MIDTERM UNIT TEST NCM 112 LEC

1. A client is being seen in the clinic to rule out (R/O) mitral valve stenosis. Which
assessment data would be most significant?
 The client complains of shortness of breath when walking.

2. Which assessment data would the nurse expect to auscultate in the client
diagnosed with mitral valve insufficiency?
 A holosystolic murmur heard best at the cardiac apex.

3. The client has just received a mechanical valve replacement. Which behavior by
the client indicates the client needs more teaching?
 The client takes an enteric-coated aspirin daily.

4. The nurse is teaching a class on valve replacements. Which statement identifies

a disadvantage of having a biological tissue valve replacement?
 The valve has to be replaced frequently.

5. The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant,

to a client with a mechanical valve replacement. The client’s INR is 2.7. Which
action should the nurse implement?
 Administer the medication as ordered.

6. Which signs/symptoms should the nurse assess in any client who has a long-
term valvular heart disease? Select all that apply.
 Paroxysmal nocturnal dyspnea.
 Cough.
 Orthopnea.

7. The client is being evaluated for valvular heart disease. Which information would
be most significant?
 The client has a history of rheumatic heart disease.

8. The client who has just had a percutaneous balloon valvuloplasty is in the
recovery room. Which intervention should the Post Anesthesia Care Unit nurse
implement?
 Keep the client’s affected leg straight.

9. The client with a mechanical valve replacement asks the nurse, “Why do I have
to take antibiotics before getting my teeth cleaned?” Which response by the
nurse is most appropriate?
 “You are at risk of developing an infection in your heart.”

10. The client had open-heart surgery to replace the mitral valve. Which intervention
should the intensive care unit nurse implement?
 Restrict the client’s fluids as ordered.
11. Which client would the nurse suspect of having a mitral valve prolapse?
 A 23-year-old male with Marfan’s syndrome.

12. The charge nurse is making shift assignments. Which client would be most
appropriate for the charge nurse to assign to a new graduate who just completed
orientation to the medical floor?
 The client three (3) days post–myocardial infarction being discharged
tomorrow.

13. Patient Rhasta man hapman hamzombie is diagnosed with constipation. As a

knowledgeable nurse, which nursing intervention is appropriate for maintaining
normal bowel function?
 Assessing dietary intake

14. Patient Kalbong Bato with tented skin turgor, dry mucous membranes, and
decreased urinary output is under nurse Mark’s care. Which nursing intervention
should be included in the care plan of Mark for his patient?
 Administering I.V. and oral fluids.

15. Rhastaman hapman hapzombie is admitted to the hospital due to having a 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 bananas

16. nanay leni, 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.

17. Sanaoil kiko'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

18. Manny Pabahay 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

19. Which client situation requires the nurse to discuss the importance of avoiding
foods high in potassium?
 An 18-year-old who has renal disease.
20. Isko etneb is diagnosed with hypomagnesemia, which nursing intervention would
be appropriate?
 Instituting seizure precaution to prevent injury.

21. Which electrolyte would the nurse identify as the major electrolyte responsible for
determining the concentration of the extracellular fluid?
 Sodium

22. Jon has a potassium level of 6.5 mEq/L, which medication would nurse Wilma
anticipate?
 Kayexalate

23. Juswa is receiving furosemide and Digoxin, which laboratory data would be the
most important to assess in planning the care for the client?
 Potassium level

24. 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.

25. A client is diagnosed with metabolic acidosis, which would the nurse expect the
health care provider to order?
 Sodium bicarbonate

26. Bongbong putobong’s lab test just revealed that her chloride level is 96 mEq/L.
As a nurse, you would interpret this serum chloride level as:
 Within normal range

27. In the extracellular fluid, chloride is a major:

 Anion

28. Etiologies associated with hypocalcemia may include all of the following except:
 Metastatic bone lesions

29. Which of the following findings would the nurse expect to assess in
hypercalcemia?
 Urinary calculi
30. Which of the following is not an appropriate nursing intervention for a patient with
hypercalcemia?
 Administering calcium gluconate

31. Nursing interventions for a patient with hypermagnesemia include administering

calcium gluconate to:
 Antagonize the cardiac effects of magnesium.

32. 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

33. Insensible fluid losses include:

 Perspiration

34. 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

35. Aldosterone secretion in response to fluid loss will result in which one of the
following electrolyte imbalances?
 Hypokalemia

36. Normal venous blood pH ranges from:

 7.31 to 7.41

37. Which of the following conditions is an equal decrease of extracellular fluid (ECF)
solute and water volume?
 Isotonic FVD

38. Dietary recommendations for a patient with a hypotonic fluid excess should
include:
 Increased sodium intake

39. Osmotic pressure is created through the process of:

 Diffusion

40. When assessing a patient for electrolyte balance, the nurse is aware that
etiologies for hyponatremia include:
 AOTA

41. A nurse is caring for a client with a nasogastric tube that is attached to low
suction. The nurse monitors the client knowing that the client is at risk for which
of the following acid-base disorder?
 Metabolic alkalosis
42. A nurse caring for a client with hypocalcemia would expect to note which of the
following changes on the electrocardiogram?
 Prolonged QT interval

43. A nurse caring for a group of client reviews the electrolyte laboratory results and
notes a potassium level of 5.3 meq/L on one client’s laboratory result. The nurse
understands that which of the following is the reason for the patient’s potassium
level?
 The client who has sustained traumatic burn

44. A nurse reviews the electrolyte results of an assigned client and notes that the
potassium level is 5.4 meq/L. Which of the following would the nurse expect to
note on the ECG as a result of the laboratory value?
 Tall peaked T waves

45. A nurse assigned to care for a group of clients. On review of the client’s medical
records, the nurse determines that which client is at risk for fluid volume deficit?
 A client with colostomy

46. A nurse is instructing a patient with hypokalemia about diet. Which of the
following food will the nurse advised to the patient to consume?
 Spinach

47. A nurse is caring for a client with chronic renal failure. Blood gas results indicate
a PH of 7.30, PCO2: 32, and bicarbonate of 20 meq/l. The nurse has determined
that the client is experiencing metabolic acidosis. Which of the following
laboratory values would the nurse expect to note?
 Potassium level of 5.2 meq/l

48. A nurse reviews the blood gas results of a client with GBS. The nurse analyse
the results and determine that the client is experiencing respiratory acidosis.
Which of the following validates the nurse’s finding?
 Ph: 7.25, PCO2: 50 mmhg

49. A nurse plans care for a client with COPD, knowing that the client is most likely to
experience what type of acid-base imbalance?
 Respiratory acid

50. A nurse reviews the arterial blood gas results of a client and notes the following:
pH 7.45, Pco2 of 30mmHg, and bicarbonate concentration of 22 mEq/L. The
nurse analyzes these results as indicating
 Respiratory alkalosis, Fully compensated.