Question 1
Question
A nurse is admitting a client who reports nausea, vomiting, and weakness. Upon assessment, the client has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min, respirations 24/min, skin cool with tenting present, and blood pressure 102/64 mm Hg. His urine is concentrated with a high specific gravity. Which of the following are clinical manifestations of fluid volume deficit? (Select all that apply.)
Answer
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Decreased skin turgor
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Concentrated urine
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Bradycardia
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Low-grade fever
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Tachypnea
Question 2
Question
A nurse is admitting an older adult client who is experiencing dyspnea, weakness, and weight gain of 2 lb, with 1+ bilateral edema of the lower extremities. Upon assessment, the client has a temperature 37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal cannula, and blood pressure 152/96 mm Hg. Which of the following clinical manifestations are indicative of fluid volume excess? (Select all that apply.)
Answer
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Dyspnea
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Edema
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Bradycardia
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Hypertension
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Weakness
Question 3
Question
A nurse is caring for a client who is dehydrated. Which of the following clinical manifestations should the nurse assess for that is indicative of fluid volume deficit?
Answer
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Moist skin
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Distended neck veins
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Increased urinary output
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Tachycardia
Question 4
Question
A nurse is caring for an older adult client in a long-term care facility. The client has become weak and confused. He ate 40% of his breakfast and lunch. Upon assessment, the client’s temperature is 38.3° C (100.9° F), pulse rate 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. He has lost ¾ lb and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with diminished breath sounds in the right lower lobe. Which of the following actions should the nurse take?
Answer
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Initiate fluid restrictions to limit intake.
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Observe for signs of hypertension.
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Encourage the client to ambulate to promote oxygenation.
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Monitor respirations for shortness of breath.
Question 5
Question
A nurse is caring for a client who has laboratory findings of serum Na+ 133 mEq/L and K+ 3.4 mEq/L. Which of the following treatments can result in these laboratory findings?
Answer
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Three tap water enemas
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0.9% sodium chloride solution IV at 50 mL/hr
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5% dextrose in water solution with 20 mEq of K+ IV at 80 mL/hr
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Administration of glucocorticoids
Question 6
Question
A nurse is caring for a client who has a laboratory finding of serum potassium 5.4 mEq/L. The nurse should assess for which of the following clinical manifestations?
Answer
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ECG changes
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Constipation
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Polyuria
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Hypotension
Question 7
Question
A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances?
Answer
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Hypercalcemia
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Hyponatremia
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Hyperphosphatemia
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Hypomagnesemia
Question 8
Question
A nurse is assessing a client for Chovstek’s sign. Which of the following techniques should the nurse use to perform this test?
Answer
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Apply a blood pressure cuff to the client’s arm.
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Place the stethoscope bell over the client’s carotid artery.
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Tap lightly on the client’s cheek.
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Ask the client to lower his chin to his chest.
Question 9
Question
A nurse is assessing a client who has hyperkalemia. Which of the following conditions is associated with this electrolyte imbalance?
Answer
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Diabetic ketoacidosis
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Heart failure
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Cushing’s syndrome
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Thyroidectomy
Question 10
Question
A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to her bed. Vital signs reveal a blood pressure of 104/72 mm Hg, heart rate of 116 beats/min with a regular rhythm, and a respiratory rate of 42/min and deep. Which of the following arterial blood gases findings should the nurse expect?
Answer
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pH 7.68, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3 - 24 mEq/L
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pH 7.48, PaO2 100 mm Hg, PaCO2 28 mm Hg, HCO3 - 23 mEq/L
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pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3 - 18 mEq/L
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pH 7.58, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3 - 29 mEq/L
Question 11
Question
A nurse is caring for a client who was in a motor-vehicle accident. He is reporting chest pain and difficulty breathing. A chest x-ray reveals the client has a pneumothorax, and arterial blood gases are obtained. Which of the following findings should the nurse expect?
Answer
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pH 7.06, PaO2 86 mm Hg, PaCO2 52 mm Hg, HCO3 - 24 mEq/L
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pH 7.42, PaO2 100 mm Hg, PaCO2 38 mm Hg, HCO3 - 23 mEq/L
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pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3 - 18 mEq/L
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pH 7.58, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3 - 29 mEq/L
Question 12
Question
A nurse is admitting a client who has been vomiting for 24 hr. Arterial blood gases are obtained. Based on the laboratory findings, which of the following conditions should the nurse expect?
Answer
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Respiratory acidosis
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Respiratory alkalosis
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Metabolic acidosis
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Metabolic alkalosis
Question 13
Question
A nurse is orienting a newly licensed nurse on conditions related to metabolic acidosis. Which of the following statements by the new nurse indicates the teaching has been effective?
Answer
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“Metabolic acidosis can occur due to diabetic ketoacidosis.”
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“Metabolic acidosis can occur in a client who has myasthenia gravis.”
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“Metabolic acidosis can occur in a client who has asthma.”
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“Metabolic acidosis can occur due to cancer.”
Question 14
Question
A nurse is assessing a client who has pancreatitis. His arterial blood gases reveal metabolic acidosis. Which of the following is an expected finding? (Select all that apply.)
Answer
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Tachycardia
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Hypertension
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Bounding pulses
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Hyperreflexia
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Dysrhythmia
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Tachypnea