pratice test
A nurse is caring for a child who has Addison's disease. Which of the following actions should the nurse take?
Teach the parents about cortisol replacement therapy.
Which of the following are NOT a symptom of hyperparathyroidism?
Tetany
The physician has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer?
0.45% sodium chloride
Which is considered and isotonic solution?
0.9% normal saline
A nurse is reviewing the laboratory results for four clients. The nurse should recognize which of the following clients has a manifestation of hypoparathyroidism?
A client who has a phosphate of 5.7 mg/dL
The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)?
Active transport
The nursing instructor is discussing fluid and electrolyte balance with a group of students. One of the students asks the instructor how fluids move to maintain homeostasis. The instructor formulates her response based on her knowledge that fluid homeostasis can be maintained by which of the following? SATA (4 correct answers)
Active transport Osmosis Filtration Diffusion
Which hormone causes the kidney to reabsorb sodium?
Aldosterone
What should the nurse teach a patient on corticosteroid therapy in order to reduce the patient's risk of adrenal insufficiency?
Always have enough medication on had to avoid running out
The nurse is caring for a patient with hyperparathyroidism. What level of activity would the nurse expect to promote?
Ambulation and activity as tolerated.
A nurse is caring for a client who has Cushing syndrome. Which of the following interventions should the nurse expect to perform?
Assess blood glucose level
A patient's most recent laboratory results show a slight decrease in potassium. The physician has opted to forgo drug therapy but has suggested increasing the patient's dietary intake of potassium. Which of the following would be a good source of potassium?
Bananas
A patient is recovering from a thyroidectomy. The patient starts to complain of tingling and numbness in the face, toes, and fingers. Which of the following findings below warrants attention?
CA level 6mg/dL
A nurse is assessing an older client who id receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? SATA (3 correct answers)
Crackles upon auscultation Bounding pulse Pitting edema
The nurse is caring for a client with laboratory values indication dehydration. Which clinical symptom is consistent with dehydration?
Dark, concentrated urine
A patient with hypofunction of the adrenal cortex has been admitted to the medical unit. What would the nurse most likely find when assessing this patient?
Decreased BP
You are caring for a 72-year-old client who has been admitted to your unit for fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults?
Dehydration
The nurse reviews the laboratory results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system?
Diarrhea
The nurse is caring for a patient post colon resection, is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. the patient reports pain at the incision site rated at a 3 on a 0-10 rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTR'S), and you suspect the patient has hypokalemia. What another sign or symptom would you expect this patient to exhibit?
Diluted urine
30-year-old female patient has been diagnosed with Cushing syndrome. What psychosocial nursing diagnosis should the nurse most likely prioritize when planning the patient's care?
Disturbed body image related to changes in physical appearance.
A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. what is the nurse's priority during assessment?
Electrocardiogram (ECG) results
The nurse is caring for a client who has a peripheral IV in place for fluid replacement. When caring for the client's IV site, the nurse should
Ensure that the tubing is firmly anchored to the client's skin.
A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances?
Ensure the client has sufficient potassium intake.
A nurse providing care for a patient with Cushing syndrome has identified the nursing diagnosis of risk for injury related to weakness. How should the nurse best reduce this risk?
Establish fall prevention measures
The nurse is assessing the patient and notes a bounding pulse, neck vein distention when supine, presence of crackles in the lungs, and increasing peripheral edema. What condition does the nurse suspect?
Fluid excess
A nurse is teaching a client who has a new diagnosis of hyperparathyroidism. The nurse should include in the teaching that the client is at risk for which of the following complications?
Fractures
When planning the care of a client with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur?
Hydrostatic pressure resulting from the pumping action of the heart.
A nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. Which of the following findings should the nurse expect?
Hyperpigmentation
The nurse is assessing the patient for the Prescence of Chvostek's sign. What electrolyte imbalance would a positive Chvostek's sign indicate?
Hypocalcemia
You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand, and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?
Hypokalemia
Oral intake is controlled by the thirst center, located in which of the following cerebral areas?
Hypothalamus
The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of what imbalance?
Hypovolemia
A nurse is education a patient with hyperparathyroidism. Which response by the client indicates the need for further education?
I will avoid drinking too much fluid in order to prevent the formation of kidney stones.
A patient is hospitalized with severe hypoparathyroidism. She knows that it is essential to have which medication on hand in case of an emergency.
IV Calcium gluconate
Clients diagnosed with hypervolemia should avoid sweet or dry food because it.
Increases the client's desire to consume fluid.
The nurse is performing an admission assessment on an older adult client newly admitted for end-stage liver disease. What principle should guide the nurse's assessment of the client's skin turgor?
Inelastic skin turgor is a normal part of aging.
A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make?
It is caused by the lack of production of aldosterone by the adrenal. Gland.
A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment?
Lethargy
Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate?
Limit sodium and water intake.
The community health nurse is performing a home visit to an older client recovering from hip surgery. The nurses notes that the client seems uncharacteristically confused and has dry mucous membranes. When asked about fluid intake, the client states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response?
Limiting your fluids can create imbalances that can result in confusion. Maybe we need to adjust the timing of your fluids.
A priority nursing intervention for a client with hypervolemia involves which of the following?
Monitoring respiratory status for signs and symptoms of pulmonary complications
A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize which of the following are manifestations of Cushing syndrome? SATA (4 correct answers)
Moon face Striae Excessive hair Buffalo hump
A nurse is assessing a preschooler who has a calcium level of 8.0 mg/dL. which of the the following findings should the nurse expect?
Muscle tremors
The nurse is caring for a client with a diagnosis of Addison's disease. What sign or symptom is most closely associated this health problem?
Muscle weakness
A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings would the nurse expect?
Nausea and vomiting
64-year-old client is brought into the clinic with thirsty, dry sticky mucous membranes, decreased urine output, fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. should the nurse start salt tablets when caring for this client?
No, sodium intake should be restricted
A nurse is assessing a client who has hypoparathyroidism. Which of the following findings should the nurse expect?
Observation of tetany
Fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area?
Osmosis
The nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a client with intracranial pressure. This solution will increase the number of dissolved particles in the client's blood, creating pressure for fluids in the tissue to shift into the capillaries' and increase the blood volume. The process is best described as which of the following?
Osmosis and osmolality
A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. what should the nurse assess first?
Pulse
A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching which of the following will the nurse teach the client and family? SATA (3 correct answers)
Respond to thirst. Drink at least eight glasses of fluid each day Drink water as an inexpensive way to meet fluid needs
A nurse is providing dietary teaching for a client who has Cushing's disease. Which of the following recommendations would the nurse include in the teaching?
Restrict sodium intake.
A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test results is most significant?
Serum potassium level of 3 mEq/L
A patient has been taking prednisone for several weeks after experiencing a hypersensitivity reaction. To prevent adrenal insufficiency, the nurse should ensure that the patient knows to do which of the following?
Slowly taper down the dose of prednisone, as ordered.
Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality?
Sodium
A nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia?
Spironolactone
To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body?
Tachycardia
The nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
The client who has a gastroenteritis and is febrile
A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?
The client who has a nasogastric (NG) tube to suction
The nursing instructor hears students discussing fluid and electrolyte balance. Which statement would warrant further instruction?
The kidneys store and release antidiuretic hormone to increase water retention
The nurse is caring for a patient with Addison's disease who is scheduled for discharge. When teaching the patient about hormone replacement therapy, the nurse should address what topic?
The need for life long steroid replacement
A patient is undergoing testing for suspected adrenocortical insufficiency. The care team should ensure that the patient has been assessed for the most common cause of adrenocortical insufficiency. What is the most common cause of this health problem?
Therapeutic use of corticosteroids
A client has been admitted to the hospital unit with signs and symptoms of hypovolemia, however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. Which condition could the client be presenting?
Third-spacing
A nurse is caring for a client who had a total thyroidectomy and serum calcium level of 7.7 mg/dL. Which of the following findings should the nurse expect?
Tingling of the extremities
What does the nurse understand is the primary method by which fluid volume is regulated?
Urine excretion
A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?
Weak, irregular pulse
The patient is at risk for fluid volume excess. For self-management at home, what dies the nurse teach the patient to do?
Weigh self each day on the same scale.
A nurse is caring for a client who has Addison's disease and is at risk for Addisonian crisis. Which of the following actions should the nurse take?
Weigh the client daily.
Treatment of FVE involves dietary restrictions of sodium. Which of the following food choices would be a part of a low-sodium diet, mild restriction (2 to 3 g/day)?
three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad
