NR446 W3 EDAPT: NCLEX Readiness: Physiological
Adaptation Part 2 Exam Latest Update
The nurse is caring for a client with heart failure. Upon assessment, the nurse
notes dyspnea and crackles bilaterally. For each additional assessment finding,
indicate if the finding is related to fluid volume overload or not related. -
ANSWER *Related:*
Tachycardia
Peripheral edema
Hemoglobin decreased
*Not Related:*
Hypotension
Weak, thready pulses
The nurse is caring for a client with a serum potassium level of 6.2 mEq/L. Which
changes should the nurse monitor on the electrocardiogram (ECG) because of
this laboratory value? Select all that apply. - ANSWER Tall, peaked T wave
Prolonged PR interval
Widened QRS complex
The nurse recognizes that a client with __________ is most at risk for hypokalemia
due to __________. - ANSWER Nasogastric suctioning
Increased loss of potassium
The nurse is caring for a client with hypothyroidism and hypocalcemia. Highlight
the assessment findings that relate to the diagnosis. - ANSWER Confusion
Weakness
Paresthesia of the extremities
Trousseau's sign is present
BP 92/63
The nurse is caring for a client with hypothyroidism and hypocalcemia. The
client has clinical manifestations consistent with hypocalcemia caused by
__________ and placing the client at greatest risk for __________. - ANSWER
Hypothyroidism
Seizures
The nurse is caring for a client with hypothyroidism and hypocalcemia. The
nurse is providing education to the client about prescribed oral calcium
, supplements 1000 mg daily. Match each statement made by the nurse to the
corresponding rationale. - ANSWER "Take calcium 1000 mg daily, divided into
two doses."
*Increases intestinal absorption*
"Take calcium supplements with food."
*Stomach acid is needed to dissolve supplement*
"Take a vitamin D supplement."
*Necessary to push calcium into the bones*
"Calcium carbonate is the preferred supplement."
*Highest percentage of elemental calcium*
The nurse is caring for four clients. Which client should be closely monitored for
manifestations of hyponatremia? - ANSWER Middle adult client with syndrome of
inappropriate antidiuretic hormone
The nurse is planning care for a client with fluid volume deficit secondary to
dehydration. For each healthcare provider prescription, indicate if the
prescription is anticipated or contraindicated. - ANSWER *Anticipated:*
Administer 0.9% sodium chloride 150 mL/hour intravenously.
Implement fall precautions.
Document hourly intake and output (I&O) and daily weight.
*Contraindicated:*
Administer 3% sodium chloride 500 mL intravenous bolus now.
Administer desmopressin 3 mcg via intravenous injection twice daily.
The nurse is caring for a client with a serum potassium level of 2.8 mEq/L who is
prescribed intravenous potassium chloride 5 mEq per hour. The pharmacy
supplies:
What action should the nurse take when preparing and administering the
solution? - ANSWER Verify adequate urine output.
The nurse should administer __________ mL/hour to deliver 5 mEq per hour.
Round answer to the nearest whole number. - ANSWER 125
The nurse is caring for a client with acute food poisoning who reports dizziness
and a mild headache. Upon assessment, the nurse notes flat neck veins, poor
skin turgor, and prolonged capillary refill. For each additional assessment
finding, indicate if the finding is related to fluid volume deficit or not related. -
ANSWER *Related:*
Elevated temperature
Increased urine specific gravity
Adaptation Part 2 Exam Latest Update
The nurse is caring for a client with heart failure. Upon assessment, the nurse
notes dyspnea and crackles bilaterally. For each additional assessment finding,
indicate if the finding is related to fluid volume overload or not related. -
ANSWER *Related:*
Tachycardia
Peripheral edema
Hemoglobin decreased
*Not Related:*
Hypotension
Weak, thready pulses
The nurse is caring for a client with a serum potassium level of 6.2 mEq/L. Which
changes should the nurse monitor on the electrocardiogram (ECG) because of
this laboratory value? Select all that apply. - ANSWER Tall, peaked T wave
Prolonged PR interval
Widened QRS complex
The nurse recognizes that a client with __________ is most at risk for hypokalemia
due to __________. - ANSWER Nasogastric suctioning
Increased loss of potassium
The nurse is caring for a client with hypothyroidism and hypocalcemia. Highlight
the assessment findings that relate to the diagnosis. - ANSWER Confusion
Weakness
Paresthesia of the extremities
Trousseau's sign is present
BP 92/63
The nurse is caring for a client with hypothyroidism and hypocalcemia. The
client has clinical manifestations consistent with hypocalcemia caused by
__________ and placing the client at greatest risk for __________. - ANSWER
Hypothyroidism
Seizures
The nurse is caring for a client with hypothyroidism and hypocalcemia. The
nurse is providing education to the client about prescribed oral calcium
, supplements 1000 mg daily. Match each statement made by the nurse to the
corresponding rationale. - ANSWER "Take calcium 1000 mg daily, divided into
two doses."
*Increases intestinal absorption*
"Take calcium supplements with food."
*Stomach acid is needed to dissolve supplement*
"Take a vitamin D supplement."
*Necessary to push calcium into the bones*
"Calcium carbonate is the preferred supplement."
*Highest percentage of elemental calcium*
The nurse is caring for four clients. Which client should be closely monitored for
manifestations of hyponatremia? - ANSWER Middle adult client with syndrome of
inappropriate antidiuretic hormone
The nurse is planning care for a client with fluid volume deficit secondary to
dehydration. For each healthcare provider prescription, indicate if the
prescription is anticipated or contraindicated. - ANSWER *Anticipated:*
Administer 0.9% sodium chloride 150 mL/hour intravenously.
Implement fall precautions.
Document hourly intake and output (I&O) and daily weight.
*Contraindicated:*
Administer 3% sodium chloride 500 mL intravenous bolus now.
Administer desmopressin 3 mcg via intravenous injection twice daily.
The nurse is caring for a client with a serum potassium level of 2.8 mEq/L who is
prescribed intravenous potassium chloride 5 mEq per hour. The pharmacy
supplies:
What action should the nurse take when preparing and administering the
solution? - ANSWER Verify adequate urine output.
The nurse should administer __________ mL/hour to deliver 5 mEq per hour.
Round answer to the nearest whole number. - ANSWER 125
The nurse is caring for a client with acute food poisoning who reports dizziness
and a mild headache. Upon assessment, the nurse notes flat neck veins, poor
skin turgor, and prolonged capillary refill. For each additional assessment
finding, indicate if the finding is related to fluid volume deficit or not related. -
ANSWER *Related:*
Elevated temperature
Increased urine specific gravity
