Questions And Answers!!
A nurse is assigned to care for four clients on the medical-surgical unit. Which client
should the nurse see first on the shift assessment? - AnswerA client with new-onset of
shortness of breath (SOB) and a history of pulmonary edema.
A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the
hospital with a diagnosis of dehydration. For which clinical manifestations that correlate
with this fluid imbalance would the nurse assess the client? - AnswerDecreased urine
output
Increased respiratory rate
A nurse is reviewing the medical records of the clients to whom she is assigned on the 7
am-7 pm shift. Which client will the nurse monitor most closely for excessive fluid
volume? - AnswerAn 85-year-old client receiving intravenous (IV) therapy at a rate of
100 mL/h.
A nurse is caring for a client who is being treated for congestive heart failure and has
been assigned a nursing diagnosis of excessive fluid volume. Which assessment finding
causes the nurse to determine that the client's condition has improved? -
AnswerWeight loss of 4 lb in 24 hours.
A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG)
monitor. With which of the following serum potassium readings does the nurse
associate this finding? - Answer3.1 mEq/L.
A healthcare provider writes a prescription for the administration of intravenous (IV)
potassium chloride to a client with hypokalemia. What does the nurse plan to do when
preparing and administering this medication? - AnswerEnsure that the medication is
diluted in an appropriate amount of normal saline solution.
A nurse notes that a client's serum potassium level is 5.8 mEq/L. The nurse interprets
this as an expected finding in the client with: - AnswerAddison disease.
A nurse is caring for a client experiencing hyponatremia who was admitted to the
medical-surgical unit with fluid-volume overload. For which clinical manifestations of this
electrolyte imbalance does the nurse monitor this client? - AnswerHyperactive bowel
sounds
Skeletal muscle weakness
, A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For
which of the following clinical manifestations, associated with this electrolyte imbalance,
does the nurse assess the client? - AnswerMuscle weakness
Increased urine output
A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mg/dL.
Which assessment findings does the nurse expect to note? - AnswerAbdominal
distention
Trousseau sign
A nurse enters a client's room and finds the client unconscious. The nurse quickly
performs an assessment and determines that the client is not breathing. Which action
does the nurse take first? - AnswerBeginning chest compressions.
A nurse arrives at the scene of a code and begins to assist with cardiopulmonary
resuscitation (CPR) of an adult. The nurse delivers compressions by pushing down on
the chest to a depth of: - Answer2 inches.
The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client.
Which compression-ventilation ratio is correct? - Answer30:2.
A pediatric nurse finds a hospitalized child unresponsive. A quick assessment reveals
that the child is not breathing and does not have a pulse. The nurse initiates
cardiopulmonary resuscitation (CPR). How many chest compressions per minute does
the nurse deliver? - Answer100.
A nurse attending a recertification course in basic life support (BLS) for healthcare
professionals is practicing BLS on an infant mannequin. Where does the nurse place
the fingers to assess the infant's pulse? - AnswerAntecubital fossa of the arm.
A nurse is working in the emergency department. Which of the following clients should
be assessed first? - AnswerA client with new-onset atrial fibrillation with a rate of 118
beats/min.
A nurse is having dinner at a restaurant when a man sitting at the next table collapses
and falls to the floor. The nurse yells for help and quickly assesses the client, noting that
the client is not breathing and does not have a pulse. The nurse initiates
cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes
to the scene with an automatic external defibrillator (AED). What should the nurse do
next? - AnswerUse the AED.
A client with cancer of the larynx is receiving external radiation therapy of the neck.
Which side effect related specifically to the site of irradiation does the nurse tell the
client to expect? - AnswerDysphagia.