MS Week 2 Practice Assessment

A nurse is reinforcing teaching with a client who has cancer about foods that prevent protein-energy malnutrition. Which of the following foods should the nurse include in the teaching? (Select all that apply.) ​1. Cottage cheese ​2. Milkshake ​3. Tuna fish ​4. Strawberries and bananas ​5. Egg and ham omelet

Ans: 1, 2, 3, 5 Rationale: Cottage cheese is correct. Cottage cheese is a good source of protein. Milkshake is correct. Milkshakes are a good source of protein. Tuna fish is correct. Tuna fish is a good source of protein. Egg and ham omelet is correct. An egg and ham omelet is a good source of protein. Strawberries and bananas is incorrect. The nurse should instruct the client that foods high in protein prevent protein-energy malnutrition. Although strawberries and bananas do provide essential nutrients, they are not protein-rich foods. Therefore; the nurse should not include this information in the teaching.

A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.) 1. Shallow respirations 2. Cardiac dysrhythmias 3. Flushing 4. Hyperactive reflexes 5. Abdominal pain

Ans: 1, 2, 4 Rationale: Shallow respirations is correct. Manifestations of metabolic alkalosis include slow and shallow respirations, dizziness, paresthesias, and lightheadedness. Cardiac dysrhythmias is correct. Manifestations of metabolic alkalosis include dizziness, paresthesias, lightheadedness, and cardiac dysrhythmias. Hyperactive reflexes is correct. Manifestations of metabolic alkalosis include dizziness, paresthesias, lightheadedness, hypertonic muscles, and hyperactive reflexes. 3. Flushing is incorrect. Flushing is a manifestation of respiratory acidosis, not metabolic alkalosis. 5. Abdominal pain is incorrect. Abdominal pain is a manifestation of metabolic acidosis, not metabolic alkalosis.

A nurse is assisting in planning an educational session regarding risk factors for skin cancer to a group of clients. Which of the following information should the nurse plan to include in the session? (Select all that apply.) ​1. Being dark-skinned ​2. Age under 40 years ​3. Overexposure to ultraviolet light ​4. Chronic skin irritations ​5. Genetic predisposition

Ans: 3, 4, 5 Rationale : Overexposure to ultraviolet light is correct. Overexposure to ultraviolet light is a risk factor for developing skin cancer. Rays from the sun are known to be carcinogenic and can result in malignant changes. Chronic skin lesions is correct. Chronic skin lesions are a risk factor for developing skin cancer. Clients are taught to monitor for a change in these chronic lesions as a precursor to a malignancy. Genetic predisposition is correct. Genetic predisposition is a risk factor for developing skin cancer, particularly malignant melanoma. 1. Being dark-skinned is incorrect. Light-skinned individuals are at greater risk for developing skin cancer. 2. Age under 40 years is incorrect. Individuals between the ages of 30 and 60 are at the greatest risk for developing nonmelanoma skin cancers.

A nurse is collecting data from a client who is admitted to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make? A) "It's okay to feel afraid. Let's talk about what you are afraid of." B) "Don't worry. The important thing is you have now quit smoking." C) "I understand your fears. I was a smoker also." D) "Your doctor is a great surgeon. You will be fine."

Ans: A) "It's okay to feel afraid. Let's talk about what you are afraid of." Rationale: It is the nurse's responsibility to acknowledge the client's statement, to encourage verbalization, and to explore the client's feelings. B) "Don't worry. The important thing is you have now quit smoking.": By telling the client not to worry because she has quit smoking, the nurse gives false reassurance and approval. This minimizes the client's feelings and concerns. C) "I understand your fears. I was a smoker also.": Telling the client that the nurse understands the fears and disclosing personal information about smoking is inappropriate, since the nurse has not asked the client about her fears. In addition, it is inappropriate to disclose personal information to the client. D) "Your doctor is a great surgeon. You will be fine.": Telling the client that she will be fine is false reassurance and it demeans the client's concerns.

A nurse is caring for four clients who have drainage tubes. The nurse should identify the client who has which of the following tubes as being at risk for hypokalemia? A) An NG tube to suction B) An indwelling urinary catheter to gravity drainage C) A chest tube to water-seal drainage D) A nephrostomy tube to a drainage bag

Ans: A) An NG tube to suction Rationale: Hypokalemia is low serum potassium. When connected to a suction source, an NG tube empties the stomach of gastric contents. Gastric contents are high in electrolytes, and losing them puts the client at risk for hypokalemia and other electrolyte imbalances. B) An indwelling urinary catheter to gravity drainage: Drainage of urine does not deplete potassium, unless the client is taking a potassium-wasting diuretic, such as hydrochlorothiazide. C) A chest tube to water-seal drainage Drainage of air, blood, and fluid from a chest tube does not deplete potassium. D) A nephrostomy tube to a drainage bag: Drainage of urine does not deplete potassium, unless the client is taking a potassium-wasting diuretic, such as hydrochlorothiazide.

A nurse is reviewing the laboratory results of a client who is taking a loop diuretic and notes the client's potassium level is 3.0 mEq/L. Which of the following physiological responses should the nurse expect related to the client's hypokalemia? A) Cardiac dysrhythmias B) Hypoglycemia C) Hyperreflexia D) Increased appetite

Ans: A) Cardiac dysrhythmias Rational: Low potassium levels affect cardiovascular function, causing ventricular dysrhythmias, ECG changes, and a weak, irregular pulse. B) Hypoglycemia: Low potassium levels do not cause hypoglycemia, although they can cause weakness and fatigue. C) Hyperreflexia: Low potassium levels cause decreased deep tendon reflexes, not hyperreflexia. D) Increased appetite Low potassium levels do not increase appetite. However, hypokalemia can cause nausea and vomiting.

A nurse receives a client's laboratory results and notes a potassium level of 3.1 mEq/L. When reviewing the client's medication administration record, which of the following types of medication should the nurse identify as a contributing factor to the client's electrolyte imbalance? A) Corticosteroids B) NSAIDs C) ACE inhibitors D) SSRIs

Ans: A) Corticosteroids Rational: Corticosteroids are a common cause of hypokalemia and metabolic alkalosis. B) NSAIDs cause hyponatremia, not hypokalemia. C) ACE inhibitors cause hyperkalemia, not hypokalemia. D) SSRI antidepressants cause hyponatremia, not hypokalemia.

A nurse is collecting data from a client who has heart failure and takes chlorothiazide sodium. Which of the following findings should the nurse identify as indicating hypokalemia? A) Decreased deep-tendon reflexes B) Restlessness C) Hyperactive bowel sounds D) Bounding peripheral pulses

Ans: A) Decreased deep-tendon reflexes Rationale: The nurse should expect a client who has hypokalemia to report decreased deep tendon reflexes. Thiazide diuretics cause excessive potassium loss; therefore, it is important for the nurse to monitor for and report findings of hypokalemia. B) Restlessness ​The nurse should expect a client who has hypokalemia to exhibit lethargy. C) Hyperactive bowel sounds The nurse should expect a client who has hypokalemia to have hypoactive bowel sounds, which could cause an ileus. D) Bounding peripheral pulses The nurse should expect a client who has hypokalemia to have an irregular pulse that is weak.

A nurse is reviewing the medical record of a client who has metabolic acidosis. The nurse should realize that which of the following findings contributes to the development of metabolic acidosis? A) Diarrhea B) Vomiting C) hyperventilation D) Salicylate intoxication

Ans: A) Diarrhea Rational: Diarrhea can cause bicarbonate loss, which can contribute to the development of metabolic acidosis. B) Vomiting: Vomiting can cause acid loss, which can contribute to the development of metabolic alkalosis. C) Hyperventilation: Hyperventilation can cause carbon dioxide loss, which can contribute to the development of respiratory alkalosis. D) Salicylate intoxication: ​Salicylate intoxication can contribute to the development of respiratory alkalosis.

A client who has metastatic bone cancer tells the nurse, " I want to go home and die." The client's family is concerned about meeting the client's care needs at home. Which of the following actions should the nurse take? A) Discuss a referral to home health and hospice care with the client and family. B) Contact the social worker to assist with nursing home placement. C) Talk with the provider about extending the client's hospital stay. D) Instruct the family about meeting the client's palliative care needs at home.

Ans: A) Discuss a referral to home health and hospice care with the client and family. Rationale: The client has expressed a wish to go home. The nurse should discuss the availability of resources that can assist with the care of the client and determine the appropriateness of the use of the resources for the family. Home health and hospice care are both resources that could provide support for the care of the client at home. B) Contact the social worker to assist with nursing home placement. The client wishes to die at home, not in a long-term care facility. C) Talk with the provider about extending the client's hospital stay. The client wishes to die at home, not in the hospital. D) Instruct the family about meeting the client's palliative care needs at home. Palliative care can be complex and can also exhaust family caregivers. It is naïve to presume that the nurse can provide all the information the family will need to manage this situation.

A nurse is planning to speak to a group of adolescents about toxic shock syndrome (TSS). The nurse include that TSS is commonly associated with which of the following? A) High-absorbency tampons B) Mosquito bites C) International travel D) Multiple sexual partners

Ans: A) High-absorbency tampons Rationale: TSS is a severe disease caused by a toxin made by Staphylococcus aureus and can lead to shock and multiple organ dysfunction. It most often affects menstruating women who use highly absorbent tampons. B) Mosquito bites: Mosquito bites contribute to vector-borne diseases, such as West Nile virus, but are not associated with TSS. C) International travel: International travel can lead to diseases endemic to the area of travel, such as malaria, but is not associated with TSS. D) Multiple sexual partners: Multiple sexual partners increase the risk of contracting sexually transmitted infections but are not associated with TSS.

A nurse is reinforcing teaching with a client who has neutropenia as a result of radiation therapy for the treatment of lung cancer. Which of the following should the nurse plan to include in the teaching? A) Increase fluid intake by drinking bottled water. B) A salad bar is a healthy choice when dining out. C) Soft-boiled eggs are an appropriate source of protein. D) Eating at buffets is a good choice to increase caloric intake.

Ans: A) Increase fluid intake by drinking bottled water. Rationale: The client who has neutropenia is at risk for foodborne illness. Bottled water prevents the client's exposure to pathogens that might be found in other water sources. B) A salad bar is a healthy choice when dining out. The client who has neutropenia should avoid salad bars due to a higher risk of exposure to pathogens from raw foods, as well as from other individuals. C) Soft-boiled eggs are an appropriate source of protein. The client who has neutropenia should avoid foods that are not fully cooked due to a higher risk of foodborne illness. D) Eating at buffets is a good choice to increase caloric intake. The client who has neutropenia should avoid buffets due to a higher risk of foodborne illness and pathogen exposure.

A nurse is collecting data from a client who has shallow respirations and a respiratory rate of 9/min. Which of the following acid-base imbalances should the nurse expect? A) Respiratory acidosis B) Respiratory alkalosis C) Metabolic acidosis D) Metabolic alkalosis

Ans: A) Metabolic alkalosis Rationale: Respiratory acidosis represents an increase in the acid component, carbon dioxide, due to inadequate excretion, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. A major cause of this imbalance is hypoventilation. B) Respiratory alkalosis Hyperventilation, not hypoventilation, causes respiratory alkalosis. C)Metabolic acidosis Metabolic acidosis results from a metabolic disturbance, such as diarrhea or diuresis, not a respiratory disturbance. D)Metabolic alkalosis Metabolic alkalosis results from a metabolic disturbance, such as vomiting, not a respiratory disturbance.

The nurse assisting in the collection of data for a client who is in the early compensatory stage of hypovolemic shock. Which of the following findings should the nurse expect? A) Tachycardia B) Cold clammy skin C) Unconsciousness D) Diminished urine output

Ans: A) Tachycardia Rationale: The client who is in the early compensatory stage of hypovolemic shock will manifest tachycardia and as the blood volume decreases the pulse becomes rapid and thready. B) Cold clammy skin The client who is in the later compensatory stage of hypovolemic shock with 40% volume lost will manifest cold clammy skin. C) Unconsciousness The client who is unconscious from hypovolemic shock with at least 50% volume lost is characteristic of irreversible stage of shock. D) Diminished urine output The client who has diminished urine output characterizes the progressive stage of shock.

A nurse is assisting with the care of a client who is in hemorrhagic shock and has a prescription for packed red blood cells. Which type of blood can be administered to the client while awaiting blood from a type and cross-match? A) Type O B) Type A C) Type B D) Type AB

Ans: A) Type O Rationale: Type O blood can be given to clients who have any of the four blood types. B) Type A Type A blood can be given to clients who have A and AB blood types. C) Type B Type B blood can be given to clients who have B and AB blood types. D) Type AB Type AB blood can be given to clients who have the AB blood type.

A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements should the nurse identify as an indication that the client understands and accepts his prognosis? A) "I am thinking of getting a second opinion." B) "I am hoping this will help relieve my discomfort." C) "This is making me stronger every day." D) "This is not working, and I plan to stop treatment."

Ans: B) "I am hoping this will help relieve my discomfort." Rationale: Clients receiving palliative care are aware that the outcome is to relieve symptoms and provide the best possible quality of life. A) "I am thinking of getting a second opinion.": Clients receiving palliative care are aware that there is no hope of cure or recovery and are unlikely to seek a second opinion. C) "This is making me stronger every day.": Clients receiving palliative care are aware that there is no hope for cure or recovery and the outcome is to maintain and support, not improve functional ability as they transition to other levels of care. D) "This is not working, and I plan to stop treatment.": Clients receiving palliative care are aware that there is no hope for cure or recovery and would accept ongoing support to prevent suffering and maintain the best possible quality of life.

A nurse is assisting with the care of a client who has developed cardiogenic shock. When evaluating circulation to the client's brain, which of the following pulse sites should the nurse take? A) Femoral B) Carotid C) Popliteal D) Radial

Ans: B) Carotid Rationale: The nurse should palpate the client's carotid pulse at a location between the sternocleidomastoid muscle and the trachea, to evaluate circulation to the brain. Adequate carotid pulsations indicate circulation to the brain. A) Femoral: The nurse should use the femoral pulse site, along the inguinal ligament, to evaluate circulation to a leg. C) Popliteal: The nurse should use the popliteal pulse site, behind the knee, to evaluate circulation to a lower leg. D) Radial The nurse should use the radial pulse site, on the inner aspect of the wrist on the thumb side, as an easy-to-access site for routine pulse measurements.

A nurse is collecting data from a client who has pneumonia and is experiencing acute respiratory acidosis. Which of the following manifestations should the nurse expect to find? A) Cool, clammy skin B) Decreased level of consciousness C) Muscle flaccidity D) Circumoral numbness and tingling

Ans: B) Decreased level of consciousness Rationale: The nurse should expect to find a decreased level of consciousness in a client who is experiencing respiratory acidosis. The rise in carbon dioxide dilates the cerebral vessels causing a feeling of fullness in the head, leading to mental cloudiness and a decreased level of consciousness. A) Cool, clammy skin The nurse should expect to find warm, flushed skin in a client who is experiencing respiratory acidosis. C) Muscle flaccidity The nurse should expect to find muscle twitching, dizziness, and possibly seizures in a client who is experiencing respiratory acidosis. D) Circumoral numbness and tingling The nurse should expect to find circumoral numbness and tingling in a client who is experiencing respiratory alkalosis.

A nurse is reviewing the medication history of a client. The nurse should identify that which of the following medications places the client at risk for hypokalemia? A) Ketoprofen 75 mg PO three times a day B) Furosemide 80 mg PO daily C) Acyclovir 400 mg PO twice daily D) Ranitidine 150 mg PO twice daily

Ans: B) Furosemide 80 mg PO daily Rationale: This dose of 80 mg per day is within the acceptable dosage range, but it is high. An adverse effect of furosemide is hypokalemia, which can lead to life-threatening cardiac dysrhythmias. A) Ketoprofen 75 mg PO three times a day Ketoprofen can cause numerous adverse effects, including GI bleeding and agranulocytosis, but it does not cause hypokalemia. C) Acyclovir 400 mg PO twice daily: Oral acyclovir can cause CNS and GI effects, such as nausea, vomiting, and headache. Intravenous acyclovir can cause reversible nephrotoxicity as well as neurologic toxicity. D) Ranitidine 150 mg PO twice daily: Adverse effects of ranitidine include thrombocytopenia as well as dizziness and central nervous system effects, but it does not cause hypokalemia.

A nurse is collecting data from a client who has a sodium of 128 mEq/L. which of the following manifestations should the nurse expect? A) Hyporeflexia B) Headache C) Constipation D) Increased appetite

Ans: B) Headache Rationale: A client who has a sodium level of 128 mEq/L is experiencing hyponatremia. The nurse should expect this client to have neurologic manifestations such as a headache due to swelling of brain cells. A) Hyporeflexia A client who has a sodium level of 128 mEq/L is experiencing hyponatremia. The nurse should expect this client to have hyperreflexia, muscle twitching, and tremors. C) Constipation A client who has a sodium level of 128 mEq/L is experiencing hyponatremia. The nurse should expect this client to have diarrhea. D) Increased appetite A client who has a sodium level of 128 mEq/L is experiencing hyponatremia. The nurse should expect this client to have anorexia, nausea, and vomiting.

A nurse is collecting data from a client wo has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? A) Cool, clammy skin B) Hyperventilation C) Increased blood pressure D) Bradycardia

Ans: B) Hyperventilation Rationale: The nurse should expect to find hyperventilation in a client who is experiencing metabolic acidosis. The system attempts to compensate or return the pH to normal by increasing the rate and depth of respirations. A) Cool, clammy skin: The nurse should expect to find warm, flushed skin in a client who is experiencing metabolic acidosis. C) Increased blood pressure: The nurse should expect to find hypotension in a client who is experiencing metabolic acidosis. D) Bradycardia: The nurse should expect to find tachycardia in a client who is experiencing metabolic acidosis.

A nurse is assisting with the care of a client who is hypovolemic due to blood loss following a motor-vehicle crash and needs a blood transfusion immediately. The nurse should anticipate a prescription for which of the following IV solutions while awaiting blood from a type and cross-match? A) 0.45% sodium chloride B) Lactated Ringer's C) Dextrose 10% in water D) 0.33% sodium chloride

Ans: B) Lactated Ringer's Rationale: Lactated Ringer's solution is administered to the client who has hypovolemic shock because it contains electrolytes and expands plasma volume. A) 0.45% sodium chloride 0.45% sodium chloride is hypotonic and is not used to treat hypovolemia due to blood loss. C) Dextrose 10% in water Dextrose 10% in water is hypertonic and is not used to treat hypovolemia due to blood loss. D) 0.33% sodium chloride 0.33% sodium chloride is hypertonic and is not used to treat hypovolemia due to blood loss.

A nurse is caring for a client who is experiencing severe nausea and vomiting following chemotherapy. The nurse should monitor the client for which of the following acid-base imbalances? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis

Ans: B) Metabolic alkalosis Rationale: Metabolic alkalosis can occur with excessive vomiting, gastric suctioning, with hypokalemia, or with excess bicarbonate ingestion. The client who has metabolic alkalosis might be dizzy, display hyperactive reflexes, and might have numbness or tingling in the extremities and around the mouth.

A nurse is reviewing the laboratory values for a client who takes spironolactone and noes that the client's serum potassium level is 6.8 mEq/L. The nurse notifies the provider and anticipates that the provider will provide which of the following instructions? A) Administer potassium gluconate 40 mEq orally. B) Obtain a 12-lead ECG. C) Restrict fluid intake. D) Have the laboratory draw a blood sample for an erythrocyte sedimentation rate.

Ans: B) Obtain a 12-lead ECG. Rationale: This client's potassium level is above the expected reference range. Because hyperkalemia can cause ECG changes, including ventricular dysrhythmias and cardiac arrest, it is essential to obtain a 12-lead ECG and to monitor for such changes. A) Administer potassium gluconate 40 mEq orally.: Potassium gluconate is a potassium supplement that is used to treat hypokalemia. C) Restrict fluid intake.: The nurse should encourage the client to increase fluid intake to promote excretion of the excess potassium. D) Have the laboratory draw a blood sample for an erythrocyte sedimentation rate.: The nurse should anticipate instructions to obtain an erythrocyte sedimentation rate for a client who has an infection.

A nurse is caring for an older adult client who has cancer and is receiving opioids for pain relief. The client has a new prescription for docusate PO daily. When collecting data from client, which of the following therapeutic effects of docusate should the nurse expect? A) Decreased drowsiness B) Relief from constipation C) Relief from nausea D) Decreased cancer pain

Ans: B) Relief from constipation Rationale: Constipation is a serious adverse effect of opioid medications. The intended outcome of docusate therapy is to relieve constipation by producing stool that is softer in consistency and easier for the client to pass. A) Decreased drowsiness Docusate does not affect the central nervous system and is not expected to decrease drowsiness. C) Relief from nausea Docusate does not treat nausea. D) Decreased cancer pain Docusate does not affect cancer pain.

A nurse in a provider's office is collecting data from a client who takes furosemide daily for heart failure. Which of the following findings is a manifestation of hypokalemia? A) Reports of numbness in the feet B) Reports of fatigue C) Increased bowel sounds D) Positive Trousseau's sign

Ans: B) Reports of fatigue Rationale: Fatigue and muscle weakness are manifestations of hypokalemia. A) Reports of numbness in the feet Paresthesias and numbness in the extremities is a manifestation of hyperkalemia. C) Increased bowel sounds Decreased bowel sounds are a manifestation of hypokalemia. D) Positive Trousseau's sign A positive Trousseau is a manifestation of hypocalcemia and hypomagnesaemia.

A nurse is reinforcing teaching about TNM staging with a client who has cancer. Which of the following information should the nurse include in the teaching? A) "T4 indicates a tumor at its smallest size." B) "N0 indicates regional lymph node involvement." C) "M1 indicates tumor metastasis to a single site." D) "TIS indicates that a tumor has resolved."

Ans: C) "M1 indicates tumor metastasis to a single site." Rationale: Following the TNM staging guidelines, the nurse should identify that the "M" indicates the degree of metastasis, with "0" indicating no metastasis, and increasing numbers (1, 2, 3) indicating metastasis to one or multiple distant sites. A) "T4 indicates a tumor at its smallest size.": The nurse should identify that a T4 rating indicates a large tumor. T0 indicates no tumor and increasingly higher numbers indicate increased tumor size. B) "N0 indicates regional lymph node involvement.": The nurse should identify that an N0 rating indicates no lymph node changes. D) "TIS indicates that a tumor has resolved.": The nurse should identify that a TIS rating indicates carcinoma "in situ," or confined to the original tumor location.

A nurse is reviewing a client's admission laboratory findings that indicate the client has hyponatremia. Which of the following laboratory findings should the nurse also expect to be below expected reference range? A) Magnesium B) Calcium C) Chloride D) Potassium

Ans: C) Chloride Rationale: Hyponatremia refers to a decrease in the sodium level. The loss of sodium, a positively-charged ion, results in the loss of chloride, a negatively-charged ion, because these electrolytes have an electrical attraction to each other. A) Magnesium Hyponatremia refers to a decrease in the sodium level. The loss of sodium does not result in the loss of magnesium. B) Calcium Hyponatremia refers to a decrease in the sodium level. The loss of sodium does not result in the loss of calcium. D) Potassium Hyponatremia refers to a decrease in the sodium level. The loss of sodium does not result in the loss of potassium.

A nurse is caring for a client who is at risk for shock? Which of the following findings should the nurse expect? A) Hypotension B) Decreased urine output C) Increased blood pressure D) Increased bowel sounds

Ans: C) Increased blood pressure Rationale: Decreased blood pressure is a manifestation of shock. A) ​Hypotension: Hypotension is a manifestation of shock. B) Decreased urine output: Increased urine output is a manifestation of shock. D) Increased bowel sounds: Decreased bowel sounds is a manifestation of shock.

A nurse is reviewing the arterial blood gas (ABG) results of a client. The client's ABGs are: pH: 7.6 PaCO2: 40 mm Hg HCO3: 32 mEq/L Which of the following acid base conditions should the nurse identify the client is experiencing? A) Metabolic acidosis B) Respiratory acidosis C) Metabolic alkalosis D) Respiratory alkalosis

Ans: C) Metabolic alkalosis Rationale: The nurse should identify that the client is experiencing metabolic alkalosis. The client's pH is above 7.45, the PaCO2 is within the expected reference range and the HCO3 is above 26 mEq/L.

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following of the findings should the nurse expect? A) Hypotension B) Purpura C) Oliguria D) Bradypnea

Ans: C) Oliguria Rationale: Oliguria is present in hypovolemic shock as a result of decreased blood flow to the kidneys. A) ​Hypertension Hypotension is a manifestation of hypovolemic shock. B) Purpura Pallor is a manifestation of hypovolemic shock. D) Bradypnea Tachypnea is a manifestation of hypovolemic shock.

A nurse is caring for a client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40% by face tent. The client's SiO2 is 89%. ABG results are pH 7.31, PaO2 93 mm Hg, PCO2 50 mmHg, HCO3 25 mEq/L. Which of the following is an appropriate action by the nurse? A) ​Switch oxygen to a nonrebreather mask. B) Increase oxygen to 70%. C) Place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing. D) Position the client prone and have the respiratory therapist perform postural drainage.

Ans: C) Place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing. Rationale: Positioning the client to improve gas exchange by deep-breathing, coughing, and removal of secretions may resolve the problem and is an appropriate action by the nurse. A) ​Switch oxygen to a nonrebreather mask. The client is exhibiting manifestations of respiratory acidosis from decreased ventilation. A nonrebreather is used for respiratory alkalosis. B) Increase oxygen to 70%. Increasing the oxygen (O2) is not necessary because the PaO2 level is within normal limits. D) Position the client prone and have the respiratory therapist perform postural drainage. Positioning the client prone is not beneficial because this position limits expansion of the lungs and makes it difficult for the client to cough and deep breathe to blow off the retained carbon dioxide.

A nurse is caring for a client whose arterial blood gas results show the following results: pH: 7.2 PaCO2: 50 mm Hg HCO3: 24 mEq/L The nurse should identify the client is experiencing which of the following acid-base conditions? A) Metabolic acidosis B)Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis

Ans: C) Respiratory acidosis Rationale: With uncompensated respiratory acidosis, the client's pH is below 7.35, the PaCO2 is above 45 mm Hg, and the HCO3 is within the expected reference range. A) Metabolic acidosis With metabolic acidosis, the client's pH is below 7.35, the PaCO2 is within the expected reference range, and the HCO3 is below 22 mEq/L. B) Metabolic alkalosis With metabolic alkalosis, the client's pH is above 7.45, the PaCO2 is within the expected reference range, and the HCO3 is above 26 mEq/L or average. D) Respiratory alkalosis With respiratory alkalosis, the client's pH is above 7.45, the PaCO2 is below 35 mm Hg, and the HCO3 is within the expected reference range.

A nurse is caring for a client whose serum potassium level is 5.3 mEq/L. The nurse should anticipate a prescription for which of the following medications? A) Potassium chloride B) Acetylcysteine C) Sodium polystyrene D) Potassium iodide

Ans: C) Sodium polystyrene Rationale: In addition to calcium gluconate, glucose and insulin, sodium polystyrene is administered orally or rectally to absorb excess potassium. A) Potassium chloride A serum potassium level of 5.3 mEq/L is above the expected reference range. The nurse should not anticipate the administration of potassium chloride, because it is used to treat hypokalemia. B) Acetylcysteine Acetylcysteine is an antidote used to treat acetaminophen poisoning. D) Potassium iodide A serum potassium level of 5.3 mEq/L is above the expected reference range. The nurse should not anticipate the administration of potassium iodide, because it is used to treat hypokalemia.

A nurse is reviewing the medical record of a client and identifies a serum potassium 6.8 mEq/L. Which of the following medications should the nurse expect to administer? A) Lactulose B) Triamterene C) Sodium polystyrene D) Acetylcysteine

Ans: C) Sodium polystyrene Rationale: The client's potassium level is above the expected reference range; therefore, the nurse should expect to administer sodium polystyrene for the treatment of hyperkalemia. A) Lactulose: The nurse should recognize that lactulose is a laxative, and is also used to decrease ammonia levels for clients who have liver failure. B) Triamterene: The nurse should recognize that triamterene is a potassium-sparing diuretic; therefore, administering this medication will cause harm to the client. D) Acetylcysteine: The nurse should recognize that acetylcysteine is used to remove toxins of acetaminophen for clients who have acute acetaminophen overdose.

A nurse is phoning a provider to report a client's serum potassium of 6.2 mEq/L. Which of the following medications should the nurse expect the provider to prescribe? A) Acetylcysteine B) Potassium iodide C) Sodium polystyrene sulfonate D) Lactulose

Ans: C) Sodium polystyrene sulfonate Rationale: This potassium level is above the expected reference range. Therefore, the nurse should expect to administer sodium polystyrene sulfonate, which absorbs potassium from within the large intestine. A) Acetylcysteine The nurse should expect to administer acetylcysteine to treat a client who has an overdose of acetaminophen B) Potassium iodide The nurse should expect to administer potassium iodide to treat a client who has excessive thyroid hormone. D) Lactulose The nurse should expect to administer lactulose to treat a client who has an ammonia level above the expected reference range.

A nurse is collecting data from a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? A) Hyperactive reflexes B) Extreme thirst C) Weak, irregular pulse D) Hyperactive bowel sounds

Ans: C) Weak, irregular pulse Rationale: Common manifestations of potassium depletion include a weak and irregular pulse, muscle weakness, fatigue, and ventricular dysrhythmias. A) Hyperactive reflexes A client who has depleted potassium levels is more likely to experience decreased deep-tendon reflexes than hyperactive reflexes. B) Extreme thirst Extreme thirst is a common manifestation of elevated sodium levels. D) Hyperactive bowel sounds Hyperactive bowel sounds are a common manifestation of elevated potassium levels.

A nurse is assisting with the care of a client who has septic shock and is at risk for disseminated intravascular coagulation (DIC). Which of the following nursing statements indicates an understanding of the condition? A) ​"DIC is controllable with lifelong heparin usage." B) ​"DIC is characterized by an elevated platelet count." C) ​"DIC is caused by abnormal coagulation involving fibrinogen." D) ​"DIC is a genetic disorder involving vitamin K deficiency."

Ans: C) ​"DIC is caused by abnormal coagulation involving fibrinogen." Rationale: The nurse should understand that DIC is caused by an abnormal coagulation following fibrinogen levels below the expected reference range. A) DIC is controllable with lifelong heparin usage.": The nurse should understand that DIC is not controlled with lifelong heparin usage, but heparin is administered to minimize uncontrolled clotting that can deplete the body's supply of clotting factors. B) ​"DIC is characterized by an elevated platelet count.": The nurse should understand that DIC causes bleeding due to a platelet count below the expected reference range. D) ​"DIC is a genetic disorder involving vitamin K deficiency.": The nurse should understand that DIC is not a genetic disorder involving vitamin K deficiency. Vitamin K prolongs bleeding time.

A nurse is assisting with the admission of a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, "I don't know what I will do if they discover I have cancer." Which of the following responses should the nurse make? A) "Why do you think you might have cancer when your diagnosis is a benign condition?" B) "I have reviewed your history and I don't see any reason for you to worry about that." C) "I think that's something you need to discuss further with your doctor." D) "I'm hearing that you are concerned that you could have cancer."

Ans: D) "I'm hearing that you are concerned that you could have cancer." Rationale: This response illustrates the therapeutic communication technique of seeking clarification and restating. It demonstrates the nurse's willingness to explore the client's fears and encourages communication. A) "Why do you think you might have cancer when your diagnosis is a benign condition?" This response illustrates the nontherapeutic communication technique of requesting an explanation. Asking "why" questions can be intimidating and might cause the client to become defensive. B) "I have reviewed your history and I don't see any reason for you to worry about that." This response illustrates the nontherapeutic communication technique of giving false reassurance. This belittles the client's concerns and may cause the client to stop sharing feelings. C) "I think that's something you need to discuss further with your doctor." By offering to pass the client's concerns to someone else, the nurse is demonstrating that she does not wish to discuss the issue. This is a dismissive action and can cause the client to feel misunderstood or not supported.

A nurse is collecting data from a client who has a sodium level of 155 mEq/L. Which of the following manifestations should the nurse expect? A) Cool, clammy skin B) Hypertension C) ​Increased salivation D) Decreased level of consciousness

Ans: D) Decreased level of consciousness Rationale: A client who has a sodium level of 155 mEq/L is experiencing hypernatremia. The nurse should expect this client to have a decreased level of consciousness from the dehydration of brain cells. A) Cool, clammy skin A client who has a sodium level of 155 mEq/L is experiencing hypernatremia. The nurse should expect this client to have hot, dry skin; fever; and decreased sweating. B) Hypertension A client who has a sodium level of 155 mEq/L is experiencing hypernatremia. The nurse should expect this client to have postural hypotension. C) Increased salivation A client who has a sodium level of

A nurse is caring for a client who is receiving chemotherapy for treatment of ovarian cancer and experiencing nausea. Which of the following actions should the nurse take? A) Advise the client to lie down after meals. B) Instruct the client to restrict food intake prior to treatment. C) Provide the client with an antiemetic 2 hr prior to the chemotherapy. D) Encourage the client to drink a carbonated beverage 1 hr before meals.

Ans: D) Encourage the client to drink a carbonated beverage 1 hr before meals. Rationale: The nurse should instruct the client to drink a carbonated beverage 1 hr before or after meals to reduce the risk for nausea. A) Advise the client to lie down after meals. The nurse should advise the client to not lie down for 2 hr after meals to reduce the risk for nausea. B) Instruct the client to restrict food intake prior to treatment. The nurse should instruct the client to eat before treatment to reduce the risk of nausea. C) Provide the client with an antiemetic 2 hr prior to the chemotherapy. The nurse should administer an antiemetic 30 min to 1 hr prior to treatments, to reduce the risk of nausea and vomiting. Preventive treatment should start before the chemotherapy is given and continue for as long as the chemotherapy agent is likely to cause nausea.

A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect? A) High BP and low pulse rate B) Low BP and low pulse rate C) High BP and high pulse rate D) Low BP and high pulse rate

Ans: D) Low BP and high pulse rate Rationale: Shock is a serious complication that develops from a lack of adequate blood flow, decreased tissue perfusion, and decreased cardiac output. Vital signs reflecting shock include low blood pressure, increased respiratory rate, and a rapid pulse as the cardiovascular system tries to compensate. A) High BP and low pulse rate These findings reflect hypertension, but not shock. B) Low BP and low pulse rate These findings reflect hypotension, but not shock C) High BP and high pulse rate These findings reflect hypertension, but not shock

A nurse is caring for a client who has acute kidney injury. The client's ABGS are: pH: 7.26 PaCO2: 30 mm Hg HCO3: 14 mEq/L A) Metabolic alkalosis B) Respiratory alkalosis C) Respiratory acidosis D) Metabolic acidosis

Ans: D) Metabolic acidosis Rationale: Acute renal failure causes metabolic acidosis because clients cannot process and excrete the acidic substances the usual bodily functions produce every day. With metabolic acidosis, the pH is below 7.35, the PaCO2 is below 35 mm Hg or in the expected range, and the HCO3 is below 22 mEq/L. A) With metabolic alkalosis the pH is above 7.45, the PaCO2 is within the expected reference range and the HCO3 is above 26 mEq/L. B) With respiratory alkalosis the pH is above 7.45, the PaCO2 is below 35 mm Hg, and the HCO3 is within the expected reference range. C) With respiratory acidosis the pH is below 7.35, the PaCO2 is above 45 mm Hg, and the HCO3 is within the expected reference range.

A nurse is assisting with a presentation about caring for clients who are receiving diuretic therapy. The nurse should explain that which of the following medications can put clients at risk for hyperkalemia? A) Furosemide B) Hydrochlorothiazide C) ​Mannitol D) Spironolactone

Ans: D) Spironolactone Rationale: Spironolactone is a potassium-sparing diuretic that blocks the effects of aldosterone in the renal tubules, causing a loss of sodium and water and retention of potassium. The nurse should instruct that spironolactone therapy can increase the risk of hyperkalemia and hyponatremia. A) Furosemide Furosemide is a high-ceiling (loop) diuretic that increases the risk of hyponatremia and hypokalemia, not hyperkalemia. B) ​Hydrochlorothiazide Hydrochlorothiazide is a thiazide diuretic that increases the risk of hypokalemia, not hyperkalemia. C) ​Mannitol Mannitol is an osmotic diuretic that can cause hyponatremia, not hyperkalemia.

A nurse is collecting data from a client who sustained blood loss. Which of the following findings should the nurse identify as a manifestation of hypovolemia? A) Decreased heart rate B) Dyspnea C) Increased blood pressure D) Thready pulse

Ans: D) Thready pulse Rationale: A client who has hypovolemia will experience decreased volume of circulating blood and less pressure within the vessels, resulting in weak, thready peripheral pulses and flat neck veins. A) Decreased heart rate: The heart rate increases in clients who have hypovolemia. B) Dyspnea: Dyspnea is a common finding in clients who have cardiovascular and pulmonary problems, but it is not common with hypovolemia. C) Increased blood pressure: Blood pressure decreases in clients who have hypovolemia due to the drop in circulating blood volume.

The nurse is assisting with the admission of a client who is hyperventilating, reports lightheadedness and paresthesias, and has blurred vision and a new onset of confusion. The nurse should suspect that the client has developed which of the following imbalances? A) ​Metabolic acidosis B) ​Metabolic alkalosis C) ​Respiratory acidosis D) ​Respiratory alkalosis

Ans: D) ​Respiratory alkalosis Rationale: Clients who have respiratory alkalosis have an increased depth and rate of respiration, confusion, lightheadedness, paresthesias, tremors, and blurred vision. A) Metabolic acidosis Clients who have metabolic acidosis have lethargy, confusion, deep and rapid respirations, weakness, and abdominal pain. B) ​Metabolic alkalosis Clients who have metabolic alkalosis have slow and shallow respirations, dizziness, paresthesias, lightheadedness, cardiac dysrhythmias, and hypertonic muscles C) ​Respiratory acidosis Clients who have respiratory acidosis have tachycardia, lethargy, headache, lightheadedness, and muscle twitching.

A nurse is collecting data from a client whose arterial blood gas values reveal a pH of 7.24, PaCO2 of 53, and an HCO3 of 24. The nurse should prepare to treat the client for which of the following acid-base imbalances? A) Metabolic acidosis B) Respiratory alkalosis C) Respiratory acidosis D) Metabolic alkalosis

Ans: Respiratory acidosis Rationale: In analyzing blood gases, the nurse should first determine if the result is acidosis (pH less than 7.35) or alkalosis (pH greater than 7.45). A pH of 7.24 is decreased. Therefore, this is acidosis. The next step is to look at the PaCO2 (expected reference range 35 to 45) and the HCO3- (expected reference range 22 to 26). A PaCO2 of 53 is elevated (greater than 45) and the HCO3- of 24 is within the expected reference range. Therefore, if the pH is decreased, the PaCO2 is elevated and the HCO3- is within the expected reference range, the client is experiencing respiratory acidosis.

A nurse is caring for a client who has syndrome of inappropriate hormone (SIADH) and a sodium level of 123 mEq/L. Which of the following actions should the nurse take? A) Maintain an IV of 0.45% sodium chloride. B) Restrict oral fluids to 800 to 1,000 mL/day. C) Ensure the client receives a 2 g/day sodium diet. D) Administer desmopressin acetate 0.2 mg orally.

B) Restrict oral fluids to 800 to 1,000 mL/day. Rationale: Clients who have SIADH have an increased amount of antidiuretic hormone, which results in excess fluid volume. This excess fluid dilutes the sodium level in the blood, causing dilutional hyponatremia. Oral fluids are restricted in an attempt to restore the fluid balance and therefore the sodium level in the blood. This dilutional hyponatremia does not occur only in clients who have SIADH, but also can result in clients with excess fluid volume (e.g., heart failure, liver cirrhosis, nephrotic syndrome). A) Maintain an IV of 0.45% sodium chloride.: This is a hypotonic IV fluid and can worsen hyponatremia by further diluting the blood. If the client requires IV fluids, an isotonic IV fluid such as 0.9% sodium chloride is preferred. For very low sodium levels, the use of hypertonic saline (e.g., 3% sodium chloride) may be used. The nurse should be very cautious with hypertonic saline because it can add to the existing fluid overload and promote pulmonary edema. C) Ensure the client receives a 2 g/day sodium diet.: A diet of 2 g/day is considered a low-sodium diet. This client would benefit from increasing the sodium in the diet, not restricting it. Two grams is equivalent to 2,000 mg/day. A low-sodium diet is considered anything less than 2,400 mg/day. This would not correct the sodium level and could further decrease it. D) Administer desmopressin acetate 0.2 mg orally.: Diabetes insipidus is an endocrine disorder that is caused by a deficiency of antidiuretic hormone (ADH). Desmopressin is an analog of ADH and the hormone replacement of choice for diabetes insipidus. It is available orally, IV, or as a nasal spray. In SIADH, there is an excess of ADH, so desmopressin would not be indicated.