Unit 1 and 2 Nursing 102
What foods can the nurse recommend for the patient with hyperkalemia? Apples and berries Green, leafy vegetables Milk and yogurt Melons
Apples and berries
Which electrolyte is a major anion in body fluid? Chloride Potassium Sodium Calcium
Chloride
A client with a magnesium concentration of 2.6 mEq/L (1.3 mmol/L) is being treated on a medical-surgical unit. Which treatment should the nurse anticipate will be used? Intravenous furosemide Fluid restriction Oral magnesium oxide Dialysis
Intravenous furosemide
Which is a common anion? magnesium potassium chloride calcium
chloride
A client is receiving IV fluid administration and consuming a rather large amount of fluids orally. In calculating the client's fluid intake for the past 24 hours, the nurse notes the amount and immediately notifies the physician of this finding. Notification of a physician regarding fluid intake should occur after exceeding how many milliliters in 24 hours? 3000 2500 1500 2000
3000
A patient is admitted with a diagnosis of renal failure. The patient complains of "stomach distress" and describes ingesting several antacid tablets over the past 2 days. Blood pressure is 110/70 mm Hg, face is flushed, and the patient is experiencing generalized weakness. Which is the most likely magnesium level associated with the symptoms the patient is having? 11 mEq/L 5 mEq/L 2 mEq/L 1 mEq/L
5 mEq/L
Water is a vital element for the human body. What is one of its functions? Serves as an emulsifier for vitamins and glucose Aids in digestion and absorption Decreases structure in cells Provides energy for metabolism
Aids in digestion and absorption
A client suffers from infectious diarrhea. Based on her loss of fluid, her protein level is below normal. What blood product will the physician order to restore intravascular volume? Whole blood Packed red cells Platelets Albumin
Albumin
The nurse is assessing a client for local complications of intravenous therapy. Which are local complications? Select all that apply. Extravasation Infection Hematoma Phlebitis Air embolism
Extravasation Infection Hematoma Phlebitis
The nurse is caring for a 65-year-old client admitted to the hospital unit 72 hours ago with pyloric stenosis. A nasogastric tube was placed upon admission has been on low intermittent suction. Lab values indicate the client's potassium is very low. What should the nurse be concerned that the client may be at risk for? Hypercalcemia Metabolic acidosis Metabolic alkalosis Respiratory acidosis
Metabolic alkalosis
A nurse is conducting a physical examination and is percussing the gastric area of a client. What percussion tone is normally heard in this area? flat dull resonant tympany
tympany
The human body is an intricate mechanism which maintains homeostasis through a multitude of chemical reactions. The measurable chemical levels disclose how well the body is (or is not) functioning. Which of these chemical substances release hydrogen into fluid? Acids Alkalines Bases Electrolytes
Acids
The nurse is preparing to administer a unit of platelets to an adult client. When administering this blood product, which of the following actions should the nurse perform? Administer the platelets as rapidly as the client can tolerate. Establish IV access as soon as the platelets arrive from the blood bank. Ensure that the client has a patent central venous catheter. Aspirate 10 to 15 mL of blood from the client's IV immediately following the transfusion.
Administer the platelets as rapidly as the client can tolerate.
The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance? Select all that apply. Increase oral intake to flush excess fluids. 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.
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.
The nurse is caring for a patient with a diagnosis of hyponatremia. What nursing intervention is appropriate to include in the plan of care for this patient? (Select all that apply.) Assessing for symptoms of nausea and malaise Encouraging the intake of low-sodium liquids Monitoring neurologic status Restricting tap water intake Encouraging the use of salt substitute instead of salt
Assessing for symptoms of nausea and malaise Monitoring neurologic status Restricting tap water intake
A nurse is preparing to complete a physical assessment on an older adult client with a history of emphysema. What is the nurse's mostappropriate action? Dim the lights to avoid eye strain. Assist the client to a sitting position. Begin with auscultation of the lungs. Lie the client supine on the exam table.
Assist the client to a sitting position.
A client suffers from a genetic bleeding deficiency. What blood product will be administered? Whole blood Albumin Platelets Cryoprecipitate
Cryoprecipitate
A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Which of the following are signs and symptoms consistent with that diagnosis? Select all that apply. Crackles on auscultation Cyanosis Hypertension Shoulder pain Dyspnea Tachycardia
Cyanosis Shoulder pain Dyspnea Tachycardia
Baroreceptors in the left atrium and in the carotid and aortic arches respond to changes in the circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect? Decrease in the release of aldosterone Increase of filtration in the Loop of Henle Decrease in the reabsorption of sodium Decrease in glomerular filtration
Decrease in glomerular filtration
The nurse is caring for a client with a serum potassium concentration of 6.0 mEq/L (6.0 mmol/L) and a fluid volume excess. The client is ordered to receive oral sodium polystyrene sulfonate and furosemide. What other order should the nurse anticipate giving? Discontinue the intravenous lactated Ringer solution. Increase the rate of the intravenous lactated Ringer solution. Change the lactated Ringer solution to 3% saline. Change the lactated Ringer solution to 2.5% dextrose.
Discontinue the intravenous lactated Ringer solution.
Upon assessment of an older adult, the nurse notes the client's skin to have a yellow color. The nurse interprets this finding as a result of which health condition? Hepatitis Appendicitis Diverticulitis Cellulitis
Hepatitis
When planning the care of a client with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur? Active transport of hydrogen ions across the capillary walls Pressure of the blood in the renal capillaries Action of the dissolved particles contained in a unit of blood Hydrostatic pressure resulting from the pumping action of the heart
Hydrostatic pressure resulting from the pumping action of the heart
A client demonstrating electrocardiography (EKG) changes and dysthymias would be expected to have which electrolyte imbalance? Hypokalemia Hypernatremia Hyperkalemia Hyponatremia
Hypokalemia
The nurse caring for a client post colon resection is assessing the client on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. What assessment finding would suggest that the client's potassium levels are too low? Diarrhea Large amounts of dilute urine Increased muscle tone Joint pain
Large amounts of dilute urine
The nurse is preparing to auscultate the lung sounds of a client with asthma. How should the nurse complete the assessment? Listen to at least one full respiration in each location. Listen as the client inhales and then move to the next site during exhalation. Instruct the client to rapidly breathe in and out the nurse listens. Auscultate lung sounds over the client's clothing or hospital gown.
Listen to at least one full respiration in each location.
The nurse is examining the client's skin to determine whether the delivery of oxygenated blood is sufficient. Which body area(s) will the nurse assess for color change? Select all that apply. Nail beds Tongue Lips Scalp Palms of hands
Nail beds Tongue Lips
A client has questioned the nurse's administration of IV normal saline, asking, "Wouldn't sterile water would be a more appropriate choice than saltwater?" Under what circumstances would the nurse administer electrolyte-free water intravenously? Never, because it rapidly enters red blood cells, causing them to rupture. When the client is severely dehydrated resulting in neurologic signs and symptoms When the client is in excess of calcium and/or magnesium ions When a client's fluid volume deficit is due to acute or chronic kidney disease
Never, because it rapidly enters red blood cells, causing them to rupture.
Which of the following would be appropriate nursing interventions for a client with hypokalemia? Select all that apply. Offer a diet with fruit juices and citrus fruits. Administer the ordered Kayexalate enema. Administer the ordered furosemide 60 mg po. Monitor intake and output every shift. Administer the ordered potassium 40 mg IV push.
Offer a diet with fruit juices and citrus fruits. Monitor intake and output every shift.
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? Ask the client every hour to drink more fluid. Offer small amounts of preferred beverage frequently. Have a loved one tell the client to drink more. Leave water on the bedside table.
Offer small amounts of preferred beverage frequently.
A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanisms associated with hypovolemia would cause what clinical manifestations? (Select all that apply.) Hypertension Oliguria Tachycardia Bradycardia Tachypnea
Oliguria Tachycardia Tachypnea
A client is diagnosed with hypocalcemia. Which of the following conditions most commonly causes this condition? Cancer Parathyroid hormone deficit Primary hyperparathyroidism Immobilization
Parathyroid hormone deficit
The nurse is caring for a client who has been receiving intravenous therapy via a central venous catheter inserted through the subclavian vein. Suddenly after the tubing to the intravenous solution is changed, the client develops shortness of breath, chest pain, and tachycardia. What should be the PRIORITY action of the nurse at this time? Place the bed in Trendelenburg position with the client on the left side. Place the bed in reverse Trendelenburg position with the client on the right side. Elevate the head of the bed to 75° and place the client in the supine position. Position the bed completely flat and place the client in the fetal position.
Place the bed in Trendelenburg position with the client on the left side.
A client with renal disease requires IV fluids. It is important for the nurse to Catch the rate up when it falls behind Place the fluids on an electronic device Check the intravenous rate every hour Assess the intravenous site for infiltration
Place the fluids on an electronic device
The nurse is preparing to administer a blood transfusion to a client and plans to spend the first 15 minutes of the transfusion with the client observing for what manifestations of an incompatibility transfusion reaction? Select all that apply. Hypertension Rapid pulse Increased temperature Back pain Muscle cramps
Rapid pulse Back pain
A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan? Impaired Skin Integrity Risk for Deficient Fluid Volume Impaired Urinary Elimination Urinary Retention
Risk for Deficient Fluid Volume
The nurse is participating in the care of a client who had a peripherally inserted central catheter (PICC) placed in the right arm. After catheter placement, the nurse should complete which action? Send the client for a chest x-ray. Administer the prescribed IV fluids. Obtain written consent for the procedure. Assess the client's blood pressure (BP) on the right arm.
Send the client for a chest x-ray.
The nurse is caring for a client with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis? Hypertension Kussmaul respirations Increased DTRs Shallow respirations
Shallow respirations
A client receiving IV fluid therapy suddenly becomes anxious and exhibits an elevated blood pressure, a bounding pulse, and shortness of breath. Which nursing action(s) would be mostappropriate to assist this client? Select all that apply. Slow the IV rate. Contact the physician. Lower the client's head. Provide oxygen to the client. Restart the IV.
Slow the IV rate. Contact the physician. Provide oxygen to the client.
A client is receiving a blood transfusion and reports a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? Slow the infusion rate and monitor the client closely. Discontinue the transfusion and begin resuscitation. Pause the transfusion and administer a 250 mL bolus of normal saline. Discontinue the transfusion and administer a beta-blocker, as prescribed.
Slow the infusion rate and monitor the client closely.
A nurse is caring for client with a serum potassium level of 7 mEq/L. Which treatments does the nurse anticipate the prescriber to order? Select all that apply. Sodium bicarbonate Glucose and insulin Calcium gluconate Magnesium sulfate and dextrose Potassium chloride
Sodium bicarbonate Glucose and insulin Calcium gluconate
During the admission assessment of a new client, the nurse is preparing to assess the client's thyroid gland. How should the nurse perform this assessment? Stand behind the client and palpate the sides of the trachea. Auscultate over the client's trachea while asking the client to hold his breath. Lightly percuss slightly off midline over the client's trachea. Observe the midline of the client's neck while asking him to bear down.
Stand behind the client and palpate the sides of the trachea.
A physician orders IV solution for a 92-year-old client to treat dehydration. The order was written to administer the fluid at a slower rate than what the nurse expected. Why would the physician designate the slower infusion rate for this client? The client may have cardiac or renal disorders. Older adults may have poor skin turgor. Veins of older adults tend to be rigid. Older adults often find infusions painful.
The client may have cardiac or renal disorders.
A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction? Antibodies to donor leukocytes remained in the blood. The donor blood was incompatible with that of the client. The client had a sensitivity reaction to a plasma protein in the blood. The blood was infused too quickly and overwhelmed the client's circulatory system.
The donor blood was incompatible with that of the client.
The nursing instructor is discussing metabolic acidosis with senior nursing students. What would the instructor tell the students about the role of the kidneys in metabolic acidosis? The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance The kidneys react rapidly to compensate for imbalances in the body The kidneys regulate the bicarbonate level in the ICF
The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance
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 increased blood volume and intracellular dehydration increased blood volume and extracellular overhydration decreased blood volume and extracellular overhydration
decreased blood volume and intracellular dehydration
A nurse is preparing to examine the breasts of a client. In what position should the nurse place the client? prone standing dorsal recumbent lithotomy
dorsal recumbent
A nurse uses percussion to assess a client's liver. What is the normal tone that should be heard in this situation? flat dull resonance tympany
dull
A nurse is preparing to complete a basic physical assessment. Which supplies will the nurse gather before preparing the client? Select all that apply. gloves ophthalmoscope Snellen chart stethoscope pen light
gloves stethoscope pen light
To assess an adult client's hearing, the nurse performs the Rinne test by activating the tuning fork and placing it first at the: front of the ear. mastoid process. top of the head. affected ear.
mastoid process.
Which client has more extracellular fluid? adult woman adolescent man female school-age child newborn
newborn
A school nurse will perform a hearing screening test for a group of elementary grade school students. What equipment will be needed for this examination? no equipment percussion hammer speculum ophthalmoscope
no equipment
The nurse palpating the skin of a client documents a firm 1.5-cm mass on the lower right leg. What type of skin lesion does this describe? macule wheal vesicle nodule
nodule nodule: enlarged lymph nodes wheal:hives vesicle: blister pupil:boil macule:freckles
The nurse is performing a physical examination on a sleeping newborn. Which body system should the nurse examine last? heart abdomen lungs throat
throat
A nurse is preparing to assess a client with abdominal pain. Which statement is most appropriate for the nurse to use to gain cooperation from the client? "Let me explain what I am going to do and how you can help." "I am going to examine your abdomen." "I need to report what is going on to your health care provider. Can I look at your abdomen?" "Open your shirt, I need to look at your abdomen."
"Let me explain what I am going to do and how you can help."
The pediatric nurse is performing a health assessment on a child. Which question(s) will the nurse ask when determining the social history portion of the assessment? Select all that apply. "What jobs do your mommy and daddy have?" "Can you tell me about your mommy and daddy?" "What grade are you in?" "What church do you go to?" "What are your favorite foods?"
"What jobs do your mommy and daddy have?" "What church do you go to?"
A client diagnosed with hypernatremia needs fluid volume replacement. What intravenous solution would be the safest for the nurse to administer? 0.45% sodium chloride 0.9% sodium chloride 5% dextrose in water 5% dextrose in normal saline solution
0.45% sodium chloride
The nurse assesses a cardiac patient's urinary output. The patient weighs 175 pounds. Based on the normal daily range of urine volume, the nurse expects a 4-hour output of: 40 mL to 80 mL. 80 mL to 160 mL. 120 mL to 240 mL. 160 mL to 320 mL.
160 mL to 320 mL.
A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison? 1,500 mL 1,800 mL 2,300 mL 2,600 mL
2,600 mL
The nurse is caring for a client who has been NPO since admission two days ago and was admitted with vomiting as a primary symptom. The client has been receiving intravenous therapy at 100 mL/hr. since admission with Lactated Ringers (LR) as the intravenous solution. What nursing diagnosis is most appropriate for this client? Fluid overload R/T excess intravenous fluids Pain R/T intravenous insertion site Anxiety R/T extended hospitalization Altered Nutrition: Less than body requirements R/T lack of adequate caloric intake
Altered Nutrition: Less than body requirements R/T lack of adequate caloric intake
The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance? An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide. A 45-year-old client who had a laparoscopic appendectomy 24 hours ago and is being advanced to a regular diet. A 79-year-old client admitted with a diagnosis of pneumonia. A 66-year-old client who had an open cholecystectomy with a T-tube placed that is draining 125 mL of bile per shift.
An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide.
The nurse is caring for a client in the postoperative period after undergoing a total hysterectomy. The nurse is determining when the client can be advanced to a full diet. Which assessment will the nurse conduct before advancing the diet? Perform abdominal percussion. Auscultate the abdomen. Listen for presence of flatus. Palpate the abdomen.
Auscultate the abdomen.
At what point do baroreceptors signal the brain to release ADH? Select all that apply. Blood volume decreases by 10%. Systolic BP falls below 90 mm Hg. Blood volume increases by 10%. The right atrium is overfilled.
Blood volume decreases by 10%. Systolic BP falls below 90 mm Hg.
A client with aplastic anemia is going to receive a blood transfusion. In addition to taking vital signs and verifying that the unit of blood cells is matched to the client, what other assessments/actions would you take? Assess pain at the transfusion site and transfuse the packed blood cells over 5 hours to prevent fluid overload. Check the client regarding chills, low back pain, dyspnea, and skin itching during the transfusion. Ask the client about headaches; maintain bed rest during the transfusion, and reduce intake of fluids. Rapidly transfuse the blood for the first 15 minutes to detect transfusion reactions and allergic responses.
Check the client regarding chills, low back pain, dyspnea, and skin itching during the transfusion.
The nurse is caring for a client in metabolic alkalosis. The client has an NG tube set to low intermittent suction for a diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication prescriptions? Cimetidine Maalox Potassium chloride elixir Furosemide
Cimetidine stomach acid reducer that is used to treat and prevent certain types of stomach ulcer.
The nurse is examining the posture of a toddler and notes lordosis. What would be the appropriate reaction of the nurse to this finding? Explain that the child will need a back brace. Refer the toddler to a physical therapist. Do nothing; this is a normal condition for toddlers. Refer the child to an orthopedic specialist.
Do nothing; this is a normal condition for toddlers.
A nurse is caring for a client who is to receive IV potassium. Which action would be appropriate? Ensure that potassium infuses in no less than 4 hours. Administer the potassium before meals. Use the veins in the back of the hand. Inject potassium directly into the client's vein.
Ensure that potassium infuses in no less than 4 hours.
The nurse in the medical ICU is caring for a client who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the client have that could cause inadequate ventilation? Endocarditis Multiple myeloma Guillain-Barré syndrome Overdose of amphetamines
Guillain-Barré syndrome
One day after a client is admitted to the medical unit, the nurse determines that the client is oliguric. The nurse notifies the acute-care nurse practitioner who prescribes a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve what goal? Help distinguish hyponatremia from hypernatremia Help evaluate pituitary gland function Help distinguish reduced renal blood flow from decreased renal function Help provide an effective treatment for hypertension-induced oliguria
Help distinguish reduced renal blood flow from decreased renal function
A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider? The nurse should use new tubing when attaching additional IV solutions As one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 10 mL of fluid remains in the original container. It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order. Generally, the nurse should change the administration sets of simple IV solutions every 24 hours.
It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order.
The nurse is caring for a client with a diagnosis of pancreatitis. The client was admitted from a homeless shelter and is a vague historian. The client appears malnourished and on day 3 of the client's admission, total parenteral nutrition (TPN) has been started. Why should the nurse start the infusion of TPN slowly? Clients receiving TPN are at risk for hypercalcemia if calories are started too rapidly. Malnourished clients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively. Malnourished clients who receive fluids too rapidly are at risk for hypernatremia. Clients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate
Malnourished clients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively.
You are caring for a 65-year-old male patient admitted to your unit 72 hours ago with pyloric stenosis. A nasogastric tube was placed upon admission and has been on low intermittent suction ever since. You notice that the patient's potassium is very low. What would you be concerned that the patient may be at risk for? Hypercalcemia Metabolic acidosis Metabolic alkalosis Respiratory acidosis
Metabolic alkalosis
A senior level nurse is teaching a new nurse about lifespan considerations. Which of the following information would the nurse include while teaching the subject? Older adults are at increased risk for fluid overload because of an increased risk of cardiac and renal disease. Older adults are at increased risk for fluid overload because of an increased risk of cardiac and liver disease. Older adults are at decreased risk for fluid overload because of an increased risk of cardiac and renal disease. Older adults are at decreased risk for fluid overload because of an increased risk of cardiac and liver disease.
Older adults are at increased risk for fluid overload because of an increased risk of cardiac and renal disease.
A 3-year-old child has been diagnosed with an acute gastrointestinal infection that has caused severe diarrhea for the past 36 hours. The pediatric nurse should anticipate the prescription of which treatment? Magnesium gluconate Oral electrolyte solution Sodium bicarbonate 50% dextrose
Oral electrolyte solution
A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a client with increased intracranial pressure. This solution will increase the number of dissolved particles in the client's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? Hydrostatic pressure Osmosis and osmolality Diffusion Active transport
Osmosis and osmolality
The nurse is gathering data on a child being admitted. Which would be considered collecting subjective data? Select all that apply. The nurse interviews the child's caregiver. The nurse asks questions about the child's history. The nurse finds out the reason for the child's visit to the health care setting. The nurse takes the child's vital signs and height and weight. The nurse observes the general appearance of the child.
The nurse interviews the child's caregiver. The nurse asks questions about the child's history. The nurse finds out the reason for the child's visit to the health care setting.
The nurse is preparing to administer a unit of blood to a client and should know that which is the FIRST action of the nurse prior to the administration? The nurse will obtain the client's vital signs. The nurse will connect the unit of blood to Y-administration set tubing. The nurse will check that the numbers of the client's wrist band and the unit of blood match and that this information is confirmed by another nurse. The nurse will explain to the client the symptoms associated with a transfusion reaction.
The nurse will check that the numbers of the client's wrist band and the unit of blood match and that this information is confirmed by another nurse.
A client receiving intravenous therapy shows signs of swelling at the infusion site and says it is uncomfortable. The infusion is also slowing. Which of the following complications would the nurse most likely prepare to assist in managing? Infection Pulmonary embolus Thrombus formation Circulatory overload
Thrombus formation
A nurse is preparing to examine a client with a suspected sinusitis. What is the most appropriate action the nurse should take before performing a physical examination? Put on gloves. Wash their hands. Assist the client to lie on the exam table. Assess the client's height and weight.
Wash their hands.
A nurse is having difficulty hearing lung sounds on a client with a large amount of chest hair. What is the appropriate action of the nurse? Cut the chest hair and press firmly with the chest piece. Wet the chest hair and auscultate with the chest piece. Auscultate using the bell of the stethoscope. Ask another nurse to evaluate the client's lung sounds
Wet the chest hair and auscultate with the chest piece.
While assessing the characteristics of the skin of the client, the nurse observes a mouth slit at the aperture of the mouth. The nurse documents this finding as a fissure. What is a fissure? an area of the skin that has been rubbed away by friction a mark left on the skin by the healing of a wound or lesion a crack in the skin, especially in or near a mucous membrane an open, crater-like area on the skin
a crack in the skin, especially in or near a mucous membrane
A nurse caring for a patient with metabolic alkalosis knows to assess for the primary, compensatory mechanism of: a. Increased serum HCO3. b. Increased PaCO2. c. Decreased serum HCO3. d. Decreased PaCO2.
b. Increased PaCO2.
During a physical exam, the nurse assesses a client's eyes for the accommodation response. When looking at a near object, what would the nurse observe for? constriction of the pupils a consensual light reflex conjugate movement of the eyes convergence of the eyes
constriction of the pupils
A nurse examining the lungs of a client percusses over the anterior thorax using the proper sequence. This technique helps to identify: masses. muscle tenderness. density and location of lungs. normal breath sounds.
density and location of lungs.
Heart block may occur when magnesium is administered to a client taking which medications? digoxin metoprolol enalapril clonidine
digoxin Antiarrhythmic and Blood pressure support
Which way(s) is/are the correct way to maintain intravenous (IV) access ? (Select all that apply.) direct IV push intermittent infusion extravasation continuous infusion infiltration
direct IV push intermittent infusion continuous infusion
The nurse is caring for a client who was found without food or water for 2 days in the desert. What explanation for the need for fluid does the client have? Select all that apply. facilitates cellular metabolism helps maintain normal body temperature acts as a solvent for electrolytes provides free hydrogen ions for cells supplies glucose for energy
facilitates cellular metabolism helps maintain normal body temperature acts as a solvent for electrolytes
A nurse is assessing the skin of a middle-aged client with hypoxia. Which color could the skin of this client be? Select all that apply. gray yellow blue purple red
gray blue purple
The physician's order of IV therapy for a client includes the use of a medication lock. Why would this device be ordered? Select all that apply. The client needs intermittent IV medication. The client will eventually transition from continuous infusion. The client needs total parenteral nutrition (TPN) administration. The client may require emergency IV fluids.
he client needs intermittent IV medication. The client will eventually transition from continuous infusion. The client may require emergency IV fluids.
A client presents with muscle weakness, tremors, slow muscle movements, and vertigo. The following are the client's laboratory values:Sodium 134 mEq/L (134 mmol/L)Potassium 3.2 mEq/L (3.2 mmol/L)Chloride 111 mEq/L (111 mmol/L)Magnesium 1.1 mg/dL (0.45 mmol/L)Calcium 8.4 mg/dL (2.1 mmol/L)What fluid and electrolyte imbalance would the nurse relate to the client's findings? hyponatremia hypokalemia hypocalcemia hypomagnesemia
hypomagnesemia
A nurse is preparing to administer prescribed plasma protein fraction to a client. The nurse understands that this drug is used to treat which condition? hypovolemic shock proteinuria protein C deficiency anemia
hypovolemic shock
A nurse assessing the IV site of a client observes swelling and pallor around the site, and notes a significant decrease in the flow rate. The client reports coldness around the infusion site. What IV complication does this describe? infiltration sepsis thrombus speed shock
infiltration
Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? hypertonic colloid isotonic hypotonic
isotonic
A nurse is caring for a client prescribed warfarin for chronic atrial fibrillation. Which information should be included in this client's medication teaching plan? Keep intake of vitamin K foods constant. If you miss a dose, take a double dose. Call the provider for additional information. Schedule annual laboratory appointments.
keep intake of vitamin K foods constant.
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: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l) pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) pH: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l) pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l)
pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)
A client has a history of congestive heart failure (CHF) and arthritis that causes significant discomfort. The physician has prescribed daily doses of NSAIDS to fight inflammation and pain. The client has developed a GI bleed as a result of the medication, and blood values indicate the need for a transfusion. Considering the client's history, which colloid solution would the nurse expect to be administered? packed cells whole blood blood products plasma expanders
packed cells
Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of: phlebitis. an infiltration. a systemic blood infection. rapid fluid administration.
phlebitis.
A nursing student has been instructed that total parenteral nutrition (TPN) should never be stopped suddenly but instead the client should gradually be weaned from it. The rationale is that sudden withdrawal of TPN can cause: rebound hyperglycemia. rebound hypoglycemia. hypotension. hypertension.
rebound hypoglycemia.
A mother brings her 3-year-old daughter to the emergency department because the child has been vomiting and having diarrhea for the past 36 hours. When assessing this child's temperature, which method would be least appropriate? oral tympanic rectal axillary
rectal
A parent has brought the child into the clinic for a routine health assessment. The parent asks when routine screening for back symmetry will begin. Which response by the nurse is most accurate? Infancy Preschool age School age Adolescence Young adulthood
school age
A nurse is caring for a client who received IV calcium. Assessment of the client reveals elevated plasma calcium levels. The health care provider suspects hypercalcemic syndrome. Which finding would support this suspicion? Select all that apply. severe vomiting phlebitis lethargy weakness depressed reflexes
severe vomiting lethargy weakness
A nurse is conducting an auditory assessment of an older adult with conductive hearing loss. The nurse performs the Weber test. Which finding would the nurse expect to assess in this client? The client hears sound that is lateralized to the unaffected ear. The client hears vibrations in the affected ear. The client hears vibrations equally in both ears. The client hears a hyperresonant sound in both ears.
the client hears vibrations in the affected ear.
The nurse is preparing to give a client morphine intravenously (IV) through a heparin lock. Prior to giving the drug, the nurse flushes the heparin lock with normal saline. This is done for which reason? to make the morphine more potent to prevent incompatibility of heparin with other drugs to prevent the morphine from burning when infusing to counteract the side effects of morphine
to prevent incompatibility of heparin with other drugs
A client is receiving total parenteral nutrition. The physician order includes lipid emulsion administration (contained in glass bottles) on Monday, Wednesday, and Friday. What type of IV tubing would the nurse select for the lipid administration? vented tubing unvented tubing macro drip tubing None of the options is correct.
vented tubing
As Americans live longer, relatively rare conditions are becoming more commonplace - one of which is hypervolemia. What are early signs of hypervolemia? Select all that apply. weight gain increased breathing effort decrease in BP moist breath sounds
weight gain increased breathing effort
