front 1 The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse?
| back 1 A. Client behavior that changes from anxious to lethargic |
front 2 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.
| back 2 A. Place the client on bed rest. B. Evaluate the electrolyte levels. D. Assess for orthostatic hypotension. E. Initiate cardiac monitoring |
front 3 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.
| back 3 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. |
front 4 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.
| back 4 A. Assess daily weights. B. Encourage consumption of citrus fruits. D. Monitor serum potassium. |
front 5 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?
| back 5 A. Heart rate |
front 6 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?
| back 6 C. The client is free from adventitious breath sounds. |
front 7 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?
| back 7 C. “Inverted T waves and a U wave may appear on the ECG.” |
front 8 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.
| back 8 B. Bananas C. ACE inhibitors E. Salt substitute |
front 9 The nurse is assessing a client with a sodium level of 118 mEq/L (118 mmol/L). Which activity takes priority?
| back 9 C. Instructing the client not to ambulate without assistance |
front 10 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?
| back 10 B. Crackles ½ way up the lung fields |
front 11 The nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical?
| back 11 C. Assessing the blood pressure hourly |
front 12 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.
| back 12 B. Use of salt substitute C. Use of an ACE inhibitor D. Potassium-sparing diuretics |
front 13 After receiving change-of-shift report, which client does the RN assess first?
| back 13 C. A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg |
front 14 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?
| back 14 C. Place the client on a cardiac monitor. |
front 15 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)?
| back 15 D. Offering fluids to drink every hour |
front 16 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?
| back 16 B. “Offer fluids that they prefer frequently and on a regular schedule.” |
front 17 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?
| back 17 D. “Weighing myself daily can reveal increased fluid retention.” |
front 18 The nurse is caring for a group of clients on a medical surgical unit. Which newly written prescription will the nurse administer first?
| back 18 D. Oral potassium chloride to a client whose serum potassium is 3 mEq/L (3 mmol/L) |
front 19 Which client is most appropriate for the nurse manager of the medical-surgical unit to assign to the LPN/LVN?
| back 19 C. A client admitted yesterday with heart failure with dependent pedal edema |
front 20 A client with hypermagnesemia is seen in the emergency department (ED). Which of these interventions is most appropriate?
| back 20 D. Place the client on a cardiac monitor |
front 21 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?
| back 21 A. Calcium level of 9.5 mg/dL (2.4 mmol/L) |
front 22 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?
| back 22 C. RN who has floated from the intensive care unit |
front 23 The nurse is caring for an older adult with hypernatremia. Which of these interventions does the nurse perform first?
| back 23 D. Encourage fluid intake |
front 24 The nurse is caring for a group of clients with electrolytes and blood chemistry abnormalities. Which client will the nurse see first?
| back 24 C. The client whose potassium is 6.2 mEq/L (6.2 mmol/L) |
front 25 The RN is caring for a client who is severely dehydrated. Which nursing action can be delegated to the unlicensed assistive personnel (UAP)?
| back 25 D. Providing oral care every 1 to 2 hours |
front 26 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?
| back 26 C. A 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/kg (300 mmol/kg) |
front 27 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.
| back 27 B. Blood pressure C. Pulse rate and quality D. Urinary output E. Urine specific gravity |
front 28 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?
| back 28 A. Insulin |
front 29 A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first?
| back 29 B. Elevates the head of the bed |
front 30 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?
| back 30 B. Checks for orthostatic blood pressure changes |
front 31 The nurse is assessing fluid balance in the client with heart failure. Which of these strategies will the nurse employ?
| back 31 D. Weigh the client daily, at the same time. |
front 32 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.
| back 32 A. Ensuring that the concentration is no greater than 1?9?mEq/10?9?mL of solution C. Use an IV pump to deliver the medication |
front 33 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?
| back 33 D. Measurement of the client’s weight |