Foundations 2 exam

The nurse in a medical unit is collecting a client's history and asks the client about the use of complementary and alternative therapies. The client asks why the nurse needs to know about this. What is the nurse's best response?

"It's important that we list all your home care needs for the hospital."

flow rate claculation

(ml / mins) X gtt

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

1

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

2,500 ml/ day

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine?

24 hr specimen

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?

3,000

potassium levels

3.5-5.5

what is the standard drop factor of micro drip tubing?

60 drops/ml

A client with type AB blood has experienced a precipitous drop in hemoglobin levels due to a gastrointestinal bleed and now requires a blood transfusion. Which blood types may this client safely receive?

A, B, AB, O

The nurse explains to the client that which statement is true regarding the difference between allopathic therapy and complementary and alternative therapy?

Allopathic therapy emphasizes treatments for diseases. Complementary and alternative therapy emphasizes treatments for health.

A nurse is assessing a client after surgery and obtains the client's vital signs: pulse rate is 65 bpm, blood pressure is 122/76 mm Hg in the supine position. The nurse then obtains the client's vital signs on standing. Which finding would alert the nurse to the possibility of a an ECF volume deficit? Select all that apply.

Blood pressure 104/68 mm Hg and pulse of 90

A client with frequent urinary tract infections (UTIs) has returned to the ambulatory clinic with symptoms of another UTI. The nurse reviews measures to follow to promote health and decrease the risk of contracting a UTI. Which measure is appropriate for the client to follow?

Drink two glasses of water before and after sexual intercourse.

A nurse is caring for a client with an external condom catheter. What is a guideline for applying and caring for this type of catheter?

Fasten the condom securely enough to prevent leakage without constricting the blood vessels.

interstitial fluid

Fluid in the tissue space between and around cells

The nurse is changing a stoma appliance on an ileal conduit. Which nursing action is recommended procedure?

Gently remove the appliance, starting at the top and keeping the abdominal skin taut. Apply a silicone-based adhesive remover by spraying or wiping as needed. Make sure skin around stoma is thoroughly dry by patting it dry.

A male patient is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. His skin is also excoriated from urinary incontinence. Which nursing diagnosis is most appropriate for this patient?

Impaired Skin Integrity related to urinary bladder infection and dehydration

Extracellular fluids

Newborns have the most extracellular fluid Take up 30% of fluid in the body (adults)

The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client?

O negative

A client at a health care facility is being treated for cancer of the bladder. The physician uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion?

One or both of the ureters are surgically implanted elsewhere

Primary extracellular electrolytes

Sodium, chloride, bicarbonate

The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present?

The renal system retains more water.

A client is preparing to give a clean-catch specimen. Which instruction will the nurse provide?

after stream is initiated collect the sample

Major control over the extracellular concentration of potassium within the human body is exerted by:

aldosterone

Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?

altered thought processes related to cerebral edema

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication?

apply warm compress

What is the lab test commonly used in the assessment and treatment of acid-base balance?

arterial blood gas

What accurately describes a guideline when inserting an indwelling catheter?

avoid irrigation unless it is to clear an obstruction

When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine?

blood

The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?

calcium and phosphorus

older adults age related fluid consideration

cardiac volume intolerance

A nurse is researching a standardized herbal supplement to help a client with pain. What does the word standardized mean?

certain amt of active ingredient

what is a common anion?

chloride

client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply.

confusion, respiratory muscle weakness, ventricular dysrhythmia

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

decreased potassium levels

A patient with dermatitis has sought care from a homeopathic practitioner seeking treatment for her dry, itchy, and inflamed skin. Which of the following statements is characteristic of homeopathy?

diluted solution

The nurse has an order to obtain a 24-hour urine from a client. Which of the following instructions would be accurate for collection of the specimen?

discard your first urination and start the collection after that

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

distended neck veins

The doctor has ordered the collection of a fresh urine sample for a particular examination. Which urine sample would the nurse discard?

first voiding of the day

When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing:

fluid overload

A client in a long-term care facility becomes confused and disoriented at night and is incontinent during these periods of confusion due to the inability to find the commode. During the day, the client does not experience confusion and is continent. What type of incontinence is this client experiencing during the nighttime hours?

functional

The mind and body are connected in the provision of care. This statement describes:

holistic

The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing?

hypertonic

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:

hypokalemia

low potassium

hypokalemia

Which of the following has been known to achieve benefits for clients with cancer through the use of the mind to visualize a positive physiologic effect?

imagery

Ayurvedic medicine has its roots in which of the following areas?

india

A nurse is reading a journal article about fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances?

infants

The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment?

intracellular

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?

isotonic

hypovolemia orders

lactated ringer solution, 0.9% NaCl, 5% dextrose in 0.9% NaCl

potassium is needed for

neural, muscle, and cardiac function

The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention?

phlebitis

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?

potassium

A nurse is caring for a client who is catheterized following a surgery of the prostate. When caring for the client, the nurse performs a continuous irrigation of the catheter. Which of the following interventions should the nurse perform when providing continuous irrigation?

prime tubing

The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?

renal failure

decreased arterial blood pressure released

renin

During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first?

stop transfusion immediately

pituitary glands

store and release antidiuretic hormone rather than the kidneys

A nurse is caring for a client who has an infant age 4 months. The client informs the nurse that she has been experiencing a sudden loss of urine whenever she laughs; this is causing embarrassment to her. Which type of urinary incontinence is this client experiencing?

stress

The nurse is assessing a female client who states that she notices an involuntary loss of urine following a coughing episode. What would be the nurse's best reply?

stress inconinance, legal exercises

The nurse measures a client's residual urine by catheterization after the client voids. Which condition would this test verify?

unrinary retention

The nurse is caring for a male patient who has a urinary obstruction and is not a candidate for surgery. What intervention would the nurse expect the health care provider to perform?

urologic stent

osmosis

water moves from an area of lower solute concentration to an are of higher concentration

An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use a(an)

winged infusion needle