N3362, FOUNDATION exam 3 prep
A nurse has a prescription to transfuse a unit of packed red blood cells to a client who does not currently have an intravenous (IV) line inserted. When obtaining supplies to start the IV infusion, the nurse should select an angiocatheter of which size? 1. 20 gauge 2. 21 gauge 3. 22 gauge 4. 24 gauge
1. 20 gauge Rationale: The IV catheter used for a blood transfusion should be at least 18 or 20 gauge. Compared with IV solutions, blood has a thicker and stickier consistency, and use of an 18- or 20-gauge catheter will ensure that the bore of the catheter is large enough to prevent damage to the blood cells. Therefore the remaining options are incorrect because the gauge size is too small for the administration of blood.
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? 1.An oral temperature of 98.8° F 2.A urine specific gravity of 1.043 3.A urine output that is pale yellow 4.A blood pressure of 120/80 mm Hg
2. A urine specific gravity of 1.043 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 reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid? -Peas -Nuts -Cauliflower -Processed oat cereals
---Processed oat cereals Rationale: The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. -- Nuts, cauliflower, and peas are good food sources of phosphorus. Peas are also a good source of magnesium. Processed foods are high in sodium content.
Which intravenous solution would be most appropriate for a client who may be experiencing excess fluid volume secondary to heart failure? 1. 0.9% normal saline 2. 0.45% normal saline 3. Lactated Ringer's solution 4. 5% dextrose in 0.9% normal saline
--5% dextrose in 0.9% normal saline Rationale: --The fluid of choice for a client with excess fluid volume is a hypertonic solution of 5% dextrose in 0.9% normal saline. This solution would pull fluid into the intravascular space; the kidneys could then excrete the excess fluid. --The 0.45% normal saline solution is hypotonic, which pulls fluid into the intracellular space. --The lactated Ringer's and 0.9% normal saline solutions are both isotonic solutions that would worsen the excess fluid volume.
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? -Tetany -Twitches -Positive Trousseau's sign -Loss of deep tendon reflexes
--Loss of deep tendon reflexes Rationale: The normal magnesium level is 1.3-2.3 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 caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level? -The client who is taking diuretics -The client with hyperaldosteronism -The client with Cushing's syndrome -The client who is taking corticosteroids
--The client who is taking diuretics Rationale: Hyponatremia is evidenced by a serum sodium level less than 135 mEq/L. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.
The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. On the basis of this documentation, which pattern did the nurse observe? -Respirations that cease for several seconds -Respirations that are regular but abnormally slow -Respirations that are labored and increased in depth and rate -Respirations that are abnormally deep, regular, and increased in rate
-Respirations that are abnormally deep, regular, and increased in rate Rationale: --Kussmaul's respirations are abnormally deep, regular, and increased in rate. --Apnea is described as respirations that cease for several seconds. --bradypnea, respirations are regular but abnormally slow. --hyperpnea, respirations are labored and increased in depth and rate.
A client with a traumatic closed head injury shows signs that indicate the presence of cerebral edema. Which intravenous solution would increase cellular swelling and cerebral edema? (which IV solution would cause the swelling and cerebra edma to INCREASE / SWELL MORE?) 1. 0.9% normal saline 2. 0.45% normal saline 3. 5% dextrose in water 4. Lactated Ringer's solution
0.45% Rationale: Hypotonic solutions such as 0.45% normal saline are inappropriate for the client with cerebral edema because hypotonic solutions have the potential to cause cellular swelling and cerebral edema. The remaining choices of solutions would be appropriate because they are examples of isotonic solutions and thus are similar in composition to plasma. These fluids would remain in the intravascular space without potentiating the client's cerebral edema.
The nurse is picking up a unit of packed red blood cells at the hospital blood bank. After putting the pen down, the nurse glances at the clock, which reads 1:00. The nurse calculates that the transfusion must be started by which time? 1. 1:30 2. 2:00 3. 2:30 4. 3:00
1. 1:30 Rationale: Blood must be hung as soon as possible (within 30 minutes) after it is obtained from the blood bank. After that time, the blood temperature will be higher than 50° F, and the blood could be unsafe for use. --For this reason, options 2, 3, and 4 are incorrect.
Which client statements best demonstrate to the nurse that the client understands the concepts of an advance directive? Select all that apply. 1."This document is a separate document from my final will." 2."This document is strictly for indicating if I want to be resuscitated." 3."I need to have my family sign this document in case my condition worsens." 4."This document describes the kind of treatment I want depending on how sick I am." 5."This document tells what I want and gives medical power of attorney to my doctor."
1."This document is a separate document from my final will." 4."This document describes the kind of treatment I want depending on how sick I am." Rationale: --An advance directive describes the specific medical treatment that a client wants if he or she is unable to make decisions about care. --An advance directive is a separate document from the final will. --The family does not need to sign an advance directive. Medical power of attorney is a type of advance directive but requires separate documentation. --A do not resuscitate is a type of advance directive but an advance directive encompasses additional information. Therefore, options 2, 3, and 5 are incorrect.
A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse should plan to carry out which prescribed measure as the most effective means to treat the problem? 1.Administer prescribed antibiotics. 2.Have the client breathe into a paper bag. 3.Administer antipyretics as needed (on PRN basis). 4.Request a prescription for a partial rebreather oxygen mask.
1.Administer prescribed antibiotics. Rationale: The most effective way to treat an acid-base disorder is to treat the underlying cause of the disorder. In this case, the problem is sepsis, which is most effectively treated with antibiotic therapy. Antipyretics will control fever secondary to sepsis but do nothing to treat the acid-base balance. --The paper bag and partial rebreather mask will assist the client to rebreathe exhaled carbon dioxide, but again, these do not treat the primary cause of the imbalance.
The nurse is told by a health care provider that a client in hypovolemic shock will require plasma expansion. The nurse anticipates receiving a prescription to transfuse which product? 1.Albumin 2.Platelets 3.Cryoprecipitate 4.Packed red blood cells
1.Albumin Rationale: Albumin may be used as a plasma expander. -- Platelets are used when the client's platelet count is low. --Cryoprecipitate is useful in treating bleeding from hemophilia or disseminated intravascular coagulopathy because it is rich in clotting factors. --Packed red blood cells replace erythrocytes and are not a plasma expander.
The nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2 mg/dL. Which condition most likely caused this serum phosphorus level? normal phosphorus level (2.5-4.5) 1.Alcoholism 2.Renal insufficiency 3.Hypoparathyroidism 4.Tumor lysis syndrome
1.Alcoholism Rationale: The normal serum phosphorus level is 2.7 to 4.5 mg/dL. The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Malnutrition is associated with alcoholism. --Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.
The nurse attends an educational conference on leadership styles. A colleague at the conference who is employed at a large trauma center states that the leadership style at the trauma center is task oriented and directive. The nurse recognizes that what type of leadership style is used at the trauma center? 1.Autocratic 2.Situational 3.Democratic 4.Laissez-faire
1.Autocratic Rationale: --The autocratic style of leadership is task oriented and directive. --Situational leadership style uses a style depending on the situation and events. -- Democratic styles best empower staff toward excellence because this type of leadership allows nurses to provide input and provides an opportunity to grow professionally. --The laissez-faire style allows staff to work without assistance, direction, or supervision.
The nurse has discontinued a unit of blood that was infusing into a client because the client experienced a transfusion reaction. After documenting the incident appropriately, the nurse sends the blood bag and tubing to which department? 1.Blood bank 2.Infection control 3.Risk management 4.Environmental services
1.Blood bank Rationale: The nurse returns the blood transfusion bag containing any remaining blood to the blood bank. This allows the blood bank to complete any follow-up testing procedures needed once a transfusion reaction has been documented. --The other options identify incorrect departments.
The nurse is rearranging the client assignments after several discharges and admissions occurred. Which tasks can be assigned to the unlicensed assistive personnel (UAP)? Select all that apply. 1.Cleaning a client's dentures 2.Ambulating a postoperative client 3.Taking 4:00 pm vital signs on clients 4.Giving medications left by the nurse for the client to take 5.Assisting a client with a urinary drainage catheter into a chair 6.Obtaining a catheterized urinalysis and taking it to the laboratory
1.Cleaning a client's dentures 2.Ambulating a postoperative client 3.Taking 4:00 pm vital signs on clients 5.Assisting a client with a urinary drainage catheter into a chair Rationale: Medication administration and invasive procedures, such as urinary catheterization for specimen collection cannot be done by the UAP; therefore these options are incorrect. The remaining options identify activities that can be performed by the UAP.
During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? 1.Dehydration 2.Hypokalemia 3.Fluid overload 4.Hypernatremia
1.Dehydration Rationale: When a client is dehydrated, the heart rate increases in an attempt to maintain blood pressure. Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when the client stands, he may experience dizziness because of insufficient blood flow to the brain. Alterations in mental status also may occur. The oral mucous membranes, usually moist, are dry and may be covered with a thick, pasty coating. These findings are not manifestations of the conditions noted in the other options.
The newly appointed vice president for nursing operations has announced that the authority for decision making will be decentralized and distributed throughout the organization. The nurse managers anticipate that the channel of communication and authority will be characterized by which organizational chart? 1.Flat 2.Vertical 3.Circular 4.Horizontal
1.Flat Rationale: --In "flat" organizations, authority and responsibility are delegated to the lowest operational level possible. Option 2 is incorrect because a vertical chart indicates a formal line of authority and communications. Traditionally, vertical charts indicate decision making at the upper levels of management. Option 3 indicates a concentric or circular chart, with the chief executive in the center and successive layers of authority. Option 4 refers to a horizontal, or left-to-right, chart that depicts the chief executive at the left, with lower layers of the authority to the right.
A client with diabetes mellitus has a blood glucose level of 644 mg/dL. The nurse should develop a plan of care because the client is at risk for the development of which type of acid-base imbalance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis
1.Metabolic acidosis Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic, potentially leading to the condition known as diabetic ketoacidosis. --Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Focus on the subject, acid-base disturbance associated with diabetes mellitus. Noting the client's diagnosis will assist in eliminating options 3 and 4. Regarding the remaining options, recall that the client with diabetes mellitus is at risk for the development of metabolic acidosis. Review: Causes of metabolic acidosis
The nurse is reviewing a client's laboratory report and notes that the serum calcium level is 4.0 mg/dL. [8.6-10.2] normal range. The nurse understands that which condition most likely caused this serum calcium level? 1.Prolonged bed rest 2.Renal insufficiency 3.Hyperparathyroidism 4.Excessive ingestion of vitamin D
1.Prolonged bed rest Rationale: --The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 4.0 mg/dL is experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. --End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. --Hyperparathyroidism and excessive ingestion of vitamin D are causative factors associated with hypercalcemia.
A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8° F orally from a baseline of 99.2° F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? 1.Septicemia 2.Hyperkalemia 3.Circulatory overload 4.Delayed transfusion reaction
1.Septicemia Rationale: --Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. --Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. --A delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level
A nurse notes that a client's serum calcium level is 6.0 mg/dL. Which assessment findings should be anticipated in this client? Select all that apply. [ 8.6-10.2] normal range 1.Tetany 2.Constipation 3.Renal calculi 4.Hypotension 5.Prolonged QT interval 6.Positive Chvostek's sign
1.Tetany 4.Hypotension 5.Prolonged QT interval 6.Positive Chvostek's sign Rationale: The normal serum calcium level is 8.6 to 10.2 mg/dL; thus, the client's results are reflective of hypocalcemia. The most common manifestations of hypocalcemia are caused by overstimulation of the nerves and muscles; therefore, tetany and presence of Chvostek's sign would be expected. Calcium is needed by the heart for contraction. When the serum calcium level is decreased, cardiac contractility is decreased and the client will experience hypotension. A low serum calcium level could also lead to severe ventricular dysrhythmias and prolonged QT and ST intervals on the electrocardiogram.
A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client's bedside? 1.Lactated Ringer's 2. 0.9% sodium chloride 3. 5% dextrose in 0.9% sodium chloride 4. 5% dextrose in 0.45% sodium chloride
2. 0.9% sodium chloride Rationale: Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. --Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells. --Lactated Ringer's is not the solution of choice with this procedure.
The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition (PN) bag of an assigned client is empty. Which solution readily available on the nursing unit should the nurse hang until another PN solution is mixed and delivered to the nursing unit? 1. 5% dextrose in water 2. 10% dextrose in water 3. 5% dextrose in Ringer's lactate 4. 5% dextrose in 0.9% sodium chloride
2. 10% dextrose in water Rationale: The client is at risk for hypoglycemia; therefore the solution containing the highest amount of glucose should be hung until the new PN solution becomes available. Because PN solutions contain high glucose concentrations, the 10% dextrose in water solution is the best of the choices presented. The solution selected should be one that minimizes the risk of hypoglycemia. --The remaining options will not be as effective in minimizing the risk of hypoglycemia.
The nurse is caring for a client with chronic kidney disease. Arterial blood gas (ABG) results indicate a pH of 7.30, a Pco2 of 32 mm Hg, and a bicarbonate concentration of 20 mEq/L. Which laboratory value should the nurse expect to note? 1.Sodium level of 145 mEq/L [135-145] normal range 2.Potassium level of 5.2 mEq/L [3.5-5.0] normal range 3.Phosphorus level of 4.0 mg/dL [2.5-4.5] normal range 4.Magnesium level of 2.0 mg/dL [1.2-2.3] normal range
2. Potassium level of 5.2 mEq/L Rationale: Interpretation of the ABG indicates metabolic acidosis with partial compensation by the respiratory system. Clinical manifestations of metabolic acidosis include hyperpnea with Kussmaul's respirations; headache; nausea, vomiting, and diarrhea; fruity-smelling breath resulting from improper fat metabolism; central nervous system depression, including mental dullness, drowsiness, stupor, and coma; twitching; and convulsions. Hyperkalemia will occur.
The registered nurse is beginning a new job in a clinic and attends an orientation session. After the session, another new employee asks the registered nurse to describe case management, a component of the discussions in the orientation session, because the employee did not clearly understand the concept. The registered nurse responds by making which statement? 1."Case management is an important concept, but it doesn't promote appropriate use of personnel." 2."Case management will maximize hospital revenues and at the same time provide optimal outcome of client care." 3."Case management saves money for the institution because clients with similar problems are all treated in the same manner." 4."Case management requires an experienced nurse because it represents a primary health prevention focus and is managed by a single nurse."
2."Case management will maximize hospital revenues and at the same time provide optimal outcome of client care." Rationale: Case management represents an interdisciplinary health care delivery system that promotes appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal outcomes of client care. The remaining options are inaccurate statements regarding case management.
The nurse has developed a teaching plan for a client with hypertension regarding the administration of prescribed medications. What is the initial nursing action? 1.Set priorities for the client. 2.Assess the client's readiness to learn. 3.Find out whether anyone lives with the client. 4.Use only one teaching method to prevent confusion.
2.Assess the client's readiness to learn. Rationale: Until the client is ready to learn, teaching sessions will be ineffective. Teaching should be in short sessions, early in the day, when the client is well rested. It is important to include the client in the development of the teaching plan and to set priorities with him or her. Although it may be important to determine whether anyone lives with the client, this is not the initial nursing action. Varied teaching methods are best, such as verbal instruction with visual aids and the provision of written material for later reference.
A client's kidneys are retaining increased amounts of sodium. The nurse plans care, anticipating that the kidneys also are retaining greater amounts of which substances? 1.Calcium and chloride 2.Chloride and bicarbonate 3.Potassium and phosphates 4.Aluminum and magnesium
2.Chloride and bicarbonate Rationale: Sodium is a cation. With increased retention of sodium, the kidneys also increase reabsorption of chloride and bicarbonate, which are anions. --Options 1 and 3 are incorrect because calcium and potassium are cations. The same is true for option 4.
A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse should monitor this client, expecting to note which signs/symptoms? 1.Disorientation and dyspnea 2.Decreased respiratory rate and depth 3.Drowsiness, headache, and tachypnea 4.Tachypnea, dizziness, and paresthesias
2.Decreased respiratory rate and depth Rationale: --A client with metabolic alkalosis is likely to exhibit decreased respiratory rate and depth as a compensatory mechanism. --A client with metabolic acidosis would display the symptoms noted in option 3. --The client with respiratory acidosis and alkalosis would display the symptoms noted in options 1 and 4, respectively.
Which nursing action is essential prior to initiating a new prescription for 500 mL of fat emulsion (lipids) to infuse at 50 mL/hour? 1.Ensure that the client does not have diabetes. 2.Determine whether the client has an allergy to eggs. 3.Add regular insulin to the fat emulsion, using aseptic technique. 4.Contact the health care provider (HCP) to have a central line inserted for fat emulsion infusion.
2.Determine whether the client has an allergy to eggs Rationale: The client beginning infusions of fat emulsions must be first assessed for known allergies to eggs to prevent anaphylaxis. Egg yolk is a component of the solution and provides emulsification. --The remaining options are unnecessary and are not related to the administration of fat emulsion
A client has a high potassium level. The nurse plans care, knowing that retention of potassium by the kidneys will be accompanied by which process? 1.Increased sodium excretion 2.Increased sodium retention 3.Increased glucose retention 4.Increased magnesium excretion
2.Increased sodium retention Rationale: --With increased potassium retention, the kidneys excrete more sodium. --The other options do not reflect the correct relationship between these two electrolytes. Review: Sodium and potassium balance
A registered nurse (RN) is supervising a licensed practical nurse (LPN) administering an intramuscular (IM) injection of iron to an assigned client. The RN would intervene if the LPN is observed performing which action? 1.Using a Z-track method for injection 2.Massaging the injection site after injection 3.Preparing an air lock when drawing up the medication 4.Changing the needle after drawing up the dose and before injection
2.Massaging the injection site after injection Rationale: --The site should not be massaged after injection because massaging could cause staining of the skin. --Z-track technique and an air lock both should be used. Proper technique for administering iron by the IM route includes changing the needle after drawing up the medication and before giving it. --The medication should be given in the upper outer quadrant of the buttock, not in an exposed area such as the arms or thighs.
A nurse is admitting a client with a diagnosis of Guillain-Barré syndrome to the hospital. The nurse knows that if the disease is severe enough, the client will be at risk for which acid-base imbalance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis
3.Respiratory acidosis Rationale: --Guillain-Barré is a neuromuscular disorder in which the client may experience weakening or paralysis of the muscles used for respiration. This could cause the client to retain carbon dioxide, leading to respiratory acidosis and ventilatory failure as the paralysis develops. --Therefore, options 1, 2, and 4 are incorrect.
The nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central line. Which nursing intervention would specifically provide assessment data related to the most common complication associated with TPN? 1.Weighing the client daily 2.Monitoring the temperature 3.Monitoring intake and output (I&O) 4.Monitoring the blood urea nitrogen (BUN) level
2.Monitoring the temperature Rationale: The most common complication associated with TPN is infection. Monitoring the temperature provides assessment data that would indicate infection in the client. -Weighing the client daily and monitoring I&O provides information related to fluid volume overload. --Monitoring the BUN level does not provide information about infection and is most closely related to assessing renal function.
The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? 1.Sodium level of 145 mEq/L [135-145] normal range 2.Potassium level of 3.0 mEq/L [3.5-5.0] normal range 3.Magnesium level of 2.0 mg/dL [1.2-2.3] normal range 4.Phosphorus level of 4.0 mg/dL [2.5-4.5] normal range
2.Potassium level of 3.0 mEq/L Rationale: --Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. --This occurs in conditions that cause overstimulation of the respiratory system. --Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. --All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia.
The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. 1.Peas 2.Raisins 3.Potatoes 4.Cantaloupe 5.Cauliflower 6.Strawberries
2.Raisins 3.Potatoes 5.Cauliflower 6.Strawberries Rationale: --The normal potassium level is 3.5 to 5.0 mEq/L. Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. --Peas and cauliflower are high in magnesium.
A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action? 1.Increase fluid intake. 2.Resume full activity level. 3.Stay in a cool environment when possible. 4.Monitor voiding for adequacy of urine output.
2.Resume full activity level. Rationale: Discharge instructions for the client hospitalized with hyperthermia include the prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting.
A nurse is caring for a client who is experiencing metabolic alkalosis. The nurse plans to protect the client's safety knowing the risks of this imbalance, by carefully implementing which prescribed precaution? 1.Contact isolation 2.Seizure precautions 3.Bleeding precautions 4.Neutropenic precautions
2.Seizure precautions Rationale: -The client with metabolic alkalosis is at risk for tetany and seizures. The nurse would maintain client safety by using seizure precautions with this client. -Options 1, 3, and 4 are unnecessary in the care of the client experiencing metabolic alkalosis.
The 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 fluid volume excess? 1.The client taking diuretics 2.The client with kidney disease 3.The client with an ileostomy 4.The client who requires gastrointestinal suctioning
2.The client with kidney disease 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. --The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. --The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.
A nurse is caring for a client with a nasogastric tube (NGT) who has a prescription for NGT irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NGT? 1. Tap water 2. Sterile water 3. 0.9% sodium chloride 4. 0.45% sodium chloride
3. 0.9% sodium chloride Rationale: --Homeostasis is maintained by irrigating with an isotonic solution, such as 0.9% sodium chloride. --Tap water, sterile water, and sodium chloride are hypotonic solutions.
The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of U waves. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value? 1.Sodium 135 mEq/L 2.Sodium 140 mEq/L 3.Potassium 3.0 mEq/L 4.Potassium 5.0 mEq/L
3.Potassium 3.0 mEq/L Rationale: The normal sodium level is 135 to 145 mEq/L. The normal potassium level is 3.5 to 5.0 mEq/L. A serum potassium level lower than 3.5 mEq/L is indicative of hypokalemia. In hypokalemia, the electrocardiographic (ECG) changes that occur include inverted T waves, ST segment depression, heart block, and prominent U waves.
The nurse caring for a client with hypocalcemia would expect to note which change on the electrocardiogram (ECG)? 1.Widened T wave 2.Prominent U wave 3.Prolonged QT interval 4.Shortened ST segment
3.Prolonged QT interval Rationale: The normal serum calcium level is 8.6 to 10.2 mg/dL. A serum calcium level lower than 8.6 mg/dL indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave occur with hypercalcemia. --Prominent U waves occur with hypokalemia
A nurse is evaluating a client's serum creatinine level. On noting that the level is high, the nurse plans care, knowing that creatinine is not being adequately secreted by which part of the nephron? 1.Distal tubule 2.Loop of Henle 3.Proximal tubule 4.Collecting duct
3.Proximal tubule Rationale: --Using the process of filtration, the glomerulus removes creatinine from the body. The kidney actively secretes creatinine from the nephron in the proximal tubule. --Options 1, 2, and 4 are not associated with the secretion of creatinine.
A client with cancer is placed on permanent parenteral nutrition. The nurse considers psychosocial support when planning care for this client because of which piece of information? 1.Death is imminent for this client. 2.Parenteral nutrition requires disfiguring surgery for permanent port implantation. 3.The client will need to adjust to the idea of living without eating by the usual route. 4.Nausea and vomiting occur regularly with this type of treatment and will prevent the client from social activity.
3.The client will need to adjust to the idea of living without eating by the usual route. Rationale: Permanent parenteral nutrition is indicated for clients who can no longer absorb nutrients via the enteral route. These clients may no longer be able to take nutrition orally and will need to adjust to the idea of living without eating by the usual route. --Options 1, 2, and 4 are incorrect statements. There are no data in the question that indicate that death is imminent. Port implantation does not require disfiguring surgery. Nausea and vomiting are not associated with administering parenteral nutrition.
The nurse is delegating the morning hygienic care of a man to the unlicensed assistive personnel (UAP). In reviewing the assigned tasks, the nurse should instruct the UAP to use an electric razor for which client? 1.The client with severe pain related to osteoporosis 2.The client with hypokalemia related to diuretic therapy 3.The client with thrombocytopenia related to chemotherapy 4.The client with an elevated white blood cell count related to infection
3.The client with thrombocytopenia related to chemotherapy Rationale: --The client with thrombocytopenia has a low platelet count. Using a straight razor increases the risk of abrasion and bleeding caused by ineffective clotting capability. --The client with hypokalemia has a low potassium level. Shaving the client has no relationship to the client's potassium level. --The client with severe pain is not affected by the different choices in shaving tools. --Likewise, the client with an elevated white blood cell count will not be affected by the different choices in shaving tools.
Which intravenous solution would be most appropriate for a client who may be experiencing excess fluid volume secondary to heart failure? 1. 0.9% normal saline 2 .0.45% normal saline 3 .Lactated Ringer's solution 4. 5% dextrose in 0.9% normal saline
4. 5% dextrose in 0.9% normal saline Rationale: The fluid of choice for a client with excess fluid volume is a hypertonic solution of 5% dextrose in 0.9% normal saline. This solution would pull fluid into the intravascular space; the kidneys could then excrete the excess fluid. --The 0.45% normal saline solution is hypotonic, which pulls fluid into the intracellular space. --The lactated Ringer's and 0.9% normal saline solutions are both isotonic solutions that would worsen the excess fluid volume. Test-Taking Strategy: Note the strategic words most appropriate and focus on the subject of the question, excess fluid volume. Recall that a hypertonic solution (5% dextrose in 0.9% normal saline) would pull fluid into the intravascular space for excretion from the body.
A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that planning care delivery will be based on which characteristic of this type of nursing model of practice? 1.A task approach method is used to provide care to clients. 2.Managed care concepts and tools are used in providing client care. 3.A single registered nurse is responsible for providing care to a group of clients. 4.A registered nurse leads nursing personnel in providing care to a group of clients.
4.A registered nurse leads nursing personnel in providing care to a group of clients. Rationale: --In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. --Option 1 identifies functional nursing. --Option 2 identifies a component of case management. --Option 3 identifies primary nursing (relationship-based practice).
The nurse is supervising a nursing student who is delivering care to a client with a burn injury to the chest. Nitrofurazone is prescribed to be applied to the site of injury. The nurse should intervene if the student planned to implement which action to apply the medication? 1.Wash the burn site. 2.Apply 1/16-inch film directly to the burn sites. 3.Apply the medication with a sterile gloved hand. 4.Apply saline-soaked dressings over the medication.
4.Apply saline-soaked dressings over the medication. Rationale: --Nitrofurazone is applied topically to the burn and has a broad spectrum of antibiotic activity. --It is used in second- or third-degree burns when bacterial resistance to other agents is a potential problem. --The burn site is washed before medication application. --A film of 1/16 inch is applied directly to the burn using a sterile gloved hand. ---Saline-soaked dressings are not used with this medication because they will inactivate the medication's effect. ---In addition, wet dressings present the risk for infection, and infection is a primary concern with a client who is burned.
A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias? 1.Infusion pump 2.Pulse oximeter 3.Cardiac monitor 4.Blood-warming device
4.Blood-warming device Rationale: -If several units of blood are to be administered, a blood warmer should be used. --Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To prevent this, the nurse warms the blood with a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. --Electronic infusion devices are not helpful in this case because the infusion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products.
A client becomes hypovolemic as a result of excess blood loss during surgery. The nurse plans care, knowing that which physiological response is needed to restore adequate circulating volume? 1.Decreased production of angiotensin 2.Decreased production of aldosterone 3.Increased production of erythropoietin 4.Increased production of antidiuretic hormone (ADH)
4.Increased production of antidiuretic hormone (ADH Rationale: The client must produce increased ADH, which will increase reabsorption of water in the renal tubules and increase circulating volume. --The production of angiotensin is stimulated, not inhibited, so that vasoconstriction may occur. --A decrease in aldosterone will decrease the reabsorption of sodium and water in the kidneys. --The client does not require increased erythropoietin to restore circulating volume.
The nurse is caring for a client who has just returned from having a cystoscopy with biopsy. The nurse should intervene if an unlicensed assistive personnel (UAP) is observed taking which action? 1.Obtaining the client's vital signs 2.Assisting the client with repositioning in bed 3.Telling the client that warm sitz baths may be prescribed 4.Insisting that the client ambulate immediately after the procedure
4.Insisting that the client ambulate immediately after the procedure Rationale: The client who has undergone a cystoscopy and biopsy should not walk alone immediately after the procedure because orthostatic hypotension may occur. ---Options 1, 2, and 3 are appropriate. Therefore if the nurse would intervene if the UAP is observed insisting that the client ambulate immediately after the procedure.
A client who had intracranial surgery is experiencing diabetes insipidus. The nurse plans care, knowing that the client is experiencing which problem? 1.Water intoxication 2.Excess production of dopamine 3.Excess production of angiotensin II 4.Insufficient production of antidiuretic hormone (ADH)
4.Insufficient production of antidiuretic hormone (ADH) Rationale: --In diabetes insipidus there is insufficient ADH production, which causes the kidneys to excrete large volumes of urine. --Water intoxication occurs when there is excess ADH production, resulting in water retention. --Options 2 and 3 have nothing to do with diabetes insipidus.
A client receiving total parenteral nutrition (TPN) is demonstrating signs and symptoms of an air embolism. What is the first action by the nurse? 1.Stop the PN solution. 2.Notify the health care provider (HCP). 3.Place the client in high Fowler's position. 4.Place the client on the left side in Trendelenburg's position
4.Place the client on the left side in Trendelenburg's position Rationale: --Lying on the left side may prevent air from flowing into the pulmonary veins. --Trendelenburg's position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during inspiration. --Stopping the PN solution will not treat the problem. The high Fowler's position is not helpful at this time. --The HCP should be notified, but this is not the first action
A client with pancreatitis is being weaned from total parenteral nutrition (TPN). The client asks the nurse why the TPN cannot just be stopped. The nurse formulates a response knowing that which complication could occur with sudden termination of TPN formula? 1.Dehydration 2.Hypokalemia 3.Hypernatremia 4.Rebound hypoglycemia
4.Rebound hypoglycemia Rationale: Clients receiving PN are receiving high concentrations of glucose. To give the pancreas time to adjust to decreasing glucose loads, the infusion rates are tapered down. Before discontinuing the PN, the body must adjust to the lowered glucose level. If the PN were suddenly withdrawn, the client could have rebound hypoglycemia. --Although the other options are potential complications, they are not risks associated with discontinuing PN abruptly.
The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment? 1.Urine pH of 6 2.Urine that is pale yellow 3.Urine output of 40 mL/hr 4.Urine specific gravity of 1.032
4.Urine specific gravity of 1.032 Rationale: (text p. 1435) Normal [1.005-1.030] The client who is not adequately hydrated will have an elevated urine specific gravity. Normal values for urine specific gravity range from approximately 1.016 to 1.022. Pale yellow urine is a normal finding, as is a urine output of 40 mL/hr (minimum is 30 mL/hr). A urine pH of 6 is adequate (4.5 to 8.0 normal), and this value is not used in monitoring hydration status.
A client is hypovolemic, and plasma expanders are not available. The nurse anticipates that which solution available on the nursing unit will be prescribed by the health care provider? 1. 5% dextrose in water 2. 0.9% sodium chloride 3. 0.45% sodium chloride 4. 5% dextrose in 0.45% sodium chloride
5% dextrose in 0.45% sodium chloride Rationale: --A solution of 5% dextrose in 0.45% sodium chloride is hypertonic. An advantage of hypertonic solutions is that they may be used to treat hypovolemia when plasma expanders are not readily available. --Options 1 and 2 are isotonic solutions. --Option 3 is a hypotonic solution.
The new graduate nurse is having difficulty managing the time required to care for a group of complex clients and is several hours behind in completing nursing interventions. Of the following outstanding tasks, which nursing intervention should the nurse complete first? a) Perform a dressing change to an abdominal abscess that is three hours behind schedule. b) Administer a dose of digoxin (lanoxin) that is two hours behind schedule. c) Complete a medication reconciliation form on a client who has recently been admitted to the hospital. d) Obtain discharge orders for a client who is ready to be transferred to a long-term nursing facility.
Administer a dose of digoxin (lanoxin) that is two hours behind schedule. Explanation: The first step in time management is to determine which tasks are priority tasks. Digoxin (lanoxin) is a critical client medication and therefore takes priority when considering the other options. Dressing changes, discharge orders, and completing facility forms can be delayed until critical tasks are complete.
The new graduate nurse is evaluating the effectiveness of her assigned nurse mentor. Which characteristic should the new graduate recognize as being inappropriate for the nurse mentor to role model? a) Encouragings the new graduate to enroll in continuing education courses b) Providing daily feedback to the new graduate c) Introducing the new graduate to members of the interdisciplinary team d) Advising the new graduate to consult her before making decisions regarding client care
Advising the new graduate to consult her before making decisions regarding client care Explanation: Effective mentors should provide feedback to the mentee, encourage opportunities for continued growth, and provide resources that will be supportive in the new role of nurse including members of the interdisciplinary team. Effective mentors should promote confidence in new nurse in the decision making process. --Requiring the new nurse to report to her before making decisions can hinder the new graduate's confidence level
A nurse is monitoring a client receiving total parenteral nutrition (TPN). The client suddenly develops respiratory distress, dyspnea, and chest pain, and the nurse suspects air embolism. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used.
Clamp the intravenous (IV) catheter. Position the client in left Trendelenburg's position. Contact the health care provider (HCP). Administer Oxygen Take the client's vital signs. Document the occurrence Rationale: --Air embolism occurs when air enters the catheter system during IV tubing changes or when the IV tubing disconnects. --Air embolism is a critical situation. --If air embolism is suspected, the nurse would first clamp the IV catheter to prevent further introduction of air and the air embolism from traveling through the heart to the pulmonary system. --The nurse would next place the client in a left side-lying position with the head lower than the feet (to trap air in right side of the heart). --The nurse would notify the health care provider and administer oxygen as prescribed. --The nurse would monitor the client closely and take the client's vital signs. --Finally, the nurse documents the occurrence.
Two new graduate nurses are requesting the same preceptor for unit orientation. Both new graduates have been very vocal about being unhappy if they do not receive their choice of preceptor. The nurse manager sets up a meeting with the new graduate nurses in order to come to a resolution regarding the preceptor. Which conflict resolution style is the nurse manager using? a) Compromising b) Accommodating c) Avoiding d) Collaborating
Collaborating Explanation: Collaborating involves working with all parties to resolve the assignment issue. --Compromising involves discussing with the new graduate nurses independently to develop a mutually agreeable solution. --Accommodating involves the nurse manager independently placing one new graduate nurse with the preceptor and disregarding the other new nurse graduate's upset feelings. --Avoiding involves the nurse manager ignoring the problem altogether.
The designated charge nurse on the telemetry unit organizes and facilitates the unit meetings; however, during most of the meetings, another registered nurse runs the show and influences staff decisions just by her charisma and personality. Her power to lead is defined by which of the following terms? a) Democratic b) Explicit c) Situational d) Implied
Implied Explanation: Implied power arises when a person who has no official assigned role assumes a leadership role by virtue of the force of his or her personality and charisma. The designated charge nurse's official assigned role gives her explicit power by virtue of that assignment. Situational and democratic are types of leadership rather than power
The client with a history of lung disease is at risk for developing respiratory acidosis. The nurse assesses this client for which signs/symptoms that are characteristic of this disorder? 1.Bradycardia and hyperactivity 2.Decreased respiratory rate and depth 3.Headache, restlessness, and confusion 4.Bradypnea, dizziness, and paresthesias
Headache, restlessness, and confusion Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache, restlessness, and mental status changes such as drowsiness and confusion, visual disturbances, diaphoresis, and cyanosis as the hypoxia becomes more acute, hyperkalemia, a rapid irregular pulse, and dysrhythmias.
Which of these statements regarding a nurse manager role is accurate? a) The nurse manager will decide on the financial targets for the nursing unit. b) The nurse manager's main role in the nursing unit is to manage the unit budget. c) A healthy work environment is not within the scope of the nurse manager's role. d) To effectively manage the nursing unit, the nurse manager should also be a leader.
To effectively manage the nursing unit, the nurse manager should also be a leader. --In order to be an effective nurse manager, the nurse manager must also be a leader. --This is important with management of a healthy work environment, which is a responsibility of the nurse manager. This is done by helping ensure that interpersonal conflicts are resolved. The nurse manager is also accountable for client census, staffing, supplies, and budget, but is not responsible for setting financial targets for the budget; this is usually managed at the executive level.
A specific nursing unit practices functional nursing. What was the basis for this concept? a) individual patient care b) case management c) industrial assembly line d) primary nursing
industrial assembly line Explanation: In functional nursing, which is based on the assembly line concept found in industry, nursing and other staff are assigned to specific tasks for a group of patients. Specializing tasks in this way increases efficiency but results in impersonal care.
