Practice Questions

The nurse is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate? A. "Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)." B. "We do not record fluids absorbed into undergarments." C. If the undergarment is soiled, document this fact but do not estimate its contents." D. "You only record urine output in an adult undergarment; you do not record diarrhea output."

A. "Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."

The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response? A. "You are free to move onto the stretcher without assistance, but I will supervise for your safety." B. "I can only allow you to transfer without assistance with a health care provider's order, so I will help you now." C. "You may not transfer without my help, because you need a friction-reducing device to prevent harm to your skin." D. "That is fine if you want to transfer without my help; ring your call bell after you have transferred and are ready to go."

A. "You are free to move onto the stretcher without assistance, but I will supervise for your safety."

The nurse is monitoring fluid intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the record? Select all that apply. A. 100 ml from melted ice chips B. serving of jello C. bowl of chili D. infusion of intravenous solution E. barbecue sandwich F. cup of ice cream

A. 100 ml from melted ice chips B. serving of jello D. infusion of intravenous solution F. cup of ice cream

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate? A. 83 mL/hr B. 103 gtts/hr C. 100 mL/hr D. 13 mL/hr

A. 83 mL/hr

The nurse observes a client independently move all the joints through their normal motions. Which range of motion has the client demonstrated? A. Active range of motion B. Passive range of motion C. Active assistive range of motion D. Limited range of motion

A. Active range of motion

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement? A. Adduction B. Abduction C. Circumduction D. Extension

A. Adduction

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? A. Avoid salty or excessively sweet fluids. B. Use regular gum and hard candy. C. Eat crackers and bread. D. Use an alcohol-based mouthwash to moisten your mouth.

A. Avoid salty or excessively sweet fluids.

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation? A. Discontinue the IV and relocate it to another site. B. Call the primary care provider to see whether anti-inflammatory drugs should be administered. C. Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV D. Stop the infusion, cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site.

A. Discontinue the IV and relocate it to another site.

A nurse is inspecting the IV site of a client and notices that the site is swollen, red, warm to the touch, and painful. Which action by the nurse is appropriate? A. Discontinue the IV and relocate it to another spot. B. Call the health care provider and ask if anti-inflammatory drugs should be administered. C. Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours. D. Cleanse the site with alcohol and apply transparent polyurethane dressing over the entry site.

A. Discontinue the IV and relocate it to another spot.

A client is experiencing withdrawal from alcohol and admitted to the behavioral health unit. The client begins to have muscle weakness, tremors, hyperactive deep tendon reflexes, and a change in mental status. What should the nurse prepare to replace in this client? A. Magnesium B. Chloride C. Potassium D. Phosphorus

A. Magnesium

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? A. Stop the transfusion and infuse normal saline using a new administration set. B. Check the client's vital signs. C. Stop the transfusion and infuse normal saline using the blood tubing. D. Notify the health care provider of the client's response.

A. Stop the transfusion and infuse normal saline using a new administration set.

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? A. cardiac irregularities B. muscle weakness C. increased intracranial pressure (ICP) C. metabolic acidosis

A. cardiac irregularities

The nurse is preparing to move a client from bed into a wheelchair to eat lunch. What client data would the nurse check to see if the assistance of another nurse is needed? A. client restrictions B. client age C. client food preferences D. client restraints

A. client restrictions

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? A. decreased blood volume and intracellular dehydration B. increased blood volume and intracellular dehydration C. increased blood volume and extracellular overhydration D. decreased blood volume and extracellular overhydration

A. decreased blood volume and intracellular dehydration

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair 3 times per day. Which action will be most effective to transfer the client safely into the chair? A. having the client sit on the side of the bed for several minutes before moving to the chair. B. infusing an intravenous fluid bolus 15 minutes before transferring the client into the chair C. positioning a friction-reducing sheet under the client D. obtaining a quad cane for the client to use as a transfer aid

A. having the client sit on the side of the bed for several minutes before moving to the chair.

A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address? A. increased hydrostatic pressure B. decreased colloid oncotic pressure C. blockage of the lymph nodes D. increased capillary permeability

A. increased hydrostatic pressure

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? A. platelets B. granulocytes C. albumin D. cryoprecipitate

A. platelets

A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply. A. respiratory muscle weakness B. confusion C. ventricular dysrhythmia D. abdominal distention E. constipation

A. respiratory muscle weakness B. confusion C. ventricular dysrhythmia

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? A.Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. B.Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. C.Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. D.Discontinue the infusion immediately, apply warm compresses to the site, and restart the IV at another site.

A.Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately.

A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? A. "I was breathing so fast because I was so anxious and in so much pain." B. "I've been taking antacids almost every 2 hours over the past several days." C. "I've had a fever for the past 3 days that just doesn't seem to go away." D. "I've had a GI virus for the past 3 days with severe diarrhea."

B. "I've been taking antacids almost every 2 hours over the past several days."

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response? A. "Unfortunately, your own blood cannot be reinfused during surgery." B. "Let me refer you to the blood bank so they can provide you with information." C. "This surgery has a very low chance of hemorrhage, so you will not need blood." D. "We now have artificial blood products, so giving your own blood is not necessary."

B. "Let me refer you to the blood bank so they can provide you with information."

An older adult client is transferring from a supine position to a sitting position in a chair. The client reports dizziness when transferring. Which teaching by the nurse is most appropriate? A. "Place your head lower than your heart if you begin to feel dizzy." B. "Move slowly and sit on the edge of the bed before transferring to the chair." C. "Place feet firmly on the floor when rising to maintain balance." D. "Drink a glass of water before attempting to stand to promote circulation."

B. "Move slowly and sit on the edge of the bed before transferring to the chair."

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? A. As fast as the client can tolerate B. 1 unit over 2 to 3 hours, no longer than 4 hours C. 75 mL/hr for the first 15 minutes, then 200 mL/hr D. 200 mL/hr

B. 1 unit over 2 to 3 hours, no longer than 4 hours

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? A. 3,750 B. 3,000 C. 1,000 D. 500

B. 3,000

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? A. 30 drops/mL B. 60 drops/mL C. 90 drops/mL D. 120 drops/mL

B. 60 drops/mL

The nurse is applying graduated compression stockings to the legs of a postsurgical client. The client suddenly complains of sharp pain to his left leg as the nurse is unrolling the stockings. What is the nurse's most appropriate action? A. Roll back the stocking partially and apply padding over the tender region. B. Assess the client's leg for signs and symptoms of deep vein thrombosis and inform the primary care provider. C. Stop applying the stocking and reattempt in 30 minutes. D. Apply the stocking, administer analgesia to the client, and then inform the primary care provider.

B. Assess the client's leg for signs and symptoms of deep vein thrombosis and inform the primary care provider.

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. A. Prescribing the kind of IV solution. B. Deciding the location of the IV catheter. C. Deciding the size of the IV catheter. D. Administering the IV solution. E. Determining the amount of IV solution.

B. Deciding the location of the IV catheter. C. Deciding the size of the IV catheter. D. Administering the IV solution.

A nurse is promoting exercise and activities for an older adult client. Which teaching point would be appropriate for this client? A. Encourage the client to quickly increase the repetitions for arm and leg exercises. B. Encourage the client to warm up before beginning exercises and to cool down after exercising. C. Instruct the client to continue exercise even if feeling weak, to build up stamina. D. Teach the client to force joints to meet their natural limit and beyond prior to modifying exercises.

B. Encourage the client to warm up before beginning exercises and to cool down after exercising.

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? A. Select a primary tubing of about 37 inches (94 cm) long. B. Ensure that the prescribed solution the expected color and consistency. C. Use half-instilled IV solutions before infusing a new one. D. Avoid replacing IV solutions every 24 hours.

B. Ensure that the prescribed solution the expected color and consistency.

Tell whether the following statement is true or false: Jogging is an example of isometric exercise. A. True B. False

B. False

A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? A.Explaining the mechanisms involved in transporting fluids to and from intracellular compartments. B. Keeping fluids readily available for the patient. C. Emphasizing the long-term outcome of increasing fluids when the patient returns home. D. Planning to offer most daily fluids in the evening.

B. Keeping fluids readily available for the patient.

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? A. Ask the client every hour to drink more fluid. B. Offer small amounts of preferred beverage frequently. C. Have a loved one tell the client to drink more. D. Leave water on the bedside table.

B. Offer small amounts of preferred beverage frequently.

A client with chronic anemia is admitted for the administration of blood. What would the nurse expect the physician to order? A. Whole blood B. Packed cells C. White blood cells D. Platelets E. D5W 1000 mL

B. Packed cells

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? A. Slow the rate of IV fluids. B. Remove the IV. C. Apply a warm compress. D. Elevate the arm.

B. Remove the IV.

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? A. muscle twitching B. distended neck veins C. fingerprinting over sternum D. nausea and vomiting

B. distended neck veins

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)Based on these levels, the nurse would identify which imbalance? A. hyponatremia B. hypokalemia C. hypercalcemia D. hypermagnesemia

B. hypokalemia

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? A. pH: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l) B. pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) C. pH: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l) D. pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l)

B. pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? A. asking the client to pump their fist several times B. placing the tourniquet on the upper arm for 2 minutes C. asking if the client is right or left handed D. palpating the veins on the nondominant hand

B. placing the tourniquet on the upper arm for 2 minutes

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? A. "Fluid inside cells." B. "Fluid outside cells." C. "Fluid in the tissue space between and around cells." D. "Watery plasma, or serum, portion of blood."

C. "Fluid in the tissue space between and around cells."

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? A. "I need to drink no more than 1,000 mL/day" B. "I should drink 1,500 mL/day of fluid." C. "I should drink 2,500 mL/day of fluid." D. "I should drink more than 3,500 mL/day of fluid."

C. "I should drink 2,500 mL/day of fluid."

A home health nurse is visiting a client who was taught to crutch-walk in the hospital following a knee surgery. The client says, "My armpits are so sore." Which information does the nurse provide? A. "Your armpits will grow accustomed to the weight in a few days." B. "I hear that a lot from clients." C. "Try to bear your weight on your hands, not your armpits." D. "Fortunately you will only need to be on crutches for a week or two."

C. "Try to bear your weight on your hands, not your armpits."

What is the lab test commonly used in the assessment and treatment of acid-base balance? A. Complete blood count B. Basic metabolic panel C. Arterial blood gas D. Urinalysis

C. Arterial blood gas

A nurse stretches out a patient's leg and moves it in a circle. This is an example of what type of body movement? A. Abduction B. Flexion C. Circumduction D. Dorsiflexion

C. Circumduction

A nurse is caring for clients with alterations in mobility. Which nursing interventions are recommended for these clients? Select all that apply. A. For increased cardiac workload, instruct the client to lie in the prone position. B. For ineffective breathing patterns, encourage shallow breathing and coughing. C. For orthostatic hypotension, have the client sleep sitting up or in an elevated position. D. For impaired physical mobility, perform ROM exercises every 2 hours. E. For constipation, increase fluid intake and roughage. F. For impaired skin integrity, reposition the client in correct alignment at least every 1 to 2 hours.

C. For orthostatic hypotension, have the client sleep sitting up or in an elevated position. E. For constipation, increase fluid intake and roughage. F. For impaired skin integrity, reposition the client in correct alignment at least every 1 to 2 hours.

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)? A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis

C. Metabolic alkalosis

Which is a common anion? A. magnesium B. potassium C. chloride D. calcium

C. chloride

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? A. hyperphosphatemia B. hyperchloremia C. hypokalemia D. hypomagnesemia

C. hypokalemia

The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment? A. interstitial B. extracellular C. intracellular D. intravascular

C. intracellular

When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness. For what adverse condition is the nurse assessing in the client? A. deep vein thrombosis B. circulatory alterations C. orthostatic hypotension D. hypertension

C. orthostatic hypotension

A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse? A. standing at the top of the bed and having a colleague stand at the bottom of the bed B. placing the bed in its lowest position to reduce the client's risk for falls C. positioning a friction-reducing sheet under the client to facilitate movement D. using back muscles to gently and gradually pull the client to the side

C. positioning a friction-reducing sheet under the client to facilitate movement

The primary extracellular electrolytes are: A. potassium, phosphate, and sulfate. B. magnesium, sulfate, and carbon. C. sodium, chloride, and bicarbonate. D. phosphorous, calcium, and phosphate.

C. sodium, chloride, and bicarbonate.

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: A. cellular hydration. B. volume expander. C. total parenteral nutrition. D. blood transfusion therapy.

C. total parenteral nutrition.

The 55-year-old client who is newly diagnosed with osteoarthritis of the hips asks the nurse why it hurts when walking. What is the nurse's best response? A. "If you recently fell, you might have a fractured hip." B. "Osteoarthritis is painful and very common as you age." C. "Because you lose muscle tone with age, it hurts to walk." D. "You have lost the padding in your joints and the friction causes pain."

D. "You have lost the padding in your joints and the friction causes pain."

A patient takes hydralazine 25 mg QID. How many mg of hydralazine does the patient take in a day? A. 25 mg B. 50 mg C. 75 mg D. 100 mg

D. 100 mg

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? A. Fully open the roller clamp on the infusion set and infuse the remaining PRBCs as rapidly as possible. B. Continue to infuse the PRBCs until they are completely infused. C. Insert a larger gauge IV catheter and transfer the infusion to the new insertion site. D. Discontinue the infusion and record the volume left in the blood bag.

D. Discontinue the infusion and record the volume left in the blood bag.

The nurse is assisting a client from a bed to a wheelchair. Which nursing action is appropriate? A. Discourage the client from helping with the transfer. B. Administer pain medication following the transfer. C. Grab and hold the client by the arms. D. Lock the wheelchair prior to moving the client.

D. Lock the wheelchair prior to moving the client.

The nurse is assisting a client to ambulate following knee surgery. What is a key concern when assisting clients with activity? A. Nurse-client relationship B. Privacy C. Confidentiality D. Safety

D. Safety

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? A. a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today B. a 60-year-old who is 3 days post-myocardial infarction and has been stable. C. a 47-year-old who had a colon resection yesterday and is reporting pain D. a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

D. a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

Edema happens when there is which fluid volume imbalance? A. extracellular fluid volume deficit B. water deficit C. water excess D. extracellular fluid volume excess

D. extracellular fluid volume excess

A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from: A. decubitus ulcers. B. pooling of blood. C. blood pressure changes. D. foot drop.

D. foot drop.

When moving a client up in bed with the assistance of another caregiver, the nurse should: A. ask another nurse about the plan of care. B. elevate the head of the bed. C. maintain a pillow under the client's head. D. have the client fold the arms across the chest.

D. have the client fold the arms across the chest.

T/F: Diffusion is the process in which solutes move from an area of higher concentration to an area of lower concentration and requires energy.

False

T/F: The Humulin R insulin administered subcutaneously is an antagonist drug.

False

T/F: An isotonic solution, such as 0.9% NaCl (Normal Saline), is the only intravenous solution that may be administered with blood products.

True

T/F: As part of a patient's health history the nurse obtains information about the amount and type of any herbal substances they consumed for their personal use in their private environments (home, school, work, etc.).

True

The nurse is caring for a 74-year-old woman. What would be a normal age-related finding? a.Kyphosis b.Back pain c.Loss of height d.Spinal crepitation

c.Loss of height