Académique Documents
Professionnel Documents
Culture Documents
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
1. The nurse is planning care for a patient with severe burns. Which of the following is
this patient at risk for developing?
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
811 glasses
1520 glasses
56 glasses
23 glasses
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
3. A female client was admitted to an acute care unit with weakness and complaints of
dizziness. Dehydration is suspected as the cause. The nurse would expect which of the
following lab values?
1.
2.
3.
4.
Correct Answer: Sodium of 150 mEq/L; potassium 5.1 mEq/L; hematocrit of 50%
Rationale: For a dehydrated client, the nurse would expect the hematocrit, sodium, and
potassium to be high (sodium of 150 mEq/L; potassium 5.1 mEq/L; hematocrit of 50%).
For overhydration, the client would have low levels of sodium, potassium, and hematocrit
(sodium of 132 mEq/L; potassium 3.1 mEq/L; hematocrit of 35%). Lab results within
normal limits would not be expected with dehydration.
Cognitive Level: Analyzing
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
4. A female patients hematocrit is 38% with serum sodium of 140 mEq/L. The nurse
realizes this patient is demonstrating:
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
7. A pregnant client is admitted with excessive thirst, increased urination, and has a
medical diagnosis of diabetes insipidus. The nurse chooses which of the following
nursing diagnoses as most appropriate?
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
8. The patient with renal disease is prescribed a diuretic. Which of the following
laboratory values does the nurse expect would reflect the outcome of diuretic therapy?
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
9. An elderly client is received into the postanesthesia recovery room (PACU) following a
6-hour abdominal surgery. The client received several liters of IV fluids during the
surgery. Which of the following lab results would the nurse most likely see with this
client?
1. Sodium128 mEq/L; potassium3.0 mEq/L; chloride96 mEq/L
2. Sodium148 mEq/L; potassium5.1 mEq/L; chloride107 mEq/L
3. Sodium140 mEq/L; potassium4.0 mEq/L; chloride100 mEq/L
4. Sodium135 mEq/L; potassium3.5 mEq/L; chloride98 mEq/L
Correct Answer: Sodium128 mEq/L; potassium3.0 mEq/L; chloride96 mEq/L
Rationale: This client has an excess fluid volume and the nurse would anticipate the
electrolytes to be low (sodium128 mEq/L; potassium3.0 mEq/L; chloride96
mEq/L). These values would be of greatest concern. If the electrolyte values are high
(sodium148 mEq/L; potassium5.1 mEq/L; chloride107 mEq/L), the nurse could
anticipate the client to be dehydrated. For the answer response with the sodium140
mEq/L; potassium4.0 mEq/L; chloride100 mEq/L, these reflect normal lab values.
The sodium level of 135 mEq/L is just barely below normal limits; however, the client
could still be at risk for excess fluid volume since all electrolytes are at the lower end of
normal range.
Nursing Process: Planning
Cognitive Level: Applying
Client Need: Physiological Integrity
LO: 3
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
10. The postoperative client has a nasogastric tube in place for 5 days. On the fifth day,
the client begins to exhibit confusion and lethargy. The nurse anticipates which of the
following?
1. The confusion is related to the gastric suctioning removing electrolytes from
the stomach.
2. The confusion is a delayed effect from anesthesia.
3. The confusion is most likely age related.
4. The confusion is related to the gastric suctioning and has decreased the
clients fluid volume.
Correct Answer: The confusion is related to the gastric suctioning removing electrolytes
from the stomach.
Rationale: Gastric suctioning via nasogastric tube may impact a clients electrolyte
balance by removing electrolytes via extracted gastric fluids. Confusion can occur as a
result of hyponatremia. While confusion can occur as a result of anesthesia, it usually
does not take 5 days to occur. Elderly clients are more susceptible to electrolyte
imbalance, but electrolyte imbalance is not exclusive to the elderly client. Decreasing the
clients fluid volume is not the cause of electrolyte disturbance, but can also cause
acidbase problems.
Cognitive Level: Analyzing
Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
LO: 4
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
11. An elderly patient tells the nurse that she does not drink many fluids because she is on
a water pill and does not want to harm what the water pill is supposed to do. Which
of the following is the nurses best response to this patient?
1. Taking a water pill does not mean you should not drink fluids. You can
become dehydrated.
2. Limiting fluids will ensure that you wont be overhydrated.
3. Just make sure you drink the things that you like, such as coffee and juice.
4. Its not necessary for you to drink water throughout the day.
Correct Answer: Taking a water pill does not mean you should not drink fluids. You can
become dehydrated.
Rationale: The most common cause of dehydration or pure water deficit is the excessive
loss of free water through urine as seen in people taking diuretics and not replacing fluids
through drinking. Elderly individuals have decreased perception of thirst due to aging and
may not replace fluids appropriately. The elderly are particularly vulnerable to
dehydration because many are taking prescription diuretics. The nurse should explain that
drinking fluids is important to avoid dehydration. The nurse should not support the
patients reasoning that by limiting fluids, the diuretic would work more effectively.
Everyone needs an intake of fluids every day.
Cognitive Level: Applying
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 4
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
Hyperkalemia.
Hypokalemia.
Hypercalcemia.
Hyopcalcemia.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
13. A patient is admitted with fluid-volume deficit. Which of the following will the nurse
most likely assess in this patient?
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
14. A nurse is providing discharge instructions for a client with a history of heart failure.
Until a scale is obtained, which of the following instructions would be most helpful if the
client does not have a scale at home to weigh on?
1. Wear the same belt in the same location around the waist and alert the
physician if the belt becomes tighter.
2. Wear a name band around the wrist to see if it gets tighter.
3. Wear a ball cap every day to determine whether there is an increase in head
circumference.
4. Discuss taking extra medication if the client feels there is weight gain.
Correct Answer: Wear the same belt in the same location around the waist and alert the
physician if the belt becomes tighter.
Rationale: If the client does not have access to a scale initially and is waiting to get one,
the nurse can advise the client to utilize a piece of clothing, such as a belt, used in the
same location, to help determine weight gain. Other methods might be to discuss
awareness of socks or rings getting tight. The wrist and head circumference are not good
locations to judge weight gain. Discussing taking extra medication based upon a clients
feeling like there is weight gain is not advised without consulting the health care
provider. The most reliable measurement of weight gain is utilizing scales.
Cognitive Level: Analyzing
Nursing Process: Evaluation
Client Need: Physiological Integrity
LO: 5
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
15. A patient is admitted with fluid-volume overload. The nurse realizes the laboratory
value that supports this finding is:
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
16. The nurse is planning care for a patient with fluid-volume overload and
hyponatremia. Which of the following should be included in this patients plan of care?
1.
2.
3.
4.
Restrict fluids.
Administer intravenous fluids.
Provide Kayexalate.
Administer intravenous normal saline with furosemide.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
17. If a client has hypocalcemia, the nurse should also evaluate the client for:
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
Correct Answer: Request dietitian consult for selecting foods high in phosphorous.
Rationale: Treatment of hypophosphatemia includes treating the underlying cause and
promoting a high-phosphate diet, especially milk, if it is tolerated. Other foods high in
phosphate are dried beans and peas, eggs, fish, organ meats, Brazil nuts and peanuts,
poultry, seeds, and whole grains. Phosphate-binding antacids, such as aluminum
hydroxide, should be avoided. Mild hypophosphatemia may be corrected by oral
supplements, such as sodium phosphate.
Cognitive Level: Applying
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 6
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
19. A client who experienced hypokalcemia is being discharged. Which of the following
foods contain the best choices for increasing the clients potassium?
1.
2.
3.
4.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
20. Discharge teaching for the client with electrolyte disturbances is aimed at:
1.
2.
3.
4.
21. The nurse is planning the care of a patient diagnosed with hyperkalemia. Which of the
following should be included in this patients plan of care?
1. Providing oral Kayexalate as prescribed
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.