,A nurse is assessing a client who has hyperkalemia. Which of the following findings
should the nurse expect?
A. Decreased muscle strength
B. Decreased gastric motility
C. Increased heart rate
D. Increased blood pressue - CORRECT ANSWERS-A. Decreased muscle strength
A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the
client is confused and lethargic. Which of the following laboratory values should the
nurse report to the provider?
A. Sodium 128 mEq/L
B. Potassium 4.8 mEq/L
C. Calcium 9.1 mg/dL
D. Magnesium 2.0 mEq/L - CORRECT ANSWERS-A. Sodium 128 mEq/L
A nurse is assessing a client who is using PCA following a thoracotomy. The client is
short of breath, appears restless, and has respirations of 28/min. The client's ABG
results are pH 7.52, PaO2 89mm hg, PaCO2 28 mmHg, and HCO3 -24 mEq/L. Which
of the following actions should the nurse take?
A. Instruct the client to cough forcefully.
B. Assist the client with ambulation.
C. Provide calming interventions.
D. Discontinue the PCA. - CORRECT ANSWERS-C. Provide calming interventions.
A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the
following findings is the priority for the nurse to assess?
A. Deep-tendon reflexes
B. Cardiac rhythm
C. Peripheral sensation
D. Bowel sounds - CORRECT ANSWERS-B. Cardiac rhythm
A nurse is caring for a client who is experiencing respiratory distress as a result of acute
pulmonary edema. Which of the following actions should the nurse take first?
A. Assist with intubation
B. Initiate high-flow oxygen therapy
C. Administer a rapid-acting diuretic
D. Administer morphine IV - CORRECT ANSWERS-B. Initiate high-flow oxygen therapy
A nurse is evaluating a client who is receiving IV fluids to treat isotonic dehydration.
Which of the following laboratory findings indicates that the fluid therapy has been
effective?
A. BUN 26 mg/dL
B. Serum sodium 138 mEq/L
C. Hct 56%
D. Urine specific gravity 1.035 - CORRECT ANSWERS-B. Serum sodium 138 mEq/L
, A nurse is teaching nutritional strategies to a client who has a low serum calcium level
and an allergy to milk. Which of the following statements by the client indicates an
understanding of the teaching?
A. "I will eat extra cheese because I can't drink milk."
B. "I will need to avoid foods with vitamin D because I am allergic to milk."
C. "I will stop taking my calcium supplements if they irritate my stomach."
D. "I will add broccoli and kale to my diet." - CORRECT ANSWERS-D. "I will add
broccoli and kale to my diet."
A nurse is caring for a client who has dehydration and is receiving IV fluids. When
assessing for complications, the nurse should recognize which of the following
manifestations as a sign of fluid overload?
A. Increased urine specific gravity
B. Hypoactive bowel sounds
C. Bounding peripheral pulses
D. Decreased respiratory rate - CORRECT ANSWERS-C. Bounding peripheral pulses
A nurse is admitting a client who has status asthmaticus. The client's ABG results are
pH 7.32, PaO2 74 mm Hg, PaCO2 56 mm Hg, and HCO3 -26 mEq/L. The nurse should
interpret these laboratory values as which of the following imbalances?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis - CORRECT ANSWERS-A. Respiratory acidosis
A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has
experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the
following medications should the nurse prepare to administer?
A. Sodium polystyrene sulfonate 30 g/day
B. 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr
C. Bumetanide 8 mg/day
D. 100 mL of dextrose 10% in water with 10 units of insulin - CORRECT ANSWERS-B.
0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr
A nurse is providing teaching for a client who has venous insufficiency of the lower
extremities. Which of the following statements made by the client indicates an
understanding of the instructions?
A. "If my stockings feel tight, I'll just roll them down for a while."
B. "I'll put on my elastic stockings at the first sign of swelling."
C. "When I sit down to watch television, I'll be sure to put my feet up."
D. "It's okay to cross my legs as long as it's for less than an hour." - CORRECT
ANSWERS-C. "When I sit down to watch television, I'll be sure to put my feet up."
should the nurse expect?
A. Decreased muscle strength
B. Decreased gastric motility
C. Increased heart rate
D. Increased blood pressue - CORRECT ANSWERS-A. Decreased muscle strength
A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the
client is confused and lethargic. Which of the following laboratory values should the
nurse report to the provider?
A. Sodium 128 mEq/L
B. Potassium 4.8 mEq/L
C. Calcium 9.1 mg/dL
D. Magnesium 2.0 mEq/L - CORRECT ANSWERS-A. Sodium 128 mEq/L
A nurse is assessing a client who is using PCA following a thoracotomy. The client is
short of breath, appears restless, and has respirations of 28/min. The client's ABG
results are pH 7.52, PaO2 89mm hg, PaCO2 28 mmHg, and HCO3 -24 mEq/L. Which
of the following actions should the nurse take?
A. Instruct the client to cough forcefully.
B. Assist the client with ambulation.
C. Provide calming interventions.
D. Discontinue the PCA. - CORRECT ANSWERS-C. Provide calming interventions.
A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the
following findings is the priority for the nurse to assess?
A. Deep-tendon reflexes
B. Cardiac rhythm
C. Peripheral sensation
D. Bowel sounds - CORRECT ANSWERS-B. Cardiac rhythm
A nurse is caring for a client who is experiencing respiratory distress as a result of acute
pulmonary edema. Which of the following actions should the nurse take first?
A. Assist with intubation
B. Initiate high-flow oxygen therapy
C. Administer a rapid-acting diuretic
D. Administer morphine IV - CORRECT ANSWERS-B. Initiate high-flow oxygen therapy
A nurse is evaluating a client who is receiving IV fluids to treat isotonic dehydration.
Which of the following laboratory findings indicates that the fluid therapy has been
effective?
A. BUN 26 mg/dL
B. Serum sodium 138 mEq/L
C. Hct 56%
D. Urine specific gravity 1.035 - CORRECT ANSWERS-B. Serum sodium 138 mEq/L
, A nurse is teaching nutritional strategies to a client who has a low serum calcium level
and an allergy to milk. Which of the following statements by the client indicates an
understanding of the teaching?
A. "I will eat extra cheese because I can't drink milk."
B. "I will need to avoid foods with vitamin D because I am allergic to milk."
C. "I will stop taking my calcium supplements if they irritate my stomach."
D. "I will add broccoli and kale to my diet." - CORRECT ANSWERS-D. "I will add
broccoli and kale to my diet."
A nurse is caring for a client who has dehydration and is receiving IV fluids. When
assessing for complications, the nurse should recognize which of the following
manifestations as a sign of fluid overload?
A. Increased urine specific gravity
B. Hypoactive bowel sounds
C. Bounding peripheral pulses
D. Decreased respiratory rate - CORRECT ANSWERS-C. Bounding peripheral pulses
A nurse is admitting a client who has status asthmaticus. The client's ABG results are
pH 7.32, PaO2 74 mm Hg, PaCO2 56 mm Hg, and HCO3 -26 mEq/L. The nurse should
interpret these laboratory values as which of the following imbalances?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis - CORRECT ANSWERS-A. Respiratory acidosis
A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has
experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the
following medications should the nurse prepare to administer?
A. Sodium polystyrene sulfonate 30 g/day
B. 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr
C. Bumetanide 8 mg/day
D. 100 mL of dextrose 10% in water with 10 units of insulin - CORRECT ANSWERS-B.
0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr
A nurse is providing teaching for a client who has venous insufficiency of the lower
extremities. Which of the following statements made by the client indicates an
understanding of the instructions?
A. "If my stockings feel tight, I'll just roll them down for a while."
B. "I'll put on my elastic stockings at the first sign of swelling."
C. "When I sit down to watch television, I'll be sure to put my feet up."
D. "It's okay to cross my legs as long as it's for less than an hour." - CORRECT
ANSWERS-C. "When I sit down to watch television, I'll be sure to put my feet up."
