Advanced Skills Exam Part One

A nurse is evaluation the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicated that treatment has been successful? A. Clear breath sounds B. Positive pedal pulses C. Normal potassium level D. Increased urine specific gravity

A. Clear breath sounds

Which statement by a client with hypocolemia related to dehydration is the best indicator to the nurse of the need for additional teaching? A. "I will drink 2-3L of fluid every day" B. "I will drink a glass of water whenever I feel thirsty" C. "I will drink coffee and cola drinks throughout the day" D. "I will avoid drinks containing alcohol"

C. "I will drink coffee and cola drinks throughout the day"

A nurse is concerned that a client is at risk for developing hyperkalemia. Which disease does the client have that has caused this concern? A. Crohn B. Cushing C. End-Stage Renal D. GERD

C. End-Stage Renal

The PACU nurse caring for a client with a NG tube notes that 300mL or bright red blood has collected. What is the appropriate nursing action? A. Document as a normal finding B. Immediately remove the NG C. Place the client in Trendelenburg position D. Call the client's surgeon to report the drainage

D. Call the client's surgeon to report the drainage

A nurse is assigned to change a central line dressing. The agency policy is to clean the site with Betadine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede Betadine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and Betadine. The nurse has a sample of the new product. How should the nurse proceed? A. Use the new product sample when changing the dressing B. Cleanse the site with alcohol first and then with Betadine C. Cleanse the site with the new product first and then follow the agency's protocol D. Follow the agency's policy unless it is contradicted by a health care provider's order.

D. Follow the agency's policy unless it is contradicted by a health care provider's order.

After a partial gastrectomy, a client is returned from the PACU to the surgical unit with an IV solution infusing and a NG tube in place. The nurse identifies that there is no NG tube drainage for 30 min. There is an order for instillation of the NG tube PRN. The nurse should instill: A. 30 mL of normal saline and continue the suction B. 20 mL of air and clamp off the suction for 1 hour C. 50 mL of saline and increase the pressure of the suction D. 15 mL of distilled water and disconnect the suction for 30 minutes.

A. 30 mL of normal saline and continue the suction

The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to a new graduated RN. Which actions can the new-graduate RN delegate to the UAP? SATA A. Providing oral care every 3-4 hours B. Monitoring for indications of dehydration C. Administering 0.45% saline by IV line D. Record urine output when client voids E. Assessing daily weights for trends F. Help the client change position every 2 hours

A. Providing oral care every 3-4 hours D. Record urine output when client voids F. Help the client change position every 2 hours

A client is admitted to the surgical care unit from the postanesthesia care unit with a Salem sump NG tube that is to be attached to wall suction. Which nursing action should the nurse implement when caring for this client? A. Use normal saline to irrigate the tube B. Employ sterile technique when irrigating the tube C. Withdraw the tube quickly when decompression is terminated. D. Allow the client to have small sips of water unless nauseated

A. Use normal saline to irrigate the tube

How should a nurse prepare an IV piggyback medication for administration to a client receiving an IV infusion? SATA A. Wear clean gloves to check the IV site B. Rotate the bag after adding the medication C. Use 100 mL of fluid to mix the medication D. Change the needle before adding the medication E. Place the IVPB at a lower level than the existing IV F. Use a sterile technique when preparing the medication

A. Wear clean gloves to check the IV site B. Rotate the bag after adding the medication F. Use a sterile technique when preparing the medication

A nurse in reviewing the lab report of a client with a tentative diagnosis of kidney failure. What mechanism does the nurse expect to be maintained when ammonia is excreted by healthy kidneys? A. Osmotic pressure of the blood B. Acid-base balance of the body C. Low bacterial levels in the urine D. Normal RBC production

B. Acid-base balance of the body

A nurse is analyzing how a hyperglycemic client's blood glucose can be lowered. The nurse considers that the chemical that buffers the client's excessive acetoacetic acid is: A. Potassium B. Bicarbonate C. Carbon Dioxide D. Sodium Chloride

B. Bicarbonate

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? A. Rapid, thready pulse B. Distended jugular veins C. Elevated hematocrit level D. Increased serum sodium level

B. Distended jugular veins

A nurse explains to an obese client that the rapid weight loss during the first week after initiating a diet is because of fluid loss. The weight of extracellular body fluid is approximately 20% of the total body weight of an average individual. Which component of the extracellular fluid contributes the greatest proportion to this amount? A. Plasma B. Interstitial C. Dense tissue D. Body secretions

B. Interstitial

An experienced LPN reports to the RN that a client's BP and HR have decreased, and when his face was assessed, one side twitches. What action should the RN take at this time? A. Reassess the client's BP and HR B. Review the client's morning calcium C. Request a neurological consult today D. Check the client's pupillary reaction to light

B. Review the client's morning calcium

Two hours after a subtotal gastrectomy, the nurse identifies that the drainage from the client's NG tube is bright red. What should the nurse do first? A. Notify the healthcare provider B. Clamp the NG tube for one hour C. Determine that this is an expected finding D. Irrigate the NG tube with iced saline

C. Determine that this is an expected finding

A nurse administers an IV solution of 0.45% sodium chloride. In what category does this solution belong? A. Isotonic B. Isomeric C. Hypotonic D. Hypertonic

C. Hypotonic

A nurse adds 20 mEq of potassium chloride the the IV solution of a patient with diabetic ketoacidosis. What is the primary purpose for administering this drug? A. Treat hyperpnea B. Prevent flaccid paralysis C. Replace excessive losses D. Treat cardiac dysrhythmias

C. Replace excessive losses

The UAP reports to the nurse that a client's urine output for the past 24 hours has only been 360 mL. What is the nurse's priority action at this time? A. Place an 18-gauge IV in the nondominant arm B. Elevate the client's HOB at least 45 degrees C. Instruct the UAP to provide the client with a pitcher of ice water D. Contact and notify the health care provider immediately

D. Contact and notify the health care provider immediately

A nurse is caring for a client with albuminuria resulting in edema. What pressure change does the nurse determine as the cause of the edema? A. Decrease in tissue hydrostatic pressure B. Increase in plasma hydrostatic pressure C. Increase in tissue colloid osmotic pressure D. Decrease in plasma colloid oncotic pressure

D. Decrease in plasma colloid oncotic pressure

The RN is providing care for a client diagnosed with dehydration and hypovolemic shock. Which prescribed intervention from the health care provider should the RN question? A. BP every 15 min B. Place two 18-gauge IV lines C. Oxygen at 3L via nasal cannula D. IV 5% dextrose in water to run at 250 mL/hr

D. IV 5% dextrose in water to run at 250 mL/hr

A nurse is reviewing the health care provider's orders for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which order should the nurse question? A. Oral psyllium (Metamucil) B. Oral potassium supplement C. Parenteral hald normal saline D. Parenteral albumin (Albuminar)

D. Parenteral albumin (Albuminar)

A nurse assesses a client's serum electrolyte levels in the lab report. When electrolyte in intracellular fluid should the nurse consider most important? A. Sodium B. Calcium C. Chloride D. Potassium

D. Potassium

The RN is reviewing the client's morning laboratory results. Which of these results is of most concern? A. Serum potassium lever of 5.2 B. Serum sodium of 134 C. Serum calcium of 10.6 D. Serum magnesium of 0.8

D. Serum magnesium of 0.8

A client's potassium level is 6.7 mEq/L. Which intervention should the nurse delegate to the first-year student nurse whom he or she is supervising? A. Administer sodium polystyrene sulfonate 15g orally B. Administer spironolactone 25mg orally C. Assess the ECG strip for tall T waves D. Administer potassium 10 mEq orally

A. Administer sodium polystyrene sulfonate 15g orally

The nursing care plan for an older client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN being supervised by a nurse? SATA A. Reminding the client to avoid commercial mouthwashes B. Encouraging mouth rinsing with warm saline C. Assess skin turgor by pinching the skin over the back of the hand D. Observing the lips, tongue, and mucous membranes E. Providing mouth care every 2 hours while the client is awake F. Seeking a dietary consult to increase fluids on meal trays

A. Reminding the client to avoid commercial mouthwashes B. Encouraging mouth rinsing with warm saline D. Observing the lips, tongue, and mucous membranes E. Providing mouth care every 2 hours while the client is awake

A nurse is reviewing a client's serum electrolyte lab report. What is the comparison between blood plasma and interstitial fluid? A. The both contain the same kind of ions B. Plasma exerts lower osmotic pressure than does interstitial fluid C. Plasma contains more of each kind of ion than does interstitial fluid D. Sodium is higher in plasma, whereas potassium is higher in interstitial fluid

A. The both contain the same kind of ions

The client has a NG tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate and depth has decreased. What is the nurse's best response? A. "It's common for clients with uncomfortable equipment such as NG tubes to have a lower rate of breathing." B. "The client my have a metabolic alkalosis due to the NG tube suctioning, and the decreased respiratory rate is a compensatory mechanism." C. "Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps correct the problem." D. "The client is hypoventilating because of anxiety, and we will have to stay alert for the development of respiratory acidosis."

B. "The client my have a metabolic alkalosis due to the NG tube suctioning, and the decreased respiratory rate is a compensatory mechanism."

A client is receiving an IV infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. What nutritional problem prompts the nurse to notify the health care provider? A. Excessive carbohydrate intake B. Lack of protein supplementation C. Insufficient intake of soluble vitamins D. Increased concentration of electrolytes in cells

B. Lack of protein supplementation

A client reports vomiting and diarrhea for 3 days. When clinical finding will most accurately indicate that the client has a fluid deficit? A. Presence of dry skin B. Loss of body weight C. Decrease in blood pressure D. Altered general appearance

B. Loss of body weight

The client has a fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by the RN to a UAP? A. Administering IV fluids as prescribed by the physician B. Providing straws and offering fluids between meals C. Developing a plan for added fluid intake over 24 hours D. Teaching family members to assist the client with fluid intake

B. Providing straws and offering fluids between meals

A client's serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first? A. Call the lab to repeat the test B. Take vital signs and notify the health care provider C. Inform the cardiac arrest team to place them on alert D. Take an electrocardiogram and have lidocaine available.

B. Take vital signs and notify the health care provider

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? SATA A. Tetany B. Seizures C. Diarrhea D. Weakness E. Dysrhythmias

C. Diarrhea D. Weakness E. Dysrhythmias

For what clinical indicator should a nurse assess a client who is having a gastric lavage? A. Decreased serum pH B. Increased serum oxygen level C. Increased serum bicarbonate level D. Decreased serum osmotic pressure

C. Increased serum bicarbonate level

A nurse is caring for a client with ascites. What does the nurse consider to be the cause of ascites? A. Portal hypotension B. Kidney malfunction C. Diminished plasma protein level D. Decreased production of potassium

C. Diminished plasma protein level

A client is to have gastric gavage. In which position should the nurse place the client when the NG tube is being inserted? A. Supine B. Mid-Fowler C. High-Fowler D. Trendelenburg

C. High-Fowler

A nurse is caring for a client with ascites who is receiving albumin. What infusion rate and oral fluid intake should the nurse expect to have the greatest therapeutic effect? A. Slow IV rate and liberal fluid intake B. Slow IV rate and restricted fluid intake C. Rapid IV rate and withheld fluid intake D. Rapid IV rate and moderate fluid intake

B. Slow IV rate and restricted fluid intake

A nurse is caring for a client with diarrhea. In which clinical indicator does the nurse anticipate a decrease? A. Pulse rate B. Tissue turgor C. Specific gravity D. Body temperature

B. Tissue turgor