27. A client with acute kidney injury has a serum potassium level of 6.0 mEq/L. The nurse should plan which action
as a priority?
1. Check the sodium level.
2. Place the client on a cardiac monitor.
3. Encourage increased vegetables in the diet.
4. Allow an extra 500 mL of fluid intake to dilute the electrolyte concentration.
29. The nurse is collecting data from a client who has a history of benign prostatic hyperplasia. To determine
whether the client currently is experiencing this condition, the nurse should ask the client about the presence of
which early symptom?
1. Nocturia
2. Urinary retention
3. Urge incontinence
4. Decreased force in the stream of urine
30. The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow.
Which actions should the nurse take?Select all that apply.
1. Check the level of the drainage bag.
2. Reposition the client to his or her side.
3. Contact the health care provider (HCP).
4. Place the client in good body alignment.
5. Check the peritoneal dialysis system for kinks.
6. Increase the flow rate of the peritoneal dialysis solution.
33. A nurse instructor is evaluating a nursing student for knowledge regarding care of a client with acute kidney
injury. Which statement by the student demonstrates the need for further educationabout the diuretic phase of acute
kidney injury?
1. "The increase in urine output indicates the return of some renal function."
2. "The diuretic phase develops about 14 days after the initial insult and lasts about 10 days."
3. "The diuretic phase is characterized by an increase in urine output of about 500 mL in a 24-hour period."
4. "The blood urea nitrogen (BUN) and creatinine levels will continue to rise during the first few days of diuresis.
34. Before providing care for a client in the late stages of chronic kidney disease (CKD), the nurse should review
the results of which most relevant laboratory study?
1. Urinalysis, hematocrit, hemoglobin
2. Culture and sensitivity testing, serum sodium
3. Urine specific gravity, intravenous pyelogram
4. Fasting blood glucose, serum potassium, serum calcium
35. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR
interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. Which
would be a correct interpretation based on these characteristics?
1. Sinus bradycardia
2. Sick sinus syndrome
3. Normal sinus rhythm
4. First-degree heart block
36. A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of
which item?
1. Sensation of palpitations
2. Causative factors, such as caffeine
3. Precipitating factors, such as infection
4. Blood pressure and oxygen saturation
37. A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14
second, the QRS complex measures 0.08 second, and the PP and RR intervals are regular. How should the nurse
correctly interpret this rhythm?
1. Sinus dysrhythmia
2. Sinus tachycardia
3. Sinus bradycardia
4. Normal sinus rhythm
This study source was downloaded by 100000869267694 from CourseHero.com on 08-14-2023 02:29:17 GMT -05:00
https://www.coursehero.com/file/14178612/NCLEX-session-exam2/
, 38. A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each
day, most often at rest in the absence of precipitating factors. How would the nurse bestdescribe this type of anginal
pain?
1. Stable angina
2. Variant angina
3. Unstable angina
4. Nonanginal pain
39.
The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that
the client has developed atrial fibrillation and has a ventricular rate of 150 beats/min. The nurse should next assess
the client for which finding?
1. Hypotension
2. Flat neck veins
3. Complaints of nausea
4. Complaints of headache
40. The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment
component would elicit specific information regarding the client's left-sided heart function?
1. Listening to lung sounds
2. Monitoring for organomegaly
3. Assessing for jugular vein distention
4. Assessing for peripheral and sacral edema
41. A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the
dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to
the touch. The nurse should document that these findings identify which type of ulcer?
1. A stage 1 ulcer
2. A vascular ulcer
3. An arterial ulcer
4. A venous stasis ulcer
42. The nurse is caring for a client who has been hospitalized with a diagnosis of angina pectoris. The client is
receiving oxygen via nasal cannula at 2 L/min. The client asks why the oxygen is necessary. The nurse should
provide which information to the client?
1. Oxygen has a calming effect.
2. Oxygen will prevent the development of any thrombus.
3. Oxygen dilates the blood vessels so that they can supply more nutrients to the heart muscle.
4. The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells
43. A client with a first-degree heart block has an electrocardiogram (ECG) taken during an episode of chest pain.
The nurse knows that which ECG finding would be an indication of first-degree heart block?
1. Presence of Q waves
2. Tall, peaked T waves
3. Prolonged PR interval
4. Widened QRS complex
44. A nurse is reinforcing instructions to a hospitalized client with heart block about the fundamental concepts
regarding the cardiac rhythm. The nurse explains to the client that the normal site in the heart responsible for
initiating electrical impulses is which site?
1. Bundle of His
2. Purkinje fibers
3. Sinoatrial (SA) node
4. Atrioventricular (AV) node
45. The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. No P waves or QRS
complexes are seen; instead, the monitor screen shows an irregular wavy line. The nurse interprets that the client is
experiencing which rhythm?
1. Sinus tachycardia
2. Ventricular fibrillation
3. Ventricular tachycardia
4. Premature ventricular contractions (PVCs
This study source was downloaded by 100000869267694 from CourseHero.com on 08-14-2023 02:29:17 GMT -05:00
https://www.coursehero.com/file/14178612/NCLEX-session-exam2/
as a priority?
1. Check the sodium level.
2. Place the client on a cardiac monitor.
3. Encourage increased vegetables in the diet.
4. Allow an extra 500 mL of fluid intake to dilute the electrolyte concentration.
29. The nurse is collecting data from a client who has a history of benign prostatic hyperplasia. To determine
whether the client currently is experiencing this condition, the nurse should ask the client about the presence of
which early symptom?
1. Nocturia
2. Urinary retention
3. Urge incontinence
4. Decreased force in the stream of urine
30. The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow.
Which actions should the nurse take?Select all that apply.
1. Check the level of the drainage bag.
2. Reposition the client to his or her side.
3. Contact the health care provider (HCP).
4. Place the client in good body alignment.
5. Check the peritoneal dialysis system for kinks.
6. Increase the flow rate of the peritoneal dialysis solution.
33. A nurse instructor is evaluating a nursing student for knowledge regarding care of a client with acute kidney
injury. Which statement by the student demonstrates the need for further educationabout the diuretic phase of acute
kidney injury?
1. "The increase in urine output indicates the return of some renal function."
2. "The diuretic phase develops about 14 days after the initial insult and lasts about 10 days."
3. "The diuretic phase is characterized by an increase in urine output of about 500 mL in a 24-hour period."
4. "The blood urea nitrogen (BUN) and creatinine levels will continue to rise during the first few days of diuresis.
34. Before providing care for a client in the late stages of chronic kidney disease (CKD), the nurse should review
the results of which most relevant laboratory study?
1. Urinalysis, hematocrit, hemoglobin
2. Culture and sensitivity testing, serum sodium
3. Urine specific gravity, intravenous pyelogram
4. Fasting blood glucose, serum potassium, serum calcium
35. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR
interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. Which
would be a correct interpretation based on these characteristics?
1. Sinus bradycardia
2. Sick sinus syndrome
3. Normal sinus rhythm
4. First-degree heart block
36. A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of
which item?
1. Sensation of palpitations
2. Causative factors, such as caffeine
3. Precipitating factors, such as infection
4. Blood pressure and oxygen saturation
37. A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14
second, the QRS complex measures 0.08 second, and the PP and RR intervals are regular. How should the nurse
correctly interpret this rhythm?
1. Sinus dysrhythmia
2. Sinus tachycardia
3. Sinus bradycardia
4. Normal sinus rhythm
This study source was downloaded by 100000869267694 from CourseHero.com on 08-14-2023 02:29:17 GMT -05:00
https://www.coursehero.com/file/14178612/NCLEX-session-exam2/
, 38. A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each
day, most often at rest in the absence of precipitating factors. How would the nurse bestdescribe this type of anginal
pain?
1. Stable angina
2. Variant angina
3. Unstable angina
4. Nonanginal pain
39.
The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that
the client has developed atrial fibrillation and has a ventricular rate of 150 beats/min. The nurse should next assess
the client for which finding?
1. Hypotension
2. Flat neck veins
3. Complaints of nausea
4. Complaints of headache
40. The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment
component would elicit specific information regarding the client's left-sided heart function?
1. Listening to lung sounds
2. Monitoring for organomegaly
3. Assessing for jugular vein distention
4. Assessing for peripheral and sacral edema
41. A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the
dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to
the touch. The nurse should document that these findings identify which type of ulcer?
1. A stage 1 ulcer
2. A vascular ulcer
3. An arterial ulcer
4. A venous stasis ulcer
42. The nurse is caring for a client who has been hospitalized with a diagnosis of angina pectoris. The client is
receiving oxygen via nasal cannula at 2 L/min. The client asks why the oxygen is necessary. The nurse should
provide which information to the client?
1. Oxygen has a calming effect.
2. Oxygen will prevent the development of any thrombus.
3. Oxygen dilates the blood vessels so that they can supply more nutrients to the heart muscle.
4. The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells
43. A client with a first-degree heart block has an electrocardiogram (ECG) taken during an episode of chest pain.
The nurse knows that which ECG finding would be an indication of first-degree heart block?
1. Presence of Q waves
2. Tall, peaked T waves
3. Prolonged PR interval
4. Widened QRS complex
44. A nurse is reinforcing instructions to a hospitalized client with heart block about the fundamental concepts
regarding the cardiac rhythm. The nurse explains to the client that the normal site in the heart responsible for
initiating electrical impulses is which site?
1. Bundle of His
2. Purkinje fibers
3. Sinoatrial (SA) node
4. Atrioventricular (AV) node
45. The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. No P waves or QRS
complexes are seen; instead, the monitor screen shows an irregular wavy line. The nurse interprets that the client is
experiencing which rhythm?
1. Sinus tachycardia
2. Ventricular fibrillation
3. Ventricular tachycardia
4. Premature ventricular contractions (PVCs
This study source was downloaded by 100000869267694 from CourseHero.com on 08-14-2023 02:29:17 GMT -05:00
https://www.coursehero.com/file/14178612/NCLEX-session-exam2/
