practice questions

A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has been made. What is the primary nursing concern? - Chronic pain - Risk for injury - Electrolyte imbalance - Inadequate gas exchange

Electrolyte imbalance

The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of what? - Hypercalcemia - Hypocalcemia - Hyperkalemia - Hypokalemia

Hypokalemia

When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is what? - Sodium - Potassium - Calcium - Calcitonin

Potassium

The nurse assesses a client who is receiving total parenteral nutrition for the specific complication of what condition? - Infection - Hepatitis - Anorexia - Dysrhythmias

Infection

The nurse providing care for a client with a diagnosis of neutropenia reviews isolation procedures with the client's spouse. The nurse determines that the teaching was effective when the spouse states that protective environment isolation helps prevent the spread of infection in which direction? - To the client from outside sources - From the client to others - From the client by using special techniques to destroy infectious fluids and secretions - To the client by using special sterilization techniques for linens and personal items

To the client from outside sources

A nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue, and bleeding gums. The nurse recognizes that these clinical manifestations are most likely a result of what? - A food allergy - Noncompliance with medications - Side effects from medications - A nutritional deficiency

A nutritional deficiency

A registered nurse instructed the nursing assistive personnel (NAP) to measure the temperature of a client who reports chills and coldness. The nurse believes that the reading is inaccurate. What observations may have led to this conclusion? Select all that apply. - The client has a habit of breathing through his or her mouth. - The client smoked 40 minutes after his or her temperature was taken. - The client ingested juice 20 minutes before his or her temperature was taken. - The client ingested food 20 minutes after having his or her temperature was taken. - The client ingested medications 10 minutes after having his or her temperature was taken.

A,C

A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. What are the best sites to assess this condition? Select all that apply. - Lips - Sclera - Mouth - Sacrum - Nail beds - Shoulders

A,C,E

An older adult client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which nursing actions have specific gerontologic implications the nurse must consider? Select all that apply. - Assessment of skin turgor - Documentation of vital signs - Assessment of intake and output - Administration of antiemetic drugs - Replacement of fluid and electrolytes

A,D,E

A 93-year-old client in a nursing home has been eating less food during mealtimes. What is the priority nursing intervention? - Substitute a supplemental drink for the meal. - Spoon-feed the client until the food is completely eaten. - Allow the client a longer period of time to complete the meal. - Arrange a consultation for the placement of a gastrostomy tube.

Allow the client a longer period of time to complete the meal.

A client is placed on a restricted diet. What is the best communication technique for the nurse to use when beginning to teach the client about the diet? - Asking about what type of foods the client usually eats - Telling the client that the diet must be followed exactly as written - Telling the client that the intake of foods on the list must be limited - Asking about what the client knows about the diet that was prescribed

Asking about what the client knows about the diet that was prescribed

A client who is human immunodeficiency virus (HIV) positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissible through what means? Select all that apply. - Feces - Blood - Semen - Urine - Sweat - Tears

B,C

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? - Skin turgor - Intake and output results - Client's report about fluid intake - Blood lab results

Blood lab results

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. - Tetany - Seizures - Confusion - Weakness - Dysrhythmias

C,D,E

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply. - Diplopia - Skin rash - Leg cramps - Tachycardia - Muscle weakness

C,E

The nurse understands that the action of an antidiuretic hormone (ADH) is to do what? - Reduce blood volume - Decrease water loss in urine - Increase urine output - Initiate the thirst mechanism

Decrease water loss in urine

A nurse reviews the medical record of a client with ascites. Which client condition may be contributing to the development of ascites? - Portal hypotension - Kidney malfunction - Diminished plasma protein level - Decreased production of potassium

Diminished plasma protein level

A 2 g sodium diet is prescribed for a client with stage 2 hypertension, and the nurse teaches the client the rationale for this diet. The client reports distaste for the food. The primary nurse hears the client request that the family "bring in a ham and cheese sandwich and fries." What is the most effective nursing intervention? - Discuss the diet with the client and family. - Tell the client why salty foods should not be eaten. - Explain the dietary restriction to the client's visitors. - Ask the dietitian to teach the client and family about sodium restrictions.

Discuss the diet with the client and family.

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? - Crohn disease - Cushing disease - End-stage renal disease - Gastroesophageal reflux disease

End-stage renal disease

The nurse is caring for a client who has an implanted port and is receiving intravenous fluids. To decrease the risk of infection, the nurse should change the noncoring needle how often? - Every 3 days - Every 5 days - Every 7 days - Every 9 days

Every 7 days

A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what client data or assessment finding? - Skin condition - Fluid and electrolyte balance - Food intake - Fluid intake and output

Fluid and electrolyte balance

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 105° F. Which condition does the nurse suspect in the client? - Heat stroke - Heat exhaustion - Accidental hypothermia - Malignant hyperthermia

Heat stroke

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing? - Hypernatremia - Hyponatremia - Hyperkalemia - Hypokalemia

Hyponatremia

A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, what should the nurse instruct the client to do? - Increase oral fluid intake to 2 to 3 L/day. - Maintain bed rest after discharge. - Limit fluid intake to 1 L/day. - Void at least every hour.

Increase oral fluid intake to 2 to 3 L/day.

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? - Monitor for signs of electrolyte imbalance. - Change the tube at least once every 48 hours. - Connect the nasogastric tube to high continuous suction. - Assess placement by injecting 10 mL of water into the tube.

Monitor for signs of electrolyte imbalance.

The nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. What is the nurse assessing for? - Pain tolerance - Skin turgor - Ecchymosis formation - Tissue mass

Skin turgor

A client has a paracentesis, and the healthcare provider removes 1500 mL of fluid. To monitor for a serious postprocedure complication, what should the nurse assess for? - Dry mouth - Tachycardia - Hypertensive crisis - Increased abdominal distention

Tachycardia

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus? - Limit the client's fluid intake. - Teach the client how to exercise the legs - Encourage use of the incentive spirometer. - Maintain the knee gatch position at an angle.

Teach the client how to exercise the legs.

To prevent septic shock in the hospitalized client, what should the nurse do? - Maintain the client in a normothermic state. - Administer blood products to replace fluid losses. - Use aseptic technique during all invasive procedures. - Keep the critically ill client immobilized to reduce metabolic demands.

Use aseptic technique during all invasive procedures.

A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? - Increase fluids. - Increase fiber in the diet. - Wash hands with soap and water. - Wash hands with an alcohol-based hand sanitizer.

Wash hands with soap and water.

The nurse who is working during the 8:00 am to 4:00 pm shift must document a client's fluid intake and output. An intravenous drip is infusing at 50 mL per hour. The client drinks 4 oz of orange juice and 6 oz of tea at 8:30 am and vomits 200 mL at 9:00 am. At 10:00 am the client drinks 60 mL of water with medications; the client voids 550 mL of urine at 11:00 am. At 12:30 pm, 3 oz of soup and 4 oz of ice cream are ingested. The client voids 450 mL at 2:00 pm. Calculate the total intake for the 8:00 am to 4:00 pm shift. Record your answer using a whole number.

970 mL

The nurse receives a report on a newly admitted client who is positive for Clostridium difficile. Which category of isolation would the nurse implement for this client? - Airborne precautions - Droplet precautions - Contact precautions - Protective environment

Contact precautions

A cachectic adolescent with the diagnoses of anorexia nervosa, dehydration, and electrolyte imbalances is admitted to a mental health facility. The adolescent has been obsessed with weight, has exercised for hours every day, has taken enemas and laxatives several times a week, and has engaged in self-induced vomiting. What outcome is a priority for the nurse planning care for this client? - Identifying personal strengths - Controlling impulsive behaviors - Correcting electrolyte imbalances - Developing a contract for treatment goals

Correcting electrolyte imbalances

A nurse explains to an obese client that the rapid weight loss during the first week after initiating a diet is because of fluid loss. The weight of extracellular body fluid is approximately 20% of the total body weight of an average individual. Which component of the extracellular fluid contributes the greatest proportion to this amount? - Plasma - Interstitial - Dense tissue - Body secretions

Interstitial

A client reports vomiting and diarrhea for 3 days. Which clinical indicator is most commonly used to determine whether the client has a fluid deficit? - Presence of dry skin - Loss of body weight - Decrease in blood pressure - Altered general appearance

Loss of body weight

The healthcare provider prescribes a low-fat, 2-gram sodium diet for a client with hypertension. The nurse should explain that the purpose of restricting sodium is to do what? - Chemically stimulate the loop of Henle - Diminish the thirst response of the client - Prevent reabsorption of water in the distal tubules - Cause fluid to move toward the interstitial compartment

Prevent reabsorption of water in the distal tubules

A client with bone cancer is receiving hospice care at home. The hospice program also provides respite care. What is the purpose of respite care? - Assisting the client with meals and personal care - Providing short-term relief to the family caregiver - Providing skilled nursing interventions for the client - Providing counseling and treatment for behavioral problems

Providing short-term relief to the family caregiver

The registered nurse is teaching the student nurse about writing nursing interventions. Which intervention written by the student nurse indicates effective learning? - "Turn the client every 2 hours." - "Perform blood glucose measurements regularly." - "Change the client's dressing once a shift: 6 AM—2 PM—10 PM." - "Irrigate the wound with 100 mL normal saline until clear: 6 AM—2 PM—8 PM."

"Irrigate the wound with 100 mL normal saline until clear: 6 AM—2 PM—8 PM."

Which nursing interventions require a nurse to wear gloves? Select all that apply. - Giving a back rub - Cleaning a newborn immediately after delivery - Emptying a portable wound drainage system - Interviewing a client in the emergency department - Obtaining the blood pressure of a client who is human immunodeficiency virus (HIV) positive

B,C

A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte? - Sodium - Calcium - Potassium - Phosphorus

Calcium

A 78-year-old client who has hypertension is beginning treatment with furosemide. Considering the client's age, what should the nurse teach the client to do? - Limit fluids at bedtime. - Change positions slowly. - Take the medication between meals. - Assess the skin for breakdown daily.

Change positions slowly.

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as what? - Vesicular - Bronchial - Crackles - Rhonchi

Crackles

A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client? - Fatigue related to weight loss secondary to COPD - Imbalanced nutrition: less than body requirements, related to fatigue - Imbalanced nutrition: less than body requirements, related to COPD - Ineffective breathing pattern, related to alveolar hypoventilation

Imbalanced nutrition: less than body requirements, related to fatigue

The nurse is assisting with the end-of-life care of an older adult. Which activity is performed when the nurse views family as context? - Assess the resources available to the family - Meet the client's family's comfort and nutritional needs - Meet the client's comfort, hygiene and nutritional needs - Determine the family's need for rest and their stage of coping

Meet the client's comfort, hygiene and nutritional needs

A nurse preceptor is evaluating a nurse who is preparing to administer digoxin intravenously (IV) to a client. The preceptor should stop the nurse from continuing with the procedure when the preceptor observes the nurse doing what? - Checking the serum potassium level - Verifying the serum level of digoxin - Piggybacking the digoxin in an existing infusion - Administering the dose over a 5-minute time period

Piggybacking the digoxin in an existing infusion

A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important? - Sodium - Calcium - Chloride - Potassium

Potassium

What should the nurse include in dietary teaching for a client with a colostomy? - Liquids should be limited to 1 L per day. - Nondigestible fiber and fruits should be eliminated. - A formed stool is an indicator of constipation. - The diet should be adjusted to include foods that result in manageable stools.

The diet should be adjusted to include foods that result in manageable stools.

A client is admitted to the hospital with severe back and abdominal pain, nausea and occasional vomiting, and an oral temperature of 101° F (38.3° C). The client reports drinking six to eight beers a day. A diagnosis of acute pancreatitis is made. Based on the data presented, what symptom is the primary nursing concern for this client? - Acute pain - Inadequate nutrition - Electrolyte imbalance - Disturbed self-concept

acute pain

When the nurse arrives at 8:00 am, a client has a 1000 mL bag of D5W hanging, with 450 mL infused during the prior shift. The IV infusion is to deliver 100 mL per hour. At 11:00 am the healthcare provider changes the prescription for the intravenous solution to 1000 mL 0.9% sodium chloride to be administered at 75 mL per hour and changes the dietary order from nothing by mouth to clear liquids. From 1:00 pm to the end of the 12-hour shift at 8:00 pm, the client has 4 oz (120 mL) of apple juice, a half cup of tea, a half cup of gelatin, and 6 oz (180 mL) of water. How many milliliters should the nurse document as the client's total fluid intake for the 12-hour shift? Record your answer using a whole number.

1515 mL

A client has been given a prescription for furosemide 40 mg every day in conjunction with digoxin. What would prompt the nurse to ask the provider about potassium supplements? - Digoxin causes significant potassium depletion. - The liver destroys potassium as digoxin is detoxified. - Lasix requires adequate serum potassium to promote diuresis. - Digoxin toxicity occurs rapidly in the presence of hypokalemia.

Digoxin toxicity occurs rapidly in the presence of hypokalemia.

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? - Rapid, thready pulse - Distended jugular veins - Elevated hematocrit level - Increased serum sodium level

Distended jugular veins

A client who develops heart failure has a serum potassium level of 2.3 mEq/L (2.3 mmol/L). Digoxin and potassium chloride are prescribed. What action should the nurse take? - Double the dose of potassium chloride and administer it with the prescribed digoxin. - Hold the dose of digoxin, administer the potassium chloride, and call the primary healthcare provider immediately. - Give the digoxin and potassium chloride as prescribed and report the laboratory results to the primary healthcare provider. - Administer the prescribed digoxin and potassium chloride with a glass of orange juice and continue to monitor the client.

Hold the dose of digoxin, administer the potassium chloride, and call the primary healthcare provider immediately.

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client? - Alkalosis - Renal failure - Hypervolemia - Pulmonary edema

Pulmonary edema

The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. What is the pathophysiological reason for the excessive edema? - Shift of fluid into the interstitial spaces - Weakening of the cell wall - Increased intravascular compliance - Increased intracellular fluid volume

Shift of fluid into the interstitial spaces