Nursing 3000 Exam questions and
answers graded A+
1. The nurse is caring for a client with deficient fluid volume caused by a massive burn injury. Which
of the following assessment data will be of greatest concern to the nurse?
1. The blood pressure is 90/40 mm Hg.
2. Urine output is 30 mL over the last hour.
3. Oral fluid intake is 100 mL for the last 8 hours.
4. There is prolonged skin tenting over the sternum. - ANS✅✅1. The blood pressure is 90/40
mmHg
2. The nurse is caring for a client recently admitted with small cell carcinoma of the lung and the
syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following assessments
should the nurse carefully monitor?
1. Increased total urinary output
2. Elevation of serum hematocrit
3. Decreased serum sodium level
4. Rapid and unexpected weight loss - ANS✅✅2. Decreased serum sodium level
3. The nurse is evaluating the fluid balance for a client admitted for hypovolemia associated with
multiple draining wounds. Which of the following assessments is the most accurate to evaluate
volume status in this client?
1. Skin turgor
2. Daily weight
3. Presence of edema
4. Hourly urine output - ANS✅✅2. Daily weight
4. The nurse is caring for an alert and oriented older-adult client with a history of dehydration.
Which of the following information should the home health nurse teach the client as to when to
increase fluid intake?
1. In the late evening hours
2. If the oral mucosa feels dry
3. When the client feels thirsty
,4. As soon as changes in level of consciousness (LOC) occur - ANS✅✅2. If the oral mucosa feels dry
The nurse is caring for a client who is taking a potassium-wasting diuretic for treatment of
hypertension. Which of the following assessment data would the nurse include in the teaching plan?
1. Personality changes
2. Frequent loose stools
3. Facial muscle spasms
4. Lower extremity weakness - ANS✅✅4. lower extremity weakness
6. The nurse is teaching a client about spironolactone as a diuretic. Which statement by the client
indicates that the teaching about this medication has been effective?
1. "I will try to drink at least eight glasses of water every day."
2. "I will use a salt substitute to decrease my sodium intake."
3. "I will increase my intake of potassium-containing foods."
4. "I will drink apple juice instead of orange juice for breakfast." - ANS✅✅4. I will drink apple juice
instead of orange juice for breakfast
7. The nurse is caring for a client admitted with hyponatremia. Which of the following actions should
the nurse anticipate implementing?
1. Restrict client's oral free water intake.
2. Avoid use of electrolyte-containing drinks.
3. Infuse a solution of 5% dextrose in 0.45% saline.
4. Administer vasopressin (antidiuretic hormone, [ADH]). - ANS✅✅A. Restrict client's oral free
water intake
8. The nurse is caring for a client with severe hypokalemia and is preparing to administer intravenous
potassium chloride (KCl) 40 mmol as prescribed by the health care provider. Which of the following
actions should the nurse take?
1. Administer the KCl as a rapid IV bolus.
2. Infuse the KCl at a rate of 20 mEq/hour.
3. Give the KCl only through a central venous line.
4. Add no more than 40 mEq/L to a litre of IV fluid. - ANS✅✅2. Infuse KCl at a rate of 20 mEq/hour
,The nurse is caring for a client with hyperkalemia and is interpreting the electrocardiogram (ECG)
report. Which of the following ECG changes would the nurse expect to assess in this client?
1. Ventricular dysrhythmias
2. Bradycardia
3. Flatten T wave
4. Prolonged P-R interval - ANS✅✅4. Prolonged P-R interval
The nurse is caring for a client who has required prolonged mechanical ventilation and has the
following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25
mmol/L. Which of the following interpretations would the nurse document?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis - ANS✅✅4. Respiratory alkalosis
The nurse is caring for a client who was admitted with diabetic ketoacidosis and has rapid, deep
respirations. Which of the following actions should the nurse implement?
1. Notify the client's health care provider.
2. Give the prescribed PRN lorazepam.
3. Start the prescribed PRN oxygen at 2-4 L/minute.
4. Encourage the client to take deep, slow breaths. - ANS✅✅1. Notify the client's health care
provider
The home health nurse is visiting an older-adult client who has a low serum protein level. Which of
the following assessment areas should the nurse assess?
a. Pallor
b. Edema
c. Confusion
d. Restlessness - ANS✅✅b. edema
The nurse is caring for a client who is receiving 3% NaCl solution for correction of hyponatremia.
During administration of the solution, which of the following assessments is a priority for the nurse
to monitor?
1. Lung sounds
, 2. Urinary output
3. Peripheral pulses
4. Peripheral edema - ANS✅✅1. lung sounds
The nurse is caring for a client who has a low serum total protein level and is taking protein
supplements. Which of the following data indicate that the client's condition has improved?
1. Hematocrit 28%
2. Good skin turgor
3. Absence of peripheral edema
4. Blood pressure 110/72 mm Hg - ANS✅✅3. absence of peripheral edema
The nurse is caring for a client who has the following arterial blood gas (ABG) results: pH 7.32, PaO2
88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mmol/L. Which of the following interpretations would
the nurse document?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis - ANS✅✅1. metabolic acidosis
The nurse is caring for a client who has been receiving diuretic therapy and is admitted to the
emergency department with a serum potassium level of 3.1 mmol/L. Of the following medications
that the client has been taking at home, which of the following would be of most concern to the
nurse?
1. Oral digoxin 0.25 mg daily
2. Ibuprofen 400 mg every 6 hours
3. Metoprolol 12.5 mg orally daily
4. Lantus insulin 24 U subcutaneously every evening - ANS✅✅1. oral digoxin 0.25 mg daily
The nurse is caring for a client with hypercalcemia. Which of the following actions would be included
in the client's nursing care plan?
1. Maintain the client on bed rest.
2. Auscultate lung sounds every 4 hours.
3. Monitor for Trousseau's and Chvostek's signs.
answers graded A+
1. The nurse is caring for a client with deficient fluid volume caused by a massive burn injury. Which
of the following assessment data will be of greatest concern to the nurse?
1. The blood pressure is 90/40 mm Hg.
2. Urine output is 30 mL over the last hour.
3. Oral fluid intake is 100 mL for the last 8 hours.
4. There is prolonged skin tenting over the sternum. - ANS✅✅1. The blood pressure is 90/40
mmHg
2. The nurse is caring for a client recently admitted with small cell carcinoma of the lung and the
syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following assessments
should the nurse carefully monitor?
1. Increased total urinary output
2. Elevation of serum hematocrit
3. Decreased serum sodium level
4. Rapid and unexpected weight loss - ANS✅✅2. Decreased serum sodium level
3. The nurse is evaluating the fluid balance for a client admitted for hypovolemia associated with
multiple draining wounds. Which of the following assessments is the most accurate to evaluate
volume status in this client?
1. Skin turgor
2. Daily weight
3. Presence of edema
4. Hourly urine output - ANS✅✅2. Daily weight
4. The nurse is caring for an alert and oriented older-adult client with a history of dehydration.
Which of the following information should the home health nurse teach the client as to when to
increase fluid intake?
1. In the late evening hours
2. If the oral mucosa feels dry
3. When the client feels thirsty
,4. As soon as changes in level of consciousness (LOC) occur - ANS✅✅2. If the oral mucosa feels dry
The nurse is caring for a client who is taking a potassium-wasting diuretic for treatment of
hypertension. Which of the following assessment data would the nurse include in the teaching plan?
1. Personality changes
2. Frequent loose stools
3. Facial muscle spasms
4. Lower extremity weakness - ANS✅✅4. lower extremity weakness
6. The nurse is teaching a client about spironolactone as a diuretic. Which statement by the client
indicates that the teaching about this medication has been effective?
1. "I will try to drink at least eight glasses of water every day."
2. "I will use a salt substitute to decrease my sodium intake."
3. "I will increase my intake of potassium-containing foods."
4. "I will drink apple juice instead of orange juice for breakfast." - ANS✅✅4. I will drink apple juice
instead of orange juice for breakfast
7. The nurse is caring for a client admitted with hyponatremia. Which of the following actions should
the nurse anticipate implementing?
1. Restrict client's oral free water intake.
2. Avoid use of electrolyte-containing drinks.
3. Infuse a solution of 5% dextrose in 0.45% saline.
4. Administer vasopressin (antidiuretic hormone, [ADH]). - ANS✅✅A. Restrict client's oral free
water intake
8. The nurse is caring for a client with severe hypokalemia and is preparing to administer intravenous
potassium chloride (KCl) 40 mmol as prescribed by the health care provider. Which of the following
actions should the nurse take?
1. Administer the KCl as a rapid IV bolus.
2. Infuse the KCl at a rate of 20 mEq/hour.
3. Give the KCl only through a central venous line.
4. Add no more than 40 mEq/L to a litre of IV fluid. - ANS✅✅2. Infuse KCl at a rate of 20 mEq/hour
,The nurse is caring for a client with hyperkalemia and is interpreting the electrocardiogram (ECG)
report. Which of the following ECG changes would the nurse expect to assess in this client?
1. Ventricular dysrhythmias
2. Bradycardia
3. Flatten T wave
4. Prolonged P-R interval - ANS✅✅4. Prolonged P-R interval
The nurse is caring for a client who has required prolonged mechanical ventilation and has the
following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25
mmol/L. Which of the following interpretations would the nurse document?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis - ANS✅✅4. Respiratory alkalosis
The nurse is caring for a client who was admitted with diabetic ketoacidosis and has rapid, deep
respirations. Which of the following actions should the nurse implement?
1. Notify the client's health care provider.
2. Give the prescribed PRN lorazepam.
3. Start the prescribed PRN oxygen at 2-4 L/minute.
4. Encourage the client to take deep, slow breaths. - ANS✅✅1. Notify the client's health care
provider
The home health nurse is visiting an older-adult client who has a low serum protein level. Which of
the following assessment areas should the nurse assess?
a. Pallor
b. Edema
c. Confusion
d. Restlessness - ANS✅✅b. edema
The nurse is caring for a client who is receiving 3% NaCl solution for correction of hyponatremia.
During administration of the solution, which of the following assessments is a priority for the nurse
to monitor?
1. Lung sounds
, 2. Urinary output
3. Peripheral pulses
4. Peripheral edema - ANS✅✅1. lung sounds
The nurse is caring for a client who has a low serum total protein level and is taking protein
supplements. Which of the following data indicate that the client's condition has improved?
1. Hematocrit 28%
2. Good skin turgor
3. Absence of peripheral edema
4. Blood pressure 110/72 mm Hg - ANS✅✅3. absence of peripheral edema
The nurse is caring for a client who has the following arterial blood gas (ABG) results: pH 7.32, PaO2
88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mmol/L. Which of the following interpretations would
the nurse document?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis - ANS✅✅1. metabolic acidosis
The nurse is caring for a client who has been receiving diuretic therapy and is admitted to the
emergency department with a serum potassium level of 3.1 mmol/L. Of the following medications
that the client has been taking at home, which of the following would be of most concern to the
nurse?
1. Oral digoxin 0.25 mg daily
2. Ibuprofen 400 mg every 6 hours
3. Metoprolol 12.5 mg orally daily
4. Lantus insulin 24 U subcutaneously every evening - ANS✅✅1. oral digoxin 0.25 mg daily
The nurse is caring for a client with hypercalcemia. Which of the following actions would be included
in the client's nursing care plan?
1. Maintain the client on bed rest.
2. Auscultate lung sounds every 4 hours.
3. Monitor for Trousseau's and Chvostek's signs.
