exam 3 practice question

A nurse is participating in a blood drive and is taking a donation from a client who has type O+ blood. The client asks the nurse what type of blood they can receive. Which of the following statements should the nurse make? a. "You can receive a blood donation from donors with type O- and type O+ blood." b. "You can receive a blood donation from donors with type B- and type A+ blood." c. "You can receive a blood donation from donors with type B- and type AB+ blood." d. "You can receive a blood donation from donors with type AB- and type A- blood."

a

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 b. potassium 3.6 c. magnesium 1.9 d. chloride 99

a

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following? a. Urinary tract infection b. Urinary incontinence c. Urinary frequency d. Urinary retention

a A client who has a urinary tract infection has urine that appears cloudy and concentrated because of the presence of WBCs, RBCs and bacteria. The urine often has an unpleasant odor.

A nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. Which of the following actions should the nurse take? a. Place the client in the dorsal recumbent position on a bedpan. b. Administer the enema while the client sits on the toilet. c. Administer an antidiarrheal medication 3 hr prior to the enema. d. Instill 200 mL of fluid over an hour at 15-min intervals.

a A client who has poor sphincter control might not be able to retain the enema solution at all. Repositioning the client over the bedpan in the dorsal recumbent position after insertion of the rectal tube will help contain the fluid that is likely to be expelled.

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? a. A reddened area over the sacrum b. Stiffness in the lower extremities c. Difficulty moving the upper extremities d. Difficulty hearing some types of sounds

a A reddened area over bony prominence is a stage 1 pressure ulcer, a complication of immobility. If the nurse recognizes it at this stage and implements measures to avoid additional pressure, it might not progress to the next stage.

A nurse is caring for a client who is experiencing respiratory alkalosis. Which of the following actions should be the goal of treatment for the client? a. Increase the carbon dioxide level. b. Increase the respiratory rate. c. Increase the bicarbonate level. d. Increase the pH level.

a A state of respiratory alkalosis indicates that the client's carbon dioxide level is currently below the expected reference range. The goal of treatment should be to raise the level of carbon dioxide level back to within the expected reference range for PaCO2 of 35 to 45 mm Hg.

A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. The nurse should initiate a referral with which of the following members of the interprofessional health care team? a. Occupational therapist b. Social worker c. Registered dietitian d. Speech pathologist

a An occupational therapist assists clients who have physical challenges to use adaptive devices and strategies to help with self-care activities such as feeding.

A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall? a. An older adult client who is confused and has urinary frequency b. A client with diabetes mellitus who has a leg ulcer c. A client who is 1 day postoperative and has a nursing assistant helping him out of bed d. An adolescent client who has a leg fracture and has been using crutches for the past 2 days

a An older adult client who is confused and has urinary frequency is at the greatest risk for a fall because this client might attempt to go to the bathroom without assistance. The nurse should implement interventions to prevent a fall, such as using a bed alarm, and placing the client close to the nurses' station.

A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching? a. "It is a good idea to use the handrails in the bathroom." b. "I should use chairs without armrests." c. "I should place a throw rug over electrical cords." d. "I should get a longer cord for my telephone."

a Handrails or grab bars in the bathroom can help prevent falls. Clients should use them for added stability when changing positions.

A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort? a. Lower the height of the solution container. b. Encourage the client to bear down. c. Allow the client to expel some fluid before continuing. d. Stop the enema and document that the client did not tolerate the procedure.

a If nausea or cramping occurs, the flow of water should momentarily be slowed or stopped by lowering the device or clamping the tubing. This allows the intestinal spasm to pass while leaving the catheter in place. The nurse should then continue administering the enema at a slower rate once the cramping has passed.

A nurse is providing teaching to a group of adult athletes about prevention the effects of dehydration on the body. Which of the following manifestations should the nurse include in the teaching? a. Impaired motor control b. Drop in body temperature during exercise c. Increase in appetite. d. Decreased resting heart rate

a Impaired motor control is a clinical manifestation of dehydration.

A nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a client in preparation for a diagnostic procedure. Which of the following actions should the nurse take? a. Warm the enema solution prior to instillation. b. Prepare 1,500 mL of enema fluid. c. Use tap water as the enema fluid. d. Hang the enema container 24 inches above the anus.

a It is important to warm the enema solution because cold fluid can cause abdominal cramping. The solution should not be too hot, though, because hot fluid can injure the intestinal mucosa.

A nurse is teaching a group of nursing students about pyelonephritis. Which of the following statements should the nurse include in the teaching? a. "Pyelonephritis increases a pregnant woman's risk for preterm labor." b. "Pyelonephritis is most often caused by Staphylococcus saprophyticus." c. "Pyelonephritis is an infection of the lower urinary tract." d. "Pyelonephritis often causes no symptoms in affected clients."

a Pyelonephritis is a serious complication of pregnancy that can lead to preterm labor.

A nurse is assessing a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal? a. The client faces the direction of movement when sliding an object across the floor. b. When pushing an object, the client moves his front foot backward. c. When moving an object to one side, the client puts his weight on his heels. d. The client stands with his feet close together when lifting an object.

a Sliding an object across the floor rather than lifting it prevents strain on the lower back muscles. Facing the direction of movement prevents twisting his back.

A charge nurse is observing a newly licensed nurse who is preparing to administer a blood transfusion to a client. For which of the following actions by the newly licensed nurse should the charge nurse intervene? a. The nurse selects 0.45% sodium chloride to use to prime the tubing. b. The nurse asks another nurse to check the blood unit label and client identification prior to beginning the transfusion. c. The nurse uses tubing with a filter for the blood transfusion. d. The nurse discards the tubing after the first unit of blood is completed.

a The charge nurse should intervene if the newly licensed nurse selects 0.45% sodium chloride to prime the tubing. The nurse should identify that 0.9% sodium chloride is the only IV solution that should be used to prime the tubing for blood administration.

A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take? a. Give the ordered KCL as prescribed. b. Omit the KCL dose and document that it was not given. c. Hold the prescribed dose and notify the provider of the serum potassium level. d. Call the lab to verify the client's results.

a The client's serum potassium level is below the recommended reference range. The nurse should administer the KCL as prescribed.

A nurse is admitting a client who was prescribed antibiotic therapy and now has a Clostridium difficile infection. Which of the following actions should the nurse take? a. Disinfect equipment in the client's room daily. b. Place the client in a protective environment. c. Use alcohol hand sanitizer after completing tasks for the client. d. Have the client wear a mask when out of the room.

a The nurse should disinfect equipment in the client's room every day, or when visibly soiled, to minimize the C. difficile spores in the client's room. The nurse should choose a solution that is effective against spores.

A nurse on a pediatric floor is teaching a newly licensed nurse about IV therapy. Which of the following information should the nurse include? a. Perform range of motion exercises on the extremity containing the IV site. b. Shave the client's hair if the IV is to be placed in the scalp. c. IV sites can be placed in the lower extremities up to the age of 2 years. d. Monitor the IV site, tubing, and connections every 4 hr.

a The nurse should instruct the newly licensed nurse to perform range of motion exercises on the client's extremity that contains the IV site.

A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care? a. Auscultate breath sounds at least every 2 hr. b. Perform range-of-motion (ROM) exercises at least two to three times daily. c. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day. d. Apply antiembolic stockings.

a The priority action the nurse should contribute to the plan of care when using the airway, breathing, circulation approach to client care is auscultating breath sounds to determine the client's need for suctioning. With inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea.

a nurse is reviewing a client's 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? a. Decreased pH and metabolic acidosis b. Decreased pH and respiratory acidosis c. Elevated pH and metabolic alkalosis d. Elevated pH and respiratory alkalosis

a This client would have a decreased pH and be in metabolic acidosis. Other findings would include diarrhea, circulatory shock, decreased level of consciousness, abdominal pain, cardiac dysrhythmia, and increased depth and rate of respirations.

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal? a. Temporary urinary retention b. Urinary frequency for several days c. Blood-tinged urine d. Highly concentrated urine

a Until the bladder regains its full tone, it is common for clients to develop urinary retention. If a client does not urinate for 6 to 8 hr after catheter removal, reinsertion might become necessary.

A nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should the nurse take first? a. Determine if the client can bear weight. b. Place a transfer belt on the client. c. Position the bed at an appropriate height. d. Assist the client to a seated position.

a Using the nursing process, the nurse should first determine if the client can bear weight.

A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding? a. Potassium 2.9 mEq/L b. Phosphorous 4.5 mEq/L c. Sodium 145 mEq/L d. Calcium 8.2 mg/dL

a Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is the client's potassium level. The client's level is below the expected reference range of 3.5 to 5.0 mEq/L. Hypokalemia can be a life-threatening condition if left untreated. Potassium is the primary electrolyte vital for cell metabolism and cardiac and neuromuscular function.

A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times? a. When the client has the urge to defecate b. Every 2 hr while the client is awake c. Immediately before the client has a meal d. After the client feels abdominal cramping

a When on a bowel training program, the nurse should take the client to the toilet when the client recognizes the urge to defecate. A bowel training program focuses on identifying times in the client's bowel pattern to promote self-control of defecation.

A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients' use of a cane? a. "When the client moves, he should move the cane forward first." b. "The client should hold the cane on the weak side of his body." c. "The grip should be level with the client's waist." d. "The client should first move the strong leg, then the weak one."

a When the client moves, he should first move the cane forward about 30.5 cm (12 in). Then, he should move the weak leg even with the cane. Finally, he should bring the strong leg forward and ahead of the cane and his weak leg.

A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching? a. "I will need to wipe my perineal area from back to front after urination." b. "I will need to empty my bladder regularly and completely." c. "I will need to drink apple cider vinegar each day." d. "I need to drink 8 cups of liquid each day."

a Wiping the perineal area from back to front increases the risk for urethral contamination and a resulting UTI.

a nurse is assessing a client who has a sodium level of 116 mEq/mL. which of the following findings should the nurse expect? a. nausea and vomiting b. extreme thirst c. flushed skin d. fever

a a sodium level of 116 is a critical value indicating hyponatremia. nausea and vomiting are expected findings for a client with this sodium level

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? a. Bananas b. Cooked carrots c. Cheddar cheese d. 2% milk

a bananatoes

A nurse is receiving report on four clients. The nurse should identify that which of the following clients might be experiencing hypomagnesemia? a. A client who has vomited four times during the last 8 hr. b. A client who requested an extra breakfast tray to eat. c. A client who can ambulate without assistance. d. A client who reports extreme thirst.

a doesn't matter magnesium isn't on the exam

a nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. which of the following findings should the nurse identify as an indication the client is experiencing fluid overload? a. the client has a 5 lb weight gain since yesterday b. flattened neck veins c. O2 sat of 93% d. return of the skin to previous position when the client's shin is palpated

a the nurse should identify that a gain of 2 lb per day is stable; a gain of more than 2 lb per day or 5 lb per week is an indication of fluid overload

a nurse is reviewing the ABG results of a client who the provider suspects has metabolic acidosis. which of the following results would the nurse expect to see? a. pH below 7.35 b. HCO3 above 26 c. PaO2 below 70 d. PaCO2 above 45

a with acidosis, the pH is below 7.35

A nurse is caring for an older adult client who is experiencing dehydration. The nurse should identify that which of the following factors increases the risk for dehydration in older adult clients? (Select all that apply.) a. Decreased kidney function b. Decreased thirst response c. Decreased total body fluid d. Eating watermelon daily e. Eating cucumbers with each meal

a, b, c

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.) a. Excessive laxative use b. Ignoring the urge to defecate c. Inadequate fluid intake d. Increased fiber in the diet e. Increased activity

a, b, c

A nurse is teaching a client who has a new diagnosis of urge incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.) a. "Your provider might prescribe anticholinergic medications." b. "You should limit fluids in the evening." c. "You should restrict your intake of caffeine." d. "You might require intermittent urinary catheterization." e. "You might require an anterior vaginal repair."

a, b, c Anticholinergic medications suppress bladder contractions and increase bladder capacity. Limiting fluid intake in the evening prior to bedtime helps prevent an overload of fluid in the bladder during hours of sleep. The restriction of caffeine is effective in the treatment of urge incontinence because caffeine is a bladder irritant.

A nurse is teaching a client who has constipation about a high-fiber diet. Which of the following foods should be included as sources of fiber? (Select all that apply.) a. Kidney beans b. Blackberries c. Refined cereals d. Whole wheat bread e. Lean turkey

a, b, d

A nurse is caring for a client who is recovering from a cerebrovascular accident (CVA). Which of the following information should the nurse include when teaching family members about repositioning the client? (Select all that apply.) a. Remove pillows prior to repositioning. b. Elevate the bed to waist height. c. Position the client toward the edge of the bed on the side the client will face after turning. d. Stand with feet wide apart. e. Face the direction of movement when positioning the client.

a, b, d, e

A nurse is reviewing arterial blood gas (ABG) values for a client who is experiencing uncompensated metabolic acidosis. Which of the following ABG values should the nurse expect? (Select all that apply.) a. HCO3- 19 mEq/L b. pH 7.29 c. PaCO2 49 mm Hg d. pH 7.49 e. PaCO2 35 mm Hg

a, b, e

A nurse is caring for a client who is receiving treatment for hyponatremia. The nurse should identify that which of the following findings is an indication that the treatment has been effective? (Select all that apply.) a. The client states their muscle spasms are absent. b. The client reports a headache. c. The client denies being confused. d. The client reports being nauseated. e. The client reports feeling tired.

a, c

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.) a. Poor skin turgor b. Bradycardia c. Hypotension d. Pale yellow urine e. Flat neck veins

a, c, e Poor skin turgor is correct. Frequent vomiting and diarrhea cause dehydration, which manifests as skin that lacks elasticity. Hypotension is correct. Frequent vomiting and diarrhea cause dehydration, which manifests as postural hypotension. Flat neck veins is correct. Frequent vomiting and diarrhea cause dehydration, which manifests as flat neck veins when the client is lying supine.

A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.) a. Bicarbonate excess b. Kussmaul's respirations c. Flushing d. Circumoral paresthesia e. Lethargy

a, d Bicarbonate excess is a clinical manifestation for a client experiencing metabolic alkalosis. Circumoral paresthesia is a clinical manifestation for a client experiencing metabolic alkalosis.

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.) a. Contractures of the extremities b .Polyuria c. Diarrhea d. Crackles in the lungs e. Pressure ulcers

a, d, e Contractures of the extremities are a complication of immobility because of disuse of muscles and joints. Crackles in the lungs are a complication of immobility, due to mucus that collects in the dependent airways. The client often cannot cough effectively and oxygenation status declines. Pressure ulcers are a complication of immobility, due to increased pressure on skin and bony prominences, which affects tissue metabolism.

A nurse is participating in a blood drive and is taking a donation from a client who has type A- blood. The client asks the nurse what blood types can receive their blood donation. Which of the following responses should the nurse make? (Select all that apply.) a. A+ b. B+ c. O+ d. AB- e. AB+ f. A-

a, d, e, f

A nurse is caring for a client who has heart failure and is receiving IV furosemide. The nurse should monitor the client for which of the following electrolyte imbalances? a. hypernatremia b. hyperuricemia c. hypercalcemia d. hyperchloremia

b

A nurse is reviewing prescriptions for a client who needs intravenous fluid replacement therapy due to vomiting and diarrhea. Which of the following fluid prescriptions should the nurse expect to initiate? a. 3% sodium chloride solution b. 0.9% sodium chloride solution c. 0.45% sodium chloride solution d. Dextrose 10% in water

b A 0.9% sodium chloride solution is isotonic and is used for hydration needs such as from vomiting, diarrhea, hemorrhage, and shock. This is the most appropriate solution for the provider to prescribe for this client.

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? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

b A client who has influenza has experienced excessive vomiting leading to metabolic alkalosis. Manifestations include dizziness, Circumoral paresthesias, and numbness and tingling of the extremities.

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances? a. Steatorrhea b. Blood c. Bacteria d. Parasites

b A guaiac test detects the presence of occult or hidden blood in the stool. The guaiac test is an extremely useful diagnostic screening test for the presence of colon cancer and gastrointestinal ulcers.

A nurse is completing dietary teaching on consuming a low fiber diet with a client who has ulcerative colitis. Which of the following foods should be eliminated in the client's diet? a. Cooked cabbage b. Dried apricots c. Ripe bananas d. Ice cream

b A nurse should instruct a client who has ulcerative colitis to consume a diet low in fiber and should eliminate dried apricots from his diet. Dried apricots are high in fiber and may cause an exacerbation of the client's disease process.

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen? a. After palpating the abdomen b. Prior to percussing the abdomen c. After assessing for kidney tenderness d. Prior to inspecting the abdomen

b According to evidence-based practice, the nurse should auscultate the abdomen prior to percussing it to prevent altering the bowel sounds. Both percussion and palpation can stimulate the intestines, increase their motility, and intensify the bowel sounds.

A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization? a. Urge incontinence b. Dribbling of urine c. Weight gain d. Rectal distention

b Dribbling of urine, or overflow incontinence, is an indicator of bladder distention. The nurse should perform intermittent catheterization when this occurs to prevent bladder trauma or infection. A regular schedule to drain the flaccid bladder should be established, with no longer than 8 hr. between catheterizations.

A nurse is preparing a male client for intermittent urethral catheterization. Which of the following actions should the nurse take? a. Grasp the penis at its base. b. Lift the penis perpendicular to the body. c. Hold the penis parallel to the client's body. d. Lift the penis to a 45° angle to the client's body.

b Lifting the penis to a position perpendicular to the body, or at a 90° angle, while applying light traction straightens the urethral canal to facilitate catheter insertion.

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? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

b Metabolic alkalosis can occur in clients who have excessive vomiting because of the loss of hydrochloric acid.

A nurse is preparing to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take? a. Pull the catheter out as quickly as possible. b. Deflate the balloon completely before removal. c. Cut the inflation port to deflate the balloon. d. Tell the client to expect to feel a tugging sensation on removal.

b Removing an indwelling urinary catheter while inflation solution remains in the balloon is likely to cause trauma to the urethral canal. Therefore, the nurse should deflate the balloon completely prior to removing an indwelling urinary catheter.

A nurse is administering a return-flow enema to a client. After instilling 100 mL of enema fluid, which of the following actions should the nurse take? a. Instruct the client to retain the fluid. b. Lower the container to allow the solution to flow back out. c. Help the client to the toilet or bedside commode. d. Wait 5 min and instill another 100 mL of fluid.

b Return-flow enemas involve moving 100 to 200 mL of fluid into and out of the rectum. After instilling the solution, the nurse lowers the container to allow the solution to flow back into the container and then repeats the process several times.

A client who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should expect the provider to prescribe which of the following types of enemas? a. Cleansing b. Return-flow c. Medicated d. Oil-retention

b Return-flow, or flush, enemas are used to expel flatus, stimulate peristalsis, and relieve abdominal distention.

A nurse is administering a cleansing enema to a client who reports mild cramping. The client asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take? a. Discontinue the enema. b. Slow the flow of enema solution briefly. c. Continue the enema and reassure the client. d. Pause the enema and administer oral pain medication.

b Slowing the enema solution flow temporarily prevents cramping.

A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure? a. "I'll urinate a little then stop." b. "I'll use the cleansing wipe from front to back." c. "I'll clean the inside of the container with a wipe." d. "I'll use each cleansing wipe twice."

b The client should cleanse the perineal area from front to back to avoid introducing bacteria from the anal area into the area of the urinary meatus.

A nurse is preparing a teaching plan for a client who has chronic constipation secondary to irregular bowel habits. Which of the following should the nurse plan to include in the teaching? a. The client should drink two to three 8 oz glasses of water each day. b. The client should follow a high-fiber diet to establish bowel regularity. c. The client should try to take in all of the required dietary fiber with the morning meal. d. The client should be taught that the goal of therapy is to have a bowel movement daily.

b The client who has chronic constipation should consume a diet with high-fiber food sources, including bran and complex carbohydrates.

A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine? a. The client's ability to communicate b. The client's current weight-bearing status c. The client's height d. The type of equipment used in previous transfers

b The client's weight-bearing status is the most important information the nurse needs to know to identify the safest method of transfer.

A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first? a. Increase fluids. b. Perform a bladder scan. c. Insert a straight catheter. d. Provide assistance to bathroom.

b The first action the nurse should take using the nursing process is to assess the client. The nurse should assess the post void residual (PVR) using a bladder scanner.

A nurse is caring for a client who has an acid-base imbalance and is experiencing hypoxia. Which of the following actions should the nurse take first? a. Initiate continuous cardiac monitoring. b. Elevate the head of the client's bed. c. Instruct the client to deep breathe and cough. d. Initiate continuous SpO2 monitoring.

b The first action the nurse should take when using the airway, breathing, circulation approach to client care is to elevate the head of the client's bed. Placing the client in the Fowler's or semi-Fowler's position will promote effective breathing and chest expansion.

A nurse is caring for a client who reports taking bisacodyl to promote a daily bowel movement. Which of the following assessment questions should be the nurse's priority? a. "What do your bowel movements look like?" b. "How long have you been taking the bisacodyl?" c. "Do you take the bisacodyl with a glass of milk?" d. "How often do you have a bowel movement?"

b The greatest risk to this client is injury from dependency on laxatives, as bowel tone can be lost; therefore, the priority question the nurse should ask the client is how long he has been using bisacodyl.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? a. Replace the catheter every 3 days. b. Check the catheter tubing for kinks or twisting. c. Irrigate the catheter once each shift. d. Clean the perineal area with an antiseptic solution daily.

b The nurse should check the catheter for twisting or kinks in the tubing. These obstructions can affect the flow of urine causing pooling in the tubing that could backflow into the bladder.

A nurse is assessing a client who is exhibiting signs of a fluid and electrolyte imbalance. Which of the following findings should the nurse identify as a potential cause for the client's fluid and electrolyte imbalance? a. The client reports working in a warehouse in 21.1° C (70° F) temperature. b. The client reports that they performed yard work for 8 hr in 35° C (95° F) temperature earlier that day. c. The client reports that their provider decreased their diuretic dose. d. The client reports they had a 24-hr intestinal virus 2 weeks ago.

b The nurse should identify that working outside in high temperatures for an extended period can cause profuse sweating and lead to a fluid and electrolyte imbalance.

A nurse is planning care for a client who has cystitis. Which of the following interventions should the nurse include in the plan? a. Instruct the client to take antibiotics until dysuria is no longer present. b. Instruct the client to avoid drinking carbonated beverages. c. Instruct the client to drink 240 mL of tomato juice each day. d. Instruct the client to drink 1 L of fluid each day.

b The nurse should instruct the client to avoid drinking carbonated beverages and caffeine to reduce bladder irritation.

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take? a. Place the wheelchair at a 90° angle to the bed. b. Lock the wheels of the bed and the wheelchair. c. Acquire the help of several people to lift the client. d. Elevate the bed to a position of comfort for the nurse.

b The nurse should keep the wheels of the bed and the wheelchair in the locked position to prevent them from moving when transferring a client.

A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions should the nurse plan to take? a. Raise the client's bed to the nurse's waist level. b. Use a gait belt to stand and pivot the client. c. Instruct the client to place his hands around the nurse's neck during the transfer. d. Place the chair on the client's weak side.

b The nurse should stand and pivot the client using a gait belt to reduce the risk for injury to the client or the nurse.

A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following complications should the nurse monitor? a. The need for multiple IV sticks b. Infection at the access site c. Dehydration d. Infiltration

b This nurse should monitor the client who has a PICC for complications, such as infection at the access site and blood clots. It is important for the nurse to use aseptic technique when accessing and flushing the PICC line and during dressing changes.

a nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. the nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? a. BP b. heart rate c. urine output d. weight

b a decrease in heart rate indicates adequate fluid replacement

a nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. which of the following interventions should the nurse include in the plan of care? a. monitor the client's intake and output every 6 hours b. offer the client 240 mL (8 oz) of oral fluids every 4 hours c. check the clients IV infusion every 8 hours d. administer furosemide to the client

b the nurse should offer 60 to 120 mL (2 to 4 oz) of fluids every 1 to 2 hours to manage the dehydration as well as prevent further dehydration

A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.) a. Green Beans b. Tomatoes c. Bananas d. Asparagus e. Raisins

b, c, e

A nurse is administering an enema medicated with sodium polystyrene sulfonate to an adult client who has hyperkalemia. To which of the following lengths should the nurse insert the rectal tube? a. 2.5 cm to 3.75 cm (1 to 1.5 in) b. 5 cm to 7.5 cm (2 to 3 in) c. 7.5 cm to 10 cm (3 to 4 in) d. 10 cm to 12.5 cm (4 to 5 in)

c

A nurse is caring for a client who has the following arterial blood gas (ABG) values: pH 7.44, PaCO2 37 mm Hg, and HCO3- 24 mEq/L. The nurse should identify that these values are an indication of which of the following? a. Metabolic acidosis b. Respiratory acidosis c. Acid-base balance d. Respiratory alkalosis

c

A nurse is caring for a client who requires a replacement peripheral IV. The client is dehydrated and requires a smaller gauge catheter than the #20-gauge being replaced. Which of the following gauge catheters should the nurse plan to use? a. #16-gauge b. #18-gauge c. #22-gauge d. #14-gauge

c

A nurse is reviewing the arterial blood gas (ABG) values for a client and notes the following results: pH 7.49, PaCO2 39 mm Hg, and HCO3- 35 mEq/L. The nurse should interpret this ABG reading as an indication of which of the following acid-base imbalances? a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis

c

A nurse is reviewing a client's laboratory results. Which of the following results should the nurse report to the provider? a. Potassium 4.5 mEq/L b. Sodium 138 mEq/L c. Magnesium 3 mEq/L d. Calcium 10 mg/dL

c A magnesium level of 3 mEq/L is above the expected reference range of 1.3 to 2.1 mEq/L. Therefore, the nurse should report this finding to the provider.

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? a. An upper respiratory infection b. Pulmonary edema c. Atelectasis d. Delayed gastric emptying

c Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or bronchioles) or by hypoventilation. Prolonged bedrest with few changes in position, ineffective coughing, and underlying lung disease are risk factors for the development of atelectasis.

A nurse is caring for a client who has heart failure and a prescription to receive a unit of packed red blood cells. The nurse should plan to infuse the blood over which of the following lengths of time? a. 1 hr b. 2 hr c. 4 hr d. 6 hr

c Blood can be administered over a period of 1 to 4 hr. For a client who is at risk for circulatory overload, such as a client who has heart failure, a disorder in which compromised cardiac output results in poor tissue perfusion and fluid overload, the transfusion should be administered slowly (maximum time of 4 hr) to avoid increasing the workload of the heart.

A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? a. Remind the client to tell the nurse when he has to urinate. b. Use adult diapers to prevent frequent clothing changes. c. Take the client to the bathroom every 2 hr. d. Request a prescription for an indwelling urinary catheter.

c By assisting the client to the bathroom every 2 hr, the staff establishes a regular pattern of toileting, and the client learns to trust that the staff places value on his bladder-training needs. He also learns a physical pattern that promotes bladder control.

A nurse is assessing a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate? a. Needs assistance raising her legs to put on socks b. Demonstrates mild dyspnea when eating breakfast c. Performs active range-of-motion (ROM) exercises of all extremities d. Develops fatigue when assisting with morning hygiene care

c During periods of immobility, it is important to have the client perform ROM exercises to reduce the hazards of immobility (contractures, loss of muscle mass, thrombosis). A client who is weak might need the nurse to support her extremities during movement (passive ROM). During active ROM, the client is doing the movement with little to no assistance.

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? a. Sodium 165 mEq/L b. Potassium 5.2 mEq/L c. Urine specific gravity 1.020 d. Hct 62%

c In cases of dehydration or fluid volume deficit, the kidney reabsorbs all available water, making the urine more concentrated and increasing the urine specific gravity. A level of 1.020 is within the expected reference range of 1.005 to 1.030, which indicates that the treatment is effective.

A nurse is reviewing the latest arterial blood gas (ABG) values for a client who is experiencing metabolic alkalosis. The nurse should identify that this action is part of which of the following steps of the nursing process? a. Planning b. Assessment c. Evaluation d. Implementation

c Reviewing the client's ABG values is part of the evaluation stage of the nursing process. During the evaluation stage, the nurse should determine if the actions taken in the implementation stage were successful in meeting the goals in the client's plan of care.

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? a. Measure the client's vital signs. b. Notify the primary care provider. c. Lower the enema fluid container. d. Stop the enema instillation.

c Some abdominal cramping is to be expected during enema administration. To ease the client's discomfort, the nurse should slow the rate of instillation by reducing the height of the enema fluid container.

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching? a. Bear down hard when defecating. b. Drink four to five glasses of water daily. c. Increase dietary intake of raw vegetables. d. Limit activity.

c The client should increase dietary intake of raw vegetables to help provide fiber in the diet, which will increase stool bulk and move the stool through the colon to prevent constipation.

A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse expect to receive a prescription for urinary catheterization? a. A client who has a persistent urinary tract infection. b. A client who has urge incontinence. c. A client who is in the ICU for a gastrointestinal bleed. d. A client who has incontinence due to cognitive decline.

c The nurse should expect a prescription for urinary catheterization for this client because precise measurement of urinary output is crucial for managing fluid balance in clients who are critically ill.

A nurse is providing home safety information for an older adult client who uses a cane. Which of the following statements should the nurse include in the teaching? a. You should hold the cane in your weak hand when ambulating." b. "You should advance the cane 12 to 14 inches before taking a step." c. "You should advance your weak leg forward to the cane, then move your strong leg." d. "The cane's height should be the same as the distance from the floor to the crest of your hip bone."

c The nurse should instruct the client to move the cane and then advance his weak leg forward to the cane, followed by advancing the stronger leg past the cane. This provides for the client's body weight to be distributed between the cane and the stronger leg.

A nurse is teaching a client about crutch walking using the three-point gait. Which of the following statements by the nurse should be included in the teaching? a. "Look down at your feet before moving the crutches." b ."Place one crutch forward with the opposite foot and then place the second crutch forward followed by the second foot." c. "Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches." d. "Support your body weight on the underarm crutch pads."

c The nurse should instruct the client to use this method of crutch walking for a three-point gait.

A nurse is applying a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse take? a. Stretch the sheath portion of the condom catheter along the length of the penis. b. Secure the sheath portion with adhesive tape. c. Leave a space between the penis and sheath portion tip. d. Reposition the foreskin after application.

c The nurse should leave a space of 2.5 to 5 cm (1 to 2 in) between the tip of the penis and the end of the catheter. This space helps prevent irritation of the tip of the penis and allows full drainage of urine.

A nurse is caring for a client who has a prescription to receive one unit of packed red blood cells. The client's blood type is AB+, and the nurse receives a unit of A- blood from the blood bank. Which of the following actions should the nurse take? a. Return the blood unit as it is not compatible with the client's blood type. b. Stay with the client for 15 min prior to starting the blood transfusion. c. Verify the unit of blood with another nurse. d. Prime the blood tubing with 0.45% sodium chloride.

c The unit of blood is compatible with the client's blood type. However, the nurse should ensure that the blood unit had been verified by two nurses before initiating the transfusion.

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take? a. provide support by holding the client's arm. b. Lean the client toward the wall. c. Lower the client to the floor. d. Assume a narrow base of support.

c This is an appropriate action. The nurse should gently lower the client to the floor.

a nurse is assessing a client who has hypokalemia as a result of n/v/d. which of the following findings should the nurse expect? a. hyperactive reflexes b. extreme thirst c. weak, irregular pulse d. hyperactive bowel sounds

c common manifestations of potassium depletion include a weak and irregular pulse, muscle weakness, fatigue, and ventricular dysrhythmias

A nurse is caring for a client who has a prescription for KCL 20 mEq PO daily. the nurse reviews the client's most recent lab results and finds the client's potassium level is 5.2 mEq/L. which of the following actions should the nurse take? a. give the ordered KCL as prescribed b. omit the KCL dose and document it was not given c. call the prescribing physician and inform her of the client's serum potassium level results d. call the lab to verify the client's results

c the client's potassium level is above the expected reference range, so the nurse should hold the medication and notify the provider of the client's serum potassium level

A nurse is providing perineal care for a female client who has an indwelling urinary catheter. Which of the following areas should the nurse cleanse last? a. Urethral meatus b. Labia minora c. Perineum d. Anus

d

A nurse is admitting a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have upon admission? a. 3.1 mg/dL b. 10 mg/dL c. 16.5 mg/dL d. 35 mg/dL

d A BUN of 35 mg/dL is an expected finding for a client who has dehydration. Clients who have dehydration can have decreased blood flow, which leads to decreased renal excretion of BUN. Other causes of increased BUN levels include GI bleeding, heart failure, burns, shock, and myocardial infarction.

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? a. Decreased heart rate b. Dyspnea c. Increased blood pressure d. Weak pulse

d A decreased volume of circulating blood and less pressure within the vessels results in weak peripheral pulses (rated as +1), which can be described as thready.

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown? a. An adolescent who has a cervical fracture and is in a halo brace b. A young adult who has a femur fracture and is in skeletal balanced suspension traction c. A middle adult who has a fractured radius and an arm cast d. An older adult who has a hip fracture and is in Buck's traction

d According to evidenced-based practice, this client has multiple risk factors for skin breakdown: the aging process (decreased muscle mass, thin and fragile skin) and the limitation of movement due to traction. Therefore, this client is at the greatest risk for skin breakdown.

A nurse has completed assessing and analyzing data for a client who has an acid-base imbalance. Which of the following steps of the nursing process should the nurse take next? a. Implementation b. Reassessment c. Evaluation d. Planning

d After assessing and analyzing data for a client who has an acid-base imbalance, the nurse should move into the planning stage of the nursing process and establish goals and outcomes for the client.

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength? a. Ask the client how strong she feels today. b. Ask the client to touch her finger to her nose. c. Palpate the client's pedal pulses. d. Ask the client to push her feet against the nurse's palms.

d Asking the client to push with her feet against the nurse's hands is an appropriate method of determining the client's level of physical strength, which is needed for ambulation.

A nurse is ready to insert an indwelling urinary catheter for a female client. Which of the following instructions should the nurse give the client as the catheter is inserted? a. Contract the pelvic muscles. b. Take a sip of water. c. Exhale slowly. d. Bear down.

d Bearing down gently as if to void relaxes the external sphincter and eases urinary catheter insertion.

A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect? a. Hypothermia b. Protruding eyeballs c. Elevated blood pressure d. Furrows in the tongue

d In older adult clients who have dehydration, the surface of the tongue will be dry with deep furrows.

A nurse is preparing to start an IV for a client who has a high risk for bleeding. Which of the following actions should the nurse take? a. Apply a cold compress to the selected IV site. b. Ask the client to hold the extremity up prior to searching for an IV site. c. Ask the client to spread the fingers of the selected extremity. d. Apply a blood pressure cuff set to 30 mm Hg.

d Instead of using a tourniquet, the nurse should apply a blood pressure cuff set to 30 mm Hg prior to starting an IV for this client. This will help protect the client's extremity from bruising and bleeding.

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care? a. Ask the client to move her arms and legs while applying slight resistance. b. Move the client's limbs through their complete range of motion. c. Have the client move each limb independently through its complete range of motion. d. Instruct the client to tighten muscle groups for a short period, and then relax.

d Isometric exercises involves static (no movement) contraction of a muscle without any movement of the joint. Isometrics promote increased muscle mass, strength, and tone for clients who are on bedrest.

A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect? a. Increased insulin production b. Decreased RBC production c. Decreased sodium excretion d. Increased calcium excretion

d Prolonged immobility leads to the breakdown of bone tissue. This results in increased calcium excretion.

A nurse is instructing a female client on obtaining a midstream urine specimen. Which of the following statements by the client indicates an understanding of the teaching? a. "I will wipe from the back to front with the cleansing cloth." b. "I should not collect a urine sample when I am menstruating." c. "I should let the urine cool to room temperature before sending it to the lab." d. "I need to urinate a small amount in the toilet before collecting the sample."

d The client should begin the stream of urine in the toilet first, and then pass the container through the urine stream to obtain the sample. This action will wash off any bacteria at the distal urethra that could contaminate the sample.

A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include? a. Perform catheterization when you recognize the urge to void. b. Hold the penis at a 30° to 45° angle when inserting the catheter. c. Inflate the balloon when the urine flow stops. d. Use soap and water to wash the catheter after each use.

d The client should wash the catheter using soap and water and store it in a clean container after each use.

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor? a. Client is currently prescribed spironolactone. b. Client has a history of alcohol abuse disorder. c. Client reports drinking 3.5 to 4 L of water each day. d. Client has an NG tube to gastric suction.

d The client who has an NG tube to gastric suction is at risk for developing hypokalemia due to the gastrointestinal loss of potassium.

A nurse is preparing to administer an oil retention enema to a client who has constipation. The nurse should instruct the client to retain the solution for which of the following durations? a. The duration of the procedure b. 10 to 15 min c. Until the client feels the urge to defecate d. At least 30 min

d The enema will be most effective in softening the stool and lubricating its passageway if the client retains the oil for a minimum of 30 min.

A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first? a. Deflate the catheter balloon using a sterile syringe. b. Measure and document the urine in the drainage bag. c. Remove the tape or device securing the catheter to the client's thigh. d. Position the client supine.

d The first action the nurse should take using the nursing process is to place the client in a supine position. This permits adequate visualization and assessment of the perineal area and promotes client comfort and relaxation.

A nurse is assessing a client who has a urine output of 250 mL in a 24-hr period. Which of the following descriptive terms should the nurse place in the client's electronic record? a. Enuresis b. Anuria c. Nocturia d. Oliguria

d The nurse should document the client has oliguria, which is urine output between 100 mL and 400 mL of urine in 24 hr.

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene? a. The nurse initiates the feeding after aspirating 50 mL of gastric residual. b. The nurse irrigates the NG tube with tap water after feeding. c. The nurse administers the feeding through a syringe barrel by gravity. d. The nurse allows the client to rest in a supine position during feeding.

d The nurse should elevate the head of the bed to a minimum of 30° to prevent aspiration from reflux during feedings.

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? a. Mix the three medications together prior to administering. b. Dilute each medication with 10 mL of tap water. c. Maintain the head of the bed in a flat position for 30 min following medication administration. d. Flush the NG feeding tube with 30 mL of water immediately following medication administration

d The nurse should flush the NG feeding tube with 15 to 60 mL of sterile water following medication administration to ensure the feeding tube is cleared of the medications.

A nurse is assessing a client who has been receiving IV therapy for several days and notes that the client's daily weight has increased. The nurse should identify that the client is at increased risk for developing which of the following IV-related complications? a. Phlebitis b. Extravasation c. Air embolism d. Circulatory overload

d The nurse should identify that a client who has been receiving IV therapy and whose daily weight has increased is at risk for circulatory overload. The nurse should assess the client for other indications of circulatory overload, including tachycardia, increased blood pressure, edema, cough, and tachypnea. The nurse should also inform the provider of the client's increased weight.

A nurse is assessing a client's indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. Which of the following actions should the nurse take first? a. Irrigate the catheter. b. Assess for peripheral edema. c. Palpate for bladder distention. d. Check the catheter for kinks.

d The nurse should identify that output that is considerably less than intake is a sign that the catheter is blocked. Therefore, the first action the nurse should take is to check the tubing for kinks and ensure the client's urine flow is not obstructed.

A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse include in the plan? a. Soak in a sitz bath for 20 min after each stool. b. Administer a soap-suds enema to cleanse the colon. c. Cleanse with antimicrobial scrub and vigorously dry. d. Wipe perianal area with warm water and apply a barrier cream

d The nurse should instruct the client to wipe the perianal area and apply a barrier cream to decrease skin breakdown when in contact with fecal material.

A nurse is caring for a client who needs a stool specimen collected. Which of the following actions should the nurse take when obtaining the specimen? a. Use a sterile swab to obtain the specimen. b. Place the specimen in a sterile container. c. Label the paper bag in which specimen container is placed. d. Send specimen container immediately to the lab.

d The nurse should label the specimen contain and send it immediately to the laboratory. A delay in transport can result in altered laboratory findings.

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use? a. one nurse lifting as the client pushes with his feet b. two nurses lifting the client under the shoulders c. one nurse lifting the client's legs as the client uses a trapeze bar d. two nurses using a friction reducing device

d This method reduces the risk of injury to the nurses and to the client. The nurses can use a draw sheet as a friction-reducing device.

A nurse is preparing an adult client for an enema. The nurse should assist the client into which of the following positions? a. Prone b. Dorsal recumbent c. Right lateral with both knees at chest d. Left lateral with the right leg flexed

d This position makes it easier for the enema solution to flow by gravity into the sigmoid and descending colon. The flexed leg promotes exposure of the anus for insertion of the rectal tube.

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

d This temperature is greater than the expected reference range of 36° C (96.8° F) to 37° C (98.6° F). An elevated temperature is a manifestation of dehydration.

A nurse caring for a client who is experiencing hypovolemia. Which of the following findings should the nurse identify as the priority to report to the provider? a. Dry mucous membranes b. Decreased urine output c. Report of thirst d. Decrease in level of consciousness

d When using the urgent vs non-urgent priority framework, the nurse determines that the priority finding is a decrease in the client's level of consciousness. This is an indication that the hypovolemia has progressed to a critical level and requires immediate intervention.

A nurse is reviewing a client's latest arterial blood gas (ABG) report. Which of the following values should the nurse identify as the priority to report to the provider? a. pH 7.37 b. PaCO2 43 mm Hg c. HCO3- 27 mEq/L d. PaO2 76 mm Hg

d When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority value to report to the provider is PaO2 76 mm Hg. This value is below the expected reference range of 80 to 100 mm Hg and could be an indication the client is decompensating.

A nurse is teaching a client about which foods she should include in her low-fiber diet. Which of the following statements indicates the client understands the teaching? a. "A fresh pear would be a good snack option." b. "I can prepare refried beans for supper." c. "Bran cereal would be a good breakfast choice." d. "I should choose white rice as a side dish."

d White rice is a refined grain and has less fiber than whole or unrefined grains. The client can include white rice as part of a low-fiber diet.

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

a A client experiencing fluid volume deficit would manifest an increased urine specific gravity greater than 1.030.

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? a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis

a A client experiencing metabolic acidosis would have a decreased pH, a decreased HCO3 and a decreased PaCO2.

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of following indications should the nurse include? (Select all that apply). a. Relief of urinary retention b. Convenience for the nursing staff or the client's family c. Measurement of residual urine after urination d. Routine acquisition of a urine specimen e. An open perineal wound

a, c, e

A nurse is reviewing laboratory results for a client and notes the following arterial blood gas (ABG) values: pH 7.31, PaCO2 49 mm Hg, and HCO3- 25 mEq/L. The nurse should interpret these findings as an indication of which of the following acid-base imbalances? a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis

b

A nurse is calculating a client's intake and output for the last 4 hr. The client consumed 480 mL of water and 240 mL of coffee. The client has also received IV fluids for 4 hr infusing at 100 mL/hr. Which of the following amounts represents the client's intake over the last 4 hr? a. 1,120 mL b. 720 mL c. 480 mL d. 580 mL

a