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Fluids & Electrolytes
Lab Values
Prioritization/ Delegation
Peds
Maternity
100
A nurse caring for a client with IV diuretics suspects a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? a. Lung congestion b. Decreased hematocrit c. Increased blood pressure d. Decreased central venous pressure
What is d. central venous pressure
100
The nurse is assigned to a 40 y.o. pt with chronic pancreatitis. The nurse anticipates the serum amylase level to be which of the following? a. 45 u/L b. 100 u/L c. 300 u/L d. 500 u/L
What is c. 300 u/L
100
A nurse is assigned to care for four clients. In planning rounds, which should the nurse assess first? a. pt. scheduled for chest x-ray b. pt. requiring daily dressing changes c. postoperative pt. preparing for discharge d. pt. with nasal oxygen with difficulty breathing last shift
What is d. pt. with nasal oxygen with difficulty breathing last shift
100
A nurse is caring for an infant with bronchiolitis, and tests confirm respiratory synctial virus (RSV). Based on this finding, which of the following is appropriate? a. Initiate strict enteric precautions b. Move pt. to room with another child with RSV c. Leave infant in present room, it's not contagious d. Inform staff they must wear mask, gloves, and gown
What is b. Move pt. to room with another child with RSV
100
A nurse is performing an assessment of a pregnant pt. who is at 28 wks gestation. The nurse measures the fundal height in cm and expects which of the following? a. 22 cm b. 30 cm c. 36 cm d. 40 cm
What is b. 30 cm
200
A nurse is assessing a client with suspected hypocalcemia. Which of the following would the nurse expect to see? a. Twitching b. Hypoactive bowel sounds c.Negative Trousseau's sign d. Hypoactive deep tendon reflexes
What is a. twitching
200
The nurse checks the lab result of serum digoxin and notes the result as 2.4 ng/mL. The nurse should take which immediate action? a. Notify the physician b. Check the last pulse rate c. Record the normal value on the flow sheet d. Administer next dose of medication as scheduled
What is a. Notify the physician
200
A nurse in the ER is assigned to triage patients. The nurse should assign highest priority to which of the following patients? a. pt. c/o muscle aches, headache, malaise b. pt. twisted ankle when fell rollerblading c. pt. with minor laceration on finger from cutting eggplant d. pt. with chest pain who states he just ate spicy pizza
What is d. pt. with chest pain who states he just ate spicy pizza
200
Mother arrives at ER with 5 y.o. who fell off bunk, head injury suspected. The nurse checks airway and assesses for signs of increased ICP. Which is a late sign of increased ICP? a. Nausea b. Bradycardia c. Bulging fontanel d. Dilated scalp veins
What is b. Bradycardia
200
A nurse is performing assessment on pt. who is at 38 wks getation and notes fetal heart rate is 174. The appropriate nursing action is to a. Notify the physician b. Document the finding c. Check the mother's heart rate d. Tell the pt. that the fetal heart rate is normal
What is a. Notify the physician
300
The nurse provides instructions to a client with hypokalemia about pottasium rich foods. Select all that apply a. peas b. raisins c. potatoes d. cauliflower e.cantaloupe f. strawberries
What are raisins, potatoes, cantaloupe, and strawberries (bcef)
300
An adult female has a hemoglobin level of 10.8 g/dL. The nurse interprets this result as most likely caused by which of the following? a. Dehydration b. Heart failure c. Iron deficiency anemia d. COPD
What is c. iron deficiency anemia
300
The RN needs to assign four clients and has an LPN and three NA's. Which of the following would the RN assign to the LPN? a. pt. who requires bed bath b. older pt. requiring frequent ambulation c. pt. who requires 24 hr urine collection d. pt. requiring abdominal wound irrigation and dressing changes q3h
What is d. pt. requiring abdominal wound irrigation and dressing changes q3h
300
A nurse caring for an infant with congenital heart disease is monitoring for signs of CHF. The nurses assess for which early sign of CHF? a. pallor b. cough c. tachycardia d. slow and shallow breathing
What is c. tachycardia
300
After an amiotomy has been performed, the nurse should first assess a. for cervical dilation b. for bladder distention c. maternal blood pressure d. fetal heart rate pattern
What is d. fetal heart rate pattern
400
A nurse reviews a client's lab report and notes the serum phosphorous is 2 mg/dL. Which condition most likely cause this phosphorous level? a. Alcoholism b. Renal insufficiency c. Hypoparathyroidism d. Tumor lysis syndrome
What is a. Alcoholism
400
The nurse is caring for a client with cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the WBC count was which of the following? a. 2000 cells/mm3 b. 5800 cells/mm3 c. 8400 cells/mm3 d. 11,500 cells/mm3
What is a. 2000 cells/mm3
400
An RN has received assignment for day shift. After making initial rounds and checking all assigned pts, which will the RN plan to care for first? a. pt. who is ambulatory b. pt. scheduled for PT at 1300 c. pt. with fever who is diaphoretic and restless d. postoperative pt. who just received pain meds
What is c. pt. with fever who is diaphoretic and restless
400
A nurse reviews an infant's records and finds suspected Hirschsprung's disease. Which symptom most likely led the mother to seek healthcare for the infant? a. diarrhea b. projectile vomiting c. regurgitation of feedings d. foul-smelling ribbon-like stools
What is d. foul-smelling ribbon-like stools
400
A nursing student is preparing for class on fetal circulation. The instructor asks the student to describe the process through the umbilical cord. Which of the following is correct? a. The one artery carries freshly oxygenated blood and nutrient-rich blood back from the placenta to the fetus b. The two arteries carry freshly oxygenated blood and nutrient-rich blood black from the placenta to the fetus c. The two arteries in the umbilical cord carry deoxygenated blood and waste products away from the fetus to the placenta d. The two veins in the umbilical cord carry blood that is high in carbon dioxide and other waste away from the fetus to the placenta
What is c. The two arteries in the umbilical cord carry deoxygenated blood and waste products away from the fetus to the placenta
500
A nurse reviews a client's electrolyte lab report and notes the potassium level is 3.2. Which of the following would the nurse note on the electrocardiogram? a. U waves b. Absent P waves c. Elevated T waves d. Elevated ST segment
What is a. U waves
500
Several laboratory tests are prescribed for a client. Select the abnormal results the nurse should report. a. Calcium 7 mg/dL b. Magnesium 1 mg/dL c. Phosphorous 3.6 mg/dL d. Neutrophils 1000/mm3 e. Serum creatinine 1 mg/dL f. WBC 3000/mm3
What is calcium 7, magnesium 1, neutrophils 1000, WBC 3000 (abdf)
500
An RN is planning pt. assignment. Which of the following is the most appropriate for a nursing assistant? a. pt. requiring colostomy irrigation b. pt. receiving continuous tube feeding c. pt. who requires urine specimen collections d. pt. with difficulty swallowing food and fluids
What is c. pt. who requires urine specimen collections
500
A nurse is reviewing order for a child with sickle cell anemia who was admitted for vaso-occlusive crisis. Which orders should the nurse question? a. restrict fluid intake b. position for comfort c. avoid strain on painful joints d. apply nasal oxygen at 2 L/min e. provide high calorie, high protein diet f. give meperidine 25 mg IV q4h for pain
What is restrict fluid intake, give meperdine 25 mg IV q4h for pain (a,f)
500
A nurse is monitoring a pt. in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction a. variability b. accelerations c. early decelerations d. variable decelerations
What is d. variable decelerations