1. All the following are LOCs. Starting with the optimal LOC, place these in order of a decreasing
... [Show More] LOC.
Alert
Confused
Lethargy
Obtunded
Stuporous
Comatose
Alert
Lethargic
Confused
Obtunded
Comatose
Stuporous
2. Interventions to prevent which problem are the priority for a patient with myasthenia gravis (MG)?
A. Accidental injury
B. Uncontrolled pain
C. Inability to maintain own airway
D. Decreased functional ability and mobility
3. The nurse writes the nursing problem of "fluid volume excess" (FVE). Which intervention
should be included in the plan of care?
A. Change the IV fluid from 0.9% NS to D5W.
B. Restrict the client's sodium in the diet.
C. Monitor blood glucose levels.
D. Prepare the client for hemodialysis.
4. The nurse assists a client with serum potassium of 3.2 mEq/L to make which of the
following menu selections? Select all that apply.
A. Baked cod
B. Ham and cheese omelet
C. Fried eggs
D. Baked potato
E. spinach
5. The nurse evaluates which of the following clients to have hypermagnesemia?
A. A client who has chronic alcoholism and a magnesium level of 1.3 mEq/L
B. A client who has hyperthyroidism and a magnesium level of 1.6 mEq/L
C. A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L
D. A client who has congestive heart disease, takes a diuretic, and has a magnesium level of 2.3
mEq/L
6. The nurse is evaluating the serum laboratory results on the following four clients. Which of
the following laboratory results is a priority for the nurse to report first?
A. A client with osteoporosis and a calcium level of 10.6 mg/dl
B. A client with renal failure and a magnesium level of 2.5 mEq/L
C. A client with bulimia and a potassium level of 3.6 mEq/L
D. A client with dehydration and a sodium level of 149 mEq/L
7. The registered nurse is delegating client assignments to unlicensed assistive personnel.
Which of the following clients does not require additional monitoring and assessment and
may be delegated to unlicensed assistive personnel?
A. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L
B. A client with renal failure who has a serum magnesium level of 3.0 mEq/L
C. A client who has experienced a fracture of the femur and has a serum phosphate of 5.0 mg/dl
D. A client with dehydration who has a serum sodium level of 128 mEq/L
8. The client is admitted to a nursing unit from a long-term care facility with a hematocrit of
56% and a serum sodium level of 152 mEq/L. Which condition would be a cause for these
findings?
A. Over hydration.
B. Anemia.
C. Dehydration.
D. Renal failure. [Show Less]