Nursing 1, Unit 4 Questions

a (metabolic acidosis results from an excess production of hydrogen ions, which occurs in diabetic ketoacidosis.)

A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis. Which of the following statements by a unit nurse indicates the teaching has been effective? a. "Metabolic acidosis can occur due to diabetic ketoacidosis." b. "Metabolic acidosis can occur in a client who has myasthenia gravis." c. "Metabolic acidosis can occur and a client who has asthma." d. "Metabolic acidosis can occur due to cancer."

a, d (The nurse should cover the wound with a sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissue moist until the surgeon can assess and intervene. The supine position with hips and knees bent minimizes pressure to the abdominal area.)

A client who had abdominal surgery 24 hours ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply) a. Cover the area with Saline-soaked sterile dressings. b. Apply an abdominal binder snugly around the abdomen. c. Use sterile gauze to apply gentle pressure to the exposed tissue. d. Position the client supine with his hips and knees bent. e. Offer the client a warm beverage, such as herbal tea.

a (A clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate.)

A client who has an indwelling catheter reports the need to urinate. Which of the following actions should the nurse take? a. Check to see whether the catheter is patent. b. Reassure the client that it is not possible for her to urinate. c.Recatheterize the bladder with the large-gauge catheter. d. Collect a urine specimen for analysis.

a, e (Open pressure ulcers and open burns heal by secondary intention which is the process for wounds that have tissue loss and widely separated edges.)

A nurse educator is reviewing the world healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply) a. Stage III pressure ulcer b. Sutured surgical incision c. Casted bone fracture d. Laceration sealed with adhesive e. Open burn area

b, d (caffeine is a bladder irritant and can worsen stress incontinence. Alcohol is a bladder irritant and can worsen stress incontinence.)

A nurse in a providers office is evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions should the nurse suggest for helping to control or illuminate the clients incontinence? (Select all that apply) a. Limit total daily fluid intake. b. Decrease or avoid caffeine. c. Take calcium supplements. d. Avoid drinking alcohol. e. Use the Credé maneuver.

a, b, d, e (decreased skin turgor is a manifestation present with fluid volume deficit. Skin turgor is decreased due to the lack of fluid within the body and results in dryness of the skin. Concentrated urine is a manifestation present with fluid volume deficit. Urine is concentrated due to lack of fluid in the vascular system causing a decrease profusion of the kidneys and resulting in an increased urine specific gravity. Low-grade fever is a manifestation present with fluid volume deficit. Low-grade fever is one of the body's ways to maintain homeostasis to compensate for lack of fluid within the body. Tachypnea is a manifestation present with fluid volume deficit. Increased respirations are the body's way to obtain oxygen due to the lack of fluid volume within the body.)

A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? (Select all that apply) a. Decreased skin turgor b. Concentrated urine c. Bradycardia d. Low-grade fever e. Tachypnea

a, b, d, e (dyspnea is a manifestation present with fluid volume excess. Dyspnea is due to excess of fluids within the body and lungs, and the client is struggling to breathe to obtain oxygen. Edema is a manifestation present with fluid volume excess, weight gain can be a result of Edema. Hypertension is a manifestation related to fluid volume excess. Blood pressure rises as the heart must work harder due to the excess of fluid. Weakness is a manifestation present with fluid volume excess. Weakness is due to the excess fluid that is retained, which depletes energy and increases the workload for the body.)

A nurse is admitting an older adult client who is experiencing dyspnea, weakness, weight gain of 2 lbs, and 1+ bilateral Edema of the lower extremities. The client has a temperature of 37.2°C (99°F), a pulse of 96 bpm, respirations of 26 per minute, oxygen saturation 94% on 3 L oxygen via nasal cannula, and blood pressure 152/96 mmHg. Which of the following manifestations of fluid volume excess should the nurse expect? (Select all that apply) a. Dyspnea b. Edema c. Bradycardia d. Hypertension e. Weakness

c (The nurse taps the clients cheek over the facial nerve just below and anterior, to the ear to elicit Chvostek's sign. A positive response is indicated when the client exhibits facial twitching on the side of her face.)

A nurse is assessing a client for Chvostek's sign. Which of the following techniques should the nurse use to perform this test? a. Apply a blood pressure cuff to the clients arm. b. Place the stethoscope bell over the clients carotid artery. c. Tap lightly on the client's cheek. d. Ask the client to lower her chin to her chest.

a (Hyperkalemia, an increase in serum potassium, is a laboratory findings associated with diabetic ketoacidosis.)

A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance? a. Diabetic ketoacidosis b. Heart failure c. Cushing's syndrome d. Thyroidectomy

e, f (dysrhythmia & tachypnea are expected findings in a client who has pancreatitis and metabolic acidosis)

A nurse is assessing a client who has pancreatitis. The clients arterial blood gases reveal metabolic acidosis. Which of the following are expected findings? (Select all that apply.) a. Tachycardia b. Hypertension c. Bounding pulses d. Hyperreflexia e. Dysrhythmia f. Tachypnea

d (Tachycardia is an attempt to maintain blood pressure, a manifestation of fluid volume deficit.)

A nurse is assessing a client who is dehydrated for fluid volume deficit. Which of the following findings should the nurse expect in the client? a. Moist skin b. Distended neck veins c. Increased urinary output d. Tachycardia

c (an aspirin overdose would result in arterial blood gas findings of metabolic acidosis.)

A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to her bed. Vital signs revealed blood pressure 104/70 2 mmHg, heart rate 116 bpm with regular rhythm, and respiratory rate 42/minute and deep. Which of the following arterial blood gas findings should the nurse expect? a.pH: 7.68 PaO2: 96 mmHg PaCO2: 38 mmHg HCO3-: 28mEq/L b.pH: 7.48 PaO2: 100 mmHg PaCO2: 28 mmHg HCO3-: 23 mEq/L c.pH: 6.98 PaO2: 100 mmHg PaCO2: 30 mmHg HCO3-: 18mEq/L d.pH: 7.58 PaO2: 96 mmHg PaCO2: 38 mmHg HCO3-:29mEq/L

b (The nurse should monitor the client for hyponatremia. Nasogastric losses are isotonic and contain sodium.)

A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances? a. Hypercalcemia b. Hyponatremia c. Hyperphosphatemia d. Hyperkalemia

a (The nurse should discard the first voiding of the 24-hour urine specimen, and note the time.)

A nurse is caring for a client who has a prescription for a 24 hour urine collection. Which of the following actions should the nurse take? a. Discard the first voiding. b. Keep the urine in a single container at room temperature. c. Ask the client to urinate and pour the urine into a specimen container. d. Asked the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.

a (The nurse should assess for ECG changes. Potassium levels can affect the heart and result in arrhythmias.)

A nurse is caring for a client who has a serum potassium 5.4 mEq/L. The nurse should assess for which of the following manifestations? a. ECG changes b. Constipation c. Polyuria d. Paresthesia

a (three tap water enema's can result in a decrease in serum sodium and potassium. Tapwater is hypotonic, and gastrointestinal losses are isotonic. This creates an imbalance and solute dilution.)

A nurse is caring for a client who has a serum sodium level 133 mEq/L and serum potassium level 3.4 mEq/L. The nurse should recognize that which of the following treatments can result in these laboratory findings? a. Three tap water enema's b. 0.9% sodium chloride solution IV at 50 mL/hour c. 5% dextrose with 0.45% sodium chloride solution with 20 mEq of K+ IV at 80 mL/hour d. Antibiotic therapy

b, c, d (prolonged diarrhea leads to dehydration - the nurse should expect the client to have an increased blood pressure, increased temperature, and have poor skin turgor.)

A nurse is caring for a client who has had diarrhea for 4 days. When assessing the client, the nurse should expect which of the following findings? (Select all that apply) a. Bradycardia b. Hypotension c. Elevated temperature d. Poor skin turgor e. Peripheral edema

a, c, e (The nurse should immediately stop the infusion if an allergic transfusion reaction is suspected. The nurse should administer 0.9% sodium chloride solution through new IV tubing if an allergic transfusion reaction is suspected. The nurse should administer an antihistamine, such as diphenhydramine, if an allergic transfusion reaction as suspected.)

A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse expect if an allergic transfusion reaction is suspected? (Select all that apply) a. Stop the transfusion. b. Monitor for hypertension. c. Maintain an IV infusion with 0.9% sodium chloride. d. Position the client in an upright position with the feet lower than the heart. e. Administer diphenhydramine.

a (A pneumothorax can cause alveolar hypoventilation and increased carbon dioxide levels, resulting in a state of respiratory acidosis.)

A nurse is caring for a client who was in a motor vehicle accident. The client reports chest pain and difficulty breathing. A chest x-ray reveals the client has pneumothorax. Which of the following arterial blood gas finding should the nurse expect? a . pH: 7.06 PaO2: 86 mmHg PaCO2: 52 mmHg HCO3-: 24mEq/L b . pH: 7.42 PaO2: 100 mmHg PaCO2: 38 mmHg HCO3-: 23 mEq/L c . pH: 6.98 PaO2: 100 mmHg PaCO2: 30 mmHg HCO3-: 18 mEq/L d . pH: 7.58 PaO2: 96 mmHg PaCO2: 38 mmHg HCO3-: 29 mEq/L

d (for fecal occult blood testing, the nurse should warn the client not to contaminate the stool specimens with water or urine.)

A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client? a. Eating more protein is optimal prior to testing. b. One stool specimen is sufficient for testing. c. A red color change indicates a positive test. d. The specimen cannot be contaminated with urine.

b, c (The client who has type 1 diabetes mellitus is at risk for impaired circulation and impaired immune system function.)

A nurse is caring for an adolescent client who is 2 days post operative following an appendectomy and has type 1 diabetes Mellitus. The client is tolerating a regular diet. He has ambulated successfully around the unit with Assistance. He requests pain medication every 6 to 8 hours while reporting pain at a 2 on a scale of 0 to 10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing?Select all that apply) a. Extremes in age b. Impaired circulation c. Impaired/suppressed immune system d. Malnutrition e. Poor wound care

d (The nurse should monitor for orthostatic hypotension because he has manifestations of dehydration due to decreased circulatory volume.)

A nurse is caring for an older adult client in a long-term care facility. The client has become weak and confused. He ate 40% of his breakfast at lunch. The clients temperature is 38.3°C (100.9°F), pulse 92 bpm, respirations 20/minute, and blood pressure 108/60 mmHg. He has lost 3/4 lbs and reports dizziness when assisting to the bathroom. He also has a non-productive cough with diminished breath sounds in the right lower lobe. Which of the following actions should the nurse take? a. Initiate fluid restrictions to limit intake. b. Observe for signs of peripheral Edema c. Encourage the client to ambulate to promote oxygenation. d. Monitor for orthostatic hypotension.

a, d (The nurse should slightly elevate the client head of bed, reduce sheering forces that could tear sensitive skin on the sacrum, but ox, and heels. The nurse should have a client sit on a gel, air, or foam cushion to redistribute weight away from ischial areas.)

A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse used to help maintain the integrity of the clients skin? (Select all that apply) a. Keep the head of the bed elevated 30°. b. Massage the clients bony prominences frequently. c. Apply cornstarch liberally to the skin after bathing. d. Have the client sit on a gel cushion when in a chair. e. Re-position the client at least every three hours while in bed.

a, b, c (The nurse should expect the client to have pain and tenderness, to have fever and chills, and to have reddened and or inflamed wound edges with an incisional infection.)

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (Select all that apply) a. Increase in incisional pain b. Fever and chills c. Reddened wound edges d. Increase in serosanguineous drainage e. Decrease in thirst

c, e (tachycardia is an indication of a febrile transfusion reaction. A flushed appearance of the client can indicate a febrile transfusion reaction.)

A nurse is monitoring a client who began receiving a unit of packed RBCs 10 minutes ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? (Select all that apply) a. Temperature change from 37°C (98.6°F) pre-transfusion to 37.2°C (99.0°F) b. Current blood pressure 178/90 mmHg c. Heart rate change from 88 bpm pre-transfusion to 120 bpm d. Client reports of itching e. Client appears flushed

d (Excessive vomiting causes a loss of gastric acids and an accumulation of bicarbonate in the blood, resulting in metabolic alkalosis.)

A nurse is obtaining arterial blood gases for a client who has vomited for 24 hours. The nurse should expect which of the following acid-base imbalances to result from vomiting for 24 hours? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

c, d, e (Tachycardia and syncope are expected findings of hypovolemia. Decreased skin turgor is an expected finding up hypovolemia.)

A nurse is performing in admission assessment on a client who has hypervolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply) a. Distended neck veins b. Hyperthermia c. Tachycardia d. Syncope e. Decreased skin turgor

b (The nurse should include obtaining the clients weight each day in the plan of care. To ensure accuracy the clients weight should be obtained at the same time each day using the same scale. By determining the clients weight gain or loss each day the nurse can evaluate the clients response to treatment.)

A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? a. Administering antihypertensive on schedule. b. Check the clients weight each morning. c. Notify the provider of a urine output greater than 30 mL/hr. d. Encourage independent ambulation four times a day.

a, b, c (The nurse should warm the enema solution because cold fluid can cause abdominal cramping, and hot fluid can injure the intestinal mucosal. The nurse should place the client in this position to promote a downward flow of solution by gravity along the natural anatomical curve of the sigmoid colon. The nurse should lubricate the tubing to prevent trauma or irritation to the rectal mucosa.)

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which if the following steps should the nurse take? a. Warm the enema solution prior to instillation. b. Position the client in the left side with the right leg flexed forward. c. Lubricator the recital tube or nozzle. d. Hang the enema container 61 cm (24 in) above the client's anus. e.

b (The nurse should assess for an acute hemolytic reaction during the first 15 minutes of the transfusion. This form of a reaction can occur following the transfusion of as little as 10 mL of blood product.)

A nurse is preparing to administer packed RBCs to a client who has a Hgb of 8 g/dL. Which of the following actions should the nurse plan to take during the first 15 minutes of the transfusion? a. Obtain consent from the client for the transfusion. b. Assess for an acute hemolytic reaction. c. Explain the transfusion procedure to the client. d. Obtain blood culture specimens to send to the lab.

b, c, d (The nurse should ask the client to keep track of urination times as a record of progress towards the goal of 4-hour intervals between urination. Gradually increasing the urination intervals helps the client progress towards the goal of 4-hour intervals between urination. The nurse should remind the client to hold urine until the next scheduled urination time as part of progressing toward the goal of 4-hour intervals between urination.)

A nurse is preparing to initiate a bladder retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply) a. Establish a schedule of urinating prior to the meal times. b. Have the client record urination times. c. Gradually increase the urination intervals. d. Remind the client to hold urine until the next scheduled urination time. e. Provide a sterile container for urine.

c (beginning six weeks prior to surgery, the client can donate blood to each week for autologous transfusion if his Hgb and Hct remain stable.)

A nurse is providing preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching? a."You should make an appointment to donate blood at eight weeks prior to the surgery." b. "If you need an autoLou's transfusion, the blood your brother donates can be used." c. "You can donate blood to each week if your hemoglobin is stable." d. "Any unused blood that is donated can be used for other clients."

a, d, e (having frequent sexual intercourse increases the risk of UTIs in both men and women. The close proximity of the female urethra to the anus is a factor that increases the risk of UTIs. Frequent catheterization and the use of indwelling catheter are risk factors for UTIs.)

A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has recurrent UTIs. Which of the following factors should the nurse include? (Select all that apply.) a. Frequent sexual intercourse b. Lowering of testosterone levels c. Wiping from front to back d. Location of the urethra in relation to the anus e. Frequent catheterization

a, c, d (The Hct is greater than the expected reference range of 42 to 52% for men, and 37 to 47% for women and is an indication of dehydration due to hemoconcentration. The serum sodium level is greater than the expected reference range of 136 to 145 mEq/L and is an indication of dehydration due to hemoconcentration. This urine specific gravity is greater than the expected reference range of 1.005 to 1.030. And increased urine specific gravity is an indication of dehydration.)

A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should recognize which of the following findings is a manifestation of dehydration? (Select all that apply) a. Hct 55% b. Serum osmolarity 260 mOsm/kg c. Serum sodium 150 mEq/L d. Urine specific gravity 1.035 e. Serum creatinine 0.6 mg/dL

b (A high fiber diet promotes normal bowel elimination. The nurse should recommend the client consume fresh fruits and vegetables with whole-grain carbohydrates to provide the highest fiber option.)

A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? a. Macaroni and cheese b. Fresh fruit and whole wheat toast c. Bread putting and yogurt d. Roast chicken and white rice

b (The nurse should anticipate a client who has heart failure to require fluid and sodium restriction to reduce the workload on the heart.)

A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse anticipate a prescription for fluid restriction? a. A client who has a new diagnosis of adrenal insufficiency b. A client who has heart failure c. A client who is receiving treatment for diabetic ketoacidosis d. A client who has abdominal ascites

a (The nurse should identify that a client who has nasogastric suctioning is at risk for hypovolemia due to excessive gastrointestinal losses.)

A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypervolemia? a. A client who has nasal gastric suctioning. b. A client who has chronic constipation. c. A client who has syndrome of inappropriate antidiuretic hormone. d. A client who took an overdose of sodium bicarbonate antacids.

d (The nurse should check the older adult clients vital signs every 15 minutes throughout the transfusion to allow for early detection of fluid overload or other transfusion reaction.)

A nurse preceptor is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? a. Inserts and 18 gauge IV catheter and the client b. Verifies blood compatibility and expiration date of the blood with an assistive personnel (AP) c. Administers dextrose 5% in 0.9% sodium chloride IV with the transfusion d. Obtained vital signs every 15 minutes throughout the procedure

d (to relieve the clients discomfort, the nurse should slow the rate of installation by reducing the height of the enema solution container.)

While a nurse Is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? a. Have the client hold his breath briefly and bear down. b. Discontinue the fluid instillation. c. Remind the client that cramping is common at this time. d. Lower the enema fluid container.