1. A nurse is caring for a client who is acidotic. The nurse asks the charge
nurse why the client is breathing rapidly. What response by the charge nurse
is best?
A. anxiety is causing the client to breathe rapidly
B. the client is trying to get rid of extra body acids
C. the rapid respirations cause buildup of bicarbonate
D. an increased respiratory rate is due to increased metabolism: B
resp system is trying to compensate for build up of extra acid
2. A client has urinary incontinence. Which assessment finding indicates the
outcomes for a priority nursing diagnosis have been met?
A. client reports satisfaction with undergarments for incontinence
B. client reports drinking 8-9 glasses of water each day
C. skin in perineal area is intact without redness on inspection
D. family states that client is more active and socializes more: C
3. The nurse caring for a client with malnutrition assesses which lab value as
priority?
A. albumin
B. prealbumin
C. prothrombin time
D. serum sodium: B
prealbumin changes more rapidly with decreased nutrition compared to albumin
4. The ED nurse is caring for 4 clients. Which client does the nurse assess for
gas exchange abnormalities first?
A. involved in MVC, has broken femur
B. brought in unconscious by roommate after opioid overdose
C. asthmatic client being discharged home after bronchodilator therapy
D. Hx COPD, presents to ED after being bitten by dog: B
5. A nurse is caring for clients on an in client surgical unit. Which clients does
the nurse identify as having a risk for impaired immunity? SATA
,A. 86 y/o
B. has type 2 DM
,C. taking prednisone
D. has many allergies
E. drinks a beer a day
F. low socioeconomic status: ABCF
6. A client has impaired tissue integrity and a nonhealing wound. The nurse
has taught the client about diet changes to improve wound healing. What diet
selections does the nurse evaluate as good understanding by the client? SATA
A. chicken breast
B. orange juice
C. boost supplement
D. spinach salad
E. cantaloupe
F. whole wheat bread: ABCD
7. After teaching a client who is being treated for dehydration, a nurse assesses
the client's understanding. Which statement indicates the client correctly
understands the teaching?
A. I must drink a quart (liter) of water or other liquids each day
B. I will weight myself each morning before I eat or drink
C. I will use a salt substitute when making and eating my meals
D. I will not drink liquids after 6pm so I wont have to get up at night: B
8. A nurse is assessing clients on a medsurg unit. Which adult client does the
nurse identify as being at greatest risk for insensible water loss?
A. client taking furosemide
B. anxious client who has tachypnea
C. client who is on fluid restrictions
D. client who is constipated with abdominal pain: B
insensible water loss is through skin, lungs, and stool
9. A nurse is evaluating a client being treated for dehydration. Which assess-
ment result does the nurse correlate with a therapeutic response to the
treatment plan?
A. increased RR from 12 to 22 breaths/min
, B. decreased skin turgor on the client's posterior hand and forehead
C. increased urine specific gravity from 1.012 to 1.030
D. decreased orthostatic changes when standing: D
10. A nurse is assessing clients for fluid and electrolyte imbalances. Which
client will the nurse assess first for potential hyponatremia?
A. 34 y/o NPO and receiving rapid IV D5W infusions
B. 50 y/o with infection prescribed sulfonamide antibiotic
C. 67y/o who is experiencing pain and is prescribed ibuprofen
D. 73y/o with tachycardia who is receiving digoxin: A
11. A nurse teaches a client who is at risk for hyponatremia. Which statement
does the nurse make in this client's teaching?
A. have your spouse watch for irritability and anxiety
B. notify the clinic if you notice muscle twitching
C. call your PCP if you experience diarrhea
D. bake or grill your meat rather than frying it: C
12. A nurse is caring for a client who has the following labs: potassium 2.4,
magnesium 1.8, calcium 8.5, and sodium 144. Which assessment does the
nurse complete first?
A. depth of resp
B. bowel sounds
C. grip strength
D. electrocardiography: A
13. A nurse cares for a client who has serum potassium of 6.5 and is exhibiting
cardiovascular changes. Which intervention will the nurse implement first?
A. prepare to admin patiromer by mouth
B. provide heart healthy low potassium diet
C. prepare to admin dextrose 20% and 10 units of regular insulin IV push
D. prepare client for hemodialysis treatment: C
14. The nurse is caring for a client who has fluid overload. What action by the
nurse takes priority?
A. admin high-ceiling (loop) diuretics
nurse why the client is breathing rapidly. What response by the charge nurse
is best?
A. anxiety is causing the client to breathe rapidly
B. the client is trying to get rid of extra body acids
C. the rapid respirations cause buildup of bicarbonate
D. an increased respiratory rate is due to increased metabolism: B
resp system is trying to compensate for build up of extra acid
2. A client has urinary incontinence. Which assessment finding indicates the
outcomes for a priority nursing diagnosis have been met?
A. client reports satisfaction with undergarments for incontinence
B. client reports drinking 8-9 glasses of water each day
C. skin in perineal area is intact without redness on inspection
D. family states that client is more active and socializes more: C
3. The nurse caring for a client with malnutrition assesses which lab value as
priority?
A. albumin
B. prealbumin
C. prothrombin time
D. serum sodium: B
prealbumin changes more rapidly with decreased nutrition compared to albumin
4. The ED nurse is caring for 4 clients. Which client does the nurse assess for
gas exchange abnormalities first?
A. involved in MVC, has broken femur
B. brought in unconscious by roommate after opioid overdose
C. asthmatic client being discharged home after bronchodilator therapy
D. Hx COPD, presents to ED after being bitten by dog: B
5. A nurse is caring for clients on an in client surgical unit. Which clients does
the nurse identify as having a risk for impaired immunity? SATA
,A. 86 y/o
B. has type 2 DM
,C. taking prednisone
D. has many allergies
E. drinks a beer a day
F. low socioeconomic status: ABCF
6. A client has impaired tissue integrity and a nonhealing wound. The nurse
has taught the client about diet changes to improve wound healing. What diet
selections does the nurse evaluate as good understanding by the client? SATA
A. chicken breast
B. orange juice
C. boost supplement
D. spinach salad
E. cantaloupe
F. whole wheat bread: ABCD
7. After teaching a client who is being treated for dehydration, a nurse assesses
the client's understanding. Which statement indicates the client correctly
understands the teaching?
A. I must drink a quart (liter) of water or other liquids each day
B. I will weight myself each morning before I eat or drink
C. I will use a salt substitute when making and eating my meals
D. I will not drink liquids after 6pm so I wont have to get up at night: B
8. A nurse is assessing clients on a medsurg unit. Which adult client does the
nurse identify as being at greatest risk for insensible water loss?
A. client taking furosemide
B. anxious client who has tachypnea
C. client who is on fluid restrictions
D. client who is constipated with abdominal pain: B
insensible water loss is through skin, lungs, and stool
9. A nurse is evaluating a client being treated for dehydration. Which assess-
ment result does the nurse correlate with a therapeutic response to the
treatment plan?
A. increased RR from 12 to 22 breaths/min
, B. decreased skin turgor on the client's posterior hand and forehead
C. increased urine specific gravity from 1.012 to 1.030
D. decreased orthostatic changes when standing: D
10. A nurse is assessing clients for fluid and electrolyte imbalances. Which
client will the nurse assess first for potential hyponatremia?
A. 34 y/o NPO and receiving rapid IV D5W infusions
B. 50 y/o with infection prescribed sulfonamide antibiotic
C. 67y/o who is experiencing pain and is prescribed ibuprofen
D. 73y/o with tachycardia who is receiving digoxin: A
11. A nurse teaches a client who is at risk for hyponatremia. Which statement
does the nurse make in this client's teaching?
A. have your spouse watch for irritability and anxiety
B. notify the clinic if you notice muscle twitching
C. call your PCP if you experience diarrhea
D. bake or grill your meat rather than frying it: C
12. A nurse is caring for a client who has the following labs: potassium 2.4,
magnesium 1.8, calcium 8.5, and sodium 144. Which assessment does the
nurse complete first?
A. depth of resp
B. bowel sounds
C. grip strength
D. electrocardiography: A
13. A nurse cares for a client who has serum potassium of 6.5 and is exhibiting
cardiovascular changes. Which intervention will the nurse implement first?
A. prepare to admin patiromer by mouth
B. provide heart healthy low potassium diet
C. prepare to admin dextrose 20% and 10 units of regular insulin IV push
D. prepare client for hemodialysis treatment: C
14. The nurse is caring for a client who has fluid overload. What action by the
nurse takes priority?
A. admin high-ceiling (loop) diuretics
