NRS 3015: Exam #3 Practice Questions

A nurs is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources? a. Cadaver skin b. Pig skin c. Amniotic membranes d. Beef collagen

b

A nurse at a provider's office is reviewing information with a client scheduled for pulmonary function tests (PFTs). Which of the following information should the nurse include? a. "Do not use inhaler medications for 6 hr following the test." b. "Do not smoke tobacco for 6 to 8 hr prior to the test." c. "You will be asked to bear down and hold your breath during the test." d. "The arterial blood flow to your hand will be evaluated as part of the test."

b

A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? a. Estimation of the burn injury b. Characteristics of cough and sputum c. Extent of peripheral edema d. Amount of urine output

b

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 rhythms c. Peripheral effusion d. Bowel sounds

b

A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid or electrolyte imbalances should the nurse expect? a. Hypokalemia b. Hypernatremia c. Elevated Hct d. Decreased Hgb

c

A nurse enters a client's room and notes smoke coming from a wastebasket in the adjacent bathroom. Which of the following actions should the nurse take first? a. Close the door to the client's room b. Attempt to extinguish the fire c. Activate the facility's fire alarm system d. Transport the client to an area away from the smoke

d

A nurse in an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following actions should the nurse take first? a. Cover the child's wound with a clean, dry cloth b. Establish IV access with a large-bore catheter c. Provide reassurance to the child's parents d. Determine the child's breathing pattern

d

A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? a. Respiratory alkalosis b. Metabolic alkalosis c. Respiratory acidosis d. Metabolic acidosis

d

A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? a. Blood-tinged sputum b. Dry, nonproductive cough c. Sore thorat d. Bronchospasms

d

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

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 mouth." d. "I will add broccoli and kale to my diet."

d

A nurse is assessing a client who has pancreatitis. The client's arterial blood gases reveal metabolic acidosis. Which of the following are expected findings? (select all that apply.) a. Tachycardia b. Hypertension c. Bounding pulses d. Hyperreflexia e. Dysrhythmias f. Tachypnea

e, f

A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis. Which of the following statements by a unit nurse indicates the teaching has been effective? a. "Metabolic acidosis can occur due to diabetic ketoacidosis." b. "Metabolic acidosis can occur in a client who has myasthenia gravis." c. "Metabolic acidosis can occur in a client who has asthma." d. "Metabolic acidosis can occur due to cancer."

a

A nurs is caring for a client who has burn injuries on his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching? a. "I will be on a special shower table." b. "The water temperature will be very cool to ease my pain." c. "The nurse will use a firm-bristled brush to remove loose skin." d. "The nurse will use scissors to open small blisters."

a

A nurse in a provider's office is assessing a client who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? a. Superficial thickness b. Superficial partial thickness c. Deep partial thickness d. Full thickness

a

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 imbalance? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

a

A nurse is assessing a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances? a. Hypokalemia b. Hypophosphatemia c. Hypercalcemia d. Hypermagnesemia

a

A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance? a. Diabetic ketoacidosis b. Heart failure c. Cushing's syndrome d. Thyroidectomy

a

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

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

A nurse is assessing a client who has isotonic dehydration. Which of the following findings should the nurse expect? a. Increased hematocrit level b. Bradycardia c. Distended neck veins d. Decreased urine specific gravity

a

A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? a. Weight gain of 1 kg (2.2 lb) in 1 day b. Pitting edema +1 c. Client report of a nocturnal cough d. B-type natriuretic peptide (BNP) level of 100 pg/mL

a

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

A nurse is assessing a client who is receiving a hydrochlorothiazide and notes that the client is confused and lethargic. Which of the 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

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/dL

a

A nurse is caring for a child who has electrical burns on the lower arms and hands. Which of the following findings indicate the child is experiencing a complication of the injury? a. Dark urine b. 2+ radial pulses c. Respiratory rate of 20/min d. Minimal pain

a

A nurse is caring for a client who has a blood potassium 5.4 meq/L. The nurse should assess for which of the following manifestations? a. ECG changes b. Constipation c. Polyuria d. Paresthesia

a

A nurse is caring for a client who has a blood sodium level 133 meq/L and blood potassium level 3.4 meq/L. The nurse should recognize that which of the following treatments can result in these laboratory findings? a. Three tap water enemas b. 0.9% sodium chloride solution IV at 50 mL/hr c. 5% dextrose with 0.45% sodium chloride solution with 20 mEq of K+ IV at 80 mL/hr d. Antibiotic therapy

a

A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances? a. Hyperkalemia b. Hyponatremia c. Hypercalcemia d. Hypomagnesemia

a

A nurse is caring for a client who has osteoporosis and a new prescription for calcium supplements. Which of the following foods should the nurse recommend to promote calcium absorption? a. Fortified milk b. Ripe bananas c. Steamed broccoli d. Green leafy vegetables

a

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume? a. Sodium b. Calcium c. Potassium d. Magnesium

a

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion? a. Sodium 123 mEq/L b. Blood glucose 100 mg/dL c. Potassium 3.5 mEq/L d. Hemoglobin 13 g/dL

a

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? a. Position the client in an upright position, leaning over the bedside table b. Explain the procedure c. Obtain ABGs d. Administer benzocaine spray

a

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

a

A nurse is caring for a client with heart failure whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG cahge? a. Potassium 2.8 mEq/L b. Digoxin level 0.7 ng/mL c. Hemoglobin 9.8 g/dL d. Calcium 8.0 mg

a

A nurse is caring for accident. The client reports chest pain and difficulty breathing. A chest x‐ray reveals the client has a pneumothorax. Which of the following arterial blood gas findings should the nurse expect? a. pH 7.06, PaO2 86 mm Hg, PaCO2 52 mm Hg, HCO3− 24 meq/L b. pH 7.42, PaO2 100 mm Hg, PaCO2 38 mm Hg, HCO3− 23 meq/L c. pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg. HCO3− 18 meq/L d. pH 7.58, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3− 29 meq/L

a

A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image? a. "May I go with my family to the visitor's lounge?" b. "I'll see my friends when I get home." c. "My dad is coming to visit. Can you fix my hair for me?" d. "I told my cousins I'm in protective isolation."

a

A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? a. Elevated ST segments b. Absent P waves c. Depressed ST segments d. Varying PP intervals

a

A nurse is planning care for a client who has deep-partial thickness and full-thickness thermal burns over 40% of his total body surface and is in the acute phase of burn injury. Which of the following interventions should the nurse include in the plan? a. Initiate range-of-motion exercises b. Use clean technique to provide wound care c. Place the client on a low-protein diet d. Maintain the client on bed rest

a

A nurse is providing teaching to a client about pulmonary function testing. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? a. Total lung capacity b. Vital lung capacity c. Functional residual capacity d. Residual volume

a

A nurse is reviewing a client's laboratory report. The client's ABG levels are 7.5, PaCO2 32 mmHg, and HCO3 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances? a. Respiratory alkalosis b. Metabolic acidosis c. Respiratory acidosis d. Metabolic alkalosis

a

A nurse is reviewing the laboratory values of a client who has positive Chvstek's sign. Which of the following laboratory findings should the nurse expect? a. Decreased calcium b. Decreased potassium c. Increased potassium d. Increased calcium

a

A nurse is teaching a client who has extensive deep partial- and full-thickness burns and requires a topical antimicrobial medication. The goal of this medication therapy is to reduce which of the following outcomes? a. Bacterial growth b. Scarring c. Skin graft size d. Pain

a

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

A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (Select all that apply.) a. Explain that the client will receive sedation and will not remember the procedure b. Verify that the client understands the purpose and nature of the procedure c. Offer the client sips of clear liquids until 1 hr before the test d. Obtain a pre-procedural sputum specimen e. Instruct the client to keep his neck in a neutral position

a, b

A nurse is assessing a client who has fluid volume overload from a client from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select all that apply.) a. Jugular vein distention b. Moist crackles c. Postural hypotension d. Increased heart rate e. Fever

a, b, d

A nurse is admitting a client who reports, nausea, vomiting, and weakness. The client has dry oral mucous membranes and blood pressure 102/64 mmHg. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? (Select all that apply.) a. Decreased skin turgor b. Concentrated urine c. Bradycardia d. Low-grade fever e. Tachypnea

a, b, d, e

A nurse is admitting an older adult client who reports a weight gain of 2.3 kg (5 lb) in 48 hr. Which of the following manifestations of fluid volume excess should the nurse expect? (Select all that apply.) a. Dyspnea b. Edema c. Bradycardia d. Hypertension e. Weakness

a, b, d, e

A nurse is assessing a client who has sustained partial-thickness and full-thickness burns over 40% of the body 24 hr ago. Which of the following are findings are common during this phase? (Select all that apply.) a. Temperature 36.1º C (97º F) b. Bradycardia c. Hyperkalemia d. Hyponatremia e. Decreaed hematocrit

a, c, d

A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply.) a. Dyspnea b. Localized bloody drainage on the dressing c. Fever d. Hypotension e. Report of pain at the puncture site

a, c, d

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? (Select all that apply.) a. Oxygen equipment b. Incentive spirometer c. Pulse oximeter d. Sterile dressing e. Suture removal kit

a, c, d

A nurse is planning care for an adult client who has sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) a. LImit visitors in the client's room b. Encourage fresh vegetables in the diet c. Increase protein intake d. Instruct the client to consume 2,000 calories/day e. Restrict fresh flowers in the room

a, c, e

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, d, e

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 polysterene 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

A nurse is caring for a 4-year-old child who has superfiical partial-thickness burns over 50% of his body. To meet the nutritional needs of the child, which of the following actions should the nurse plan to take? a. Administer pancrelipase to the child prior to each meal b. Supplement the child's feedings with enteral feedings c. Provide the child with a low-protein meal d. Perform dressing changes 10 min prior to the child's meals

b

A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances? a. Hypercalcemia b. Hyponatremia c. Hyperphosphatemia d. Hyperkalemia

b

A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings? a. Hyponatremia b. Leukopenia c. Hyperchloremia d. Elevated BUN

b

A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following medications should the nurse have available at the bedside? a. Naloxone b. Calcium gluconate c. Protamine sulfate d. Atropine

b

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 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

A nurse is caring for an older adult client who has chronic obstructive pulmonary disease (COPD) with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic alkalosis d. Metabolic acidosis

b

A nurse is evaluating a client who is receiving IV fluids to treat dehydration. Which of the following laboratory findings indicates 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

A nurse is evaluating a client who is receiving IV fluids. to treat isotonic dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective? a. BUN 26 mg/dL b. Serum sodium 138 mEq/L c. Hct 56% d. Urine specific gravity 1.035

b

A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? a. Hemoglobin 10 g/dL b. Sodium 132 mEq/L c. Albumin 3.6 g/dL d. Potassium 4.0 mEq/dL

b

A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider? a. Sodium 140 mEq/L b. Potassium 3.0 mEq/L c. Chloride 100 mEq/L d. Magnesium 2.0 mEq/L

b

A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect? a. Flattened T waves b. Prolonged QT intervals c. Shortened QT intervals d. Widened QRS complexes

b

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

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 of whole grain bread d. 1/2 cup cooked tofu

b

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider? a. Calcium 9.5 mg/dL b. Sodium 150 mEq/L c. Potassium 4 mEq/L d. Magnesium 1.5 mEq/L

b

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. Hemoglobin 20 g/dL b. Hematocrit 34% c. BUN 25 mg/dL d. Urine specific gravity 1.050

b

A nures is assessing a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect? a. Muscle tremors b. Positive Chvostek's sign c. Depressed deep-tendon reflexes d. Numbness around the mouth

c

A nurse in the emergency department is admitting a child who has full-thickness burns over 45% of his body. Which of the following actions should the nurse take first? a. Administer IV morphine b. Administer topical antimicrobials c. Administer IV fluid replacement d. Administer tetanus prophylaxis

c

A nurse is assessing a client for a Chvostek's sign. Which of the following techniques should the nurse use to perform this test? a. Apply a blood pressure cuff to the client's arm b. Place the stethoscope bell over the client's carotid artery c. Tap lightly on the client's cheek d. Ask the client to lower their chin to their chest

c

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

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 7.52, PaO2 89 mmHg, PaCO2 24 mEq/L, 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

A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to the bed. Vital signs reveal blood pressure 104/72 mm Hg, heart rate 116/min with regular rhythm, and respiratory rate 42/min and deep. Which of the following arterial blood gas findings should the nurse expect? a. pH 7.68, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3− 28 meq/L b. pH 7.48, PaO2 100 mm Hg, PaCO2 28 mm Hg, HCO3− 23 meq/L c. pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3− 18 meq/L d. pH 7.58, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3− 29 meq/L

c

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 of fluid overload? a. Increased urine specific gravity b. Hypoactive bowel sounds c. Bounding peripheral pulses d. Decreased respiratory rate

c

A nurse is caring for a client who has full-thickness burns covering 63% of her body and smoke inhalaiton. Which of the following nursing actions is the tope priority? a. Monitor intake and output b. Administer antibiotics c. Monitor respiratory status d. Encourage fluid and food intake

c

A nurse is caring for a client who has sustained burns over 35% of total body surface area. The client's voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the client has which of the following? a. Pulmonary edema b. Bacterial pneumonia c. Inhalation injury d. Carbon monoxide poisoning

c

A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? a. Respiratory acidosis b. Metabolic acidosis c. Respiratory alkalosis d. Metabolic alkalosis

c

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client? a. BUN 18 mg/dL b. Capillary refill 1.5 sec c. Hct 55% d. Urine specific gravity 1.001

c

A nurse is preparing to administer fentanyl to a client who has sustained deep partial-thickness and full-thickness burns over 60% of the body 24 hr ago. The nurse should plan to use which of the following routes to administer the medication? a. Subcutaneous b. Oral c. Intravenous d. Transdermal

c

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 hypotonic solution b. Repeat the potassium level c. Withhold the medication d. Monitor for paresthesia

c

A nurse is preparing to assist a provider with an arterial blood withdrawal from a client's radial artery for ABG measurement. Which of the following actions should the nurse plan to take? a. Hyperventilate the client with 100% oxygen prior to obtaining the specimen b. Apply ice to the site after obtaining the specimen c. Perform an Allen's test prior to obtaining the specimen d. Release the pressure applied to the puncture site 1 min after the needle is withdrawn

c

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 teaching? a. "If my stockings feel tight, I'll 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 one hour."

c

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

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

A nurse is assessing a client who is dehydrated. Which of the following findings should the nurse expect? a. Moist skin b. Distended neck veins c. Increased urinary output d. Tachycardia

d

A nurse is assessing a client who sustained superifical partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? a. Edema in the burned extremities b. Severe pain at the burn sites c. Urine output of 30 mL/hr d. Temperature of 39.1º C (102.4º F)

d

A nurse is caring for a child who adheres to a vegetarian diet and has sustained superficial partial-thickness burns. The nurse should recommend which of the following food choices due to the high protein content? a. Medium baked potato b. Wheat bagel with 1 tbsp of apricot jam c. Large orange d. 1/2 cup of peanut butter with apple slices

d

A nurse is caring for a client in a long-term care facility who has become weak, confused, and experienced dizziness when standing. The client's temperature is 38.3º C (100.9º F), pulse 92/min, respirations 20/min, and blood pressure 108/60 mmHg. Which of the following actions should the nurse take? a. Initiate fluid restrictions to limit intake b. Check for peripheral edema c. Encourage the client to ambulate to promote oxygenation d. Monitor for orthostatic hypotension

d

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 chlroide d. 0.45% sodium chloride

d

A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? a. 0.45% sodium chloride b. Dextrose 5% in 0.9% sodium chloride c. Dextrose 10% in water d. 0.9% sodium chloride

d

A nurse is caring for a client who is recovering at home after inpatient treatment for burn injuries. To increase the protein density of the client's meals, which of the following recommendations should the nurse make to the client's caregiver? a. Use sour cream instead of plain yogurt b. Add honey to cooked cereals c. Use salad dressing in place of mayonnaise d. Add chopped hard-boiled eggs to soups and casseroles

d

A nurse is obtaining arterial blood gases fora client who has vomited for 24 hr. The nurse should expect which of the following acid‐base imbalances to result from vomiting for 24 hr? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

d

A nurse is planning to administer fluids to a client who has 25% total body surface area burns. The client has no prior medical history. Which of the following intravenous fluids is contraindicated for this lcient? a. Whole blood b. Lactated Ringer's c. Dextran 40 in 0.9% sodium chloride d. 0.45% sodium chloride

d

A nurse is preparing a client for discharge following a bronchoscopy. Which of the following assessments is the nurse's monitoring priority? a. Measuring heart rate b. Palpating peripheral pulses c. Observing sputum for blood d. Confirming the gag reflex

d

A nurse is providing teaching 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

A nurse is reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis? a. pH 7.51, PaO2 94 mmHg, PaCO2 38 mmHg, HCO3 29 mEq/L b. pH 7.48, PaO2 89 mmHg, PaCO2 30 mmHg, HCO3 24 mEq/L c. pH 7.36, PaO2 77 mmHg, PaCO2 52 mmHg, HCO3 26 mEq/L d. pH 7.26, PaO2 84 mmHg, PaCO2 38 mmHg, HCO3 20 mEq/L

d

A nurse is reviewing the laboratory findings of a client who has chronic kidney disease. The client reports significant persistent nausea and muscle weakness. Which of the following findings should the nurse expect? a. Hypernatremia b. Hypomagnesemia c. Hypercalcemia d. Hyperkalemia

d

A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the following laboratory values should the nurse expect? a. pH 7.31, HCO3 22 mEq/L, PaCO2 50 mmHg b. pH 7.48, HCO3 23 mEq/L, PaCO2 25 mmHg c. pH 7.32, HCO3 18 mEq/L, PaCO2 40 mmHg d. pH 7.49, HCO3 32 mEq/L, PaCO2 40 mmHg

d