NR 226: Exam 2 review questions
1. A nurse suspects that an older adult may have a fluid and electrolyte imbalance. Which assessment best reflects
fluid
... [Show More] and electrolyte balance in an older adult?
a. Intake and output results
b. Serum laboratory values
c. Condition of the skin
d. Presence of tenting
2. A nurse is caring for a patient with an intestinal stoma. Which intervention is most important?
a. Cleansing the stoma with cool water
b. Spraying an air-freshening deodorant in the room
c. Selecting a bag with an appropriate-size stomal opening
d. Wearing sterile nonlatex gloves when caring for the stoma
3. A nurse is caring for a patient who had an abdominal hysterectomy. Which intervention best prevents
postoperative thrombophlebitis (DVT)?
a. Utilization of compression stockings at night
b. Deep breathing and coughing daily
c. Leg exercises 10 times per hour when awake
d. Elevation of the legs on 2 pillows
4. 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?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
5. The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of
acid-base imbalance?
a. Respiratory acidosis from inadequate ventilation
b. Respiratory alkalosis from anxiety and hyperventilation
c. Metabolic acidosis from calcium loss due to broken bones
d. Metabolic alkalosis from taking analgesics containing base products
6. A patient is experiencing diarrhea and needs to replace potassium. Which nutrients selected by the patient
indicate that additional teaching is necessary regarding nutrients high in potassium. Select all that apply.
a. Beef boullion
b. Orange juice
c. Poached egg
d. Warm tea
e. avocado
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7. A 750-mL tap-water enema is ordered for a patient. Which should the nurse do to best promote acceptance of
the volume ordered?
a. Administer the fluid slowly, and have the patient take shallow breaths
b. Place the patient in the left lateral position, and slowly administer the fluid
c. Have the patient take shallow breaths, and keep the fluid at body temperature
d. Keep the fluid at body temperature, and place the patient in the left lateral position
8. A nurse collected information from several patients. Which information indicates the patient who has the highest
risk for developing diarrhea?
a. Is physically active
b. Drinks a lot of fluid
c. Eats whole-grain bread
d. Is experiencing emotional problems
9. Sequential compression devices (SCD), are ordered for a postoperative patient. The patient asks the nurse, “Why
do I have to wear these things? Which information should the nurse include in the response to the patient’s
question? Select all that apply.
a. Keeps the lower extremities warm
b. Helps prevent deep vein thrombosis
c. Accelerates the rate of wound healing
d. Promotes circulation of blood back to the heart
e. Eliminates the need for leg and foot exercises after surgery
10. A patient is admitted to the post anesthesia care unit (PACU) after abdominal surgery. The patient’s vital signs
are blood pressure 150/90 mm Hg, pulse 88 and bounding, respirations 24 with some crackles. Which response
does the nurse conclude that the patient most likely is experiencing?
a. Hypoglycemia
b. Hyponatremia
c. Hyperkalemia
d. Hypervolemia
11. A newly admitted patient reports not having had a good bowel movement in 10 days. Which questions should
the nurse ask the patient to identify the possibility of fecal impaction? Select all that apply.
a. “How long has it been since you had a formed stool?”
b. “have you had small amounts of liquid stool?”
c. “do you notice a bad odor to your breath?”
d. “have you been eating food with fiber?”
e. “are you having any vomiting?”.......... [Show Less]