1. 1.ID: 18630147534
A nurse is assigned to care four clients on the medical-surgical unit. Which client should
the nurse see first on the shift
... [Show More] assessment?
A. A client admitted with pneumonia with a fever of 100°F and some
diaphoresis
B. A client with congestive heart failure with clear lung sounds on the
previous shift
C. A client with new-onset of shortness of breath (SOB) and a history of
pulmonary edema Correct
Rationale: The client who should be seen first is the one with SOB and a history
of pulmonary edema. In light of such a history, SOB could indicate that fluidvolume overload has once again developed. The client with a fever and who is
diaphoretic is at risk for insufficient fluid volume as a result of loss of fluid
through the skin, but this client is not the priority.
Test-Taking Strategy: Use the process of elimination and focus on the subject of
the question, the client who should be seen first. Recall the rule of assessment
of the ABCs—airway, breathing, and circulation—which means that the client
experiencing shortness of breath should take precedence over the other clients
on the unit. This client’s condition could progress to respiratory arrest if the
client were not assessed immediately on the basis of the signs and symptoms.
Read each option and think about the client in most critical condition and
review the disorders to determine which clients have the most critical needs. If
you had difficulty with this question, review the various disease processes
presented in this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Delegating/Prioritizing
D. A client undergoing long-term corticosteroid therapy with mild bruising on
the anterior surfaces of the arms
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 18630146839
A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the
hospital with a diagnosis of dehydration. For which clinical manifestations that correlate
with this fluid imbalance would the nurse assess the client? Select all that apply.
A. Decreased pulse
B. Decreased urine output Correct
C. Increased blood pressure
D. Increased respiratory rate Correct
E. Decreased respiratory depth
Rationale: A client with dehydration has an increased depth and rate of respirations. The
diminished fluid volume is perceived by the body as a decreased oxygen level (hypoxia),
and increased respiration is an attempt to maintain oxygen delivery. Other assessment
findings in insufficient fluid volume are decreased urine volume, increased pulse, weight
loss, poor skin turgor, dry mucous membranes, concentrated urine with increased
specific gravity, increased hematocrit, and altered level of consciousness. Increased
blood pressure, decreased pulse, and increased urine output occur with fluid-volume
overload.
Test-Taking Strategy: Use the process of elimination and focus on the subject,
dehydration (deficient fluid volume). Think about the pathophysiology of deficient fluid
volume. Remember that the body will increase the respiratory rate in an attempt to
maintain the oxygen level. If you had difficulty with this question, review the signs of
insufficient fluid volume.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Fluid and Electrolytes
Awarded 2.0 points out of 2.0 possible points.
3. 3.ID: 18630147505
A nurse is reviewing the medical records of the clients for the assigned 7 a.m.–7 p.m.
shift. Which client will the nurse monitor most closely for excessive fluid volume?
A. A 48-year-old client receiving diuretics to treat hypertension
B. A 35-year old client who is vomiting undigested food after eating
C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100
mL/hrCorrect
Rationale: The older adult client receiving IV therapy at 100 mL/hr is at the
greatest risk for excessive fluid volume because of the diminished
cardiovascular and renal function that occur with aging. Other causes of
excessive fluid volume include renal failure, heart failure, liver disorders,
excessive use of hypotonic IV fluids to replace isotonic losses, excessive
irrigation of body fluids, and excessive ingestion of table salt. A client who is
receiving diuretics, vomiting, or has a nasogastric tube attached to suction is at
risk for deficient fluid volume.
Test-Taking Strategy: Read the question carefully, noting that it asks for the
client at risk for excessive fluid volume. Look for comparable or alike options
that indicate fluid volume deficits. Read each option and think about the fluid
imbalance that could occur in each situation; in the case of the incorrect
options, it is fluid-volume deficiency; the only option reflecting conditions that
could result in an excess is the correct option. If you had difficulty with this
question, review the causes of excessive fluid volume.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Fluid and Electrolytes
D. A 65-year-old client with a nasogastric tube attached to low suction
following partial gastrectomy
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 18630146876
A nurse is caring for a client who is being treated for congestive heart failure and has
been assigned a nursing diagnosis of excessive fluid volume. Which finding causes the
nurse to determine that the client’s condition has improved?
A. Dyspnea
B. 1+ edema in the legs
C. Moist crackles in the lower lobes of the lungs
D. Weight loss of 4 lb in 24 hours Correct
Rationale: One sign that excessive fluid volume is resolving is loss of body
weight. It is important to recall that 1 L of fluid weighs 1 kg, which equals 2.2 lb
(1 liter = 2.2 lb = 1 kg). The other options listed indicate that the client is
retaining fluid. Assessment findings associated with excessive fluid volume
include cough, dyspnea, rales or crackles, tachypnea, tachycardia, increased
blood pressure and bounding pulse, increased central venous pressure, weight
gain, edema, neck and hand vein distention, altered level of consciousness,
and decreased hematocrit. These symptoms must be reversed if the fluidvolume excess is to be resolved.
Test-Taking Strategy: Use the process of elimination and focus on the subject, a
sign that the client’s condition is improving. The only such finding is decreasing
body weight. If you had difficulty with this question, review the assessment
findings noted in excessive fluid volume and the signs that the condition is
resolving.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Fluid and Electrolytes
Awarded 1.0 points out of 1.0 possible points.
5. 5.ID: 18630146862
A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG)
monitor. With which potassium reading does the nurse associate this finding?
A. 3.1 mEq/L Correct
Rationale: A serum potassium level below 3.5 mEq/L is indicative of
hypokalemia, the most common electrolyte imbalance, which is potentially lifethreatening. ECG changes in hypokalemia include peaked P waves, flat T
waves, a depressed ST segment, and prominent U waves. Readings of 4.5
mEq/L and 4.2 mEq/L are normal potassium levels; 5.4 mEq/L indicates
hyperkalemia.
Test-Taking Strategy: Begin to answer this question by recalling the normal
range of values for serum potassium. Next it is necessary to know that STsegment depression occurs in hypokalemia. Look for comparable or alike
options that indicate a normal potassium reading. If you had difficulty with this
question, review the ECG changes that occur in hypokalemia.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Analysis
Content Area: Fluid and Electrolytes
B. 4.2 mEq/L
C. 4.5 mEq/L
D. 5.4 mEq/L
Awarded 1.0 points out of 1.0 possible points.
6. 6.ID: 18630146885
A health care provider writes a prescription for the administration of intravenous (IV)
potassium chloride to a client with hypokalemia. The nurse should reinforce which client
instructions?
A. A catheter will be inserted to drain your bladder.
B. A large intravenous line will be inserted into your chest vein.
C. This infusion requires use of a large caliber IV tubing.
D. This medication is diluted in a large bag of IV fluid and infused slowly into
your vein. Correct
Rationale: Potassium chloride administered IV must always be diluted in IV
fluid. Undiluted potassium chloride given IV can cause cardiac arrest. Potassium
chloride is never administered as a bolus (IV push) injection; an IV push would
result in sudden severe hyperkalemia, which could precipitate cardiac arrest.
Although urine output is monitored carefully during administration, it is not
necessary to insert a Foley catheter unless this is specifically prescribed.
Potassium chloride should be administered with the use of a controlled IV
infusion device to avoid bolus infusion and increased risk of cardiac arrest. A
central IV line is not necessary; potassium chloride may be administered
through a peripheral IV line.
Test-Taking Strategy: Use the process of elimination and note the strategic
words “intravenous potassium chloride.” Recalling that the medication must be
diluted will direct you to the correct option. If you had difficulty with this
question, review the guidelines for the administration of potassium chloride.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Awarded 1.0 points out of 1.0 possible points.
7. 7.ID: 18630146897
A nurse notes that a client’s serum potassium level is 5.8 mEq/L. The nurse interprets
this as an expected finding in the client with?
A. Diarrhea
B. Wound drainage
C. Addison disease Correct
Rationale: A serum potassium level greater than 5.1 mEq/L indicates
hyperkalemia, and the nurse would report the finding to the health care
provider. Adrenal insufficiency (Addison disease) is a cause of hyperkalemia.
Other common causes of hyperkalemia include tissue damage, such as that in
burn injuries, renal failure, and the use of potassium-sparing diuretics. The
client with diarrhea or wound drainage or the client being treated with diuretics
is at risk for hypokalemia.
Test-Taking Strategy: Use the process of elimination. Eliminate the comparable
or alike options that indicate that the client is experiencing body fluid losses
and therefore a loss of potassium. If you had difficulty with this question,
review the risk factors associated with hyperkalemia.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Analysis
Content Area: Fluid and Electrolytes
D. Heart failure being treated with loop diuretics
Awarded 1.0 points out of 1.0 possible points.
8. 8.ID: 18630146883
A nurse is caring for a client experiencing hyponatremia who was admitted to the
medical-surgical unit with fluid-volume overload. For which clinical manifestations of this
electrolyte imbalance does the nurse monitor this client? Select all that apply.
A. Slow pulse
B. Decreased urine output
C. Skeletal muscle weakness Correct
D. Hyperactive bowel sounds Correct
E. Hyperactive deep tendon reflexes
Rationale: Signs of hyponatremia include a rapid, thready pulse; skeletal muscle
weakness; diminished deep tendon reflexes; abdominal cramping and hyperactive
bowel sounds; increased urine output; headache; and personality changes. The nurse
must assess these changes from baseline. If muscle weakness is detected, the nurse
should immediately check respiratory effectiveness because ventilation depends on
strength of the respiratory muscles.
Test-Taking Strategy: Specific knowledge of the subject, the manifestations of
hyponatremia, is needed to answer this question. Remember that muscle weakness and
hyperactive bowel sounds are characteristics of hyponatremia. If you had difficulty with
this question, review the clinical manifestations of hyponatremia.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Fluid and Electrolytes
Awarded 2.0 points out of 2.0 possible points.
9. 9.ID: 18630148316
A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For
which of the following clinical manifestations, associated with this electrolyte imbalance,
does the nurse assess the client? Select all that apply.
A. Paresthesias
B. Muscle weakness Correct
C. Increased urine output Correct
D. Chvostek sign
E. Hyperactive deep tendon reflexes
Rationale: Signs of hypercalcemia include muscle weakness, diminished deep tendon
reflexes or an absence thereof, increased urine output, decreased gastrointestinal
motility, and increased heart rate and blood pressure. Hyperactive deep tendon
reflexes, the presence of the Chvostek sign, and paresthesias are signs of
hypocalcemia.
Test-Taking Strategy: Use the process of elimination, focusing on the subject, signs of
hypercalcemia. Note that all of the incorrect options are comparable or alike options in
that they reflect hyperactivity of the neuromuscular system. Review the clinical signs
noted in hypercalcemia if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Fluid and Electrolytes
Awarded 2.0 points out of 2.0 possible points.
10. 10.ID: 18630146837
A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mg/dL.
Which assessment findings does the nurse expect to note? Select all that apply.
A. Hypotension
B. Abdominal distention Correct
C. Trousseau sign Correct
D. Skeletal muscle weakness
E. Decreased deep tendon reflexes
Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0
mg/dL reflects hypomagnesemia. Assessment signs include hypertension;
gastrointestinal manifestations such as anorexia, nausea, abdominal distention, and
decreased bowel sounds; shallow respirations; neuromuscular manifestations such as
twitches, paresthesias, hyperreflexia, and the Trousseau and Chvostek signs; and
irritability and confusion.
Test-Taking Strategy: Use the process of elimination, noting the options that are
comparable or alike options because they reflect neurological, musculoskeletal, and
cardiovascular depression. If you had difficulty with this question, review the clinical
signs found in magnesium imbalances.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Fluid and Electrolytes
Awarded 2.0 points out of 2.0 possible points.
11. 11.ID: 18630146847
A nurse enters a client’s room and finds the client unconscious. The nurse quickly
determines that the client is not breathing. Which action does the nurse take first?
A. Beginning chest compressions Correct
Rationale: According to the American Heart Association, detecting a pulse may
be difficult. The health care provider should take not more than 10 seconds to
check for a pulse; if the rescuer does not definitely feel a pulse within that
period, he or she should start chest compressions. The acronym CAB
(circulation, airway, and breathing) is used to prioritize the steps of
cardiopulmonary resuscitation (CPR). Effective chest compressions are
essential for providing blood flow during CPR. To provide effective chest
compressions, the provider must push hard and fast. Current guidelines for CPR
call for the initiation of compressions before ventilations. Oxygen may be
helpful at some point, but the airway is opened before the administration of
oxygen. Checking the client’s pulse oximetry reading delays implementation of
lifesaving measures.
Test-Taking Strategy: Visualize the steps of CPR to answer the question. Recall
the subject, the guidelines of life support: C (circulation), A (airway), B
(breathing). This will direct you to the correct option. Review the steps of basic
life support if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care
B. Checking the client’s pulse oximetry reading
C. Placing an oxygen mask on the client
D. Counting the client’s carotid pulse for 15 seconds
Awarded 1.0 points out of 1.0 possible points.
12. 12.ID: 18630146870
A nurse arrives at the scene of a client experiencing a cardiac/respiratory arrest and
begins to assist with cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers
compressions by pushing down on the chest to which depth?
A. 1 inch
B. 1½ inches
C. 2 inches Correct
Rationale: When CPR is being performed on an adult, the sternum should be
depressed at least 2 inches (5 cm). The other options are incorrect because
they are too shallow to be effective or are too deep, which can cause damage
to internal organs. The rescuer should allow complete recoil of the chest after
each compression to allow the heart to fill completely before the next
compression.
Test-Taking Strategy: Knowledge regarding the subject, the procedure for
performing chest compressions on an adult, is necessary to answer the
question. Consider the normal body structure of an adult to answer the
question correctly. If you had difficulty with this question, review the procedure
for CPR for an adult.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care
D. 4 inches
Awarded 1.0 points out of 1.0 possible points.
13. 13.ID: 18630146889
The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client. Which
compression/ventilation ratio is correct?
A. 15:1
B. 15:2
C. 20:2
D. 30:2 Correct
Rationale: A 30:2 ratio of compressions to ventilations is recommended for CPR
in adults. The other options are incorrect.
Test-Taking Strategy: Knowledge regarding the subject, the procedure for
performing CPR on an adult client, is needed to answer this question.
Remember that the 30:2 ratio of compressions to ventilations is recommended
for CPR in adults. Review CPR procedure if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care
Awarded 1.0 points out of 1.0 possible points.
14. 14.ID: 18630147576
A nurse finds a hospitalized child unresponsive. A quick assessment reveals that the
child is not breathing and does not have a pulse. The nurse initiates cardiopulmonary
resuscitation (CPR). How many chest compressions per minute does the nurse deliver?
A. 15
B. 30
C. 50
D. 100 Correct
Rationale: In an infant or child, the rate of chest compressions is at least
100/min.
Test-Taking Strategy: Knowledge regarding the subject, the procedure for
performing CPR on a child, is needed to answer this question. Remember that
the rate of chest compressions is at least 100/min. Review CPR procedure for a
child if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care [Show Less]