Test 2 NCLEX Practice Questions

A nurse working in the eR admits a client with renal failure and a serum K+ level of 6.2. all of these orders are received from the physician. Which order should the nurse implement first? A. Give IV Furosemide 40mg. B. Administer Sodium Polystyrene Sulfonate15g p.o. C. Place the client on a cardiac monitor D. Insert a retention catheter

C. Place the client on a cardiac monitor

A client with a recent thyroidectomy complains of numbness and tingling around the mouth. Which of the following findings indicates the serum calcium is low? A. Bone pain B. Depressed deep tendon reflexes C. Positive Chvostek's sign D. Nausea

C. Positive Chvostek's sign

A nurse caring for a client with hypocalcemia would expect to note which of the following changes on the electrocardiogram? A. Widened T wave B. Prominent U wave C. Prolonged QT interval D. Shortened ST segment

C. Prolonged QT interval

After a head injury, the patient begins to have drainage from the nose. The nurse assesses the drainage by which method? A. Halo test B. Tinel sign C. Battle sign D. Babinski sign

A. Halo Test

the nurse is preparing to administer IV fluids to a client with a serum potassium of 6.2. The nurse would question the order if it was for which of the following fluids? A. D5W B. 0.9% NS C. D51/2 NS D. LR

D. LR

A nurse checks a unit of blood received from the blood bank and notes the presence of gas bubbles in the bag. Which should the nurse implement? 1) return the bag to the blood bank 2) infuse the blood using filter tubing 3) add 10 mL normal saline to the bag 4) agitate the bag to mix contents gently

1) return the bag to the blood bank

A client is going to be transfused with a unit of packed RBCs. The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started? 1. 5 minutes 2. 15 minutes 3. 30 minutes 4. 45 minutes

2. 15 minutes

A nurse is assisting with caring for a client who is receiving a unit of packed RBCs. The nurse tells the client that it is most important to report which of the following signs immediately? 1. Sore throat or earache 2. Chills, itching, or rash 3. Unusual sleepiness or fatigue 4. Mild discomfort at the catheter site

2. Chills, itching, or rash

A client who is receiving a blood transfusion rings the call bell for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. The nurse interprets that the client is experiencing: 1. Bacteremia 2. Fluid overload 3. Hypovolemic shock 4. A transfusion reaction

4. A transfusion reaction

A patient with a traumatic brain injury is in need of fluid replacement therapy to maintain a systole blood pressure of at least 90 mm Hg. The nurse realizes that the best fluid replacement for this patient would be: a.) Normal saline. b.) D5W c.) D5 1/2 0.9% NS d.) 0.45% NS

A ~ A systolic blood pressure less than 90 mm Hg in a patient with a traumatic brain injury is a predictor of a poor outcome. Initial management usually involves assuring that the patient is hydrated. Isotonic crystalloids such as 0.9% saline or Ringer's solution are most commonly used. Normal Saline is preferred because it is inexpensive, iso-osmolar and has no free water. #2 and #4 are not correct. In general, the use of hypotonic crystalloids, such as D5W or 0.45% normal saline is avoided because of the potential for worsening cerebral edema. #3 is not correct. D51/2 NS is hypertonic and will draw fluid from the cells & interstial tissue into the vascular space. This could worsen cerebral edema.

The nurse is caring for a client with a closed head injury. Which of the following would contribute to intracrainal hypertension? a.) hypoventilation b.) elevating the head of the bed c.) hypernatremia d.) quiet darkened environnent

A ~ Hypoventilation leads to vasodilation and increased intracranial pressure.

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? a.) Urine output increases b.) Pupils are 8 mm and nonreactive c.) Systolic blood pressure remains at 150 mm Hg d.) BUN and creatinine levels return to normal

A ~ Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.

A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? a.) Evaluate urine specific gravity b.) Anticipate treatment for renal failure c.) Provide emollients to the skin to prevent breakdown d.) Slow down the IV fluids and notify the physician

A ~ Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There's no evidence that the client is experiencing renal failure. Providing emollients to prevent skin breakdown is important, but doesn't need to be performed immediately. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.

The nurse is caring for the following clients. Which of them is at highest risk for developing fluid volume deficit? A. 76 year old with an NG tube to suction s/p colon surgery B. 1 year old with runny nose and ear infection C. 30 year old with HIV infection D. 50 year old who takes steroids for chronic lung disease

A. 76 year old with an NG tube to suction s/p colon surgery

A nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level? A. Alcoholism B. Renal insufficiency C. Hypoparathyroidism D. Tumor lysis syndrome

A. Alcoholism

Which clinical manifestation do you interpret as representing neurogenic shock in a patient with acute spinal cord injury? A. Bradycardia B. Hypertension C. Neurogenic spasticity D. Bounding pedal pulses

A. Bradycardia Neurogenic shock results from loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output.

The client has a traumatic brain injury from a motor vehicle accident. Which sign does the nurse associate with increased intracranial pressure (ICP)? A. Changes in breathing pattern B. Dizziness when sitting up C. Increasing level of consciousness D. Equal and reactive pupils

A. Changes in breathing pattern

When the nurse applies a painful stimulus to the unconscious client, the client responds by stiffly extending and adducting the arms and hyperpronating the wrists. Which of the following does the nurse note in the client's record? A. Decerebrate posturing B. Decorticate posturing C. Purposeful movement D. Babinski response

A. Decerebrate posturing

The nurse is assessing a client with hypercalcemia. The nurse expects the neuromuscular exam on this client to show which of the following? A. Muscle weakness B. Twitching C. Tetany D. Hyperactive DTR's

A. Muscle weakness

The nurse is caring for a client with dry mucous membranes, orthostatic blood pressure changes, and decreased urine output. The client's serum osmolality is normal. Which of the following iv fluids would the nurse anticipate administering? A. Normal Saline B. D5W C. ¼ normal saline D. D10W

A. Normal Saline

The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition would be a cause for these findings? A. Overhydration. B. Anemia. C. Dehydration. D. Renal failure.

A. Overhydration.

A patient with a spinal cord injury at C5-C6 reports a sudden severe headache. The patient is flushed. His blood pressure is 190/100 mm Hg, and heart rate is 52 beats/min. What should the nurse do first? A. Place the patient in a sitting position. B. Page/notify the health care provider. C. Check the urinary catheter tubing for kinks or obstruction. D. Check the patient for fecal impaction.

A. Place the patient in a sitting position. Autonomic dysorflexia

The nurse suspects that a 36-year-old patient recovering from a hypophysectomy (removal of the pituitary gland) has developed diabetes insipidus (DI). What sign or symptom is most indicative of DI? A. Polyuria B. Polyphagia C. Hypertension D. Hyperkalemia

A. Polyuria

The nurse is caring for a client with metabolic acidosis. The nurse would also expect to see which of the following electrolyte levels? A. Potassium 5.9 B. Magnesium 2.4 C. Phosphorous 2.3 D. Sodium 145

A. Potassium 5.9

The nurse is caring for a client with fluid volume excess. Which of the following findings would indicate that the client's fluid volume status has not returned to normal? A. S3 heart sound & crackles in the lungs B. Hypotension and weak pulses C. Increased urine output and decreased urine specific gravity D. Poor skin turgor & dry mucous membranes

A. S3 heart sound & crackles in the lungs

The client is arousable only if his trapezius muscle is pinched. How will the nurse document this client's level of consciousness? A. Stuporous B. Lethargic C. Comatose D. Drowsy

A. Stuporous

A patient is bought in by ambulance with a suspected brain injury. What are the outward symptoms of head injury? (Select all that apply.) A. Tinnitus B. Diarrhea C. Ottorhea D. Battle sign E. Chvostek sign

A. Tinnitus C. Ottorhea D. Battle sign

A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value? A. U waves B. Absent P waves C. Elevated T waves D. Elevated ST segment

A. U waves

If the blood plasma has a higher osmolality than the fluid within a red blood cell, the mechanism involved in equalizing the fluid concentration is A. osmosis. B. diffusion. C. active transport. D. facilitated diffusion.

A. osmosis.

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a.Infuse 5% dextrose in water at 125 mL/hr. b.Administer IV morphine sulfate 4 mg every 2 hours PRN. c.Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d.Administer 3% saline if serum sodium decreases to less than 128 mEq/L.

ANS: A Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a.Lung sounds b.Urinary output c.Peripheral pulses d.Peripheral edema

ANS: A Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Oral digoxin (Lanoxin) 0.25 mg daily b. Ibuprofen (Motrin) 400 mg every 6 hours c. Metoprolol (Lopressor) 12.5 mg orally daily d.Lantus insulin 24 U subcutaneously every evening

ANS: A Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level.

A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make? a.Daily alcohol intake b.Intake of dietary protein c.Multivitamin/mineral use d.Use of over-the-counter (OTC) laxatives

ANS: A Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium levels.

A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first? a. Depth of respirations b. Bowel sounds c. Grip strength d. Electrocardiography

ANS: A - A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased hand grips. The nurse should assess the client's respiratory status first to ensure respirations are sufficient. The respiratory assessment should include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the client's respiratory status.

A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia? a. Client with pancreatitis who has continuous nasogastric suctioning b. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor c. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells d. Client with uncontrolled diabetes and a serum pH level of 7.33

ANS: A - A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to hypokalemia. The other clients are at risk for potassium excess or hyperkalemia.

A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess? a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg b. Daily weight increase from 55 kg to 57 kg c. Heart rate decrease from 100 beats/min to 82 beats/min d. Respiratory rate increase from 12 breaths/min to 15 breaths/min

ANS: A - ACE inhibitors will disrupt the reninangiotensin II pathway and prevent the kidneys from reabsorbing water and sodium. The kidneys will excrete more water and sodium, decreasing the client's blood pressure.

A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia? a. A 34-year-old on NPO status who is receiving intravenous D5W b. A 50-year-old with an infection who is prescribed a sulfonamide antibiotic c. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin) d. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)

ANS: A - Dextrose 5% in water (D5W) contains no electrolytes. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.

A nurse is assessing a client with hypokalemia, and notes that the clients handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first? a. Assess the client's respiratory rate, rhythm, and depth. b. Measure the client's pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care provider.

ANS: A - In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The client's pulse and blood pressure should be assessed after assessing respiratory status. Next, the nurse would call the health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client should occur during and after potassium replacement therapy.

A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that apply.) a. A 36-year-old who is malnourished b. A 42-year-old with uncontrolled diabetes c. A 50-year-old with hyperparathyroidism d. A 58-year-old with chronic renal failure e. A 76-year-old who is prescribed antacids

ANS: A, B, E - Clients at risk for hypophosphatemia include those who are malnourished, those with uncontrolled diabetes mellitus, and those who use aluminum hydroxide-based or magnesium-based antacids. Hyperparathyroidism and chronic renal failure are common causes of hyperphosphatemia.

A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.) a. Increased pulse rate b. Distended neck veins c. Decreased blood pressure d. Warm and pink skin e. Skeletal muscle weakness

ANS: A, B, E - Manifestations of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, and skeletal muscle weakness.

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a.Administer the KCl as a rapid IV bolus. b.Infuse the KCl at a rate of 10 mEq/hour. c.Only give the KCl through a central venous line. d.Discontinue cardiac monitoring during the infusion.

ANS: B IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias.

A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first? a. Measure intake and output every 4 hours. b. Apply oxygen by mask or nasal cannula. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler's position.

ANS: B - Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimal. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the client too rapidly with IV fluids can lead to cerebral edema. Measuring intake and output and placing the client in a high-Fowler's position will not address the clients problem.

A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss? a. Client taking furosemide (Lasix) b. Anxious client who has tachypnea c. Client who is on fluid restrictions d. Client who is constipated with abdominal pain

ANS: B - Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for fluid loss.

A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first? a. Encourage oral fluid intake. b. Connect the client to a cardiac monitor. c. Assess urinary output. d. Administer oral calcitonin (Calcimar).

ANS: B - This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.) a. Urine output of 25 mL/hr b. Serum potassium level of 5.4 mEq/L c. Urine specific gravity of 1.02 g/mL d. Serum sodium level of 128 mEq/L e. Blood osmolality of 250 mOsm/L

ANS: B, E - Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client's risk for excessive water loss (increased urine output), increased potassium reabsorption, decreased blood osmolality, and increased urine specific gravity. The client would not be at risk for sodium imbalance.

When reviewing the health history of a patient, the nurse will note that a potential contraindication to potassium supplements exists if the patient has which problem? a. Burns b.Diarrhea c.Renal disease d.Cardiac tachydysrhythmias

ANS: C Potassium supplements are contraindicated in the presence of renal disease; the other conditions listed may be treated with potassium supplements.

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? a.K+ 3.4 mEq/L (3.4 mmol/L) b.Ca+2 7.8 mg/dL (1.95 mmol/L) c.Na+ 154 mEq/L (154 mmol/L) d.PO4-3 4.8 mg/dL (1.55 mmol/L)

ANS: C The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from normal but do not require immediate action by the nurse. The phosphate level is normal.

A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first? a. Prepare to administer sodium polystyrene sulfonate (Kayexalate) 15 g by mouth. b. Provide a heart healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment.

ANS: C - A client with a high serum potassium level and cardiac changes should be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore should be administered with dextrose to prevent hypoglycemia. Kayexalate may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first prescription the nurse should implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client's current potassium level.

After teaching a client to increase dietary potassium intake, a nurse assesses the client's understanding. Which dietary meal selection indicates the client correctly understands the teaching? a. Toasted English muffin with butter and blueberry jam, and tea with sugar b. Two scrambled eggs, a slice of white toast, and a half cup of strawberries c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk d. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee

ANS: C - Meat, dairy products, and dried fruit have high concentrations of potassium. Eggs, breads, cereals, sugar, and some fruits (berries, peaches) are low in potassium. The menu selection of sausage, toast, raisins, and milk has the greatest number of items with higher potassium content.

A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this clients teaching? a. Weigh yourself every morning and every night. b. Check your radial pulse twice a day. c. Read food labels to determine sodium content. d. Bake or grill the meat rather than frying it.

ANS: C - Most prepackaged foods have a high sodium content. Teaching clients how to read labels and calculate the sodium content of food can help them adhere to prescribed sodium restrictions and can prevent hypernatremia. Daily self-weighing and pulse checking are methods of identifying manifestations of hypernatremia, but they do not prevent it. The addition of substances during cooking, not the method of cooking, increases the sodium content of a meal.

A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration? a. A 36-year-old who is prescribed long-term steroid therapy b. A 55-year-old receiving hypertonic intravenous fluids c. A 76-year-old who is cognitively impaired d. An 83-year-old with congestive heart failure

ANS: C - Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration.

Spironolactone (Aldactone), is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? a."I will try to drink at least 8 glasses of water every day." b "I will use a salt substitute to decrease my sodium intake." c. "I will increase my intake of potassium-containing foods." d."I will drink apple juice instead of orange juice for breakfast."

ANS: D Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action? a. Assess for facial muscle spasms. b Ask the patient about loose stools. c.Suggest that the patient avoid orange juice with meals. d. Ask the health care provider to order a basic metabolic panel.

ANS: D Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient was hypokalemic. Loose stools are associated with hyperkalemia.

A client has a magnesium deficit in addition to congestive heart failure (CHF). The most appropriate nursing diagnosis is a. Altered Comfort. b. High Risk for Injury. c. Impaired Skin Integrity. d. Risk for Decreased Cardiac Output.

ANS: D Low magnesium levels have been linked with increased ventricular dysrhythmias and decreased 1-year survival rates in CHF clients as well as with lethal dysrhythmia in clients with myocardial infarction.

A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

ANS: D Many diuretics, especially loop diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an acid deficit of metabolic origin.

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital? a. Ask family members to speak quietly to keep the client calm. b. Assess urine color, amount, and specific gravity each day. c. Encourage the client to drink at least 1 liter of fluids each shift. d. Dangle the client on the bedside before ambulating.

ANS: D - An older adult with moderate dehydration may experience orthostatic hypotension. The client should dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the client's urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 liter of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency.

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates the client correctly understood the teaching? a. Slices of smoked ham with potato salad b. Bowl of tomato soup with a grilled cheese sandwich c. Salami and cheese on whole wheat crackers d. Grilled chicken breast with glazed carrots

ANS: D - Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham, tomato soup, salami, and crackers are often high in sodium.

A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 breaths/min to 22 breaths/min b. Decreased skin turgor on the clients posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic lightheadedness and dizziness

ANS: D - The focus of management for clients with dehydration is to increase fluid volumes to normal. When fluid volumes return to normal, clients should perfuse the brain more effectively, therefore improving confusion and decreasing orthostatic lightheadedness or dizziness. Increased respiratory rate, decreased skin turgor, and increased specific gravity are all manifestations of dehydration.

The nurse is caring for a client who has undergone craniotomy with a supratentoral incision. The nurse should plan to place the client in which position post-op? A. Head of bed flat, head and neck midline B. Head of bed flat, head turned to the nonoperative side C. Head of bed elevated 30 to 45 degrees head and neck midline D. Head of bed elevated 30 to 45 degrees, head turned to the operative side

C. Head of bed elevated 30 to 45 degrees head and neck midline

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note? A. Hypotension B. Increased heart rate C. Bounding peripheral pulses D. Shortened QT interval on electrocardiography (ECG)

Answer: A Rationale: Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the electrocardiogram (ECG), the nurse would note a prolonged ST interval and a prolonged QT interval.

The nurse is reading a health care provider's (HCP) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse interprets that this type of fluid loss can occur through which route? A. The Skin B. Urinary Output C. Wound Drainage D. The gastrointestinal tract

Answer: A Rationale: Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.3 mg/dL. Which would be the most appropriate nursing action for this client? A. Monitor the client for dysrhythmias B. Encourage increased intake of phosphate antacids C. Discontinue any magnesium-contain medications. D. Encourage intake of foods such as ground beef, eggs, or chicken breast.

Answer: A Rationale: The normal serum magnesium level is 1.6 to 2.6 mg/dL. Cardiac monitoring is indicated because this client is at risk for ventricular dysrhythmias. Phosphate use should be limited in the presence of hypomagnesemia because it worsens the condition. It is not necessary to discontinue magnesium products. Ground beef, eggs, and chicken breast are low in magnesium.

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply. A. Dehydration B. HTN C. Physiological stress D. Decreased blood volume E. Decreased plasma osmolarity

Answer: A, C, and D Rationale: Antidiuretic hormone, or vasopressin, is produced in the brain and stored in the posterior pituitary gland. Its release from the posterior pituitary gland is controlled by the hypothalamus in response to changes in blood osmolarity. Stimuli for ADH release are increased plasma osmolality, decreased blood volume, hypotension, pain, dehydration from nausea, vomiting, or diarrhea, and stress.

A nurse is planning care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply. A. Ensure adequate fluid intake. B. Implement safety measures to prevent falls C. Encourage low fiber foods to prevent diarrhea. D. Instruct the client about foods that contain potassium. E. Encourage the client to obtain assistance to ambulate.

Answer: A,B, D, and E Rationale: Clients with hypokalemia will need instruction on potassium-rich foods, and all clients should maintain adequate hydration, Safety is also a priority because hypokalemia may cause muscle weakness, resulting in falls and injury. Hypokalemia is associated with constipation, not diarrhea, owing to decreased peristalsis.

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment data would indicate to the nurse that the dehydration remains unresolved? A. An oral temperature of 98.8 F B. A urine specific gravity of 1.043 C. A urine output that is pale yellow D. A blood pressure of 120/80 mmHg

Answer: B Rationale: The client who is dehydrated will have a urine specific gravity greater than 1.030. Normal values for urine specific gravity are 1.010 to 1.030. A temperature of 98.8° F is only 0.2 point above the normal temperature and would not be as specific an indicator of hydration status as would the urine specific gravity. Pale yellow urine is a normal finding. A blood pressure of 120/80 mm Hg is within normal range.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present? A. Weight Loss B. Flat neck and Hand veins C. An increase in blood pressure D. Decreased central venous pressure (CVP)

Answer: C Rationale:A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. The remaining options identify signs noted in fluid volume deficit.

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note? A. Bradycardia B. Elevated blood pressure C. Changes in mental status D. Bilateral crackles in the lung

Answer: C Rationale: A client with dehydration is likely to be lethargic or complaining of a headache. The client would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins, tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral crackles in the lungs because these are signs of fluid overload and an unrelated finding of dehydration.

Which client is least likely to be at risk for the development of third spacing? A. The client with cirrhosis B. The client with liver failure C. The client with diabetes mellitus D. The client with chronic kidney disease

Answer: C Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors for third spacing include clients with liver or kidney disease, major trauma, burns, sepsis, wound healing or major surgery, malignancy, gastrointestinal malabsorption, malnutrition, and alcoholic or older adult clients.

A nurse is caring for a client whose magnesium level is 3.5 mg/dL. Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level? A. Tetany B. Twitches C. Positive Trousseau's sign D. Loss of deep tendon reflexes

Answer: D Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A client with a magnesium level of 3.5 mg/dL is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau's sign are seen in a client with hypomagnesemia.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? a.) Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. b.) Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. c.) Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. d.) Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

B ~ A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient complains of having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

B ~ To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.

Dobutamine is a ____________ drug. A) Neuro B) Cardiac C) Renal D) Gastrointestinal

B) Cardiac

What is acetaminophen used for with patients with increased ICP? A) Discomfort B) Fever C) Inflammation

B) Fever

The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made? A. " I will use a straw for drinking" B. " I will drive only during the daytime" C. " I will use caution because the device alters balance" D. " I will wash the skin daily under the lambs wool liner of the vest"

B. " I will drive only during the daytime"

The nurse is caring for a post-op client that has had nausea, vomiting, and a urine output of 200 mL in the past 8 hrs. The client's BP is 90/60. Which of the following orders would the nurse implement first? A. Increase IV rate to 150 mL/hr B. Administer 750 mL IV bolus of normal saline C. Administer Ondansetron (Zofran) IV for vomiting D. Discontinue the PRN IV Morphine

B. Administer 750 mL IV bolus of normal saline

While the patient is monitored in the ED, which finding will you immediately report to the physician? A. Unresolved headache B. Blood pressure of 84/60 mm Hg C. Neck pain of "5" on a 0-to-10 scale D. Increase in the Glasgow Coma Scale score

B. Blood pressure of 84/60 mm Hg

The nurse is caring for a diabetic client who has been npo for surgery. The nurse would question which of the following iv fluid choices? A. LR B. D5LR C. NS D. ¼ N

B. D5LR

The nurse is caring for a diabetic client who has been npo for surgery. The nurse would question which of the following iv fluid choices? A. LR B. D5LR C. NS D. ¼ NS

B. D5LR

The nurse has administered sodium polystyrene sulfonate to a client. Which of the following findings would the nurse determine as positive? A. Muscle weakness B. Decrease in height of T wave C. Decrease in ST depression D. Serum K+ of 6.2

B. Decrease in height of T wave

The nurse is caring for a client with hypomagnesemia. Which of the following findings would the nurse expect? A. Bilateral muscle weakness B. Deep tendon reflexes 4+ C. Hypotension D. Bradycardia

B. Deep tendon reflexes 4+

The nurse is caring for a client and receives the following lab results: HCT 54, BUN 25, creatinine 1.1. Based on these findings the nurse would suspect: A. Fluid volume excess B. Fluid volume deficit C. Renal insufficiency D. Renal failure

B. Fluid volume deficit

The nurse is caring for a client that is hypovolemic and plasma expanders are not available. The nurse would correctly anticipate that which type of solution would be ordered? A. TPN B. Isotonic C. Hypertonic D. Hypotonic

B. Isotonic

The nurse is caring for a client that is hypovolemic and plasma expanders are not available. The nurse would correctly anticipate that which type of solution would be ordered? A. TPN B. Isotonic C. Hypertonic D. Hypotonic

B. Isotonic

A client has fluid leaking from the nose after a basilar skull fracture. Which of the following would indicate that the fluid is cerebrospinal fluid? A. It clumps together on the paper and has a pH of 7 B. It leaves a yellowish ring on the paper and tests positive for glucose. C. It is grossly bloody in appearance and has a pH of 6. D. It is clear in appearance and tests negative for glucose.

B. It leaves a yellowish ring on the paper and tests positive for glucose.

The client was seen and treated in the ER for a concussion. Before discharge, the nurse explains the signs and symptoms of worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign and symptom? A. Vomiting B. Minor headache C. Difficulty speaking D. Difficulty awakening

B. Minor headache

The nurse is caring for a client in renal failure. Which of the following assessments would the nurse anticipate? A. Weight loss B. Neck vein distention C. Weak, thready pulse D. Decreased blood pressure

B. Neck vein distention

Nursing students have prepared a presentation on prevention of intracranial trauma. Where should they offer this in order to benefit the population with the highest risk? A. Education group for parents of teenagers B. Neighborhood center teen activity program C. Well-woman community health fair D. Federal office building for workers in tax office

B. Neighborhood center teen activity program

The nurse should include which of the following instructions to assist in controlling phosphorus levels for a client in renal failure? A. Increase intake of dairy products and nuts B. Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals C. Reduce intake of chocolate, meats, and whole grains D. Avoid calcium supplements

B. Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals

A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for excess fluid volume? A. The client taking diuretics B. The client with renal failure C. The client with an ileostomy D. The client who requires gastrointestinal suctioning

B. The client with renal failure

A patient is admitted with a spinal cord injury at the C7 level. During assessment the nurse identifies the presence of spinal shock on finding a. paraplegia with flaccid paralysis b. tetraplegia with total sensory loss c. total hemiplegia with sensory and motor loss d. spastic tetraplegia with loss of pressure sensation

B. tetraplegia with total sensory loss Rationale: At the C7 level, spinal shock is manifested by tetraplegia and sensory loss. The neurologic loss may be temporary or permanent. Paraplegia with sensory loss would occur at the level of T1. A hemiplegia occurs with central (brain) lesions affecting motor neurons and spastic tetraplegia occurs when spinal shock resolves.

When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? a.) An interval when the client's speech is garbled b.) An interval when the client is alert but can't recall recent events c.) An interval when the client is oriented but then becomes somnolent d.) An interval when the client has a "warning" symptom, such as an odor or visual disturbance.

C ~ A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness. Garbled speech is known as dysarthria. An interval in which the client is alert but can't recall recent events is known as amnesia. Warning symptoms or auras typically occur before seizures

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? a.) To reduce intraocular pressure b.) To prevent acute tubular necrosis c.) To promote osmotic diuresis to decrease ICP d.) To draw water into the vascular system to increase blood pressure

C ~ Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.

Which of the following signs and symptoms of increased ICP after head trauma would appear first? a.) Bradycardia b.) Large amounts of very dilute urine c.) Restlessness and confusion d.) Widened pulse pressure

C ~ The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.

The most widely used diuretic for increased ICP is : A) Lasix B) Glycerol C) Mannitol D) Plavix

C) Mannitol

The nurse is monitoring the client with ↑intracranial pressure (ICP). Which of the following does the nurse expect to be ordered to maintain the ICP within a specified range? A. Dexamethasone (Decadron) B. Hydrochlorothiazide (HydroDIURIL) C. Mannitol (Osmitrol) D. Phenytoin (Dilantin)

C. Mannitol (Osmitrol)

The nurse hears the physician stating that the client needs a hypotonic iv solution. Which of the following solutions would the nurse expect to administer? A. LR B. D5W C. 0.45% NS D. D51/2 NS

C. 0.45% NS

The client diagnosed with diabetes insipidus weighed 180 pounds when the daily weight was taken yesterday. This morning's weight is 175.6 pounds. One liter of fluid weighs approximately 2.2 pounds. How much fluid has the client lost (in milliliters)? A. 500 mL B. 1000 mL C. 2000 mL D. 4400 mL

C. 2000 mL

The healthcare provider has ordered IV dopamine (Intropin) for a patient in the emergency deparement with a spinal cord injury. The nurse determines that the drug is having the desired effect when assessment findings include a. pulse rate of 68 b. respiratory rate of 24 c. BP of 106/82 d. temperature of 96.8

C. BP of 106/82 Rationale: Dopamine is a vasopressor that is used to maintain BP during states of hypotension that occur during neurogenic shock associated with spinal cord injury. Atropine would be used to treat bradycardia. The T reflects some degree of poikilothermism, but this is not treated with medications.

Which of the following represents the best explanation of secondary brain injury? A. Trauma to the brain causes bleeding and swelling of the tissues increasing pressure within the brain B. Trauma to neurons from the impact of the injury impairs brain function C. Breathing problems and low blood pressure cause chemical changes that contribute to brain swelling D. Swelling of the axon of the nerve causes it to disconnect from the cell body interrupting conduction of the impuls

C. Breathing problems and low blood pressure cause chemical changes that contribute to brain swelling

The nurse is planning to administer a hypertonic fluid to a client. WhicH of the following fluids would the nurse anticipate being ordered? A. 0.22% NS B. LR C. D10W D. 0.9% NS

C. D10W

The nurse is planning to administer a hypertonic fluid to a client. WhicH of the following fluids would the nurse anticipate being ordered? A. 0.22% NS B. LR C. D10W D. 0.9% NS

C. D10W

A nurse caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which electrocardiographic change would the nurse expect to note based on the magnesium level? A. Prominent U waves B. Prolonged PR interval C. Depressed ST segment D. Widened QRS complexes

C. Depressed ST segment

The nurse is caring for a client taking large doses of diuretics. Which of the following lab results would indicate excessive response to diuretic therapy? A. Decreased BUN & HCT and 8 lb weight gain in 24 hrs B. Decreased BUN & HCT and 8 lb weight loss in 24 hrs C. Elevated BUN & HCT and 8 lb weight loss in 24 hrs D. Elevated BUN & HCT and 8 lb weight gain in 24 hrs

C. Elevated BUN & HCT and 8 lb weight loss in 24 hrs

The nurse is caring for a client with a fluid & electrolyte imbalance. Which of the following would the nurse associate with this problem? A. Anemia B. Pneumonia C. Food poisoning D. Hepatitis

C. Food poisoning

The nurse is assessing the client with a traumatic brain injury after a skateboarding accident. Which symptom is the nurse most concerned about? A. Amnesia for events of accident B. Bleeding head laceration C. Pupil changes in one eye D. Restlessness and confusion

C. Pupil changes in one eye

A recently admitted client has a small-cell carcinoma of the lung, which is causing SIADH. A priority for The nurse will be: A. Monitor hourly I&O B. Ambulate client at least once per shift C. Restrict oral free water intake D. Encourage use of incentive spirometer every 2 hrs.

C. Restrict oral free water intake

The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor? A. Serum calcium. B. Serum phosphorus. C. Serum potassium. D. Serum sodium.

C. Serum potassium.

A client who sustained a closed head injury has elevation of ICP. Currently the client is putting out nearly a liter of pale urine each hour. The client is diagnosed with diabetes insipidus (DI). The nurse prepares for interventions based on which pathophysiology? A. The client has too much circulating vasopressin (DDAVP). B. The client is producing too much growth hormone (GH). C. The client is not producing enough antidiuretic hormone (ADH). D. The client is retaining sodium.

C. The client is not producing enough antidiuretic hormone (ADH). DI is a result of a deficiency in antidiuretic hormone.

Which statement best explains the scientific rationale for Kussmaul's respirations in the client diagnosed with diabetic ketoacidosis (DKA)? A. The kidneys produce excess urine and the lungs try to compensate. B. The respirations increase the amount of carbon dioxide in the bloodstream. C. The lungs speed up to release carbon dioxide and increase the pH. D. The shallow and slow respirations will increase the HCO3 in the serum.

C. The lungs speed up to release carbon dioxide and increase the pH.

A client is admitted to ICU from PACU after craniotomy to remove a clot in the frontal lobe. How will the nurse position the client? A. With flexed knees to decrease intra-abdominal pressure B. On the right side to prevent bleeding at incision site C. With head of bed elevated at least 30 degrees to promote venous drainage D. Log rolled to bed and head of bed no more than 15 degrees elevation

C. With head of bed elevated at least 30 degrees to promote venous drainage

Which of the following signs and symptoms in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? A) Headache and rising blood pressure B) Irregular respirations and shortness of breath C) Decreased level of consciousness or hallucinations D) Abdominal distention and absence of bowel sounds

Correct Answer(s): A Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and a throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic.

A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patient's arms will be retained. c. total loss of respiratory function may occur temporarily. d. elevations in heart rate are common with this type of injury.

Correct Answer(s): B Rationale: The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Total loss of respiratory function occurs with injuries above the C4 level and is permanent. Bradycardia is associated with injuries above the T6 level.

The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia? A) Tachycardia B) Hypotension C) Hot, dry skin D) Throbbing headache

Correct Answer(s): D Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? A) Risk for impairment of tissue integrity caused by paralysis B) Altered patterns of urinary elimination caused by quadriplegia C) Altered family and individual coping caused by the extent of trauma D) Ineffective airway clearance caused by high cervical spinal cord injury

Correct Answer(s): DMaintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs.

A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly? 1. autonomic dysreflexia 2. autonomic crisis 3. autonomic shutdown 4. autonomic failure

Correct Answer: 1 Rationale: Be attuned to the prevention of a distended bladder when caring for spinal cord injury (SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia. Track urinary output carefully. Routine use of bladder scanning can help prevent the occurrence. Other causes of autonomic dysreflexia are impacted stool and skin pressure. Autonomic crisis, autonomic shutdown, and autonomic failure are not terms used to describe common complications of spinal injury associated with bladder distension.

A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse? 1. Try to calm the patient and make the environment soothing. 2. Assess for a full bladder. 3. Notify the healthcare provider. 4. Prepare the patient for diagnostic radiography.

Correct Answer: 2 Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or higher, and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. A calm, soothing environment is fine, though not what the patient needs in this case. The nurse should recognize this as an emergency and proceed accordingly. Once the assessment has been completed, the findings will need to be communicated to the healthcare provider.

The patient is admitted with injuries that were sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are consistent with which of the following? 1. paralysis 2. spinal shock 3. high cervical injury 4. temporary hypovolemia

Correct Answer: 2 Rationale: Spinal shock is common in acute spinal cord injuries. In addition to the signs and symptoms mentioned, the additional sign of absence of the cremasteric reflex is associated with spinal shock. Lack of respiratory effort is generally associated with high cervical injury. The findings describe paralysis that would be associated with spinal shock in an spinal injured patient. The likely cause of these findings is not hypovolemia, but rather spinal shock.

A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which of the following actions is the nurse responsible for when caring for this patient? Select all that apply. 1. modifying the traction weights as needed 2. assessing the patient's skin integrity 3. applying the traction upon admission 4. administering pain medication 5. providing passive range of motion

Correct Answer: 2,4,5 Rationale: The healthcare provider is responsible for initial applying of the traction device. The weights on the traction device must not be changed without the order of a healthcare provider. When caring for a patient in traction, the nurse is responsible for assessment and care of the skin due to the increased risk of skin breakdown. The patient in traction is likely to experience pain and the nurse is responsible for assessing this pain and administering the appropriate analgesic as ordered. Passive range of motion helps prevent contractures; this is often performed by a physical therapist or a nurse.

A patient has manifestations of autonomic dysreflexia. Which of these assessments would indicate a possible cause for this condition? Select all that apply. 1. hypertension 2. kinked catheter tubing 3. respiratory wheezes and stridor 4. diarrhea 5. fecal impaction

Correct Answer: 2,5 Rationale: Autonomic dysreflexia can be caused by kinked catheter tubing allowing the bladder to become full, triggering massive vasoconstriction below the injury site, producing the manifestations of this process. Acute symptoms of autonomic dysreflexia, including a sustained elevated blood pressure, may indicate fecal impaction. The other answers will not cause autonomic dysreflexia.

The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse realizes that some nursing actions are contraindicated with IICP. Which nursing action should be avoided? 1. Reposition the patient every two hours. 2. Position the patient with the head elevated 30 degrees. 3. Suction the airway every two hours per standing orders. 4. Provide continuous oxygen as ordered.

Correct Answer: 3 Rationale: Suctioning further increases intracranial pressure; therefore, suctioning should be done to maintain a patent airway but not as a matter of routine. Maintaining patient comfort by frequent repositioning as well as keeping the head elevated 30 degrees will help to prevent (or even reduce) IICP. Keeping the patient properly oxygenated may also help to control ICP.

A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and complete paralysis of the lower part of the body. The nurse should use which medical term to adequately describe this in documentation? 1. hemiplegia 2. paresthesia 3. paraplegia 4. quadriplegia

Correct Answer: 4 Rationale: Quadriplegia describes complete paralysis of the upper extremities and complete paralysis of the lower part of the body. Hemiplegia describes paralysis on one side of the body. Paresthesia does not indicate paralysis. Paraplegia is paralysis of the lower body.

A hospitalized patient with a C7 cord injury begins to yell "I can't feel my legs anymore." Which is the most appropriate action by the nurse? 1. Remind the patient of her injury and try to comfort her. 2. Call the healthcare provider and get an order for radiologic evaluation. 3. Prepare the patient for surgery, as her condition is worsening. 4. Explain to the patient that this could be a common, temporary problem.

Correct Answer: 4 Rationale: Spinal shock is a condition almost half the people with acute spinal injury experience. It is characterized by a temporary loss of reflex function below level of injury, and includes the following symptomatology: flaccid paralysis of skeletal muscles, loss of sensation below the injury, and possibly bowel and bladder dysfunction and loss of ability to perspire below the injury level. In this case, the nurse should explain to the patient what is happening.

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

D ~ The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.

The nurse is evaluating the effectiveness of protein supplements on a client with a low serum total protein level. Which of these data indicate that the client's condition has improved? A. Hematocrit 28% B. Good skin turgor C. Blood pressure 110/72 D. Absence of third-spacing

D. Absence of third-spacing

The nurse is caring for an adult client with complaints of cough, fever and n/v for 3 days. The client is also complaining of dizziness and weakness. Which of the following assessments would provide the best indicator of fluid volume status? A. Temperature B. Respiratory rate & status C. Pulse ox reading at rest D. BP & pulse lying & standing

D. BP & pulse lying & standing

The nurse assesses clear fluid coming from the nose and ears of a client admitted to the Emergency Department after a fall. The fluid is found to be cerebral spinal fluid. Based on this information, the nurse plans care for a client with which type of fracture? A. Open B. Depressed C. Linear D. Basilar

D. Basilar Otorrhea and rhinorrhea are common with basilar skull fracture.

Following surgery, the nurse has administered albumin to a client. The nurse would evaluate this intervention to be effective if which of the following assessments was obtained? A. Heart rate 96 B. Temperature 98.8 C. Respirations 24 D. Blood pressure 140/80

D. Blood pressure 140/80

Following surgery, the nurse has administered albumin to a client. The nurse would evaluate this intervention to be effective if which of the following assessments was obtained? A. Heart rate 96 B. Temperature 98.8 C. Respirations 24 D. Blood pressure 140/80

D. Blood pressure 140/80

The nurse is caring for a client with nausea, vomiting and diarrhea for 3 days. The nurse would anticipate which of the following fluid choices as best for this client? A. D5 ½ NS B. D5W C. LR D. D5LR

D. D5LR

A nurse caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition? A. Lung congestion B. Decreased hematocrit C. Increased blood pressure D. Decreased central venous pressure (CVP)

D. Decreased central venous pressure (CVP)

The nurse is analyzing lab results on a client and notes a serum sodium of 165. which of the following clients is likely to have this lab result? The client with: A. Low aldosterone levels B. SIADH C. Constipation D. Inadequate fluid intake

D. Inadequate fluid intake

The nurse is preparing to administer IV fluids to a client with a serum potassium of 6.2. The nurse would question the order if it was for which of the following fluids? A. D5W B. 0.9% NS C. D51/2 NS D. LR

D. LR

The nurse is caring for a client with hypercalcemia. Which of the following labs would the nurse expect to find as well? A. Magnesium 3.4 B. Phosphorous 5.1 C. Magnesium 1.2 D. Phosphorous 1.8

D. Phosphorous 1.8

The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented? A. Encourage fluids orally. B. Administer 10% saline solution IVPB. C. Administer antidiuretic hormone intranasally. D. Place on seizure precautions.

D. Place on seizure precautions.

Following a thyroidectomy, a client complains of "a tingling feeling around my mouth". You as the nurse would immediately check for: A. An elevated serum potassium level B. Decreased thyroid hormone level C. Bleeding on the patient's dressing D. Presence of a Chvostek's sign

D. Presence of a Chvostek's sign

When increased ICP is suspected, the nurse performs a complete neurologic assessment. What does the pupillary response indicate? A. High pressure can cause blurred vision. B. Hemorrhage can cause visual impairment. C. Pupil dilation is the first sign of increased ICP. D. Pupil changes can be caused by pressure on the ocular nerve.

D. Pupil changes can be caused by pressure on the ocular nerve.

A patient experienced injury to the spinal cord in the cervical region, with paralysis and loss of sensory perception in both legs and both arms. What term is used to describe this condition? A. Paraplegia B. Hemiplegia C. Homoplegia D. Quadriplegia

D. Quadriplegia or tetraplegia

the nurse is administering 0.9% ns at 150 ml/hr and notes the client becoming short of breath and coughing up pink frothy sputum. The nurse's priority intervention is: A. Obtain a sputum specimen B. Call the physician C. Slow the IV rate down to KVO D. Raise the head of the bed

D. Raise the head of the bed

The nurse is caring for a client with hypernatremia. Which of the following would be contraindicated for this client? A. Encouraging fluids B. Implementing fall precautions C. Monitoring intake & output D. Restriction of fluid intake

D. Restriction of fluid intake

A client was admitted to the ICU after sustaining a closed head injury. Several hours later, the nurse assesses that the client is more lethargic and confused, is mumbling her speech, and is very difficult to arouse. The nurse takes action on this assessment for which reason? A. The client's ICP may be decreasing. B. The client is overtired from the events of the day. C. The client is oversedated. D. The client's brain injury may be worsening.

D. The client's brain injury may be worsening. The signs are indicative of deterioration in the client's level of consciousness associated with a worsening of a brain injury.

A nurse is caring for a client who has a C4 spinal cord injury. which of the following should the nurse recognize the client as being at the greatest risk for? a. neurogenic shock b. paralytic ileus c. stress ulcer d. respiratory compromise

D. respiratory compromise Rationale: Using the airway, breathing and circulation priority framework, the greatest risk to the client with a SCI at the level of C4 is respiratory compromise secondary to involvement of the phrenic nerve. Maintainance of an airway and provision of ventilator support as needed is the priority intervention.

Vasopressin is not used for diabetes insipidus. True/False

False

What would you do if your patient was B+ and the blood bank sent you O+ blood?

Go ahead with transfusion; O+ blood is universal.

What would you do if your patient was O- and the blood bank sent you O+ blood?

Send back to blood bank due to mismatched Rh factors.

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? Metabolic/Respiratory or acidosis/alkalosis

The pH and HCO3 indicate that the patient has a metabolic acidosis.

A patient with diabetes insipidus will most likely be treated with an ADH replacement. True/False

True

The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse? a. Client behavior that changes from anxious to lethargic b. Deep furrows on the surface of the tongue c. Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched d. Urine output of 950 mL for the past 24 hours

a. Client behavior that changes from anxious to lethargic

A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which of the following findings is of most concern to the nurse? a. SpO2 of 92% b. HR of 42 beats/min c. BP of 88/60 d. loss of motor and sensory function in arms and legs

b. HR of 42 beats/min Rationale: Neurogenic shock associated with cord injuries above the level of T6 greatly decrease the effect of the sympathetic nervous system, and bradycardia and hypotension occur. A heart rate of 42 is not adequate to meet oxygen needs of the body, and while low, the BP is not at a critical point. The O2 sat is ok, and the motor and sensory loss are expected.

A nurse identifies that an older patient may have a problem with excess fluid volume. What characteristics of the skin support this conclusion? a. Dry and scaly b. Taut and shiny c. Red and irritated d. Thin and elastic

b. Taut and shiny

A patient with paraplegia has developed an irritable bladder with reflex emptying. The nurse teaches the patient a. hygiene care for an indwelling urinary catheter b. how to perform intermittent self-catheterization c. to empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns d. that a urinary diversion, such as an ileal conduit, is the easiest way to handle urinary elimination

b. how to perform intermittent self-catheterization Rationale: Intermittent self cath five to six times a day is the recommended method of bladder management for the patient with a spinal cord injury because it more closely mimics normal emptying and has less potential for infectinon. The patient and family should be taught the procedure using clean technique, and if the patient has use of the arms, self-cath is use during the acute phase to prevent overdistention of the bladder and surgical urinary diversions are used if urinary complications occur.

A patient is admitted with a subacute subdural hematoma. The nurse realizes this patient will most likely be treated with: a.) Emergency craniotomy. b.) Elective draining of the hematoma. c.) Burr holes to remove the hematoma. d.) Removal of the affected cranial lobe.

b.) Elective draining of the hematoma.

An initial incomplete spinal cord injury often results in complete cord damage because of a. edematous compression of the cord above the level of the injury b. continued trauma to the cord resulting from damage to stabilizing ligaments c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites d. mecheanical transection of the cord by sharp vertebral bone fragments after the initial injury

c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolitesRationale: The primary injury of the spinal cord rarely affects the entire cord, but the patho of secondary injury may result in damage that is the same as mechanical severance of the cord. Complete cord dissolution occurs through autodestruction of the cord by hemorrhage, edema, and the presence of metabolites and norepinephrine. resulting in anoxia and infarction of the cord. Edema resulting from the inflammatory response may increase the damage as it extends above and below the injury site.

A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on the knowledge that a. rehabilitation measures cannot be initiated until spinal shock has resolved b. the patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia c. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder d. the patient will have complete loss of motor and sensory functions below the level of the injury, but autonomic functions are not affected

c. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder Rationale: Spinal shock occurs in about half of all people with acute spinal cord injury. In spinal shock, the entire cord below the level of the lesion fails to function, resulting in a flaccid paralysis and hypomotility of most processes without any reflex activity. Return of reflex activity signals the end of spinal shock. Sympathetic function is impaired belwo the level of the injury because sympathetic nerves leave the spinal cord at the thoracic and lumbar areas, and cranial parasympathetic nerves predominate in control over respirations, heart, and all vessels and organ below the injury. Neurogenic shock results from loss of vascular tone caused by the injury and is manifested by hypotension, peripheral vasodilation, and decreased CO. Rehab activities are not contraindicated during spainl shock and should be instituted if the patient's cardiopulmonary status is stable.

Nurse would be most concerned about which lab values obtained fro ma client receiving furosemide (Lasix) therapy? a. BUN 20 b. K 3.4 c. Creatinine 1.1 d. K 3.2

d. K 3.2

A nurse is assessing several patients for fluid and electrolyte imbalances. Which response is common to both excess fluid volume and deficit fluid volume? a. Increased pulse amplitude b. Decreased blood pressure c. Difficulty breathing d. Muscle weakness

d. Muscle weakness

A patient is admitted after experiencing vomiting and diarrhea for several days. The provider orders intravenous lactated Ringer's solution. The nurse understands that this fluid is given for which purpose? a. To increase interstitial and intracellular hydration b. To maintain plasma volume over time c. To pull water from the interstitial space into the extracellular fluid d. To replace water and electrolytes

d. To replace water and electrolytes

The nurse is working with a graduate nurse to prepare an intravenous dose of potassium. Which statement by the graduate nurse reflects a need for further teaching? a."We will need to monitor this infusion closely." b."The infusion rate should not go over 10 mEq/hour." c."The intravenous potassium will be diluted before we give it." d."The intravenous potassium dose will be given undiluted."

d."The intravenous potassium dose will be given undiluted." When giving intravenous potassium, the medication must always be given in a diluted form and administered slowly. Intravenous bolus or undiluted forms may cause cardiac arrest. Intravenous rates are not to exceed 10 mEq/hr unless the patient is on a cardiac monitor. Oral forms should be mixed with juice or water or taken according to instructions.