Question 1

The nurse is caring for a patient who has a central venous access device (CVAD).Which action by the nurse is appropriate?

Accepted Answer

A)  Avoid using friction when cleaning around the CVAD insertion site. 
B)  Use the push-pause method to flush the CVAD after giving medications. 
C)  Obtain an order from the health care provider to change CVAD dressing. 
D)  Position the patient's face toward the CVAD during injection cap changes. 
A)  Avoid using friction when cleaning around the CVAD insertion site. 
B)  Use the push-pause method to flush the CVAD after giving medications. 
C)  Obtain an order from the health care provider to change CVAD dressing. 
D)  Position the patient's face toward the CVAD during injection cap changes.

Question 2

The nurse assesses a patient who has been hospitalized for 2 days.The patient has been receiving normal saline IV at 100 mL/hr,has a nasogastric tube to low suction,and is NPO.Which assessment finding would be a priority for the nurse to report to the health care provider?

Accepted Answer

A)  Oral temperature of 100.1° F 
B)  Serum sodium level of 138 mEq/L (138 mmol/L) 
C)  Gradually decreasing level of consciousness (LO
C)  
D)  Weight gain of 2 pounds (1 kg) above the admission weight 
A)  Oral temperature of 100.1° F 
B)  Serum sodium level of 138 mEq/L (138 mmol/L) 
C)  Gradually decreasing level of consciousness (LO
C)  
D)  Weight gain of 2 pounds (1 kg) above the admission weight

Question 3

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused.The patient complains of "just blowing up" and has peripheral edema and shortness of breath.Which assessment should the nurse complete first?

Accepted Answer

A)  Skin turgor 
B)  Heart sounds 
C)  Mental status 
D)  Capillary refill 
A)  Skin turgor 
B)  Heart sounds 
C)  Mental status 
D)  Capillary refill

Question 4

After receiving change-of-shift report,which patient should the nurse assess first?

Accepted Answer

A)  Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping 
B)  Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water 
C)  Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes 
D)  Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates 
A)  Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping 
B)  Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water 
C)  Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes 
D)  Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates

Question 5

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH).The nurse should notify the health care provider about which assessment finding?

Accepted Answer

A)  Reported weight gain 
B)  Serum hematocrit of 42% 
C)  Serum sodium level of 120 mg/dL 
D)  Total urinary output of 280 mL during past 8 hours 
A)  Reported weight gain 
B)  Serum hematocrit of 42% 
C)  Serum sodium level of 120 mg/dL 
D)  Total urinary output of 280 mL during past 8 hours

Question 6

A patient is admitted to the emergency department with severe fatigue and confusion.Laboratory studies are done.Which laboratory value will require the most immediate action by the nurse?

Accepted Answer

A)  Arterial blood pH is 7.32. 
B)  Serum calcium is 18 mg/dL. 
C)  Serum potassium is 5.1 mEq/L. 
D)  Arterial oxygen saturation is 91%. 
A)  Arterial blood pH is 7.32. 
B)  Serum calcium is 18 mg/dL. 
C)  Serum potassium is 5.1 mEq/L. 
D)  Arterial oxygen saturation is 91%.

Question 7

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL.Which nursing action should the nurse include on the care plan?

Accepted Answer

A)  Maintain the patient on bed rest. 
B)  Auscultate lung sounds every 4 hours. 
C)  Monitor for Trousseau's and Chvostek's signs. 
D)  Encourage fluid intake up to 4000 mL every day. 
A)  Maintain the patient on bed rest. 
B)  Auscultate lung sounds every 4 hours. 
C)  Monitor for Trousseau's and Chvostek's signs. 
D)  Encourage fluid intake up to 4000 mL every day.

Question 8

A patient who is lethargic and exhibits deep,rapid respirations has the following arterial blood gas (ABG)results: pH 7.32,PaO2 88 mm Hg,PaCO2 37 mm Hg,and HCO3 16 mEq/L.How should the nurse interpret these results?

Accepted Answer

A)  Metabolic acidosis 
B)  Metabolic alkalosis 
C)  Respiratory acidosis 
D)  Respiratory alkalosis 
A)  Metabolic acidosis 
B)  Metabolic alkalosis 
C)  Respiratory acidosis 
D)  Respiratory alkalosis

Question 9

A newly admitted patient is diagnosed with hyponatremia.When making room assignments,the charge nurse should take which action?

Accepted Answer

A)  Assign the patient to a room near the nurse's station. 
B)  Place the patient in a room nearest to the water fountain. 
C)  Place the patient on telemetry to monitor for peaked T waves. 
D)  Assign the patient to a semi-private room and place an order for a low-salt diet. 
A)  Assign the patient to a room near the nurse's station. 
B)  Place the patient in a room nearest to the water fountain. 
C)  Place the patient on telemetry to monitor for peaked T waves. 
D)  Assign the patient to a semi-private room and place an order for a low-salt diet.

Question 10

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration.Which instructions should the nurse give to this patient related to fluid intake?

Accepted Answer

A)  "Increase fluids if your mouth feels dry. 
B)  "More fluids are needed if you feel thirsty." 
C)  "Drink more fluids in the late evening hours." 
D)  "If you feel lethargic or confused, you need more to drink." 
A)  "Increase fluids if your mouth feels dry. 
B)  "More fluids are needed if you feel thirsty." 
C)  "Drink more fluids in the late evening hours." 
D)  "If you feel lethargic or confused, you need more to drink."

Question 11

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid,deep respirations.Which action should the nurse take?

Accepted Answer

A)  Give the prescribed PRN lorazepam (Ativan). 
B)  Start the prescribed PRN oxygen at 2 to 4 L/min. 
C)  Administer the prescribed normal saline bolus and insulin. 
D)  Encourage the patient to take deep, slow breaths with guided imagery. 
A)  Give the prescribed PRN lorazepam (Ativan). 
B)  Start the prescribed PRN oxygen at 2 to 4 L/min. 
C)  Administer the prescribed normal saline bolus and insulin. 
D)  Encourage the patient to take deep, slow breaths with guided imagery.

Question 12

When caring for a patient with renal failure on a low phosphate diet,the nurse will inform unlicensed assistive personnel (UAP)to remove which food from the patient's food tray?

Accepted Answer

A)  Grape juice 
B)  Milk carton 
C)  Mixed green salad 
D)  Fried chicken breast 
A)  Grape juice 
B)  Milk carton 
C)  Mixed green salad 
D)  Fried chicken breast

Question 13

A patient is receiving a 3% saline continuous IV infusion for hyponatremia.Which assessment data will require the most rapid response by the nurse?

Accepted Answer

A)  The patient's radial pulse is 105 beats/minute. 
B)  There is sediment and blood in the patient's urine. 
C)  The blood pressure increases from 120/80 to 142/94. 
D)  There are crackles audible throughout both lung fields. 
A)  The patient's radial pulse is 105 beats/minute. 
B)  There is sediment and blood in the patient's urine. 
C)  The blood pressure increases from 120/80 to 142/94. 
D)  There are crackles audible throughout both lung fields.

Question 14

During the admission process,the nurse obtains information about a patient through the physical assessment and diagnostic testing.Based on the data shown in the accompanying figure,which nursing diagnosis is appropriate?

Accepted Answer

A)  Deficient fluid volume 
B)  Impaired gas exchange 
C)  Risk for injury: Seizures 
D)  Risk for impaired skin integrity 
A)  Deficient fluid volume 
B)  Impaired gas exchange 
C)  Risk for injury: Seizures 
D)  Risk for impaired skin integrity

Question 15

A patient receives 3% NaCl solution for correction of hyponatremia.Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?

Accepted Answer

A)  Lung sounds 
B)  Urinary output 
C)  Peripheral pulses 
D)  Peripheral edema 
A)  Lung sounds 
B)  Urinary output 
C)  Peripheral pulses 
D)  Peripheral edema

Question 16

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL.The nurse would expect which clinical manifestation?

Accepted Answer

A)  Pallor 
B)  Edema 
C)  Confusion 
D)  Restlessness 
A)  Pallor 
B)  Edema 
C)  Confusion 
D)  Restlessness

Question 17

A patient is admitted for hypovolemia associated with multiple draining wounds.Which assessment would be the most accurate way for the nurse to evaluate fluid balance?

Accepted Answer

A)  Skin turgor 
B)  Daily weight 
C)  Presence of edema 
D)  Hourly urine output 
A)  Skin turgor 
B)  Daily weight 
C)  Presence of edema 
D)  Hourly urine output

Exam 13: Nursing Management: Fluid,electrolyte and Acidbase Imbalances

The nurse is caring for a patient who has a central venous access device (CVAD).Which action by the nurse is appropriate?

The nurse assesses a patient who has been hospitalized for 2 days.The patient has been receiving normal saline IV at 100 mL/hr,has a nasogastric tube to low suction,and is NPO.Which assessment finding would be a priority for the nurse to report to the health care provider?

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused.The patient complains of "just blowing up" and has peripheral edema and shortness of breath.Which assessment should the nurse complete first?

After receiving change-of-shift report,which patient should the nurse assess first?

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH).The nurse should notify the health care provider about which assessment finding?

A patient is admitted to the emergency department with severe fatigue and confusion.Laboratory studies are done.Which laboratory value will require the most immediate action by the nurse?

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL.Which nursing action should the nurse include on the care plan?

A patient who is lethargic and exhibits deep,rapid respirations has the following arterial blood gas (ABG)results: pH 7.32,PaO2 88 mm Hg,PaCO2 37 mm Hg,and HCO3 16 mEq/L.How should the nurse interpret these results?

A newly admitted patient is diagnosed with hyponatremia.When making room assignments,the charge nurse should take which action?

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration.Which instructions should the nurse give to this patient related to fluid intake?

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid,deep respirations.Which action should the nurse take?

When caring for a patient with renal failure on a low phosphate diet,the nurse will inform unlicensed assistive personnel (UAP)to remove which food from the patient's food tray?

A patient is receiving a 3% saline continuous IV infusion for hyponatremia.Which assessment data will require the most rapid response by the nurse?

During the admission process,the nurse obtains information about a patient through the physical assessment and diagnostic testing.Based on the data shown in the accompanying figure,which nursing diagnosis is appropriate?

A patient receives 3% NaCl solution for correction of hyponatremia.Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL.The nurse would expect which clinical manifestation?

A patient is admitted for hypovolemia associated with multiple draining wounds.Which assessment would be the most accurate way for the nurse to evaluate fluid balance?

The Importance of Nursing

Health Disparities and Cultural Care

Pain Management

Palliative Care

Substance Use and Dependency

Nursing Management: Inflammation and Wound Healing

Genetics and Genomics

Altered Immune Responses and Transplantation

Nursing Management: Infection and Human Immunodeficiency Virus Infection

Cancer

Nursing Management: Preoperative Care

Nursing Management: Intraoperative Care

Nursing Management: Postoperative Care

Nursing Assessment: Visual and Auditory Systems

Nursing Management: Visual and Auditory Problems

Nursing Assessment: Integumentary System

Nursing Management: Integumentary Problems

Nursing Management: Burns

Nursing Assessment: Respiratory System

Nursing Management: Upper Respiratory Problems

Nursing Management: Lower Respiratory Problems

Nursing Management: Obstructive Pulmonary Diseases

Nursing Assessment: Haematological System

Nursing Management: Haematological Problems

Nursing Assessment: Cardiovascular System

Nursing Management: Hypertension

Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome

Nursing Management: Heart Failure

Nursing Management: Ecg Monitoring and Arrhythmias

Nursing Management: Inflammatory and Structural Heart Disorders

Nursing Management: Vascular Disorders

Nursing Assessment: Gastrointestinal System

Nursing Management: Nutritional Problems

Nursing Management: Obesity

Nursing Management: Upper Gastrointestinal Problems

Nursing Management: Lower Gastrointestinal Problems

Nursing Management: Liver,pancreas and Biliary Tract Problems

Nursing Assessment: Urinary System

Nursing Management: Renal and Urological Problems

Nursing Management: Acute Kidney Injury and Chronic Kidney Disease

Nursing Assessment: Endocrine System

Nursing Management: Diabetes Mellitus

Nursing Management: Endocrine Problems

Nursing Assessment: Reproductive System

Nursing Management: Breast Disorders

Nursing Management: Sexually Transmitted Infections

Nursing Management: Female Reproductive Problems

Nursing Management: Male Reproductive Problems

Nursing Assessment: Nervous System

Nursing Management: Acute Intracranial Problems

Nursing Management: the Patient With a Stroke

Nursing Management: Chronic Neurological Problems

Nursing Management: Delirium,depression and Dementia

Nursing Management: Peripheral Nerve and Spinal Cord Problems

Nursing Assessment: Musculoskeletal System

Nursing Management: Musculoskeletal Trauma and Orthopaedic Surgery

Nursing Management: Musculoskeletal Problems

Nursing Management: Arthritis and Connective Tissue Diseases

Nursing Management: Critical Care Environment

Nursing Management: Shock,systemic Inflammatory Response Syndrome and Multiple Organ Dysfunction Syndrome

Nursing Management: Respiratory Failure and Acute Respiratory Distress Syndrome

Nursing Management: Emergency Care Situations

A patient who is lethargic and exhibits deep,rapid respirations has the following arterial blood gas (ABG)results: pH 7.32,PaO₂ 88 mm Hg,PaCO₂ 37 mm Hg,and HCO₃ 16 mEq/L.How should the nurse interpret these results?