MS Exam 3 Exam Questions And Answers
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A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from
converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which
expected therapeutic effect should the nurse assess?
a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
b. Daily weight increase from 55 kg to 57 kg
c. Heart rate decrease from 100 beats/min to 82 beats/min
d. Respiratory rate increase from 12 breaths/min to 15 breaths/min
A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse
identify as being at greatest risk for insensible water loss?
a. Client taking furosemide (Lasix)
b. Anxious client who has tachypnea
c. Client who is on fluid restrictions
d. Client who is constipated with abdominal pain
A nurse is evaluating a client who is being treated for dehydration. Which assessment result
should the nurse correlate with a therapeutic response to the treatment plan?
a. Increased respiratory rate from 12 breaths/min to 22 breaths/min
b. Decreased skin turgor on the clients posterior hand and forehead
c. Increased urine specific gravity from 1.012 to 1.030 g/mL
d. Decreased orthostatic light-headedness and dizziness
A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L,
magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the
nurse complete first?
a. Depth of respirations
b. Bowel sounds
c. Grip strength
d. Electrocardiography
A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting
cardiovascular changes. Which prescription should the nurse implement first?
a. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g by mouth.
b. Provide a heart healthy, low-potassium diet.
c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
d. Prepare the client for hemodialysis treatment.
A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia?
a. Client with pancreatitis who has continuous nasogastric suctioning
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b. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor
c. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells
d. Client with uncontrolled diabetes and a serum pH level of 7.33
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A nurse is assessing a client with hypokalemia, and notes that the clients handgrip strength has
diminished since the previous assessment 1 hour ago. Which action should the nurse take
first?
a. Assess the clients respiratory rate, rhythm, and depth.
b. Measure the clients pulse and blood pressure.
c. Document findings and monitor the client.
d. Call the health care provider.
A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order
should the nurse implement first?
a. Encourage oral fluid intake.
b. Connect the client to a cardiac monitor.
c. Assess urinary output.
d. Administer oral calcitonin (Calcimar).
A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which
potential complications of this electrolyte imbalance should the nurse assess? (Select all that
apply.)
a. Electrocardiogram changes
b. Slow, shallow respirations
c. Orthostatic hypotension
d. Paralytic ileus
e. Skeletal muscle weakness
A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which
clinical manifestations are correctly paired with the contributing electrolyte imbalance?
(Select all that apply.)
a. Hypokalemia Flaccid paralysis with respiratory depression
b. Hyperphosphatemia Paresthesia with sensations of tingling and numbness
c. Hyponatremia Decreased level of consciousness
d. Hypercalcemia Positive Trousseaus and Chvosteks signs
e. Hypomagnesemia Bradycardia, peripheral vasodilation, and hypotension
A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance.
The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3
18 mEq/L. Which manifestation should the nurse identify as an example of the clients
compensation mechanism?
a. Increased rate and depth of respirations
b. Increased urinary output
c. Increased thirst and hunger
d. Increased release of acids from the kidneys
A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood
gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which
assessment should the nurse perform first?
a. Cardiac rate and rhythm 2