Physiological Aspects of Care

An intravenous (IV) solution of 1000 mL 5% dextrose in water is to be infused at 125 mL/hr to correct a client's fluid imbalance. The infusion set delivers 15 drops/mL. To ensure that the solution will infuse over an eight-hour period, at how many drops per minute should the nurse set the rate of flow? Record the answer using a whole number. ______ gtts/min

31 gtt

A client is to receive 2000 mL of intravenous (IV) fluid in 12 hours. At what rate should the nurse set the electronic infusion control device? Record the answer using a whole number. ______ mL/hr

167 mL

A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have? 1. 7.20 2. 7.35 3. 7.45 4. 7.48

1. 7.20

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration? 1.Sunken eyes 2.Dry, flaky skin 3.Change in mental status 4.Decreased bowel sounds

3.Change in mental status

What clinical finding indicates to the nurse that a client may have hypokalemia? 1.Edema 2.Muscle spasms 3.Kussmaul breathing 4.Abdominal distention

4.Abdominal distention

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? 1.Skin turgor 2.Intake and output results 3.Client's report about fluid intake 4.Blood lab results

4.Blood lab results

A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important? 1.Sodium 2.Calcium 3.Chloride 4.Potassium

4.Potassium

A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? (Select all that apply.) 1.Take the aspirin with meals or a snack. 2.Make an appointment with a dentist if bleeding gums develop. 3.Do not chew enteric-coated tablets. 4.Switch to Tylenol (acetaminophen) if tinnitus occurs. 5.Report persistent abdominal pain

1.Take the aspirin with meals or a snack. 3.Do not chew enteric-coated tablets 5.Report persistent abdominal pain

A client has a paracentesis, and the health care provider removes 1500 mL of fluid. To monitor for a serious postprocedure complication, the nurse should assess for: 1.Dry mouth 2.Tachycardia 3.Hypertensive crisis 4.Increased abdominal distention

2.Tachycardia

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? 1.Skeletal and nervous 2.Circulatory and urinary 3.Respiratory and urinary 4.Muscular and endocrine

3.Respiratory and urinary

What factors are most important for the nurse to consider when delegating responsibilities? 1.Preferences of the clients and staff 2.Physical layout of the unit and client rooms 3.Staff member's level of education and expertise 4.Client's diagnosis and length of time in the hospital

3.Staff member's level of education and expertise

A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? (Select all that apply.) 1.Diplopia 2.Dysphagia 3.Tachypnea 4.Bradycardia 5.Hypotension

3.Tachypnea 5.Hypotension

A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? 1.Increase fluids. 2.Increase fiber in the diet. 3.Wash hands with soap and water. 4.Wash hands with alcohol based hand sanitizer.

3.Wash hands with soap and water

A nurse is assigned to take care of a group of clients. Which client should the nurse see first? 1.A 2-yr-old male with diarrhea 2.A 35-yr-old male who is nauseated 3.A 40-yr-old female who has vomiting due to food poisoning 4.An 83-yr-old female whose last bowel movement was three days ago

1.A 2-yr-old male with diarrhea

What is a nurse's responsibility when administering prescribed opioid analgesics? (Select all that apply.) 1.Count the client's respirations. 2.Document the intensity of the client's pain. 3.Withhold the medication if the client reports pruritus. 4.Verify the number of doses in the locked cabinet before administering the prescribed dose. 5.Discard the medication in the client's toilet before leaving the room if the medication is refused

1.Count the client's respirations. 2.Document the intensity of the client's pain. 4.Verify the number of doses in the locked cabinet before administering the prescribed dose.

A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam (Ativan); I get so annoyed when people drink too much." What does this nurse's comment reflect? 1.Demonstration of a personal bias. 2.Problem solving based on assessment. 3.Determination of client acuity to set priorities. 4.Consideration of the complexity of client care

1.Demonstration of a personal bias

A client with arthritis increases the dose of ibuprofen (Motrin, Advil) to abate joint discomfort. After several weeks the client becomes increasingly weak. The client is admitted to the hospital and is diagnosed with severe anemia. What clinical indicators does the nurse expect to identify when performing an admission assessment? (Select all that apply.) 1.Melena 2.Tachycardia 3.Constipation 4.Clay-colored stools 5.Painful bowel movements

1.Melena 2.Tachycardia

A nurse understands that the primary purpose for a client to undergo reconstructive surgery is to: 1.Restore function and/or appearance. 2.Replace an organ or tissue. 3.Relieve or reduce symptoms. 4.Remove or excise an organ or tissue.

1.Restore function and/or appearance.

A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator? 1.Pulse rate 2.Tissue turgor 3.Specific gravity 4.Body temperature

2.Tissue turgor

A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions? 1."Inhale completely and exhale in short, rapid breaths." 2."Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale." 3."Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale." 4."Exhale halfway, then inhale a rapid, small breath; repeat several times."

2."Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale."

A client who is to have brain surgery has a signed advance directive in the medical record. In what situation should this document be used? 1.Discharge planning is not covered by insurance. 2.Client cannot consent to his or her own surgery. 3.Postoperative complications occur that require additional treatment. 4.Client death and which client's belongings are to be given to family members.

2.Client cannot consent to his or her own surgery.

Based on the client's reported pain level, the nurse administers 8 mg of the prescribed morphine. The medication is available in a 10 mg syringe. Wasting of the remaining 2 mg of morphine should be done by the nurse and a witness. It is most appropriate for the nurse to ask which member of the health care team to be the witness? 1.Nursing supervisor 2.Licensed practical nurse (LPN) 3.Client's health care provider 4.Designated nursing assistant

2.Licensed practical nurse (LPN)

A pain scale of 1 to 10 is used by a nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. What conclusion should the nurse make regarding the client's response to pain medication? 1.Client has a low pain tolerance. 2.Medication is not adequately effective. 3.Medication has sufficiently decreased the pain level. 4.Client needs more education about the use of the pain scale.

2.Medication is not adequately effective

The nurse is caring for a client that is hyperventilating. The nurse recalls that the client is at risk for: 1.Respiratory acidosis 2.Respiratory alkalosis 3.Respiratory compensation 4.Respiratory decompensation

2.Respiratory alkalosis

An adolescent that had an inguinal hernia repair is being prepared for discharge home. The nurse provides instructions about resumption of physical activities. Which statement by the adolescent indicates that the client understands the instructions? 1."I can ride my bike in about a week." 2."I don't have to go to gym class for 3 months." 3."I can't perform any weightlifting for at least 3 weeks." 4."I can never participate in football again."

3."I can't perform any weightlifting for at least 3 weeks."

A client has a right above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the client states, "What happened to me? I don't remember a thing." What is the nurse's best initial response? 1."Tell me what you think happened." 2."You will remember more as you get better." 3."You were in a work-related accident this morning." 4."It was necessary to amputate your leg after the accident."

3."You were in a work-related accident this morning."

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority? 1.Place the client in a left side-lying position. 2.Apply oxygen via non-rebreather mask. 3.Apply a petroleum gauze dressing over the site. 4.Prepare to reinsert a new chest tube

3.Apply a petroleum gauze dressing over the site.

A client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication? 1.Sprinkle the powder from the capsule into a cup of water. 2.Insert a rectal suppository containing 100 mg of phenytoin. 3.Contact the prescriber to determine if a change to a suspension form would be possible. 4.Obtain a change in the administration route to allow an intramuscular (IM) injection.

3.Contact the prescriber to determine if a change to a suspension form would be possible.

A primary nurse receives prescriptions for a newly admitted client and has difficulty reading the health care provider's writing. Who should the nurse ask for clarification of this prescription? 1.Nurse practitioner 2.House health care provider that is on-call 3.Health care provider who wrote the prescription 4.Nurse manager familiar with the health care provider's writing

3.Health care provider who wrote the prescription

The health care provider prescribes a low-fat, 2-gram sodium diet for a client with hypertension. The nurse should explain that the purpose of restricting sodium is to: 1.Chemically stimulate the loop of Henle 2.Diminish the thirst response of the client 3.Prevent reabsorption of water in the distal tubules 4.Cause fluid to move toward the interstitial compartment

3.Prevent reabsorption of water in the distal tubules