front 1 A nurse teaches clients at a community center about risks for
dehydration. Which client is at greatest risk for dehydration? | back 1 C. A 76 year old who is cognitively impaired |
front 2 A nurse is caring for a client who exhibits dehydration-induced
confusion. Which intervention should the nurse implement
first? | back 2 b. Apply oxygen by mask or nasal cannula. |
front 3 After teaching a client who is being treated for dehydration, a nurse
assesses the client's understanding. Which statement indicates the
client correctly understood the teaching? | back 3 b. "I will weigh myself each morning before I eat or drink." |
front 4 A nurse assesses a client who is prescribed a medication that
inhibits angiotensin I from converting into angiotensin II
(angiotensin-converting enzyme [ACE] inhibitor). For which expected
therapeutic effect should the nurse assess? | back 4 a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg |
front 5 A nurse is assessing clients on a medical-surgical unit. Which adult
client should the nurse identify as being at greatest risk for
insensible water loss? | back 5 b. Anxious client who has tachypnea |
front 6 A nurse is evaluating a client who is being treated for dehydration.
Which assessment result should the nurse correlate with a therapeutic
response to the treatment plan? | back 6 d. Decreased orthostatic light-headedness and dizziness |
front 7 After teaching a client who is prescribed a restricted sodium diet, a
nurse assesses the client's understanding. Which food choice for lunch
indicates the client correctly understood the teaching? | back 7 d. Grilled chicken breast with glazed carrots |
front 8 A nurse is assessing clients for fluid and electrolyte imbalances.
Which client should the nurse assess first for potential
hyponatremia? | back 8 a. A 34-year-old on NPO status who is receiving intravenous D5W |
front 9 A nurse teaches a client who is at risk for mild hypernatremia. Which
statement should the nurse include in this client's teaching? | back 9 c. "Read food labels to determine sodium content." |
front 10 A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching? A. Have your spouse watch you for irritability and anxiety B. Notify the clinic if you notice muscle twitching C. Call your primary health care provider for diarrhea D. Bake or grill your meat rather than frying it. | back 10 C. Call your primary health care provider for diarrhea |
front 11 A nurse is caring for a client who has the following laboratory
results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L,
sodium 144 mEq/L. Which assessment should the nurse complete
first? | back 11 a. Depth of respirations |
front 12 A nurse cares for a client who has the following laboratory results: Potassium 2.4, Magnesium 1.8, calcium 8.5, and sodium 144. Which assessment does the nurse complete first? A. Depth of respirations B. Bowel sounds C. Grip strength D. Electrocardiography | back 12 A. Depth of respirations |
front 13 A nurse cares for a client who has a serum potassium of 7.5 mEq/L and
is exhibiting cardiovascular changes. Which prescription should the
nurse implement first? | back 13 c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. |
front 14 A nurse is assessing clients on a medical-surgical unit. Which client
is at risk for hypokalemia? | back 14 a. Client with pancreatitis who has continuous nasogastric suctioning |
front 15 The nurse is caring for a client who has fluid overload. What action by the nurse takes priority? A. Administer high-ceiling loop diuretics B. Assess the client's lung sounds ever 2 hours C. Place a pressure-relieving overlay on the mattress D. Weigh the client daily at the same time on the same scale. | back 15 B. Assess the client's lung sounds ever 2 hours |
front 16 A nurse is assessing a client with hypokalemia, and notes that the
client's handgrip strength has diminished since the previous
assessment 1 hour ago. Which action should the nurse take
first? | back 16 a. Assess the client's respiratory rate, rhythm, and depth. |
front 17 After teaching a client to increase dietary potassium intake, a nurse
assesses the client's understanding. Which dietary meal selection
indicates the client correctly understands the teaching? | back 17 c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk |
front 18 A client at risk for developing hyperkalemia states, "I love
fruit and usually eat it every day, but now I can't because of my high
potassium level." How should the nurse respond? | back 18 c. "Berries, cherries, apples, and peaches are low in potassium." |
front 19 A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure? A. Notifies the pharmacy of the IV potassium order B. Asses the client's IV site every hour during infusion C. Sets the IV pump to deliver 30 mEq of potassium an hour D. Double checks the IV bag against the order with the precepting nurse | back 19 C. Sets the IV pump to deliver 30 mEq of potassium an hour |
front 20 A nurse is caring for a client who has a serum calcium level of 14
mg/dL. Which provider order should the nurse implement first? | back 20 b. Connect the client to a cardiac monitor. |
front 21 A nurse is caring for an older adult client who is admitted with
moderate dehydration. Which intervention should the nurse implement to
prevent injury while in the hospital? | back 21 d. Dangle the client on the bedside before ambulating. |
front 22 A nurse assesses a client who is admitted for treatment of fluid
overload. Which manifestations should the nurse expect to find?
(Select all that apply.) | back 22 a. Increased pulse rate e. Skeletal muscle weakness |
front 23 A nurse is assessing clients on a medical-surgical unit. Which
clients are at increased risk for hypophosphatemia? (Select all that
apply.) | back 23 a. A 36-year-old who is malnourished e. A 76-year-old who is prescribed antacids |
front 24 A nurse assesses a client who is prescribed a medication that
inhibits aldosterone secretion and release. For which potential
complications should the nurse assess? (Select all that
apply.) | back 24 b. Serum potassium level of 5.4 mEq/L e. Blood osmolality of 250 mOsm/L |
front 25 A nurse is assessing a client who has an electrolyte imbalance
related to renal failure. For which potential complications of this
electrolyte imbalance should the nurse assess? (Select all that
apply.) | back 25 a. Electrocardiogram changes d. Paralytic ileus |
front 26 A nurse is caring for clients with electrolyte imbalances on a
medical-surgical unit. Which clinical manifestations are correctly
paired with the contributing electrolyte imbalance? (Select all that
apply.) c. Hyponatremia - Decreased level of consciousness | back 26 a. Hypokalemia - Flaccid paralysis with respiratory depression c. Hyponatremia - Decreased level of consciousness |
front 27 After administering 40 mEq of potassium chloride, a nurse evaluates
the client's response. Which manifestations indicate that treatment is
improving the client's hypokalemia? (Select all that apply.) | back 27 c. Strong productive cough d. Active bowel sounds |
front 28 A nurse develops a plan of care for a client who has a history of
hypocalcemia. What interventions should the nurse include in this
client's care plan? (Select all that apply.) | back 28 b. Use a draw sheet to reposition the client in bed. d. Provide nonslip footwear for the client to use when out of bed. |
front 29 A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition? A. Assesses the client's Chvostek and Trousseau sign. B. Keeps the client's room quiet and dimly lit C. Moves the client carefully to avoid fracturing bones. D. Administers bisphosphonates as prescribed. | back 29 D. Administers bisphosphonates as prescribed. |
front 30 A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (select all that apply) A. Increased pulse rate B. distended neck veines C. Decreased Blood pressure D. Warm and pink skin E. Skeletal muscle weakness F. Visual disturbances. | back 30 A. Increased pulse rate B. distended neck veines E. Skeletal muscle weakness F. Visual disturbances. |
front 31 A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretions and release. For which potential complications will the nurse assess? Select all that apply A. Urine output of 25 mL/ hr B. Serum potassium level of 5.4 mEq/L C. Urine specific gravity of 1.02 g/mL D. Serum sodium level of of 128 mEq/L E. Blood osmolarity of 250 mOsm/kg | back 31 B. Serum potassium level of 5.4 mEq/L E. Blood osmolarity of 250 mOsm/kg |
front 32 A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For Which potential complications of this electrolyte imbalance does the nurse assess? Select all that apply A. Reports of palpitations B. Slow, shallow respirations C. Orthostatic hypotension D. Paralytic ileus E. Skeletal muscle weakness F. Tall, peaked T waves on ECG | back 32 A. Reports of palpitations E. Skeletal muscle weakness F. Tall, peaked T waves on ECG |
front 33 A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) A. Hypokalemia- muscle weakness with respiratory depression B. Hypermagnesemia- Bradycardia and hypotension C. Hyponatremia - Decreased level of consciousness D. Hypercalcemia- positive Trousseau and chveostek signs E. Hypomagnesemia - Hyperactive deep tendon reflexes F. Hypernartemia- Weak peripheral pulses | back 33 A. Hypokalemia- muscle weakness with respiratory depression B. Hypermagnesemia- Bradycardia and hypotension C. Hyponatremia - Decreased level of consciousness E. Hypomagnesemia - Hyperactive deep tendon reflexes F. Hypernartemia- Weak peripheral pulses |
front 34 After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that treatment is improving the client's hypokalemia? Select all that apply A. Respiratory rate of 8 Breaths/ min B. Absent deep tendon reflexes C. Strong productive cough D. Active bowel sounds E. U waves present on the Electrocardiogram | back 34 C. Strong productive cough D. Active bowel sounds |
front 35 A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? Select all that apply A. Calculate pulse pressure with each blood pressure reading B. Assess skin tumor using the back of the client's hand C. Assess for pitting edema in dependent body areas. D. Monitor trends in the client's daily weights. E. Assist the client to change positions frequently F. Teach client and family how to read food labels for sodium | back 35 A. Calculate pulse pressure with each blood pressure reading C. Assess for pitting edema in dependent body areas. D. Monitor trends in the client's daily weights. E. Assist the client to change positions frequently F. Teach client and family how to read food labels for sodium |
front 36 A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are paired with the correct potential imbalance? Select all that apply A. Sodium 160 mEq Over hydration B. Potassium 5.4 Dehydration C. Osmolarity 250 Overhydration D. Hematocrit 68% Dehydration E. BUN 39 mg/dL. Overhydration F. Magnesium 0.8 mg/dL Dehydration | back 36 B. Potassium 5.4 Dehydration C. Osmolarity 250 Overhydration D. Hematocrit 68% Dehydration F. Magnesium 0.8 mg/dL Dehydration |