abdomen. The client is severely hypotensive, tachycardic, and pale with diaphoretic skin. The nurse estimates how much fluid loss has occurred? 1. 15% 2. 20% 3. 25% 4. 40%
4. 40%
The nurse is reviewing arterial blood gas (ABG) results for a client admitted with hypokalemia. What can the nurse expect for a pH result? 1. 7.25 2. 7.35 3. 7.45 4. 7.55
4. 7.55
The nurse is caring for a group of clients. Which client is at highest risk for developing hypercalcemia? 1. A client with Crohn's disease 2. A client with hyperthermia 3. A client with dehydration 4. A client with metastatic lung cancer
4. A client with metastatic lung cancer
A client develops dry mucous membrane, skin tenting, and a decrease in urine output. Which of the following orders from the health-care provider should the nurse expect to implement? 1. Administer furosemide 2. Insert an indwelling Foley catheter 3. Implement a fluid restriction of 1500 mL per day 4. Administer 0.9% normal saline intravenously
4. Administer 0.9% normal saline intravenously
The nurse in the emergency room is observing a 6-year-old client after a bee sting. Which symptom should concern the nurse for anaphylaxis? 1. Hypothermia 2. Bulging jugular veins 3. Bradycardia 4. Angioedema
4. Angioedema
The nurse is assisting the RN in administering an intravenous (IV) piggyback medication. Which action is essential for the nurse to take? 1. Keep the IV site lower than the heart 2. Verify the client's identity with a single identifier 3. Double-check the dose with another nurse 4. Check compatibility of the medication with the IV infusion
4. Check compatibility of the medication with the IV infusion
The nurse is performing a test on a client with suspected hypocalcemia. Which test is shown in the graphic? (one eyed closed) 1. Trousseau's sign 2. Allen test 3. Homan's sign 4. Chvostek sign
4. Chvostek sign
The nurse is caring for a client returning from a computed tomography (CT) scan with contrast. Which symptom should concern the nurse? 1. Blood pressure of 145/87 2. Urine output of 36 mL/hr 3. SpO2 93% on room air 4. Diffuse wheezing in lungs
4. Diffuse wheezing in lungs
The nurse is caring for a client who has developed hyperthermia from working in extremely high temperatures. Which of the following electrolyte imbalances will the nurse expect the client to develop? 1. Hypomagnesemia 2. Hypocalcemia 3. Hypokalemia 4. Hyponatremia
4. Hyponatremia
The nurse is caring for a client diagnosed with septic shock. Which assessment finding warrants immediate intervention by the nurse? 1. Pedal edema 2. Distended jugular vein 3. Bounding pulse 4. Hypotension
4. Hypotension
A client has arrived at the emergency room after sustaining a fractured pelvis and fractured right femur from a motor vehicle accident. Vitals are pulse 144 beats/min, blood pressure 74/39 mm Hg, SpO2 93% on 2 L oxygen, temperature 99.0° F (37.2° C). The nurse understands that this client is most likely suffering from which type of shock? 1. Obstructive shock 2. Distributive shock 3. Septic shock 4. Hypovolemic shock
4. Hypovolemic shock
The nurse assists with care of a client suffering from heat stroke. The nurse notes pallor, clammy skin, and sinus tachycardia on the monitor. Which is the most likely cause? 1. Anaphylactic shock 2. Neurogenic shock 3. Obstructive shock 4. Hypovolemic shock
4. Hypovolemic shock
The nurse is caring for a client presenting with a penetrating wound to the left chest. The client is currently unconscious, and the nurse hears no breath sounds on the left lung. Vitals are blood pressure 69/29, pulse 155 beats/min, and SpO2 86% on room air. Which type of shock does the nurse expect the health-care provider to diagnose? 1. Neurogenic shock 2. Hypovolemic shock 3. Anaphylactic shock 4. Obstructive shock
4. Obstructive shock
The nurse is caring for a client admitted with vomiting and diarrhea for 3 days. Which lab test should the nurse monitor? 1. Calcium 2. Phosphorus 3. Sodium 4. Potassium
4. Potassium
The nurse is caring for a client admitted to the unit for myocarditis that has progressed to cardiogenic shock. Which symptom would the nurse expect to see in cardiogenic shock? 1. Hypertension 2. Urticaria 3. Bradycardia 4. Pulmonary edema
4. Pulmonary edema
The nurse is reviewing the physiological response to shock. The nurse determines that the response to shock results from which mechanism? 1. Parasympathetic nervous system stimulation 2. Sympathetic nervous system inhibition 3. Central nervous system depression 4. Sympathetic nervous system stimulation
4. Sympathetic nervous system stimulation
The nurse is performing a test on a client with suspected hypocalcemia. Which is shown in the graphic? (fingertips facing downward) 1. Allen test 2. Chvostek sign 3. Homan's sign 4. Trousseau's sign
4. Trousseau's sign
The nurse is caring for a client receiving furosemide. Which of the following clinical manifestations would be of most concern to the nurse? 1. Paresthesia and irritability 2. Increased blood pressure and muscle spasms 3. Restlessness and agitation 4. Weak, irregular pulse and decreased muscle tone
4. Weak, irregular pulse and decreased muscle tone
A client weighed 140 pounds yesterday. Today the client weighs 138 pounds. 1 pint of fluid (473 mL) weighs 1 pound. How many milliliters of fluid did the client lose? Enter the numeral only.
946
