PN2 exam 1
Which client is at greatest risk for the development of hyperkalemia?
A male with type 2 diabetes taking oral antidiabetic agent/ A female with hypertension using a salt substitue
Which client is at greatest risk for development of hypercalcemia?
A middle-aged adult with a thyroid disorder
A client has the following ABG result: pH HCO3 22, PaCO2 67, PaO2 66. Which intervention is the nurse's priority?
Assessing the airway
A nurse enters a client semiprivate room and prepares to administer the 0900 medications. Place the steps in chronological sequence, indicating the measures Too thick to administer the medications Safely. 1) open the unit dose packages 2) confirm the client identity 3) administer the medication 4) check the client medication administration record (MAR) for 0900 medication 5) Obtain the correct unit dose medications
B) 4 > 5 > 2 > 1 > 3
A nurse is assessing a client who states she has leakage of small amounts of urine when attempting to get out of bed. The nurse should associate these findings with which of the following types of urinary incontinence?
stress incontinence
The nurse is assessing the client who has started to complain of muscle cramps and paresthesia in his hands and feet. The nurse notes a positive Chvostek sign upon assessment and knows this result is associated with which electrolyte disorder?
B) Hypocalcemia
A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTI's). Which of the following clients' statements indicate a need for further teaching?
B) I will need to wipe my perineal area from back to front after urination
The nurse is evaluating the arterial blood gas (ABG) result of her clients. Which of the following ABG results exhibits partially compensated metabolic alkalosis?
B) PH 7.55. PaCO2: 30mm Hg. HCO3: 19mEq/L
The nurse is assessing an elderly client receiving IV fluid. which of the following would not indicate fluid volume overload?
B) Weak and steady pulse
When teaching a client with a urinary tract infection about taking a prescribed antibiotic for 7 days, the nurse should tell the client to report which symptom to the health care provider (HCP) (SATA)
new onset of blood in the urine,Fever above 100F,Rash
Of the following blood gas values, which would the nurse needs further assessment of the client?
pH 7.49, HCO3 23 mEq/L, Pa Co2 mm 31 Hg
A client with renal failure who has been taking aluminum hydroxide/magnesium hydroxide suspension at home for ingestion is somnolent and has decreased deep tendon reflexes. Which action should the nurse take first?
A) Review the magnesium level of the client's chart
The client has the following arterial blood gas (ABG) results, pH 7.48, HCO3: 35mEq/L, PaCO2: 46 mm Hg. The nurse correlates these values to which clinical situation in the client?
A) Shallow respiration of 5/minute
A client has renal colic due to renal lithalsas. What is the nurse's priority in managing care of this client?
A) administer an opioid analgesic as prescribed
The nurse is to administer ampicillin 500 mg orally to a client with a ruptured appendix. The nurse checks the capsule in the client's medication box, located inside the client room. The medication dosage is not labeled, but the nurse recognizes the color and shape of the capsule. Which of the following should the nurse do next?
B) contact the pharmacy to bring a properly labeled medication
the nurse has just received change of sheet report for four clients. based on this report, the nurse should assess which client first?
B) A 35-year-old admitted after motor vehicle accident whose urine output has total 30 milliliters over the last 2 hours
a client with a serum sodium level of 113 mEq/L has been receiving 3% surgeon chloride Ivy infusion at 50Ml/hr for 16 hrs. The client feels tired and short of breath. which of the following Is a priority?
B) Assess signs of fluid overload
A nurse assesses a client with mechanical bowel obstruction who reports intermittent abdominal pain. An hour later, the client reports constant abdominal pain. Which action would the nurse take next?
B) Assess the clients' bowel sounds
Before the nurse administers IV replacement of 5% dextrose in water with potassium chloride, what action is appropriate for the nurse to take?
B) evaluating laboratory results for electrolytes
A provider orders a continuous IV infusion of normal saline (NS) with 20 mEq of potassium chloride (KCl)/ liter to infuse at 50 mL/hr. The first 1-liter bag was hung at 0300. What time does the nurse anticipate needing to hang the second bag of IV fluids? (record answer in military time).
0800
A nurse is reviewing the blood urea nitrogen (BUN) and creatinine levels of an older adult client admitted for acute renal failure as a result of obstructive renal calculi. The nurse should expect which of the following laboratory findings?
B) BUN 34 mg/dl and creatinine 5.2 mg/dl
The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? (SATA)
B) Corticosteroids C) Alcohol D) Caffeine E) Nonsteroidal anti-inflammatory drugs (NSAIDs)
The provider ordered a continuous IV infusion of normal saline (NS) with 20 mEq of potassium chloride (KCI)/ liter to infuse at 100 mL/hr. The first 1-liter bag was hung at 0500. What time does the nurse anticipate needing to hang the second bag of IV fluids? (Record answer in military time).
1500
A nurse is preparing to administer intravenous ciprofloxacin 400 mg IV to her client diagnosed with a urinary tract infection. The medication is available as 400 mg/100 mL normal saline solution. The order is to infuse the 100 mL bag in 30 minutes. What is the rate (in mL/hour) the nurse must infuse the medication at? (Round the answer to the nearest whole number. Do not use trailing zero).
200
The provider orders a continuous IV infusion of normal saline (NS) With 20 mEq of potassium chloride (KCl)/Liter to infuse at 50Ml/hr. The first 1-liter bag was home at 0300. what time does the nurse anticipate needing to hang the second bag of IV fluids? (Record your answer in military time)
2300
A nurse is preparing to administer intravenous ciprofloxacin 400 mg IV to her client diagnosed with a urinary tract infection. The medication is available as 400 mg/100mL normal saline solution. The order is infusing the 50mL in 30 minutes. What is the rate (in mL/hr) the nurse must infuse the medication at? (Round to the nearest whole number)
50/0.5(30 min)= 100
A nurse is preparing to infuse 400 ML Unit of packed red blood cells (PRBCs) over 4 hrs. The drop factor of the manual IV tubing is 45 gtts/mL. What is the infusion rate in gtts/min?
75
A nurse is preparing to infuse a 400 mL unit of packed red blood cells (PRBCs) over 4 hours. The drop factor of the manual tubing is 45 gtts/mL. What is the infusion rate in gtts/min? (Round the answer to the nearest whole number. Do not use trailing zero).
75
The nurse just received change of shift report on all of the following clients. Which one should the nurse assess first?
A 23-year old adult male admitted with pyelonephritis, a temperature of 100.1 F, and a white blood cell (WBC) count of 13,500 cells/mcl
The nurse just received change of shift report on all the following clients. Which of these should the nurse assess first?
A 29-year-old client who had a colon resection yesterday, Foley catheter removed 12 hrs. ago, has been receiving morphine sulfate for pain, and has not voided for 14hrs
When obtaining health history from a 22-year-old female client with new onset urinary incontinence. Which findings or factors does the nurse consider significant? (Select all that apply).
A burning sensation occurring during urination. A new inability to hold urine (Urgency). A "stinky odor from the urine.
Which client is at greater risk for development of hyperkalemia?
A female with hypertension using a salt substitute
The nurse is caring for a client who has been diagnose with his esophageal cancer. The client appears anxious and ask the nurse, "does this mean I'm going to die?" Which nursing response is appropriate (SATA)
A) Is there someone you would like us to call for you? C) it sounds like death frightens you D) Let me sit with you for a while, and we can discuss how you're feeling about this
Which client being managed for dehydration thus the nurse consider a greatest risk for possible reduced kidney function?
An 80-year-old man who has benign prostatic hyperplasia
A client has the following arterial blood gas results: Ph 7.30, HCO3 17mEq/L, PaCO2 25 mm Hg, PaO2 98 mm Hg. Which intervention by the nurse is most appropriate?
Assess the client and notify the provider using SBAR communication.
A nurse is providing teaching to a client who has experienced an acute exposure to gastric. which of the following instructions should the nurse include in the teaching?
Avoid drinking alcohol
The community nurse is talking with a group of individuals about colorectal cancer risk factors. Which community participant is at the highest risk for development of colorectal cancer?
B) A 30 yrs old with Crohn's disease
A nurse is admitting a client who has type 2 diabetes and is scheduled for surgery. Which laboratory findings from the client's admission panel does the nurse report as indicating possible abnormal kidney function? (Select all that apply)
B.Presence of protein in the urine C. Urine specific gravity of 1.028 D. Blood urea nitrogen of 38 mg/dl E. Serum creatinine 2.2mg/dl
A nurse is reviewing the blood urea nitrogen (BUN) and creatinine levels of an older client admitted for acute renal failure as a result of obstructive renal calculi. The nurse should expect which of the following laboratory findings?
BUN 40 mg/dL and creatinine 6.4 mg/dL
A client is receiving 250 mL of a 3% sodium chloride solution intravenous for severe hyponatremia. Which signs or symptoms indicate to the nurse that this therapy is effective?
Blood pressure has increased from 100/50 mm/Hg TO 112/70 mm/Hg Or Blood pressure has increased from 100/50 mm Hg to 112/70 mm Hg
A nurse is caring for a client who has a postoperative ileus and nasogastric (NG) tube that has drained 2500 ml in the past 6 hrs. which of the following electrolytes imbalances should the nurse expect and monitor for this client?
C) Decreased potassium levels
The nurse will anticipate preparing an older client who is vomiting "coffee ground" emesis for which of the following?
C) Endoscopy
A nurse is caring for a client whose arterial blood gas results (ABG) results show pH of 7.36, HCO3: 30 mEq/L, PaCO2 50mm Hg. The nurse correctly interprets these results are switch of the following?
C) Fully compensated respiratory acidosis
The nurse obtains all of the following assessment data about a client with deficient fluid volume caused by dehydration, which of the following assessment data will be greatest concern?
C) Oral fluid intake is 100 ml for the last 8 hrs
A clear with a calcium level of 14 mg/Dl is being cared for on the medical unit. nursing actions included in the care plan will include Which of the following?
C) monitoring for bounding pulses
A client is admitted to the emergency room with a respiratory rate of 6 breath/min. Arterial blood gases have been drawn and reveal the following values, pH 7.22, PaCO2: 68 mm Hg, HCO3: 25mEq/L. Which of the following is an appropriate analysis of this ABGs?
C. Uncompensated respiratory acidosis
A client with renal failure who has been taking aluminum hydroxide/magnesium hydroxide suspension at home for indigestion is somnolent and has decreased deep tendon reflexes. Which action should the nurse take first?
Check the chart for the most recent BUN (Blood urea nitrogen) and creatinine levels
a nurse is caring for client who has been admitted for an exacerbation of Crohn's disease. An NG tube has been placed and is to suction, and the client is currently receiving an infusion of total parental nutrition via a peripherally inserted central catheter (PICC) line. Which of the following actions should the nurse take?
monitor laboratory values and assess for abnormal respiratory or cardiac functioning
The nurse writes the nursing problem of fluid volume access (FVE). Which intervention should be included in the plan of care?
restrict the sodium and declares diet
A 10 yrs old with a history of recent respiratory infection has swelling around the eyes in the morning and dark urine. What question should the nurse ask first?
D) Has the child had a sore throat?
Immediately after having surgery to create an ileostomy, which goals has the highest priority?
D) Maintaining fluid and electrolyte balance
A nurse is admitting a client with suspected appendicitis. The nurse understands that this client will most likely identify pain in which of the following location.
D) Right lower quadrant (RLQ). McBurney's point
The primary goal of nursing care of a client with stress incontinence is which of the following?
Decrease the number of incontinence episodes
the nurse is caring for an adult client who experiences an exacerbation of ulcerative colitis with severe diarrhea that has lasted a week. for which complications will the nurse assess? (SATA)
Dehydration,Hypokalemia,skin breakdown
Which instruction should the nurse include in the teaching plan for a client experiencing gastroesophageal reflux disease (GERD)?
Do not lie down for at least 1-2 hours after eating
A client with calcium level of 14 mg/dl is being cared for on the medical unit. Nursing actions included in the care plan will include which of the following.
Encourage increased fluid intake
A new nurse is working with a preceptor on an inpatient medical surgical unit. The preceptor advises the student that which is the priority when working as a professional nurse?
Ensuring client safety
A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which of the following?
Hypokalemia
A nurse is teaching a client who has fluid overload about recognizing symptoms associated with this condition. Which of the following statements indicates the teaching was understood?
If my legs have edema, this means I am retaining fluid, Increased blood pressure may indicate a worsening problem, resting heart rate elevated
A nurse is teaching a client who has fluid overload about recognizing symptoms associated with this condition. Which of the following client statements indicate the teaching was understood (SATA)?
Increased blood pressure might indicate a worsening problem If my legs have edema, this could mean i am retaining fluid
A nurse is assessing a newly admitted client with chronic heart failure who forgot to take prescribed medication and seems confused. The client has peripheral edema and shortness of breath. Which assessment should the nurse complete first?
Mental status.
Which blood laboratory value does the nurse need to evaluate to determine whether the client's acidosis has been compensated or remains uncompensated?
PaCo2
A nurse is caring for a postoperative client following abdominal surgery. Which of the following findings should indicate to the nurse the client's. peristalsis is returning?
Passage of flatus
A client with a calcium level of 14 mg/dL is being cared for on the medical unit. Nursing actions include which of the following?
Provide with continuous IV infusions
The nurse is caring for a client with abdominal pain. Which assessment finding requires the nurses immediate action?
Rebound tenderness at McBurney's point
When admitting a client with acute glomerulonephritis. It is important that the nurse ask the client about which of the following?
Recent sore throat and fever.
A man is brought to the emergency department after fainting and in state of emotional distress. He tells the nurse that he feels dizzy and does not remember what happened but scared and anxious. His vital signs are blood pressure 139/92 mm hg, heart rate 109 beats/minute, and respirations are 37 breath/minute, regular and deep. Which primary acid-base disturbance is this client at risk for developing?
Respiratory alkalosis
The nurse is planning to teach a client with gastroesophageal reflux disease about substance to avoid. Which item should the nurse include in the list?
Smoking
The nurse obtains all the following assessment data about a client with deficient fluid volume caused by dehydration. Which of the following assessment data will be of greatest concern?
The blood pressure is 88/40 mm/Hg
Which assessment finding would alert the nurse to a client worsening hypernatremia?
The client has an altered mental status The client has an irregular heart rhythm
The healthcare provider prescribes decompression with a nasogastric (NG) tube for a client with an intestinal obstruction. To determine the effectiveness of the NG tube, the nurse should evaluate the client to determine which of the following?
The client's gastric content collects in the suction canister.
A nurse is caring for a client whose arterial blood gas (ABG) results show a ph 7.36, HCO3: 30 mEq/L, PaCO2: 50. The nurse correctly interprets these results as which of the following?
Uncompensated respiratory acidosis
The nurse is evaluating the fluid volume status of a client after ileostomy surgery. Which findings indicates that adequate fluid replacement has been achieved?
Urine output greater than 30 mls an hour
An elderly client admitted with new onset confusion, headache, poor skin turgor, bounding pulse, and urinary incontinence has been drinking copious amount of water. Upon reviewing the lab results, the nurse discovers a sodium level of 122mEq/ L (122 mmoI/L). A report to the healthcare provider should include what recommendations? (Select all that apply).
Vital signs every 4 hours instead of every shift. Strict intake and output.
The nurse is evaluating the fluid volumes status of a client after ileostomy surgery. which finding indicates that adequate fruit replacement has been achieved in the client?
an increase in body weight
The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. which item show the nurse include on the list?
chocolate
A client has the following arterial blood gas result (ABG) Ph 7.30, HCO3: 22mEq Hg, Pa02: 66 mm Hg. Which intervention by the nurse takes priority?
d. PaCO2
The nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi?
dehydration
The nurse is caring for a client with a bleeding duodenal ulcer Who was admitted to the hospital after vomiting bright red blood. which condition does the nurse anticipate when the client develops a sudden sharp pain in the mid-epigastric rigid, board-like abdomen?
ulcer perforation
