Test 2

A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider?

Sodium 126 mEq/L

A nurse is assessing a client who has fluid volume overload. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY)

-Increased heart rate -Increased blood pressure -Increased respiratory rate

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY)

-Poor Skin Turgor -Hypotension -Flat Neck Veins

A nurse is admitting a 6-month-old infant who has dehydration. Which of the following amounts of urinary output should indicate to the nurse that the treatment had corrected the fluid imbalance?

2 mL/kg/hr

A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect?

Nausea and vomiting

A nurse is calculating the intake of a client during the past 9 hr. The client's intake includes lactated Ringer's IV at 150 mL/hr, cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride, two units of packed RBCs of 275 mL and 250 mL; two IV bolus infusions of 250 mL of 0.9% sodium chloride, ranitidine 50 mg IV intermittent bolus in 50 mL of dextrose 5% in water. How many mL of intake should the nurse record?

2525 mL

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

Body weight

A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect?

Furrows in the tongue

A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer?

Sodium polystyrene

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

A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Skin tenting present

A nurse is calculating the output of a client at the end of the shift. The nurse notes the following: client voided 400 mL at 1100 and 350 mL at 1430. The closed chest drainage system was previously marked at 155 mL and is now at 175 mL. The NG tube has 575 mL in drainage container, and 25 mL is emptied out of the Jackson-Pratt drainage tube. How many mL should the nurse record in the medical record as the client's output?

1370 mL

A nurse is reviewing the laboratory results of a client who is dehydrated. Which of the following BUN lab values should the nurse report to the provider?

25 mg/dL

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed 1/2 cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?

260 mL

A nurse is assessing four female clients for obesity. Which of the following clients have manifestations of obesity?

A client who weighs 28% above ideal body weight

A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client's most recent laboratory results and finds the client's potassium level is 5.3 mEq/L. Which of the following actions should the nurse take?

Call the prescribing physician and inform her of the client's serum potassium level results.

A nurse is caring for a client who has postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for?

Decreased potassium level

A nurse is instructing a clients family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instruction should the nurse include?

Encourage the client to take small bites

A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take?

Give the ordered KCL as prescribed.

A nurse is planning care for a client who has acute dysphagia. Which of the following nursing interventions should be included in the plan of care?

Instructing the client to tilt head forward when swallowing

A nurse in an emergency department is assessing an infant who is dehydrated. Which of the following findings should the nurse expect?

Irritability

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

A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which of the following statements by the clients partner indicated the need for further teaching?

"I will monitor my husband for titling his head forward when he swallows."

A nurse is caring for a client who has heart failure and a new prescription for furosemide. For which of the following adverse effects should the nurse monitor?

Hypokalemia

A nurse is assessing a preschooler who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect?

Muscle tremors

A nurse is caring for a client who is experiencing dysphagia. The nurse should recommend a referral to which of the following members of the health care team?

Speech therapist

A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provide. Which of the following nutritional therapies will likely be prescribed?

Supplements via nasogastric tube

A 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 gastroenteritis and is febrile.

A nurse is caring for a client who had a total thyroidectomy and a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect?

Tingling of the extremities