Med Surg II Unit 1 Exam
A 90-year-old patient with hypermagnesemia is seen in the emergency department (ED). The ED nurse prepares the patient for admission to which inpatient unit? 1 Medical-surgical 2 Dialysis/home care 3 Geriatric/rehabilitation 4 Telemetry/cardiac stepdown
4 Telemetry/cardiac stepdown
When planning care for a patient with hypercalcemia, which intervention does the nurse consider? 1 Monitor cardiac rhythm for changes. 2 Limit activities to protect against injury. 3 Assess oxygen saturation levels every 4 hours. 4 Avoid invasive procedures due to increased bleeding tendency.
1 Monitor cardiac rhythm for changes.
The nurse is teaching a patient with congestive heart failure about monitoring fluid volume in the home setting. What are the best indicators of fluid losses or gains? 1 Monitoring daily weights 2 Observing ankles for swelling 3 Monitoring daily intake and output 4 Observing for pulse elevations with activity
1 Monitoring daily weights
The health care provider writes orders for a patient who is admitted with a serum potassium (K) level of 6.9 mEq/L. What does the nurse implement first? 1 Place the patient on a cardiac monitor. 2 Administer sodium polystyrene sulfonate orally. 3 Ensure that a potassium-restricted diet is ordered. 4 Teach the patient about foods that are high in potassium.
1 Place the patient on a cardiac monitor.
Which nursing action is recommended when providing care to a patient with hypokalemia? 1 Question the continued administration of bumetanide. 2 Administer prescribed oral potassium chloride before a meal or snack. 3 Establish a peripheral IV, preferably in the hand, for administering IV potassium chloride. 4 Obtain the prescribed vial of IV potassium chloride from the pharmacy and dilute before administration.
1 Question the continued administration of bumetanide.
Which condition would stimulate the renin-angiotensin II to maintain fluid balance within the body? 1 Shock 2 Hypoglycemia 3 Hypercalcemia 4 Water intoxication
1 Shock
Which electrolyte deficiency results in decreased depolarization in the excitable cells and increased cellular swelling? 1 Sodium 2 Calcium 3 Potassium 4 Magnesium
1 Sodium
Which electrolyte excess results in irritability and severe cellular dehydration? 1 Sodium 2 Calcium 3 Phosphorus 4 Magnesium
1 Sodium
What parameter does the nurse assess for in a postoperative patient to determine perfusion adequacy? 1 Urine output 2 Blood volume 3 Blood pressure 4 Glomerular filtration rate
1 Urine output
A patient receiving insulin and glucose infusion therapy for hyperkalemia now has a serum potassium level of 3.6 mEq/L. What is the nurse's first action? 1 Stop the infusion immediately. 2 Continue the infusion at the prescribed rate. 3 Assess the patient's heart rate, rhythm, and respiratory status. 4 Slow the infusion and increase the frequency of vital sign assessment.
3 Assess the patient's heart rate, rhythm, and respiratory status.
Which drug therapy might be used to manage symptoms of hypocalcemia? 1 Vitamin E 2 Zinc sulfate 3 Calcium chloride 4 Potassium chloride
3 Calcium chloride
As adults age, which common physiologic change is likely to alter their hydration status? 1 Poor skin turgor 2 Adrenal gland growth 3 Decreased muscle mass 4 Increased thirst mechanism
3 Decreased muscle mass
The nurse is caring for a patient who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical? 1 24-hour urine output 2 Monitoring of serum calcium levels 3 Hourly deep tendon reflexes (DTRs) 4 Asking the patient about feeling depressed
3 Hourly deep tendon reflexes (DTRs)
The nurse is assessing an older adult patient during a scheduled health maintenance visit. Which assessment finding, related to fluid balance, does the nurse anticipate? 1 Decreased turgor 2 Increased elasticity 3 Increased oil production 4 Decreased risk for injury
1 Decreased turgor
The nurse is providing care to a patient who is experiencing severe nausea, vomiting, and diarrhea. Which is the patient at risk of developing? Select all that apply. 1 Dehydration 2 Hypertension 3 Hypokalemia 4 Hypercalcemia 5 Hypernatremia
1 Dehydration 3 Hypokalemia 5 Hypernatremia
What is the major cause of death in patients diagnosed with hypokalemia? 1 Stroke 2 Renal failure 3 Cardiac arrest 4 Respiratory insufficiency
4 Respiratory insufficiency
When treating a patient for hyponatremia, which type of drug must be altered to decrease sodium loss? 1 Diuretics 2 Biphosphates 3 Corticosteroids 4 Beta-adrenergic agonists
1 Diuretics
Which medication classification does the nurse anticipate being prescribed to help a patient maintain an appropriate fluid balance? 1 Diuretics 2 Anticoagulants 3 Mood stabilizers 4 Opioid analgesics
1 Diuretics
Which situation can cause a patient to experience "insensible water loss?" Select all that apply. 1 Fever 2 Nausea 3 Diarrhea 4 Dry, hot weather 5 Mechanical ventilation 6 Increased respiratory rate
1 Fever 3 Diarrhea 4 Dry, hot weather 5 Mechanical ventilation 6 Increased respiratory rate
The nurse is assessing a patient admitted with intractable vomiting. Which assessment findings indicate the patient is also dehydrated? Select all that apply. 1 Fever 2 Hypertension 3 Poor skin turgor 4 Pulmonary crackles 5 Low blood pressure 6 Concentrated urine
1 Fever 3 Poor skin turgor 5 Low blood pressure 6 Concentrated urine
Laboratory results report a patient's serum potassium at 5.6 mEq/L. What does the nurse immediately assess in the patient? 1 Heart rate 2 Bowel sounds 3 Feet for paresthesias 4 Level of consciousness
1 Heart rate
The primary health care provider prescribes intravenous administration of 100 mL of 20% glucose along with 20 units of insulin in a patient who is receiving furosemide therapy. What is the probable diagnosis of the patient? 1 Hyperkalemia 2 Hyperglycemia 3 Hypernatremia 4 Hypercalcemia
1 Hyperkalemia
A patient is admitted to the hospital with a heart rate of 166 beats/min, increased thirst, restlessness, and agitation. Which electrolyte imbalance does the nurse suspect? 1 Hypernatremia 2 Hypercalcemia 3 Hypomagnesemia 4 Hyperphosphatemia
1 Hypernatremia
A patient reports painful muscle spasms in the lower legs at rest, a tingling sensation in the hands and lips, and abdominal cramping and diarrhea. The nurse reviews the patient's laboratory results for the presence of which disorder? 1 Hypocalcemia 2 Hypernatremia 3 Hypermagnesemia 4 Hypophosphatemia
1 Hypocalcemia
The nurse is providing care to a patient who is receiving diuretic therapy. Which electrolyte imbalance will the nurse monitor this patient for while providing care? 1 Hypokalemia 2 Hypercalcemia 3 Hypernatremia 4 Hypophosphatemia
1 Hypokalemia
A patient has a low serum potassium level and is ordered a dose of parenteral potassium chloride (KCl). How does a nurse safely administer KCl to the patient? 1 Infuses 10 mEq over a 1-hour period 2 Administers 5 mEq intramuscularly (IM) 3 Pushes 5 mEq through a central access line 4 Dilutes 200 mEq in 1 liter of normal saline and infuses at 100 mL/hr
1 Infuses 10 mEq over a 1-hour period
The student nurse is explaining body responses to alterations of fluid balance. Which statement made by the student requires correction? 1 "Natriuretic peptides (NPs) are secreted by the kidneys to restore tissue perfusion." 2 "The hypothalamus contains osmoreceptors that are sensitive to changes in blood osmolarity." 3 "Antidiuretic hormone (ADH) is released from the posterior pituitary gland in response to changes in blood osmolarity." 4 "Aldosterone is secreted by the adrenal cortex whenever sodium levels in the extracellular fluid are low."
1 "Natriuretic peptides (NPs) are secreted by the kidneys to restore tissue perfusion."
A patient has a serum magnesium level of 1.2 mEq/L. Which instruction by the nurse is appropriate? 1 "Notify me if you have diarrhea." 2 "I will be giving you an intramuscular injection of magnesium sulfate." 3 "Your urine may become darker and more concentrated in appearance." 4 "I will be administering a phosphorus supplement in addition to the magnesium supplement."
1 "Notify me if you have diarrhea."
A patient with severe hypokalemia is prescribed parenteral administration of potassium. How does the nurse administer potassium to the patient? 1 1 mEq of potassium to 10 mL intravenous solution 2 10 mEq of potassium to 10 mL intravenous solution 3 1 mEq of potassium to 10 mL solution intramuscularly 4 10 mEq of potassium to 10 mL solution intramuscularly
1 1 mEq of potassium to 10 mL intravenous solution
When administering 20 mEq potassium chloride intravenously (IV), which is the priority intervention? 1 Administer at a rate of 10 mEq/hr. 2 Monitor respiratory rate and depth. 3 Monitor for pain or burning at the IV infusion site. 4 Place the patient on a heart monitor during administration.
1 Administer at a rate of 10 mEq/hr.
An older adult patient with a history of renal failure is brought in to the emergency department with sudden onset of acute confusion, worsening muscle weakness in the extremities, abdominal cramps, and a weak, rapid, and thready pulse. What are the immediate nursing interventions to stabilize the patient? Select all that apply. 1 Administering diuretics 2 Administering 0.9% saline 3 Administering anti-psychotics 4 Administering calcium channel blockers 5 Administering 5% dextrose in 0.45% sodium chloride
1 Administering diuretics 2 Administering 0.9% saline 5 Administering 5% dextrose in 0.45% sodium chloride
Which will the nurse take into consideration when assessing a patient's fluid balance? Select all that apply. 1 Age 2 Height 3 Gender 4 Body fat 5 Cholesterol
1 Age 3 Gender 4 Body fat
When assessing patients for potential fluid imbalances, what factors does the nurse know affect the amount and distribution of body fluids? Select all that apply. 1 Age 2 Poverty 3 Activity 4 Gender 5 Body fat 6 Cognition
1 Age 4 Gender 5 Body fat
The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The patient with which electrolyte laboratory value is assigned to the LPN/LVN? 1 Calcium level of 9.5 mg/dL 2 Sodium level of 120 mEq/L 3 Potassium level of 6.0 mEq/L 4 Magnesium level of 4.1 mEq/L
1 Calcium level of 9.5 mg/dL
Hyponatremia most affects the cells of which body systems? Select all that apply. 1 Cerebral 2 Endocrine 3 Respiratory 4 Cardiovascular 5 Neuromuscular
1 Cerebral 4 Cardiovascular 5 Neuromuscular
The nurse is providing education to a patient diagnosed with hypertension. Which statement by the nurse is most appropriate to help the patient maintain a normal fluid balance? 1 "Increase your intake of water each day to increase urine output." 2 "Limit your intake of sodium to decrease the water you are retaining." 3 "Foods rich in potassium, such as bananas, will increase urine output." 4 "Foods rich in calcium, such as milk, will help to decrease urine output."
2 "Limit your intake of sodium to decrease the water you are retaining."
A patient is being monitored for daily weights. The night nurse asks the nursing assistant for the morning weight, and the assistant replies, "She was sleeping so well, I didn't want to wake her to get her weight." How does the nurse respond? 1"Never mind—I will do it myself." 2 "Weigh her now. We need her weight daily, at the same time." 3 "Fast thinking! She really needs to rest after the night she had." 4 "Get the information now, or I'll report you for not doing your job."
2 "Weigh her now. We need her weight daily, at the same time."
Which statement by the nurse is most appropriate when teaching a patient about maintaining fluid balance? 1 "If you increase your intake of salt, you are at a greater risk for dehydration." 2 "Your intake and output has the most influence on your body's fluid balance." 3 "If you decrease your intake of potassium, you are at a greater risk for dehydration." 4 "Your prescribed medications have the largest impact on fluid balance within the body."
2 "Your intake and output has the most influence on your body's fluid balance."
How much fluid should a healthy adult consume each day to maintain adequate urine output? 1 2 L/day 2 2.3 L/day 3 2.6 L/day 4 2.9 L/day
2 2.3 L/day
Which is the expected insensible water loss for a healthy adult each day? 1 250 to 500 mL 2 500 to 1000 mL 3 1000 to 1250 mL 4 1250 to 1750 m
2 500 to 1000 mL
A hypertensive patient was brought to the emergency department with a heart rate of 115 beats per minute and an abnormal electrocardiogram showing a shortened QT interval. The laboratory findings of the patient show a serum calcium level of 11 mg/dL. What nursing interventions would help stabilize the patient? Select all that apply. 1 Administering thiazide diuretics 2 Administering high ceiling or loop diuretics 3 Administering 0.9% normal saline intravenously 4 Administering nonsteroidal, anti-inflammatory agents 5 Administering lactated Ringer's solution intravenously
2 Administering high ceiling or loop diuretics 3 Administering 0.9% normal saline intravenously
A patient's morning laboratory results show a serum ionized calcium of 2.85 mmol/L. For what sign must the nurse assess? 1 Tachypnea 2 Blood clotting 3 Muscle spasms 4 Increased peristalsis
2 Blood clotting
An older adult patient with a history of coronary artery disease complains of leg swelling. After assessing the patient's legs, the nurse documents the presence of excess tissue fluid as which condition? 1 Ascites 2 Edema 3 Turgor 4 Filtration
2 Edema
Which will the nurse include when documenting a patient's fluid intake for the shift? Select all that apply. 1 Emesis 2 Enemas 3 Oral fluids 4 Solid foods 5 Irrigation fluids
2 Enemas 3 Oral fluids 5 Irrigation Fluids
A patient who recently experienced an anterior neck injury reports frequent and painful muscle spasms in the calf during sleep. Which condition does the nurse suspect in the patient? 1 Hypokalemia 2 Hypocalcemia 3 Hyponatremia 4 Hypophosphatemia
2 Hypocalcemia
When assessing the laboratory results of a patient who has hypomagnesemia, for which additional electrolyte imbalance should the nurse monitor? 1 Hyperkalemia 2 Hypocalcemia 3 Hypernatremia 4 Hypophosphatemia
2 Hypocalcemia
A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Her laboratory results include a potassium level of 3.0 mEq/L. What does the nurse include in the patient's medication teaching? Select all that apply. 1 Diuretics increase fluid retention. 2 Laxatives can lead to fluid imbalance. 3 It is important to weigh daily at the same time. 4 Diuretics can lead to fluid and electrolyte imbalances. 5 Daily weights are a poor indicator of fluid loss or gain.
2 Laxatives can lead to fluid imbalance. 3 It is important to weigh daily at the same time. 4 Diuretics can lead to fluid and electrolyte imbalances.
The nurse is assessing a patient with hyponatremia. Which finding requires immediate action? 1 Heightened acuity 2 Muscular weakness 3 Urine output of 35 mL/hr 4 Diminished bowel sounds
2 Muscular weakness
A patient is admitted to the nursing unit with a diagnosis of hypokalemia. Which assessment does the nurse complete first? 1 Auscultating bowel sounds 2 Obtaining a pulse oximetry reading 3 Checking deep tendon reflexes (DTRs) 4 Determining the level of consciousness (LOC)
2 Obtaining a pulse oximetry reading
An older adult patient is admitted with dehydration. Which nursing assessment data identify that the patient is at risk for falling? 1 Dry oral mucous membranes 2 Orthostatic blood pressure changes 3 Serum potassium level of 4.0 mEq/L 4 Pulse rate of 72 beats/min and bounding
2 Orthostatic blood pressure changes
A patient is admitted with hypokalemia and skeletal muscle weakness. Which assessment does the nurse perform first? 1 Pulse 2 Respirations 3 Temperature 4 Blood pressure
2 Respirations
What history and assessment findings may be associated with hypocalcemia in a 22-year-old man? Select all that apply. 1 Absent bowel sounds 2 Tingling around the mouth 3 Awakening at night with muscle spasms in the calf 4 Decreased deep tendon reflexes without paresthesia 5 Recent blunt trauma to the throat during a football game
2 Tingling around the mouth 3 Awakening at night with muscle spasms in the calf 5 Recent blunt trauma to the throat during a football game
The nurse is administering sodium chloride 0.9% (normal saline) intravenously to a patient who is dehydrated. Which assessments does the nurse perform to evaluate the effectiveness of rehydration therapy? Select all that apply. 1 Temperature 2 Urinary output 3 Bowel sounds 4 Pulse rate and quality 5 Level of consciousness
2 Urinary output 4 Pulse rate and quality
The nurse is assessing a patient prescribed an angiotensin-converting enzyme (ACE) inhibitor to treat blood pressure. The patient states, "This medication makes me urinate all the time. I didn't think it was a water pill." Which is the appropriate response by the nurse? 1 "You are probably not taking your medication as prescribed." 2 "This medication is a diuretic. I will print literature for you to review." 3 "This medication causes greater excretion of water and sodium in your urine." 4 "You must not be following your dietary restrictions. How much sodium are you eating?"
3 "This medication causes greater excretion of water and sodium in your urine."
A patient with hyperkalemia is being treated with drugs to improve the condition. Which potassium level indicates that therapy is effective? 1 7.6 mEq/L 2 5.6 mEq/L 3 4.6 mEq/L 4 2.6 mEq/L
3 4.6 mEq/L
Which patient is at greatest risk for hypernatremia? 1 30-year-old on a low-salt diet 2 42-year-old receiving hypotonic fluids 3 54-year old who is sweating profusely 4 17-year-old with a serum blood glucose of 189 mg/dL
3 54-year old who is sweating profusely
The nurse manager of the medical-surgical unit assigns which patient to the LPN/LVN? 1 44-year-old admitted with dehydration who has a heart rate of 126 2 54-year-old just admitted with hyperkalemia who takes a potassium-sparing diuretic at home 3 64-year-old admitted yesterday with heart failure who still has dependent pedal edema 4 74-year-old who has just been admitted with severe nausea, vomiting, and diarrhea
3 64-year-old admitted yesterday with heart failure who still has dependent pedal edema
The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which patient is assigned to the LPN/LVN? 1 44-year-old with congestive heart failure (CHF) who has gained 3 pounds since the previous day 2 58-year-old with chronic renal failure (CRF) who has a serum potassium level of 6 mEq/L 3 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/L 4 80-year-old with 3+ peripheral edema and crackles throughout the posterior chest
3 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/L
Which hormone regulates fluid and electrolyte balance by preventing water and sodium loss? 1 Antidiuretic 2 Thyrotropin 3 Aldosterone 4 Natriuretic peptide (NP)
3 Aldosterone
Which hormones are responsible for maintaining fluid balance within the body? Select all that apply. 1 Insulin 2 Glucagon 3 Aldosterone 4 Natriuretic peptide (NP) 5 Antidiuretic hormone (ADH)
3 Aldosterone 4 Natriuretic peptide (NP) 5 Antidiuretic hormone (ADH)
A patient's electrocardiogram (ECG) demonstrates a heart rate of 52 beats/minute and prolonged PR interval with widened QRS complex, and the patient is also hypotensive. Which laboratory results are consistent with these findings? 1 Hypocalcemia, hyperkalemia, hypernatremia 2 Hypokalemia, hypocalcemia, hypermagnesemia 3 Hyperkalemia, hypercalcemia, hypermagnesemia 4 Hypernatremia, hypercalcemia, hypophosphatemia
3 Hyperkalemia, hypercalcemia, hypermagnesemia
Positive Trousseau's and Chvostek's signs are consistent with which electrolyte imbalance? 1 Hypokalemia 2 Hyperkalemia 3 Hypocalcemia 4 Hypercalcemia
3 Hypocalcemia
The nurse is reviewing the basic metabolic panel for a patient who was admitted to the medical-surgical unit the previous day. Which finding would place the patient at risk for fluid volume overload? 1 Hyperkalemia 2 Hypocalcemia 3 Hyponatremia 4 Hyperchloremia
3 Hyponatremia
An electrocardiogram (ECG) is ordered for a patient who was placed on intravenous (IV) fluids containing potassium. Which ECG finding is consistent with hyperkalemia? 1 Absent T waves 2 Elevated P waves 3 Prolonged PR intervals 4 Shortened QRS complexes
3 Prolonged PR intervals
A patient with a history of hypertension asks the nurse what dietary changes are necessary to make in order to control the blood pressure. What does the nurse include in the instruction? 1 Reduce the intake of iron 2 Reduce the intake of calcium 3 Reduce the intake of sodium 4 Reduced the intake of phosphorous
3 Reduce the intake of sodium
The nurse is planning care for a patient with hypocalcemia. Which nursing action is appropriate to delegate to unlicensed assistive personnel (UAP)? 1 Evaluating the patient's laboratory results 2 Implementing seizure precautions for the patient 3 Transferring the patient from the bed to a stretcher using a lift sheet 4 Collaborating with the dietitian to provide calcium-rich foods for the patient
3 Transferring the patient from the bed to a stretcher using a lift sheet
A patient is brought to the emergency department with symptoms of diarrhea, chest discomfort, and paresthesia. The patient has a heart rate of 60 beats per minute. The electrocardiogram (ECG) of the patient shows missed P waves, tall T waves, prolonged PR intervals, and wide QRS complexes. Which laboratory finding would be consistent with the patient's condition? 1 Serum sodium levels below 135 mEq/L 2 Serum sodium levels above 145 mEq/L 3 Serum potassium levels below 3.5 mEq/L 4 Serum potassium levels above 5.0 mEq/L
4 Serum potassium levels above 5.0 mEq/L
The nurse is teaching proper nutrition to a patient who has been prescribed high-ceiling diuretic therapy. Which patient response indicates a need for further teaching? 1 "I should eat fish a few times a week." 2 "Eating meat will help with my potassium needs." 3 "I should have fruits such as oranges and bananas every day." 4 "I should eat more eggs and cereals to maintain a high potassium intake."
4 "I should eat more eggs and cereals to maintain a high potassium intake."
Which person attending an all-day outdoor festival on a hot August day is at greatest risk for dehydration? 1 32-year-old man consuming alcoholic beverages 2 28-year-old woman with type 1 diabetes mellitus 3 68-year-old man who frequently wipes sweat from his forehead 4 72-year-old woman appearing to be at least 20 pounds overweight
4 72-year-old woman appearing to be at least 20 pounds overweight
The nurse instructs an older adult patient to increase intake of dietary potassium when the patient is prescribed which classification of drugs? 1 Beta blockers 2 Corticosteroids 3 Alpha antagonists 4 High-ceiling (loop) diuretics
4 High-ceiling (loop) diuretics
Which output source would the nurse exclude from the total output from the previous shift? 1 Urine 2 Emesis 3 Liquid feces 4 Lung vaporization
4 Lung vaporization
The nurse is reviewing lab values for a patient recently admitted to the medical-surgical unit. Which lab result is severely abnormal? 1 Sodium, 137 mEq/L 2 Chloride, 107 mEq/L 3 Potassium, 3.5 mEq/L 4 Magnesium, 6.2 mEq/L
4 Magnesium, 6.2 mEq/L
A patient with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide? 1 Instruction on the proper use of drugs 2 Education about potassium-rich foods 3 Assessment of muscle tone and strength 4 Measurement of the patient's urine output
4 Measurement of the patient's urine output
What route of fluid loss is nonmeasurable? 1 Urine 2 Feces 3 Emesis 4 Perspiration
4 Perspiration
Which written order does the nurse clarify with the provider when caring for a patient with a serum sodium level of 149 mEq/L? 1 Weigh the patient daily. 2 Monitor intake and output. 3 Institute seizure precautions. 4 Place the patient on nothing by mouth (NPO) status.
4 Place the patient on nothing by mouth (NPO) status.
Hyponatremia nursing interventions
I&O, lab data, daily weights, vitals, prevention, neuro status, monitor sodium levels, general safety, fluid restriction, increase oral intake
S/S of hyponatremia
Muscle spasm, weakness, decreased urine output, shallow respiration, decreased deep tendon reflexes, increased bowel motility, orthostatic hypotension
Causes of hyponatremia
vomiting, diarrhea, NG suction, sweating, diuretics, burns/wounds, CHF, and renal failure, low intake, low aldosterone, SIADH, diabetes insipidus, fluid overload, fluid volume deficit