Nursing 201 Week 3 questions

A client admitted to the intensive care unit is expected to remain for 3 weeks. The nurse has orders to start an IV. Which vascular access device is best for this client? A. Midline catheter B. Peripherally inserted central catheter (PICC) C. Short peripheral catheter D. Tunneled central catheter

A

A client is being admitted to the burn unit from another hospital. The client has an intraosseous IV that was started 2 days ago, according to the client's medical record. What does the admitting nurse do first? A. Anticipate an order to discontinue the intraosseous IV and start an epidural IV. B. Call the previous hospital to verify the date. C. Immediately discontinue the intraosseous IV. D. Nothing; this is a long-term treatment.

A

A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does the nurse teach the new graduate nurse to use for this client? A. Midline catheter B. Tunneled percutaneous central catheter C. Peripherally inserted central catheter D. Short peripheral catheter

A

During the insertion of an IV catheter, a patient with dehydration reports feeling "pins and needles" in his arm. The nurse is aware that this sensation may have been caused by what? A. Nerve puncture may have occurred. B. The patient's dehydration caused this sensation. C. The vein has collapsed during the catheter insertion. D. The vein has been accessed properly for the infusion.

A

How does the nurse accurately calculate a client's body mass index (BMI)? A. BMI = weight (kg)/height (in meters)2 B. BMI = weight (lb)/height (in inches)2 C. BMI = weight (kg)/height (in meters) D, BMI = weight (lb)/height (in meters)

A

The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse? A. Client behavior that changes from anxious to lethargic B. Deep furrows on the surface of the tongue C. Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched D. Urine output of 950 mL for the past 24 hours

A

The RN who usually works on the pediatric unit is floated to the GI medical-surgical unit. Which client is most appropriate for the charge nurse to assign to the float nurse? A. A 20-year-old with anorexia nervosa receiving total parenteral nutrition through a central venous line B. A 35-year-old who had a laparoscopic gastroplasty yesterday and is now taking sips of clear liquids C. A 60-year-old with gastric cancer receiving elemental feedings through a jejunostomy tube D. A 65-year-old with morbid obesity who requires a preoperative bariatric surgery assessment

A

The nurse is caring for a client who takes furosemide (Lasix) and digoxin (Lanoxin). The client's potassium (K+) level is 2.5 mEq/L (2.5 mmol/L). Which additional assessment will the nurse make? A. Heart rate B. Blood pressure (BP) C. Increases in edema D. Sodium level

A

The nurse is caring for a client with sepsis and impending septic shock. Which of these interventions will help prevent lactic acidosis? A. Ensure adequate oxygenation B. Restrict carbohydrates C. Supplement potassium D. Monitor hemoglobin

A

The nurse is caring for a group of clients. Which client will the nurse carefully observe for signs and symptoms of hyperkalemia? A. The client who has metabolic acidosis B. The client receiving total parenteral nutrition C. The client who has profuse vomiting D. The client taking a thiazide diuretic

A

The nurse is monitoring a client who is receiving an intravenous fat emulsion (IVFE) nutritional supplement. What action does the nurse take in the event that the client develops fever, increased triglycerides, and clotting problems? A. Discontinues the IVFE infusion and notifies the health care provider (HCP) B. Documents the findings and continues to monitor C. Slows the rate of flow of the IVFE infusion D. Switches to total parenteral nutrition (TPN)

A

The nurse is teaching a hospitalized client who is being discharged about how to care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education? A. "I can continue my 20-mile (32-km) running schedule as I have for the past 10 years." B. "I can still go about my normal activities of daily living." C. "I have less chance of getting an infection because the line is not in my hand." D. "The PICC line can stay in for months."

A

The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the LPN/LVN? A. Calcium level of 9.5 mg/dL (2.4 mmol/L) B. Magnesium level of 4.1 mEq/L (2.1 mmol/L) C. Potassium level of 6.0 mEq/L (6.0 mmol/L) D. Sodium level of 120 mEq/L (120 mmol/L)

A

The nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What does the nurse do initially? A. Assess the insertion site. B. Check connections. C. Check the infusion rate. D. Discontinue the IV and start another.

A

The rapid response team (RRT) is called to the bedside of a client with heart rate of 38 beats per minute and a potassium level of 7.0 mEq/L (7.0 mmol/L). For which medication will the nurse anticipate a prescription? A. Insulin B. atropine C. Sodium polystyrene sulfonate (Kayexalate) D. potassium phosphate

A

When caring for a client with a burn injury and eschar banding the chest, the nurse plans to observe the client for which of these acid base disturbances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A

Which morbidly obese client is the least likely candidate for bariatric surgery? A. A 34-year-old woman experiencing mental confusion B. A 44-year-old man with a history of hypertension C. A 50-year-old woman with a history of sleep apnea D. A 52-year-old man with a history of type 1 diabetes mellitus

A

Which of these findings causes the critical care nurse to notify the primary care provider (PCP) for evaluation for intubation? A. Increasing somnolence B. Pallor C. Deep respirations D. Bounding pulse

A

A client with hypokalemia has a prescription for parenteral potassium chloride (KCl). Which of these interventions does the nurse use to safely administer KCl? Select all that apply. A. Use a potassium infusion prepared by a registered pharmacist. B. Assess for burning or redness during infusion. C. Infuse at a rate of no more than 10 mEq per hour. D. Administer only through a central venous catheter. E. Administer by IV push only during cardiac arrest.

A, B, C

The nurse is starting a peripheral IV catheter on a recently admitted client. What actions does the nurse perform before insertion of the line? Select all that apply . A. Apply povidone-iodine to clean skin, dry for 2 minutes. B. Clean the skin around the site. C. Prepare the skin with 70% alcohol or chlorhexidine. D. Shave the hair around the area of insertion. E. Wear clean gloves and touch the site only with fingertips after applying antiseptics.

A, B, C

The nurse is caring for a client who is receiving a loop diuretic for treatment of heart failure. Which of these actions will be included in the plan of care? Select all that apply. A. Assess daily weights. B. Encourage consumption of citrus fruits. C. Weigh the client weekly. D. Monitor serum potassium. E. Discourage intake of spinach. F. Monitor for bradycardia.

A, B, D

A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure (CHF). What nursing actions are indicated at this time? Select all that apply. A. Place the client on bed rest. B. Evaluate the electrolyte levels. C. Administer the ordered diuretic. D. assess for orthostatic hypotension. E. initiate cardiac monitoring

A, B, D, E

A client is admitted to the hospital with dehydration secondary to influenza and vomiting. The provider orders an intravenous (IV) potassium replacement for potassium level of 2.7 mEq/L (2.7 mmol/L). Which of these best practice techniques does the nurse include when administering this medication? Select all that apply. A. Ensuring that the concentration is not greater than 1 mEq/10 mL of solution B. Use a vein in the hand for better flow C. Use an IV pump to deliver the medication D. Check IV access for blood return after the infusion E. Push the medication over 5 minutes

A, C

A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first? A. Draws blood for laboratory tests B. Elevates the head of the bed C. Places the extremities in a dependent position D. Puts the client in a side-lying position

B

A client has a primary problem of inadequate nutrition caused by the effects of chemotherapy. The client is receiving continuous enteral feedings through a nasogastric (NG) tube. What does the RN ask the LPN/LVN to do for this client? A. Assess nutritional parameters on the client every 3 days. B. Check the residual volume of the NG tube every 4 hours. C. Monitor the client for signs and symptoms of pneumonia. D. Teach the client about the purpose of enteral feedings.

B

A client is admitted to the cardiothoracic surgical intensive care unit after cardiac bypass surgery. The client is still sedated on a ventilator and has an arterial catheter in the right wrist. What assessment does the nurse make to determine patency of the client's arterial line? A. Blood pressure B. Capillary refill and pulse C. Neurologic function D. Questioning the client about the pain level at the site

B

A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened and begun 20 hours ago. What action does the nurse take? A. Change the set immediately. B. Change the set in about 4 hours. C. Change the set in the next 12 to 24 hours. D. Nothing; the set is for long-term use.

B

A nursing student is preparing to insert a vascular access device in an older patient. Which action by the nursing student requires intervention by the nurse? A. Performing hand hygiene prior to insertion. B. Preparing for insertion immediately following cleaning with iodophors. C. Using friction to clean the skin around the insertion site. D. Clipping the hairs in the preferred insertion area.

B

A patient has been having frequent liquid diarrhea for the last 24 hours. A stool sample was sent to the laboratory to confirm possible Clostridium difficile infection. The nurse should monitor the patient for which electrolyte imbalance? A. Dehydration B. Hypokalemia C. Hyponatremia D. Hypocalcemia

B

A patient is brought to the ED with respiratory depression. The patient has a history of COPD. What acid-base imbalance is most likely? A. Metabolic alkalosis B. Respiratory acidosis C. Metabolic acidosis and respiratory acidosis D. Metabolic alkalosis and respiratory alkalosis

B

An older adult is admitted to the medical surgical unit with dehydration. The nurse performs which of these assessments to determine whether the client is safe for independent ambulation? A. Assesses for dry oral mucous membranes B. Checks for orthostatic blood pressure changes C. Notes pulse rate is 72 beats/min and bounding D. Evaluates that the serum potassium level is 4.0 mEq/L (4.0 mmol/L)

B

An older adult with severe rheumatoid arthritis in the upper extremities is malnourished. What does the nurse suspect as the cause of this client's malnutrition? A. A decrease in the client's appetite B. Decreasing ability to manipulate eating utensils C. Inadequate income to purchase sufficient food D. Metabolic requirements that are increased owing to immobility

B

An older client is at risk for malnutrition. Which nursing intervention is most appropriate to ensure optimum nutritional intake? A. Administering antiemetics and analgesics after meals B. Assisting the client with toileting and oral care prior to meals C. Turning on the television during meals to provide distraction D. Reminding UAPs to allow the client to remain in bed during meals

B

An underweight client is receiving nutritional supplements to restore nutritional status. What does the nurse do to assess the effectiveness of the supplements for the client? A. Keeps an accurate and precise food and fluid intake record daily B. Makes certain the client is weighed daily at the same time C. Monitors vital signs every 4 hours and as needed D. Assesses the client's skin for evidence of breakdown weekly

B

The nurse and nursing student are caring for a client with a new diagnosis of diabetes whose blood glucose is 974 mg/dL (54.1 mmol/L). Which of these statements indicates the student understands the relationship between blood glucose and acid base balance? A. "The excess glucose in the blood causes the client to hypoventilate and retain carbon dioxide resulting in respiratory acidosis" B. "The hyperglycemia is caused by inability of glucose to enter the cell causing a starvation state and break down of fats" C. "The client has a hyperosmolar condition causing polyuria and polyphagia, but the acid base balance is normal" D. "The client is retaining carbon dioxide which led to respiratory acidosis and somnolence"

B

The nurse assessing a client's peripheral IV site obtains and documents information about it. Which assessment data indicate the need for immediate nursing intervention? A. Client states, "It really hurt when the nurse put the IV in." B. The vein feels hard and cordlike above the insertion site. C. Transparent dressing was changed 5 days ago. D. Tubing for the IV was last changed 72 hours ago.

B

The nurse at a long-term care facility is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. Which of these should be included in the education session? A. "Be careful not to overload them with too many oral fluids." B. "Offer fluids that they prefer frequently and on a regular schedule." C. "Restrict their fluids if they are incontinent." D. "Wake them every 2 hours during the night with a drink."

B

The nurse checking an IV fluid order questions its accuracy. What does the nurse do first? A. Asks the charge nurse about the order B. Contacts the health care provider who ordered it C. Contacts the pharmacy for clarification D. Starts the fluid as ordered, with plans to check it later

B

The nurse is administering a drug to a client through an implanted port. Before giving the medication, what does the nurse do to ensure safety? A. Administer 5 mL of a heparinized solution. B. Check for blood return. C. Flush the port with 10 mL of normal saline. D. Palpate the port for stability.

B

The nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters does the nurse choose most often? A. Back of the hand for an older adult B. Cephalic vein of the forearm C. Lower arm on the side of a radical mastectomy D. Subclavian vein

B

The nurse is caring for a client who has developed postoperative respiratory acidosis. Which of these interventions will the nurse use to help correct this problem? A. Medicate for pain. B. Encourage use of incentive spirometer. C. Perform fingerstick blood glucose. D. Encourage protein intake.

B

The nurse is infusing 3% saline for a client with syndrome of inappropriate secretion (SIADH). Which of these complications does the nurse report to the primary care provider? A. Peripheral edema B. Crackles ½ way up the lung fields C. Serum osmolarity of 294 mOsm/kg (294 mmol/kg) D. Urine output of 1300 mL over 24 hours

B

The nurse is teaching a group of adults in the community about the 2015-2020 Dietary Guidelines for Americans. What does the nurse emphasize as a dietary strategy suggested in these guidelines? A. Half of each meal should consist of dairy, fruits, and proteins. B. Adults should focus on variety and nutrient density and not calories. C. Older adults should consider lacto-ovarian diets for improved health. D. Adults should include a multivitamin with iron and vitamin B12 in their diet.

B

The nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion? A. Asks the client to both say and spell his or her full name before starting the blood transfusion B. Ensures that another qualified health care professional checks the unit before administering C. Checks the blood identification numbers with the laboratory technician at the blood bank at the time it is dispensed D. Makes certain that an IV solution of 0.9% normal saline is infusing into the client before starting the unit

B

The nursing assistant reports that the client with metabolic acidosis due to kidney failure is breathing rapidly and deeply. The nurse explains this to the nursing assistant in which of these manners? A. "The client is acting out and we should pay him no mind" B. "Rapid breathing is a way to compensate for acidosis caused by his condition" C. "Normally a client with this disorder will breathe slowly, I will go assess him" D. "Deep breathing is a symptom of diabetes, I will check his blood glucose"

B

Which serum albumin level does the nurse expect to see in a healthy, ambulatory adult client? A. 2.3 g/dL (23 g/L) B. 3.7 g/dL (37 g/L) C. 5.1 g/dL (51 g/L) D. 5.8 g/dL (58 g/L)

B

Which statement is true about the special needs of older adults receiving IV therapy? A. Placement of the catheter on the back of the client's dominant hand is preferred. B. Skin integrity can be compromised easily by the application of tape or dressings. C. To avoid rolling the veins, a greater angle of 25 degrees between the skin and the catheter will improve success with venipuncture. D. When the catheter is inserted into the forearm, excess hair should be shaved before insertion.

B

A client is brought to the emergency department for increasing weakness and muscle twitching. The laboratory results include a potassium level of 7.0 mEq/L (7.0 mmol/L). Which assessments does the nurse make? Select all that apply. A. History of liver disease B. Use of salt substitute C. Use of an ACE inhibitor D. Potassium-sparing diuretics E. Prescription for insulin

B, C, D

An obese client has been taking orlistat (Xenical) 60 mg orally three times a day for 4 weeks, but has only lost 10 pounds (4.5 kg). The health care provider doubles the dosage and recommends behavioral changes. What behavioral changes does the nurse include in the teaching plan? Select all that apply. A. Cognitive restructuring to learn negative coping statements B. Keeping a daily food diary C. Identifying emotional and situational factors that stimulate eating D. Increasing exercise E. Seeking behaviors in others that one can model

B, C, D

The nurse is caring for a client receiving lactated Ringer's solution IV for rehydration. Which assessments will the nurse monitor during intravenous therapy? Select all that apply. A. Blood serum glucose B. Blood pressure C. Pulse rate and quality D. Urinary output E. Urine specific gravity

B, C, D, E

The nurse is instructing a group of overweight clients on the complications of obesity that develop when weight is not controlled through diet and exercise. Which lifestyle changes does the nurse emphasize? Select all that apply. A. "Begin a weight-training program for building muscle mass." B. "Consume a diet that is moderate in salt and sugar and low in fats and cholesterol." C. "Eat a variety of foods, especially grain products, vegetables, and fruits." D. "Engage in moderate physical activity for at least 30 minutes each day." E. "Foods eaten away from home tend to be higher in fat, cholesterol, and salt and lower in calcium than foods prepared at home." F. "Liquid dietary supplements can be substituted safely for solid food while attempting to lose weight."

B, C, D, E

The nurse is documenting peripheral venous catheter insertion for a client. What does the nurse include in the note? Select all that apply. A. Client's name and hospital number B. Client's response to the insertion C. Date and time inserted D. Type and size of device E. Type of dressing applied F. Vein used for insertion

B, C, D, E, F

The nurse is caring for a client with acute respiratory failure and PaCO2 level of 88 mm Hg For which of these signs and symptoms will the nurse assess? Select all that apply. A. Hyperactivity B. Headache C. Shallow breathing D. pH 7.49 E. Fatigue

B, C, E

The nurse is teaching a client who is taking a potassium-sparing diuretic about precautions while taking this medication. Which of these does the nurse teach the client to avoid or use cautiously? Select all that apply. A. Apples B. Bananas C. ACE inhibitors D. Grapes E. Salt substitute

B, C, E

The nurse is revising an agency's recommended central line catheter-related bloodstream infection prevention (CR-BSI) bundle. Which actions decrease the client's risk for this complication? Select all that apply. A. During insertion, draping the area around the site with a sterile barrier B. Immediately removing the client's venous access device (VAD) when it is no longer needed C. Making certain that observers of the insertion are instructed to look away during the procedure D. Thorough hand hygiene (i.e., no quick scrub) before insertion E. Using chlorhexidine for skin disinfection

B, D, E

A 22-year-old client is seen in the emergency department (ED) with acute right lower quadrant abdominal pain, nausea, and rebound tenderness. It appears that surgery is imminent. What gauge catheter does the ED nurse choose when starting this client's intravenous solution? A. 24 B. 22 C. 18 D. 14

C

A client is placed on orlistat (Xenical) as part of a treatment regimen for morbid obesity. What side effects does the nurse tell the client to expect from using this drug? A. Dry mouth, constipation, and insomnia B. Insomnia, dry mouth, and blurred vision C. Loose stools, abdominal cramps, and nausea D. Palpitations, constipation, and restlessness

C

A client is seen in the emergency department (ED) with pain, redness, and warmth of the right lower arm. The client was in the ED last week after an accident at work. On the day of the injury, the client was in the ED for 12 hours receiving IV fluids. On close examination, the nurse notes the presence of a palpable cord 1 inch (2.5 cm) in length and streak formation. How does the nurse classify this client's phlebitis? A. Grade 1 B. Grade 2 C. Grade 3 D. Grade 4

C

A client is to receive an IV solution of 5% dextrose and 0.45% normal saline at 125 mL/hr. Which system provides the safest method for the nurse to accurately administer this solution? A. Controller B. Glass container C. Infusion pump D. Syringe pump

C

A client receiving total parenteral nutrition (TPN) exhibits symptoms of congestive heart failure (CHF) and pulmonary edema. Which complication of TPN is the client most likely experiencing? A. Calcium imbalance B. Fluid volume deficit C. Fluid volume overload D. Potassium imbalance

C

A client who used to work as a nurse asks, "Why is the hospital using a 'fancy new IV' without a needle? That seems expensive." How does the nurse respond? A. "OSHA, a government agency, requires us to use this new type of IV." B. "These systems are designed to save time, not money." C. "They minimize health care workers' exposure to contaminated needles." D. "They minimize clients' exposure to contaminated needles."

C

A female client is concerned that her inability to conceive a child is connected to her morbid obesity. How does the nurse respond? A. "Do you feel that your obesity is keeping you from getting pregnant?" B. "Have you considered adoption as an option?" C. "Tell me about any changes in your menstrual cycle each month." D. "What has your health care provider told you about your problems in getting pregnant?"

C

A man with severe burns over 90% of his body has been brought to the ED. The rescue personnel were unable to establish IV access during transport to the hospital. Which type of IV device would be most appropriate at this time? A. PICC line B. Central line C. Intraosseous catheter D. Subcutaneous infusion

C

A young adult man says that he cannot stay on a diet because of trouble finding one that will incorporate his food preferences. How does the nurse most effectively plan nutritional care for this client? A. Calculates his body mass index (BMI) B. Records a 24-hour diary of his physical activities C. Obtains a 24-hour recall (diary) of his food intake D. Measures his accurate height and weight measurements

C

After receiving change-of-shift report, which client does the RN assess first? A. A client with nausea and vomiting who complains of abdominal cramps B. A client with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst C. A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg D. A client with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL

C

An 87-year-old resident from an extended care facility has not been eating for several days and is admitted to the hospital with a diagnosis of malnutrition. She has an enteral feeding tube placed in her left nostril. Her medications include digoxin (Lanoxin), ranitidine (Zantac), and potassium chloride elixir (Kay Ciel). The nurse checks the gastric pH of the feeding tube and obtains a value of 6.0, which may indicate that the feeding tube is in the client's lungs. Is there another possible explanation for the nurse to consider? A. No; the feeding tube must be removed. B. No; the potassium effect will prevent the pH from reaching 6.0. C. Yes; the client is taking Zantac. D. Yes; the pH paper has expired and is giving a false reading.

C

An obese client is prescribed orlistat (Xenical). The client asks the nurse how the drug works. How does the nurse respond? A. "It decreases the amount of norepinephrine in your brain. This action will increase your feeling of being satisfied on less food." B. "It increases the amount of serotonin in your brain. This action will greatly increase your metabolic rate, and you will burn calories quicker." C. "It inhibits enzymes and changes the way your body digests fats. Because fats are only partially digested and absorbed, calorie intake is decreased." D. "It will alter the chemistry of your brain. Consequently, you will feel full before you overeat."

C

An older adult with pernicious anemia requests help with menu choices. What type of food will the nurse encourage the patient to eat? A. Prunes B. Oranges C. Skim milk D. Wheat bread

C

An older malnourished client who is taking digoxin (Lanoxin), ranitidine (Zantac), and potassium chloride elixir (Kay Ciel) develops a severe case of diarrhea. What does the nurse suspect is a possible cause? A. Digoxin (Lanoxin) B. Gastritis C. Potassium chloride (Kay Ciel) D. Ranitidine (Zantac)

C

Furosemide (Lasix) has been ordered for a client with heart failure, shortness of breath, and 3+ pitting edema of the lower extremities. Which assessment finding indicates to the nurse that the medication has been effective? A. The client's potassium level is 5.1 mEq/L (5.1 mmol/L). B. The client's heart rate is 101 beats per minute. C. The client is free from adventitious breath sounds. D. The client has experienced a weight gain of 1 pound (0.5 kg).

C

The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which client is most appropriate to assign to the LPN/LVN? A. A 44-year-old with congestive heart failure (CHF) who has gained 3 pounds (1.4 kg) since the previous day B. A 58-year-old with chronic renal failure (CRF) who has a serum potassium level of 6 mEq/L (6.0 mmol/L) C. A 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/kg (300 mmol/kg) D. An 80-year-old with 3+ peripheral edema and crackles throughout the posterior chest

C

The nurse is assessing a client with a sodium level of 118 mEq/L (118 mmol/L). Which activity takes priority? A. Monitoring urine output B. encouraging sodium rich fluids and foods throughout the day C. instructing the client not to ambulate without assistance D. assessing deep tendon reflexes

C

The nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical? A. Monitoring 24-hour urine output B. Asking the client about feeling depressed C. Assessing the blood pressure hourly D. Monitoring the serum calcium levels

C

The nurse is caring for a group of clients with electrolytes and blood chemistry abnormalities. Which client will the nurse see first? A. The client with a random glucose reading of 123 mg/dL (6.8 mmol/L) B. The client who has a magnesium level of 2.1 mEq/L (1.0 mmol/L) C. The client whose potassium is 6.2 mEq/L (6.2 mmol/L) D. The client with a sodium level of 143 mEq/L (143 mmol/L)

C

The nurse is caring for a patient who is preparing for bariatric surgery. What is the appropriate nursing response when the patient states, "I am afraid this surgery won't work"? A. "Are you afraid you will stay overweight for life?" B. "This surgery always works. It will be fine." C. "Tell me what concerns you most." D. "We will postpone the surgery until you decide how you feel."

C

The nurse is discussing safety when administering bumetanide with a nursing student. The nurse recognizes that the student understands side effects of this medication when the student makes which statement? A. "The client's PT and INR may be prolonged while taking this medication." B. "The client may develop hypoglycemia during treatment." C. "Inverted T waves and a U wave may appear on the ECG." D. "I need to tell the client to avoid salt substitutes."

C

The nurse is inserting a peripheral intravenous (IV) catheter. Which client statement is of greatest concern during this procedure? A. "I hate having IVs started." B. "It hurts when you are inserting the line." C. "My hand tingles when you poke me." D. "My IV lines never last very long."

C

The nurse is performing a health assessment on an obese client who states, "I have tried many diets in an effort to lose weight, but have been unsuccessful." How does the nurse assess whether the client's response to stress is related to the client's obesity? A. "Do you have a history of mental problems, especially depression?" B. "Do you usually use alcohol or drugs when you feel stressed?" C. "Tell me what you do to relieve stress in your daily life." D. "What is it about your obesity that causes you to feel uncomfortable?"

C

The nurse is reviewing the standing orders for a patient who was admitted for evaluation of chest pain. The patient has a history of chronic obstructive pulmonary disease (COPD) and his laboratory results and assessment reveal that he has mild respiratory acidosis. The nurse would question which order? A. Encourage oral fluids B. Keep head of bed elevated C. Oxygen therapy at 4 L/min as needed D. Bedrest with bathroom privileges only

C

The nurse is teaching a class of older adults in the community about engaging in "regular" exercise. What does the nurse advise them? A. "One to two hours of cardiovascular exercise every day is a good idea." B. "Joining a fitness program or gym will help greatly with your exercise." C. "Walking 30 to 40 minutes provides the same benefit as long periods of exercise." D. "You will benefit most if you get into a group that shares your exercise goals."

C

The nurse is teaching a middle-aged adult client with a body mass index (BMI) of 27.5 and a height of 5'2" (157.5 cm) about what the BMI number means, and about malnutrition. Which client statement indicates a need for further instruction? A. "If I could get my BMI below 25, my risk for malnutrition would decrease." B. "I realize that this means that I have some increased health risks." C. "My goal should be to get my BMI below 18.5." D. "This means that I have an increased amount of total fat stored in my body."

C

The nurse manager in a long-term care facility plans nutritional assessments of all residents. Which nutritional assessment activity does the nurse delegate to unlicensed assistive personnel (UAP) at the facility? A. Assessing residents' abilities to swallow B. Determining residents' functional status C. Measuring the daily food and fluid intake of residents D. Screening a portion of the residents with the Mini Nutritional Assessment

C

The primary care provider writes prescriptions for a client who is admitted with a serum potassium level of 6.9 mEq/L (6.9 mmol/L). What does the nurse implement first? A. Administer sodium polystyrene sulfonate (Kayexalate) orally. B. Ensure that a potassium-restricted diet is ordered. C. Place the client on a cardiac monitor. D. Teach the client about foods that are high in potassium.

C

The step down unit receives a new admission who has uncontrolled diabetes, polyuria, and a blood pressure of 86/46 mm Hg. Which staff member is assigned to care for her? A. LPN/LVN who has floated from the hospital's long-term care unit B. LPN/LVN who frequently administers medications to multiple clients C. RN who has floated from the intensive care unit D. RN who usually works as a diabetes educator

C

What possible complication does the nurse observe for when administering total parenteral nutrition (TPN)? Select all that apply. A. Infection B. Dehydration C. Hyperglycemia D. Electrolyte imbalance

C

When caring for a client who has the following blood gas results, which of these interventions does the nurse plan to use to correct the acid base disturbance? pH 7.47—pCO2 37 mm hg- HCO3 30 mEq/L (30 mmol/L)—pO2 88mm hg A. Endotracheal suctioning B. Applying oxygen C. Administering an antiemetic D. Administering sodium bicarbonate

C

When flushing a client's central line with normal saline, the nurse feels resistance. Which action does the nurse take first? A. Decrease the pressure being used to flush the line. B. Obtain a 10-mL syringe and reattempt flushing the line. C. Stop flushing and try to aspirate blood from the line. D. Use "push-pull" pressure applied to the syringe while flushing the line.

C

Which client does the charge nurse on a medical-surgical unit assign to the LPN/LVN? A. Cardiac client who has a diltiazem (Cardizem) IV infusion being titrated to maintain a heart rate between 60 and 80 beats/min B. Diabetic client admitted for hyperglycemia who is on an IV insulin drip and needs frequent glucose checks C. Older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours D. Postoperative client receiving blood products after excessive blood loss during surgery

C

Which client is most appropriate for the nurse manager of the medical-surgical unit to assign to the LPN/LVN? A. A client admitted with dehydration who has a heart rate of 126 beats/min B. A client just admitted with hyperkalemia who takes a potassium-sparing diuretic at home C. A client admitted yesterday with heart failure with dependent pedal edema D. A client who has just been admitted with severe nausea, vomiting, and diarrhea

C

A 25-year-old student has been taken to an urgent care clinic because of dehydration. She says she has had "the flu," with vomiting and diarrhea "all night" and has had very little to eat or drink. She says the GI symptoms have subsided, but she feels weak. The nurse expects which type of rehydration to occur? A. IV fluid replacement B. Oral rehydration therapy with tea C. Oral rehydration therapy with water D. Oral rehydration therapy with a solution containing glucose and electrolytes

D

A 70-year-old client with severe dehydration is ordered an infusion of an isotonic solution at 250 mL/hr through a midline IV catheter. After 2 hours, the nurse notes that the client has crackles throughout all lung fields. Which action does the nurse take first? A. Assess the midline IV insertion site. B. Have the client cough and deep-breathe. C. Notify the health care provider about the crackles. D. Slow the rate of the IV infusion.

D

A client has undergone bariatric surgery. Which nursing intervention is the highest priority in preventing dehydration in this client? A. Ambulating the client as quickly as possible after surgery B. Applying an abdominal binder daily when the client is out of bed C. Observing for tachycardia, nausea, diarrhea, and abdominal cramping D. Providing six small feedings daily and offering fluids frequently

D

A client who has undergone a bariatric surgical procedure is recuperating after surgery. Which nursing intervention most effectively prevents injury to the client who is being re-positioned postoperatively? A. Administering pain medication B. Making sure not to move the client's nasogastric (NG) tube C. Monitoring skinfold areas and keeping them clean and dry D. Using a weight-rated extra-wide bed for the client

D

A client who is receiving total enteral nutrition exhibits acute confusion and shallow breathing and says, "I feel weak." As the client begins to have a generalized seizure, how does the nurse interpret this client's signs and symptoms? A. The enteral tube is dislodged. B. Abdominal distention is present. C. Severe hyperglycemia is present. D. Refeeding syndrome is occurring.

D

A client with hypermagnesemia is seen in the emergency department (ED). Which of these interventions is most appropriate? A. Monitor for hyperactive reflexes B. prepare for endotracheal intubation C. Institute teaching on avoiding magnesium rich foods D. Place the client on a cardiac monitor

D

A client with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide? A. Assessment of muscle tone and strength B. Education about potassium-rich foods C. Instruction on the proper use of drugs D. Measurement of the client's weight

D

A severely dehydrated client requires a rapid infusion of normal saline and needs a midline IV placed. Which staff member does the emergency department (ED) charge nurse assign to complete this task? A. RN who is certified in the administration of oral and infused chemotherapy medications B. RN with 2 years of experience in the ED who is skilled at insertion of short peripheral catheters C. RN with 10 years of experience on a medical-surgical unit who has cared for many clients requiring IV infusions D. RN with certified registered nurse infusion (CRNI) certification who is assigned to the ED for the day

D

An RN receives the change-of-shift report about these four clients. Which client does the nurse assess first? A. A 30-year-old admitted 2 hours ago with malnutrition associated with malabsorption syndrome B. A 45-year-old who had gastric bypass surgery and is reporting severe incisional pain C. A 50-year-old receiving total parenteral nutrition (TPN) with a blood glucose (BG) level of 300 mg/dL (16.7 mmol/L) D. A 75-year-old with dementia who is receiving nasogastric feedings and has a respiratory rate of 38 breaths/min

D

An obese client with a body mass index of 30 and hypertension has been taking prescription orlistat for 4 weeks and reports loose stools, abdominal cramps, and nausea. What does the nurse recommend for this client? A. Asking the provider to change the medication to phendimetrazine (Bontril). B. Changing to the lower dose, over-the-counter form of orlistat to reduce these effects. C. Increasing the daily activity level to improve overall metabolism. D. Reducing nutritional fat intake to less than 30% of the client's daily food intake.

D

An older adult client needs additional dietary protein, but refuses to drink the prescribed liquid protein supplements. Which nursing intervention is most effective in increasing the client's protein intake? A. Administering the liquid supplement with routine medications B. Giving a glucose polymer modular supplement C. Keeping a food and fluid intake diary for at least 3 days D. Providing protein modular supplements in the form of puddings

D

Based on nutritional screening findings and assessments, which client will be the preferred candidate for surgical treatment for obesity? A. Man with a body mass index (BMI) of 40, weight 75% above ideal body weight B. Man with a BMI of 41, weight 80% above ideal body weight C. Woman with a BMI of 38, weight 50% above ideal body weight D. Woman with a BMI of 42, weight 100% above ideal body weight

D

The RN is caring for a client who is severely dehydrated. Which nursing action can be delegated to the unlicensed assistive personnel (UAP)? A. Consulting with a health care provider about a client's laboratory results B. Infusing 500 mL of normal saline over 60 minutes C. Monitoring IV fluid to maintain the drip rate at 75 mL/hr D. Providing oral care every 1 to 2 hours

D

The nurse is assessing fluid balance in the client with heart failure. Which of these strategies will the nurse employ? A. Ask the client how much fluid was consumed yesterday. B. Place an indwelling catheter to measure urine output. C. Auscultate the lungs for adventitious sounds. D. Weigh the client daily, at the same time.

D

The nurse is caring for a client with long standing emphysema and respiratory acidosis. For which of these compensatory mechanisms will the nurse assess? A. Decreased rate of breathing B. Increased loss of bicarbonate through the kidney C. Decreased depth of breathing D. Decreased loss of bicarbonate through the kidney

D

The nurse is caring for a group of clients on a medical surgical unit. Which newly written prescription will the nurse administer first? A. Intravenous normal saline to a client with a serum sodium of 132 mEq/L (132 mmol/L) B. Oral calcium supplements to a client with severe osteoporosis C. Oral phosphorus supplements to a client with acute hypophosphatemia D. Oral potassium chloride to a client whose serum potassium is 3 mEq/L (3 mmol/L)

D

The nurse is caring for an older adult with hypernatremia. Which of these interventions does the nurse perform first? A. Restrict the client's intake of sodium B. Administer a diuretic C. Monitor the serum osmolarity D. Encourage fluid intake

D

The nurse is evaluating the laboratory work of a patient who has uncontrolled metabolic acidosis. Which outcome would result from this condition? A. pH 7.40 B. Pao2 98 mm Hg C. Bicarbonate 38 mEq/L D. Serum potassium 5.7 mEq/L

D

The nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed assistive personnel (UAP)? A. Assessing oral mucosa for dryness B. Choosing appropriate oral fluids C. Monitoring skin turgor for tenting D. Offering fluids to drink every hour

D

The nurse is preparing a client a diagnosis of congestive heart failure (CHF) for discharge. Which statement by the client indicates a correct understanding of self-management of CHF? A. "I can gain 2 pounds (1 kg) of water a day without risk." B. "I should call my provider if I gain more than 1 pound (0.5 kg) a week." C. "Weighing myself daily can determine if my caloric intake is adequate." D. "Weighing myself daily can reveal increased fluid retention."

D

The nurse obtains assessment data on a client who had bariatric surgery today. Which finding does the nurse report to the surgeon immediately? A. Bowel sounds are not audible in all quadrants. B. Client's skin under the panniculus is excoriated. C. The client reports pain when being repositioned. D. Urine output total is 15 mL for the past 2 hours.

D

Which client on the medical-surgical unit does the charge nurse assign to the LPN/LVN? A. A 28-year-old with morbid obesity who had bariatric surgery today B. A 30-year-old recently admitted with severe diarrhea and Clostridium difficile infection C. A 36-year-old whose family needs instruction about how to use a gastric feeding tube D. A 39-year-old with a jejunal feeding tube who needs elemental feedings administered

D

Which nursing care activity for a malnourished client does the nurse safely delegate to unlicensed assistive personnel (UAP)? A. Completing the Mini Nutritional Assessment B. Determining body mass index (BMI) C. Estimating body fat using skinfold measurements D. Measuring current height and weight

D

While monitoring a patient who has fluid overload, which assessment is most concerning to the nurse? A. Bounding pulse B. Neck vein distention C. Pitting edema in the feet D. Presence of crackles in the lungs

D