older adults

A client with chronic back pain is seen in the pain clinic for follow-up. To evaluate whether the pain management regimen is effective, which question is best for the nurse to ask? "Has there been a change in pain location?" "Can you describe the quality of your pain?" "How would you rate your pain on a 0 to 10 scale?" "How does the pain affect your ability to engage in activities that you enjoy?"

"How does the pain affect your ability to engage in activities that you enjoy?"

Which serum potassium result best supports the need for administering a stat dose of IV potassium chloride 20 mEq in 200 mL of normal saline over 2 hours? 3.0 mEq/L 3.5 mEq/L 4.6 mEq/L 5.3 mEq/L

3

The nurse caring for a patient with a sodium imbalance anticipates assessment changes primarily for what body system? Central nervous system Musculoskeletal system Renal system Cardiovascular system

CNS

The nurse reviews the lab report for a patient and sees a pH of 7.0. How the does nurse interpret this result? Acidosis Alkalosis Normal acid-base balance

acidosis

Age-related changes that affect hearing include all of the following except: Blood supply to the inner ear is increased. Cochlear neurons are lost. Ossicles calcify. Cerumen is drier and more difficult to expel.

blood supply to the inner ear is increased

The nurse is providing dietary teaching to a client diagnosed with hyperkalemia. Which statement by the client indicates a need for further instruction? "I will switch from drinking tomato juice to cranberry juice." "I will continue to use salt substitutes instead of real salt." "I should avoid eating a lot of bananas." "I can include pasta in my diet."

"I will continue to use salt substitutes instead of real salt."

A client has been prescribed IV potassium chloride (KCl) for the treatment of hypokalemia. What precautions should the nurse take to prevent severe complications related to KCl administration? Administer KCl as an IV push medication Verify the patient has adequate urine output prior to administration Inject KCl to an existing IV bag that is currently infusing into the patient Avoid inverting IV bags containing KCl upside down and upright several times prior to administration

verify the patient has adequate urine output prior to administration

When planning the care of a patient with dehydration, what urine output would the nurse instruct the assistive personnel (AP) to report? 60 mL in 90 minutes 1200 mL in 24 hours 300 mL per 8-hour shift 20 mL for 2 consecutive hours

20 ml for 2 consective hours

When planning care for stable adult patients, the oral intake that is adequate to meet daily fluid needs is 500 to 1500 mL. 1200 to 2200 mL. 2000 to 3000 mL. 3000 to 4000 mL.

2000 to 3000

The nurse is caring for a client who is taking furosemide (Lasix). Which new potassium level would be of greatest concern to the nurse? 3.5 mEq/L 3.1 mEq/L 4.1 mEq/L 5.2 mEq/L

3.1

A client with consistent dietary intake loses 0.5 kg in 24 hours. How much fluid has this client lost? This cannot be determined with the information provided 500 mL 1 liter 1500 mL

500 mL

While caring for an 84-year-old patient, the nurse monitors the patient's fluid balance, recognizing what as a normal change of aging? Increased plasma oncotic pressure Increased thirst sensitivity Decreased insensible losses Hyponatremia from increased secretion of antidiuretic hormone (ADH)

Hyponatremia from increased secretion of antidiuretic hormone (ADH)

A patient is admitted with metabolic acidosis. Which system is not functioning normally? Renal system Buffer system Endocrine system Respiratory system

renal

A patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid was removed. Which IV solution may be used to pull fluid into the intravascular space after the paracentesis? 0.9% sodium chloride 25% albumin solution Lactated Ringer's solution 5% dextrose in 0.45% saline

25% albumin solution

The nurse on a medical-surgical unit identifies which patient as having the highest risk for metabolic alkalosis? A patient with type 1 diabetes A patient with a traumatic brain injury A patient with acute respiratory failure A patient with nasogastric tube suction

A patient with nasogastric tube suction

A client asks about heat and cold therapies for pain control. Which statement by the nurse is most appropriate? Apply cold therapy directly on the skin. Use heat therapy and menthol containing products simultaneously. Use heat therapy on skin areas that have undergone radiation treatment. Apply cold therapy to the opposite side of the body, if the site experiencing pain is not accessible.

Apply cold therapy to the opposite side of the body, if the site experiencing pain is not accessible.

The nurse is caring for a patient admitted to the medical unit with hypokalemia. The best foods to offer the patient are? (Select all that apply.) Apple Banana Orange juice Chocolate milk Cooked broccoli

Banana Orange juice Chocolate milk Cooked broccoli

When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit? Fluid movement from the blood vessels into the cells Fluid movement from the interstitial space into the cells Fluid movement from the interstitial spaces into the plasma Fluid movement from the blood vessels into interstitial spaces

Fluid movement from the interstitial spaces into the plasma

A patient with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which provider prescription would the nurse question? Limit foods high in potassium. Calcium gluconate IV piggyback. Give a potassium-sparing diuretic daily. Administer intravenous insulin and glucose.

Give a potassium-sparing diuretic daily.

Which patient statement indicates a need for further education about use of non-steroidal anti-inflammatory drugs (NSAIDs)? "I should always take this medication on an empty stomach." "I should report black, tarry stools to my provider." "I can still use heat and cold therapies along with the NSAIDs." "It is okay to drive while taking this medication."

I should always take this med on an empty stomach

The nurse is providing teaching to a client with hypercalcemia. Which client statement indicates a need for more teaching? Weight-bearing exercises can help keep calcium in my bones. Kidney stones may occur as a complication of hypercalcemia. If I experience heartburn, it can be managed with a magnesium-containing antacid. I should restrict my fluid intake to less than 2000 mL/day.

I should restrict my fluid intake to less than 2000 mL/day

An older patient is receiving IV fluids postoperatively. During the 8:00 am assessment, the nurse notes that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 am. What is the priority nursing intervention? Slow the rate to keep vein open until next bag is due at noon. Notify the health care provider and complete an incident report. Listen to the patient's lung sounds and assess respiratory status. Assess the patient's cardiovascular status by checking pulse and blood pressure.

Listen to the patient's lung sounds and assess respiratory status.

A patient is admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medication would the nurse hold until the health care provider is consulted? Antibiotics Loop diuretics Bronchodilators Antihypertensives

Loop diuretics

A patient with dehydration is receiving a hypertonic solution. Which assessments must be done to avoid adverse risks associated with these solutions? (Select all that apply.) Lung sounds Bowel sounds Blood pressure Serum sodium level Serum potassium level

Lung sounds Blood pressure Serum sodium level

A patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would the nurse identify as an adverse effect related to this therapy? Sodium falling to 138 mEq/L Potassium rising to 4.1 mEq/L Magnesium rising to 2.9 mg/dL Phosphorus falling to 2.1 mg/dL

Phosphorus falling to 2.1 mg/dL

Which statements are appropriate to include when teaching a patient about hypercalcemia? (Select all that apply.) Have patient restrict fluid intake to less than 2000 mL/day. Renal calculi may occur as a complication of hypercalcemia. Weight-bearing exercises can help keep calcium in the bones. The patient should increase daily fluid intake of 3000 to 4000 mL. Any heartburn can be managed with an as needed calcium-containing antacid.

Renal calculi may occur as a complication of hypercalcemia. Weight-bearing exercises can help keep calcium in the bones. The patient should increase daily fluid intake of 3000 to 4000 mL.

The nurse receives a provider's prescription to change an IV from 5% dextrose in 0.45% saline with 40 mEq KCl/L to 5% dextrose in 0.9% saline with 20 mEq KCl/L. Which serum laboratory values best support the indication for this change? Sodium, 136 mEq/L; potassium, 3.6 mEq/L Sodium, 145 mEq/L; potassium, 4.8 mEq/L Sodium, 133 mEq/L; potassium, 4.5 mEq/L Sodium, 144 mEq/L; potassium, 3.7 mEq/L

Sodium, 133 mEq/L; potassium, 4.5 mEq/L

The nurse is caring for a patient admitted with diabetes, malnutrition, and a massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient? (Select all that apply.) The potassium level may be increased if the patient has nephropathy. The patient has been eating excessive amounts of foods that increase potassium levels. The patient may be excreting extra sodium and retaining potassium secondary to malnutrition. There may be excess potassium being released into the blood as a result of massive blood transfusion. The potassium level may be increased because of dehydration that accompanies high blood glucose levels.

The potassium level may be increased if the patient has nephropathy. There may be excess potassium being released into the blood as a result of massive blood transfusion. The potassium level may be increased because of dehydration that accompanies high blood glucose levels.

A client is prescribed hydrocodone and acetaminophen (Vicodin) for pain control. The client takes Tylenol PM every night for sleep. Which statement by the nurse is best? You should not take any over the counter medications while on prescription medications. You should read all medication labels and keep daily total acetaminophen intake to less than 3 grams. You can continue to take the Tylenol PM without concern, since it was being used before surgery. You should use the Vicodin instead of the Tylenol PM for sleep.

You should read all medication labels and keep daily total acetaminophen intake to less than 3 grams.

A client with good chronic pain control with a fentanyl patch reports a rapid increase in pain intensity. The client requests "something for pain that will work quickly." Based on the information provided, how should the nurse document the type of pain reported by this client? Somatic pain Referred pain Neuropathic pain Breakthrough pain

breakthrough pain

Which physiologic change of aging affects thermoregulation in older adults? Rapid onset of sweating when exposed to warm environments. Decreased subcutaneous tissue and muscle mass. Tendency to easily start shivering. Increased cardiac output.

decreased subcutaneous tissue and muscle mass

Which assessment finding would the nurse expect to find in a client with uncontrolled acute pain? Decreased heart rate Increased gastric motility Decreased urine output Enhanced decision making

decreased urine output

During start-of-shift report, the nurse is told one of the clients is experiencing second spacing of fluid. What does the nurse expect to find when assessing this client? Edema Urinary retention Poor skin turgor Distended, fluid-filled abdomen

edema

The nurse notices an involuntary contraction of the muscles of the client's hand and wrist when inflating a blood pressure cuff. Which electrolyte imbalance does the nurse suspect? Hypokalemia Hypermagnesemia Hypocalcemia Hypernatremia

hypocalcemia

A postoperative patient is receiving epidural fentanyl for pain relief. For which common side effects would the nurse monitor the patient? (Select all that apply.) Ataxia Itching Nausea Urinary retention Gastrointestinal bleeding

itching, nausea, urinary retention

Which assessment finding best supports the nursing diagnosis of fluid volume excess? Hypotension Tachycardia Jugular venous distention Poor skin turgor

jugular venous distention

Which nursing assessment is most important while caring for a client who is receiving 3% NaCl intravenously for correction of severe hyponatremia? Urinary output Lung sounds Peripheral pulses Peripheral edema

lung sounds

Which acid-base imbalance will the nurse expect in a patient experiencing sepsis? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory Alkalosis

metabolic acidosis

The nurse is admitting a patient who reports abdominal pain, nausea, and vomiting. A proximal bowel obstruction is suspected. Which acid-base imbalance would the nurse anticipate in this patient? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

metabolic alkalosis

What is a physiologic change of aging that may occur in the cardiovascular system? The heart reduces in size, and heart muscle contractility strength increases. Myocardial cells become less responsive to sympathetic nervous system impulses. Veins increase in elasticity and ability to vasoconstrict. The number of pacemaker cells increases.

myocardial cells become less responsive to sympathetic nervous system impulses

The nurse assists the patient who is experiencing severe pain and anxiety with relaxation and deep breathing strategies. Which step in the pain pathway do these strategies target? Perception Transduction Transmission Modulation

perception

The physician prescribes Maalox, 1 tablet by mouth PRN, for a client with chronic kidney disease (CKD) who has indigestion. Which intervention should the nurse implement? Question the healthcare provider's prescription. Administer 30 minutes before eating. Instruct the client to swallow the tablet whole. Evaluate the effectiveness 1 hour after administration.

question the healthcare providers prescription

Which acid-base imbalance will the nurse expect in a patient experiencing respiratory arrest? Respiratory acidosis Respiratory Alkalosis Metabolic acidosis Metabolic alkalosis

respiratory acidosis

When assessing a patient admitted with nausea and vomiting, which finding best supports the patient problem of deficient fluid volume? Polyuria Bradycardia Restlessness Difficulty breathing

restlessness

While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia? (Select all that apply.) Weakness Paresthesia Facial spasms Muscle tremors Depressed reflexes

weakness, depressed reflexes,