Evolve Practice Questions for Exam 1

Which type of collaborative action would the nurse anticipate the need to rapidly implement when caring for a client who has a blood pressure of 80/60 mmHg and heart rate of 120 beats/minutes after motor vehicle accident? A: Increase circulating blood volume B: Administer arterial vasopressors C: Stimulate increased heart rate D: Correct electrolyte disturbances

A: Increase circulating blood volume

While in the post anesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse A: Initiate oxygen via a nasal cannula B: Administer the prescribed morphine C: Prepare the client for endotracheal intubation D: Place a nitroglycerin tablet under the client's tongue

A: Initiate oxygen via a nasal cannula

Which dietary restriction will the nurse expect to be included in the plan for a client with left ventricular failure? A: Sodium B: Calcium C: Potassium D: Magnesium

A: Sodium

A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse would monitor which laboratory results? A: Sodium and chloride levels B: Bicarbonate and sulfate levels C: Magnesium and protein levels D: Calcium and phosphate levels

A: Sodium and chloride levels

Which explanation would the nurse include when teaching a client with heart failure about the reason for a low-sodium diet A: Body weight control B: Decreased fluid retention C: Lowering of blood pressure D: Prevention of hypernatremia

B: Decreased fluid retention

Which clinical manifestation would the nurse include when teaching a client with heart failure about signs and symptoms that indicate a need to contact the primary health care provider? Select all that apply. A: Weight loss B: Extreme fatigue C: Coughing at night D: Excessive urination E: Difficulty breathing

B: Extreme fatigue C: Coughing at night E: Difficulty breathing

Which instruction would the nurse use when preparing a client who successfully passed his or her renal calculus for discharge home? A: Continue to strain all urine B: Increase your fluid intake C: Limit dietary potassium D: Maintain bed rest for 24 hours

B: Increase your fluid intake

Which diagnostic test will the nurse use to confirm the diagnosis when hypokalemia is suspected? A: Complete blood cell count B: Serum potassium level C: X-ray film of long bones D: Blood cultures x3

B: Serum potassium level

For which clinical manifestation will the nurse monitor for when caring for a client admitted with heart failure? Select all that apply A: Weight loss B: Unusual fatigue C: Dependent edema D: Nocturnal dyspnea E: Increased urinary output

B: Unusual fatigue C: Dependent edema D: Nocturnal dyspnea

How would the nurse describe heart failure to a client? A: A cardiac condition caused by inadequate circulating blood volume B: An acute state in which the pulmonary circulation pressure decreases C: An inability of the heart to pump blood in proportion to metabolic needs D: A chronic state in which the systolic blood pressure drops below 90 mmHg

C: An inability of the heart to pump blood in proportion to metabolic needs

Which condition unrelated to cardiac disease is the major cause of right ventricular failure? A: Hypovolemic shock B: Chronic kidney disease C: COPD D: Systemic inflammatory response syndrome

C: COPD

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles, Which is the priority nursing intervention A: Obtain chest a-ray film immediately B: Notify the primary health care provider C: Place client in high-Fowler's position D: Assess the client's oxygen saturation level

C: Place client in high-Fowler's position

A client with coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen? A: To prevent dyspnea B: To prevent cyanosis C: To increase oxygen concentration to heart cells D: To increase oxygen tension in the circulating blood

C: To increase oxygen concentration to heart cells

Which response would the nurse make to a 30-year-old client diagnosed with hyperlipidemia and hypertension who asks the nurse to explain why treatment is important stating "I feel fine" A: Both high blood pressure and high cholesterol contribute to development of heart disease B: Lifestyle adaptations alone will be adequate enough as long as you continue to be asymptomatic C: Usually someone with these diagnoses will have symptoms of heart disease already D: You should discuss your questions about medical problems with the health care provider

A: Both high blood pressure and high cholesterol contribute to development of heart disease

Which finding by the nurse when assessing a client who is receiving intravenous fluid indicates need for a change in the fluid infusion rate? A: Crackles in lungs B: Supple skin turgor C: Urine output of 480 mL over 8 hours D: Heart rate decrease from 126 bpm to 96 bpm

A: Crackles in lungs

Which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply. A: Diuretic B: Low salt diet C: Daily weight checks D: Fluid restriction E: Intake and output F: Oxygen administration

A: Diuretic B: Low salt diet C: Daily weight checks D: Fluid restriction E: Intake and output F: Oxygen administration

Which action would the nurse take FIRST when a client with heart failure reports sudden dyspnea and has bilateral crackles throughout the lungs with a respiratory rate of 32 breaths per minutes A: Elevate the head of the bed to 75 degrees B: Obtain apical pulse and blood pressure C: Notify the hospital Rapid Response Team D: Check oxygen saturation with the pulse oximeter

A: Elevate the head of the bed to 75 degrees

The nurse is teaching a client about a sodium-restricted diet. Which foods should the nurse encourage the client to consume. Select all that apply A: Fruits B: Sliced deli meats C: Condiments D: Fresh vegetables E: Processed cheese

A: Fruits D: Fresh vegetables

Which electrolyte disorder would the nurse consider when a client's telemetry monitor shows flattening T waves and peaked P waves? A: Hypokalemia B: Hypocalcemia C: Hyponatremia D: Hypomagnesemia

A: Hypokalemia

Which physiological response occurs first when a client experiences sudden hypovolemia caused by hemorrhage? A: Peripheral vasoconstriction B: Elevation of serum cortisol levels C: Release of immature erythrocytes D: Increased antidiuretic hormone (ADH)

A: Peripheral vasoconstriction

Which likely cause would a nurse suspect is responsible for a drop in blood pressure after a client sustains multiple internal injuries in a motor vehicle accident and the blood pressure suddenly drops from 134/90 to 80/60 mmHg A: Reduction in the circulating blood volume B: Diminished vasomotor stimulation to the arterial wall C: Vasodilation resulting from diminished vasoconstrictor tone D: Cardiac decompensation resulting from electrolyte imbalance

A: Reduction in the circulating blood volume

Which recommendation is important for the nurse to include in a teaching program for a client who has been placed on a 2-gram sodium diet? A: Use lemon juice to season meat B: Put condiments on food to add flavor C: Include canned vegetables in meal preparation D: Drink carbonated beverages instead of decaf coffee

A: Use lemon juice to season meat

Which action by the nurse will be the MOST effective in determining whether fluid overload is improving when caring for a client who was admitted with heart failure? A: Weighing the client B: Monitoring intake and output C: Assessing the extent of pitting edema D: Asking the client about subjective symptoms

A: Weighing the client

Which signs of hypokalemia would the nurse monitor in the postoperative surgical client with a nasogastric tube attached to continuous low suction? Select all that apply A: Irritability B: Dysrhythmias C: Muscle weakness D: Abdominal cramps E: Acidosis

B: Dysrhythmias C: Muscle weakness

Which element would the nurse conclude is likely to have contributed to the development of hyponatremia in an older client found unconscious at home and admitted to the hospital with a fractured hip, renal failure, and dehydration who received 3 L of intravenous fluid in the 24 hours since admission A: Reduced dietary salt intake B: Intravenous fluid infusion C: Potassium reabsorption rate D: Increased glomerular filtration

B: Intravenous fluid infusion

Which physiological factor helps maintain blood pressure in the client with hypovolemia? Select all that apply A: Arteriolar dilation B: Release of aldosterone C: Activation of angiotensin 2 D: Sympathetic nervous system activation E: Stimulation of the vagus nerve

B: Release of aldosterone C: Activation of angiotensin 2 D: Sympathetic nervous system activation NOTE: dilation lowers BP constriction raises BP

Which symptom would the nurse monitor for when caring for a client who has hyponatremia? A: Increased urine output B: Deep rapid respirations C: Change in level of consciousness D: Distended neck veins

C: Change in level of consciousness

Which lab result is important to communicate quickly to the health care provider? A: Blood glucose 98 mg/dL B: Hemoglobin 14.1 g/dL C: Potassium 3.0 mEq/L D: White blood cell 9200/mm^3

C: Potassium 3.0 mEq/L

Which test result would the nurse anticipate in the laboratory reports of a client with a diagnosis of end-stage renal disease A: Arterial pH of 7.5 B: Hematocrit of 54% C: Potassium of 6.3 mEq/L D: Creatinine of 1.2 mg/dL

C: Potassium of 6.3 mEq/L

Which nursing action is a priority before administering prescribed furosemide? A: Weight the client B: Assess skin turgor C: Review the potassium level results D: Check the 24-hour intake and output

C: Review the potassium level results NOTE: before administering diuretics you must check the potassium levels

Which rational supports the nurse's instruction that client with chronic kidney disease is to avoid all salt substitutes? A: A person's body tends to retain fluid when a salt substitute is included in the diet B: Limiting salt substitutes in the diet prevent a buildup of waste products in the blood C: Salt substitutes contain potassium, which must be limited to prevent abnormal heartbeats D: The salt substances interfere with capillary membrane transfer, resulting in anasarca

C: Salt substitutes contain potassium, which must be limited to prevent abnormal heartbeats

Which prescription would the nurse question when a client's serum sodium is 123 mEq/L? A: Add table salt to each meal B: Fluid restriction 1000 mL per day C: Assess neurological status every 2 hours D: Provide 0.45% sodium chloride intravenously at 125 mL/h

D: Provide 0.45% sodium chloride intravenously at 125 mL/h NOTE: the more water you intake, the more it dilutes the sodium

Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client? A: Serum sodium if 139 mEq/L B: Serum chloride of 100 mEq/L C: Serum calcium of 10.2 mg/dl D: Serum potassium of 7.2 mEq/L

D: Serum potassium of 7.2 mEq/L