3/6/24, 10:16 PM Nursing Fund | Quizlet
Name: Score:
13 Multiple choice questions
Term 1 of 25
A nurse is caring for an elderly client with dementia who has developed dehydration as a result
of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?
Blood lab results
Rationale: Blood lab results provide objective data about fluid and electrolyte status as
well as about hemoglobin and hematocrit. Intake and output results provide data only
about fluid balance but doesn't present a comprehensive picture of the client's fluid and
electrolyte status and therefore is not the best answer. Skin turgor is not a reliable
indicator of hydration status for the elderly client because it is generally decreased with
age. The client's report about fluid intake is a subjective data in general and not reliable
because this client has dementia and therefore has memory problems.
Abnormalities in cardiac rhythm
Rationale: Doxorubicin is cardiotoxic, which is manifested by transient ECG
abnormalities. Alopecia is an expected side effect of doxorubicin, not a toxic effect.
Dyspnea and a metallic taste to food are not effects of doxorubicin.
Tender mass in the left upper abdomen
Rationale: Splenomegaly usually accompanies chronic myelogenous leukemia; the
spleen usually is gross, palpable, and tender and necessitates removal. The spleen is
located high in the abdomen on the left side and usually is not palpable unless it is
enlarged. The urinary output is not affected with these conditions. With leukemia and
splenomegaly there is increased destruction of blood cells; the erythrocyte count will
be low. Polydipsia, increased appetite, and urinary frequency are not associated with
leukemia or splenomegaly, but rather diabetes.
Blurred Vision
Rationale: Visual disturbances, such as blurred or yellow vision, may be evidence of
digoxin toxicity. Chest pain is not a toxic effect of digoxin. Persistent hiccups (singultus)
are not related to digoxin toxicity. An increased urinary output is not a sign of digoxin
toxicity; it may be a sign of a therapeutic response to the drug, an improved cardiac
output.
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,3/6/24, 10:16 PM Nursing Fund | Quizlet
Definition 2 of 25
Obtaining daily weights
Daily weighing provides an objective measurement because a weight loss indicates a loss of
fluid; approximately 1 kg (2.2 lb) is equal to 1 L of fluid. Although a wet diaper count is an
objective measure, it is necessary to weigh the diapers before and after the infant voids to
estimate the amount of fluid loss. Intake can be measured accurately; however, output,
especially with diarrhea, is difficult to measure. Tissue turgor is a subjective assessment, open
to a variety of interpretations. Also, the site that should be assessed is over the sternum, not
the abdomen.
A dehydrated 2-month-old infant with a history of diarrhea is admitted to the pediatric
unit. Oral rehydration therapy is instituted. What is the most accurate method of
monitoring the infant's hydration status?
A specimen for arterial blood gases is obtained from a severely dehydrated 3-month-
old infant with a history of diarrhea. The pH is 7.30, Pco2 is 35 mm Hg, and HCO3- is 17
mEq/L. What complication does the nurse conclude has developed?
A client with a history of chronic myelogenous leukemia and splenomegaly is admitted
to the hospital. What should the nurse expect to identify when completing the admission
assessment?
A 4-year-old child is admitted to the pediatric unit with a tentative diagnosis of acute
lymphocytic leukemia (ALL). What signs and symptoms does the nurse expect when
obtaining the health history and performing a physical assessment? Select all that apply
https://quizlet.com/407821800/test?answerTermSides=6&promptTermSides=6&questionCount=25&questionTypes=5&showImages=true 2/16
, 3/6/24, 10:16 PM Nursing Fund | Quizlet
Definition 3 of 25
1. Check health care provider's prescription
2. Obtain vital signs and history of transfusions
3. Ascertain that intravenous catheter size is 18 or 20 gauge
4. Change main line solution to normal saline
5. Check client identification before hanging unit of blood
Rationale: Check the health care provider's prescription to notify blood bank what product will
be needed. Obtain the client's baseline vital signs and ask if the client has had previous
transfusions and if there were any untoward effects. Ascertaining the intravenous catheter size
is at least an 18 will prevent hemolysis of red blood cells. The main line solution must be
normal saline 0.9 to flush the line and use as a main line if the blood administration must occur
because of a reaction. Other solutions can affect blood, causing it to clot. Checking the client
identification and verification of blood product is necessary before proceeding.
A blood transfusion of packed cells has been prescribed for a client with leukemia. The
nurse will complete the following steps in what order?
A hospitalized 3-year-old child with leukemia is undergoing chemotherapy. The mother
tells the nurse that her child is asking for fried chicken. How should the nurse respond?
A client is receiving whole-body radiation for Hodgkin disease. Which side effect should
the nurse expect as a result of this therapy?
A client is scheduled for a transurethral resection of the prostate (TURP). Which
statement made by the client most indicates the need for further preoperative teaching?
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Name: Score:
13 Multiple choice questions
Term 1 of 25
A nurse is caring for an elderly client with dementia who has developed dehydration as a result
of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?
Blood lab results
Rationale: Blood lab results provide objective data about fluid and electrolyte status as
well as about hemoglobin and hematocrit. Intake and output results provide data only
about fluid balance but doesn't present a comprehensive picture of the client's fluid and
electrolyte status and therefore is not the best answer. Skin turgor is not a reliable
indicator of hydration status for the elderly client because it is generally decreased with
age. The client's report about fluid intake is a subjective data in general and not reliable
because this client has dementia and therefore has memory problems.
Abnormalities in cardiac rhythm
Rationale: Doxorubicin is cardiotoxic, which is manifested by transient ECG
abnormalities. Alopecia is an expected side effect of doxorubicin, not a toxic effect.
Dyspnea and a metallic taste to food are not effects of doxorubicin.
Tender mass in the left upper abdomen
Rationale: Splenomegaly usually accompanies chronic myelogenous leukemia; the
spleen usually is gross, palpable, and tender and necessitates removal. The spleen is
located high in the abdomen on the left side and usually is not palpable unless it is
enlarged. The urinary output is not affected with these conditions. With leukemia and
splenomegaly there is increased destruction of blood cells; the erythrocyte count will
be low. Polydipsia, increased appetite, and urinary frequency are not associated with
leukemia or splenomegaly, but rather diabetes.
Blurred Vision
Rationale: Visual disturbances, such as blurred or yellow vision, may be evidence of
digoxin toxicity. Chest pain is not a toxic effect of digoxin. Persistent hiccups (singultus)
are not related to digoxin toxicity. An increased urinary output is not a sign of digoxin
toxicity; it may be a sign of a therapeutic response to the drug, an improved cardiac
output.
https://quizlet.com/407821800/test?answerTermSides=6&promptTermSides=6&questionCount=25&questionTypes=5&showImages=true 1/16
,3/6/24, 10:16 PM Nursing Fund | Quizlet
Definition 2 of 25
Obtaining daily weights
Daily weighing provides an objective measurement because a weight loss indicates a loss of
fluid; approximately 1 kg (2.2 lb) is equal to 1 L of fluid. Although a wet diaper count is an
objective measure, it is necessary to weigh the diapers before and after the infant voids to
estimate the amount of fluid loss. Intake can be measured accurately; however, output,
especially with diarrhea, is difficult to measure. Tissue turgor is a subjective assessment, open
to a variety of interpretations. Also, the site that should be assessed is over the sternum, not
the abdomen.
A dehydrated 2-month-old infant with a history of diarrhea is admitted to the pediatric
unit. Oral rehydration therapy is instituted. What is the most accurate method of
monitoring the infant's hydration status?
A specimen for arterial blood gases is obtained from a severely dehydrated 3-month-
old infant with a history of diarrhea. The pH is 7.30, Pco2 is 35 mm Hg, and HCO3- is 17
mEq/L. What complication does the nurse conclude has developed?
A client with a history of chronic myelogenous leukemia and splenomegaly is admitted
to the hospital. What should the nurse expect to identify when completing the admission
assessment?
A 4-year-old child is admitted to the pediatric unit with a tentative diagnosis of acute
lymphocytic leukemia (ALL). What signs and symptoms does the nurse expect when
obtaining the health history and performing a physical assessment? Select all that apply
https://quizlet.com/407821800/test?answerTermSides=6&promptTermSides=6&questionCount=25&questionTypes=5&showImages=true 2/16
, 3/6/24, 10:16 PM Nursing Fund | Quizlet
Definition 3 of 25
1. Check health care provider's prescription
2. Obtain vital signs and history of transfusions
3. Ascertain that intravenous catheter size is 18 or 20 gauge
4. Change main line solution to normal saline
5. Check client identification before hanging unit of blood
Rationale: Check the health care provider's prescription to notify blood bank what product will
be needed. Obtain the client's baseline vital signs and ask if the client has had previous
transfusions and if there were any untoward effects. Ascertaining the intravenous catheter size
is at least an 18 will prevent hemolysis of red blood cells. The main line solution must be
normal saline 0.9 to flush the line and use as a main line if the blood administration must occur
because of a reaction. Other solutions can affect blood, causing it to clot. Checking the client
identification and verification of blood product is necessary before proceeding.
A blood transfusion of packed cells has been prescribed for a client with leukemia. The
nurse will complete the following steps in what order?
A hospitalized 3-year-old child with leukemia is undergoing chemotherapy. The mother
tells the nurse that her child is asking for fried chicken. How should the nurse respond?
A client is receiving whole-body radiation for Hodgkin disease. Which side effect should
the nurse expect as a result of this therapy?
A client is scheduled for a transurethral resection of the prostate (TURP). Which
statement made by the client most indicates the need for further preoperative teaching?
https://quizlet.com/407821800/test?answerTermSides=6&promptTermSides=6&questionCount=25&questionTypes=5&showImages=true 3/16
