Fundamental Skills
The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?
Metabolic alkalosis
A client was diagnosed with acute pancreatitis 10 days ago. The nurse interprets that the episode of acute pancreatitis is fully resolved if the serum lipase level drops to which value?
135 units/L
A client with a seizure disorder is taking phenytoin (Dilantin). A sample for a serum phenytoin level is drawn, and the nurse determines that the next dose of the medication may be administered if which laboratory result is noted?
17 mcg/mL
A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement?
"Let's talk more about the different forms of complementary therapies."
An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is the most important to provide to the client?
"You will need to talk to your health care provider (HCP) before using an herbal substance."
The nurse is reviewing the serum magnesium results for a group of clients. Which results warrant a call to the health care provider by the nurse? Select all that apply.
1.2 mg/dL 3.0 mg/dL 4.2 mg/dL
A client has a history of mild renal insufficiency. Which serum creatinine level should the nurse determine is consistent with this problem?
1.9 mg/dL
A client with diabetes mellitus has a blood sample drawn for the determination of a fasting blood glucose level. When reviewing the client's results, the nurse determines that which requires a call to the health care provider for intervention?
240 mg/dL
The nurse determines that an adult male client admitted with dehydration and a hematocrit level of 56% has received adequate fluid volume replacement if which repeat hematocrit level is noted?
48%
A client with hepatic cirrhosis has been consuming a diet with optimal amounts of protein. The nurse determines that the client's consumption of dietary protein has been most effective if the total protein level is which value?
6.8 g/dL
The nurse is caring for a client with respiratory insufficiency. The arterial blood gas results indicate a pH of 7.50 and a PCo2 of 30 mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note?
A potassium level of 3.2 mEq/L
The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal?
Allowing the client to unwrap the utensils and prepare his own meal for eating
The nurse who is caring for a client with kidney failure notes that the client is dyspneic, and crackles are heard on auscultation of the lungs. Which additional signs/symptoms should the nurse expect to note in this client?
An increase in blood pressure
The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium?
Butter
The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL. Which prescribed medication should the nurse prepare to assist in administering to the client?
Calcitonin (Miacalcin)
The nurse is planning to reinforce nutrition instructions to an African-American client. When reviewing the plan, the nurse is aware that which food is a common dietary practice of clients with African-American heritage?
Fried foods
The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom is an indication of this electrolyte imbalance?
Generalized muscle weakness
The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use?
Increased specific gravity of the urine
The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. Which should the nurse observe for on the cardiac monitor as a result of this laboratory value?
Narrow, peaked T waves
A client with a history of gastrointestinal bleeding has a platelet count of 300,000 cells/mm3. Which action by the nurse is most appropriate after reading this report?
Place the normal report in the client's medical record.
The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional signs/symptoms should the nurse expect to note in this client if hyponatremia is present?
Postural blood pressure changes
The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL. The nurse understands which condition causes this serum calcium level?
Prolonged bed rest
The nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which information about the client is of least priority during the data collection?
Psychosocial
The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should monitor the client for which acid-base imbalance?
Respiratory acidosis
The nurse is told that the blood gas results indicate a pH of 7.50 and a PCo2 of 32 mm Hg. The nurse determines that these results are indicative of which acid-base disturbance?
Respiratory alkalosis
The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit?
The client receiving nasogastric suction
A client with a history of cardiac disease is scheduled for a dose of furosemide (Lasix). Which serum potassium level warrants a call to the health care provider by the nurse before administering the furosemide?
3.2 mEq/L
When caring for the following group of clients, who does the nurse determine is at risk for development of metabolic alkalosis? Select all that apply.
Client who has been vomiting for 2 days Client receiving furosemide (Lasix) 40 mg daily
The nurse is reading the health care provider's (HCP's) progress notes in the client's record and sees that the HCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?
Client with a fast respiratory rate
A client has the following laboratory values: a pH of 7.55, an HCO3- level of 22 mm Hg, and a PCo2 of 30 mm Hg. Which action should the nurse take?
Encourage the client to slow down breathing.
The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed, and the serum calcium level is 12.0 mg/dL. Based on this laboratory value, the nurse should take which action?
Inform the registered nurse of the laboratory value.
A client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is most likely the result of which factor in the client's history?
Iron deficiency anemia
The nurse is caring for a client with diabetic ketoacidosis and observes that the client is experiencing abnormally deep, regular, rapid respirations. How should the nurse correctly document this observation in the medical record?
Kussmaul's respirations observed
The nurse consults with a dietitian regarding the dietary preferences of an Asian-American client. Which food should the nurse suggest to include in the diet plan?
Rice
The registered nurse reviews the results of the arterial blood gases with the licensed practical nurse (LPN) and tells the LPN that the client is experiencing respiratory acidosis. The LPN should expect to note which on the laboratory result report?
pH 7.25, PCO2 50 mm Hg
A client having preadmission testing before surgery has blood drawn for the determination of serum electrolyte levels. The nurse determines that which result warrants a call to the health care provider by the nurse?
Sodium, 148 mEq/L
The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit?
The client with a colostomy
The nurse determines that sodium polystyrene sulfonate (Kayexalate) has been effective in a client if which laboratory result is noted?
Serum potassium is 4.9 mEq/L.
A nursing student is asked to identify the practices and beliefs of the Amish society. Which should the student identify? Select all that apply.
Many choose not to have health insurance. They believe that health is a gift from God. They use both traditional and alternative health care, such as healers, herbs, and massage. Funerals are conducted in the home without a eulogy, flower decorations, or any other display. Caskets are plain and simple, without adornment.
The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder?
Metabolic acidosis
The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing?
The client with diabetes mellitus
The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse expects that this sodium level would be noted in a client with which condition?
The client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)
A client arrives in the emergency department complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL. How should the nurse correctly interpret these results?
The level is indicative of a myocardial infarction.
The nurse is caring for a group of clients who are taking herbal medications at home. Which client should be given instructions in regard to avoiding the use of herbal medications?
The mother of a 10-year-old child with a urinary tract infection
A Hispanic-American mother brings her child to the clinic for an examination. Which is most important when gathering data about the child?
Touching the child during the examination
The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level should be noted with which condition?
Traumatic burn
A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. The nurse assists with performing Allen's test before drawing the blood to determine the adequacy of which?
Ulnar circulation
The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the health care provider?
Valerian
The nurse is told that the laboratory result for the serum digoxin level is 2.4 ng/mL. Which action should the nurse take?
Withhold the medication.
A client with atrial fibrillation who is receiving maintenance therapy with warfarin sodium (Coumadin) has a prothrombin time (PT) of 30 seconds. The nurse anticipates that which will be prescribed?
Withholding the next dose of warfarin sodium
