practice

Mr.Francis is a 60-year-old client admitted with PNA. You come in for morning rounds and find him sitting on the edge of the hospital bed. You have orders to ambulate with Mr. Francis since he is at risk for atelectasis and has not been very mobile. His nutrition has also been poor, and he has not consumed more than 25% of his last two meal trays. You take his vital signs, and his BP is 130/80, HR 95, RR 20, O2 sat 93% on room air and his pain is 7/10 in his lower back. Which nursing diagnosis takes priority?

1. acute pain 2. deconditioning 3. feeding ADL impairment

Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse detects dry mucous membranes and lethargy. What other finding suggests a fluid volume deficit? A. A sunken fontanelle B. Decreased pulse rate C. Increased Blood Pressure D. Low urine specific gravity

A. a sunken fontanelle

A 71year-old male has a potassium level of 3.2 mEq/L. The nurse knows that the client will be advised to alter his diet by: A. increasing his intake of bananas and oranges. B. avoiding intake of bananas and oranges. C. increasing his intake of oatmeal and apples. D. avoiding intake of oatmeal and apples.

A. increasing his intake of bananas and oranges

Before the nurse administers I.V. replacement of 5% dextrose in water with potassium chloride, what nursing intervention must be completed first? A. Adding potassium chloride to the bag at the bedside. B. Evaluating laboratory results for electrolytes. C. Priming tubing using sterile technique. D. Checking the rate for I.V. push administration.

B. Evaluating laboratory results for electrolytes

A nurse is reviewing a client's fluid intake and output record. Fluid intake and urine output should relate in which way? A. Fluid intake should be double the urine output B. Fluid intake should be about equal to the urine output. C. Fluid intake should be half the urine output. D. Fluid intake should be inversely proportional to the urine output.

B. Fluid intake should be about equal to the urine output

A client with a history of chronic renal failure is admitted with pulmonary edema following a missed dialysis treatment yesterday. His laboratory results are serum potassium 6.0 mEq/L, serum sodium 130 mEq/L, and serum bicarbonate 18 mEq/L. The nurse interprets that the client has which of the following conditions? A. Alkalemia B. Hyperkalemia C. Hypernatremia D. Hypokalemia

B. Hyperkalemia

A client is receiving intravenous fluids and upon assessment presents with increased pulse, increased respirations, and jugular vein distension. What is the priority action by the nurse? A. Repeat the vital signs in 1 hour. B. Slow the intravenous rate and notify the physician. C. Lower the head of the bed. D. Administer oxygen and encourage the client to breathe deeply.

B. Slow the intravenous rate and notify the physician

A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment? A. Encourage oral fluids B. Administer Diuretic 20mg IV C. Start Hemodialysis D. Start I.V. fluids with a normal saline solution bolus

D. Start I.V. fluids with a normal saline solution bolus

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, jugular vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? A. Electrolyte Disturbance B. Urinary Retention C. Fluid Volume Excess D. Toileting Self-Care Deficit

C. Fluid Volume Excess

Which of the following clients is most likely to exhibit dehydration? A. A 21-year-old man with profuse diaphoresis after a game of football. B. A 75-year-old woman who has been placed on NPO status 8 hours before surgery. C. An 8-month-old infant with persistent diarrhea for 24 hours. D. A 60-year-old man with pneumonia and a temperature of 101°F (38.3°C).

C. An 8-month old infant with persistent diarrhea for 24 hours