1|Page
NURS 320 EXAM 1 QUESTIONS WITH
VERIFIED SOLUTIONS
Nurse John Joseph is totaling the intake and output for Elena Reyes, a client
diagnosed with septicemia who is on a clear liquid diet. The client intakes 8 oz of
apple juice, 850 ml of water, 2 cups of beef broth, and 900 ml of half-normal
saline solution and outputs 1,500 ml of urine during the shift. How many
milliliters should the nurse document as the client's intake.
A
2,230
B
2,740
C
2,470
D
2,320 - correct-answer - C
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The fluid intake includes 8 oz (240 ml) of apple juice, 850 ml of water, 2 cups (480
ml) of beef broth, and 900 ml of I.V. fluid for a total of 2,470 ml intake for the
shift.
Marie Joy's lab test revealed that her serum calcium is 2.5 mEq/L. Which
assessment data does the nurse document when a client diagnosed with
hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is
inflated?
A
Positive Trousseau's sign
B
Positive Chvostek's sign
C
Tetany
D
Paresthesia - correct-answer - A
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In a client with hypocalcemia, a positive Trousseau's sign refers to carpopedal
spasm that develops usually within 2 to 5 minutes after applying and inflating a
blood pressure cuff to about 20 mm Hg higher than systolic pressure on the upper
arm. This spasm occurs as the blood supply to the ulnar nerve is obstructed.
Chvostek's sign refers to twitching of the facial nerve when tapping below the
earlobe. Paresthesia refers to the numbness or tingling. Tetany is a clinical
manifestation of hypocalcemia denoted by tingling in the tips of the fingers
around the mouth, and muscle spasms in the extremities and face.
Lab tests revealed that patient Z's [Na+] is 170 mEq/L. Which clinical
manifestation would nurse Natty expect to assess?
A
Tented skin turgor and thirst
B
Muscle twitching and tetany
C
Fruity breath and Kussmaul's respirations
D
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Muscle weakness and paresthesia - correct-answer - A
Hypernatremia refers to elevated serum sodium levels, usually above 145 mEq/L.
Typically, the client exhibits tented skin turgor and thirst in conjunction with dry,
sticky mucous membranes, lethargy, and restlessness. Muscle weakness and
paresthesia are associated with hypokalemia; fruity breath and Kussmaul's
respirations are associated with diabetic ketoacidosis. Muscle twitching and
tetany may be seen with hypercalcemia or hyperphosphatemia.
Mang Teban has a history of chronic obstructive pulmonary disease and has the
following arterial blood gas results: partial pressure of oxygen (PO2), 55 mm Hg,
and partial pressure of carbon dioxide (PCO2), 60 mm Hg. When attempting to
improve the client's blood gas values through improved ventilation and oxygen
therapy, which is the client's primary stimulus for breathing?
A
High PCO2
B
Low PO2
NURS 320 EXAM 1 QUESTIONS WITH
VERIFIED SOLUTIONS
Nurse John Joseph is totaling the intake and output for Elena Reyes, a client
diagnosed with septicemia who is on a clear liquid diet. The client intakes 8 oz of
apple juice, 850 ml of water, 2 cups of beef broth, and 900 ml of half-normal
saline solution and outputs 1,500 ml of urine during the shift. How many
milliliters should the nurse document as the client's intake.
A
2,230
B
2,740
C
2,470
D
2,320 - correct-answer - C
,2|Page
The fluid intake includes 8 oz (240 ml) of apple juice, 850 ml of water, 2 cups (480
ml) of beef broth, and 900 ml of I.V. fluid for a total of 2,470 ml intake for the
shift.
Marie Joy's lab test revealed that her serum calcium is 2.5 mEq/L. Which
assessment data does the nurse document when a client diagnosed with
hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is
inflated?
A
Positive Trousseau's sign
B
Positive Chvostek's sign
C
Tetany
D
Paresthesia - correct-answer - A
,3|Page
In a client with hypocalcemia, a positive Trousseau's sign refers to carpopedal
spasm that develops usually within 2 to 5 minutes after applying and inflating a
blood pressure cuff to about 20 mm Hg higher than systolic pressure on the upper
arm. This spasm occurs as the blood supply to the ulnar nerve is obstructed.
Chvostek's sign refers to twitching of the facial nerve when tapping below the
earlobe. Paresthesia refers to the numbness or tingling. Tetany is a clinical
manifestation of hypocalcemia denoted by tingling in the tips of the fingers
around the mouth, and muscle spasms in the extremities and face.
Lab tests revealed that patient Z's [Na+] is 170 mEq/L. Which clinical
manifestation would nurse Natty expect to assess?
A
Tented skin turgor and thirst
B
Muscle twitching and tetany
C
Fruity breath and Kussmaul's respirations
D
, 4|Page
Muscle weakness and paresthesia - correct-answer - A
Hypernatremia refers to elevated serum sodium levels, usually above 145 mEq/L.
Typically, the client exhibits tented skin turgor and thirst in conjunction with dry,
sticky mucous membranes, lethargy, and restlessness. Muscle weakness and
paresthesia are associated with hypokalemia; fruity breath and Kussmaul's
respirations are associated with diabetic ketoacidosis. Muscle twitching and
tetany may be seen with hypercalcemia or hyperphosphatemia.
Mang Teban has a history of chronic obstructive pulmonary disease and has the
following arterial blood gas results: partial pressure of oxygen (PO2), 55 mm Hg,
and partial pressure of carbon dioxide (PCO2), 60 mm Hg. When attempting to
improve the client's blood gas values through improved ventilation and oxygen
therapy, which is the client's primary stimulus for breathing?
A
High PCO2
B
Low PO2
