240 Exam 3
During data collection of a client with bowel elimination concerns, which appropriate questions would the nurse ask? Select all that apply.
"Do you use anything to help move your bowels?" "How often do you move your bowels?
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?
"Fluid in the tissue space between and around cells."
The experienced nurse is observing a new nurse who is preparing to catheterize a female client. Which statement by the new nurse requires immediate intervention by the experienced nurse?
"I will use clean gloves to handle the catheter and other equipment."
The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?
"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."
A client is discussing vitamin and mineral intake with the nurse. Which client statement requires further nursing teaching?
"My husband and I are ordering a product that has megadoses of vitamins."
A parent asks the nurse when his 18-month-old daughter will be ready for toilet training. Which statement best answers the parent's question regarding toilet training?
"One signal of preparedness is when your child is dry for at least 2 hours."
The nurse is teaching the caregiver of a toddler about the importance of calcium to help the toddler's teeth and bones develop properly. Which client statement reflects that nursing teaching has been effective?
"Vitamin D helps calcium absorption."
The student nurse asks, "What is intravascular fluid?" What is the appropriate nursing response?
"Watery plasma, or serum, portion of blood."
A nurse is preparing to insert an intravenous (IV) catheter into a client's arm. At which angle relative to the client's skin should the catheter be inserted?
10-15
A client is learning how to do diaphragmatic breathing. For which length of time will the nurse advise the client to rest between repetitions of the exercise?
2 minutes
What is the body mass index (BMI) of a client who is 1.68 meters tall and weighs 70 kg?
24.8
A nurse is caring for an adult client who ate a chicken breast and drank a glass of water. There are 60 grams of protein in the chicken breast. Calculate the energy intake, in kilocalories, for this food. Record your answer using a whole number.
240
Which fluid should be administered slowly to prevent circulatory overload?
5% dextrose in 0.9% NaCl
In which client should the nurse prioritize assessments for respiratory depression?
A client taking opioids for cancer pain
A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client?
Ambu bag
A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?
An implanted central venous access device (CVAD)
The nurse must obtain a blood specimen for blood gas analysis. What is the most important thing for the nurse to do immediately after the needle has been removed?
Apply steady, firm pressure on the puncture site for 5 to 15 minutes.
A nurse is planning interventions for a client to assist in establishing a normal voiding pattern. Which nursing action should be included?
Assist the client to a normal voiding position when possible.
Removal of a client's NG tube has been ordered. Which action should the nurse perform during this intervention?
Before removing the tube, discontinue suction and separate the tube from suction.
Upon auscultation of the client's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath sound?
Bronchial
A nurse is testing a client's stool specimen for occult blood. Which are responsibilities of the nurse for this testing? Select all that apply.
Collecting the specimen Handling the specimen Transporting the specimen Teaching the client about the test
When the nurse observes a newborn infant demonstrating an irregular abdominal breathing pattern, with a respiratory rate of 40 breaths/minute with occasional pauses in breathing of 5-second duration. What is the most appropriate action by the nurse?
Continue to assess the infant.
The nurse is assuming care for a client who is receiving an infusion of packed red blood cells (PRBCs). The PRBCs were hung 4 hours ago, and 100 mL is left to infuse. Which action is most appropriate?
Discontinue the infusion and record the volume left in the blood bag.
The nurse is assessing a client with a urinary sheath catheter. After removing the catheter, the nurse observes a break in skin integrity on the penis. What actions by the nurse would be appropriate at this time? Select all that apply.
Do not reapply the urinary sheath Allow the skin to be open to air as much as possible Arrange for a consult with a wound nurse
When planning care for a client with a Foley catheter, which actions should the nurse include? Select all that apply.
Encourage fluid intake, unless contraindicated. Record volume and character of the urine. Maintain a closed urinary catheter system.
A nurse is caring for a client with a nasogastric tube. The nurse enters the room to flush the nasogastric tube and check gastric residual. Which action should the nurse perform first?
Ensure the head of the bed is elevated.
"Vagal response" is the voluntary increase of intra-abdominal pressure that helps expel feces.
F
A client has had a stroke and will require long-term tube feeding. Which type of feeding tubes would be most appropriate for this client's needs?
Gastrostomy tube
The nurse is assisting with a client's blood transfusion. What type of reactions may occur during this procedure? Select all that apply.
Hives, itching, and anaphylaxis may occur during an allergic reaction. Fever, chills, headache and malaise may occur during a febrile reaction. Facial flushing, fever, chills, headache, low back pain, and shock may occur during a hemolytic transfusion reaction.
The nurse is caring for a client receiving continuous tube feeding. The client has a gastric residual of 550 mL. The previous residual was 200 mL. What action should the nurse take?
Hold the enteral nutrition and notify the primary care provider.
A nurse on a cardiac care unit oversees the care of diverse clients' cardiac health problems. Which action can be most appropriately delegated to a licensed practical nurse (LPN)?
Initiation of CPR for a client who is found unresponsive
Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply.
Intravenous therapy Electrolyte management Nutrition management
A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs?
Nasal cannula
A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply.
Nasal cannula Simple oxygen mask Partial rebreather mask
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?
Offer small amounts of preferred beverage frequently.
Which medical diagnosis is most likely to necessitate testing for fecal occult blood?
Peptic Ulcer
A nurse has just inserted a nasogastric tube in a client. Which method is most reliable for verifying the correct placement of the tube?
Radiographic confirmation of position
A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?
Remove the IV.
The nurse is caring for a client who has dysphagia and is unable to eat independently. The nurse is preparing to assist the client in eating a meal. Which action is appropriate?
Speak to the client but limit the need for the client to respond verbally while chewing and swallowing.
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?
Start an IV of normal saline as prescribed.
The student nurse is caring for a client with a colostomy. When changing the ostomy appliance, the nurse manager would intervene if which action by the student is observed?
Starts at the bottom of the appliance, holds abdominal skin taut and gently removes the faceplate
A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?
Stop the transfusion and infuse normal saline using a new administration set.
When caring for a client with a tracheostomy, the nurse would perform which recommended action?
Suction the tracheostomy tube using sterile technique.
A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate?
The client's available hemoglobin is adequately saturated with oxygen.
The nurse is assessing a client with an older arteriovenous (AV) graft for hemodialysis access in the left arm. The client reports significant pain to the distal left arm. Capillary refill in the left hand is greater than 4 seconds. Which should the nurse assess before contacting the health care provider?
Thrill and bruit
A nurse is preparing to measure a client's urine output. Which interventions would be of highest priority?
Wearing gloves when handling the urine
For which client would digital removal of stool be contraindicated?
a client recovering from prostate surgery
The nurse is assessing clients for basal metabolic rate (BMR). Which client would the nurse suspect would have an increased BMR?
a client who has a fever
How is control over the extracellular concentration of potassium within the human body is exerted?
aldosterone
The nurse is inserting a urinary catheter into a female client and has begun to inflate the balloon, an action that has caused the client to wince and cry out in pain. Consequently, the nurse should:
deflate the balloon, insert the catheter further, and slowly attempt reinflation.
The nurse is caring for a client with a chest tube. Stationary clots are noted in the tubing. What is the appropriate nursing action?
document the finding
After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client?
every 72 hours
A nurse is caring for a client in a long-term care facility. The nurse is reviewing the laboratory data for this client. The nurse should notify the primary care provider if which laboratory result is observed?
hematocrit 35
A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client?
hypertonic
The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in?
left lateral
A nurse is caring for a client who has a vitamin B12 deficiency. Which food would the nurse recommend to help with this deficiency?
liver
A nurse must deliver oxygen at a concentration of 85% to an infant. Which delivery device would be most appropriate for an infant?
oxygen hood
The nurse is performing a check with an oxygen analyzer. Which oxygen analyzer assessment finding indicates that the device is working properly?
reads 0.21 when checking oxygen in room air
The nurse observes the unlicensed assistive personnel (UAP) serving a food tray to a client with diarrhea. The nurse would intervene if which food item is included on the client's tray?
sliced red apples
The nurse is teaching four clients in a community health center. Which client does the nurse identify as needing more servings per day of milk?
teenager who is in the second trimester of pregnancy
When capping a primary line for intermittent use, a nurse notices local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. Which complication has most likely occurred?
thrombus
The school nurse is caring for a student who experienced a seizure in the classroom. The student was noted to lose a large amount of urine during the seizure. Which type of incontinence does the nurse anticipate the client may have experienced?
total
A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action?
warm the clients hands and try again
An older adult client was recently placed on home oxygen. The client's caregiver reports that the client now refuses to leave the house. What teaching will the nurse provide the caregiver? Select all that apply.
"Continued socialization with others is important." "Discuss with the client switching to a portable oxygen device." "Invite friends and family to the client's house."
What commonly used intravenous solution is hypotonic?
.45 nacl
The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?
1
A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?
1 unit over 2 to 3 hours, no longer than 4 hours
In the nursing care plan for constipation, the nurse should have an intervention that addresses the number of grams of cellulose that are needed for normal bowel function. How many grams should be in the daily diet?
20-30 g
The pediatric nurse is caring for four clients. Which client will receive the greatest benefit from the use of an oxygen analyzer to assure that the client is receiving the prescribed amount of oxygen?
3-year old in croup tent
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate?
50 gtt/min
A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?
60 drops/mL
A nurse is caring for a client with a gastrostomy tube and observes that a large amount of drainage is leaking from the tube. Upon inspection the nurse finds a great deal of slack in the tube. Which action should the nurse take next?
Apply gentle pressure to the tube while pressing the external bumper closer to the skin.
The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client?
Apply pressure to insertion site for at least 3 minutes.
The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?
Arterial blood gas
The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance? Select all that apply.
Ask provider to order a low-salt diet. Administer furosemide as ordered. Reduce infusing fluid volume as ordered. Treat the underlying condition that contributes to increased fluid volume
A nurse is assessing a client who is complaining of difficulty urinating. Which assessment would be a priority?
Asking the client when he or she had last urinated
A nurse is following a health care provider's order to irrigate a client's NG tube. Which guideline is recommended in this procedure?
Assist the client to a 30- to 45-degree position, unless this is contraindicated.
The nurse is preparing to irrigate a Foley catheter. What is the nurse's initial action?
Check electronic health record for medical order.
The client with dysphagia has a regular meal tray delivered at breakfast. Which is the best action for the nurse to take?
Check the medical record for the client's prescribed diet.
Which nursing action associated with successful tube feedings follows recommended guidelines?
Check the residual before each feeding or every 4 to 6 hours during a continuous feeding.
A client could experience increased urination when using which classification of medication?
Cholinergic agents
A client is preparing to give a clean-catch specimen. What action should the nurse have the client do first?
Clean each side of the urinary meatus with a separate wipe.
A client is receiving intermittent NG tube feedings using an open system. Which actions should the nurse implement to reduce the client's risk for infection? Select all that apply.
Cleanse the top of the feeding container with alcohol before opening it. Replace the bag and tubing every 24 hours.
The pediatric nurse is instructing parents on safety when caring for toddlers and preschoolers. Which of the following teaching interventions is appropriate for this age group?
Cut a hot dog in half, then pieces
A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply.
Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution.
Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?
Eat smaller meals that are high in protein.
The nurse is caring for a client with a history of renal insufficiency and type 2 diabetes. Which prescription, if noted in the client's chart, would alert the nurse to discuss with the health care practitioner?
Gentamicin 70 mg intramuscular (IM) every 8 hours
Which statement accurately describes appropriate nursing interventions in unexpected situations when removing a peripherally inserted central catheter (PICC)?
If a portion of the catheter breaks when removing it, apply a tourniquet to the upper arm and notify the health care provider.
A male client 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 client?
Impaired Skin Integrity related to urinary bladder infection and dehydration
The nurse is preparing a client for a complete blood count test. Which actions would the nurse perform? Select all that apply.
Inform the client that this test can assist in evaluating the body's response to illness. Inform the client that specimen collection takes approximately 5 to 10 minutes. Explain that, based on results, additional testing may be performed.
The nurse is caring for a client with emphysema. When teaching the client pursed-lip breathing, the nurse will include which instruction(s)? Select all that apply.
Inhale slowly through the nose for a count of three. Shape the lips as if you were about to blow a whistle. Over time, begin to increase the length of the exhale. Exhale slowly through pursed lips. Ensure that the exhale lasts twice as long as the inhale.
A client who is recovering from a stroke has begun tube feedings. Which principle should the nurse follow when administering the tube feeding?
Intermittent feedings use gravity for instillation or a feeding pump to administer the formula over a set period of time.
The nurse is caring for a client receiving diphenoxylate and atropine. Which nursing intervention is most important to implement when caring for this client?
Keep the client's bed in the lowest position.
A nurse is giving a large-volume enema to a client who winces in pain and complains of severe cramping. What intervention would be most appropriate in this situation?
Lower the solution container and check the temperature and flow rate.
The nurse is monitoring a client who is receiving oxygen via a nonrebreather mask at 12 L/min. What actions by the nurse will promote the best outcomes for this client? Select all that apply.
Maintain flow rate so that the reservoir bag collapses only slightly during inspiration. Check that the valves and rubber flaps are functioning properly. Monitor SaO2 with pulse oximeter.
A nurse is overseeing the care of a client who is receiving oxygen via nasal cannula. Which aspects of the client's care can the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply.
Measuring the client's respiratory rate Inserting the client's nasal cannula after it has become dislodged Reapplying the client's nasal cannula after a bath
Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert?
Muscle weakness, fatigue, and dysrhythmias
The nurse is obtaining a pulse oximetry reading for a client admitted with exacerbation of chronic obstructive pulmonary disease (COPD). When observing a reading of 89%, what action should the nurse perform?
No action is required, because this may be normal for the client
The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client?
O negative
A nurse is caring for a client who is not able to take food orally for 10 days and who will be on IV therapy during that period. The nurse knows that the client will likely receive which type of nutrition?
Peripheral parenteral nutrition
The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the siderail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate?
Remove the IV catheter and reinsert another in a different location.
The nurse is performing an assessment of a client with hypocalcemia who has been admitted to the acute care facility. Which symptom(s) does the nurse document that correlates with the admitting diagnosis? Select all that apply.
Report of muscle cramps Report of numbness and tingling of the mouth Seizure activity Blood clotting
The nurse completes the task of changing the dressing of a recent surgically inserted peritoneal dialysis catheter. The nurse has applied antibiotic ointment as prescribed, covered the site with 4 × 4 gauze, and labeled the dressing with the date, time of change, and initials of the nurse performing the task. Prior to leaving the client's bedside, the nurse should complete which task next?
Secure the tubing of the peritoneal dialysis catheter to the client's abdomen.
The nurse caring for an older adult male client is determining whether the client can use a urinal to void. Which aspects of the client's medical history may contraindicate the use of a urinal?
The client is acutely confused and has been diagnosed with delirium.
A nurse is preparing a discharge teaching plan for a client being sent home with a peritoneal dialysis catheter in place. Which guideline should be included in the instructions?
The client should avoid wearing tight clothes or belts near the site.
A nurse explains the homeostatic mechanisms involved in fluid homeostasis to a student nurse. Which statements accurately describe this process? Select all that apply.
The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the body's needs. The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acid-base balance. The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus.
The novice nurse is assessing the urinary bladder of a client with transient urinary incontinence. The nurse mentor would intervene if which action by the novice nurse is noted?
The novice nurse asks the client to urinate before palpating the bladder.
A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump?
The pump will continue to infuse fluid even when the needle is displaced.
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.
The nurse is teaching a client how to perform pelvic floor muscle exercises (Kegel exercises). Which teaching will the nurse include?
Tighten the internal muscles used to prevent or interrupt urination.
A client having a bowel surgery asks why being NPO after surgery is necessary. Which statement by the nurse best describes the reason?
To rest the gastrointestinal tract and promote healing
The nurse is observing the unlicensed assistive personnel (UAP) assist the client with the bedpan. The nurse would intervene if which action by the UAP is noted?
UAP positions the bedpan so the client's buttocks rest on the shallow end of the regular bedpan.
The nurse is choosing a collection device to collect urine from a nonambulatory male client? What would be the nurse's best choice?
Urinal
A nurse is inserting a catheter into a female urinary bladder. Which nursing action is performed correctly?
Use dominant hand to inflate the catheter balloon, and inject entire volume of sterile water supplied in prefilled syringe.
A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for:
atelectasis
A client has a history of long-term alcohol use. Which nutrient would need to be required in increased amounts?
b
Which vitamin is found only in animal foods?
b12
A client is scheduled for insertion of a peripherally inserted central catheter. When assisting with the procedure, the nurse would expect that which site would most likely be used?
basilic vein
The nurse is evaluating stool characteristics of an adult client. Which color stool does the nurse identify as abnormal? Select all that apply.
black clay colored yellow
Potassium is needed for neural, muscle, and:
cardiac function.
A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?
cardiac irregularities
The nurse is doing preoperative teaching with a client who has a prescription for Golytely® before undergoing intestinal surgery. For tolerance of drinking the solution, the nurse would advise the client to drink it in which manner?
chilled
When teaching a client, which laboratory tests will the nurse identify that assess cardiac and vascular disease risk? Select all that apply.
cholesterol level lipoprotein level triglyceride leve
Which client(s) would be an appropriate candidate for total parenteral nutrition (TPN)? Select all that apply.
client who has full-thickness (third-degree) burns over 40% of the body client who had gastric surgery and is unable to eat for a few weeks client with anorexia nervosa
A client has been receiving treatment with a nonrebreather mask for the past 96 hours. How should the nurse respond if the unlicensed assistive personnel (UAP) suddenly reports the client has vomited?
conduct a focussed assessment
A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:
congestive heart failure
Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?
corticosteroids
A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level?
crackles
A client has been admitted with fluid volume excess related to right-sided heart failure. Which assessment data would the nurse expect related to the fluid volume excess? Select all that apply.
crackles in the lungs distended neck veins
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?
decreased blood volume and intracellular dehydration
The nurse has received a prescription to obtain an arterial blood gas (ABG) on a client who has a history of chronic obstructive pulmonary disease (COPD) and is receiving oxygen via nasal cannula. Which step is the most important for the nurse to fulfill?
ensure client is at rest at least 30 minutes before obtaining the specimen
A nurse is caring for a client with a nasogastric tube. The nurse enters the room to flush the nasogastric tube and check gastric residual. Which action should the nurse perform first?
ensure head of bed is elevated
A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?
flow meter
The home health nurse arrives at a client's home and immediately notes the client is experiencing increased dyspnea. The client has a 7-year history of chronic obstructive pulmonary disease (COPD). Which assessment finding should the nurse prioritize?
flow meter set at 5 liters of oxygen
A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to:
fluid and electrolyte levels.
A client reports frequently experiencing urine loss when moving from the wheelchair to bed. Which type of incontinence does the nurse anticipate?
functional
A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client?
gauze dressing
The process of filtration begins at the:
glomerulus
A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather?
hypertonic saline
A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse likely to find?
hypokalemia
A nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 4.5 mg/dL (2.6 mEq/L)
hypokalemia
The nurse is caring for Mrs. Roberts, an 86-year-old client, who fell at home and was not found for 2 days. Mrs. Roberts is severely dehydrated. The nurse is aware that older adults are at increased risk for fluid imbalance due to:
increase in fat cells
A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid?
maintenance of cell size
Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking?
muscle cramping and tetany
The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client?
nasal cannula
A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use?
nonrebreather mask
A 45-year-old client on the inpatient unit has just resumed eating a normal diet. The nurse checks a blood sugar with the morning labs and the result is 99.10 mg/dL (5.5 mmol/L). How would the nurse interpret this blood glucose?
normal
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
Digital rectal examination confirms that a client has an impaction, and an enema solution has been ordered to lubricate the stool and intestinal mucosa without distending the intestine. What solution best meets this client's needs?
oil
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
The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding?
pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)
A client with chronic anemia is admitted for the administration of blood. What would the nurse expect the physician to order?
packed cells
A client with renal disease requires IV fluids. It is important for the nurse to:
place the fluids on an electronic device.
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?
placing the tourniquet on the upper arm for 2 minutes
The nurse is caring for a client who has excess levels of carbon dioxide in the blood, and chronic hypoxemia. Which intervention will the nurse recommend?
pursed-lip breathing
Which breathing technique(s) will the nurse teach to the client who has hypoxemia and hypercarbia? Select all that apply.
pursed-lip breathing diaphragmatic breathin
The nurse is reviewing the urinalysis of a client suspected of having a urinary tract infection. The potential diagnosis will be supported by the presence of:
pus
The health care provider prescribes a large-volume cleansing enema for a client. What outcome does the nurse identify that will be optimal for this client?
removes hardened fecal impactions from the rectum
The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly?
respirations are at 20 breaths per min
A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area?
sacral area
A health care provider has prescribed oxygen to be delivered at 8 L/minute for a client who does not have a tracheostomy. Which oxygen delivery device(s) will the nurse consider using? Select all that apply.
simple mask partial rebreather mask
The nurse is performing an assessment for an older adult client admitted with dehydration. When assessing the skin turgor of this client, which area of the body will be best for the nurse to assess?
sternum
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 incontinence
A client is prescribed a large volume cleansing enema and is concerned as to why the large volume is indicated. What response should the nurse give to the client? Select all that apply.
to relieve constipation to prevent involuntary escape of fecal material during surgical procedures to promote optimal visualization of the colon during a colonoscopy
The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select?
tracheostomy collar
A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur?
trauma to the tracheal mucosa
A nurse in a rural health center meets a new client, age 4. The nurse notices as the client enters the clinic that his legs appear to be bowed. When he smiles, the nurse also notes that his dentition is quite malformed for a child his age. What vitamin deficiency would the nurse most suspect?
vitamin D
Which of the following is a fat-soluble vitamin?
vitamin E
