NCLEX Review Content Are: Fundamental skills: Fluids & Electrolytes

A nurse is planning care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply. 1. Ensure adequate fluid intake. 2. Implement safety measures to prevent falls. 3. Encourage low fiber foods to prevent diarrhea. 4. Instruct the client about foods that contain potassium. 5. Encourage the client to obtain assistance to ambulate.

1, 2, 4, 5 Clients with hypokalemia will need instruction on potassium-rich foods, and all clients should maintain adequate hydration, Safety is also a priority because hypokalemia may cause muscle weakness, resulting in falls and injury. Hypokalemia is associated with constipation, not diarrhea, owing to decreased peristalsis.

A client in the hospital emergency department who received nitroglycerin for chest pain has obtained relief but now complains of a headache. The nurse should interpret that this client is most likely experiencing which condition? 1. An expected medication side effect 2. An allergic reaction to nitroglycerin 3. An early sign of tolerance to the medication 4. A warning that the medication should not be used again

1. An expected medication side effect Headache is a frequent side effect of nitroglycerin, resulting from its vasodilator action. It often subsides as the client becomes accustomed to the medication and is effectively treated with acetaminophen (Tylenol). The other options are incorrect interpretations.

The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate? 1. Pour into the NG tube through a syringe with the plunger removed. 2. Dilute with water and inject into the NG tube by putting pressure on the plunger. 3. Discard properly and record as output on the client's intake and output (I&O) record. 4. Mix with the formula and pour into the NG tube through a syringe with the plunger removed.

1. Pour into the NG tube through a syringe with the plunger removed. After checking residual feeding contents, the gastric contents should be reinstilled to maintain the client's electrolyte balance. The gastric contents should be poured into the NG tube through a syringe without a plunger and not injected by pushing on the plunger. Gastric contents are not mixed with formula or diluted with water, and should not be discarded.

The nurse has provided instructions to a client receiving enalapril maleate (Vasotec). Which statement by the client indicates a need for further instruction? 1. "I need to rise slowly from a lying to sitting position." 2. "I need to notify the health care provider if fatigue occurs." 3. "I need to notify the health care provider (HCP) if a sore throat occurs." 4. "I know that several weeks of therapy may be required for the full therapeutic effect."

2. "I need to notify the health care provider if fatigue occurs." To reduce the hypotensive effect of this medication, the client is instructed to rise slowly from a lying to a sitting position and to permit the legs to dangle from the bed momentarily before standing. If fatigue occurs, it is not necessary to notify the HCP; the client is encouraged to pace activities. The client should report signs of a sore throat or fever to the HCP because these may indicate infection. The client should be notified that several weeks may be needed for the full therapeutic effect of blood pressure reduction. The client also should be instructed not to skip doses or discontinue the medication because severe rebound hypertension could occur.

Atenolol (Tenormin) has been prescribed for a client, and the nurse provides instructions to the client about the medication. Which statement by the client indicates the need for further teaching? 1. "I need to rise slowly from a lying to a sitting position." 2. "If I feel that my heart rate is too low, I should stop the medication." 3. "It will take 1 to 2 weeks before my blood pressure becomes controlled." 4. "I should avoid tasks that require alertness until I know how the medication will affect my body."

2. "If I feel that my heart rate is too low, I should stop the medication." Atenolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, and antidysrhythmic. It blocks β-adrenergic receptors in cardiac tissue and produces the therapeutic effects of slowing the heart rate, decreasing cardiac output, decreasing blood pressure, and decreasing myocardial oxygen demand. The client should not abruptly stop the medication. Abrupt withdrawal may result in sweating, palpitations, headache, and tremulousness and may precipitate heart failure or myocardial infarction in a client with cardiac disease. Abrupt withdrawal can also cause rebound hypertension. A pulse rate of 60 or below should be reported to the client's health care provider. Options 1, 3, and 4 are correct client statements.

A nurse is assisting in the care of a group of clients on the nursing unit. When considering effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third-spacing of fluid? 1. Client with a major burn 2. Client with an ischemic stroke 3. Client with Laënnec's cirrhosis 4. Client with chronic kidney disease

2. Client with an ischemic stroke Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third-spacing include the pleural and peritoneal cavities and pericardial sac. Risk factors include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal (GI) malabsorption, and malnutrition. The client who has suffered a stroke is not at risk for third-spacing.

A client with heart disease is taking digoxin (Lanoxin) and complains of having no appetite, and experiencing diarrhea and blurry vision. The nurse notes that the client's serum potassium (K) level is 3.0 mEq/L. Based on analysis of the data, what might the nurse expect to note when reviewing the digoxin level results? 1. Digoxin level of 1.8 ng/mL 2. Digoxin level higher than 2 ng/mL 3. Digoxin level lower than 0.5 ng/mL 4. Digoxin level of 0 ng/mL because of diarrhea

2. Digoxin level higher than 2 ng/mL When a client is taking digoxin, digoxin toxicity is a concern. The therapeutic digoxin level is 0.5 to 2 ng/mL. Anorexia, diarrhea, and visual disturbances are symptoms of digoxin toxicity. In addition, a low serum potassium level potentiates the risk for digoxin toxicity. This client's potassium level is low at 3.0 mEq/L. The client's complaints are indicative of digoxin toxicity. Therefore the only correct choice is option 2.

The nurse is providing medication information to a client who is beginning medication therapy with enalapril (Vasotec). The nurse should tell the client that which is an anticipated, although unpleasant, side effect of this medication? 1. Rapid pulse 2. Persistent dry cough 3. Increased blood pressure 4. Metallic taste in the mouth

2. Persistent dry cough The principal side/adverse effects of enalapril, an angiotensin-converting enzyme (ACE) inhibitor, are persistent cough, first-dose hypotension, and hyperkalemia. The medication is used to treat hypertension. A persistent dry cough is a harmless side effect, although it can be disturbing. If this side effect occurs and is troublesome, the health care provider should be notified so that the medication can be changed to a different one. A rapid pulse and metallic taste in the mouth are not side or adverse effects.

Intravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit? 1. Vitamin K 2. Protamine sulfate 3. Potassium chloride 4. Aminocaproic acid (Amicar)

2. Protamine sulfate The antidote to heparin is protamine sulfate; it should be readily available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin sodium. Potassium chloride is administered for a potassium deficit. Aminocaproic acid is the antidote for thrombolytic therapy.

A client with pulmonary edema has a prescription to receive morphine sulfate intravenously. The nurse should determine that the client is experiencing an intended effect of the medication as indicated by which assessment finding? 1. Increased pulse rate 2. Relief of apprehension 3. Decreased urine output 4. Increased blood pressure

2. Relief of apprehension Morphine sulfate reduces anxiety and dyspnea in the client with pulmonary edema. It also promotes peripheral vasodilation and causes blood to pool in the periphery. It decreases pulmonary capillary pressure, which reduces fluid migration into the alveoli. The client receiving morphine sulfate is monitored for signs and symptoms of respiratory depression and extreme drops in blood pressure, especially when it is administered intravenously. Options 1, 3, and 4 are unrelated to the action of morphine sulfate.

A hospitalized client with coronary artery disease complains of substernal chest pain. After assessing the client's heart rate and blood pressure, a nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes the client states, "My chest still hurts." Which actions should the nurse take? Select all that apply. 1. Call a Code Blue. 2. Contact the client's family. 3. Assess the client's pain level. 4. Check the client's blood pressure. 5. Contact the health care provider (HCP). 6. Administer a second nitroglycerin, 0.4 mg, sublingually.

3, 4, 6 The usual guidelines for administering nitroglycerin tablets for chest pain to a hospitalized client include administering one tablet every 5 minutes PRN for chest pain, for a total dose of three tablets. If the client does not obtain relief after taking a third dose of nitroglycerin, the HCP is notified. Because the client is still complaining of chest pain, the nurse would administer a second nitroglycerin tablet. The nurse would assess the client's pain level and check the client's blood pressure before administering each nitroglycerin dose. There are no data in the question that indicate the need to call a Code Blue. Additionally it is not necessary to contact the client's family unless he or she has requested this.

The clinic nurse is providing instructions to a client with hypertension who will be taking captopril (Capoten). Which statement by the client indicates a need for further instruction? 1. "I need to change positions slowly." 2. "I need to avoid taking hot baths or showers." 3. "I need to drink at least 4 quarts of water daily." 4. "I need to sit down and rest if dizziness or lightheadedness occurs."

3. "I need to drink at least 4 quarts of water daily." Captopril is an antihypertensive medication (angiotensin-converting enzyme [ACE] inhibitor). Orthostatic hypotension can occur in clients taking this medication. Adequate fluid is important, but 4 quarts of water daily could actually aggravate the hypertension. Clients are advised to avoid standing in one position for long periods, to change positions slowly, and to avoid extreme warmth such as with baths, showers, or heat from the sun in warm weather. The client should be instructed to monitor for signs of orthostatic hypotension, such as dizziness, lightheadedness, weakness, and syncope.

During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What should the nurse do next? 1. Document this assessment finding. 2. Call another nurse to verify this finding. 3. Check skin turgor over the client's sternum. 4. Call the prescriber to obtain a prescription for fluid replacement.

3. Check skin turgor over the client's sternum. In an older adult, skin turgor should be checked by pinching the skin over the sternum or even the forehead, instead of the back of the hand or forearm. As a client gets older, the skin loses elasticity and can tent over the hands and arms, even when the client is adequately hydrated. Therefore the next nursing action would be to obtain additional assessment data.

The nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which action is part of the plan for preparation and administration of the potassium? 1. Obtaining an intravenous (IV) infusion pump 2. Monitoring urine output during administration 3. Preparing the medication for bolus administration 4. Ensuring that the medication is diluted in the appropriate amount of normal saline

3. Preparing the medication for bolus administration Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, and dextrose solution is avoided because this type of solution increases intracellular potassium shifting. The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored closely because potassium chloride is irritating to the veins and there is risk of phlebitis. The nurse monitors urinary output during administration and contacts the health care provider if the urinary output is less than 30 mL/hour.

A nurse prepares to administer sodium polystyrene sulfonate (Kayexalate) to a client. Before administering the medication, the nurse reviews the action of the medication and understands that which is released by this medication? 1. Bicarbonate in exchange for primarily sodium ions 2. Potassium ions in exchange for primarily sodium ions 3. Sodium ions in exchange for primarily potassium ions 4. Sodium ions in exchange for primarily bicarbonate ions

3. Sodium ions in exchange for primarily potassium ions Sodium polystyrene sulfonate is a cation exchange resin used for the treatment of hyperkalemia. The resin passes through the intestine or is retained in the colon. It releases sodium ions primarily in exchange for potassium ions. The therapeutic effect occurs 2 to 12 hours after oral administration and longer after rectal administration. Therefore, the remaining options are incorrect.

A client who has begun taking betaxolol (Kerlone) demonstrates an effective response to the medication as indicated by which nursing assessment finding? 1. Increase in edema to 3+ 2. Weight gain of 5 pounds 3. Decrease in pulse rate from 74 beats/min to 58 beats/min 4. Decrease in blood pressure from 142/94 mm Hg to 128/82 mm Hg

4. Decrease in blood pressure from 142/94 mm Hg to 128/82 mm Hg Betaxolol is a β-adrenergic blocking agent used to lower blood pressure, relieve angina, or decrease the occurrence of dysrhythmias. Side effects include bradycardia and signs and symptoms of heart failure, such as increased edema and weight gain.

The nurse has a prescription to give a client a scheduled dose of digoxin (Lanoxin). Prior to administering the medication, the nurse should assess for which manifestations that could indicate digoxin toxicity? 1. Dyspnea, edema, and palpitations 2. Chest pain, hypotension, and paresthesias 3. Constipation, dry mouth, and sleep disorder 4. Double vision, loss of appetite, and nausea

4. Double vision, loss of appetite, and nausea Double vision, loss of appetite, and nausea are signs of digoxin toxicity. Other signs of digoxin toxicity include bradycardia, visual alterations (such as green and yellow vision, or seeing spots or halos), confusion, vomiting, diarrhea, decreased libido, and impotence. The other options are incorrect because they do not identify manifestations of digoxin toxicity.

A client is seen in the clinic complaining of anorexia and nausea. The health care provider suspects that the client may be experiencing digoxin toxicity. While waiting for test results to become available, the nurse should assess the client for which sign or symptom that would support a diagnosis of digoxin toxicity? 1. Edema 2. Chest pain 3. Constipation 4. Photophobia

4. Photophobia The most common early manifestations of digoxin toxicity are gastrointestinal disturbances such as anorexia, nausea, and vomiting and neurological disturbances such as fatigue, headache, weakness, drowsiness, confusion, and nightmares. Visual disturbances such as photophobia, light flashes, halos around bright objects, and yellow or green color perception also may occur.

The nurse is administering a dose of triamterene (Dyrenium) to an assigned client. The nurse monitors the client, expecting that the effect of this medication will result in retention of which substance? 1. Water 2. Sodium 3. Chloride 4. Potassium

4. Potassium Triamterene is a potassium-retaining diuretic. Potassium-retaining diuretics decrease reabsorption of sodium and water and inhibit the excretion of potassium in the renal collecting ducts. The medication has no direct effect on chloride excretion or retention.

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid? 1. Peas 2. Nuts 3. Cauliflower 4. Processed oat cereals

4. Processed oat cereals The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Nuts, cauliflower, and peas are good food sources of phosphorus. Peas are also a good source of magnesium. Processed foods are high in sodium content.

A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data and then checks the client's skin turgor by taking which action? Click on the Question Video button to view a video showing preparation procedures. 1. Pinching the skin on the thigh 2. Pushing on the skin in the ankle area 3. Assessing the skin in the radial pulse area 4. Pulling up and releasing the skin on the sternal area

4. Pulling up and releasing the skin on the sternal area Click on the Rationale Video button. When preparing to place a client on I&O, the nurse explains the procedure to the client. This will provide the client with information about the purpose and procedure and allow client participation, if feasible, such as contacting the nurse when oral intake is consumed or if the bathroom is used. The nurse also performs a baseline assessment for later comparison and checks for signs of fluid imbalance, including measuring the client's vital signs, weight, and skin turgor. Skin turgor is the skin's elasticity. To assess turgor, a fold of skin is grasped on the back of the forearm or sternal area with the fingertips and released. Normally the skin lifts easily and snaps back to its resting position. The skin stays pinched when turgor is poor. The actions in options 1, 2, and 3 would not assess turgor.

A registered nurse (RN) has instructed an unlicensed assistive personnel (UAP) to administer soap solution enemas until clear to a client. The UAP reports that three enemas have been administered and that the client is still passing brown liquid stool. What should the RN instruct the UAP to do? 1. Administer a Fleet enema. 2. Administer an oil retention enema. 3. Wait 30 minutes and then administer another enema. 4. Stop administering the enemas until the health care provider (HCP) is notified.

4. Stop administering the enemas until the health care provider (HCP) is notified. Up to three enemas may be given when there is a prescription for enemas until clear. If more than three are necessary, the nurse should call the HCP (or act according to agency policy). Excessive enemas could cause fluid and electrolyte depletion. Options 1 and 3 are incorrect for these reasons. An oil retention enema is an enema that is used to soften dry, hard stool and would have no use in this situation.

A health care provider writes a prescription for digoxin (Lanoxin), 0.25 mg daily. The nurse teaches the client about the medication and tells the client that it is most important to be sure to implement which measure? 1. Count the radial and carotid pulses every morning. 2. Check the blood pressure every morning and evening. 3. Stop taking the medication if the pulse is faster than 100 beats/min. 4. Withhold the medication, and call the health care provider if the pulse is slower than 60 beats/min.

4. Withhold the medication, and call the health care provider if the pulse is slower than 60 beats/min. An important component of taking digoxin is monitoring the pulse rate; however, it is not necessary for the client to take both radial and carotid pulses. It is also unnecessary for the client to check the blood pressure every morning and evening because the medication does not directly affect blood pressure. It is most important for the client to know the guidelines related to withholding the medication and calling the health care provider. The client should not stop taking the medication.

A client being treated for heart failure is administered intravenous bumetanide. Which outcome indicates the medication has achieved the expected effect? 1. Cough becomes productive of frothy pink sputum 2. The serum potassium level changes from 3.8 to 3.1 mEq/L 3. B-natriuretic peptide (BNP) factor increases from 200 to 262 pg/mL 4. output increases from 10 mL/hour to greater than 50 mL hourly

4. output increases from 10 mL/hour to greater than 50 mL hourly Bumetanide is a diuretic and expected outcomes include increased urine output, decreased crackles, and decreased weight. Options 1, 2, and 3 are incorrect.

A client is hypovolemic, and plasma expanders are not available. The nurse anticipates that which solution available on the nursing unit will be prescribed by the health care provider? 1.) 5% dextrose in water 2.) 0.9% sodium chloride 3.) 0.45% sodium chloride 4.) 5% dextrose in 0.45% sodium chloride

4.) 5% dextrose in 0.45% sodium chloride A solution of 5% dextrose in 0.45% sodium chloride is hypertonic. An advantage of hypertonic solutions is that they may be used to treat hypovolemia when plasma expanders are not readily available. Options 1 and 2 are isotonic solutions. Option 3 is a hypotonic solution.

A nurse should educate the client receiving pravastatin (Pravachol) to immediately report which finding? 1. Fatigue 2. Diarrhea 3. Sore throat 4. Muscle pain

4. Muscle pain Pravastatin is used to treat hyperlipidemia. Muscle pain could indicate rhabdomyolysis, a serious complication of this medication. It must be reported immediately. Options 1, 2, and 3 are not associated concerns with the medication.

The nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte result indicates a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L. Based on these laboratory findings, the nurse should select which solution to use for the nasogastric tube irrigation? 1. Tap water 2. Sterile water 3. Distilled water 4. Sodium chloride

4. Sodium chloride A potassium level of 4.5 mEq/L is within normal range. A sodium level of 132 mEq/L is low, indicating hyponatremia. In clients with hyponatremia, sodium chloride (normal saline) should be used rather than water for gastrointestinal irrigations because it is an isotonic solution.

A nurse is caring for a client with hyperlipidemia who is taking cholestyramine (Questran). Which nursing assessment is most significant for this client relative to the medication therapy? 1. Observe for joint pain. 2. Auscultate bowel sounds. 3. Assess deep tendon reflexes. 4. Monitor cardiac rate and rhythm.

2. Auscultate bowel sounds. Cholestyramine is used to treat hyperlipidemia. The site of action of the medication is the bowel; therefore option 2 is correct. Options 1, 3, and 4 are unrelated assessments.

A nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited? 1. Tetany 2. Tremors 3. Areflexia 4. Muscular excitability

3. Areflexia Signs of hypermagnesemia include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes (areflexia), respiratory paralysis, and loss of consciousness. Tetany, muscular excitability, and tremors are seen with hypomagnesemia.

A client is admitted to a hospital with acute myocardial infarction and is started on tissue plasminogen activator (tPA, Activase) by infusion. Of the following parameters, which one should a nurse determine requires the least frequent assessment to detect complications of therapy with tPA? 1. Neurological signs 2. Blood pressure and pulse 3. Presence of bowel sounds 4. Complaints of abdominal and back pain

3. Presence of bowel sounds Thrombolytic agents dissolve existing clots, and bleeding can occur anywhere in the body. The nurse monitors for any obvious signs of bleeding and also for occult signs of bleeding, which would include hemoglobin and hematocrit values, blood pressure and pulse, neurological signs, assessment of abdominal and back pain, and the presence of blood in the urine or stool.

Gemfibrozil (Lopid) is prescribed for a client. Which laboratory finding should alert the nurse about the need to withhold the medication and contact the health care provider? 1. Elevated glucose 2. Elevated triglycerides 3. Elevated liver function tests 4. Elevated blood urea nitrogen (BUN)

3. Elevated liver function tests Gemfibrozil is used to treat hypercholesterolemia. One adverse effect is hepatotoxicity. The medication does not affect glucose. An elevated triglyceride level is not an indication to hold the medication. An elevated BUN is unrelated to this medication and would not be an indication that the medication should be held.

A client is hypovolemic, and plasma expanders are not available. The nurse anticipates that which solution available on the nursing unit will be prescribed by the health care provider? 1. 5% dextrose in water 2. 0.9% sodium chloride 3. 0.45% sodium chloride 4. 5% dextrose in 0.45% sodium chloride

4. 5% dextrose in 0.45% sodium chloride A solution of 5% dextrose in 0.45% sodium chloride is hypertonic. An advantage of hypertonic solutions is that they may be used to treat hypovolemia when plasma expanders are not readily available. Options 1 and 2 are isotonic solutions. Option 3 is a hypotonic solution.

Which intravenous solution would be most appropriate for a client who may be experiencing excess fluid volume secondary to heart failure? 1. 0.9% normal saline 2. 0.45% normal saline 3. Lactated Ringer's solution 4. 5% dextrose in 0.9% normal saline

4. 5% dextrose in 0.9% normal saline The fluid of choice for a client with excess fluid volume is a hypertonic solution of 5% dextrose in 0.9% normal saline. This solution would pull fluid into the intravascular space; the kidneys could then excrete the excess fluid. The 0.45% normal saline solution is hypotonic, which pulls fluid into the intracellular space. The lactated Ringer's and 0.9% normal saline solutions are both isotonic solutions that would worsen the excess fluid volume.

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1. Lung congestion 2. Decreased hematocrit 3. Increased blood pressure 4. Decreased central venous pressure (CVP)

4. Decreased central venous pressure (CVP) A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased CVP, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H2O. A client with dehydration (fluid volume deficit) has a low CVP. The assessment findings in the remaining options are seen in a client with fluid volume excess.

The nurse has a prescription to give a first dose of hydrochlorothiazide (HydroDIURIL) to an assigned client. The nurse would question the prescription if the client has a history of allergy to which item? 1. Iodine 2. Shellfish 3. Penicillin 4. Sulfa drugs

4. Sulfa drugs Thiazide diuretics, such as hydrochlorothiazide, are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. A sulfa allergy must be communicated to the pharmacist, health care provider, nurse, and other health care providers. The other options are not contraindications for administering the medication.

A client's kidneys are retaining increased amounts of sodium. The nurse plans care, anticipating that the kidneys also are retaining greater amounts of which substances? 1. Calcium and chloride 2. Chloride and bicarbonate 3. Potassium and phosphates 4. Aluminum and magnesium

2. Chloride and bicarbonate Sodium is a cation. With increased retention of sodium, the kidneys also increase reabsorption of chloride and bicarbonate, which are anions. Options 1 and 3 are incorrect because calcium and potassium are cations. The same is true for option 4.

A male client is on enalapril (Vasotec) for the treatment of hypertension. The nurse teaches the client that he should seek emergent care if he experiences which adverse effect? 1. Nausea 2. Insomnia 3. Dry cough 4. Swelling of the tongue

4. Swelling of the tongue Enalapril is an angiotensin-converting enzyme inhibitor. Angioedema is an adverse effect. Swelling of the tongue and lips can result in airway occlusion. Nausea, insomnia, and a cough can occur as side, not adverse effects of the medication.

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment? 1. Urine pH of 6 2. Urine that is pale yellow 3. Urine output of 40 mL/hr 4. Urine specific gravity of 1.032

4. Urine specific gravity of 1.032 The client who is not adequately hydrated will have an elevated urine specific gravity. Normal values for urine specific gravity range from approximately 1.016 to 1.022. Pale yellow urine is a normal finding, as is a urine output of 40 mL/hr (minimum is 30 mL/hr). A urine pH of 6 is adequate (4.5 to 8.0 normal), and this value is not used in monitoring hydration status.

The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? Select all that apply. 1. Ensure adequate oxygenation. 2. Provide assistance to prevent falls. 3. Monitor medication administration of diuretics. 4. Monitor for numbness and tingling around the mouth. 5. Prevent complications during potassium administration.

1, 2, 3, 5 The priorities for nursing care of a patient with hypokalemia are ensuring adequate oxygenation, client safety for fall prevention and potassium administration, and monitoring for complications related to diuretic therapy and client response to therapy. Option 4 is related to hypocalcemia.

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply. 1. Dehydration 2. Hypertension 3. Physiological stress 4. Decreased blood volume 5. Decreased plasma osmolarity

1, 3, 4 Antidiuretic hormone, or vasopressin, is produced in the brain and stored in the posterior pituitary gland. Its release from the posterior pituitary gland is controlled by the hypothalamus in response to changes in blood osmolarity. Stimuli for ADH release are increased plasma osmolality, decreased blood volume, hypotension, pain, dehydration from nausea, vomiting, or diarrhea, and stress.

A nurse notes that a client's serum calcium level is 6.0 mg/dL. Which assessment findings should be anticipated in this client? Select all that apply. 1. Tetany 2. Constipation 3. Renal calculi 4. Hypotension 5. Prolonged QT interval 6. Positive Chvostek's sign

1, 4, 5, 6 The normal serum calcium level is 8.6 to 10 mg/dL; thus, the client's results are reflective of hypocalcemia. The most common manifestations of hypocalcemia are caused by overstimulation of the nerves and muscles; therefore, tetany and presence of Chvostek's sign would be expected. Calcium is needed by the heart for contraction. When the serum calcium level is decreased, cardiac contractility is decreased and the client will experience hypotension. A low serum calcium level could also lead to severe ventricular dysrhythmias and prolonged QT and ST intervals on the electrocardiogram.

A hypertensive client has been prescribed clonidine hydrochloride (Catapres-TTS), a transdermal patch. The nurse provides written instructions to the client on the use of the patch. Which statement by the client indicates the need for further instruction? 1. "I need to change the patch every 24 hours." 2. "I need to apply the patch to a hairless body site." 3. "I need to apply the patch to skin areas that are not broken." 4. "I need to apply the patch to the skin on the upper arm or body."

1. "I need to change the patch every 24 hours." Clonidine is an antihypertensive medication that is applied every 7 days to a hairless intact skin area of the upper arm or torso. Options 2, 3, and 4 are correct statements.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2 mg/dL. Which condition most likely caused this serum phosphorus level? 1. Alcoholism 2. Renal insufficiency 3. Hypoparathyroidism 4. Tumor lysis syndrome

1. Alcoholism The normal serum phosphorus level is 2.7 to 4.5 mg/dL. The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Malnutrition is associated with alcoholism. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.

The long-term care client with a history of heart failure has developed paroxysmal nocturnal dyspnea (PND). The nurse reviews the client's medication record and determines that which medication has been prescribed to treat the PND? 1. Bumetanide 2. Warfarin (Coumadin) 3. Propranolol (Inderal LA) 4. Acetylsalicylic acid (aspirin)

1. Bumetanide Bumex is a diuretic that should increase urine output and lower the risk of episodes of PND. PND is most likely to occur because of increased venous return when lying in bed. Because of increased venous return and inability of the heart to effectively pump, the consequence is pulmonary congestion. Coumadin is an anticoagulant. Inderal is a beta blocker. Aspirin in low doses is an antiplatelet agent and is also an analgesic at routine doses.

The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator? 1. Daily weight 2. Urinary output 3. IV fluid intake 4. NG tube intake

1. Daily weight Daily weight is the best indicator of fluid balance. Options 2, 3, and 4 are related to intake or output but are incomplete indicators of fluid balance.

The nurse is reviewing the record of a client who arrives at the health care clinic. The nurse notes that irbesartan (Avapro) has been prescribed for the client. The nurse should suspect that the client has which condition? 1. Hypertension 2. Hypothyroidism 3. Diabetes mellitus 4. Renal transplant rejection

1. Hypertension Irbesartan is an angiotensin II type 1 receptor antagonist. It is used to treat hypertension. This medication is not used to treat hypothyroidism, diabetes mellitus, or renal transplant rejection.

A client who is taking chlorothiazide (HydroDIURIL) comes to the clinic for periodic evaluation. In monitoring the client's laboratory test results for medication side effects, what is the clinic nurse most likely to note if a side effect is present? 1. Hypokalemia 2. Hypocalcemia 3. Hypernatremia 4. Hyperphosphatemia

1. Hypokalemia The client taking a potassium-losing diuretic such as chlorothiazide should be monitored for decreased potassium levels. Other possible fluid and electrolyte imbalances that occur with use of this medication include hypercalcemia, hyponatremia, hypophosphatemia, and hypomagnesemia.

An intravenous (IV) Ringer's lactate solution is prescribed for the postoperative client. The nursing instructor asks the nursing student who is caring for the client about the tonicity of the prescribed IV solution. The nursing student responds correctly by stating that this solution is which type of solution? 1. Isotonic 2. Hypotonic 3. Hypertonic 4. Normotonic

1. Isotonic Ringer's lactate solution is an isotonic solution. Isotonic solutions include 5% dextrose in water (D5W), 0.9% saline (NS), and 5% dextrose in 0.225% saline (5% D/¼ NS); 0.45% saline (½ NS) is hypotonic; and 10% dextrose in water (D10W), 5% dextrose in 0.9% saline (5% D/NS), and 5% dextrose in 0.45% saline (5% D/½ NS) are hypertonic solutions.

The nurse is reviewing a client's laboratory report and notes that the serum calcium level is 4.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level? 1. Prolonged bed rest 2. Renal insufficiency 3. Hyperparathyroidism 4. Excessive ingestion of vitamin D

1. Prolonged bed rest The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 4.0 mg/dL is experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Hyperparathyroidism and excessive ingestion of vitamin D are causative factors associated with hypercalcemia.

A client taking an angiotensin-converting enzyme (ACE) inhibitor to treat hypertension calls the clinic nurse and reports that he has a dry, nonproductive cough that is very bothersome. The nurse should respond by making which statement? 1. The medication may need to be changed. 2. The cough must be the start of a respiratory infection. 3. The medication needs to be taken with large amounts of water to prevent the cough. 4. This sometimes happens, and the client will need to take a cough medication with each dose of medication.

1. The medication may need to be changed. An ACE inhibitor is used to treat hypertension or heart failure. An adverse effect of ACE inhibitors is a characteristic dry, nonproductive cough. This can be quite bothersome to a client, and the medication may need to be changed. The cough is reversible with discontinuation of therapy. Options 2, 3, and 4 are incorrect.

The nurse is reading a health care provider's (HCP) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse interprets that this type of fluid loss can occur through which route? 1. The skin 2. Urinary output 3. Wound drainage 4. The gastrointestinal tract

1. The skin Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1. Twitching 2. Hypoactive bowel sounds 3. Negative Trousseau's sign 4. Hypoactive deep tendon reflexes

1. Twitching The normal serum calcium level is 8.6 to 10 mg/dL. A serum calcium level lower than 8.6 mg/dL indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L. Which pattern would the nurse note on the electrocardiogram as a result of the laboratory value? 1. U waves 2. Absent P waves 3. Elevated T waves 4. Elevated ST segment

1. U waves A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life-threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms.

The nurse is providing instructions to a client with chronic atrial fibrillation who is being started on quinidine sulfate. The nurse should plan to provide which instruction to the client? 1. Wear a Medic-Alert bracelet. 2. Take the medication only on an empty stomach. 3. Stop taking the prescribed digoxin (Lanoxin) when this medication is started. 4. Open the sustained-release capsules and mix with applesauce if the medication is difficult to swallow.

1. Wear a Medic-Alert bracelet. The client should be instructed to wear a Medic-Alert bracelet or tag and continue taking digoxin as prescribed. The client should be instructed to take quinidine sulfate exactly as prescribed. The client should not chew the sustained-release capsules or open the capsules and mix them with food. Quinidine sulfate is administered for atrial flutter or fibrillation only after the client has been digitalized.

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. 1. Peas 2. Raisins 3. Potatoes 4. Cantaloupe 5. Cauliflower 6. Strawberries

2, 3, 4, 6 The normal potassium level is 3.5 to 5.0 mEq/L. Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.

A client with a traumatic closed head injury shows signs that indicate the presence of cerebral edema. Which intravenous solution would increase cellular swelling and cerebral edema? 1. 0.9% normal saline 2. 0.45% normal saline 3. 5% dextrose in water 4. Lactated Ringer's solution

2. 0.45% normal saline Hypotonic solutions such as 0.45% normal saline are inappropriate for the client with cerebral edema because hypotonic solutions have the potential to cause cellular swelling and cerebral edema. The remaining choices of solutions would be appropriate because they are examples of isotonic solutions and thus are similar in composition to plasma. These fluids would remain in the intravascular space without potentiating the client's cerebral edema.

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment data would indicate to the nurse that the dehydration remains unresolved? 1. An oral temperature of 98.8° F 2. A urine specific gravity of 1.043 3. A urine output that is pale yellow 4. A blood pressure of 120/80 mm Hg

2. A urine specific gravity of 1.043 The client who is dehydrated will have a urine specific gravity greater than 1.030. Normal values for urine specific gravity are 1.010 to 1.030. A temperature of 98.8° F is only 0.2 point above the normal temperature and would not be as specific an indicator of hydration status as would the urine specific gravity. Pale yellow urine is a normal finding. A blood pressure of 120/80 mm Hg is within normal range.

Atenolol (Tenormin) has been prescribed for a hospitalized client. The nurse should check which item before administering this medication? 1. Pedal pulses 2. Apical heart rate 3. Most recent potassium level 4. Most recent electrolyte levels

2. Apical heart rate Atenolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, and antidysrhythmic. It blocks β-adrenergic receptors in cardiac tissue and produces the therapeutic effects of slowing the heart rate, decreasing cardiac output, decreasing blood pressure, and decreasing myocardial oxygen demand. The nurse should check the client's apical heart rate and blood pressure immediately before administering the medication. If the heart rate is 60 beats/min or lower or if the systolic blood pressure is less than 90 mm Hg, the medication is withheld and the health care provider is contacted. Options 1, 3, and 4 are unrelated to the administration of this medication.

A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed? 1. Weighs athletes before, during, and after football practice 2. Asks the athletes to take a salt tablet before football practice 3. Schedules fluid breaks every 30 minutes throughout practice 4. Tells the athletes to drink 16 oz of fluid per pound lost during practice

2. Asks the athletes to take a salt tablet before football practice Salt tablets should not be taken because they can contribute to dehydration. Frequent fluid breaks should be taken to prevent dehydration. Early detection of decreased body weight alerts the athlete to drink fluids before becoming dehydrated. To prevent dehydration, 16 oz of fluid should be consumed for every pound lost.

The health care provider has prescribed clonidine (Catapres) for a client with hypertension. The nurse should inform the client that which is a side effect of this medication? 1. Diarrhea 2. Constipation 3. Hypertension 4. Increased salivation

2. Constipation Clonidine is an antihypertensive medication. Side effects of clonidine include dry mouth, drowsiness, constipation, and hypotension. Therefore options 1, 3, and 4 are incorrect.

The nurse is caring for a client who is receiving dopamine. Which potential problem is a priority concern for this client? 1. Fluid overload 2. Peripheral vasoconstriction 3. Inability to perform self-care 4. Inability to discriminate hot or cold sensations

2. Peripheral vasoconstriction The client who is receiving dopamine therapy should be assessed for peripheral vasoconstriction related to the action of the medication. Options 1, 3, and 4 are not related directly to this medication therapy.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because of which situation? 1. Sustained tissue damage 2. Requires nasogastric suction 3. Has a history of Addison's disease 4. Is taking a potassium-retaining diuretic

2. Requires nasogastric suction The normal serum potassium level is 3.5 mEq/L to 5.0 mEq/L. A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client taking a potassium-retaining diuretic are at risk for hyperkalemia.

A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action? 1. Increase fluid intake. 2. Resume full activity level. 3. Stay in a cool environment when possible. 4. Monitor voiding for adequacy of urine output.

2. Resume full activity level. Discharge instructions for the client hospitalized with hyperthermia include the prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting.

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? 1. The client taking diuretics 2. The client with kidney disease 3. The client with an ileostomy 4. The client who requires gastrointestinal suctioning

2. The client with kidney disease A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.

The nurse hears the attending health care provider ask an intern to prescribe a hypotonic intravenous (IV) solution for a client. Which IV solution would the nurse expect the intern to prescribe? 1. 5% dextrose in water 2. 10% dextrose in water 3. 0.45% sodium chloride 4. 5% dextrose in 0.9% sodium chloride

3. 0.45% sodium chloride Hypotonic solutions have a lower osmolality than do body fluids. A solution of 0.45% sodium chloride is hypotonic. A solution of 5% dextrose in water (D5W) is isotonic. Solutions of 10% dextrose in water (D10W) and 5% dextrose in 0.9% sodium chloride are hypertonic.

A client is diagnosed with an ST-segment elevation myocardial infarction (STEMI) and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which action is a priority nursing intervention? 1. Monitor for kidney failure. 2. Monitor psychosocial status. 3. Monitor for signs of bleeding. 4. Have heparin sodium available.

3. Monitor for signs of bleeding. Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding. Monitoring for renal failure and monitoring the client's psychosocial status are important but are not the most critical interventions. Heparin may be administered after thrombolytic therapy, but the question is not asking about follow-up medications.

A nurse is evaluating a client's serum creatinine level. On noting that the level is high, the nurse plans care, knowing that creatinine is not being adequately secreted by which part of the nephron? 1. Distal tubule 2. Loop of Henle 3. Proximal tubule 4. Collecting duct

3. Proximal tubule Using the process of filtration, the glomerulus removes creatinine from the body. The kidney actively secretes creatinine from the nephron in the proximal tubule. Options 1, 2, and 4 are not associated with the secretion of creatinine.

The nurse is reviewing the laboratory results of a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 7 mEq/L. On the basis of this laboratory result, the nurse should expect to note which in the client? 1. Tremors 2. Hyperactive reflexes 3. Respiratory depression 4. No specific signs or symptoms because this value is a normal level

3. Respiratory depression Hypermagnesemia may be classified as mild (serum magnesia level of 3 to 5 mEq/L), moderate (6 to 7 mEq/L), severe (10 to 11 mEq/L), and emergency (12 to 15 mEq/L). A client with a mild degree of hypermagnesemia usually is asymptomatic. Neurological depression begins to occur at magnesium levels of 6 to 7 mEq/L and is manifested by drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia.

A client is taking amiloride (Midamor) 10 mg orally daily. What medication instruction should the nurse provide to the client? 1. Take the dose without food. 2. Eat foods with extra sodium. 3. Take the dose in the morning. 4. Withhold the dose if the blood pressure is high.

3. Take the dose in the morning. Amiloride is a potassium-retaining diuretic used to treat edema or hypertension. The daily dose should be taken in the morning to avoid nocturia, and the medication should be taken with food to increase bioavailability. Sodium should be restricted or limited as prescribed. Increased blood pressure is not a reason to withhold the medication; rather, it may be an indication for its use.

Which client is least likely to be at risk for the development of third spacing? 1. The client with cirrhosis 2. The client with liver failure 3. The client with diabetes mellitus 4. The client with chronic kidney disease

3. The client with diabetes mellitus Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors for third spacing include clients with liver or kidney disease, major trauma, burns, sepsis, wound healing or major surgery, malignancy, gastrointestinal malabsorption, malnutrition, and alcoholic or older adult clients.

The nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is most at risk for the development of a potassium value at this level? 1. The client with colitis 2. The client with Cushing's syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn

4. The client who has sustained a traumatic burn A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

A client with nausea and bradycardia is admitted to a medical unit. The family hands a nurse a small white envelope labeled "heart pill." The envelope is sent to the pharmacy and it is found to be digoxin (Lanoxin). A family member states, "That health care provider doesn't know how to take care of my family." Which statement would convey a therapeutic response by the nurse? 1. "Don't worry about this. I'll take care of everything." 2. "You are concerned your loved one receives the best care." 3. "You're right! I've never seen them put pills in an envelope." 4. "I think you're wrong. That health care provider (HCP) has been in practice more than 30 years."

2. "You are concerned your loved one receives the best care." Option 2 is a therapeutic, nonjudgmental response. The statement reflects the family's concern but remains nonjudgmental. Option 1dismisses the family's concerns and disempowers the family. Option 3 creates doubt about the HCP's practice without actually knowing the circumstances. Option 4 is argumentative and nontherapeutic.

The nurse is caring for a child with heart failure (HF). The nurse provides instructions to the mother regarding the procedure for administration of the prescribed digoxin (Lanoxin). Which statement by the mother indicates a need for further teaching? 1. "I will make sure to mix the medication with food." 2. "I need to take the child's pulse before administering the medication." 3. "If more than one dose is missed, I need to call the health care provider." 4. "If the child vomits after being given the medication, I should not repeat the dose."

1. "I will make sure to mix the medication with food." Medication should not be mixed with food, because this method of administration would not ensure that the child received the prescribed dose. The parents need to be instructed that if the child vomits after the digoxin is administered, they are not to repeat the dose. Additionally, the parents should be instructed that if a dose is missed and is not identified until 4 or more hours later, the dose should not be administered. If more than one dose is missed, the health care provider (HCP) needs to be notified.

A hospitalized client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin, gr 1/4 sublingually. Five minutes later, the client is still experiencing chest pain. If the blood pressure remains stable, the nurse should take which action next? 1. Administer another nitroglycerin tablet. 2. Administer 10 L of oxygen via nasal cannula. 3. Call for a 12-lead electrocardiogram (ECG) to be performed. 4. Wait an additional 5 minutes, and then give a second nitroglycerin tablet.

1. Administer another nitroglycerin tablet. Nitroglycerin tablets are usually prescribed one every 5 minutes PRN for chest pain for the hospitalized client, up to a total dose of three tablets. The nurse should administer the second tablet. The client with known angina pectoris should have low-flow oxygen at a rate of 1 to 3 L/min via nasal cannula. A 12-lead ECG would be done if prescribed by standing protocol or by individual health care provider prescription.

A client has developed paroxysmal nocturnal dyspnea. Which medication should the nurse anticipate will be prescribed by the health care provider? 1. Bumetanide 2. Lidocaine (Xylocaine) 3. Propranolol (Inderal LA) 4. Streptokinase (Streptase)

1. Bumetanide Bumetanide is a diuretic. The paroxysmal nocturnal dyspnea may be caused by increased venous return when the client is lying in bed, and the client needs diuresis. Lidocaine (Xylocaine) is an antidysrhythmic, Propranolol (Inderal LA) is an α-blocker, and streptokinase (Streptase) is a thrombolytic.

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.3 mg/dL. Which would be the most appropriate nursing action for this client? 1. Monitor the client for dysrhythmias. 2. Encourage increased intake of phosphate antacids. 3. Discontinue any magnesium-containing medications. 4. Encourage intake of foods such as ground beef, eggs, or chicken breast.

1. Monitor the client for dysrhythmias. The normal serum magnesium level is 1.6 to 2.6 mg/dL. Cardiac monitoring is indicated because this client is at risk for ventricular dysrhythmias. Phosphate use should be limited in the presence of hypomagnesemia because it worsens the condition. It is not necessary to discontinue magnesium products. Ground beef, eggs, and chicken breast are low in magnesium.

The nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level? 1. The client who is taking diuretics 2. The client with hyperaldosteronism 3. The client with Cushing's syndrome 4. The client who is taking corticosteroids

1. The client who is taking diuretics Hyponatremia is evidenced by a serum sodium level less than 135 mEq/L. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.

The health care provider (HCP) writes a prescription for atenolol (Tenormin) for a client who was admitted to the hospital. The nurse contacts the HCP to verify the prescription if which finding is noted in the assessment data? 1. Temperature is 100.1° F. 2. Apical heart rate is 48 beats/min. 3. Blood pressure is 138/82 mm Hg. 4. Pedal pulses are bounding and strong.

2. Apical heart rate is 48 beats/min. Atenolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, and antidysrhythmic. It blocks β-adrenergic receptors in cardiac tissue and produces the therapeutic effects of slowing the heart rate, decreasing cardiac output, decreasing blood pressure, and decreasing myocardial oxygen demand. Contraindications to the medication include severe bradycardia, cardiac failure, cardiogenic shock, and heart block greater than first degree. Options 1, 3, and 4 are not contraindications to this medication.

A client has recently begun medication therapy with propranolol (Inderal LA). The long-term care nurse should plan to notify the health care provider (HCP) if which assessment finding is noted? 1. Complaints of insomnia 2. Audible expiratory wheezes 3. Decrease in heart rate from 86 to 78 beats/min 4. Decrease in blood pressure from 162/90 to 136/84 mm Hg

2. Audible expiratory wheezes Propranolol (Inderal LA) is a beta-blocker. Audible expiratory wheezes could indicate bronchospasm, a serious adverse reaction. Beta blockers that are not cardioselective, such as propranolol, may induce this reaction, particularly in clients with chronic obstructive pulmonary disease (COPD) or asthma. Insomnia is a frequent mild side effect and should continue to be monitored. A normal decrease in heart rate and blood pressure is expected.

Atenolol hydrochloride (Tenormin) is prescribed for a hospitalized client. The nurse should perform which action as a priority before administering this medication? 1. Listen to the client's lung sounds. 2. Check the client's blood pressure. 3. Assess the client for muscle weakness. 4. Check the client's most recent electrolyte levels.

2. Check the client's blood pressure. Atenolol hydrochloride (Tenormin) is a β-blocker that is used to treat hypertension. Therefore the priority nursing action before administration of the medication is to check the client's blood pressure. The nurse also checks the client's apical heart rate. If the systolic blood pressure is lower than 90 mm Hg or the apical pulse is 60 beats/min or slower, the medication is withheld and the health care provider (HCP) is notified. The nurse checks baseline renal and liver function tests. The medication can cause weakness, and the nurse would assist the client with activities if weakness occurs.

A nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit? 1. Client in heart failure 2. Client with an ileostomy 3. Client in acute kidney injury 4. Client with controlled hypertension

2. Client with an ileostomy The client with an ileostomy is at risk for fluid volume deficit caused by increased gastrointestinal (GI) tract losses. Other causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. Clients who have heart failure or kidney disease are at risk for fluid volume excess. Hypertension may be associated with fluid volume excess.

A client with atrial fibrillation secondary to mitral stenosis is receiving a heparin sodium infusion at 1000 units/hour and warfarin sodium (Coumadin) 7.5 mg at 5:00 pm daily. The morning laboratory results are as follows: activated partial thromboplastin time (aPTT) = 32 seconds; internationalized normalized ratio (INR) = 1.3. The nurse should plan to take which action based on the client's laboratory results? 1. Collaborate with the health care provider (HCP) to discontinue the heparin infusion and administer the warfarin sodium as prescribed. 2. Collaborate with the HCP to obtain a prescription to increase the heparin infusion and administer the warfarin sodium as prescribed. 3. Collaborate with the HCP to withhold the warfarin sodium since the client is receiving a heparin infusion and the aPTT is within the therapeutic range. 4. Collaborate with the HCP to continue the heparin infusion at the same rate and to discuss use of dabigatran etexilate (Pradaxa) in place of warfarin sodium.

2. Collaborate with the HCP to obtain a prescription to increase the heparin infusion and administer the warfarin sodium as prescribed. When a client is receiving warfarin (Coumadin) for clot prevention due to atrial fibrillation, an INR of 2 to 3 is appropriate for most clients. Until the INR has achieved a therapeutic range the client should be maintained on a continuous heparin infusion with the aPTT ranging between 60 and 80 seconds. Therefore, the nurse should collaborate with the health care provider to obtain a prescription to increase the heparin infusion and to administer the warfarin as prescribed.

A client taking verapamil (Calan) has been given information about side effects of this medication. The nurse determines that the client understands the information if the client states to watch for which most common side effect of this medication? 1. Weight loss 2. Constipation 3. Nasal stuffiness 4. Abdominal cramping

2. Constipation Verapamil (Calan) is a calcium-channel blocker. The most common complaint with the use of verapamil is constipation. Other frequent side effects are dizziness, facial flushing, headache, and edema of the hands and feet. Weight loss, nasal stuffiness, and abdominal cramping are not associated with the use of this medication.

A client with heart failure is scheduled to be discharged to home with digoxin (Lanoxin) and furosemide (Lasix) as daily prescribed medications. The nurse tells the client to report which finding as an indication that the medications are not having the intended effect? 1. Sudden increase in appetite 2. Weight gain of 2 to 3 lb in a few days 3. Increased urine output during the day 4. Cough accompanied by other signs of respiratory infection

2. Weight gain of 2 to 3 lb in a few days Clients with heart failure should immediately report weight gain, loss of appetite, shortness of breath with activity, edema, persistent cough, and nocturia. An increase in urine output during the day is expected with diuretic therapy (Lasix). A cough resulting from respiratory infection does not necessarily indicate that heart failure is worsening.

A home health care nurse is visiting an older client at home. Furosemide (Lasix) is prescribed for the client and the nurse teaches the client about the medication. Which statement, if made by the client, indicates the need for further teaching? 1. "I will sit up slowly before standing each morning." 2. "I will take my medication every morning with breakfast." 3. "I need to drink lots of coffee and tea to keep myself healthy." 4. "I will call my health care provider (HCP) if my ankles swell or my rings get tight."

3. "I need to drink lots of coffee and tea to keep myself healthy." Tea and coffee are stimulants and mild diuretics. These are a poor choice for hydration. Sitting up slowly prevents postural hypotension. Taking the medication at the same time each day improves compliance. Because furosemide is a diuretic, the morning is the best time to take the medication so as not to interrupt sleep. Notification of the HCP is appropriate if edema is noticed in the hands, feet, or face or if the client is short of breath.

The home care nurse instructs a client on how to administer enoxaparin (Lovenox) subcutaneously. Which statement, if made by the client, indicates an understanding of how to administer this medication? 1. "I need to hold my skin flat before I put the needle into my skin." 2. "I need to massage the skin with the alcohol wipe after I give the injection." 3. "A syringe that has a small ⅝-inch needle is used to administer the injection." 4. "I need to pull back on the syringe and aspirate before pushing the medication into my skin."

3. "A syringe that has a small ⅝-inch needle is used to administer the injection." A subcutaneous injection of enoxaparin is performed using the same technique as for a heparin injection. The client should use a 25- to 27-gauge, ⅝-inch needle to prevent hematoma formation at the injection site. The client should be taught to bunch the skin rather than placing it flat. The client should not aspirate before injecting the medication and should not massage the area after injection.

Atorvastatin (Lipitor) has been prescribed for a client, and the nurse provides instructions to the client about the medication. Which statement by the client indicates the need for further teaching? 1. "This medication will lower my cholesterol level." 2. "I will need to have blood tests drawn while I am taking this medication." 3. "I won't need to adhere to a low-fat diet as long as I take this medication faithfully." 4. "I need to talk to the health care provider (HCP) before taking any over-the-counter medications."

3. "I won't need to adhere to a low-fat diet as long as I take this medication faithfully." Atorvastatin is a reductase inhibitor (HMG-CoA reductase inhibitor) that is used to treat hypercholesterolemia and hypertriglyceridemia. The client is instructed to follow a recommended diet as an important component of therapy. Liver function tests and cholesterol and triglyceride level determinations will be performed periodically while the client is taking the medication. The client needs to be instructed to consult with the HCP before taking any over-the-counter medications.

A nurse is caring for a client with a nasogastric tube (NGT) who has a prescription for NGT irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NGT? 1. Tap water 2. Sterile water 3. 0.9% sodium chloride 4. 0.45% sodium chloride

3. 0.9% sodium chloride Homeostasis is maintained by irrigating with an isotonic solution, such as 0.9% sodium chloride. Tap water, sterile water, and sodium chloride are hypotonic solutions.

A client with hypertension has a new prescription for a medication called moexipril (Univasc). The nurse plans to provide written directions that tell the client to take the medication at which time? 1. At bedtime 2. With meals 3. 1 hour before meals 4. With a snack in late afternoon

3. 1 hour before meals Moexipril (Univasc) is an angiotensin-converting enzyme (ACE) inhibitor. The client should be instructed to take the medication at least 1 hour before meals. The other ACE inhibitor that should be taken 1 hour before meals is captopril (Capoten). The other options are incorrect instructions to the client.

A nurse is obtaining the intershift report for a group of assigned clients. Which assigned client should the nurse monitor closely for signs of hyperkalemia? 1. A client with ulcerative colitis 2. A client with Cushing's syndrome 3. A client admitted 6 hours ago with a 40% burn injury 4. A client who has a history of long-term laxative abuse

3. A client admitted 6 hours ago with a 40% burn injury Hyperkalemia is likely to occur in clients who experience cellular shifting of potassium caused by early massive cell destruction, such as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis (with the exception of diabetic acidosis). Clients with Cushing's syndrome, ulcerative colitis, or those using laxatives excessively are at risk for hypokalemia.

The nurse has completed medication administration that included a nitroglycerin. Within minutes, the client is complaining of a headache. Which is the priority nursing action at this time? 1. Evaluate pupil response. 2. Place the client on the left side. 3. Administer the prescribed analgesic. 4. Notify the health care provider (HCP) immediately.

3. Administer the prescribed analgesic. Nitroglycerin causes vasodilation. The major side effect of nitroglycerin is a headache that can be alleviated by an analgesic. It is an expected response to the medication, and the health care provider (HCP) does not need to be notified. Placing the client on the left side will not alleviate the headache. There is no indication for the need to evaluate pupil response.

The nurse has given a client the prescribed dose of intravenous hydralazine (Apresoline). The nurse evaluates the effectiveness of the medication by monitoring which client parameter? 1. Pulse rate 2. Urine output 3. Blood pressure 4. Potassium level

3. Blood pressure Hydralazine is an antihypertensive medication used in the management of moderate to severe hypertension. It is a vasodilator medication that decreases afterload. The blood pressure needs to be monitored. Options 1, 2, and 4 are unrelated to the use of this medication.

A client is scheduled for a dose of ramipril (Altace). The nurse should check which measurement before administering the medication? 1. Weight 2. Apical pulse 3. Blood pressure 4. Potassium level

3. Blood pressure Ramipril (Altace) is an angiotensin-converting enzyme (ACE) inhibitor, and a serious side effect of this drug is profound hypotension. The client's blood pressure should be checked before administration of this medication. The medication does not cause weight gain or loss, bradycardia, or depletion of potassium.

A man who has developed atrial fibrillation and has been placed on warfarin (Coumadin). The nurse is doing discharge dietary teaching with the client and determines that the client needs additional education if he stated he would choose which foods while taking this medication? 1. Cherries 2. Potatoes 3. Broccoli 4. Spaghetti

3. Broccoli Anticoagulant medications work by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K are often omitted from the diet. Vitamin K is found in large amounts in green leafy vegetables, such as broccoli, cabbage, turnip greens, and lettuce. The other options listed are foods that are lower in vitamin K.

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note? 1. Bradycardia 2. Elevated blood pressure 3. Changes in mental status 4. Bilateral crackles in the lungs

3. Changes in mental status A client with dehydration is likely to be lethargic or complaining of a headache. The client would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins, tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral crackles in the lungs because these are signs of fluid overload and an unrelated finding of dehydration.

In reviewing the medication records of the following group of clients, the nurse determines that which client would be at greatest risk for developing hyperkalemia? 1. Client receiving bumetanide 2. Client receiving furosemide (Lasix) 3. Client receiving spironolactone (Aldactone) 4. Client receiving hydrochlorothiazide (HCTZ)

3. Client receiving spironolactone (Aldactone) Spironolactone is a potassium-sparing diuretic and competes with aldosterone at receptor sites in the distal tubule, resulting in excretion of sodium, chloride, and water and retention of potassium and phosphate. Use of the medications furosemide, bumetanide, and hydrochlorothiazide could result in hypokalemia.

The nurse who is caring for a client with severe malnutrition reviews the laboratory results and notes that the client has a magnesium level of 1.0 mg/dL. Which electrocardiographic change would the nurse expect to observe based on the client's magnesium level? 1. Prominent U waves 2. Prolonged PR interval 3. Depressed ST segment 4. Widened QRS complexes

3. Depressed ST segment The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL indicates hypomagnesemia. In hypomagnesemia, tall T waves and a depressed ST segment would be observed. Options 2 and 4 would be noted in a client experiencing hypermagnesemia. Prominent U waves occur with hypokalemia.

The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of U waves. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value? 1. Sodium 135 mEq/L 2. Sodium 140 mEq/L 3. Potassium 3.0 mEq/L 4. Potassium 5.0 mEq/L

3. Potassium 3.0 mEq/L The normal sodium level is 135 to 145 mEq/L. The normal potassium level is 3.5 to 5.0 mEq/L. A serum potassium level lower than 3.5 mEq/L is indicative of hypokalemia. In hypokalemia, the electrocardiographic (ECG) changes that occur include inverted T waves, ST segment depression, heart block, and prominent U waves.

The nurse caring for a client with hypocalcemia would expect to note which change on the electrocardiogram (ECG)? 1. Widened T wave 2. Prominent U wave 3. Prolonged QT interval 4. Shortened ST segment

3. Prolonged QT interval The normal serum calcium level is 8.6 to 10 mg/dL. A serum calcium level lower than 8.6 mg/dL indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with hypokalemia.

Lisinopril (Prinivil) has been prescribed for a client. What should the nurse instruct the client to do? 1. Take the medication with food only. 2. Discontinue the medication if nausea occurs. 3. Rise slowly from a reclining to a sitting position. 4. Expect to note a full therapeutic effect immediately.

3. Rise slowly from a reclining to a sitting position. Lisinopril is an angiotensin-converting enzyme inhibitor used in the treatment of hypertension. The client should be instructed to rise slowly from a reclining to a sitting position and to dangle the legs from the bed for a few moments before standing to reduce the hypotensive effect. It is not necessary to take the medication with food. If nausea occurs, the client should drink a noncola carbonated beverage and eat salted crackers or dry toast. A full therapeutic effect may be achieved in 1 to 2 weeks.

A client with angina pectoris has been given a new prescription for nitroglycerin transdermal patches. The client indicates an understanding of how to use this medication administration system by making which statement? 1. "I need to wait until the next day to apply a new patch if it falls off." 2. "I need to alternate daily dosage times to prevent tolerance to the medication." 3. "I need to place the patch in the area of a skin fold to promote better adherence." 4. "I need to apply the patch in the morning and leave it in place for 12 to 14 hours as directed."

4. "I need to apply the patch in the morning and leave it in place for 12 to 14 hours as directed." Nitroglycerin is a coronary vasodilator used for coronary artery disease. The client should apply a new patch each morning and leave it in place for 12 to 14 hours in accordance with health care provider directions. This prevents the client from developing tolerance (as happens with 24-hour use). The client does not need to wait to apply a new patch if it falls off because the medication is released continuously in small amounts through the skin. The client should avoid placing the patch in skin folds or excoriated areas.

A client receives education regarding self-administration of enoxaparin (Lovenox) on discharge to home. The client complains, "I feel as if the health care provider is discharging me too soon if I still have to take injections at home." What is the best nursing response? 1. "Are you not happy about going home?" 2. "Do you want to stay in the hospital forever?" 3. "You'll have to take that up with the health care provider." 4. "Research shows that it is best for clients to administer this medication at home rather than stay in the hospital."

4. "Research shows that it is best for clients to administer this medication at home rather than stay in the hospital." Enoxaparin (Lovenox) is a low-molecular-weight heparin that can be administered without the usual activated partial thromboplastin time testing that is required with the use of heparin. Options 1 and 2 devalue the client's feelings. Option 3 places the client's feelings on hold.

The nurse is administering a dose of intravenous hydralazine (Apresoline) to a client. The nurse should ensure that which item is in place before injecting the medication? 1. Central line 2. Foley catheter 3. Pulse oximeter 4. Blood pressure cuff

4. Blood pressure cuff Hydralazine is an antihypertensive medication used in the management of moderate to severe hypertension. The blood pressure and pulse should be monitored frequently after administration, so a blood pressure cuff is one of the items to have in place. Options 1, 2, and 3 are not necessary.

A client with hypertension has begun taking spironolactone (Aldactone). The nurse teaches the client to limit intake of which food? 1. Rice 2. Salad 3. Oatmeal 4. Citrus fruits

4. Citrus fruits Spironolactone (Aldactone) is a potassium-retaining diuretic that causes hyperkalemia as the principal adverse effect. Clients are instructed to restrict their intake of potassium-rich foods, such as citrus fruits and bananas. The other foods listed are appropriate to include in the diet.

A client is receiving scheduled doses of lovastatin (Mevacor). The nurse determines that the medication is having the intended effect if which is noted? 1. Weight loss 2. Increased pulse rate 3. Lowered blood pressure 4. Decreased cholesterol level

4. Decreased cholesterol level Triamterene is a potassium-retaining diuretic. Potassium-retaining diuretics decrease reabsorption of sodium and water and inhibit the excretion of potassium in the renal collecting ducts. The medication has no direct effect on chloride excretion or retention.

Diltiazem (Cardizem) is prescribed for a client with Prinzmetal's variant angina. The nurse should plan care, knowing that this medication works by which method? 1. Increasing the heart rate 2. Constricting peripheral arteries 3. Increasing sinoatrial (SA) and atrioventricular (AV) conduction 4. Inhibiting calcium movement across cell membranes of cardiac and smooth muscle

4. Inhibiting calcium movement across cell membranes of cardiac and smooth muscle Diltiazem is a calcium channel blocker that inhibits calcium movement across cell membranes of cardiac and smooth muscle. It dilates coronary arteries and peripheral arteries and arterioles. Diltiazem decreases the heart rate and slows SA and AV conduction.

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L. Which finding would the nurse expect to note on the electrocardiogram as a result of the laboratory value? 1. ST depression 2. Inverted T wave 3. Prominent U wave 4. Tall peaked T waves

4. Tall peaked T waves A serum potassium level greater than 5.0 mEq/L indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves.

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? 1. Dehydration 2. Hypokalemia 3. Fluid overload 4. Hypernatremia

1. Dehydration When a client is dehydrated, the heart rate increases in an attempt to maintain blood pressure. Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when the client stands, he may experience dizziness because of insufficient blood flow to the brain. Alterations in mental status also may occur. The oral mucous membranes, usually moist, are dry and may be covered with a thick, pasty coating. These findings are not manifestations of the conditions noted in the other options.

A health care provider writes a prescription for lisinopril (Zestril) for a hospitalized client. The nurse caring for the client determines that the medication has been prescribed to treat which disorder? 1. Hypertension 2. Immune disorder 3. Venous insufficiency 4. Gastroesophageal reflux disorder

1. Hypertension Lisinopril (Zestril) is an angiotensin-converting enzyme (ACE) inhibitor that is used to treat hypertension or heart failure. It is not used to treat immune disorder, venous insufficiency, or gastroesophageal reflux disorder.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note? 1. Hypotension 2. Increased heart rate 3. Bounding peripheral pulses 4. Shortened QT interval on electrocardiography (ECG)

1. Hypotension Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the electrocardiogram (ECG), the nurse would note a prolonged ST interval and a prolonged QT interval.

A client has a high potassium level. The nurse plans care, knowing that retention of potassium by the kidneys will be accompanied by which process? 1. Increased sodium excretion 2. Increased sodium retention 3. Increased glucose retention 4. Increased magnesium excretion

1. Increased sodium excretion With increased potassium retention, the kidneys excrete more sodium. The other options do not reflect the correct relationship between these two electrolytes.

What should the nurse teach a client about an expected outcome of nesiritide (Natrecor) administration? 1. The client will have an increase in urine output. 2. The client will have an absence of dysrhythmias. 3. The client will have an increase in blood pressure. 4. The client will have an increase in pulmonary capillary wedge pressure.

1. The client will have an increase in urine output. Nesiritide is a recombinant version of human B-type natriuretic peptide, which vasodilates arteries and veins. It is used for the treatment of decompensated heart failure, increases renal glomerular filtration, and increases urine output. The remaining options are incorrect about the intended effect of this medication.

A client is admitted to the emergency department with a diagnosis of myocardial infarction (MI). The health care provider (HCP) prescribes the administration of alteplase (Activase). To achieve the best therapeutic outcome, the nurse understands this medication must be administered at which time? 1. Within 4 to 6 hours after onset of chest pain 2. Concurrently with the administration of heparin 3. With the administration solution set protected from light 4. After the results of all laboratory tests have been received

1. Within 4 to 6 hours after onset of chest pain Alteplase is a fibrinolytic medication. In a client with an acute coronary artery thrombosis that evolves into a transmural MI, fibrinolytic therapy is most effective when started within 4 to 6 hours after onset of symptoms. The solution does not need to be protected from light. Heparin may be administered after the administration of alteplase but not concurrently, and it is not appropriate to wait for all laboratory tests to administer the medication.

A client who had intracranial surgery is experiencing diabetes insipidus. The nurse plans care, knowing that the client is experiencing which problem? 1. Water intoxication 2. Excess production of dopamine 3. Excess production of angiotensin II 4. Insufficient production of antidiuretic hormone (ADH)

4. Insufficient production of antidiuretic hormone (ADH) In diabetes insipidus there is insufficient ADH production, which causes the kidneys to excrete large volumes of urine. Water intoxication occurs when there is excess ADH production, resulting in water retention. Options 2 and 3 have nothing to do with diabetes insipidus.

The nurse is preparing to administer furosemide (Lasix) 40 mg by intravenous (IV) injection (IV push) to a client. The nurse should administer the medication over which time period? 1. 10 seconds 2. 30 seconds 3. 1 minute 4. 5 minutes

3. 1 minute When furosemide is administered by IV injection, each 40 mg or fraction thereof should be given over a 1- to 2-minute period. Options 1 and 2 identify administration times that are too rapid and could cause adverse effects. Option 4 is too slow of a time period for administration and may affect effectiveness of the IV medication.

Atenolol (Tenormin) has been prescribed for a client, and the client asks the nurse about the side effects of the medication. What should the nurse tell the client is an occasional side effect of this medication? 1. Dry skin 2. Flushing 3. Decreased libido 4. Increased blood pressure

3. Decreased libido Atenolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, and antidysrhythmic. It blocks β-adrenergic receptors in cardiac tissue and produces the therapeutic effects of slowing the heart rate, decreasing cardiac output, decreasing blood pressure, and decreasing myocardial oxygen demand. Frequent side effects include hypotension manifested as dizziness, nausea, diaphoresis, headache, cold extremities, fatigue, and constipation or diarrhea. Occasional side effects include insomnia, flatulence, urinary frequency, and impotence or decreased libido. Options 1, 2, and 4 are not side effects of this medication.

A thrombolytic is administered in the hospital emergency department to a client who has had a myocardial infarction. The client's spouse asks the nurse about the purpose of the medication. The nurse bases the response on which fact regarding this medication? 1. Thrombolytics suppress the production of fibrin. 2. Thrombolytics act to prevent thrombus formation. 3. Thrombolytics act to dissolve thrombi that have already formed. 4. Thrombolytics have been proved to reverse all detrimental effects of heart attacks.

3. Thrombolytics act to dissolve thrombi that have already formed. Thrombolytics are most effective when started within 4 to 6 hours after symptom onset and act to dissolve or lyse existing thrombi that are causing a blockage. Options 1, 2, and 4 are incorrect.

A client becomes hypovolemic as a result of excess blood loss during surgery. The nurse plans care, knowing that which physiological response is needed to restore adequate circulating volume? 1. Decreased production of angiotensin 2. Decreased production of aldosterone 3. Increased production of erythropoietin 4. Increased production of antidiuretic hormone (ADH)

4. Increased production of antidiuretic hormone (ADH) The client must produce increased ADH, which will increase reabsorption of water in the renal tubules and increase circulating volume. The production of angiotensin is stimulated, not inhibited, so that vasoconstriction may occur. A decrease in aldosterone will decrease the reabsorption of sodium and water in the kidneys. The client does not require increased erythropoietin to restore circulating volume.

The nurse is working with a client receiving an intravenous heparin sodium drip. The nurse should review which laboratory study to determine the therapeutic effect of heparin for the client? 1. Bleeding time 2. Thrombin time 3. Prothrombin time (PT) 4. Partial thromboplastin time (PTT)

4. Partial thromboplastin time (PTT) The PTT will assess the therapeutic effect of heparin, and the PT is one test that will assess for the therapeutic effect of warfarin (Coumadin). Bleeding time and thrombin time are hematological studies that may be prescribed for clients with coagulopathy or other disorders.

A nurse is calculating a male client's fluid intake for an 8-hour period. The client drank 8 oz of tea and 4 oz of orange juice for breakfast, 4 oz of water at 10:00 am and at 1:00 pm when taking his medications, and 6 oz of iced tea at lunch. At 8:00 am and again at 2:00 pm, the client received his intravenous antibiotics in 50 mL of normal saline. What is the client's total intake in mL? Fill in the blank.

880 mL The client consumed a total of 26 oz of fluid (12 oz at breakfast, 8 oz with medications, and 6 oz at lunch). This equals 780 mL (1 oz = 30 mL). The client also received a total of 100 mL of intravenous fluid (50 mL at 8:00 am and 50 mL at 2:00 pm). Therefore, the total intake is 880 mL.

The nurse is preparing to administer furosemide (Lasix) to a client with a diagnosis of heart failure. Which is the most important laboratory test result for the nurse to check before administering this medication? 1. Blood urea nitrogen 2. Cholesterol level 3. Potassium level 4. Creatinine level

3. Potassium level Furosemide is a loop diuretic. The medication causes a decrease in the client's electrolytes, especially potassium, sodium, and chloride. Administering furosemide to a client with low electrolyte levels could precipitate ventricular dysrhythmias. Options 1 and 4 reflect renal function. The cholesterol level is unrelated to the administration of this medication.

A nurse is caring for a client whose magnesium level is 3.5 mg/dL. Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level? 1. Tetany 2. Twitches 3. Positive Trousseau's sign 4. Loss of deep tendon reflexes

4. Loss of deep tendon reflexes The normal magnesium level is 1.6 to 2.6 mg/dL. A client with a magnesium level of 3.5 mg/dL is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau's sign are seen in a client with hypomagnesemia.

A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present? 1. Confusion 2. Muscle weakness 3.Mental status changes 4. Depressed deep tendon reflexes

2. Muscle weakness Because potassium plays a major role in neuromuscular activity, elevation in serum potassium initially causes muscle weakness. Mental status changes and confusion are most likely to be noted in the client experiencing hypocalcemia. Depressed deep tendon reflexes are noted in the client with hypermagnesemia.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present? 1. Weight loss 2. Flat neck and hand veins 3. An increase in blood pressure 4. Decreased central venous pressure (CVP)

3. An increase in blood pressure A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. The remaining options identify signs noted in fluid volume deficit.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1. Muscle twitches 2. Decreased urinary output 3. Hyperactive bowel sounds 4. Increased specific gravity of the urine

3. Hyperactive bowel sounds Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.