Saunders - Ch. 11 Nutrition, Ch. 17 Urinary and Bowel Elimination, Ch. 6 Ethical and Legal Issues, Ch. 7 Prioritizing Client Care: Delegation, Ch. 10 Vital Signs and Laboratory Reference Intervals, Ch. 8 Fluids and Electrolytes, Ch. 9 Acid-Base Balance
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AHC 1 Exam 2
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evaluation Q - the nurse is teaching a client who has iron-deficiency anemia about foods the client needs to include in the diet. the nurse determines that the client understands the dietary modifications if which items are selected from the menu?
a) nuts and milk
b) coffee and tea
c) cooked rolled oats and fish
d) oranges and dark green leafy vegetables
d) oranges and dark green leafy vegetables
application Q - the nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. the nurse develops a list of high-fat foods to avoid and would include which food items on the list? select all that apply.
a) oranges
b) broccoli
c) margarine
d) cream cheese
e) luncheon meats
f) broiled haddock
c) margarine
d) cream cheese
e) luncheon meats
evaluation Q - the nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. the nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu?
a) cream of wheat, blueberries, coffee
b) sausage and eggs, banana, orange juice
c) bacon, cantaloupe melon, tomato juice
d) cured pork, grits, strawberries, orange juice
a) cream of wheat, blueberries, coffee
application Q - the nurse is conducting a dietary assessment on a client who is on a vegan diet. the nurse plans to provide dietary teaching and would focus on foods high in which vitamin that may be lacking in a vegan diet?
a) vitamin A
b) vitamin B12
c) vitamin C
d) vitamin E
b) vitamin B12
application Q - a postoperative client has been placed on a clear liquid diet. the nurse would provide the client with which items that are allowed to be consumed on this diet? select all that apply.
a) broth
b) coffee
c) gelatin
d) pudding
e) vegetable juice
f) pureed vegetables
a) broth
b) coffee
c) gelatin
application Q - the nurse is preparing to instruct a client with hypertension on the importance of choosing foods low in sodium. the nurse would plan to teach the client to limit intake of which food?
a) apples
b) bananas
c) smoked salami
d) steamed vegetables
c) smoked salami
application Q - a client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. the client is looking forward to the diet change because they have been “bored” with the clear liquid diet. the nurse would prepare to offer which full liquid item to the client?
a) tea
b) gelatin
c) custard
d) ice pop
c) custard
application Q - a client is recovering from abdominal surgery and has a large abdominal wound. the nurse would encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing?
a) milk
b) oranges
c) bananas
d) chicken
b) oranges
evaluation Q - the nurse is caring for a client with cirrhosis of the liver. to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. the nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food?
a) milk
b) chicken
c) broccoli
d) legumes
d) legumes
application Q - the nurse prepares to provide instructions to a client with a low potassium level about the foods that are high in potassium and plans to tell the client to consume which foods? select all that apply.
a) peas
b) raisins
c) potatoes
d) cantaloupe
e) cauliflower
f) strawberries
b) raisins
c) potatoes
d) cantaloupe
f) strawberries
application Q - the nurse is reviewing laboratory results and notes that a client’s serum sodium level is 150 mEq/L (150 mmol/L). the nurse reports the serum sodium level to the primary health care provider (PHCP), and the PHCP prescribes dietary instructions based on the sodium level. which acceptable food items does the nurse instruct the client to consume? select all that apply.
a) peas
b) nuts
c) cheese
d) cauliflower
e) processed oat cereals
a) peas
b) nuts
d) cauliflower
evaluation Q - the nurse is assessing a client with bladder cancer who had a cystectomy and creation of a ureterostomy. which statement by the client indicates the need for more education about urinary stoma care?
a) “i change my pouch every week.”
b) “i change the appliance in the morning.”
c) “i empty the urinary collection bag when it is two-thirds full.”
d) “when i’m in the shower, i direct the flow of water away from my stoma.”
c) “i empty the urinary collection bag when it is two-thirds full.”
analyzing Q - the nurse is providing care for a client with ulcerative colitis who underwent the creation of a transverse colostomy. which observation requires immediate notification of the surgeon?
a) stoma is beefy red and shiny.
b) stoma has a purple discoloration.
c) skin excoriation is noted around the stoma.
d) semiformed stool is noted in the ostomy pouch.
b) stoma has a purple discoloration.
analyzing Q - a client with ulcerative colitis had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. what is the correct interpretation by the nurse?
a) this is a normal, expected event.
b) the client is experiencing early signs of ischemic bowel.
c) the client should not have the nasogastric tube removed.
d) this indicates inadequate preoperative bowel preparation.
a) this is a normal, expected event.
analyzing Q - a client with Crohn’s disease has just had surgery to create an ileostomy. the nurse assesses the client in the postoperative period for which most frequent complication of this type of surgery?
a) folate deficiency
b) malabsorption of fat
c) intestinal obstruction
d) fluid and electrolyte imbalance
d) fluid and electrolyte imbalance
evaluation Q - the staff nurse is observing a new graduate nurse provide indwelling urinary catheter care to an uncircumcised client. which action by the new graduate nurse would indicate a need for further teaching?
a) cleans the catheter proximally to distally with soap and water
b) maintains the urinary collection bag below the level of the bladder
c) removes a loose catheter anchor and places a new anchor on the lower leg
d) uses the nondominant hand to pull back the foreskin to cleanse the urethral meatus with soap and water and returns the foreskin to its normal position
c) removes a loose catheter anchor and places a new anchor on the lower leg
analyzing Q - the nurse is inserting an indwelling urinary catheter in a client. as the nurse begins to inflate the balloon, the client starts to complain of pain. which action would the nurse take?
a) continue to inflate the balloon.
b) deflate the balloon, slightly withdraw the catheter, and attempt to reinflate the balloon.
c) deflate the balloon, completely withdraw the catheter, and end the procedure to notify the primary health care provider.
d) stop inflating the balloon, allow the saline solution to drain into the syringe, and advance the catheter farther before reinflating the balloon.
d) stop inflating the balloon, allow the saline solution to drain into the syringe, and advance the catheter farther before reinflating the balloon.
application Q - the surgeon asks the nurse to obtain a urinary catheter that will be used for continuous bladder irrigation. which urinary catheter would the nurse obtain?
a) a straight catheter
b) a Coudé tip catheter
c) a triple-lumen catheter
d) a double-lumen catheter
c) a triple-lumen catheter
application Q - a primary health care provider has ordered digital removal of stool for a constipated client. how would the nurse position the client for this procedure?
a) prone position
b) lithotomy position
c) left lateral side-lying position
d) right lateral side-lying position
c) left lateral side-lying position
application Q - the nurse is preparing to irrigate a client’s sigmoid colostomy. the nurse would plan for which intervention to perform this procedure?
a) instilling 500 to 1000 mL of lukewarm tap water through the stoma
b) advising the client to hold the breath if cramping occurs during instillation of the solution
c) hanging the irrigation solution so that the bottom of the bag is 18 inches above the client’s torso
d) inserting the irrigation tube with a small amount of force and a twisting motion into the stoma and unclamping the tubing to allow the solution to flow into the stoma
a) instilling 500 to 1000 mL of lukewarm tap water through the stoma
evaluation Q - the nurse is teaching a client with a urinary stoma about how to change the collection bag and appliance at home. which of the following client statements indicates an understanding of the procedure?
a) “the stoma needs to be cleaned with only water.”
b) “the best time to change the appliance is at night.”
c) “the pouch needs to be changed every 5 to 7 days.”
d) “i’ll cut the skin barrier 10 millimeters larger than the stoma.”
c) “the pouch needs to be changed every 5 to 7 days.”
application Q - the nurse hears a client calling out for help, hurries down the hallway to the client’s room, and finds the client lying on the floor. the nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. which statement would the nurse document on the occurrence report?
a) the client fell out of bed.
b) the client climbed over the side rails.
c) the client was found lying on the floor.
d) the client became restless and tried to get out of bed.
c) the client was found lying on the floor.
application Q - a client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. the name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. an emergency craniotomy is required. regarding informed consent for the surgical procedure, which is the best action?
a) obtain a court order for the surgical procedure.
b) ask the EMS team to sign the informed consent.
c) transport the victim to the operating room for surgery.
d) call the police to identify the client and locate the family.
c) transport the victim to the operating room for surgery.
application Q - the nurse has just assisted a client back to bed after a fall. the nurse and primary health care provider (PHCP) have assessed the client and have determined that the client is not injured. after completing the occurrence report, the nurse would implement which action next?
a) reassess the client.
b) conduct a staff meeting to describe the fall.
c) contact the nursing supervisor to update information regarding the fall.
d) document in the nurse’s notes that an occurrence report was completed.
a) reassess the client.
application Q - the nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. the nurse has never worked in the ICU. the nurse would take which best action?
a) refuse to float to the ICU based on lack of unit orientation.
b) clarify the ICU client assignment with the team leader to ensure that it is a safe assignment.
c) ask the nursing supervisor to review the hospital policy on floating.
d) submit a written protest to nursing administration, and then call the hospital lawyer.
b) clarify the ICU client assignment with the team leader to ensure that it is a safe assignment.
application Q - the nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. the coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. which is the most appropriate action by the nurse?
a) call security.
b) call the police.
c) call the nursing supervisor.
d) lock the coworker in the medication room until help is obtained.
c) call the nursing supervisor.
application Q - a hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. the client asks the nurse for assistance in obtaining a witness to the will. the nurse plans to make which most appropriate response to the client?
a) “i will sign as a witness to your signature.”
b) “you will need to find a witness on your own.”
c) “whoever is available at the time will sign as a witness for you.”
d) “i will call the nursing supervisor to seek assistance regarding your request.”
d) “i will call the nursing supervisor to seek assistance regarding your request.”
application Q - the nurse has made an error in documentation of the dose administered of an opioid pain medication in the client’s record. the nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. when scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. the nurse would take which action(s) to correct the error in the MAR? select all that apply.
a) complete and file an occurrence report.
b) right-click on the entry and modify it to reflect the correct information.
c) document the correct information and end with the nurse’s signature and title.
d) obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg.
e) document in a nurse’s note in the client’s record detailing the corrected information.
b) right-click on the entry and modify it to reflect the correct information.
c) document the correct information and end with the nurse’s signature and title.
d) obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg.
e) document in a nurse’s note in the client’s record detailing the corrected information.
understanding Q - which notations indicate accurate nursing documentation by the nurse? select all that apply.
a) the client slept through the night.
b) abdominal wound dressing is dry and intact without drainage.
c) the client seemed angry when awakened for measurement of vital signs.
d) the client appears to become anxious when it is time for respiratory treatments.
e) the client’s left lower medial leg wound is 3 cm in length without redness, drainage, or edema.
a) the client slept through the night.
b) abdominal wound dressing is dry and intact without drainage.
e) the client’s left lower medial leg wound is 3 cm in length without redness, drainage, or edema.
understanding Q - a nursing instructor delivers a lecture to nursing students regarding the issue of clients’ rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. which situation, if identified by the student, indicates an understanding of a violation of this client right?
a) performing a procedure without consent
b) threatening to give a client a medication
c) telling the client that they cannot leave the hospital
d) observing care provided to the client without the client’s permission
d) observing care provided to the client without the client’s permission
application Q - an older client is brought to the emergency department for treatment of a fractured arm. on physical assessment, the nurse notes old and new ecchymotic areas on the client’s chest and legs and asks the client how the bruises were sustained. the client, although reluctant, tells the nurse in confidence that a family member frequently hits the client if supper is not prepared on time when the family member arrives home from work. the nurse plans to make which most appropriate response?
a) “oh, really? i will discuss this situation with your family member.”
b) “let’s talk about the ways you can manage your time to prevent this from happening.”
c) “do you have any friends who can help you out until you resolve these important issues with your family member?”
d) “as a nurse, i am legally bound to report abuse. i will stay with you while you give the report and help find a safe place for you to stay.”
d) “as a nurse, i am legally bound to report abuse. i will stay with you while you give the report and help find a safe place for you to stay.”
application Q - the nurse calls the primary health care provider (PHCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. the nurse is unable to locate the PHCP, and the medication is due to be administered. which action would the nurse take?
a) contact the nursing supervisor.
b) administer the dose prescribed.
c) hold the medication until the PHCP can be contacted.
d) administer the recommended dose until the PHCP can be located.
a) contact the nursing supervisor.
application Q - the nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. the fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. which is the most appropriate initial nursing action?
a) call the police.
b) cut up the photograph and throw it away.
c) call the nursing supervisor and report the occurrence.
d) call the laboratory, and ask for the name of the individual who sent the photograph.
c) call the nursing supervisor and report the occurrence.
application Q - a nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. the nurse is told that the nursing model is a team nursing approach. the nurse determines that which scenario is characteristic of the team-based model of nursing practice?
a) each staff member is assigned a specific task for a group of clients.
b) a staff member is assigned to determine the client’s needs at home and begin discharge planning.
c) a single registered nurse (RN) is responsible for providing care to a group of six clients with the aid of an assistive personnel (AP).
d) an RN leads two licensed practical nurses (LPNs) and three APs in providing care to a group of 12 clients.
d) an RN leads two licensed practical nurses (LPNs) and three APs in providing care to a group of 12 clients.
creation Q - the registered nurse is planning the client assignments for the day. which is the most appropriate assignment for an assistive personnel (AP)?
a) a client requiring a colostomy irrigation
b) a client receiving continuous tube feedings
c) a client who requires urine specimen collections
d) a client with difficulty swallowing food and fluids
c) a client who requires urine specimen collections
creation Q - the nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. the nurse needs to assign four clients and has a licensed practical nurse and three assistive personnel (APs) on a nursing team. which client would the nurse most appropriately assign to the licensed practical nurse?
a) a client who requires a bed bath
b) an older client requiring frequent ambulation
c) a client who requires hourly measurement of vital signs
d) a client requiring abdominal wound irrigations and dressing changes every 3 hours
d) a client requiring abdominal wound irrigations and dressing changes every 3 hours
application Q - the charge nurse is planning the assignment for the day. which factors would the nurse remain mindful of when delegating tasks? select all that apply.
a) the acuity level of the clients
b) specific requests from the staff
c) the clustering of the rooms on the unit
d) the number of anticipated client discharges
e) client needs and workers’ needs and abilities
a) the acuity level of the clients
e) client needs and workers’ needs and abilities
analyzing Q - a client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. on the basis of these laboratory values, the nurse anticipates which prescription?
a) adding a dose of heparin sodium
b) holding the next dose of warfarin
c) increasing the next dose of warfarin
d) administering the next dose of warfarin
b) holding the next dose of warfarin
evaluation Q - a nurse is precepting a new graduate nurse, and the new graduate is assigned to care for a client with chronic pain. which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management?
a) “i will be sure to ask my client what their pain level is on a scale of 0 to 10.”
b) “i know that i should follow up after giving medication to make sure it is effective.”
c) “i will be sure to cue in to any indicators that the client may be exaggerating pain.”
d) “i know that pain in the older client might manifest as sleep disturbances or depression.”
c) “i will be sure to cue in to any indicators that the client may be exaggerating pain.”
evaluation Q - a client has been admitted to the hospital for gastroenteritis and dehydration. the nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?
a) 3 mg/dL (1.08 mmol/L)
b) 15 mg/dL (5.4 mmol/L)
c) 29 mg/dL (10.44 mmol/L)
d) 35 mg/dL (12.6 mmol/L)
b) 15 mg/dL (5.4 mmol/L)
evaluation Q - the nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). which method, if noted by the AP as being an appropriate method, indicates the need for further teaching?
a) taking a rectal temperature for a client who has undergone nasal surgery
b) taking an oral temperature for a client with a cough and nasal congestion
c) taking an axillary temperature for a client who has just consumed hot coffee
d) taking a temperature on the neck behind the ear using an electronic device for a client who is diaphoretic
b) taking an oral temperature for a client with a cough and nasal congestion
analyzing Q - a client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. the client’s activated partial thromboplastin time (aPTT) is 65 seconds. the nurse anticipates that which action is needed?
a) discontinuing the heparin infusion
b) increasing the rate of the heparin infusion
c) decreasing the rate of the heparin infusion
d) leaving the rate of the heparin infusion as is
d) leaving the rate of the heparin infusion as is
application Q - a client with a history of heart failure is due for a morning dose of furosemide. which serum potassium level, if noted in the client’s laboratory report, would the nurse report before administering the dose of furosemide?
a) 3.2 mEq/L (3.2 mmol/L)
b) 3.8 mEq/L (3.8 mmol/L)
c) 4.2 mEq/L (4.2 mmol/L)
d) 4.8 mEq/L (4.8 mmol/L)
a) 3.2 mEq/L (3.2 mmol/L)
analyzing Q - several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. which laboratory test results would the nurse report? select all that apply.
a) platelets 35,000 mm3 (35 × 109/L)
b) sodium 150 mEq/L (150 mmol/L)
c) potassium 5.0 mEq/L (5.0 mmol/L)
d) segmented neutrophils 40% (0.40)
e) serum creatinine, 1 mg/dL (88.3 mcmol/L)
f) white blood cells, 3000 mm3 (3.0 × 109/L)
a) platelets 35,000 mm3 (35 × 109/L)
b) sodium 150 mEq/L (150 mmol/L)
d) segmented neutrophils 40% (0.40)
f) white blood cells, 3000 mm3 (3.0 × 109/L)
analyzing Q - the nurse is assessing a client who takes ibuprofen for pain. the nurse is gathering information on the client’s medication history and determines it is necessary to notify the primary health care provider (PHCP) if the client is also taking which medications? select all that apply.
a) warfarin
b) glimepiride
c) amlodipine
d) simvastatin
e) atorvastatin
a) warfarin - NSAIDs are known to interact and can cause a serious bleeding complication
b) glimepiride - ibuprofen can increase the effects of glimepiride (hypoglycemia)
c) amlodipine - NSAIDs may increase BP and blunt the effects of many antihypertensives
application Q - a client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. on the basis of this test result, the nurse plans to teach the client about the need for which measure?
a) avoiding infection
b) taking in adequate fluids
c) preventing and recognizing hypoglycemia
d) preventing and recognizing hyperglycemia
d) preventing and recognizing hyperglycemia
application Q - the nurse is caring for a client with a diagnosis of breast cancer who is immunosuppressed. the nurse would implement neutropenic precautions if the client’s white blood cell count was which value?
a) 2000 mm3 (2.0 × 109/L)
b) 5800 mm3 (5.8 × 109/L)
c) 8400 mm3 (8.4 × 109/L)
d) 11,500 mm3 (11.5 × 109/L)
a) 2000 mm3 (2.0 × 109/L)
application Q - a client with a history of atrial fibrillation brought to the emergency department has accidentally been taking two times the prescribed dose of warfarin for the past week. after noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?
a) prepare to administer an antidote.
b) draw a sample for type and crossmatch and transfuse the client.
c) draw a sample for an activated partial thromboplastin time (aPTT) level.
d) draw a sample for prothrombin time (PT) and international normalized ratio (INR).
d) draw a sample for prothrombin time (PT) and international normalized ratio (INR).
analyzing Q - the nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. the nurse enters the client’s room and finds the client drowsy and records the following vital signs: temperature 97.2° F (36.2° C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. which action would the nurse take first?
a) document the findings.
b) attempt to arouse the client.
c) contact the primary health care provider (PHCP).
d) check the medication administration history on the PCA pump.
b) attempt to arouse the client.
analyzing Q - a client has a hemoglobin level of 10.8 g/dL (108 mmol/L). the nurse interprets that this result is most likely caused by which condition noted in the client’s history?
a) dehydration
b) feart failure
c) iron-deficiency anemia
d) chronic obstructive pulmonary disease
c) iron-deficiency anemia
application Q - a client with peptic ulcer disease and a history of upper gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). the nurse would plan to take which action after seeing the laboratory results?
a) report the abnormally low count.
b) report the abnormally high count.
c) place the client on bleeding precautions.
d) place the normal report in the client’s medical record.
d) place the normal report in the client’s medical record.
analysis Q - the nurse is caring for a client with heart failure. on assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. what additional manifestations would the nurse expect to note in this client if excess fluid volume is present?
a) weight loss and dry skin
b) flat neck and hand veins and decreased urinary output
c) an increase in blood pressure and increased respirations
d) weakness and decreased central venous pressure (CVP)
c) an increase in blood pressure and increased respirations
analyzing Q - the nurse reviews a client’s record and determines that the client is at risk for developing a potassium deficit if which situation is documented?
a) sustained tissue damage
b) requires nasogastric suction
c) has a history of Addison’s disease
d) uric acid level of 9.4 mg/dL (557 mcmol/L)
b) requires nasogastric suction
analyzing Q - the nurse reviews a client’s electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). which patterns would the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? select all that apply.
a) U waves
b) absent P waves
c) inverted T waves
d) depressed ST segment
e) widened QRS complex
a) U waves
c) inverted T waves
d) depressed ST segment
analyzing Q - potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. which actions would the nurse take to plan for preparation and administration of the potassium? select all that apply.
a) obtain an intravenous (IV) infusion pump.
b) monitor urine output during administration.
c) prepare the medication for bolus administration.
d) monitor the IV site for signs of infiltration or phlebitis.
e) ensure that the medication is diluted in the appropriate volume of fluid.
f) ensure that the bag is labeled with the volume of potassium in the solution.
a) obtain an intravenous (IV) infusion pump.
b) monitor urine output during administration.
d) monitor the IV site for signs of infiltration or phlebitis.
e) ensure that the medication is diluted in the appropriate volume of fluid.
f) ensure that the bag is labeled with the volume of potassium in the solution.
analyzing Q - the nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. which clinical manifestation would the nurse expect to note in the client?
a) twitching
b) hypoactive bowel sounds
c) negative Trousseau’s sign
d) hypoactive deep tendon reflexes
a) twitching
analyzing Q - the nurse is caring for a client with Crohn’s disease who has a calcium level of 8 mg/dL (2 mmol/L). which patterns would the nurse watch for on the electrocardiogram? select all that apply.
a) peaked T wave
b) widened T wave
c) prominent U wave
d) prolonged QT interval
e) prolonged ST segment
d) prolonged QT interval
e) prolonged ST segment
analyzing Q - the nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? select all that apply.
a) ST depression
b) prominent U wave
c) tall peaked T waves
d) prolonged ST segment
e) widened QRS complexes
c) tall peaked T waves
e) widened QRS complexes
analyzing Q - which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?
a) the client who is taking diuretics
b) the client with hyperaldosteronism
c) the client with Cushing’s syndrome
d) the client who is taking corticosteroids
a) the client who is taking diuretics
analyzing Q - the nurse is caring for a client with heart failure who is receiving high doses of a diuretic. on assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. the nurse suspects hyponatremia. what additional sign would the nurse expect to note in a client with hyponatremia?
a) muscle twitches
b) decreased urinary output
c) hyperactive bowel sounds
d) increased specific gravity of the urine
c) hyperactive bowel sounds
analyzing Q - the nurse reviews a client’s laboratory report and notes that the client’s serum phosphorus (phosphate) level is 1.8 mg/dL (0.58 mmol/L). which condition most likely caused this serum phosphorus level?
a) malnutrition
b) renal insufficiency
c) hypoparathyroidism
d) tumor lysis syndrome
a) malnutrition
application Q - the nurse is reading a physician’s progress notes in the client’s record and reads that the physician has documented “insensible fluid loss of approximately 800 mL daily.” the nurse plans to monitor the client, knowing that insensible fluid loss occurs through which type of excretion?
a) urinary output
b) wound drainage
c) integumentary output
d) the gastrointestinal tract
c) integumentary output
analyzing Q - the nurse is assigned to care for a group of clients. on review of the clients’ medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?
a) a client with an ileostomy
b) a client with heart failure
c) a client on long-term corticosteroid therapy
d) a client receiving frequent wound irrigations
a) a client with an ileostomy
analyzing Q - the nurse caring for a client with heart failure who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. which assessment finding would the nurse note in a client with this condition?
a) weight loss and poor skin turgor
b) lung congestion and increased heart rate
c) decreased hematocrit and increased urine output
d) increased respirations and increased blood pressure
a) weight loss and poor skin turgor
analyzing Q - on review of the clients’ medical records, the nurse determines that which client is at risk for fluid volume excess?
a) the client taking diuretics who has tenting of the skin
b) the client with an ileostomy from a recent abdominal surgery
c) the client who requires intermittent gastrointestinal suctioning
d) the client with kidney disease that developed as a complication of diabetes mellitus
d) the client with kidney disease that developed as a complication of diabetes mellitus
analyzing Q - which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?
a) the client with colitis
b) the client with Cushing’s syndrome
c) the client who has been overusing laxatives
d) the client who has sustained a traumatic burn
d) the client who has sustained a traumatic burn
analyzing Q - the nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PaCO2 of 30 mm Hg, and HCO3– of 20 mEq/L (20 mmol/L). the nurse analyzes these results as indicating which condition?
a) metabolic acidosis, compensated
b) respiratory alkalosis, compensated
c) metabolic alkalosis, uncompensated
d) respiratory acidosis, uncompensated
b) respiratory alkalosis, compensated
analyzing Q - the nurse is caring for a client with a nasogastric tube that is attached to low suction. the nurse monitors the client for manifestations of which disorder that the client is at risk for?
a) metabolic acidosis
b) metabolic alkalosis
c) respiratory acidosis
d) respiratory alkalosis
b) metabolic alkalosis
analyzing Q - a client with a 3-day history of nausea and vomiting and suspected gastroenteritis presents to the emergency department. the client is hypoventilating and has a respiratory rate of 10 breaths per minute. the electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. arterial blood gases are drawn, and the nurse reviews the results, expecting to note which finding?
a) a decreased pH and an increased PaCO2
b) an increased pH and a decreased PaCO2
c) a decreased pH and a decreased HCO3–
d) an increased pH and an increased HCO3–
d) an increased pH and an increased HCO3–
analyzing Q - the nurse is caring for a client having respiratory distress related to an anxiety attack. recent arterial blood gas (ABG) values are pH = 7.53, PaO2 = 72 mm Hg, PaCO2 = 32 mm Hg, and HCO3– = 28 mEq/L (28 mmol/L). which conclusion about the client would the nurse make?
a) the client has acidotic blood.
b) the client is probably overreacting.
c) the client is fluid volume overloaded.
d) the client is probably hyperventilating.
d) the client is probably hyperventilating.
understanding Q - the nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. which patterns did the nurse observe? select all that apply.
a) respirations that are shallow
b) respirations that are increased in rate
c) respirations that are abnormally slow
d) respirations that are abnormally deep
e) respirations that cease for several seconds
b) respirations that are increased in rate
d) respirations that are abnormally deep
analyzing Q - a client who is found unresponsive has arterial blood gases drawn, and the results indicate the following: pH is 7.12, PaCO2 is 90 mm Hg, and HCO3– is 22 mEq/L (22 mmol/L). the nurse interprets the results as indicating which condition?
a) metabolic acidosis with compensation
b) respiratory acidosis with compensation
c) metabolic acidosis without compensation
d) respiratory acidosis without compensation
d) respiratory acidosis without compensation
analyzing Q - the nurse notes that a client’s arterial blood gas (ABG) results reveal a pH of 7.50 and a PaCO2 of 30 mm Hg. the nurse monitors the client for which clinical manifestations associated with these ABG results? select all that apply.
a) nausea
b) confusion
c) bradypnea
d) tachycardia
e) hyperkalemia
f) light-headedness
a) nausea
b) confusion
d) tachycardia
f) light-headedness
respiratory alkalosis
analyzing Q - the nurse reviews the blood gas results of a client with atelectasis. the nurse analyzes the results and determines that the client is experiencing respiratory acidosis. which result validates the nurse’s findings?
a) pH 7.25, PaCO2 50 mm Hg
b) pH 7.35, PaCO2 40 mm Hg
c) pH 7.50, PaCO2 52 mm Hg
d) pH 7.52, PaCO2 28 mm Hg
a) pH 7.25, PaCO2 50 mm Hg
analyzing Q - the nurse is caring for a client who is on a mechanical ventilator. blood gas results indicate a pH of 7.50 and a PaCO2 of 30 mm Hg. the nurse has determined that the client is experiencing respiratory alkalosis. which laboratory value would most likely be noted in this condition?
a) magnesium level of 1.8 (0.74 mmol/L)
b) sodium level of 145 mEq/L (145 mmol/L)
c) potassium level of 3.0 mEq/L (3.0 mmol/L)
d) phosphorus level of 3.0 mg/dL (0.97 mmol/L)
c) potassium level of 3.0 mEq/L (3.0 mmol/L)
analyzing Q - the nurse is caring for a client with several broken ribs. the client is most likely to experience what type of acid-base imbalance?
a) respiratory acidosis from inadequate ventilation
b) respiratory alkalosis from anxiety and hyperventilation
c) metabolic acidosis from calcium loss due to broken bones
d) metabolic alkalosis from taking analgesics containing base products
a) respiratory acidosis from inadequate ventilation
Note 
Flashcards (145)