Electrolyte Imbalance
A client is admitted to the emergency department with a magnesium level of 1.2 mg/dL. The nurse is aware that a likely cause of the value is which of the following:
A. Alcoholism
B. Dehydration
C. Kidney Failure
D. Excessive magnesium intake
A. Alcoholism
A nurse is caring for a client with sickle cell anemia during a vaso-occlusive crisis. Which of the following clinical manifestations is most likely to be observed during this crisis?
A. Increased blood pressure
B. Pale skin and mucous membranes
C. Severe joint pain
D. High energy levels
C. Severe joint pain
Which of the following is the most common risk factor for emphysema?
A. Smoking tobacco
B. Between 20 to 30 years of age
C. Asthma
D. Pollution
A. Smoking tobacco
The nurse is reviewing the health problems for a group of assign patients. Which patient does the nurse recognize as being at increased risk for developing metabolic alkalosis?
A. Patient with bulimia
B. Patient with COPD
C. Patient with venous stasis ulcer
D. Patient on dialysis
A. Patient with bulimia
A nurse is caring for a group of patients on an adult medical-surgical unit. Which patient should the nurse identify as having the highest risk of aspiration?
A. A patient who has a colostomy
B. A patient who has an ileostomy
C. A patient receiving enteral feedings through an NG tube
D. A patient who has a chest tube following a motor vehicle crash
C. A patient receiving enteral feedings through an NG tube
A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse expect?
A. Decreased deep-tendon reflexes.
B. Skeletal muscles weakness.
C. Hypoactive bowel sounds.
D. Tingling of the lips.
D. Tingling of the lips.
A client presents with a sings of hemolysis, including jaundice and an elevated bilirubin level. Which type of anemia is most likely to be associated with these findings?
A. Iron-deficiency anemia
B. Hemolytic anemia
C. Pernicious anemia
D. Aplastic anemia
B. Hemolytic anemia
Which of the following is true regarding the physiology of an open pneumothorax?
A. Air cannot pass freely into the thoracic cavity through a chest wound.
B. The air is trapped when it enters the cavity.
C. Air moves in and out of a wound in the chest wall.
D. There are no audible sounds in an open pneumothorax.
C. Air moves in and out of a wound in the chest wall.
A nurse is assessing a client with suspected fluid volume overload. Which of the findings requires further actions?
A. Pyuria
B. Weight loss
C. Jugular vein distention
D. Muscle contraction
C. Jugular vein distention
A nurse is caring for a client who is scheduled for an elective surgery to remove a rectal polyps. The nurse knows that this type of surgery is classified by degree of urgency as:
A. Emergency
B. Urgent
C. Elective
D. Optional
E. Routine
C. Elective
A nurse is caring for a client who is receiving potassium chloride 40 mEq IV every 4hr. Which of the following findings indicate the client is becoming hyperkalemic?
A. Hypoactive bowel sounds
B. Sinus rhythm with peaked T waves
C. Irritability and anxiety
D. Shallow respirations
B. Sinus rhythm with peaked T waves
A nurse is reviewing a client’s laboratory results and finds a low means corpuscular volume (MCV). Which type of anemia does this finding suggest?
A. Iron-deficiency anemia
B. Hemolytic anemia
C. Megaloblastic anemia
D. Pernicious anemia
A. Iron-deficiency anemia
A nurse is caring for a client who has COPD. Which of the following actions should the nurse take?
A. Encourage the client to drink 8 glasses of water a day.
B. Instruct the client to cough every 4 hr.
C. Provide the client with a low protein diet.
D. Advise the client to lie down after eating.
A. Encourage the client to drink 8 glasses of water a day.
A nurse is collecting data for a client who has fluid volume deficit. Which of the following is an expected finding?
A. Decreased hematocrit
B. Increased urine ketones
C. Increased urine specific gravity
D. Decrease BUN
C. Increased urine specific gravity
A nurse is caring for a patient on the third day following abdominal surgery. The nurse notes the absence of bowel sounds, abdominal distention, and the patient has not passed any flatus. Which postoperative complication is the patient likely experiencing?
A. Paralytic ileus
B. Incisional infection
C. Fecal impaction
D. Health care-associated Clostridium difficile
A. Paralytic ileus
A nurse is caring for a client being treated for hypernatremia. Which of the following are appropriate nursing interventions? (Select all that apply).
A. Encourage eating potassium-rich foods
B. Restrict sodium in the diet
C. Decrease water intake
D. Monitor vital signs
E. Monitor intake and output
A nurse is caring for a client with pernicious anemia. Which of the following statements made by the client demonstrates an understanding of the condition?
A. I should consume more iron-rich foods.
B. I need to avoid foods high in vitamin C.
C. I will need to take lifelong vitamin B12.
D. I should limit my intake of leafy greens vegetables.
C. I will need to take lifelong vitamin B12.
A nurse is caring for a client admitted with pneumonia caused by Streptococcus pneumonia. Which of the following types of pneumonia is Streptococcus pneumonia?
A. Typical pneumonia
B. Chemical Pneumonitis
C. Atypical pneumonia
D. Aspiration pneumonia
A. Typical Pneumonia
A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect?
A. Potassium 3.3mEq/L
B. HCO3 30mEq/L
C. PacO2 50mmHg
D. pH 7.45
C. PacO2 50mmHg
A nurse is planning care for a client who will undergo surgery. Which of the following interventions should the nurse include in the plan?
A. Administer an anticholinergic medications to reduce secretions.
B. Apply sequential compression devices to prevent deep vein thrombosis.
C. Shave the surgical site with a razor to prevent infection.
D. Insert a nasogastric tube to decompress the stomach.
B. Apply sequential compression devices to prevent deep vein thrombosis.
A nurse is planning care for a client who has over hydration and hyponatremia. Which of the following actions should the nurse include in the plan? (Select all that apply).
A. Monitor neurological status
B. Administer sodium polystyrene sulfonate as prescribed.
C. Provide oral hygiene frequently.
D. Restrict sodium intake as prescribed.
E. Encourage foods high in protein.
A & D
An RN is reviewing diagnostic tests for different types of anemia with a student nurse. Which of the following does the student correctly state is used for the diagnosis of types of anemia? (Select all that apply)
A. Enzyme-linked Immunosorbent assay (ELISA)
B. Schilling Test
C. Hemoglobin electrophoresis
D. Western Blot
E. Ferritin and Total Iron-Binding Capacity
B, C, & D
The nurse is in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the healthcare provider and prepares to implement which priority interventions? Select all that apply.
A. Administering morphine sulfate intravenously
B. Administering oxygen
C. Transporting the client to the coronary care unit
D. Placing the client in a low Fowler's side-lying position
E. Inserting a Foley catheter
A, B, C, & E
A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply)
A. Lethargy
B. Kussmaul's respirations
C. Circumoral paresthesia
D. Bicarbonate excess.
E. Flushing
A, C & D
A nurse is preparing a client for surgery and needs to obtain some blood samples for diagnostic test. Which of the following test are commonly done before surgery? Select all that apply.
A. Hemoglobin and hematocrit
B. Blood glucose
C. Blood urea nitrogen and creatinine
D. Thyroid stimulating hormone
E. Prothrombin time and international normalized ratio
A, B, C & E