A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the
following findings as a manifestation of
... [Show More] fluid volume excess?
a. Decreased bowel sounds
b. Distended neck veins
c. Bilateral muscle weakness
d. Thread pulse - CORRECT ANSWER b. Distended neck veins
A nurse is caring for a client who has hyponatremia and is receiving an infusion of a prescribed
hypertonic solution. Which of the following findings should indicate to the nurse that the treatment is
effective?
a. Absent Chvostek's sign
b. Improved cognition
c. Decreased vomiting
d. Cardiac arrhythmias absent - CORRECT ANSWER b. Improved cognition
A nurse is teaching a client who has a new prescription for a nitroglycerin transdermal patch. Which of
the following instructions should the nurse include?
a. "Discontinue the patch if you experience a headache."
b. "Apply a new patch if you have chest pain."
c. "Cover the patch with dry gauze when taking a shower."
d. "Remove the patch prior to going to bed." - CORRECT ANSWER d. "Remove the patch prior to going
to bed."
A nurse is reviewing he laboratory results of a client who has a prescription for sodium polystyrene
sulfonate (Kayexalate) every 6 hr. which of the following should the nurse report to the provider?
a. Creatinine 0.72 mg/dL
b. Sodium 138 mEq/L
c. Magnesium 2 mEq/L
d. Potassium 5.2 mEq/L - Hyperkalemia (serum potassium level greater than 5.0 mEq/L) increases the
client risk for fatal cardiac dysrhythmias. Kayexalate is used to decrease the serum potassium level, so
the PN should monitor the client's serum potassium level - CORRECT ANSWER d. Potassium 5.2 mEq/L -
Hyperkalemia (serum potassium level greater than 5.0 mEq/L)
increases the client risk for fatal cardiac dysrhythmias. Kayexalate is used to decrease
the serum potassium level, so the PN should monitor the client's serum potassium level
A nurse is caring for a client who has tuberculosis and is taking isoniazid and rifampin. Which of the
following outcomes indicates that the client is adhering to the medication regimen?
a. The client has a negative sputum culture
b. The client tests negative for HIV
c. The client has a positive purified protein derivative test
d. The client's liver function test results are within the expected reference range - CORRECT ANSWER a.
The client has a negative sputum culture
A client is caring for a client who develops an anaphylactic reaction to IV administration. After assessing
the client's respiratory status and stopping the medication infusion. Which of the following actions
should the nurse take next?
a. Replace the infusion with 0.9% sodium chloride
b. Give diphenhydramine IM
c. Elevate the client's legs and feet
d. Administer epinephrine IM - CORRECT ANSWER d. Administer epinephrine IM
A nurse is caring for a client who is taking sertraline and reports a desire to begin taking supplements.
Which of the following supplements should the nurse advise the client to avoid?
a. St. John's Wort
b. Ginger root
c. Black cohosh
d. Coenzyme Q10 - CORRECT ANSWER a. St. John's Wort
A nurse is caring for a client who has heart failure and a new prescription for lisinopril. For which of the
following adverse effects should the nurse monitor when administering lisinopril?
a. Bradycardia
b. Hypokalemia
c. Tinnitus
d. Hypotension - CORRECT ANSWER d. Hypotension
A nurse is assessing a client who is receiving heparin IV continuous IV. The client has an PPT of 90
seconds. They should monitor the client for which of the following changes in their vital signs?
a. Decreased temperature
b. Increased pulse rate
c. Decreased respiratory rate
d. Increased blood pressure - CORRECT ANSWER d. Increased blood pressure
A nurse is preparing to administer medication to a client and discovers a medication error. The nurse
should recognize that which of the following staff members is responsible for completing an incident
report?
a. The quality improvement committee
b. The nurse who identifies the error
c. The nurse who caused the error [Show Less]