Nursing Fundamentals Final Exam Practice Questions 7
A client is subjected to undergo a chest x-ray to confirm the endotracheal tube placement. The tube should be how many centimeters above the carina? A. 2-4 cm. B. 1.5-3 cm. C. 1-2 cm D. 0.5-1 cm.
1-2 cm
A nurse is making initial rounds at the beginning of the shift and notices that the parenteral nutrition (PN) bag of an assigned client is empty. Which of the following solutions readily available on the nursing unit should the nurse hang until another PN solution is mixed and delivered to the nursing unit? A. 10% dextrose in water. B. 5% dextrose in water. C. 5% dextrose in normal saline. D. 5% dextrose in lactated Ringer solution.
10% dextrose in water (The client is at risk of hypoglycemia. Hence the nurse will hang a solution that has the highest amount of glucose until the new parenteral nutrition solution becomes readily available.)
A client went to the emergency room with a sudden onset of high fever and diaphoresis. Serum sodium was one of the laboratory tests taken. Which of the following values would you expect to see? A. 130 mEq/L. B. 148 mEq/L. C. 143 mEq/L. D. 139 mEq/L.
148 mEq/L
Continuous type of feedings is administered over a __ hour period? A. 4. B. 12. C. 24. D. 36.
24
A client with Congestive heart failure is about to take a dose of furosemide (Lasix). Which of the following potassium levels, if noted in the client's record, should be reported before giving the due medication? A. 5.1 mEq/L. B. 4.9 mEq/L. C. 3.9 mEq/L. D. 3.3 mEq/L.
3.3 mEq/L
The nurse is handling a client with chronic pancreatitis. Upon reviewing the client's record, which of the following serum amylase levels is to be expected? A. 50 units/L. B. 150 units/L. C. 350 units/L. D. 650 units/L.
350 units/L (The normal serum amylase level is 25 to 151 unit/L. Clients with chronic pancreatitis have an increased level of serum amylase which does not exceed three times the normal value. Serum amylase and lipase levels may be slightly elevated in chronic pancreatitis; high levels are found only during acute attacks of pancreatitis.)
A nurse is checking the nasogastric tube position of a client receiving a long-term therapy of Omeprazole (Prilosec) by aspirating the stomach contents to check for the PH level. The nurse proves the correct tube placement if the PH level is? A. 7.75. B. 7.5. C. 6.5. D. 5.5.
5.5
Nurse Russell is preparing to give total parenteral nutrition using a central line. Place the following steps for administration in the correct order? Connect the tubing to the central line. Prime the IV tubing through an infusion pump. Select and flush the correct tubing and filter. Maintain an aseptic technique when handling the injection cap. Regulate the electric infusion pump at the ordered rate. Check the solution for cloudiness, particles, or a change in color.
Check the solution for cloudiness, particles, or a change in color. Select and flush the correct tubing and filter. Prime the IV tubing through an infusion pump. Maintain an aseptic technique when handling the injection cap. Connect the tubing to the central line. Regulate the electric infusion pump at the ordered rate. Incorrect
A client is being weaned off from parenteral nutrition (PN) and is given a go-signal to take a regular diet. The ongoing solution rate has been 120ml/hr. A nurse expects that which of the following prescriptions regarding the PN solution will accompany the diet order? A. Decrease the PN rate to 60ml/hr. B. Start 0.9% normal saline at 30 ml/hr. C. Maintain the present infusion rate. D. Discontinue the PN.
Decrease the PN rate to 60ml/hr
A Chinese-American client experiencing cough with clear white phlegm, which is believed to be a yin disorder, is likely to treat it with: A. Foods considered being yin. B. Foods considered being yang. C. Aromatherapy. D. Touch therapy.
Foods considered being yang
Nurse Maria is administering a cleansing enema to a client with severe constipation. She will place the client in which position? A. Low Fowler's position. B. High Fowler's position. C. Left Sim's position. D. Right Sim's position.
Left Sim's position
A nurse is caring for a client who disconnected the tubing of the parenteral nutrition from the central line catheter. A nurse suspects an occurrence of an air embolism. Which of the following is an appropriate position for the client in this kind of situation? A. On the right side, with head higher than the feet. B. On the right side, with head lower than the feet. C. On the left side, with the head higher than the feet. D. On the left side, with head lower than the feet.
On the left side, with head lower than the feet (This position will lessen the effect of the air traveling as a bolus to the lungs by trapping it on the right side of the heart.)
What type of client would benefit the most from an elevated head of the bed position? A. Patient who had a hemorrhoidectomy. B. Patient who had a laryngectomy. C. Patient who had a liver biopsy. D. Patient who had a lumbar puncture.
Patient who had a laryngectomy (to maintain a patent airway and reduce edema)
A nurse is caring for a Native American client who experiences emotional distress due to a family problem. In anticipating pharmacological treatment for the client, the nurse understands that they would most likely: A. Establish the trust of the health care provider first before accepting the treatment. B. Call a clergy to ask for the religious preference of the treatment. C. Manage the emotional distress on their own to avoid disgrace. D. Resort with the use of herbal medicines with healing properties.
Resort with the use of herbal medicines with healing properties
A nurse is caring for a combative client who is ordered to have a nutritional therapy using parenteral nutrition (PN). The nurse should plan which of the following measures to prevent the client from injury? A. Monitor blood glucose twice a day. B. Instruct the relative to stay with the nurse. C. Measure 24-hour intake and output. D. Secure all connections in the parenteral system.
Secure all connections in the parenteral system
The nurse is assessing a client with an endotracheal tube and observes that the client can make verbal sounds. What is the most likely cause of this? A. This is a normal finding. B. There is a leak. C. There is an occlusion. D. The endotracheal tube is displaced.
There is a leak.
A client is receiving nutrition via parenteral nutrition (PN). A nurse assesses the client for complications of the therapy and assesses the client for which of the following signs of hyperglycemia? A. High-grade fever, chills, and decreased urination. B. Fatigue, increased sweating, and heat intolerance. C. Coarse dry hair, weakness, and fatigue. D. Thirst, blurred vision, and diuresis.
Thirst, blurred vision, and diuresis
Which of the following food items would be appropriate for a Jewish client who follows a kosher diet? A. Shrimp and mussels. B. Beef and pork. C. Tuna and salmon. D. Cheese and milk.
Tuna and salmon
A male client with atrial fibrillation who is receiving maintenance therapy of warfarin (Coumadin) has a prothrombin time of 37 seconds. Based on the result, the nurse will follow which of the following doctor's orders? A. Administering the next dose of warfarin. B. Increasing the next dose of warfarin. C. Decreasing the next dose of warfarin. D. Withholding the next dose of warfarin.
Withholding the next dose of warfarin. (The normal prothrombin time is 9.6 to 11.8 seconds (male adult))
A client with liver cirrhosis has been advised to follow a high-protein diet. The nurse evaluates the effectiveness of the diet if the total protein level is which of the following values? A. 6.9 g/dL. B. 4.9 g/dL. C. 2.9 g/dL. D. 0.9 g/dL.
6.9 g/dL (The normal value for total serum protein is 6 to 8 g/dL)
A nurse is caring for a group of clients in a medical-surgical nursing unit. The nurse recognizes that which of the following clients would be the least likely candidate for parenteral nutrition? A. A 55-year-old with persistent nausea and vomiting from chemotherapy. B. A 44-year old client with ulcerative colitis. C. A 59-year old client who had an appendectomy. D. A 25-year old client with Hirschsprung's Disease.
A 59-year old client who had an appendectomy
A nurse observes the client receiving fat emulsions is having hives. A nurse reviews the client's history and notes which of the following may be caused by the complaint of the client? A. Allergy to an egg. B. Allergy to peanuts. C. Allergy to shellfish. D. Allergy to corn.
Allergy to an egg (Fat emulsions (lipids) contain egg yolk phospholipids and should not be given to clients with egg allergies.)
A client is to be on bed rest for 24 hours and the affected extremity is to be kept straight during this time. Which of the following procedures would require a client to do the above? A. Varicose vein surgery. B. Myelogram. C. Abdominal aneurysm resection. D. Arterial Vascular Grafting.
Arterial Vascular Grafting (To promote graft patency after the procedure, bedrest is maintained for the first 24 hours and the affected extremity is kept straight.)
When providing care for a female client with Addison disease, the nurse should be alert for which of the following laboratory values? A. Potassium level of 3.2 mEq/L. B. Calcium level of 3.3 mEq/L. C. Sodium level of 150 mg/dL. D. Hematocrit level of 25%.
Hematocrit level of 25% (The normal hematocrit level of a female adult is 35% to 45%.)
A client has just returned to a nursing unit after a cardiac catheterization performed using the femoral artery. The nurse places the client in which position? A. Bed rest with head elevation at 30°. B. Bed rest with head elevation at 45°. C. Bed rest with head elevation at 60°. D. Bed rest with head elevation at 90°.
Bed rest with head elevation at 30°
Nurse Justin is taking care of a client with deep vein thrombosis. Which position should be provided to the client? A. Bed rest with the affected extremity remains flat at all times. B. Bed rest with the unaffected extremity on top of the affected extremity. C. Bed rest with the affected extremity in a dependent position. D. Bed rest with the affected extremity elevated.
Bed rest with the affected extremity elevated
A nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that there is redness and drainage at the insertion site. The nurse next assesses which of the following? A. Time of last dressing change. B. Allergy. C. Client's temperature. D. Expiration date.
Client's temperature (Redness at the catheter insertion site is a possible sign of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess.)
After the client had tolerated the weaning process, the physician ordered the removal of the endotracheal tube and it will be shifted into a nasal cannula. Which of the following findings after the removal requires immediate intervention by the physician? A. Sore throat. B. Hoarseness of the voice. C. Coughing out blood. D. Neck discomfort.
Coughing out blood.
A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse next assesses the client to identify the presence of which of the following? A. Hypotension. B. Crackles upon auscultation of the lungs. C. Thirst. D. Polyuria.
Crackles upon auscultation of the lungs (A weight gain of five (5) pounds over a week indicates a client is experiencing fluid retention that can result in hypervolemia. Signs of hypervolemia include weight gain more than desired, headache, jugular vein distention, bounding pulse, and crackles on lung auscultation.)
The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is most appropriate for the nurse? A. Increase the suction pressure so that the bubbling becomes vigorous. B. Do nothing since this is an expected finding. C. Immediately clamp the chest tube and notify the physician. D. Check for an air leak because the bubbling should be intermittent.
Do nothing since this is an expected finding.
The nurse is assessing the functioning of a chest tube drainage system in a client with hemothorax. Which of the following findings should prompt the nurse to notify the physician? A. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation. B. Drainage system maintained below the client's chest. C. Drainage amount of 100ml in the drainage collection chamber. D. Occlusive dressing in place over the chest tube insertion site.
Drainage amount of 100ml in the drainage collection chamber. (Drainage of more than 70 to 100 mL/hour is not normal and requires the immediate notification of the physician.)
A client is brought to the emergency department and states that he has accidentally been taking two times his prescribed dose of Warfarin (Coumadin). After observing that the client has no evidence of any obvious bleeding, the nurse should do which of the following? A. Draw a sample for activated partial thromboplastin time (aPTT) level. B. Draw a sample for prothrombin time (PT) level and international normalized ratio (INR). C. Prepare to administer Vitamin K. D. Prepare to administer Protamine sulfate.
Draw a sample for prothrombin time (PT) level and international normalized ratio (INR).
While changing the tapes on a tracheostomy tube, the client coughs, and the tube is dislodged. Which is the initial nursing action? A. Call a respiratory therapist to reinsert the tracheotomy. B. Cover the tracheostomy site with a sterile dressing. C. Call the physician to reinsert the tracheotomy. D. Grasp the retention sutures to spread the opening.
Grasp the retention sutures to spread the opening.
A nurse is caring for a client with severe burns of the face and head. The nurse will place the client in which position? A. Trendelenburg. B. Head of bed elevated. C. Supine position. D. Prone position.
Head of bed elevated (to reduce the occurence of facial edema)
A nurse is reviewing the complete blood count (CBC) of a child who has been diagnosed with idiopathic thrombocytopenic purpura. Which of the following laboratory results should the nurse report immediately to the physician? A. Platelet count of 30,000/mm3. B. Hemoglobin level of 7.5 g/dL. C. Reticulocyte count of 6.5%. D. Eosinophil count of 700 cells/mm3.
Hemoglobin level of 7.5 g/dL (The low hemoglobin level indicates that the client has active bleeding, and immediate actions such as additional diagnostic exams and blood transfusions can be suggested)
Nurse Aaron is inserting a nasogastric tube to a stroke client. He understands that the best position for the insertion is? A. Low Fowler's. B. Sims position. C. Trendelenburg. D. High Fowler's.
High Fowler's
An adult male client has a hemoglobin count of 12.5 g/dL. Based on the result, the client is most likely having this due to which of the following notes in the client's record? (The normal hemoglobin level for an adult male is 14-16.5 g/dL) A. Emphysema. B. Client living at a high altitude. C. Dehydration. D. History of an enlarged spleen.
History of an enlarged spleen (An enlarged spleen may cause anemia)
A female client went to the clinic with a creatinine clearance of 200 mL/min. Which of the following conditions of the client can cause the increased level of this test? A. Renal disease. B. Dehydration. C. Congestive heart failure. D. History of high dietary protein intake.
History of high dietary protein intake. (The normal creatinine clearance for a female is 88 to 128 ml/min. An increased creatinine clearance is often referred to as hyperfiltration and is most commonly seen during pregnancy or in clients with a large dietary protein intake)
A screen test for the detection of human immunodeficiency virus (HIV) reveals a positive ELISA exam. Which of the following tests will be used to confirm the diagnosis of HIV? A. Indirect immunofluorescence assay (IFA). B. CD4-to-CD8 ratio. C. Radioimmunoprecipitation assay (RIPA) test. D. p24 antigen assay.
Indirect immunofluorescence assay (IFA).
A nurse is preparing to hang the initial bag of the parenteral nutrition (PN) solution via the central line of a malnourished client. The nurse ensures the availability of which medical equipment before hanging the solution? A. Glucometer. B. Dressing tray. C. Nebulizer. D. Infusion pump.
Infusion pump
A nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tube change? A. Turn the head to the right. B. Inhale deeply, hold it, and bear down. C. Breathe normally. D. Exhale slowly and evenly.
Inhale deeply, hold it, and bear down
Which of the following is not true regarding the types of a nasogastric tube? A. Cantor tube is a single-lumen long tube with a small inflatable bag at the distal end. B. Miller-Abbott tube is a long double-lumen used to drain and decompress the small intestine. C. Levin tube is a double-lumen nasogastric tube with an air vent. D. Sengstaken-Blakemore tube is a three-lumen tube.
Levin tube is a double-lumen nasogastric tube with an air vent.
A client with pleural effusion is scheduled to have a thoracentesis. The nurse on duty will assist the client to which position during the procedure? A. Lying in bed on the unaffected side with the head of the bed elevated about 45°. B. Forward side-lying position with head of bed flat. C. Lying in bed on the affected side with the head of the bed elevated about 45°. D. Supine position with both arms extended.
Lying in bed on the unaffected side with the head of the bed elevated about 45° (to facilitate removal of pleural fluid from the pleural space)
A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time is 77 seconds. Based on this result, the nurse anticipated which of the following prescriptions? A. Maintain the rate of the heparin infusion. B. Decrease the rate of the heparin infusion. C. Increase the rate of the heparin infusion. D. Discontinue the heparin infusion.
Maintain the rate of the heparin infusion. (The normal activated partial thromboplastin time is between 20 to 36 seconds. In the treatment of deep vein thrombosis, the therapeutic range is to maintain the aPTT level between 1.5 and 2.5 times the normal. This means that the client's aPTT level should not be less than 30 seconds or greater than 90 seconds.)
A nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 2 hours delay. The nurse should do which of the following actions? A. Adjust the infusion rate to catch up over the next hour. B. Make sure the infusion rate is infusing at the ordered rate. C. Increase the infusion rate to catch up over the next few hours. D. Adjust the infusion rate to full blast until the solution is back on time.
Make sure the infusion rate is infusing at the ordered rate
The client went to the emergency room with a sudden onset of chest pain and difficulty of breathing. Which of the following results is indicative that the client is experiencing a myocardial infarction? A. Myoglobin level of 98 mcg/L. B. Troponin T of 0.09 ng/mL. C. Troponin I 0.5 ng/mL. D. Creatine kinase (CK-MB) 155 units/L.
Myoglobin level of 98 mcg/L. (The normal value of myoglobin is lower than 90 mcg/L)
The nurse is reviewing the laboratory result of a client receiving digoxin (Lanoxin) and notes that the result is 2.5 ng/mL. The nurse plans to do which of the following? A. Give the next dose. B. Notify the physician. C. Check the client's pulse rate. D. Increase the next dose as ordered.
Notify the physician (The normal value therapeutic range for digoxin is 0.5 to 2 ng/mL. A level of 2.5 ng/mL indicates toxicity)
Nurse Sandra had just received a postoperative total hip replacement client from the recovery unit. Which is the best position in which she should place the client? A. Side-lying with the affected leg externally rotated. B. Side-lying with the affected leg internally rotated. C. On the nonoperative side with the legs abducted. D. On the nonoperative side with the legs adducted.
On the nonoperative side with the legs abducted (prevent dislocation of the prosthesis)
A nurse is handling a pregnant client who was prescribed to have an Alpha Fetoprotein level. The nurse should explain to the client that this blood test: A. Can indicate lung disorders and neural tube defects. B. Abnormal levels are associated with an increased risk for chromosome abnormality. C. Once the Alpha-Fetoprotein levels are abnormal, amniocentesis will be ordered. D. An Alpha-Fetoprotein is a definitive test for neural tube defects.
Once the Alpha-Fetoprotein levels are abnormal, amniocentesis will be ordered.
A patient receiving parenteral nutrition is administered via the following routes except: A. Subclavian line. B. Central Venous Catheter. C. PICC (Peripherally inserted central catheter) line. D. PEG tube.
PEG tube (Percutaneous endoscopic gastrostomy (PEG tube) is inserted into a person's stomach through the abdominal wall that is used to provide a means of feeding when oral intake is not adequate. While parenteral nutrition bypasses the digestive system by the administration to the bloodstream.)
A client has been undergoing radiotherapy for the treatment of mandibular cancer. After a few sessions, the client is diagnosed with Tumor Lysis Syndrome (TLS). Which of the following findings correlates with TLS? A. Phosphorus level of 6 mg/dL. B. Phosphorus level of 3 mg/dL. C. Phosphorus level of 4 mg/dL. D. Phosphorus level of 2 mg/dL.
Phosphorus level of 6 mg/dL (The normal phosphorus is 2.5 to 4.5 mg/dL)
A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 10%. Based on the result, the nurse plans to teach the client about the importance of: A. Maintaining the result. B. Preventing hypoglycemia. C. Preventing hyperglycemia. D. Avoiding infection.
Preventing hyperglycemia (Glycosylated hemoglobin A1c level of 8% higher indicates poor diabetic control.)
The nurse caring for a client with a serum calcium of 6.8 mg/dL. What would the nurse expect the change on the electrocardiogram (ECG)? A. None. This is a normal calcium level. B. Prolonged QT interval. C. Shortened ST segment. D. Widened T wave.
Prolonged QT interval (The normal serum calcium level is 8.6 to 10 mg/dL)
Before feeding a client via NGT, the nurse checks for residual and obtains a residual amount of 90ml. What is the appropriate action for the nurse to take? A. Discard the residual amount. B. Hold the due feeding. C. Skip the feeding and administer the next feeding due in 4 hours. D. Reinstill the amount and continue with administering the feeding.
Reinstill the amount and continue with administering the feeding. (If the residual feeding is less than 100ml, feeding is administered)
A nurse is supervising a student nurse who is performing tracheostomy care for a client. Which of the following actions by the student should the nurse intervene? A. Removing the inner cannula and cleaning using universal precaution. B. Suctioning the tracheostomy tube before performing tracheostomy care. C. Changing the old tracheostomy ties and securing the tube in place. D. Replacing the inner cannula and cleaning the site of the stoma.
Removing the inner cannula and cleaning using universal precaution.
Nurse Ian is handling a client with gastroesophageal reflux disease. Which of the following positions will best help the client in this case? A. Right Lateral Recumbent. B. Supine position. C. Reverse Trendelenburg position. D. Sims position.
Reverse Trendelenburg position (advised to a client to promote gastric emptying and prevent gastroesophageal reflux)
A nurse is caring for a client who has returned to the recovery unit following a craniotomy. The nurse can safely place the client in which position? A. Trendelenburg position. B. Fowler's position with the head leaning on the left side. C. Semi-fowler's position with the head in a midline position. D. Supine position with the neck flexed.
Semi-fowler's position with the head in a midline position (to facilitate venous drainage from the head)
A nurse is preparing to care for a client who had undergone an above-knee amputation of the right leg. The nurse plans to allow which position for the client in the first 24 hours? A. Supine position, with the affected limb flat on the bed. B. Supine position, with the affected limb supported with pillows. C. Prone position, with the affected limb in a dependent position. D. Trendelenburg's position.
Supine position, with the affected limb supported with pillows
A stroke client who was initially on NGT feeding was able to tolerate a soft diet so the physician ordered the removal of it. The nurse would instruct the client to do which of the following before he removes the tube?
Take a long breath and hold it.
A nurse is conducting an assessment of an American Indian woman who has come to the clinic complaining of a headache. The patient tells the nurse that the medicines prescribed by the tribal healer have done some good. What is the appropriate response of the nurse at this time? A. Tell me about these medicines and how often you are using them. B. I advise you to refrain from taking those medicines from the tribal healer. C. Could these medicines cause your headaches? D. Maybe you should increase the frequency of the healer's medicines.
Tell me about these medicines and how often you are using them
A new RN nurse is about to insert a nasogastric tube into a client with Guillain-Barre Syndrome. To determine the accurate measurement of the length of the tube to be inserted, the nurse should:
Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.
A nurse is caring for a client with diarrhea and dehydration. The nurse determines that the client has received adequate fluid replacement if the blood urea nitrogen decreases to: A. 36 mg/dL. B. 27 mg/dL. C. 18 mg/dL. D. 6 mg/dL.
18 mg/dL (The normal value of blood urea nitrogen is 8 to 25 mg/dL. Fluid status absolutely affects the levels of BUN and creatinine in the blood, but volume depletion or dehydration tends to affect BUN more so that we see a BUN: creatinine ratio of 20:1 or more in people who are very dry.)
A client receiving parenteral nutrition (PN) complains of shortness of breath and shoulder pain. A nurse notes that the client has an increased pulse rate. The nurse determines that the client is experiencing which complication of PN therapy? A. Air embolism. B. Hypervolemia. C. Hyperglycemia. D. Pneumothorax.
Pneumothorax (Symptoms include sudden chest pain, difficulty breathing, decreased breath sounds, cessation of normal chest movement on affected side, and tachycardia.)
The nurse is preparing to give bolus enteral feedings via a nasogastric tube to a comatose client. Which of the following actions is an inappropriate practice by the nurse? A. If bowel sounds are absent, hold the feeding and notify the physician. B. Assess tube placement by aspirating gastric content and check the PH level. C. Warm the feeding to room temperature to prevent the occurrence of diarrhea and cramps. D. Elevate the head of the bed to 45 degrees and maintain for 30 minutes after installation of feeding.
Elevate the head of the bed to 45 degrees and maintain for 30 minutes after installation of feeding.
The nurse is handling a client with a chest tube. Suddenly, the chest drainage system is accidentally disconnected. What is the most appropriate action for the nurse to take? A. Secure the chest tube using tape. B. Clamp the chest tube immediately. C. Place the end of the chest tube in a container of normal sterile saline. D. Apply an occlusive dressing and notify the physician.
Place the end of the chest tube in a container of normal sterile saline.
Which of the following laboratory results indicates hypoparathyroidism? (The parathyroid is responsible for the absorption of calcium and phosphorus) A. Serum potassium of 3.6 mEq/L. B. Serum calcium level of 4.3 mEq/L. C. Serum phosphorus level of 5.7 mg/dL. D. Serum magnesium level of 1.7 mg/dL.
Serum phosphorus level of 5.7 mg/dL
A nurse is preparing to hang a fat emulsion (lipids) and observes some visible fat globules at the top of the solution. The nurse ensures to do which of the following actions? A. Take another bottle of solution. B. Run the bottle solution under warm water. C. Roll the bottle solution gently. D. Shake the bottle solution vigorously.
Take another bottle of solution
A nurse is preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that surgery is necessary. The nurse considers the client's religious preferences in developing the plan of care and documents that: A. Giving any medication is not allowed. B. Surgery is strictly prohibited. C. Blood products can not be administered. D. Alternative medicines can be advised.
Blood products can not be administered
Nurse Spencer is caring for an anorexic client who is having a total parenteral nutrition solution for the first time. Which of the following assessments requires the most immediate attention? A. Dry sticky mouth. B. Temperature of 100° Fahrenheit. C. Blood glucose of 210 mg/dl. D. Fasting blood sugar of 98 mg/dl.
Blood glucose of 210 mg/dl (way too high!!)
Nurse Monica is handling a female client who had undergone a mastectomy. Which is the best position in which she should place the client? A. Head of bed elevated at least 30° with the affected arm elevated on a pillow. B. Forward side-lying position. C. Supine position with the affected arm remains flat. D. Head of bed elevated at least 30° with the unaffected arm elevated on a pillow.
Head of bed elevated at least 30° with the affected arm elevated on a pillow (to promote lymphatic fluid return after the removal of axillary lymph nodes)
Which is the best position for a client with autonomic dysreflexia? A. Sim's Position. B. Fowler's Position. C. Semi-Fowler's Position. D. High Fowler's Position.
High Fowler's Position (Autonomic dysreflexia is a condition in which there is a sudden onset of excessively high blood pressure. If it occurs, immediately place the client in a high Fowler's position to promote adequate ventilation and assist in the prevention of a hypertensive stroke.)
A client receiving parenteral nutrition (PN) complains of a headache. A nurse notes that the client has a bounding pulse, jugular distension, and weight gain greater than desired. The nurse determines that the client is experiencing which complication of PN therapy? A. Air embolism. B. Hypervolemia. C. Hyperglycemia. D. Sepsis.
Hypervolemia
Which of the following does not match with the appropriate position? A. Vaginal examination: Lithotomy position. B. Thyroidectomy: Fowler's position. C. Hemorrhoidectomy: Lateral position. D. Hypophysectomy: Prone position.
Hypophysectomy: Prone position (Hypophysectomy is the surgical removal of the hypophysis (pituitary gland)
A client is receiving parenteral nutrition (PN) and is suddenly having a fever. A nurse notifies the physician and the physician initially prescribes that the solution and tubing be changed. The nurse should do which of the following with the discontinued materials? A. Send them to the laboratory for culture. B. Save them for a return to the manufacturer. C. Return them to the hospital pharmacy. D. Discard them in the unit trash.
Send them to the laboratory for culture (When the client who is receiving PN has a high temperature, a catheter-related infection should be suspected. The solution and tubing should be changed, and the discontinued materials should be cultured for an infectious organism)
A nurse is conducting a follow-up home visit to a client who has been discharged with parenteral nutrition(PN). Which of the following should the nurse most closely monitor in this kind of therapy? A. Blood pressure and temperature. B. Blood pressure and pulse rate. C. Height and weight. D. Temperature and weight.
Temperature and weight
