Unit 5 Exam - 01

A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings? Decreased urine specific gravity Decreased Hgb Increased BUN Increased urine ketones

Increased BUN

A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as the best source of potassium? Bananas Cooked carrots Cheddar cheese 2% milk

Bananas

During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer? Squamous cell carcinoma Basal cell carcinoma Malignant melanoma Actinic keratosis

Basal cell carcinoma

A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client?Chvostek's sign Babinski's sign Brudzinski's sign Kernig's sign

Chvostek's sign

A nurse is reviewing a clients laboratory report of blood gas findings: HCO₃- 18 mEq/L and PaCO₂ 28 mm Hg. Which of the following pH values and conditions should the nurse expect when interpreting these findings? Decreased pH and metabolic acidosis Decreased pH and respiratory acidosis Elevated pH and metabolic alkalosis Elevated pH and respiratory alkalosis

Decreased pH and metabolic acidosis

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?Lactated Ringer's Dextrose 5% in 0.9% sodium chloride 0.45% sodium chloride Dextrose 10% in water

0.45% sodium chloride

A nurse is calculating the total fluid intake for a client during a 4-hr period. The client consumes 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

1170

A nurse is preparing to administer potassium chloride 20 mEq suspension PO daily. The amount available is potassium chloride suspension 10 mEq/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2

A nurse is caring for a client who has an NG tube set to low intermittent suction. The nurse irrigates the NG tube twice with 30 mL of normal saline solution during his shift. At the end of the shift, the NG canister contains 475 mL. What amount of NG drainage should the nurse record? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

415

A nurse is completing an 8-hr I&O record for a client who consumed 4 oz juice, 6 oz hot tea, 100 mL ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the clients record?

740

A nurse is assessing four clients for fluid balance. The nurse should identify that which of the following clients is exhibiting manifestations of dehydration? client who has a urine specific gravity of 1.010. A client who has a weight gain of 2.2 kg (2 lb) in 24 hr. A client who has a hematocrit of 45% A client who has a temperature of 39° C (102° F)

A client who has a temperature of 39 C (102 F)

A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis? A client who has diarrhea A client who is vomiting A client who is taking a thiazide diuretic A client who has salicylate intoxication

A client who has diarrhea A client who is vomiting A client who is taking a thiazide diuretic A client who has salicylate intoxication

A nurse is preparing to administer phenytoin IV to a client who has a seizure disorder. Which of the following actions should the nurse plan to take? Administer the medication at 100 mg/min. Administer a saline solution after injection. Hold the injection if seizure activity is present. Dilute the medication with dextrose 5% in water.

Administer a saline solution after injection.

A nurse is preparing to administer phenytoin 50 mg by intermittent IV bolus to a client who has a seizure disorder. Which of the following actions should the nurse take? Slow the injection if the medication crystallizes. Dilute the medication before injecting. Follow the IV injection with sterile water. Administer the medication over 1 min.

Administer the medication over 1 min.

A nurse is providing teaching to a client who has seizures and a new prescription for phenytoin. Which of the following information should the nurse provide? Phenytoin turns urine blue. Alcohol increases the chance of phenytoin toxicity. Avoid flossing the teeth to prevent gum irritation. Take an antacid with the medication if indigestion occurs.

Alcohol increases the chance of phenytoin toxicity.

After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?Apply hydrating lotions. ​Apply moist heat. Sit in the sun for 10 min per day. ​Wash with plain soap and water.

Apply hydrating lotions.

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss? Body weight Skin integrity Blood pressure Respiratory rate

Body weight

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings?Urge incontinence Critically elevated prostate-specific antigen (PSA) level Difficulty starting the flow of urine Painful urination

Difficulty starting the flow of urine

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate? Collect a urine specimen for culture and sensitivity. Continue routine care because the results are within the expected reference range. Decrease the IV fluid infusion rate and limit oral fluid intake. Evaluate urine for amount and for specific gravity.

Evaluate urine for amount and for specific gravity.

A nurse is caring for a client who is two days postoperative following creation of an ileal conduit. Which of the following is an unexpected finding associated with this procedure? Edema of the stoma Urine in the drainage appliance Redness of the stoma Feces in the drainage appliance

Feces in the drainage appliance

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following medications should the nurse plan to administer? Danazol Finasteride Fluoxymesterone Methyltestosterone

Finasteride

A nurse is caring for a client who has heart failure and a new prescription for furosemide. For which of the following adverse effects should the nurse monitor? Hypervolemia Hypertension Hypokalemia Hypoglycemia

Hypokalemia

A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor?Hypermagnesemia Hypokalemia Hyperkalemia Hypomagnesemia

Hypokalemia

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching? A. "I will notify my doctor before taking any other medications." B. "I have made an appointment to see my dentist next week." C."I know that I cannot switch brands of this medication." D. "I'll be glad when I can stop taking this medicine."

I'll be glad when I can stop taking this medicine.

A nurse is assessing a client who presents to the provider's office for evaluation of multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy? Irregular borders Purulent drainage Uniform pigmentation Intense pruritus

Irregular borders

A nurse is caring for a client who has prostate cancer. The nurse should expect the provider to prescribe which of the following medications for this client? Leuprolide Cyclophosphamide Finasteride Tamoxifen

Leuprolide

A nurse is caring for a client who has the following arterial blood gas results: HCO₃ 18 mEq, PaCO₂ 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis

Metabolic acidosis

A nurse is admitting a client who has influenza and is reporting numbness and tingling of the toes and fingers. The nurse should recognize the client is experiencing which of the following acid-base imbalances? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Metabolic alkalosis

A nurse is caring for a client who is experiencing severe nausea and vomiting after a course of chemotherapy. The nurse should monitor the client for which of the following clinical manifestations?Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Metabolic alkalosis

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching? "Insert a padded tongue blade into the client's mouth." "Restrain the client." "Place the client on his back." "Move objects away from the client."

Move objects away from the client.

A nurse is teaching a client who is receiving treatment for metastatic colorectal cancer about the adverse effects of bevacizumab with. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?Weight gain Mild hearing loss Temporary loss of smell Nosebleeds

Nosebleeds

A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take? Review laboratory test results for low hemoglobin. Observe for signs of infection. Monitor the mouth for signs of xerostomia. Examine the skin for generalized urticaria.

Observe for signs of infection.

A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care? Obtain IV access. Keep the lights on when the client is sleeping. Place the client's bed in the high position. Keep a padded tongue blade available at the client's bedside.

Obtain IV access.

A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect?HCO3- 30 mEq/L PaCO2 50 mm Hg pH 7.45 Potassium 3.3 mEq/L

PaCO2 50 mm Hg

A nurse enters a clients room and finds him on the floor in the clonic phase of a tonicclonic seizure. Which of the following actions should the nurse take? Insert a padded tongue blade into the client's mouth. Place a pillow under the client's head. Gently restrain the client's extremities. Apply a face mask for oxygen administration.

Place a pillow under the clients head.

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take? Attempt to stop the seizure. Restrain the child's arms. Use a padded tongue blade. Position the child laterally.

Position the child laterally.

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority? Place a pillow under the child's head. Position the child side-lying. Loosen restrictive clothing. Clear the area of hazards.

Position the child side-lying.

A nurse is evaluating a client's laboratory results. The nurse should recognize that an increase in the client's prostate specific antigen (PSA) laboratory value is indicative of which of the following diagnoses? Breast cancer Colon cancer Liver cancer Prostatic cancer

Prostatic cancer

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs?<br/><br/> pH 7.22<br/> PaCO<small>₂</small> 68 mm Hg <br/> Base excess -2<br/> PaO<small>₂</small> 78 mm Hg<br/> Saturation 80%<br/> Bicarbonate 26 mEq/L Respiratory acidosis Metabolic acidosis Metabolic alkalosis Respiratory alkalosis

Respiratory acidosis

A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO₂ of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis

Respiratory acidosis

A nurse is caring for an older adult client who has a WBC count of 2,000/mm³ after three rounds of chemotherapy. Which of the following actions should the nurse take?Humidify the client's room. Serve cooked fruit with meals. Clean dentures in a denture cup. Replace the water in flower vases with fresh water daily.

Serve cooked fruit with meals.

A nurse is caring for a 2-year-old child who has seizures and is receiving phenytoin in suspension form. Which of the following actions should the nurse take before administering each dose?Shake the container vigorously. Be sure the child has not eaten within the hour. Perform mouth care. Check the child's blood pressure.

Shake the container vigorously.

A nurse is teaching a client who has a new prescription for phenytoin. The nurse should instruct the client to monitor for and report which of the following adverse effects of this medication? Lactated Ringer's Dextrose 5% in 0.9% sodium chloride 0.45% sodium chloride Dextrose 10% in water

Skin rash

A nurse is providing teaching to a client who has a superficial lesion and has had a biopsy indicates malignant melanoma. The nurse should include which of the following options as the treatment of choice? Cryosurgery Chemotherapy Radiation therapy Surgical excision

Surgical excision

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia? The client who has a tracheostomy tube attached to humidified oxygen The client who has an indwelling urinary catheter to gravity drainage The client who has a chest tube to water seal The client who has a nasogastric (NG) tube to suction

The client who has a nasogastric (NG) tube to suction

A nurse is teaching a client about the adverse effects of cisplatin. Which of the following adverse effects should the nurse include in the teaching? Tinnitus Constipation Hyperkalemia Weight gain

Tinnitus

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?Turn the client's head to the side. Check the client's motor strength. Loosen the clothing around the client's waist. Document the time the seizure began.

Turn the client's head to the side.

A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment? Sodium 165 mEq/L Potassium 5.2 mEq/L Urine specific gravity 1.020 Hct 62%

Urine specific gravity 1.020

A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings? Urine specific gravity 1.035 Hematocrit 44% BUN 19 mg/dL Sodium 155 mEq/L

Urine specific gravity 1.035

A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? pH below 7.35 HCO3 above 26 mEq/L PaO2 below 70 mm Hg PaCO2 above 45 mmHg

pH below 7.35