Fundamental Saunders 206 | Latest Summer 2020 Complete Test Bank Solutions|Rationales.

Document Content and Description Below

Fundamental Saunders 206 Question 1 of 577 The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the... discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior? 1. Reflecting a cultural value 2. An acceptance of the treatment 3. Client agreement to the required procedures 4. Client understanding of the preoperative procedures Question 2 of 577 When communicating with a client who speaks a different language, which best practice should the nurse implement? 1. Speak loudly and slowly. 2. Arrange for an interpreter to translate. 3. Speak to the client and family together. 4. Stand close to the client and speak loudly. Question 3 of 577 The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to provide an example of the concept of acculturation. The nurse educator should make which most appropriate response? 1. "A group of individuals identifying as a part of the Iroquois tribe among Native Americans." 2. "A person who moves from China to the United States (U.S.) and learns about and adapts to the culture in the U.S." 3. "A group of individuals living in the Azores that identify autonomously but are a part of the larger population of Portugal." 4. "A person who has grown up in the Philippines and chooses to stay there because of the sense of belonging to his or her cultural group." Question 4 of 577 The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action? 1. Continue with the instructions, verifying client understanding. 2. Walk around the client so that the nurse constantly faces the client. 3. Give the client a dietary booklet and return later to continue with the instructions. 4. Tell the client about the importance of the instructions for the maintenance of health care. Question 5 of 577 A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on the client's statements, which actions by the nurse demonstrate cultural sensitivity and spiritual support? Select all that apply. 1. Ensures that a close relative stays with the client 2. Makes a referral for a Catholic priest to visit the client 3. Removes the crucifix from the wall in the client's room 4. Administers the sacrament of the sick to the client if death is imminent 5. Offers to provide a means for praying the rosary if the client wishes 6. Reminds the dietary department that meals served on Fridays during Lent do not contain meat Question 6 of 577 Which clients have a high risk of obesity and diabetes mellitus? Select all that apply. 1. Latino American man 2. Native American man 3. Asian American woman 4. Hispanic American man 5. African American woman Question 7 of 577 The nurse is preparing a plan of care for a client and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made? 1. "I cannot have surgery." 2. "I cannot have any medicine." 3. "I believe the soul lives on after death." 4. "I cannot have any food containing or prepared with blood." group believes that the soul cannot live after death. Jehovah's Witnesses avoid foods prepared with or containing blood. Question 8 of 577 Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet? 1. Pork roast, rice, vegetables, mixed fruit, milk 2. Crab salad on a croissant, vegetables with dip, potato salad, milk 3. Sweet and sour chicken with rice and vegetables, mixed fruit, juice 4. Noodles and cream sauce with shrimp and vegetables, salad, mixed fruit, iced tea Question 9 of 577 An Asian American client is experiencing a fever. The nurse plans care so that the client can self-treat the disorder using which method? 1. Prayer 2. Magnetic therapy 3. Foods considered to be yin 4. Foods considered to be yang culture or the yin and yang theory. Question 10 of 577 Which is the best nursing intervention regarding complementary and alternative medicine? 1. Advising the client about "good" versus "bad" therapies 2. Discouraging the client from using any alternative therapies 3. Educating the client about therapies that he or she is using or is interested in using 4. Identifying herbal remedies that the client should request from the health care provider Question 11 of 577 An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower his blood pressure. The nurse should take which action? 1. Advise the client to read the labels of herbal therapies closely. 2. Tell the client that herbal substances are not safe and should never be used. 3. Encourage the client to discuss the use of an herbal substance with the health care provider (HCP). 4. Tell the client that if he takes the herbal substance he will need to have his blood pressure checked frequently. Question 11 of 577 An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower his blood pressure. The nurse should take which action? 1. Advise the client to read the labels of herbal therapies closely. 2. Tell the client that herbal substances are not safe and should never be used. 3. Encourage the client to discuss the use of an herbal substance with the health care provider (HCP). 4. Tell the client that if he takes the herbal substance he will need to have his blood pressure checked frequently. Question 13 of 577 The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? 1. Reassess the client. 2. Conduct a staff meeting to describe the fall. 3. Document in the nurse's notes that an incident report was completed. 4. Contact the nursing supervisor to update information regarding the fall. Question 14 of 577 The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1. Weight loss and dry skin 2. Flat neck and hand veins and decreased urinary output 3. An increase in blood pressure and increased respirations 4. Weakness and decreased central venous pressure (CVP) Question 15 of 577 The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? 1. Sustained tissue damage 2. Requires nasogastric suction 3. Has a history of Addison's disease 4. Uric acid level of 9.4 mg/dL (559 mmol/L) Question 16 of 577 The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. 1. U waves 2. Absent P waves 3. Inverted T waves 4. Depressed ST segment 5. Widened QRS complex Question 17 of 577 The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. 1. Peas 2. Raisins 3. Potatoes 4. Cantaloupe 5. Cauliflower 6. Strawberries Question 18 of 577 The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply. 1. Peas 2. Nuts 3. Cheese 4. Cauliflower 5. Processed oat cereals Question 19 of 577 The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1. Twitching 2. Hypoactive bowel sounds 3. Negative Trousseau's sign 4. Hypoactive deep tendon reflexes Question 20 of 577 The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply. 1. U waves 2. Widened T wave 3. Prominent U wave 4. Prolonged QT interval 5. Prolonged ST segment Question 21 of 577 The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. 1. ST depression 2. Prominent U wave 3. Tall peaked T waves 4. Prolonged ST segment 5. Widened QRS complexes Question 22 of 577 Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? 1. The client who is taking diuretics 2. The client with hyperaldosteronism 3. The client with Cushing's syndrome 4. The client who is taking corticosteroids Question 23 of 577 The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1. Muscle twitches 2. Decreased urinary output 3. Hyperactive bowel sounds 4. Increased specific gravity of the urine Question 24 of 577 The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level? 1. Malnutrition 2. Renal insufficiency 3. Hypoparathyroidism 4. Tumor lysis syndrome Question 25 of 577 The nurse is reading a health care provider's (HCP's) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion? 1. Urinary output 2. Wound drainage 3. Integumentary output 4. The gastrointestinal tract Question 26 of 577 The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1. A client with an ileostomy 2. A client with heart failure 3. A client on long-term corticosteroid therapy 4. A client receiving frequent wound irrigations Question 27 of 577 The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1. Weight loss and poor skin turgor 2. Lung congestion and increased heart rate 3. Decreased hematocrit and increased urine output 4. Increased respirations and increased blood pressure Question 28 of 577 On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? 1. The client taking diuretics and has tenting of the skin 2. The client with an ileostomy from a recent abdominal surgery 3. The client who requires intermittent gastrointestinal suctioning 4. The client with kidney disease and a 12-year history of diabetes mellitus Question 29 of 577 Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? 1. The client with colitis 2. The client with Cushing's syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn Question 30 of 577 The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2of 30 mm Hg (30 mm Hg), and HCO3– of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated Question 31 of 577 The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Question 32 of 577 A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1. A decreased pH and an increased PaCO2 2. An increased pH and a decreased PaCO2 3. A decreased pH and a decreased HCO3– 4. An increased pH and an increased HCO3– Question 33 of 577 The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg (72 mm Hg), Paco2 = 32 mmHg (32 mm Hg), and HCO3– = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make? 1. The client has acidotic blood. 2. The client is probably overreacting. 3. The client is fluid volume overloaded. 4. The client is probably hyperventilating. Question 34 of 577 The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. 1. Respirations that are shallow 2. Respirations that are increased in rate 3. Respirations that are abnormally slow 4. Respirations that are abnormally deep 5. Respirations that cease for several seconds Question 35 of 577 A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mm Hg), and HCO3– is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? 1. Metabolic acidosis with compensation 2. Respiratory acidosis with compensation 3. Metabolic acidosis without compensation 4. Respiratory acidosis without compensation Question 36 of 577 The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. 1. Nausea 2. Confusion 3. Bradypnea 4. Tachycardia 5. Hyperkalemia 6. Lightheadedness Question 37 of 577 The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? 1. pH 7.25, Paco2 50 mm Hg (50 mm Hg) 2. pH 7.35, Paco2 40 mm Hg (40 mm Hg) 3. pH 7.50, Paco2 52 mm Hg (52 mm Hg) 4. pH 7.52, Paco2 28 mm Hg (28 mm Hg) Question 38 of 577 The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? 1. Sodium level of 145 mEq/L (145 mmol/L) 2. Potassium level of 3.0 mEq/L (3.0 mmol/L) 3. Magnesium level of 1.3 mEq/L (0.65 mmol/L) 4. Phosphorus level of 3.0 mg/dL (0.97 mmol/L) Question 39 of 577 The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? 1. Respiratory acidosis from inadequate ventilation 2. Respiratory alkalosis from anxiety and hyperventilation 3. Metabolic acidosis from calcium loss due to broken bones 4. Metabolic alkalosis from taking analgesics containing base products Question 40 of 577 A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? 1. "I will be sure to ask my client what his pain level is on a scale of 0 to 10." 2. "I know that I should follow up after giving medication to make sure it is effective." 3. "I know that pain in the older client might manifest as sleep disturbances or depression." 4. "I will be sure to cue in to any indicators that the client may be exaggerating their pain." Question 41 of 577 The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history, and determines it is necessary to contact the health care provider (HCP) if the client is also taking which medications, that are contraindicated for use with ibuprofen? Select all that apply. 1. Warfarin 2. Glimepiride 3. Amlodipine 4. Simvastatin 5. Hydrochlorothiazide Question 42 of 577 The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2°F (36.2°C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next? 1. Document the findings. 2. Attempt to arouse the client. 3. Contact the health care provider (HCP) immediately. 4. Check the medication administration history on the PCA pump. Question 43 of 577 The nurse is completing a time tape for a 1000-mL intravenous (IV) bag that is scheduled to infuse over 8 hours. The nurse has just placed the 1100 marking at the 500-mL level. The nurse would place the mark for 1200 at which numerical level (mL) on the time tape? Fill in the blank. Question 44 of 577 The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride and plans to use an IV infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action? 1. Initiate the IV line without the use of a pump. 2. Contact the electrical maintenance department for assistance. 3. Plug in the pump cord in the available plug above the room sink. 4. Use an extension cord from the nurses' lounge for the pump plug. Question 45 of 577 The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the UAP? 1. Placing a safety knot in the safety device straps 2. Safely securing the safety device straps to the side rails 3. Applying safety device straps that do not tighten when force is applied against them 4. Securing so that 2 fingers can slide easily between the safety device and the client's skin Question 46 of 577 The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply. 1. Bites from ticks or deer flies 2. Inhalation of bacterial spores 3. Through a cut or abrasion in the skin 4. Direct contact with an infected individual 5. Sexual contact with an infected individual 6. Ingestion of contaminated undercooked meat Question 47 of 577 The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan? 1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a lead apron when providing direct care to the client 4. Placing the client in a semiprivate room at the end of the hallway Question 48 of 577 Contact precautions are initiated for a client with a health care–associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? 1. Gloves and gown 2. Gloves and goggles 3. Gloves, gown, and shoe protectors 4. Gloves, gown, goggles, and a mask or face shield Question 49 of 577 The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? 1. Call for help. 2. Extinguish the fire. 3. Activate the fire alarm. 4. Confine the fire by closing the room door. Question 50 of 577 A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action? 1. Induce vomiting. 2. Call an ambulance. 3. Call the Poison Control Center. 4. Bring the child to the emergency department. . Question 51 of 577 The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action? 1. Prepare the triage rooms. 2. Activate the emergency response plan. 3. Obtain additional supplies from the central supply department. 4. Obtain additional nursing staff to assist in treating the casualties. Question 52 of 577 The nurse is caring for a client with meningitis and implements which transmission-based precautions for this client? 1. Private room or cohort client 2. Personal respiratory protection device 3. Private room with negative airflow pressure 4. Mask worn by staff when the client needs to leave the room Question 53 of 577 The nurse working in the emergency department (ED) is assessing a client who recently returned from Liberia and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next? 1. Check the client's temperature. 2. Contact the health care provider. 3. Isolate the client in a private room. 4. Check a complete set of vital signs. Question 54 of 577 A health care provider's prescription reads 1000 mL of normal saline (NS) to infuse over 12 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. 1000 mL × 15 gtt 15,000 –––––––––––––––– = –––––– = 20.8 gtt/min 720 minutes 720 = 21 gtt/min Question 55 of 577 A health care provider's prescription reads to administer an intravenous (IV) dose of 400,000 units of penicillin G benzathine. The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine, 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Fill in the blank. Record your answer using 1 decimal place. 400,000 units × 1 mL –––––––––––––––––––– = mL/dose 300,000 units 400,000 units ––––––––––––– = 1.33 = 1.3 mL 300,000 units Question 56 of 577 A health care provider's prescription reads potassium chloride 30 mEq to be added to 1000 mL normal saline (NS) and to be administered over a 10-hour period. The label on the medication bottle reads 40 mEq/20 mL. The nurse prepares how many milliliters of potassium chloride to administer the correct dose of medication? Fill in the blank. 30 mEq × 20 mL –––––––––––––– = 15 mL 40 mEq Question 57 of 577 A health care provider's prescription reads clindamycin phosphate 0.3 g in 50 mL normal saline (NS) to be administered intravenously over 30 minutes. The medication label reads clindamycin phosphate 900 mg in 6 mL. The nurse prepares how many milliliters of the medication to administer the correct dose? Fill in the blank. 300 mg × 6 mL ––––––––––––– 900 mg 300 mg × 6 mL = –––––––––––––– = 2 mL 900 mg Question 58 of 577 A health care provider's prescription reads phenytoin 0.2 g orally twice daily. The medication label states that each capsule is 100 mg. The nurse prepares how many capsule(s) to administer 1 dose? Fill in the blank. 200 mg × 1 Capsule –––––––––––––––––– = 2 Capsules 100 mg Question 59 of 577 A health care provider prescribes 1000 mL of normal saline 0.9% to infuse over 8 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. 1000 mL × 15 gtt 15,000 –––––––––––––––– = –––––– = 31.2 gtt/min 480 minutes 480 = 31 gtt/min Question 60 of 577 A health care provider prescribes heparin sodium, 1300 units/hour by continuous intravenous (IV) infusion. The pharmacy prepares the medication and delivers an IV bag labeled heparin sodium 20,000 units/250 mL D5W. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 1300 units/hour? Fill in the blank. Record your answer to the nearest whole number. 20,000 units –––––––––––– = 80 units/mL 250 mL 1300 units ––––––––––– = 16.25 mL/hr 80 units/mL = 16 mL/hr Question 61 of 577 A health care provider prescribes 3000 mL of D5W to be administered over a 24-hour period. The nurse determines that how many milliliters per hour will be administered to the client? Fill in the blank. 3000 mL –––––––– = 125 mL/hr 24 hours Question 62 of 577 Gentamicin sulfate, 80 mg in 100 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 10 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. 100 mL × 10 gtt 1000 ––––––––––––––– = –––– = 33.3 gtt/min 30 minutes 30 = 33 gtt/min Question 63 of 577 A health care provider's prescription reads levothyroxine, 150 mcg orally daily. The medication label reads levothyroxine, 0.1 mg/tablet. The nurse administers how many tablet(s) to the client? Fill in the blank. 0.15 mg ––––––– × 1 tablet = 1.5 tablets 0.1 mg Question 64 of 577 Cefuroxime sodium, 1 g in 50 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 15 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. 50 mL × 15 gtt 750 –––––––––––––– = ––– = 25 gtt/min 30 minutes 30 Question 65 of 577 A health care provider prescribes 1000 mL D5W to infuse at a rate of 125 mL/hour. The nurse determines that it will take how many hours for 1 L to infuse? Fill in the blank. 1000 mL ––––––– = 8 hours 125 mL Question 66 of 577 A health care provider prescribes 1 unit of packed red blood cells to infuse over 4 hours. The unit of blood contains 250 mL. The drop factor is 10 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. 250 mL × 10 gtt 2500 ––––––––––––––– = –––– = 10.4 gtt/min 240 minutes 240 = 10 gtt/min Question 67 of 577 A health care provider's prescription reads morphine sulfate, 8 mg stat. The medication ampule reads morphine sulfate, 10 mg/mL. The nurse prepares how many milliliters to administer the correct dose? Fill in the blank. 8 mg × 1 mL ––––––––––– = 0.8 mL 10 mg Question 68 of 577 A health care provider prescribes regular insulin, 8 units/hour by continuous intravenous (IV) infusion. The pharmacy prepares the medication and then delivers an IV bag labeled 100 units of regular insulin in 100 mL normal saline (NS). An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 8 units/hour? Fill in the blank. 100 units ––––––––– = 1 units/mL 100 mL 8 units –––––––––– = 8 mL/hr 1 units/mL Question 69 of 577 The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? 1. Urinary output of 20 mL/hour 2. Temperature of 37.6°C (99.6°F) 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing . Question 70 of 577 The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? 1. "Use of an incentive spirometer will help prevent pneumonia." 2. "Close monitoring of your oxygen saturation will detect hypoxemia." 3. "Administration of intravenous fluids will prevent or treat fluid imbalance." 4. "Early ambulation and administration of blood thinners will prevent pulmonary embolism." Question 71 of 577 The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash. 2. Verify that the client has not eaten for the last 24 hours. 3. Have the client void immediately before going into surgery. 4. Report immediately any slight increase in blood pressure or pulse. Question 72 of 577 A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? 1. Obtain a court order for the surgery. 2. Have the charge nurse sign the informed consent immediately. 3. Send the client to surgery without the consent form being signed. 4. Obtain a telephone consent from a family member, following agency policy. Question 73 of 577 A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery." 2. "I will be happy to explain the entire surgical procedure to you." 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate." Question 74 of 577 The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? 1. Inhale as rapidly as possible. 2. Keep a loose seal between the lips and the mouthpiece. 3. After maximum inspiration, hold the breath for 15 seconds and exhale. 4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees. Question 75 of 577 The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? 1. "Aspirin can cause bleeding after surgery." 2. "Aspirin can cause my ability to clot blood to be abnormal." 3. "I need to continue to take the aspirin until the day of surgery." 4. "I need to check with my health care provider about the need to stop the aspirin before the scheduled surgery." Question 76 of 577 The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin Question 77 of 577 The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? 1. Increasing restlessness 2. A pulse of 86 beats/minute 3. Blood pressure of 110/70 mm Hg 4. Hypoactive bowel sounds in all 4 quadrants Question 78 of 577 A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply. 1. Contact the surgeon. 2. Instruct the client to remain quiet. 3. Prepare the client for wound closure. 4. Document the findings and actions taken. 5. Place a sterile saline dressing and ice packs over the wound. 6. Place the client in a supine position without a pillow under the head. Question 79 of 577 A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. Hemoglobin, 8.0 g/dL (80 mmol/L) 2. Sodium, 145 mEq/L (145 mmol/L) 3. Serum creatinine, 0.8 mg/dL (70.6 mmol/L) 4. Platelets, 210,000 mm3 (210 × 109/L) Question 80 of 577 The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway. 2. Check tubes or drains for patency. 3. Check the dressing to assess for bleeding. 4. Assess the vital signs to compare with preoperative measurements. Question 81 of 577 The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine 4. Conjugated estrogen Question 82 of 577 The nurse is caring for a client following a craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Click on the image to indicate your answer. Question 83 of 577 The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? 1. Out-of-bed activities as desired 2. Bed rest with the affected extremity kept flat 3. Bed rest with elevation of the affected extremity 4. Bed rest with the affected extremity in a dependent position Question 84 of 577 The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client? 1. Side-lying on the operative side 2. On the nonoperative side with the legs abducted 3. Side-lying with the affected leg internally rotated 4. Side-lying with the affected leg externally rotated Question 85 of 577 The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? 1. "I should sleep on my left side." 2. "I should sleep on my right side." 3. "I should sleep with my head flat." 4. "I should not wear my glasses at any time." Question 86 of 577 A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position? 1. Prone 2. Reverse Trendelenburg's 3. Supine, with the residual limb flat on the bed 4. Supine, with the residual limb supported with pillows Question 87 of 577 The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? 1. Maintain the client in a prone position. 2. Elevate and immobilize the grafted extremity. 3. Maintain the grafted extremity in a flat position. 4. Keep the grafted extremity covered with a blanket. Question 88 of 577 The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35. Based on this information, which action should the nurse take at this time? 1. Retest the pH using another strip. 2. Document that the nasogastric tube is in the correct place. 3. Check for placement by auscultating for air injected into the tube. 4. Call the health care provider to request a prescription for a chest radiograph. Question 89 of 577 The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take? 1. Hold the feeding and reinstill the residual amount. 2. Reinstill the amount and continue with administering the feeding. 3. Elevate the client's head at least 45 degrees and administer the feeding. 4. Discard the residual amount and proceed with administering the feeding. Question 90 of 577 The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first? 1. Check for medication interactions. 2. Determine whether there are medication duplications. 3. Call the prescribing health care provider (HCP) and report polypharmacy. 4. Determine whether a family member supervises medication administration. Question 91 of 577 The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instruction? 1. "I should cuddle my child after giving the medication." 2. "I can give my child a frozen juice bar after he swallows the medication." 3. "I should mix the medication in the baby food and give it when I feed my child." 4. "If my child does not like the taste of the medicine, I should encourage him to pinch his nose and drink the medication through a straw." Question 92 of 577 A health care provider's prescription reads "ampicillin sodium 125 mg IV every 6 hours." The medication label reads "when reconstituted with 7.4 mL of bacteriostatic water, the final concentration is 1 g/7.4 mL." The nurse prepares to draw up how many milliliters to administer 1 dose? 125 mg ––––––– × 7.4 mL = 0.925 mL 1000 mg 1. 1.1 mL 2. 0.54 mL 3. 7.425 mL 4. 0.925 mL Question 93 of 577 A pediatric client with ventricular septal defect repair is placed on a maintenance dosage of digoxin. The dosage is 8 mcg/kg/day, and the client's weight is 7.2 kg. The health care provider (HCP) prescribes the digoxin to be given twice daily. The nurse prepares how many mcg of digoxin to administer to the client at each dose? 1. 12.6 mcg 2. 21.4 mcg 3. 28.8 mcg 4. 32.2 mcg Question 94 of 577 Sulfisoxazole, 1 g orally twice daily, is prescribed for an adolescent with a urinary tract infection. The medication label reads "500-mg tablets." The nurse has determined that the dosage prescribed is safe. The nurse administers how many tablets per dose to the adolescent? 1000 mg ––––––– = 2 tablets 500 mg 1. 1⁄2 tablet 2. 1 tablet 3. 2 tablets 4. 3 tablets Question 95 of 577 Penicillin G procaine, 1,000,000 units IM (intramuscularly), is prescribed for a child with an infection. The medication label reads "1,200,000 units per 2 mL." The nurse has determined that the dose prescribed is safe. The nurse administers how many milliliters per dose to the child? 1,000,000 ––––––––– × 2 mL = 1.7 mL per dose 1,200,000 1. 0.8 mL 2. 1.2 mL 3. 1.4 mL 4. 1.7 mL Question 96 of 577 The nurse prepares to administer an intramuscular injection to a 4-month-old infant. The nurse selects which best site to administer the injection? 1. Ventrogluteal 2. Lateral deltoid 3. Rectus femoris 4. Vastus lateralis Question 97 of 577 Atropine sulfate, 0.6 mg intramuscularly, is prescribed for a child preoperatively. The nurse has determined that the dose prescribed is safe and prepares to administer how many milliliters to the child? Fill in the blank (refer to figure). 0.6 mg –––––– × 1 mL = 1.5 mL 0.4 mg Question 98 of 577 When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply. Question 99 of 577 While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action? Question 100 of 577 The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy? 1. Restrict all visitors. 2. Restrict fluid intake. 3. Teach the client and family about the need for hand hygiene. 4. Insert an indwelling urinary catheter to prevent skin breakdown. Question 101 of 577 The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment? 1. The client's pain rating 2. Nonverbal cues from the client 3. The nurse's impression of the client's pain 4. Pain relief after appropriate nursing intervention Question 102 of 577 The nurse is caring for a client who is postoperative following a pelvic exenteration and the health care provider changes the client's diet from NPO (nothing by mouth) status to clear liquids. The nurse should check which priorityitem before administering the diet? 1. Bowel sounds 2. Ability to ambulate 3. Incision appearance 4. Urine specific gravity Question 103 of 577 A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action? 1. Measure abdominal girth. 2. Irrigate the nasogastric tube. 3. Continue to monitor the drainage. 4. Notify the health care provider (HCP). Question 104 of 577 The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function? 1. The passage of flatus 2. Absent bowel sounds 3. The client's ability to tolerate food 4. Bloody drainage from the colostomy Question 105 of 577 The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted? 1. A clotting time of 10 minutes 2. An ammonia level of 10 mcg/dL (6 mcmol/L) 3. A platelet count of 50,000 mm3 (50 × 109/L) 4. A white blood cell count of 5000 mm3 (5.0 × 109/L) Question 106 of 577 The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care? 1. Surgical mask and gloves 2. Particulate respirator, gown, and gloves 3. Particulate respirator and protective eyewear 4. Surgical mask, gown, and protective eyewear Question 107 of 577 The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? 1. Wearing gloves 2. Wearing a gown and gloves 3. Wearing a gown, gloves, and a mask 4. Wearing a gown and gloves to change the bed linens, and gloves only for the bath Question 108 of 577 The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the Scouts about the methods to prevent Lyme disease. Which statement by one of the Scouts indicates a need for further instruction? 1. "I need to bring a hat to wear during the trip." 2. "I should wear long-sleeved tops and long pants." 3. "I should not use insect repellents because it will attract the ticks." 4. "I need to wear closed shoes and socks that can be pulled up over my pants." Question 109 of 577 The nurse is providing care to a Puerto Rican–American client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is the most appropriate nursing action for this client? 1. Restrict the number of family members visiting at one time. 2. Inform the family that emotional outbursts are to be avoided. 3. Make the necessary arrangements so that family members can visit. 4. Contact the health care provider to speak to the family regarding their behaviors. Question 110 of 577 The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27 mEq/L (27 mmol/L). The nurse interprets that the client has which acid-base disturbance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Question 111 of 577 What action should the nurse consider when counseling a client of the Amish tradition? 1. Speak only to the husband. 2. Use complex medical terminology. 3. Avoid using scientific or medical jargon. 4. Stand close to the client and speak loudly. Question 112 of 577 The health care provider's prescription reads 150 mcg of a medication orally daily. The medication label reads 0.1 mg per tablet. The nurse should administer how many tablet(s) to the client? Fill in the blank. 0.15 mg –––––––– × 1 tablet = 1.5 tablet 0.1 mg Question 113 of 577 A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1. Bradycardia and hyperactivity 2. Decreased respiratory rate and depth 3. Headache, restlessness, and confusion 4. Bradypnea, dizziness, and paresthesias Question 114 of 577 The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction? 1. "The enema will be given while I am sitting on the toilet." 2. "I should try and hold the fluid as long as possible after it is instilled." 3. "I know that there will be some cramping after the enema administration." 4. "I should tell the nurse if cramping occurs during the instillation of the fluid." Question 115 of 577 The health care provider prescribes 2000 mL of 5% dextrose and half-normal saline to infuse over 24 hours. The drop factor is 15 drops (gtt)/mL. The nurse should set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. 2000 mL × 15 gtt 30,000 –––––––––––––– = –––––– = 20.83 gtt/min 1440 minutes 1440 = 21 gtt/min (rounded) Question 116 of 577 A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor should the nurse include when responding to the client? 1. Five blood cultures are negative. 2. Three sputum cultures are negative. 3. A blood culture and a chest x-ray are negative. 4. A sputum culture and a tuberculin skin test are negative. reliable determinants of a noninfectious status. Question 117 of 577 The health care provider prescribes erythromycin suspension 800 mg by mouth. After reconstitution, how many milliliters should the nurse pour into the medicine cup to deliver the prescribed dose? Refer to figure. Fill in the blank. 800 mg –––––––– × 5 mL = 20 mL 200 mg Question 118 of 577 A client states to the home health nurse that she has not had a bowel movement since coming home from the hospital after surgery 4 days ago. The nurse instructs the client to follow which diet at this time? 1. High-fiber diet 2. Full liquid diet 3. Low-fiber diet 4. Low-sodium diet in the diet has little, if any, effect on constipation. Question 119 of 577 The nurse is preparing to administer a soapsuds enema to a preoperative client. In which position should the nurse place the client to administer the enema? Click on the image to indicate your answer. Question 120 of 577 A cold, moist compress is prescribed to be applied to the client's right knee. Which should the nurse plan for? 1. Leave the compress on for 45 minutes. 2. Ensure that the compress material is sterile. 3. Ensure that the temperature of the compress is 15°C (59°F). 4. Expect some bluish discoloration of the skin during the application period. Question 121 of 577 Before enema administration, the nurse positions the client in a left lateral position. What is the rationale for using this position? 1. It is more comfortable. 2. It facilitates the passage of stool. 3. It prevents a vasovagal response from occurring. 4. It facilitates instillation of the enema solution into the colon. Question 122 of 577 The client has a prescription for administering an enema. After preparing the equipment and solution, the nurse should assist the client into which position? 1. Left-sided lateral Sims' position 2. Right-sided lateral Sims' position 3. Left side-lying, with the head of the bed elevated 45 degrees 4. Right side-lying, with the head of the bed elevated 45 degrees Question 123 of 577 The nurse is inserting an indwelling urinary catheter. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What should the nurse do next? 1. Immediately twist the catheter, and then slowly inflate the balloon. 2. Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon. 3. Insert the catheter until resistance is met, and then inflate the balloon. 4. Withdraw the catheter approximately 1 inch (2.5 cm), and then inflate the balloon. Question 124 of 577 The client complains of pain as the nurse is inflating the balloon during insertion of a Foley catheter. The nurse should take which immediate action? 1. Withdraw the catheter slightly and reinflate the balloon. 2. Remove the catheter, and reinsert a new one that is 1 size smaller. 3. Finish inflating the balloon; the discomfort is normal and temporary. 4. Aspirate the fluid, advance the catheter farther, and reinflate the balloon. Question 125 of 577 The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply. 1. Bounding pulse 2. Difficulty breathing 3. Increased urine output 4. Presence of dependent edema 5. Neck vein distention in the upright position Question 126 of 577 The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note? 1. Bradycardia 2. Elevated blood pressure 3. Changes in mental status 4. Bilateral crackles in the lungs Question 127 of 102 A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action? 1. Increase fluid intake. 2. Resume full activity level. 3. Stay in a cool environment when possible. 4. Monitor voiding for adequacy of urine output. Question 128 of 102 The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator? 1. Daily weight 2. Urinary output 3. IV fluid intake 4. NG tube intake Question 129of 102 The nurse is reviewing the laboratory results for a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 5 mEq/L (2.5 mmol/L). On the basis of this laboratory result, the nurse should expect to note which in the client? 1. Tremors 2. Hyperactive reflexes 3. Respiratory depression 4. No specific signs or symptoms because this value is a normal level Question 130 of 102 A registered nurse (RN) has instructed an unlicensed assistive personnel (UAP) to administer soapsuds enemas until clear to a client. The UAP reports that three enemas have been administered and the client is still passing brown, liquid stool. What should the RN instruct the UAP to do? 1. Administer a Fleet enema. 2. Administer an oil retention enema. 3. Wait 30 minutes and then administer another enema. 4. Stop administering the enemas until the health care provider (HCP) is notified. Question 131 of 102 The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? Select all that apply. 1. Ensure adequate oxygenation. 2. Provide assistance to prevent falls. 3. Monitor medication administration of diuretics. 4. Monitor for numbness and tingling around the mouth. 5. Prevent complications during potassium administration. Question 132 of 102 A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present? 1. Confusion 2. Muscle weakness 3. Mental status changes 4. Depressed deep tendon reflexes Question 133 of 102 The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment? 1. Urine pH of 6 2. Urine that is pale yellow 3. Urine output of 40 mL/hr 4. Urine specific gravity of 1.032 Question 134 of 102 The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed? 1. Heparin 2. Platelets 3. Antibiotic 4. Clotting factors Question 135 of 102 A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply. 1. Blood transfusions 2. Metabolic alkalosis 3. Bleeding or hemorrhage 4. Decreased sodium excretion 5. Ingestion of potassium in medications 6. Failure to restrict dietary potassium Question 136 of 102 A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply. 1. Dehydration 2. Hypertension 3. Physiological stress 4. Decreased blood volume 5. Decreased plasma osmolarity Question 136 of 102 The nurse is administering a dose of triamterene to an assigned client. What is the mostsignificant adverse effect of this medication for which the client should be monitored? 1. Edema 2. Bradycardia 3. Hypertension 4. Hyperkalemia Question 137 of 102 The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.0 mEq/L (0.5 mmol/L). Which would be the most appropriate nursing action for this client? 1. Monitor the client for dysrhythmias. 2. Encourage increased intake of phosphate antacids. 3. Discontinue any magnesium-containing medications. 4. Encourage intake of foods such as ground beef, eggs, or chicken breast. Question 138 of 102 A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed? 1. Weighs athletes before, during, and after football practice 2. Asks the athletes to take a salt tablet before football practice 3. Schedules fluid breaks every 30 minutes throughout practice 4. Tells the athletes to drink 16 oz (475 mL) of fluid per pound lost during practice Question 139 of 102 The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate? 1. Pour the aspirate into the NG tube through a syringe with the plunger removed. 2. Dilute with water and inject into the NG tube by putting pressure on the plunger. 3. Discard properly and record as output on the client's intake and output (I&O) record. 4. Mix with the formula and pour into the NG tube through a syringe with the plunger removed. Question 140 of 102 The nurse is calculating a client's fluid intake for a 24-hour period. The client is on hemodialysis and urinates about 100 mL a day. The client is on a fluid restriction of 750 mL per day. The client drank 4 oz of tea and 4 oz of orange juice for breakfast, 4 oz of water at 1200 and at 1700 when taking his medications, and 4 oz of iced tea at lunch and supper. At 0800 and again at 1400, the client received his intravenous antibiotics in 50 mL of normal saline. How many mL of fluid does the client have left to drink for the day? Fill in the blank. Question 141 of 102 The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding should the nurse most likelyexpect to note in the client based on this magnesium level? 1. Tetany 2. Twitches 3. Positive Trousseau sign 4. Loss of deep tendon reflexes Question 142 of 102 Which clients are most likely to be at risk for the development of third spacing? Select all that apply. 1. The client with cirrhosis 2. The client with liver failure 3. The client with diabetes mellitus 4. The client with a minor burn injury 5. The client with chronic kidney disease Question 143 of 102 The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of alcoholic cirrhosis. What action should the nurse take first? 1. Hang the solution. 2. Contact the health care provider (HCP). 3. Check the client's daily laboratory results. 4. Ask the client if any liver study tests have ever been done. Question 144 of 102 The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic? Select all that apply. 1. 10% dextrose in water 2. 0.45% sodium chloride 3. 5% dextrose in 0.9% saline 4. 5% dextrose in 0.45% saline 5. 5% dextrose in 0.225% saline 6. 5% dextrose in lactated Ringer's solution Question 145 of 102 The nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte result indicates a potassium level of 4.5 mEq/L (4.5 mmol/L) and a sodium level of 132 mEq/L (132 mmol/L). Based on these laboratory findings, the nurse should select which solution to use for the nasogastric tube irrigation? 1. Tap water 2. Sterile water 3. Distilled water 4. Sodium chloride Question 146 of 102 The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level? 1. Prolonged bed rest 2. Renal insufficiency 3. Hyperparathyroidism 4. Excessive ingestion of vitamin D Question 147 of 102 The nurse who is caring for a client with severe malnutrition reviews the laboratory results and notes that the client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which electrocardiographic change should the nurse expect to observe based on the client's magnesium level? 1. Prominent U waves 2. Prolonged PR interval 3. Depressed ST segment 4. Widened QRS complexes Question 148 of 102 During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What should the nurse do next? 1. Document this assessment finding. 2. Call another nurse to verify this finding. 3. Check skin turgor over the client's sternum. 4. Call the health care provider (HCP) to obtain a prescription for fluid replacement. Question 149 of 102 During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? 1. Dehydration 2. Hypokalemia 3. Fluid overload 4. Hypernatremia Question 150 of 102 The nurse is creating a plan of care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply. 1. Ensure adequate fluid intake. 2. Implement safety measures to prevent falls. 3. Encourage low-fiber foods to prevent diarrhea. 4. Instruct the client about foods that contain potassium. 5. Encourage the client to obtain assistance to ambulate. Question 151 of 102 A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data and then checks the client's skin turgor by taking which action? Click on the Question Video button to view a video showing preparation procedures. 1. Pinching the skin on the thigh 2. Pushing on the skin in the ankle area 3. Assessing the skin in the radial pulse area 4. Pulling up and releasing the skin on the sternal area Question 152 of 102 The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of prominent U waves. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value? 1. Sodium 135 mEq/L (135 mmol/L) 2. Sodium 140 mEq/L (140 mmol/L) 3. Potassium 3.0 mEq/L (3.0 mmol/L) 4. Potassium 5.0 mEq/L (5.0 mmol/L) the electrocardiographic (ECG) changes that occur include inverted T waves, ST segment depression, heart block, and prominent U waves. Question 153 of 102 The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note? 1. Hypotension 2. Increased heart rate 3. Bounding peripheral pulses 4. Shortened QT interval on electrocardiography (ECG) Question 154 of 102 The nurse notes that a client's total serum calcium level is 6.0 mg/dL (1.5 mmol/L). Which assessment findings should be anticipated in this client? Select all that apply. 1. Tetany 2. Constipation 3. Renal calculi 4. Hypotension 5. Prolonged QT interval 6. Positive Chvostek's sign Question 155 of 102 The nurse is assisting in the care of a group of clients on the nursing unit. When considering the effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third spacing of fluid? 1. Client with a major burn 2. Client with an ischemic stroke 3. Client with Laënnec's cirrhosis 4. Client with chronic kidney disease Question 156 of 102 The nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit? 1. Client in heart failure 2. Client in acute kidney injury 3. Client with diabetes insipidus 4. Client with controlled hypertension Question 157 of 102 The nurse is obtaining the intershift report for a group of assigned clients. Which assigned client should the nurse monitor closely for signs of hyperkalemia? 1. A client with ulcerative colitis 2. A client with Cushing's syndrome 3. A client admitted 6 hours ago with a 40% burn injury 4. A client who has a history of long-term laxative abuse Question 158 of 102 The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NG tube? 1. Tap water 2. Sterile water 3. 0.9% sodium chloride 4. 0.45% sodium chloride Question 159 of 102 The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited? 1. Tetany 2. Tremors 3. Areflexia 4. Muscular excitability Question 160 of 102 The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit who is receiving nasal oxygen and notes a pH of 7.38 (7.38), Paco2 of 38 mm Hg (38 mm Hg), Pao2 of 86 mm Hg (86 mm Hg), and HCO3 of 23 mEq/L (23 mmol/L). What action should the nurse take in response to these results? 1. Discontinue the oxygen. 2. Continue monitoring the client. 3. Call 911 to have the client intubated immediately. 4. Have another set drawn because these results are not possible. Question 161 of 102 A client's blood gas results reveal acidosis. What are some signs and symptoms the nurse would expect to see? Select all that apply. Question 162 of 102 The nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31 (7.31), Paco2 is 50 mm Hg (50 mm Hg), and the bicarbonate (HCO3) level is 26 mEq/L (26 mmol/L). The nurse concludes that which acid-base disturbance is present in this client? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Question 163 of 102 Arterial blood gas analysis yields the following results: pH 7.48 (7.48), Paco2 32 mm Hg (32 mm Hg), Pao2 94 mm Hg (94 mm Hg), HCO3 level 24 mEq/L (24 mmol/L) for a client seen in the health care clinic. The nurse interprets that the client has which acid-base disturbance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Question 164 of 102 The nurse is caring for a client whose arterial blood gas results reveal alkalosis. What client reactions would the nurse expect to see? Select all that apply. Question 165 of 102 An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? Question 166 of 102 The nurse is performing a change-of-shift assessment on a client. The client had an arterial blood gas specimen drawn during an admission workup on the previous day and has a hematoma at the puncture site. What is the priority nursing intervention? 1. Perform the Allen's test. 2. Apply a warm compress. 3. Administer the antidote for heparin. 4. Notify the hospital laboratory supervisor. Question 167 of 102 A client has a prescription for a set of arterial blood gas (ABG) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse should take which action? 1. Remove the nasal cannula for 15 minutes; then have the ABG samples drawn. 2. Change the nasal cannula to a shovel face mask; then have the ABG samples drawn. 3. Leave the nasal cannula in place for 15 minutes; then have the ABG samples drawn. 4. Change the nasal cannula to a Venturi face mask; then have the ABG samples drawn. Question 168 of 102 A client experiencing metabolic acidosis is to be admitted to the nursing unit. The nurse plans care knowing that what reaction is the most powerful regulator of acid-base balance? 1. Buffer 2. Kidney 3. Cations 4. Respiratory Question 169 of 102 The nurse is caring for a client with metabolic alkalosis. The nurse plans care knowing that most problems of metabolic alkalosis are related to increased stimulation of what systems? Select all that apply. 1. Buffer 2. Cardiac 3. Nervous 4. Chemical 5. Respiratory 6. Neuromuscular Question 170 of 102 The nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse plans interventions knowing that as the client's CO2 level rises, what will occur with the blood pH? 1. Fall 2. Rise 3. Double 4. Remain unchanged Question 171 of 102 The nurse is planning to obtain blood for arterial blood gas analysis from a client with chronic obstructive pulmonary disease. The nurse should plan time for which activity after the arterial blood specimen is drawn? 1. Holding a warm compress over the puncture site for 5 minutes 2. Encouraging the client to open and close the hand rapidly for 2 minutes 3. Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes 4. Having the client keep the radial pulse puncture site in a dependent position for 5 minutes Question 172 of 102 A client with diabetes mellitus has a blood glucose level of 644 mg/dL (35.7 mmol/L). The nurse plans care knowing that the client is at risk for the development of which type of acid-base imbalance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Question 173 of 102 A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse should plan to carry out which prescribed measure as the most effective means to treat the problem? 1. Administer prescribed antibiotics. 2. Have the client breathe into a paper bag. 3. Administer antipyretics as needed (on prn basis). 4. Request a prescription for a partial rebreather oxygen mask. Question 174 of 102 The nurse is caring for a client with chronic kidney disease. Arterial blood gas results indicate a pH of 7.30 (7.30), a Paco2 of 32 mm Hg (32 mm Hg), and a bicarbonate concentration of 20 mEq/L (20 mmol/L). Which laboratory value should the nurse expect to note? 1. Sodium level of 145 mEq/L (145 mmol/L) 2. Potassium level of 5.2 mEq/L (5.2 mmol/L) 3. Phosphorus level of 3.0 mg/dL (0.97 mmol/L) 4. Magnesium level of 1.3 mg/dL (0.53 mmol/L) Question 175 of 102 The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Question 176 of 102 The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30 (7.30), a Paco2 of 58 mm Hg (58 mm Hg), a Pao2 of 80 mm Hg (80 mm Hg), and an HCO3 of 26 mEq/L (26 mmol/L). The nurse should interpret this to mean that the client has which acid-base disturbance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Question 177 of 102 The client with a history of lung disease is at risk for developing respiratory acidosis. The nurse asks this client about which symptoms that are characteristic of this disorder? 1. "Do you have shallow breathing?" 2. "Do you feel like you have a lot of energy?" 3. "Do you have a headache or become confused?" 4. "Do you feel dizzy or have tingling sensations?" Question 178 of 102 The nurse is caring for a client with respiratory failure related to Guillain-Barré syndrome. The nurse plans care knowing that what other extrapulmonary causes can lead to respiratory failure? Select all that apply. 1. Stroke 2. Pneumonia 3. Sleep apnea 4. Myasthenia gravis 5. Obstructive lung disease 6. Opioid analgesics, sedatives, anesthetics Question 179 of 102 A client is admitted to the hospital 24 hours following an aspirin (acetylsalicylic acid) overdose. The nurse assesses this client for which signs/symptoms indicating the acid-base disturbance that could occur in the client? 1. Bradypnea, dizziness, and paresthesias 2. Headache, nausea, vomiting, and diarrhea 3. Bradycardia, listlessness, and hyperactivity 4. Restlessness, confusion, and a positive Trousseau's sign Question 180 of 102 The nurse reviews a client's arterial blood gas values and notes a pH of 7.50 (7.50), a Paco2 of 30 mm Hg (30 mm Hg), and an HCO3 of 25 mEq/L (25 mmol/L). The nurse should interpret these values as an indication of which condition? 1. Metabolic acidosis, uncompensated 2. Respiratory acidosis, uncompensated 3. Respiratory alkalosis, uncompensated 4. Metabolic acidosis, partially compensated Question 181 of 102 The nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen test on the client. The nurse would perform the steps in which order to conduct an Allen test? Arrange the actions in the order that they should be performed. All options must be used. Explain the procedure to the client. 1 Explain the procedure to the client. Apply pressure over the ulnar and radial arteries. 2 Apply pressure over the ulnar and radial arteries. Ask the client to open and close the hand repeatedly. 3 Ask the client to open and close the hand repeatedly. Release pressure from the ulnar artery. 4 Release pressure from the ulnar artery. Assess the color of the extremity distal to the pressure point. 5 Assess the color of the extremity distal to the pressure point. Document the findings. 6 Document the findings. Question 182 of 102 A client is about to have arterial blood gases drawn, and the nurse explains what an Allen's test is. What comment shows that the client understands the nurse's explanation? 1. "Blood is drawn from the ulnar artery." 2. "I know I have to lie down while blood is drawn." 3. "This test is done to ensure adequate collateral circulation." 4. "Direct pressure has to be placed over the site for 15 minutes after blood is drawn." 4 are incorrect. Question 183 of 102 The nurse is caring for a client with diabetic ketoacidosis whose respirations are abnormally deep, regular, and increased in rate. What is the purpose of this type of respiration? Select all that apply. 1. Correct bradypnea 2. Blow off carbon dioxide 3. Correct metabolic acidosis 4. Correct an acid-base imbalance 5. Cause respiratory compensation 6. Stimulate Cheyne-Stokes respirations Question 184 of 102 The nurse reviews a client's arterial blood gas results and notes that the pH is 7.30 (7.30), the Paco2 is 52 mm Hg (50 mm Hg), and the HCO3 is 22 mEq/L (22 mmol/L). The nurse interprets these results as indicating which condition? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated . Question 185 of 102 A client with diabetes mellitus is most likely to experience which type of acid-base imbalance as a complication of the disorder? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Question 186 of 102 The nurse is admitting to the hospital a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe enough, the client will be at risk for which acid-base imbalance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Question 187 of 102 A client is determined by blood gas analysis to be in respiratory alkalosis. Which electrolyte disorder should the nurse monitor for that could accompany the acid-base imbalance? 1. Hypokalemia 2. Hypercalcemia 3. Hypochloremia 4. Hypernatremia Question 188 of 102 A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client's respiratory status should avoid which action? 1. Keeping the head of the bed elevated 2. Monitoring the flow rate of supplemental oxygen 3. Assisting the client to turn, cough, and breathe deeply 4. Encouraging the client to breathe slowly and shallowly Question 189 of 102 A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client's respiratory status should avoid which action? 1. Keeping the head of the bed elevated 2. Monitoring the flow rate of supplemental oxygen 3. Assisting the client to turn, cough, and breathe deeply 4. Encouraging the client to breathe slowly and shallowly Question 190 of 102 An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse should take which action to help the client experiencing this acid-base disorder? 1. Put the client in a supine position. 2. Provide emotional support and reassurance. 3. Withhold all sedative or antianxiety medications. 4. Tell the client to breathe very deeply but more slowly. Question 191 of 102 A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse should plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis? 1. Sodium 2. Potassium 3. Magnesium 4. Phosphorus Question 192 of 102 The nurse is caring for a client who is experiencing metabolic alkalosis. Knowing the risks of this imbalance, the nurse plans to protect the client's safety by carefully implementing which prescribed precaution? 1. Contact isolation 2. Seizure precautions 3. Bleeding precautions 4. Neutropenic precautions Question 193 of 102 The nurse is caring for a client who overdosed on acetylsalicylic acid (aspirin) 24 hours ago. The nurse should expect to note which findings associated with an anticipated acid-base disturbance? 1. Disorientation and dyspnea 2. Drowsiness, headache, and tachypnea 3. Tachypnea, dizziness, and paresthesias 4. Decreased respiratory rate and depth, cardiac irregularities Question 194 of 102 A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse monitoring this client should expect to note which signs/symptoms? 1. Disorientation and dyspnea 2. Decreased respiratory rate and depth 3. Drowsiness, headache, and tachypnea 4. Tachypnea, dizziness, and paresthesias Question 195 of 102 The nurse is providing care to a client with the following arterial blood gas results: pH of 7.50 (7.50), Pao2 of 90 mm Hg (90 mm Hg), Paco2 of 40 mm Hg (40 mm Hg), and bicarbonate of 35 mEq/L (35 mmol/L). When the nurse notifies the health care provider about these levels, the nurse should anticipate receiving from the HCP which prescription for this client? 1. Obtain a serum alcohol level. 2. Obtain a serum salicylate level. 3. Discontinue nasogastric suctioning. 4. Discontinue the client's fentanyl patch. Question 196 of 102 The nurse is caring for a client with hyperglycemia and diabetic ketoacidosis (DKA) who now has developed Kussmaul respirations. The nurse knows that the purpose of this type of breathing is to correct what imbalance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Question 197 of 102 The nurse is reviewing laboratory results for a client with chronic kidney disease before a hemodialysis treatment. The serum electrolyte levels are sodium 142 mEq/L (142 mmol/L), chloride 103 mEq/L (103 mmol/L), potassium 5.2 mEq/L (5.2 mmol/L), and bicarbonate 23 mEq/L (23 mmol/L). What action should the nurse take? 1. Take no action. 2. Order a stat hemodialysis treatment. 3. Page the health care provider (HCP) with the results. 4. Recheck the labs because these values are all abnormal. [Show More]

Last updated: 1 year ago

Preview 1 out of 110 pages