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1. Patient X is diagnosed with constipation. As a knowledgeable nurse, which nursing intervention is appropriate for maintaining normal bowel
function?
-Assessing dietary intake
2. A 12-year-old boy was admitted in the hospital two days ago due to hyperthermia. His attending nurse, Dennis, is quite unsure about his plan of
care. Which of the following nursing intervention should be included in the care of plan for the client?
-Room temperature reduction
3.Tom is ready to be discharged from the medical-surgical unit after 5 days of hospitalization. Which client statement indicates to the nurse that Tom
understands the discharge teaching about cellular injury?
-“If I have redness, drainage, or fever, I should call my healthcare provider.”
4. Nurse Katee is caring for Adam, a 22-year-old client, in a long-term facility. Which nursing intervention would be appropriate when identifying
nursing interventions aimed at promoting and preventing contractures?
-Maintaining correct body alignment at all times
-Using a footboard or pillows to keep feet in correct position
-Performing active and passive range-of-motion exercises
5. A 36-year-old male client is about to be discharged from the the hospital after 5 days due to surgery. Which intervention should be included in the
home health care nurse’s instructions about measures to prevent constipation?
-Instructing the client to fill a 2-L bottle with water every night and drink it the next day.
6. Mr. McPartlin suffered abrasions and lacerations after a vehicular accident. He was hospitalized and was treated for a couple of weeks. When
planning care for a client with cellular injury, the nurse should consider which scientific rationale?
-The presence of infection may slow the healing process.
7. A 22-year-old lady is displaying facial grimaces during her treatment in the hospital due to burn trauma. Which nursing intervention should be
included for reducing pain due to cellular injury?
-Administering anti-inflammatory agents as prescribed
8.Lisa, a client with altered urinary function, is under the care of nurse Tine. Which intervention is appropriate to include when developing a plan of
care for Lisa who is experiencing urinary dribbling?
-Having the client perform Kegel exercises
To perform these exercises, the client tightens pelvic floor muscles for 4 seconds 10 times at least 20 times each day, stopping and starting the urinary
flow.
9. Jeron is admitted in the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and has shortness of breath and asthma. WHich goal is the
most important for the client?
-Maintenance of adequate oxygenation
10. Mang Rogelio, a 32-year-old patient, is about to be discharged from the acute care setting. Which nursing intervention is the most important to
include in the plan of care?
-Home environment evaluation
11. Mrs. dela Riva is in her first trimester of pregnancy. She has been lying all day because her OB-GYN requested her to have a complete bed rest.
Which nursing intervention is appropriate when addressing the client’s need to maintain skin integrity?
-Keeping the linens dry and wrinkle free
12. Maya, who is admitted in a hospital, is scheduled to have her general checkup and physical assessment. Nurse Timothy observed a reddened area
over her left hip. Which should the nurse do first?
-Turn the client to the right side for 2 hours
13. Pierro was noted to be displaying facial grimaces after nurse Kara assessed his complaints of pain rated as 8 on a scale of 1 (no pain) 10 10 (worst
pain). Which intervention should the nurse do?
-Attempting to rule out complications before administering pain medication
14. Nurse Marthia is teaching her students about bacterial control. Which intervention is the most important factor in preventing the spread of
microorganism?
-Correct handwashing technique
15. A patient with tented skin turgor, dry mucous membranes,and decreased urinary output is under nurse Mark’s care. Which nursing intervention
should be included the care plan of Mark for his patient?
-Administering I.V. and oral fluids
16. Khaleesi is admitted in the hospital due to having lower than normal potassium level in her bloodstream. Her medical history reveals vomiting
and diarrhea prior to hospitalization. Which foods should the nurse instruct the client to increase?
-Orange juice and banana
17. Mary Jean, a first year nursing student, was rushed to the clinic department due to hyperventilation. Which nursing intervention is the most
appropriate for the client who is subsequently developing respiratory alkalosis?
-Encouraging slow, deep breaths
18. Nurse John Joseph is totaling the intake and output for Elena Reyes, a client diagnosed with septicemia who is on a clear liquid diet. The client
intakes 8 oz of apple juice, 850 ml of water, 2 cups of beef broth, and 900 ml of half-normal saline solution and outputs 1,500 ml of urine during the
shift. How many milliliters should the nurse document as the client’s intake.
-2,470
19. Marie Joy’s lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with
hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated?
-Positive Trousseau’s sign
20. Lab tests revealed that patient Z’s [Na+] is 170 mEq/L. Which clinical manifestation would nurse Natty expect to assess?
-Tented skin turgor and thirst
21. Mang Teban has a history of chronic obstructive pulmonary disease and has the following arterial blood gas results: partial pressure of oxygen
(PO2), 55 mm Hg, and partial pressure of carbon dioxide (PCO2), 60 mm Hg. When attempting to improve the client’s blood gas values through
improved ventilation and oxygen therapy, which is the client’s primary stimulus for breathing?
-Low PO2
22. A client with very dry mouth, skin and mucous membranes is diagnosed of having dehydration. Which intervention should the nurse perform
when caring for a client diagnosed with fluid volume deficit?
-Assessing urinary intake and output
23. Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium?
-18-year-old Albert who has renal disease
24. Genevieve is diagnosed with hypomagnesemia, which nursing intervention would be appropriate?
-Instituting seizure precaution to prevent injury
Instituting seizure precaution is an appropriate intervention, because the client with hypomagnesemia is at risk for seizures. Hypophosphatemia may
produce changes in granulocytes, which would require the nurse to instruct the client about measures to prevent infection. Avoiding the use of a tight
tourniquet when drawing blood helps prevent pseudohyperkalemia.
25. Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid?
-Sodium
Chloride, an anion (e.g., negatively charged ion), is also present in extracellular fluid, but to a lesser extent. Potassium (a cation) and phosphate (an
anion) are the major electrolytes in the intracellular fluid.
26. Jon has a potassium level of 6.5 mEq/L, which medication would nurse Wilma anticipate?
-Kayexalate
27. Which clinical manifestation would lead the nurse to suspect that a client is experiencing hypermagnesemia?
-Hot, flushed skin and diaphoresis
The client also may exhibit hypotension, lethargy, drowsiness, and absent deep tendon reflexes. Muscle pain and acute rhabdomyolysis are indicative
of hypophosphatemia. Soft-tissue calcification and hyperreflexia are indicative of hyperphosphatemia.
28. Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to assess in planning the care for the client?
-Potassium level
Diuretics such as furosemide may deplete serum potassium, leading to hypokalemia. When the client is also taking digoxin, the subsequent
hypokalemia may potentiate the action of digoxin, placing the client at risk for digoxin toxicity. Diuretic therapy may lead to the loss of other
electrolytes such as sodium, but the loss of potassium in association with digoxin therapy is most important.
29. Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34, partial pressure of arterial oxygen of 80 mm Hg, partial pressure of
arterial carbon dioxide of 49 mm Hg, and a bicarbonate level of 24 mEq/L. Based on these results, which intervention should the nurse implement?
-Encouraging the client to cough and deep breathe
30. A client is diagnosed with metabolic acidosis, which would the nurse expect the health care provider to order?
-Sodium bicarbonate
4. Nursing intervention for the patient with hyperphosphatemia include encouraging intake of:
-amphogel
Administration of phosphate binders (amphogel and basagel) will reduce the serum phosphate levels.
5. Etiologies associated with hypocalcemia may include all of the following except:
-metastatic bone lesions
Metastatic bone lesions are associated with hypercalcemia due to accelerated bone metabolism and release of calcium into the serum.
6. Which of the following findings would the nurse expect to asses in hypercalcemia?
-urinary calculi
7. Which of the following is not an appropriate nursing intervention for a patient with hypercalcemia?
-administering calcium gluconate
9. Nursing interventions for a patient with hypermagnesemia include administering calcium gluconate to:
-antagonize the cardiac effects of magnesium
10. For a patient with hypomagnesemia, which of the following medications may become toxic?
-Digoxin
11. Which of the following is the most important physical assessment parameter the nurse would consider when assessing fluid and electrolyte
imbalance?
-cardiac rate and rhythm
13. Which of the following intravenous solutions would be appropriate for a patient with severe hyponatremia secondary to syndrome of
inappropriate antidiuretic hormone (SIADH)?
-hypertonic solution
14. Aldosterone secretion in response to fluid loss will result in which one of the following electrolyte imbalances?
-hypokalemia
Aldosterone is secreted in response to fluid loss. Aldosterone causes sodium reabsorption and potassium elimination, further exacerbating
hypokalemia
15. When assessing a patient for signs of fluid overload, the nurse would expect to observe:
-bounding pulse
16. The physician has ordered IV replacement of potassium for a patient with severe hypokalemia. The nurse would administer this:
-diluted in 100 cc over 1 hour
17. Which of the following findings would the nurse exp[ect to assess in a patient with hypokalemia?
-hyporeflexia
18. Vien is receiving oral potassium supplements for his condition. How should the supplements be administered?
-diluted
22. Which of the following conditions is an equal decrease of extracellular fluid (ECF) solute and water volume?
-isotonic FVD
23. When monitoring the daily weight of a patient with fluid volume deficit (FVD), the nurse is aware that fluid loss may be considered when weight
loss begins to exceed:
-0.50 lb
24. Dietary recommendations for a patient with a hypotonic fluid excess should include:
-increased sodium intake
26. A rise in arterial pressure causes the baroreceptors and stretch receptors to signal an inhibition of the sympathetic nervous system, resulting in:
-increased urine output
28. When assessing a patient for electrolyte balance, the nurse is aware that etiologies for hyponatremia include:
-water gain
-diuretic therapy
-diaphoresis
2. When assessing a patient’s total body water percentage, the nurse is aware that all of the following factors influence this except:
-gender
3. Orly Khan is suffering from fluid volume deficit (FVD), which of the following symptoms would the nurse expect to assess in the patient?
-tachycardia
4. John Reid is admitted in the hospital and is currently receiving hypertonic fluids. Nursing management for the client includes monitoring for all of
the following potential complications except:
-water intoxication
5. Mr. Wenceslao is scheduled to receive an isotonic solution; which one of the following is an example of such solution?
-0.9% saline
6. Which of the following arterial blood gas (ABG) values indicates uncompensated metabolic alkalosis?
-pH 7.48, PaCO2 42, HCO3 30
8. When assessing a patient for metabolic alkalosis, the nurse would expect to find:
-low serum potassium
Decreased serum potassium is a common symptom of metabolic alkalosis.
10. Which of the following statements provides the rationale for using a hypotonic solution for a patient with FVD?
-A hypotonic solution provides free water to help the kidneys eliminate the solute.
11. Redd is receiving a blood transfusion. When monitoring the patient, the nurse would analyze an elevated body temperature as indicating:
-a possible transfusion reaction
16. A patient with which of the following disorders is at high risk for developing hyperphosphatemia?
-hypocalcemia
Because calcium and phosphorus ratios are inversely proportional, when phosphorus levels are high, calcium levels are low.
19. Which of the following diagnoses is most appropriate for a patient with hypo calcemia?
-high risk for injury: bleeding
A patient with hypocalcemia may bleed, since calcium is required for normal blood clotting.
20. When serum calcium levels rise, which of the following hormones is secreted?
-calcitonin
25. Chloride helps maintain acid-base balance by performing which of the following roles?
-participating in the chloride shift
-To maintain acid-base balance, chloride shifts into and out of red blood cells in exchange for bicarbonate.
28. When chloride concentration drops below 95 mEq/L, reabsorption of which of the following electrolytes increases proportionally?
-bicarbonate
causing metabolic alkalosis
29. Jonas is admitted with 1,000 ml of diarrhea per day for the last 3 days. An IV of 0.45% NaCl mixed with 5% dextrose is infusing. Which of the
following nursing interventions is the most appropriate?
-Check the patient’s potassium level and contact the doctor for IV additive orders.
Potassium is lost via the GI and renal systems. Prolonged or excessive diarrhea can lead to hypokalemia. In the event of hypokalemia, a potassium
additive would likely be prescribed.
30. Mrs. Waltraud is receiving digoxin and Lasix daily. Today, she complains of nausea, and her apical pulse is 130 and irregular. Which of the
following nursing interventions is the most appropriate?
-Hold the digoxin and check the patient’s potassium level.
2. Mr. Miyazaki who is diagnosed of bipolar disorder has been drinking copious amounts of water and voiding frequently. The patient is experiencing
muscle cramps, twitching, and is reporting dizziness. the nurse checks lab work for:
-electrolytes, particularly the serum sodium
3. When teaching a patient about foods high in magnesium, the nurse would include:
-green vegetables
4. The balance of anions and cations as it occurs across cell membranes is known as:
-electrical neutrality
Electrical neutrality refers to a state in which the same number of positively charged ions and negatively charged ions are present on either side of the
membrane. Osmotic activity refers to the attraction of a solute to a solvent. Sodium-potassium pump refers to the exchange of electrolytes.
5. Maria, an 85-year-old patient with a feeding tube, has been experiencing severe watery stool. The patient is lethargic and has poor skin turgor, a
pulse of 120, and hyperactive reflexes. Nursing interventions would include:
-measuring and recording intake and output and daily weights
6. Disease of which of the following structures is most likely to affect electrolyte reabsorption?
-renal tubules
The renal tubules are the site of electrolyte reabsorption. The glomerulus is the site of electrolyte filtration. The renal pelvis is where urine travels as
it moves from the collecting ducts to the ureter.
8. Daniel who is a marathon runner is at high risk for fluid volume deficit. Which one of the following is a related factor?
-increased breathing and perspiration
9. Jomarick is diagnosed with FVD; which of the following nursing diagnoses might apply to his condition?
-decreased cardiac output
11. Sodium levels are affected by the secretion of which of the following hormones?
-ADH and ACTH
14. Annaliza has a nursing diagnosis of fluid volume deficit. Which one of the following medications could potentially exacerbate the problem?
-Lasix
15. Alexander has hypotonic FVE; which of the following findings would the nurse expect to assess in the patient?
-weight gain and thirst
19. Which of the following nursing diagnoses might apply to a patient with hypertonic FVE?
-potential for decreased cardiac output
23. The majority of the body’s water is contained in which of the following fluid compartments?
-intracellular
25. The danger of fluid sequestered in the third space is that the fluid:
-is not available for circulation
26. The extracellular fluid space holds water, electrolytes, proteins and:
-red blood cells
29. A diet containing the minimum daily sodium requirement for an adult would be:
-a diet including 2 gm sodium