NUR 325 Exam 2 Review Questions
What is the normal serum range for creatinine?
0.6-1.3 mg/dL
What is the normal serum range for magnesium?
1.5-2.5 mEq/L
What is the normal serum range for sodium?
135-145 mEq/L
What is the the normal serum range for albumin?
3.4-5.4 g/dL
What is the normal serum range for potassium?
3.5-5.0 mEq/L
What is the normal hematocrit level for men? For women?
38.8-50%. 34.9-44.5%.
What is the normal serum range for BUN?
6-20 mg/dL
What is the normal serum range for calcium?
8.6-10.2 mg/dL
A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider? a. Sodium 126 mEq/L b. Potassium 3.6 mEq/L c. Magnesium 1.9 mEq/L d. Chloride 99 mEq/L
A
A patient has a potassium level of 9.0. Which nursing intervention is priority? A. Prepare the patient for dialysis and place the patient on a cardiac monitor B. Administer Spironolactone C. Place patient on a potassium restrictive diet
A
A patient is being admitted with dehydration due to nausea and vomiting. Which fluid would you expect the patient to be started on? a. 0.9% Normal Saline b. 0.33% saline c. 0.225% saline d. 5% Dextrose in 0.9% Saline
A
A patient with cerebral edema would most likely be order what type of solution? A. 3% Saline B. 0.9% Normal Saline C. Lactated Ringer's D. 0.225% Normal Saline
A
Fluid excess extracellularly in the vascular system may cause all of the following effects EXCEPT: a. Edema b. High blood pressure c. Bounding pulse d. Pulmonary congestion and crackles
A
Which of the following is not a symptom of hyperkalemia? A. Positive Chvostek's sign B. Decreased blood pressure C. Muscle twitches/cramps D. Weak and slow heart rate
A
Which patient below is considered hypernatremic? A. A patient with a sodium level of 155 B. A patient with a sodium level of 145 C. A patient with a sodium level of 120 D. A patient with a sodium level of 136 8
A
Your patient taking a *diuretic* is complaining of *skeletal muscle weakness*, and *difficulty breathing*. Their *respirations are 10/min*. Upon auscultation, you hear what sounds like a *cardiac dysrhythmia in the left ventricle*. The patient also complains of *frequent dizziness* upon standing. They also say that they have been *urinating frequently*. Which of the following electrolyte imbalances do you suspect this patient of having? a. Hypokalemia b. Hyperkalemia c. Hyponatremia d. Hypernatremia
A (Hypokalemia is most commonly caused by abnormal losses from either the kidneys or gastrointestinal tract, such as taking a *diuretic* which may cause polyuria, a symptom of hypokalemia. The symptoms are similar to hyperkalemia, but it may cause potentially lethal *ventricular dysrhythmias*. It also causes *skeletal muscle weakness and paralysis*, but something that is unique about hypokalemia is that the muscle weakness affects the *respiratory muscles*, which may lead to *shallow respirations*.)
A 22-yr-old man is admitted to the emergency department with a stab wound to the abdomen. The patient's vital signs are blood pressure 82/56 mm Hg, pulse 132 beats/min, respirations 28 breaths/min, and temperature 97.9° F (36.6° C). Which fluid, if ordered by the health care provider, should the nurse question? a. D5W b. 0.9% saline c. Packed red blood cells d. Lactated Ringer's solution
A (IV administration of 0.45% saline is hypotonic and is used for maintenance fluid replacement and dilutes the extracellular fluid. IV solutions used for volume expansion for hypovolemic shock include lactated Ringer's solution and 0.9% saline. If hypovolemia is due to blood loss, blood may be administered.)
A patient's calcium level is 6.9. Which of the following is a nursing priority? A. Initiate seizure precautions B. Educate patient about foods rich in calcium C. Administer Calcitonin D. Administer Vitamin D supplements as ordered
A (Initiating seizure precautions are priority because this is a critically low calcium level and the patient is at risk for seizures. Next, you would educate the patient about calcium rich foods and administer vitamin D supplements as ordered. Calcitonin is for HYPERcalcemia.)
A patient has newly diagnosed hyperparathyroidism. What should the nurse expect to find during an assessment at the beginning of the nursing shift? a. Lethargy and constipation from hypercalcemia b. Positive Trousseau's sign from hypercalcemia c. Lethargy and constipation from hypocalcemia d. Positive Trousseau's sign from hypocalcemia
A (Parathyroid hormone (PTH) shifts calcium from the bones into the extracellular fluid (ECF). Excessive PTH causes hypercalcemia, which is manifested by lethargy and constipation. A positive Trousseau's sign is characteristic of hypocalcemia rather than hypercalcemia. Answers that indicate hypocalcemia are not correct, because PTH moves calcium into the ECF.)
The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? a. Suction her mouth and throat b. Turn her on their side c. Put on oxygen at 2-L nasal cannula d. Stop feeding her and place on NPO
A (Stop feeding and place patient on NPO. If choking persists, suction airway. Notify health care provider.)
Which serum potassium result best supports the rationale for administering a stat dose of IV potassium chloride 20 mEq in 200 mL of normal saline over 2 hours? a. 3.1 mEq/L b. 3.9 mEq/L c. 4.6 mEq/L d. 5.3 mEq/L
A (The normal range for serum potassium is 3.5 to 5.0 mEq/L. This IV order provides a substantial amount of potassium. Thus the patient's potassium level must be low. The only low value shown is 3.1 mEq/L.)
The nurse is caring for a patient diagnosed with peptic ulcer disease (PUD). The patient was prescribed the proton pump inhibitor Prevacid (lansoprazole). Which of the following supplements may be prescribed to prevent deficiency? a. Vitamin B12 b. Vitamin C c. Vitamin D d. Omega-3 fatty acids
A (Vitamin B12 deficiency can occur as a result of the reduced gastric acidity associated with use of proton pump inhibitors, and supplementation is often warranted. Vitamin C deficiency is not a known deficiency associated with medications. Vitamin D deficiency may occur in patients who take cholesterol medication, and this link is currently being investigated. Omega-3 fatty acids may be used as monotherapy or in conjunction with cholesterol medication for patients with hyperlipidemia.)
Which skills must a patient with a new colostomy be taught before discharge from the hospital? (Select all that apply.) a. How to change the pouch b. How to empty the pouch c. How to open and close the pouch d. How to irrigate the colostomy e. How to determine if the ostomy is healing appropriately
A B C E (The patient must be able to do these tasks to successfully manage his or her colostomy when going home.)
Appropriate approaches used by the long-term care nurse to provide education for a 73 year old who has just been diagnosed with diabetes include which of the following? (Select all that apply.) a. Schedule a visit by another resident who is diabetic. b. Demonstrate food choices using food photographs. c. Avoid discussion of the patient's favorite foods. d. Remind the patient that a lot of damage has already occurred. e. Encourage the patient's family to participate in teaching sessions. f. Ask the patient about past experiences with lifestyle changes.
A B E F (Strategies to promote learning in older adults include peer teaching, visual aids, family participation, and relating new learning to past experiences. Discussion of the patient's favorite foods is needed to determine how old favorites can be adapted to the new diet. Reminders about the damage already done will indicate that the changes are not worth the effort.)
What should the nurse teach a young woman with a history of urinary tract infections about UTI prevention? (Select all that apply.) a. Keep the bowels regular. b. Limit water intake to 1-2 glasses a day c. Wear cotton underwear d. Cleanse the perineum from front to back. e. Practice pelvic muscle exercise (Kegel) daily.
A C D (All are interventions that lead to healthy bladder habits. Adequate hydration will ensure that the bladder is regularly flushed out and will help prevent a UTI. Pelvic muscle exercises promote pelvic health but not necessarily prevent UTI.)
A nurse in a home setting is assessing a 79-year-old male patient's risk for malnutrition. The nurse suspects malnutrition when reviewing which laboratory results? (Select all that apply.) a. Body mass index (BMI) of 17 b. Waist-to-hip ratio of 1.0 c. Weight loss of 6% since last month's visit d. Prealbumin level of 16 mg/dL e. Hematocrit level of 50% f. Hemoglobin level of 8.2 g/dL
A C F (A BMI of 18.5 to 24.9 is normal, and this patient's BMI is below normal; a major weight loss is defined as more than a 2% weight change over 1 week; and the expected hemoglobin level for a man is 14 to 18 g/dL. The patient's values may also indicate dehydration. The expected level for prealbumin is 15 to 36 mg/dL. A hematocrit level of 50% is within normal limits.)
The nurse is talking with a patient who was just diagnosed with a urinary tract infection. The patient asks the nurse how to prevent such infections in the future. The nurse should make which appropriate recommendations for the patient? (Select all that apply.) a. Drink 6 to 8 glasses of noncaffeinated fluids daily. b. Exercise daily. c. Increase fiber in the diet. d. Void when the urge is felt. e. Eat fruit twice daily.
A D (Drinking noncaffeinated drinks and voiding when the urge happens are the most appropriate measures for avoiding a urinary tract infection. Increasing fiber, exercising, and eating fruit do not prevent a urinary tract infection.)
You are caring for a patient admitted with diabetes mellitus, malnutrition, and a massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient (select all that apply.)? a. The potassium level may be increased if the patient has nephropathy. b. The patient has been eating excessive amounts of foods that increase potassium levels. c. The patient may be excreting extra sodium and retaining potassium secondary to malnutrition. d. There may be excess potassium being released into the blood as a result of massive blood transfusion. e. The potassium level may be increased because of dehydration that accompanies high blood glucose levels.
A D E (Hyperkalemia may result from hyperglycemia, renal insufficiency, or cell death. Diabetes mellitus, along with the stress of hospitalization and illness, can lead to hyperglycemia. Renal insufficiency is a complication of diabetes. Because malnutrition does not cause sodium excretion accompanied by potassium retention, it is not a contributing factor to this patient's potassium level. Stored hemolyzed blood can cause hyperkalemia when large amounts are transfused rapidly. The patient with a massive GI bleed would have an nasogastric tube and not be eating.)
While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient (select all that apply.)? a. Weakness b. Paresthesia c. Facial spasms d. Muscle tremors e. Depressed reflexes
A E (Signs of hypercalcemia are lethargy, fatigue, weakness, depressed reflexes, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial spasms, and muscle tremors are symptoms of hypocalcemia.)
Which are key points that the nurse should include in patient education for a person with complaints of chronic constipation? (Select all that apply.) a. Increase fiber and fluids in the diet b. Use a low-volume enema daily c. Avoid gluten in the diet d. Take laxatives twice a day e. Exercise for 30 minutes every day f. Schedule time to use the toilet at the same time every day g. Take probiotics 5 times a week
A E F (These steps are the initial ones to take to resolve chronic problems with constipation before considering regular laxative or enema use.)
A patient has acute gastroenteritis with watery diarrhea. Which statement by this patient would indicate that the nurse's teaching has been effective? a. "I should drink a lot of tap water today." b. "I need to take more calcium tablets today." c. "I should avoid fruits with potassium in them." d. "I need to drink liquids with some sodium in them."
D (Sodium-containing fluids are removed from the body by acute diarrhea and must be replaced to prevent an extracellular fluid volume (ECV) deficit. Drinking tap water will not prevent ECV deficit from diarrhea, because tap water does not contain enough sodium to hold the water in the extracellular compartment. Taking calcium tablets is an incorrect answer because hypocalcemia is characteristic of chronic diarrhea rather than acute diarrhea. Restricting fruits is an incorrect answer because diarrhea increases the potassium output and the potassium intake should be increased to balance it.)
When planning the care of a patient with dehydration, what urine output would the nurse instruct the unlicensed assistive personnel to report? a. 60 mL in 90 minutes b. 1200 mL in 24 hours c. 300 mL per 8-hour shift d. 20 mL for 2 consecutive hours
D (The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for 2 consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.)
A patient with severe *dehydration* has just been admitted to your ER. They are experiencing symptoms such as *postural hypotension, weakness, and decreased skin turgor*. The patient also complains of thirst, and is exhibiting a decreased level of consciousness. By these clues alone, which of the following electrolyte imbalances do you suspect this patient of having? a. Hypokalemia b. Hyperkalemia c. Hyponatremia d. Hypernatremia
D (With dehydration, because there is so little water in the body the serum levels of sodium will increase because it isn't as diluted. The symptoms of hypernatremia are *symptoms of dehydration* and any accompanying ECF volume deficit.)
A patient has a potassium level of 2.0. What would you expect to be ordered for this patient? A. Potassium 30 meq IV push B. Infusion of Potassium intravenously C. An oral supplement of potassium D. Intramuscular injection of Potassium
B
A patient is taking a diuretic called hydrochlorothiazide (HCTZ) and has a potassium level of 2.0. Clinically, the patient is presenting with nausea and tall T-waves on EKG in the lateral leads. Which of the following electrolyte imbalances would you ALSO expect with this patient?* a. Mg+1.8 b. Mg+ 1.2 c. Mg+ 2.0 d. Mg+ 2.9
B
Fluid excess intracellularly may cause what in RBC's, possibly leading to inadequate oxygenation and perfusion? a. Edema b. Hemolysis c. High blood pressure d. Pulmonary congestion
B
The thirst drive is controlled by the: a. Anterior pituitary b. Hypothalamus c. Thyroid gland d. Adrenal glands
B
When administering a hypertonic solution the nurse should closely watch for? A. Signs of dehydration B. Pulmonary Edema C. Fluid volume deficient D. Increased Lactate level
B
Which of the following conditions can lead to cell lyses if not properly monitored? A. Isotonicity B. Hypotonicity C. Hypertonicity D. None of the options are correct
B
Which of the following health conditions would be LEAST likely to cause fluid and electrolyte imbalances? a. Vomiting and diarrhea b. Breaking a leg c. Renal failure d. Congestive heart failure (CHF)
B
Which of the following is not a hypertonic fluid? A. 3% Saline B. D5W C. 10% Dextrose in Water (D10W) D. 5% Dextrose in Lactated Ringer's
B
Which of the following patients would not be a candidate for a hypotonic solution? A. Patient with Diabetic Ketoacidosis B. Patient with increased intracranial pressure C. Patient experiencing Hyperosmolar Hyperglycemia D. All of the options are correct
B
Your patient is on a *hypotonic IV fluid* solution and is exhibiting a decreased level of consciousness, complains of *nausea*, and just had a *seizure*. Which of the following electrolyte imbalances do you suspect this patient of having? a. Hypernatremia b. Hyponatremia c. Hypercalcemia d. Hypocalcemia
B (A hypotonic IV fluid is a common cause of hyponatremia because it dilutes the serum levels of sodium too much.)
A patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid was removed. Which IV solution may be used to pull fluid into the intravascular space after the paracentesis? a. 0.9% sodium chloride b. 25% albumin solution c. Lactated Ringer's solution d. 5% dextrose in 0.45% saline
B (After a paracentesis of 5 L or greater of ascites fluid, 25% albumin solution may be used as a volume expander. Normal saline, lactated Ringer's solution, and 5% dextrose in 0.45% saline will not be effective for this action.)
An ambulatory elderly woman with dementia is incontinent of urine. She has poor short term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? a. Recommend she be evaluated for an OAB medication. b. Start a scheduled toileting program. c. Recommend she be evaluated for an indwelling catheter. d. Start a bladder retraining program
B (An appropriate first action would be to assess the patency of the drainage system. Urine output in the drainage bag should be more than the volume of the irritant solution infused. If the system is not draining urine and irritant, the irritant should be stopped immediately, the catheter may be occluded and the bladder distended.)
An elderly patient comes to the hospital with a complaint of severe weakness and diarrhea for several days. Of the following problems, which is the most important to assess initially? a. Malnutrition b. Dehydration c. Skin breakdown d. Incontinence
B (Dehydration caused by fluid loss from the intestinal tract is an immediate and possibly dangerous consequence of diarrhea.)
The patient talks with the nurse about bladder health. What is one of the most important recommendations the nurse can make for this patient? a. Eat foods high in fiber. b. Drink 6 to 8 glasses of noncaffeinated fluids daily. c. Exercise in the morning and evening. d. Visit the urologist once yearly.
B (Drinking 6 to 8 glasses of noncaffeinated fluids daily helps with bladder health because urine is not stagnating in the bladder. Exercising and eating foods high in fiber help with bowel elimination but do not have an effect on urination. Visiting the urologist is good if there is a problem, but this is not the most important recommendation from the nurse.)
What nursing intervention decreases the risk for catheter associated urinary tract infection (CAUTI)? a. Cleanse the urinary meatus 3-4 times daily with antiseptic solution. b. Hang the urinary drainage bag below the level with the bladder. c. Empty the urinary drainage bag daily. d. Irrigate the urinary catheter with sterile water.
B (Evidenced based interventions shown to decrease the risk for CAUTI include ensuring that there is a free flow of urine from the catheter to the drainage bag.)
Which of the following would NOT be a cause of fluid volume deficit? a. Diarrhea b. Heart failure c. Vomiting d. Diuretics
B (Heart failure is a cause of fluid volume excess)
You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the health care provider? a. Antibiotics b. Loop diuretics c. Bronchodilators d. Antihypertensives
B (Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing physician should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range.)
The nurse is caring for a 76-yr-old woman admitted to the medical unit with hypernatremia and dehydration after prolonged fever. The best beverage to offer the patient is a. malted milk. b. orange juice. c. tomato juice. d. hot chocolate.
B (Orange juice would be the safest option because it has the least amount of sodium (~2 mg in 8 oz). Hot chocolate has approximately 75 mg sodium in 8 ounces. Tomato juice has approximately 650 mg sodium in 8 oz. Malted milk has approximately 625 mg sodium in 8 oz.)
A patient with hyponatremia is started on IV fluids. Which of the following fluids do you expect the patient to be started on? A. 0.45% Saline B. 3% Saline C. D5W D. 0.33% Saline
B (Patients with hypovolemic hyponatremia are started on a hypertonic solution (the circulatory system is dehydrated & and the cells are swollen...so a hypertonic solution will shrink the cells and increase fluid volume) and 3% Saline is the only hypertonic solutions. The other options are either hypotonic or isotonic.)
The nurse is caring for a confused patient who is wearing a vest restraint in bed. The nurse speaks with an unlicensed assistant about toileting the patient. The nurse knows the unlicensed assistant understands the toileting procedure when making which statement? a. The patient must remain in the restraints all day. b. The patient needs to be toileted to maintain a regular toileting schedule. c. The patient needs to be provided with adult briefs for incontinence. d. The patient will use the call bell when he or she feels the urge to void.
B (The correct answer is toileting the patient so he or she can maintain a normal toileting schedule. Leaving the patient in restraints all day is against the standard of care. Providing the patient with briefs when he or she is not incontinent does not meet the patient's toileting needs. If the patient is confused, he or she will not be able to use the call bell.)
Your patient is experiencing *facial spasms and muscle tremors* after their *thyroidectomy*. Which of the following electrolyte imbalances do you suspect this patient of having? a. Hypercalcemia b. Hypocalcemia c. Hypermagnesemia d. Hypomagnesemia
B (The most common cause of hypocalcemia is a decrease in the production of the parathyroid hormone, which could occur with a thyroidectomy. Common symptoms of hypocalcemia are increased muscle excitability, such as facial spasms and muscle tremors.)
A patient has a tumor that secretes excessive antidiuretic hormone (ADH). He is confused and lethargic. His partner wants to know how a change in blood sodium can cause these symptoms. What should the nurse teach the patient's partner? a. Decreased sodium in the blood causes the blood volume to decrease so that not enough oxygen reaches the brain. b. Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively. c. Increased sodium in the blood causes the blood volume to increase so that too much oxygen reaches the brain. d. Increased sodium in the blood causes brain cells to shrivel so that they do not work as effectively.
B (The normal action of ADH is renal reabsorption of water, which dilutes the blood. Excessive ADH causes hyponatremia, which is manifested by a decreased level of consciousness because the osmotic shift of water into the brain cells impairs their function. Hyponatremia does not decrease the blood volume. Answers that include increased sodium in the blood are incorrect because ADH excess causes hyponatremia rather than hypernatremia.)
A patient injured in an earthquake today when a *wall fell on his legs* received 9 units of blood an hour ago because he was hemorrhaging. Which laboratory value should the nurse check first when the report returns? a. Serum sodium b. Serum potassium c. Serum total calcium d. Serum magnesium
B (The patient has two major risk factors for hyperkalemia: massive sudden cell death from a crushing injury (potassium shift from cells into the extracellular fluid) and massive blood transfusion (rapid potassium intake). Although massive blood transfusion may cause calcium and magnesium ions to bind to citrate in the blood, thereby decreasing the physiological availability of those ions, it does not decrease the total calcium or magnesium laboratory measurements. Clinically significant changes in serum sodium are the least likely in this patient.)
The NAP reports to the nurse that a patient's catheter drainage bag has been empty for 4 hours. What is a priority nursing intervention? a. Implement the "as needed" order to irrigate the catheter. b. Assess the catheter and drainage tubing for obvious occlusion. c. Notify the health care provider immediately. d. Assess the vital signs and intake and output record.
B (The priority nursing intervention is to ensure that there is not an occlusion in the catheter or drainage tubing.)
The nurse is assessing a group of patients to determine their risk of vitamin D deficiency. Which of the following patients has the highest risk for vitamin D deficiency? a. A Caucasian female who is 39 weeks gestation b. An African-American female who is breastfeeding c. An Asian female diagnosed with hypoglycemia d. A Hispanic female who has a BMI of 24.1
B (Vitamin D deficiency is more frequently found among persons of African heritage and has increased in prevalence, especially among the infants of breastfeeding African-American mothers. Caucasian females do not share these risk factors. There is no known risk of hypoglycemia and vitamin D deficiency; however, diabetes increases the risk for vitamin D deficiency. There is no known risk of vitamin D deficiency in normal-weight females of Hispanic heritage; however, obesity is a risk factor.)
A person of Northern heritage is at an increased risk for which of the following? (Select all that apply.) a. Vitamin C deficiency b. Type 1 diabetes c. Celiac disease d. Type 2 diabetes e. Hypertension f. Metabolic syndrome
B C (Type 1 diabetes and Celiac disease are more common in Northern heritage. African Americans and Hispanics are at increased risk for Type 2 diabetes, hypertension, and metabolic syndrome. Vitamin C deficiency is not a common deficiency related to heritage or ethnicity.)
While performing patient teaching regarding hypercalcemia, which statements are appropriate (select all that apply.)? a. Have patient restrict fluid intake to less than 2000 mL/day. b. Renal calculi may occur as a complication of hypercalcemia. c. Weight-bearing exercises can help keep calcium in the bones. d. The patient should increase daily fluid intake to 3000 to 4000 mL. e. Any heartburn can be managed with an as needed calcium-containing antacid.
B C D (A daily fluid intake of 3000 to 4000 mL is necessary to enhance calcium excretion and prevent the formation of renal calculi, a potential complication of hypercalcemia. Tums are a calcium-based antacid that should not be used in patients with hypercalcemia. Weight-bearing exercise does enhance bone mineralization.)
The home health nurse should assess a patient who has chronic diarrhea for which fluid and electrolyte imbalances? a. Extracellular fluid volume (ECV) excess b. Extracellular fluid volume (ECV) deficit c. Hypokalemia d. Hyperkalemia e. Hypocalcemia f. Hypercalcemia
B C E (Chronic diarrhea has a high risk of causing ECV deficit, hypokalemia, and hypocalcemia because it increases the fecal output of sodium-containing fluid, potassium, and calcium. Unless the intake of these substances increases appropriately, imbalances will occur. Excesses of ECV, potassium, and calcium are not likely, because the ECV, potassium, and calcium are being removed from the body.)
A patient has a sodium level of 119. Which of the following is NOT related to this finding? A. Over secretion of ADH (antidiuretic hormone) B. Low salt diet C. Inadequate water intake D. Hypotonic fluid infusion (overload)
C
A patient is presenting with an orthostatic blood pressure of 80/40 when she stands up, thready and weak pulse of 58, and shallow respirations. In addition, the patient has been having frequent episodes of vomiting and nausea and is taking hydrochlorothiazide. Which of the following findings would explain the patient's condition? A. Potassium level of 7.0 B. Potassium level of 3.5 C. Potassium level of 2.4 D. None of the options are correct
C
A patient is recovering from parathyroid surgery. Morning labs values are back. Which of the following lab values would correlate as a complication from this type of surgery? A. Calcium 8.7 B. Calcium 12.5 C. Calcium 6.9 D. Calcium 9.2
C
A patient with Cushing's Syndrome has been experiencing an infection and has a fever of 102'F. On assessment, you find the patient to be confused, restless, has dry mucous membranes, and flushed skin. Which finding below correlates with the presentation of this patient? A. Sodium level of 144 B. Sodium level of 115 C. Sodium level of 170 D. Sodium level of 135
C
A patient with a magnesium level of 3.6 would exhibit which of the signs and symptoms EXCEPT?* a. Profound Lethargy b. EKG changes with prolonged PR & QR interval and widened QRS complex c. Hyperreflexia of the deep tendons d. Hypotension
C
A patient's calcium level is 11.2. Which option below could be the cause? A. None, 11.2 is a normal calcium level B. Cushing's Syndrome C. Hydrochlorothiazide D. Hypoparathyroidism
C
Fluid excess extracellularly in the interstitial space may cause what effect? a. High blood pressure b. Bounding pulse c. Edema d. Crackles
C
Most body fluids are located in the ___________ fluid compartment. A. extracellular B. interstitial C. intracellular D. intravascular
C
The doctor orders an isotonic fluid for a patient. Which of the following is not an isotonic fluid? A. 0.9% Normal Saline B. Lactated Ringers C. 0.45% Saline D. 5% Dextrose in 0.225% saline
C
What type of fluid would a patient with severe hyponatremia most likely be started on? A. Hypotonic B. Isotonic C. Hypertonic D. Colloid
C
Where are most fluids found in the body? A. blood B. interstitial space C. cells
C
Which of the following group of symptoms would trigger you to think there may be some fluid and electrolyte imbalances in your patient? a. Tinnitus, erythema, shortness of breath b. Petechiae, fever, low blood pressure c. Unexplained nausea, dizziness, edema d. Tachycardia, drowsiness, nausea
C
Which patient is at risk for hyperkalemia? A. Patient with Parathyroid cancer B. Patient with Cushing's Syndrome C. Patient with Addison's Disease D. Patient with breast cancer
C
Your patient has a blood pressure of 88/60, a heart rate of 115, a respiratory rate of 22, a urine output of 20 mL/hr, and a BUN level of 23 mg/dL. The patient complains of feeling dizzy and is thirsty. What medical condition do you suspect this patient of having? a. Ascites b. Pleural effusion c. Hypovolemia d. Hypervolemia
C
When a patient has fecal incontinence as a result of cognitive impairment, it may be helpful to teach caregivers to do which of the following interventions? a. Cleanse the skin with antibacterial soap and apply talcum powder to the buttocks b. Use diapers and heavy padding on the bed c. Initiate bowel or habit training program to promote continence d. Help the patient to toilet once every hour
C (A cognitively impaired patient may have forgotten how to respond to the urge to defecate and benefit from a structured program of bowel retraining.)
What is a critical step when inserting an indwelling catheter into a male patient? a. Slowly inflate the catheter balloon with sterile saline. b. Secure the catheter drainage tubing to the bed sheets c. Advance the catheter to the bifurcation of the drainage and balloon ports. d. Advance the catheter until urine flows, then insert ¼ inch more.
C (Advancing the catheter to the bifurcation avoids inflating the catheter balloon in the prostatic urethra causing trauma and pain. Catheter balloons are never inflated with saline. Securing the catheter drainage tubing to the bed sheets increases the risk for accidental pulling or tension on the catheter. The advancement of the catheter until flows and then inserting ¼ inch more is not unique to the male patient.)
You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention? a. Slow the rate to keep vein open until next bag is due at noon. b. Notify the health care provider and complete an incident report. c. Listen to the patient's lung sounds and assess respiratory status. d. Assess the patient's cardiovascular status by checking pulse and blood pressure.
C (After 4 hours of infusion time, 500 mL of IV solution should have infused, not 950 mL. This patient is at risk for fluid volume excess, and you should assess the patient's respiratory status and lung sounds as the priority action and then notify the health care provider for further orders.)
When planning care for stable adult patients, the oral intake that is adequate to meet daily fluid needs is a. 500 to 1500 mL. b. 1200 to 2200 mL. c. 2000 to 3000 mL. d. 3000 to 4000 mL.
C (Daily fluid intake and output is usually 2000 to 3000 mL. This is sufficient to meet the needs of the body and replace both sensible and insensible fluid losses. These would include urine output and fluids lost through the respiratory system, skin, and GI tract.)
The nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which of the following is the priority question to ask the patient or caregiver? a. Have you eaten more high-fiber foods lately? b. Are your bowel movements soft and formed? c. Have you experienced frequent, small liquid stools recently? d. Have you taken antibiotics recently?
C (Frequent or continuous oozing of liquid stools occurs when liquid fecal matter above the impacted stool seeps around the fecal impaction.)
Which nursing intervention minimizes the risk for trauma and infection when applying an external/condom catheter? a. Leave a gap of 3-5 inches between the tip of the penis and drainage tube b. Shave the pubic area so that hair does not adhere c. Wash with soap and water prior to applying the condom type catheter. d. Apply tape to the condom sheath to keep it securely in place.
C (Hygiene minimizes skin irritation. There needs to be 2.5 to 5 cm (1 to 2 inches) of space between tip of the glans penis and the end of the catheter. Excess space may cause pooling of urine causing excessive exposure to urine. Shaving the pubic area increases the risk for skin irritation. The condom should be secure but not tight. Application of tape is contraindicated because it could interfere with circulation increasing risk for necrosis of the penis.)
Your patient appears to be *lethargic and is vomiting*. They complain of *drowsiness* and *nausea*. You check their chart, and see that they have *renal failure*. Which of the following electrolyte imbalances do you suspect this patient of having? a. Hypercalcemia b. Hypocalcemia c. Hypermagnesemia d. Hypomagnesemia
C (Hypermagnesemia usually occurs in patients with renal insufficiency or renal failure who have an increased magnesium intake. They usually get lethargic, drowsy, nauseous, and vomit. With rising levels, deep tendon reflexes are lost, followed by somnolence, then respiratory and cardiac arrest.)
What instructions should the nurse give the NAP concerning a patient who has had an indwelling urinary catheter removed that day? a. Limit oral fluid intake to avoid possible urinary incontinence. b. Expect patient complaints of suprapubic fullness and discomfort. c. Report the time and amount of first voiding. d. Instruct patient to stay in bed and use a urinal or bedpan.
C (In order to adequately assess bladder function after a catheter is removed; voiding frequency and amount should be monitored. Unless contraindicated, fluids should be encouraged. To promote normal micturition, patients should be placed in as normal a posture for voiding as possible. Suprapubic tenderness and pain are possible indicators of urinary retention and/or a UTI.)
Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately? a. Do you leak urine when you cough or sneeze? b. Do you need help getting to the toilet? c. Do you dribble urine constantly? d. Does it burn when you pass your urine?
C (Incontinence characterized by constant dribbling of urine is associated with incontinence associated with urinary retention. . The other options point to stress incontinence, functional incontinence or a UTI.)
When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider? a. Pale yellow urine b. Slightly cloudy urine c. Light pink urine d. Dark amber urine
C (Light pink urine indicates the presence of blood in the urine, which is never a normal finding. First voided urine can normally be slightly cloudy and darker in color. Pale yellow urine indicates normal finding.)
Your *kidney stone* patient is exhibiting signs of *decreased memory, confusion, muscle weakness, and is disorientated to time and place.* Which of the following electrolyte imbalances do you suspect this patient of having? a. Hypernatremia b. Hyponatremia c. Hypercalcemia d. Hypocalcemia
C (Manifestations of hypercalcemia include decreased memory, confusion, disorientation, fatigue, muscle weakness, constipation, cardiac dysrhythmias, and renal calculi.)
Which nursing intervention is most appropriate when caring for a patient with dehydration? a. Monitor skin turgor every shift. b. Auscultate lung sounds every 2 hours. c. Monitor daily weight and intake and output. d. Encourage the patient to reduce sodium intake.
C (Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume.)
When assessing a patient admitted with nausea and vomiting, which finding best supports the nursing diagnosis of deficient fluid volume? a. Polyuria b. Bradycardia c. Restlessness d. Difficulty breathing
C (Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma.)
If a patient has a colostomy in the area known as the "ascending colon," what would the nurse expect of the stool in the colostomy device? a. Stool would be dark. b. Stool would be formed. c. Stool would be loose. d. Stool would have flecks of blood.
C (The correct answer is C because stool in the ascending colon is loose or watery. Stool should not be dark or have flecks of blood. This would be an abnormal finding. Stool would not be loose, because the colon has not reabsorbed the water yet.)
Your patient who has *renal failure* has a *cardiac dysrhythmia* upon auscultation. They are also complaining of *muscle weakness* and a *cramp* in their left leg. Which of the following electrolyte imbalances do you suspect this patient of having? a. Hyponatremia b. Hypokalemia c. Hyperkalemia d. Hypocalcemia
C (The most common cause of hyperkalemia is *renal failure*, it is also common with *burn or crush injuries.* Significant manifestations of hyperkalemia are disturbances in cardiac conduction (*cardiac dysrhythmias*) as well as issues with weakness or paralysis of skeletal muscles, and leg cramping.)
You receive a physician's order to change a patient's IV from D5½ NS with 40 mEq KCl/L to D5NS with 20 mEq KCl/L. Which serum laboratory values on this same patient best support the rationale for this IV order change? a. Sodium, 136 mEq/L; potassium, 3.6 mEq/L b. Sodium, 145 mEq/L; potassium, 4.8 mEq/L c. Sodium, 135 mEq/L; potassium, 4.5 mEq/L d. Sodium, 144 mEq/L; potassium, 3.7 mEq/L
C (The normal range for serum sodium is 135 to 145 mEq/L, and the normal range for potassium is 3.5 to 5.0 mEq/L. The change in the IV order decreases the amount of potassium and increases the amount of sodium. Therefore, for this order to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective ranges.)
A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? a. Lactated Ringer's b. Dextrose 5% in 0.9% sodium chloride c. 0.45% sodium chloride d. Dextrose 10% in water
C (This is the only hypotonic solution)
A patient is being discharged home after hospitalization with hypocalcemia. Which statement by the patient indicates she understood the dietary instructions? A. "I will avoid sardines. B. "I'll avoid salt and Vitamin-D supplements." C. "I will tell my husband to only purchase skim milk." D. "I will be sure to eat lots of cheese, tofu and spinach."
D
A patient with anorexia is admitted to your ER with the following symptoms: Hyperactive deep tendon reflexes, tremors, confusion, and seizures. Which of the following electrolyte imbalances do you suspect this patient of having? a. Hypercalcemia b. Hypocalcemia c. Hypermagnesemia d. Hypomagnesemia
D
A patient's lab work shows that they have a high parathyroid hormone level. Which condition is the patient at risk for?* A. Hyperkalemia B. Hypocalcemia C. Hypokalemia D. Hypercalcemia
D
Which of the following would NOT be a cause of fluid volume excess? a. Heart failure b. Renal failure c. Excessive IV fluids d. Polyuria
D
Your patient is confused, has edema, crackles, difficulty breathing, a blood pressure of 160/100, has gained 4 lbs since the day before, and low hematocrit and hemoglobin levels. What medical condition do you suspect this patient of having? a. Ascites b. Pleural effusion c. Hypovolemia d. Hypervolemia
D
You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy? a. Sodium falling to 138 mEq/L b. Potassium rising to 4.1 mEq/L c. Magnesium rising to 2.9 mg/dL d. Phosphorus falling to 2.1 mg/dL
D (Calcium has an inverse relationship with phosphorus in the body. When phosphorus levels fall, calcium rises, and vice versa. Because hypercalcemia rarely occurs as a result of calcium intake, the patient's phosphorus falling to 2.1 mg/dL (normal, 2.4-4.4 mg/dL) may be a result of the phosphate-binding effect of calcium carbonate.)
When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit? a. Fluid movement from the blood vessels into the cells b. Fluid movement from the interstitial spaces into the cells c. Fluid movement from the blood vessels into interstitial spaces d. Fluid movement from the interstitial space into the blood vessels
D (In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.)
The nurse evaluates which laboratory values to assess a patient's potential for wound healing? a. Fluid status b. Potassium c. Lipids d. Nitrogen balance
D (Nitrogen balance is important to determining serum protein status. A negative nitrogen balance is present when catabolic states exist. When a patient has a decreased protein level, he or she is at risk for delayed wound healing.)
