Physiological Health Problems with Complete Solutions
A nurse is assigned to care for four clients on the amount of normal saline solution.
medical-surgical unit. Which client should the
nurse see first on the shift assessment? - -
1A client with new-onset of shortness of breath A nurse notes that a client's serum potassium
(SOB) and a history of pulmonary edema. level is 5.8 mEq/L. The nurse interprets this as an
expected finding in the client with: - -
1Addison disease.
A client with gastroenteritis who has been
vomiting and has diarrhea is admitted to the
hospital with a diagnosis of dehydration. For A nurse is caring for a client experiencing
which clinical manifestations that correlate with hyponatremia who was admitted to the medical-
this fluid imbalance would the nurse assess the surgical unit with fluid-volume overload. For
client? - - 1Decreased urine output which clinical manifestations of this electrolyte
Increased respiratory rate imbalance does the nurse monitor this client? -
- 1Hyperactive bowel sounds
Skeletal muscle weakness
A nurse is reviewing the medical records of the
clients to whom she is assigned on the 7 am-7
pm shift. Which client will the nurse monitor most A nurse is monitoring a client with
closely for excessive fluid volume? - - 1An hyperparathyroidism for signs of hypercalcemia.
85-year-old client receiving intravenous (IV) For which of the following clinical manifestations,
therapy at a rate of 100 mL/h. associated with this electrolyte imbalance, does
the nurse assess the client? - - 1Muscle
weakness
A nurse is caring for a client who is being treated Increased urine output
for congestive heart failure and has been
assigned a nursing diagnosis of excessive fluid
volume. Which assessment finding causes the A nurse is caring for a client with Crohn disease
nurse to determine that the client's condition has whose magnesium level is 1.0 mg/dL. Which
improved? - - 1Weight loss of 4 lb in 24 assessment findings does the nurse expect to
hours. note? - - 1Abdominal distention
Trousseau sign
A nurse notes that a client has ST-segment
depression on the electrocardiogram (ECG) A nurse enters a client's room and finds the client
monitor. With which of the following serum unconscious. The nurse quickly performs an
potassium readings does the nurse associate assessment and determines that the client is not
this finding? - - 13.1 mEq/L. breathing. Which action does the nurse take first?
- - 1Beginning chest compressions.
A healthcare provider writes a prescription for the
administration of intravenous (IV) potassium A nurse arrives at the scene of a code and
chloride to a client with hypokalemia. What does begins to assist with cardiopulmonary
the nurse plan to do when preparing and resuscitation (CPR) of an adult. The nurse
administering this medication? - - 1Ensure delivers compressions by pushing down on the
that the medication is diluted in an appropriate chest to a depth of: - - 12 inches.
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, Physiological Health Problems with Complete Solutions
irradiation does the nurse tell the client to
expect? - - 1Dysphagia.
The nurse is administering cardiopulmonary
resuscitation (CPR) to an adult client. Which
compression-ventilation ratio is correct? - - The nurse has instructed a client who is about to
130:2. begin external radiation therapy in how to
maintain optimal skin integrity during therapy.
Which statement by the client indicates a need
A pediatric nurse finds a hospitalized child for further instruction? - - 1I can use over-
unresponsive. A quick assessment reveals that the-counter cortisone cream on the radiation site
the child is not breathing and does not have a if it gets red.
pulse. The nurse initiates cardiopulmonary
resuscitation (CPR). How many chest
compressions per minute does the nurse deliver? A nurse develops a nursing care plan for a client
- - 1100. with a sealed radiation implant. Which stipulation
does the nurse include in the plan? - -
1Visitors must be limited to one half-hour per
A nurse attending a recertification course in basic day.
life support (BLS) for healthcare professionals is
practicing BLS on an infant mannequin. Where
does the nurse place the fingers to assess the A female client who has undergone placement of
infant's pulse? - - 1Antecubital fossa of the a sealed radiation implant asks the nurse
arm. whether she can take a walk around the nursing
unit. How should the nurse respond to the client's
request? - - 1You need to stay in your
A nurse is working in the emergency department. room for now.
Which of the following clients should be
assessed first? - - 1A client with new-onset
atrial fibrillation with a rate of 118 beats/min. A nurse answers the call bell of a client who has
been fitted with an internal cervical radiation
implant, and the client states that she thinks that
A nurse is having dinner at a restaurant when a the implant has fallen out. The nurse checks the
man sitting at the next table collapses and falls to client and sees the implant lying in the bed.
the floor. The nurse yells for help and quickly Which action should the nurse take first? - -
assesses the client, noting that the client is not 1Using long-handled forceps to place the implant
breathing and does not have a pulse. The nurse in a lead container.
initiates cardiopulmonary resuscitation (CPR)
immediately, and the restaurant manager rushes
to the scene with an automatic external A client who experienced a brain attack (stroke)
defibrillator (AED). What should the nurse do exhibits right-sided unilateral neglect. The nurse
next? - - 1Use the AED. caring for this client plans to place the client's
personal care items: - - 1Within the client's
reach on the right side.
A client with cancer of the larynx is receiving
external radiation therapy of the neck. Which
side effect related specifically to the site of A client who is recovering from a brain attack
2/9
A nurse is assigned to care for four clients on the amount of normal saline solution.
medical-surgical unit. Which client should the
nurse see first on the shift assessment? - -
1A client with new-onset of shortness of breath A nurse notes that a client's serum potassium
(SOB) and a history of pulmonary edema. level is 5.8 mEq/L. The nurse interprets this as an
expected finding in the client with: - -
1Addison disease.
A client with gastroenteritis who has been
vomiting and has diarrhea is admitted to the
hospital with a diagnosis of dehydration. For A nurse is caring for a client experiencing
which clinical manifestations that correlate with hyponatremia who was admitted to the medical-
this fluid imbalance would the nurse assess the surgical unit with fluid-volume overload. For
client? - - 1Decreased urine output which clinical manifestations of this electrolyte
Increased respiratory rate imbalance does the nurse monitor this client? -
- 1Hyperactive bowel sounds
Skeletal muscle weakness
A nurse is reviewing the medical records of the
clients to whom she is assigned on the 7 am-7
pm shift. Which client will the nurse monitor most A nurse is monitoring a client with
closely for excessive fluid volume? - - 1An hyperparathyroidism for signs of hypercalcemia.
85-year-old client receiving intravenous (IV) For which of the following clinical manifestations,
therapy at a rate of 100 mL/h. associated with this electrolyte imbalance, does
the nurse assess the client? - - 1Muscle
weakness
A nurse is caring for a client who is being treated Increased urine output
for congestive heart failure and has been
assigned a nursing diagnosis of excessive fluid
volume. Which assessment finding causes the A nurse is caring for a client with Crohn disease
nurse to determine that the client's condition has whose magnesium level is 1.0 mg/dL. Which
improved? - - 1Weight loss of 4 lb in 24 assessment findings does the nurse expect to
hours. note? - - 1Abdominal distention
Trousseau sign
A nurse notes that a client has ST-segment
depression on the electrocardiogram (ECG) A nurse enters a client's room and finds the client
monitor. With which of the following serum unconscious. The nurse quickly performs an
potassium readings does the nurse associate assessment and determines that the client is not
this finding? - - 13.1 mEq/L. breathing. Which action does the nurse take first?
- - 1Beginning chest compressions.
A healthcare provider writes a prescription for the
administration of intravenous (IV) potassium A nurse arrives at the scene of a code and
chloride to a client with hypokalemia. What does begins to assist with cardiopulmonary
the nurse plan to do when preparing and resuscitation (CPR) of an adult. The nurse
administering this medication? - - 1Ensure delivers compressions by pushing down on the
that the medication is diluted in an appropriate chest to a depth of: - - 12 inches.
1/9
, Physiological Health Problems with Complete Solutions
irradiation does the nurse tell the client to
expect? - - 1Dysphagia.
The nurse is administering cardiopulmonary
resuscitation (CPR) to an adult client. Which
compression-ventilation ratio is correct? - - The nurse has instructed a client who is about to
130:2. begin external radiation therapy in how to
maintain optimal skin integrity during therapy.
Which statement by the client indicates a need
A pediatric nurse finds a hospitalized child for further instruction? - - 1I can use over-
unresponsive. A quick assessment reveals that the-counter cortisone cream on the radiation site
the child is not breathing and does not have a if it gets red.
pulse. The nurse initiates cardiopulmonary
resuscitation (CPR). How many chest
compressions per minute does the nurse deliver? A nurse develops a nursing care plan for a client
- - 1100. with a sealed radiation implant. Which stipulation
does the nurse include in the plan? - -
1Visitors must be limited to one half-hour per
A nurse attending a recertification course in basic day.
life support (BLS) for healthcare professionals is
practicing BLS on an infant mannequin. Where
does the nurse place the fingers to assess the A female client who has undergone placement of
infant's pulse? - - 1Antecubital fossa of the a sealed radiation implant asks the nurse
arm. whether she can take a walk around the nursing
unit. How should the nurse respond to the client's
request? - - 1You need to stay in your
A nurse is working in the emergency department. room for now.
Which of the following clients should be
assessed first? - - 1A client with new-onset
atrial fibrillation with a rate of 118 beats/min. A nurse answers the call bell of a client who has
been fitted with an internal cervical radiation
implant, and the client states that she thinks that
A nurse is having dinner at a restaurant when a the implant has fallen out. The nurse checks the
man sitting at the next table collapses and falls to client and sees the implant lying in the bed.
the floor. The nurse yells for help and quickly Which action should the nurse take first? - -
assesses the client, noting that the client is not 1Using long-handled forceps to place the implant
breathing and does not have a pulse. The nurse in a lead container.
initiates cardiopulmonary resuscitation (CPR)
immediately, and the restaurant manager rushes
to the scene with an automatic external A client who experienced a brain attack (stroke)
defibrillator (AED). What should the nurse do exhibits right-sided unilateral neglect. The nurse
next? - - 1Use the AED. caring for this client plans to place the client's
personal care items: - - 1Within the client's
reach on the right side.
A client with cancer of the larynx is receiving
external radiation therapy of the neck. Which
side effect related specifically to the site of A client who is recovering from a brain attack
2/9
