1. You are caring for a patient who has a 10.
10. You are the surgical nurse caring for a
diagnosis of syndrome of inappropriate
antidiuretic hormone secretion (SIADH).
Your patients plan of care includes
assessment of specific gravity every 4 hours.
The results of this test will allow the nurse to
assess what aspect of the patients health?
- Fluid volume status
2. You are caring for a patient admitted with
a diagnosis of acute kidney injury. When you
review your most recent laboratory reports,
you note that the patients magnesium levels
are high. You should prioritize assessment
for which of the following health problems?
- Diminished deep tendon reflexes
3. You are working on a burns unit and one
of your acutely ill patients is exhibiting signs
and symptoms of third spacing. Based on
this change in status, you should expect the
patient to exhibit signs and symptoms of
what imbalance?
- Hypovolemia
4. A patient with a longstanding diagnosis of
generalized anxiety disorder presents to the
emergency room. The triage nurse notes
upon assessment that the patient is
hyperventilating. The triage nurse is aware
that hyperventilation is the most common
cause of which acidbase imbalance?
- Respiratory alkalosis
5. You are an emergency-room nurse caring
for a trauma patient. Your patient has the
following arterial blood gas results: pH 7.26,
PaCO2 28, HCO3 11 mEq/L. How would you
interpret these results?
- Metabolic acidosis with a compensatory
respiratory alkalosis
6. You are making initial shift assessments
on your patients. While assessing one
patients peripheral IV site, you note edema
around the insertion site. How should you
document this complication related to IV
therapy?
- Infiltration
7. You are performing an admission
assessment on an older adult patient newly
admitted for end-stage liver disease. What
principle should guide your assessment of
the patients skin turgor?
- Inelastic skin turgor is a normal
8. The physician has ordered a peripheral IV
to be inserted before the patient goes for
computed tomography. What should the
nurse do when selecting a site on the hand
or arm for insertion of an IV catheter?
- Consider potential effects on the
patients mobility when selecting a site.
. response?
9. A nurse in the neurologic ICU has orders
to infuse a hypertonic solution into a patient
with increased intracranial pressure. This
solution will increase the number of
dissolved particles in the patients blood,
creating pressure for fluids in the tissues to
shift into the capillaries and increase the
blood volume. This process is best described
as which of the following?
- Osmosis and osmolality
38. You are caring for a patient with a
secondary diagnosis of hypermagnesemia.
What assessment finding would be most
consistent with this diagnosis?
- Shallow respirations
17. A 73-year-old man comes into the
65-year-old female patient who is
postoperative day 1 following thyroidectomy.
During your shift assessment, the patient
complains of tingling in her lips and fingers.
She tells you that she has an intermittent
spasm in her wrist and hand and she exhibits
increased muscle tone. What electrolyte
imbalance should you first suspect?
- Hypocalcemia
11. A nurse is planning care for a nephrology
patient with a new nursing graduate. The
nurse states,
- The kidneys regenerate and reabsorb
bicarbonate to maintain a stable pH.
12. You are caring for a 65-year-old male
patient admitted to your medical unit 72
hours ago with pyloric stenosis. A
nasogastric tube placed upon admission has
been on low intermittent suction ever since.
Upon review of the mornings blood work, you
notice that the patients potassium is below
reference range. You should recognize that
the patient may be at risk for what
imbalance?
- Metabolic alkalosis
13. The nurse is preparing to insert a
peripheral IV catheter into a patient who will
require fluids and IV antibiotics. How should
the nurse always start the process of
insertion?
- Ask the patient about allergies to latex
or iodine.
14. A patient who is being treated for
pneumonia starts complaining of sudden
shortness of breath. An
arterial blood gas (ABG) is drawn. The ABG
has the following values: pH 7.21, PaCO2 64
mm Hg,
- Respiratory acidosis
15. One day after a patient is admitted to the
medical unit, you note that the patient is
oliguric. You notify the acute-care nurse
practitioner who orders a fluid challenge of
200 mL of normal saline solution over 15
minutes. This intervention will achieve which
of the following?
- Help distinguish reduced renal blood
flow from decreased renal function
16. The community health nurse is
performing a home visit to an 84-year-old
woman recovering from hip surgery. The
nurse notes that the woman seems
uncharacteristically confused and has dry
mucous membranes. When asked about her
fluid intake, the patient states, I stop drinking
water early in the day because it is just too
difficult to get up during the night to go to the
bathroom. What would be the nurses best
- Limiting your fluids can create
imbalances in your body that can result in
confusion. Maybe we need to adjust the
timing of your fluids.
The nurse is assessing the patient for the
presence of a Chvosteks sign. What
electrolyte imbalance would a positive
Chvosteks sign indicate?
- Hypocalcemia
emergency department (ED) by ambulance
after slipping on a small carpet in his home.
The patient fell on his hip with a resultant
fracture. He is alert and oriented; his pupils
are equal and reactive to light and
accommodation. His heart rate is elevated,
he is anxious and thirsty, a Foley catheter is
placed, and 40 mL of urine is present. What
is the nurses most likely explanation for the
low urine output?
- The man is having a sympathetic
reaction, which has stimulated the
reninangiotensinaldosterone
system that results in diminished urine
output.
18. A nurse educator is reviewing peripheral
IV insertion with a group of novice nurses.
How should these nurses be encouraged to
deal with excess hair at the intended site?
- Clip the hair in the area.
19. You are the nurse evaluating a newly
admitted patients laboratory results, which
include several values that are outside of
reference ranges. Which of the following
would cause the release of antidiuretic
hormone (ADH)?
- Increased serum sodium
20. A newly graduated nurse is admitting a
patient with a long history of emphysema.
The new nurses preceptor is going over the
patients past lab reports with the new nurse.
The nurse takes note that the patients
PaCO2 has been between 56 and 64 mm Hg
for several months. The preceptor asks the
new nurse why they will be cautious
administering oxygen. What is the new
nurses best response?
- Using oxygen may result in the patient
developing carbon dioxide narcosis and
hypoxemia.
21. The nurse is providing care for a patient
with chronic obstructive pulmonary disease.
When describing the process of respiration
the nurse explains how oxygen and carbon
dioxide are exchanged between the
pulmonary capillaries and the alveoli. The
nurse is describing what process?
- Diffusion
22. When planning the care of a patient with
a fluid imbalance, the nurse understands that
in the human body, water and electrolytes
move from the arterial capillary bed to the
interstitial fluid. What causes this to occur?
- Hydrostatic pressure resulting from the
pumping action of the heart
23. The baroreceptors, located in the left
atrium and in the carotid and aortic arches,
respond to changes in the circulating blood
volume and regulate sympathetic and
parasympathetic neural activity as well as
endocrine activities. Sympathetic stimulation
constricts renal arterioles, causing what
effect?
- Decrease in glomerular filtration
24. You are the nurse caring for a 77-year-
old male patient who has been involved in a
motor vehicle accident. You and your
colleague note that the patients labs indicate
minimally elevated serum creatinine levels,
which your colleague dismisses. What can
this increase in creatinine indicate in older
adults?
- Substantially reduced renal function
25. You are the nurse caring for a patient
who is to receive IV daunorubicin, a
chemotherapeutic agent. You start the
infusion and check the insertion site as per
protocol. During your most recent check, you
note that the IV has infiltrated so you stop
the infusion. What is your main concern with
this infiltration?
- Extravasation of the medication
26. The nurse caring for a patient post colon
resection is assessing the patient on the
second postoperative day. The nasogastric
tube (NG) remains patent and continues at
low intermittent wall suction. The IV is patent
and infusing at 125 mL/hr. The patient
reports pain at the incision site rated at a 3
on a 0-to-10 rating scale. During your initial
shift assessment, the patient complains of
cramps in her legs and a tingling sensation in
her feet. Your assessment indicates
decreased deep tendon reflexes (DTRs) and
you suspect the patient has hypokalemia.
What other sign or symptom would you
expect this patient to exhibit?
- Dilute urine
27. You are caring for a patient who is being
treated on the oncology unit with a diagnosis
of lung cancer with bone metastases. During
your assessment, you note the patient
complains of a new onset of weakness with
abdominal pain. Further assessment
suggests that the patient likely has a fluid
volume deficit. You should recognize that
this patient may be experiencing what
electrolyte imbalance?
- Hypercalcemia
28. A medical nurse educator is reviewing a
patients recent episode of metabolic acidosis
with members of the nursing staff. What
should the educator describe about the role
of the kidneys in metabolic acidosis?
- The kidneys excrete hydrogen ions and
conserve bicarbonate ions to help restore
balance.
29. The nurse in the medical ICU is caring
for a patient who is in respiratory acidosis
due to inadequate ventilation. What
diagnosis could the patient have that could
cause inadequate ventilation?
- Guillain-Barr syndrome
30. The ICU nurse is caring for a patient who
experienced trauma in a workplace accident.
The patient is complaining of having trouble
breathing with abdominal pain. An ABG
reveals the following results: pH 7.28,
PaCO2 50 mm Hg, HCO3 23 mEq/L. The
nurse should recognize the likelihood of what
acidbase disorder?
- Mixed acidbase disorder
31. A patient has questioned the nurses
administration of IV normal saline, asking
whether sterile water would be a more
appropriate choice than saltwater. Under
what circumstances would the nurse
administer electrolyte-free water
intravenously?
- Never, because it rapidly enters red
blood cells, causing them to rupture.
32. A gerontologic nurse is teaching students
about the high incidence and prevalence of
dehydration in older adults. What factors
contribute to this phenomenon? Select all
that apply.
- Decreased kidney mass
- Decreased renal blood flow
- Decreased excretion of potassium
33. You are called to your patients room by a
family member who voices concern about
the patients status. On assessment, you find
the patient tachypnic, lethargic, weak, and
exhibiting a diminished cognitive ability. You
also find 3+ pitting edema. What electrolyte
imbalance is the most plausible cause of this
patients signs and symptoms?
- Hyperchloremia
34. Diagnostic testing has been ordered to
differentiate between normal anion gap
acidosis and high anion
gap acidosis in an acutely ill patient. What
health problem typically precedes normal
anion gap acidosis?
- Excessive administration of chloride
orrect.
35. The nurse is caring for a patient in
metabolic alkalosis. The patient has an NG
tube to low intermittent suction for diagnosis
of bowel obstruction. What drug would the
nurse expect to find on the medication
orders?
- Cimetidine
36. You are caring for a patient with a
diagnosis of pancreatitis. The patient was
admitted from a homeless shelter and is a
vague historian. The patient appears
malnourished and on day 3 of the patients
admission total parenteral nutrition (TPN)
has been started. Why would you know to
start the infusion of TPN slowly?
- Malnourished patients receiving
parenteral nutrition are at risk for
hypophosphatemia if calories are started
too aggressively.
37. You are doing discharge teaching with a
patient who has hypophosphatemia during
his time in hospital. The patient has a diet
ordered that is high in phosphate. What
foods would you teach this patient to include
in his diet? Select all that apply.
-Milk
- Poultry
- Liver
39. A patients most recent laboratory results
show a slight decrease in potassium. The
physician has opted to
forego drug therapy but has suggested
increasing the patients dietary intake of
potassium. Which of the following would be a
good source of potassium?
- Bananas