1. Question1 point(s)
Question1 point(s)
Patient X is diagnosed with constipation. As a
knowledgeable nurse, which nursing intervention is
appropriate for maintaining normal bowel function?
A. Assessing dietary intake
B. Decreasing fluid intake
C. Providing limited physical activity
D. Turning, coughing, and deep breathing
Assessing dietary intake provides a foundation for the
client’s usual practices and may help determine if the
client is prone to constipation or diarrhea. Check out
usual dietary habits, eating habits, eating schedule,
and liquid intake. Irregular mealtime, type of food, and
interruption of the usual schedule can lead to
constipation. Assist the patient to take at least 20 g of
dietary fiber (e.g., raw fruits, fresh vegetables, whole
grains) per day.
2. Question1 point(s)
A 12-year-old boy was admitted to 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 interventions should be included
in the care plan for the client?
A. Room temperature reduction
B. Fluid restriction of 2,000 ml/day
C. Axillary temperature measurements every 4 hours
D. Antiemetic agent administration
For the patient with hyperthermia, reducing the room
temperature may help decrease the body temperature.
Tepid baths, cool compresses, and cooling blankets
may also be necessary. Adjust and monitor
environmental factors like room temperature and bed
linens as indicated. Room temperature may be
accustomed to near normal body temperature and
blankets and linens may be adjusted as indicated to
regulate the temperature of the patient.
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?
A. "I do not have to see my doctor unless I have
problems."
B. "I can stop taking my antibiotics once I am feeling
better."
C. "If I have redness, drainage, or fever, I should
call my healthcare provider."
D. "I can return to my normal activities as soon as I go
home."
The knowledge that redness, drainage, or fever — signs
of infection associated with cellular injury — require
reporting indicates that the client has understood the
nurse’s discharge teaching. If a cell is unable to adapt
to increased stress, injury results. Cell injury is
reversible until a certain threshold where it progresses
to cell death. Historically, cell death has been
designated into two classes: necrosis and apoptosis.
Necrosis is often coined as accidental death as it is
generally seen as not controlled by the cell. Apoptosis,
on the other hand, is typically viewed as programmed
cell death, regulated and controlled.
4. Question1 point(s)
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?
Select all that apply.
A. Clustering activities to allow uninterrupted periods
of rest.
B. Maintaining correct body alignment at all times.
C. Monitoring intake and output, using a urometer if
necessary.
D. Using a footboard or pillows to keep feet in the
correct position.
E. Performing active and passive range-of-motion
exercises.
F. Weighing the client daily at the same time and in the
same clothes.
Correct body alignment, preventing foot drop, and
range-of-motion exercises will help prevent
contractures. Clustering activities will help promote
adequate rest. Monitoring intake and output and
weighing the client will help maintain fluid and
electrolyte balance.
5. Question1 point(s)
A 36-year-old male client is about to be discharged
from 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?
A. Discouraging the client from eating large amounts
of roughage-containing foods in the diet.
B. Encouraging the client to use laxatives routinely to
ensure adequate bowel elimination.
C. Instructing the client to establish a bowel
evacuation schedule that changes every day.
D. Instructing the client to fill a 2-L bottle with
water every night and drink it the next day.
Adequate fluids and fiber in the diet are key to
preventing constipation. Having the client fill a 2-L
bottle with water every night and drink it the next day
is one method for ensuring the client receives at least
2,000 ml of water daily. The client also should be
instructed to drink any other fluids throughout the day.
6. Question1 point(s)
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?
A. Nutritional needs remain unchanged for the well-
nourished adult.
B. Age is an insignificant factor in cellular repair.
C. The presence of infection may slow the healing
process.
D. Tissue with inadequate blood supply may heal
faster.
Infection impairs wound healing. Adequate blood
supply is essential for healing. If inadequate, healing is
slowed. Simplistically, cell injury disrupts cellular
homeostasis. Cells are injured by numerous and
diverse causes (etiologic agents) from intrinsic and
extrinsic sources; however, all of these causes and they
number in the thousands, activate one or more of four
final common biochemical mechanisms leading to cell
injury.
7. Question1 point(s)
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?
A. Administering anti-inflammatory agents as
prescribed.
B. Elevating the injured area to decrease venous return
to the heart.
C. Keeping the skin clean and dry.
D. Applying warm packs initially to reduce edema.
Anti-inflammatory agents help reduce edema and
relieve pressure on nerve endings, subsequently
reducing pain. The burned patient may require
around-the-clock medication and dose titration. IV
method is often used initially to maximize drug effect.
8. Question1 point(s)
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?
A. Inserting an indwelling Foley catheter.
B. Having the client perform Kegel exercises.
C. Keeping the skin clean and dry.
D. Using pads or diapers on the client.
Kegel exercises, which help strengthen the muscles in
the perineal area, are used to maintain urinary
continence. 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. Question1 point(s)
Jeron is admitted to 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?
A. Prevention of fluid volume excess
B. Maintenance of adequate oxygenation
C. Education about infection prevention
D. Pain reduction
For the client with asthma and infection, oxygenation
is the priority. Maintaining adequate oxygenation
reduces the risk of physiologic injury from cellular
hypoxia, which is the leading cause of cell death. The
purpose of oxygen therapy is to maintain PaO2 above
60 mmHg. Oxygen is administered by the method that
provides appropriate delivery within the patient’s
tolerance.
10. Question1 point(s)
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?
A. Stress-reduction techniques
B. Home environment evaluation
C. Skin-care measures
D. Participation in activities of daily living
After discharge, the client is responsible for his own
care and health maintenance management. Discharge
includes assessing the home environment for
determining the client’s ability to maintain his health
at home. All instructions for care at home, including
medications, diet, therapy, and follow-up
appointments, must be explained in detail to all
patients and then presented in written form to take
home upon discharge.
11. Question1 point(s)
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?
A. Monitoring intake and output accurately.
B. Instructing the client to cough and deep breathe
every 2 hours.
C. Keeping the linens dry and wrinkle-free.
D. Using a footboard to maintain correct anatomic
position.
Keeping the linens dry and wrinkle-free aids in
preventing moisture and pressure from interfering with
adequate blood supply to the tissues, helping to
maintain skin integrity. Encourage the implementation
of a turning schedule, restricting time in one position
to 2 hours or less, if the patient is restricted to bed.
12. Question1 point(s)
Maya, who is admitted to 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?
A. Massage the reddened area for a few minutes.
B. Notify the physician immediately.
C. Arrange for a pressure-relieving device.
D. Turn the client to the right side for 2 hours.
Turning the client to the right side relieves the pressure
and promotes adequate blood supply to the left hip.
Encourage the patient to change position every 15
minutes and change chair-bound positions every hour.
During sitting, the pressure over the sacrum may
exceed 100 mm Hg. The pressure needed to close
capillaries is around 32 mm Hg; any pressure above 32
mm Hg leads to ischemia.
13. Question1 point(s)
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?
A. Administering the client's ordered pain medication
immediately.
B. Using guided imagery instead of administering pain
medication.
C. Using therapeutic conversation to try to discourage
pain medication.
D. Attempting to rule out complications before
administering pain medication.
When intervening with a client complaining of pain,
the nurse must always determine if the pain is
expected pain or a complication that requires
immediate nursing intervention. This must be done
before administering the medication. Perform a
comprehensive assessment of pain. Determine via
assessment the location, characteristics, onset,
duration, frequency, quality, and severity of pain.
14. Question1 point(s)
Nurse Martha is teaching her students about bacterial
control. Which intervention is the most important
factor in preventing the spread of microorganisms?
A. Maintenance of asepsis with indwelling catheter
insertion.
B. Use of masks, gowns, and gloves when caring for
clients with infection.
C. Correct handwashing technique.
D. Cleanup of blood spills with sodium hydrochloride.
Handwashing remains the most effective procedure for
controlling microorganisms and the incidence of
nosocomial infections. According to the Centers for
Disease Control and Prevention (CDC), hand hygiene is
the single most important practice in the reduction of
the transmission of infection in the healthcare setting.
According to the CDC, hand hygiene encompasses the
cleansing of your hands with soap and water,
antiseptic hand washes, antiseptic hand rubs such as
alcohol-based hand sanitizers, foams or gels, or
surgical hand antisepsis.
15. Question1 point(s)
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 in the care plan of Mark for his patient?
A. Administering I.V. and oral fluids.
B. Clustering necessary activities throughout the day.
C. Assessing color, odor, and amount of sputum.
D. Monitoring serum albumin and total protein levels.
The client’s assessment findings would lead the nurse
to suspect that the client is dehydrated. Administering
I.V. fluids is appropriate. Administer parenteral fluids as
prescribed. Consider the need for an IV fluid challenge
with immediate infusion of fluids for patients with
abnormal vital signs. Fluids are necessary to maintain
hydration status. Determination of the type and
amount of fluid to be replaced and infusion rates will
vary depending on clinical status.
16. Question1 point(s)
Khaleesi 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?
A. Whole grains and nuts
B. Milk products and green, leafy vegetables
C. Pork products and canned vegetables
D. Orange juice and bananas
The client with hypokalemia needs to increase the
intake of foods high in potassium. Orange juice and
bananas are high in potassium, along with raisins,
apricots, avocados, beans, and potatoes. Encourage
high potassium diet such as oranges, bananas,
tomatoes, coffee, red meat, and dried fruits. Discuss
the use of potassium chloride salt substitutes for a
client receiving long-term diuretics. Potassium may be
replaced and level maintained through the diet when
the client is allowed oral food and fluids.
17. Question1 point(s)
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?
A. Administering sodium chloride I.V.
B. Encouraging slow, deep breaths.
C. Preparing to administer sodium bicarbonate.
D. Administer low-flow oxygen therapy.
The client who is hyperventilating and subsequently
develops respiratory alkalosis is losing too much
carbon dioxide. Measures that result in the retention of
carbon dioxide are needed. Encourage slow, deep
breathing to retain carbon dioxide and reverse
respiratory alkalosis. Encourage the patient to breathe
slowly and deeply. Speak in a low, calm tone of voice.
Provide a safe environment. May help reassure and
calm the agitated patient, thereby aiding the reduction
of respiratory rate. Assists the patient to regain control.
18. Question1 point(s)
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? Fill in the blank
and write your answer as a whole number.
Correct answer: 2470 mL.
Rationale:
The fluid intake includes 8 oz (240 ml) of apple juice,
850 ml of water, 2 cups (480 ml) of beef broth, and 900
ml of I.V. fluid for a total of 2,470 ml intake for the shift.
Monitoring of intake helps caregivers ensure that the
patient has a proper intake of fluid and other nutrients.
Monitoring of output helps determine whether there is
adequate output of urine as well as normal defecation.
19. Question1 point(s)
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?
A. Positive Trousseau's sign
B. Positive Chvostek's sign
C. Tetany
D. Paresthesia
In a client with hypocalcemia, a positive Trousseau’s
sign refers to carpopedal spasm that develops usually
within 2 to 5 minutes after applying and inflating a
blood pressure cuff to about 20 mm Hg higher than
systolic pressure on the upper arm. This spasm occurs
as the blood supply to the ulnar nerve is obstructed.
20. Question1 point(s)
Lab tests revealed that patient Z’s [Na+] is 170 mEq/L.
Which clinical manifestation would nurse Natty expect
to assess?
A. Tented skin turgor and thirst
B. Muscle twitching and tetany
C. Fruity breath and Kussmaul's respirations
D. Muscle weakness and paresthesia
Hypernatremia refers to elevated serum sodium levels,
usually above 145 mEq/L. Typically, the client exhibits
tented skin turgor and thirst in conjunction with dry,
sticky mucous membranes, lethargy, and restlessness.
Most patients present with symptoms suggestive of
fluid loss and clinical signs of dehydration. Symptoms
and signs of hypernatremia are secondary to central
nervous system dysfunction and are seen when serum
sodium rises rapidly or is greater than 160 meq/L.
21. Question1 point(s)
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?
A. High PCO2
B. Low PO2
C. Normal pH
D. Normal bicarbonate (HCO3)
A chronically elevated PCO2 level (above 50 mmHg) is
associated with inadequate response of the respiratory
center to plasma carbon dioxide. The major stimulus
to breathing then becomes hypoxia (low PO2). High
PCO2 and normal pH and HCO3 levels would not be the
primary stimulus for breathing in this client.
22. Question1 point(s)
A client with a very dry mouth, skin, and mucous
membranes is diagnosed with dehydration. Which
intervention should the nurse perform when caring for
a client diagnosed with fluid volume deficit?
A. Assessing urinary intake and output.
B. Obtaining the client's weight weekly at different
times of the day.
C. Monitoring arterial blood gas (ABG) results.
D. Maintaining I.V. therapy at the keep-vein-open rate.
For the client with fluid volume deficit, assessing the
client’s urine output (using a urometer if necessary) is
essential to ensure an output of at least 30 ml/hour.
Assess color and amount of urine. Report urine output
less than 30 ml/hr for 2 consecutive hours. A normal
urine output is considered normal not less than
30ml/hour. Concentrated urine denotes fluid deficit.
23. Question1 point(s)
Which client situation requires the nurse to discuss the
importance of avoiding foods high in potassium?
A. A 14-year-old who is taking diuretics.
B. A 16-year-old with ileostomy.
C. A 16-year-old with metabolic acidosis.
D. An 18-year-old who has renal disease.
Clients with renal disease are predisposed to
hyperkalemia and should avoid foods high in
potassium. Clients receiving diuretics, with
ileostomies, or with metabolic acidosis may be
hypokalemic and should be encouraged to eat foods
high in potassium. Encourage intake of carbohydrates
and fats and low potassium food such as pineapple,
plums, strawberries, carrots, cauliflower, corn, and
whole grains. Reduces exogenous sources of
potassium and prevents metabolic tissue breakdown
with the release of cellular potassium.
24. Question1 point(s)
Genevieve is diagnosed with hypomagnesemia, which
nursing intervention would be appropriate?
A. Instituting seizure precaution to prevent injury.
B. Instructing the client on the importance of
preventing infection.
C. Avoiding the use of tight tourniquet when drawing
blood.
D. Teaching the client the importance of early
ambulation.
Instituting seizure precaution is an appropriate
intervention because the client with hypomagnesemia
is at risk for seizures. Changes in mentation or the
development of seizure activity in severe low
magnesium increase the risk of client injury. Provide a
quiet environment and subdued lighting. Reduces
extraneous stimuli; promotes rest.
25. Question1 point(s)
Which electrolyte would the nurse identify as the
major electrolyte responsible for determining the
concentration of the extracellular fluid?
A. Potassium
B. Phosphate
C. Chloride
D. Sodium
Sodium is the electrolyte whose level is the primary
determinant of the extracellular fluid concentration.
Sodium a cation (e.g., positively charged ion), is the
major electrolyte in extracellular fluid. Sodium, which
is an osmotically active anion, is one of the most
important electrolytes in the extracellular fluid. It is
responsible for maintaining the extracellular fluid
volume, and also for regulation of the membrane
potential of cells. Sodium is exchanged along with
potassium across cell membranes as part of active
transport.
26. Question1 point(s)
Jon has a potassium level of 6.5 mEq/L, which
medication would nurse Wilma anticipate?
A. Potassium supplements
B. Kayexalate
C. Calcium gluconate
D. Sodium tablets
The client’s potassium level is elevated; therefore,
Kayexalate would be ordered to help reduce the
potassium level. Kayexalate is a cation-exchange resin,
which can be given orally, by nasogastric tube, or by
retention enema. Potassium is drawn from the bowel
and excreted through the feces.
27. Question1 point(s)
Which clinical manifestation would lead the nurse to
suspect that a client is experiencing
hypermagnesemia?
A. Muscle pain and acute rhabdomyolysis
B. Hot flushed skin and diaphoresis
C. Soft-tissue calcification and hyperreflexia
D. Increased respiratory rate and depth
Hypermagnesemia is manifested by hot, flushed skin
and diaphoresis. The client also may exhibit
hypotension, lethargy, drowsiness, and absent deep
tendon reflexes. The most frequent symptoms and
signs may include weakness, nausea, dizziness, and
confusion (less than 7.0 mg/dL). Increasing values (7 to
12 mg/dL) induce decreased reflexes, worsening
confusional state, drowsiness, bladder paralysis,
flushing, headache, and constipation.
28. Question1 point(s)
Joshua is receiving furosemide and Digoxin, which
laboratory data would be the most important to assess
in planning the care for the client?
A. Sodium level
B. Magnesium level
C. Potassium level
D. Calcium 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. Most cases of hypokalemia
result from gastrointestinal (GI) or renal losses. Renal
potassium losses are associated with increased
mineralocorticoid-receptor stimulation such as occurs
with primary hyperreninism and primary
aldosteronism.
29. Question1 point(s)
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?
A. Instructing the client to breathe slowly into a paper
bag.
B. Administering low-flow oxygen.
C. Encouraging the client to cough and deep
breathe.
D. Nothing, because these ABG values are within
normal limits.
The ABG results indicate respiratory acidosis requiring
improved ventilation and increased oxygen to the
lungs. Coughing and deep breathing can accomplish
this. Encourage and assist with deep-breathing
exercises, turning, and coughing. Suction as necessary.
Provide airway adjunct as indicated. Place in semi-
Fowler’s position. These measures improve lung
ventilation and reduce or prevent airway obstruction
associated with the accumulation of mucus.
30. Question1 point(s)
A client is diagnosed with metabolic acidosis, which
would the nurse expect the health care provider to
order?
A. Potassium
B. Sodium bicarbonate
C. Serum sodium level
D. Bronchodilator
Metabolic acidosis results from excessive absorption or
retention of acid or excessive excretion of bicarbonate.
A base is needed. Sodium bicarbonate is a base and is
used to treat documented metabolic acidosis. The
management of metabolic acidosis should address the
cause of the underlying acid-base derangement. For
example, adequate fluid resuscitation and correction
of electrolyte abnormalities are necessary for sepsis
and diabetic ketoacidosis. Potassium, serum sodium
determinations, and a bronchodilator would be
inappropriate orders for this client.
1. Question1 point(s)
Lee Angela’s lab test just revealed that her chloride
level is 96 mEq/L. As a nurse, you would interpret this
serum chloride level as:
A. High
B. Low
C. Within normal range
D. High normal
Normal serum concentrations of chloride range from
95 to 108 mEq/L. Chloride is an anion found
predominantly in the extracellular fluid. The kidneys
predominantly regulate serum chloride levels. Most of
the chloride, which is filtered by the glomerulus, is
reabsorbed by both proximal and distal tubules
(majorly by proximal tubule) by both active and
passive transport.
2. Question1 point(s)
Which of the following conditions is associated with
elevated serum chloride levels?
A. Cystitis
B. Diabetes
C. Eclampsia
D. Hypertension
Eclampsia is associated with increased levels of serum
chloride. Metabolic alkalosis is uncommon in
pregnancy and is most often the result of severe
vomiting. If this is present at the time of delivery,
transient metabolic derangement in the fetus can
occur, potentially requiring additional organ support.
3. Question1 point(s)
In the extracellular fluid, chloride is a major:
A. Compound
B. Ion
C. Anion
D. Cation
Chloride is a major anion found in the extracellular
fluid. Chloride is an inorganic anionic halogen with an
atomic weight of 35.5. It is distributed exclusively
within the extracellular fluid compartment (ECF),
which comprises the blood/plasma (or serum)
compartment and the interstitial fluid compartment.
Chloride is the major anion associated with sodium in
the ECF.
4. Question1 point(s)
Nursing intervention for the patient with
hyperphosphatemia includes encouraging intake of:
A. Vitamin D
B. Fleets phospho-soda
C. Milk
D. Amphojel
Administration of phosphate binders (amphojel and
basagel) will reduce the serum phosphate levels.
Aluminum hydroxide (brand names: Alternagel®,
Amphojel®) is an over-the-counter oral antacid and
phosphate binder, most commonly used to treat high
phosphate levels secondary to kidney dysfunction
(abnormal or impaired function of the kidneys). It can
also be used to reduce stomach acid production.
5. Question1 point(s)
Etiologies associated with hypocalcemia may include
all of the following except:
A. Renal failure
B. Inadequate intake calcium
C. Metastatic bone lesions
D. Vitamin D deficiency
Metastatic bone lesions are associated with
hypercalcemia due to accelerated bone metabolism
and release of calcium into the serum. Although more
common in adults than pediatric patients, the next
important etiology to consider is malignancy. Renal
carcinomas, leukemias, lymphomas, and
rhabdomyosarcoma can be associated with elevated
calcium levels mediated by the action of PTH-related
peptides. Renal failure, inadequate calcium intake, and
vitamin D deficiency may cause hypocalcemia.
6. Question1 point(s)
Which of the following findings would the nurse expect
to assess in hypercalcemia?
A. Prolonged QRS complex
B. Tetany
C. Petechiae
D. Urinary calculi
Urinary calculi may occur with hypercalcemia.
Symptoms of hypercalcemia are usually seen when
serum calcium levels are more than 12 mg/dl.
Irrespective of the etiology, the broad signs and
symptoms can be summarized as “groans, bones,
stones, moans, thrones and psychic overtones”. Tetany
and petechiae are signs of hypocalcemia.
7. Question1 point(s)
Which of the following is not an appropriate nursing
intervention for a patient with hypercalcemia?
A. Administering calcitonin
B. Administering calcium gluconate
C. Administering loop diuretics
D. Encouraging ambulation
Calcium gluconate is used for replacement in
deficiency states. Calcium gluconate, gluceptate, or
chloride (IV) provides rapid treatment in acute calcium
deficit, especially in the presence of tetany or
convulsions. Calcitonin and loop diuretics are used to
lower serum calcium.
8. Question1 point(s)
A patient in which of the following disorders is at high
risk to develop hypermagnesemia?
A. Insulin shock
B. Hyperadrenalism
C. Nausea and vomiting
D. Renal failure
Renal failure can reduce magnesium excretion, leading
to hypermagnesemia. Hypermagnesemia refers to an
excess amount of magnesium in the bloodstream. It is
rare and is usually caused by renal failure or poor
kidney function. Magnesium is a mineral the body uses
as an electrolyte, meaning it carries electric charges
around the body when dissolved in the blood.
9. Question1 point(s)
Nursing interventions for a patient with
hypermagnesemia include administering calcium
gluconate to:
A. Increase calcium levels.
B. Antagonize the cardiac effects of magnesium.
C. Lower calcium levels.
D. Lower magnesium levels.
In a patient with hypermagnesemia, administration of
calcium gluconate will antagonize the cardiac effects
of magnesium. Calcium may moderate nerve and
muscle performance in hypermagnesemia. Calcium
gluconate (Kalcinate) directly antagonizes
neuromuscular and cardiovascular effects of
magnesium. Use in patients with symptomatic
hypermagnesemia that is causing cardiac effects or
respiratory distress.
10. Question1 point(s)
For a patient with hypomagnesemia, which of the
following medications may become toxic?
A. Lasix
B. Digoxin
C. Calcium gluconate
D. CAPD
In hypomagnesemia, a patient on digoxin is likely to
develop digitalis toxicity. Magnesium deficiency was
the most frequently identified significant electrolyte
disturbance in relation to digoxin toxicity. In the
presence of magnesium deficiency digoxin toxicity
developed at relatively low serum digoxin
concentrations. Neither A nor C has toxicity as a side
effect.
11. Question1 point(s)
Which of the following is the most important physical
assessment parameter the nurse would consider when
assessing fluid and electrolyte imbalance?
A. Skin turgor
B. Intake and output
C. Osmotic pressure
D. Cardiac rate and rhythm
Cardiac rate and rhythm are the most important
physical assessment parameter to measure. Skin
turgor, intake, and output are physical assessment
parameters a nurse would consider when assessing
fluid and electrolyte imbalance, but choice d is the
most important. Tachycardia and hypertension are
common manifestations. Tachypnea is usually present
with or without dyspnea. Elevated CVP may be noted
before dyspnea and adventitious breath sounds occur.
Hypertension may be a primary disorder or occur
secondary to other associated conditions such as heart
failure.
12. Question1 point(s)
Insensible fluid losses include:
A. Urine
B. Gastric drainage
C. Bleeding
D. Perspiration
Perspiration and the fluid lost via the lungs are termed
insensible losses; normally, insensible losses equal
about 1000 cc/day. Insensible fluid loss is the amount
of body fluid lost daily that is not easily measured,
from the respiratory system, skin, and water in the
excreted stool. The exact amount is unmeasurable but
is estimated to be between 40 to 800mL/day in the
average adult without comorbidities.
13. Question1 point(s)
Which of the following intravenous solutions would be
appropriate for a patient with severe hyponatremia
secondary to syndrome of inappropriate antidiuretic
hormone (SIADH)?
A. Hypotonic solution
B. Hypertonic solution
C. Isotonic solution
D. Normotonic solution
When hyponatremia is severe, hypertonic solutions
may be used but should be infused with caution due to
the potential for the development of CHF. This water
retention dilutes serum sodium levels, making the
patient hyponatremic and necessitating the
administration of hypertonic solutions to balance
sodium and water.

14. Question1 point(s)
Aldosterone secretion in response to fluid loss will
result in which one of the following electrolyte
imbalances?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypernatremia
Aldosterone is secreted in response to fluid loss.
Aldosterone causes sodium reabsorption and
potassium elimination, further exacerbating
hypokalemia. Aldosterone causes sodium to be
absorbed and potassium to be excreted into the lumen
by principal cells. In alpha intercalated cells, located in
the late distal tubule and collecting duct, hydrogen
ions and potassium ions are exchanged. Hydrogen is
excreted into the lumen, and the potassium is
absorbed.
15. Question1 point(s)
When assessing a patient for signs of fluid overload,
the nurse would expect to observe:
A. Bounding pulse
B. Flat neck veins
C. Poor skin turgor
D. Vesicular
Bounding pulse is a sign of fluid overload as more
volume in the vessels causes a stronger sensation
against the blood vessel walls. Assess for bounding
peripheral pulses and S3. These assessment findings
are signs of fluid overload.
16. Question1 point(s)
The physician has ordered IV replacement of
potassium for a patient with severe hypokalemia. The
nurse would administer this:
A. By rapid bolus
B. Diluted in 100 cc over 1 hour
C. Diluted in 10 cc over 10 minutes
D. IV push
Potassium must be well diluted and given slowly
because rapid administration will cause cardiac arrest.
Intravenous KCl may be used as an alternative in these
cases if the patient cannot tolerate oral KCl. Severe
(less than 2.5 mEq/L) or symptomatic hypokalemia
necessitates intravenous administration of KCl.
17. Question1 point(s)
Which of the following findings would the nurse expect
to assess in a patient with hypokalemia?
A. Hypertension
B. pH below 7.35
C. Hypoglycemia
D. Hyporeflexia
Hyporeflexia is a symptom of hypokalemia. Significant
muscle weakness occurs at serum potassium levels
below 2.5 mmol/L but can occur at higher levels if the
onset is acute. Similar to the weakness associated with
hyperkalemia, the pattern is ascending in nature
affecting the lower extremities, progressing to involve
the trunk and upper extremities, and potentially
advancing to paralysis.
18. Question1 point(s)
Vien is receiving oral potassium supplements for his
condition. How should the supplements be
administered?
A. Undiluted
B. Diluted
C. On an empty stomach
D. At bedtime
Oral potassium supplements are known to irritate
gastrointestinal (GI) mucosa and should be diluted.
Mild to moderate hypokalemia is typically treated with
oral potassium supplements. Providing 60 to 80
mmol/day in divided doses over days to weeks is
usually sufficient. Oral supplementation can irritate GI
mucosa leading to bleeding and/or ulceration but is
associated with a lower risk of rebound hyperkalemia.
It should be taken with plenty of fluids and food.
19. Question1 point(s)
Normal venous blood pH ranges from:
A. 6.8 to 7.2
B. 7.31 to 7.41
C. 7.35 to 7.45
D. 7.0 to 8.0
Normal venous blood pH ranges from 7.31 to 7.41.
Normal arterial blood pH ranges from 7.35 to 7.45.
Blood gas analysis is a commonly used diagnostic tool
to evaluate the partial pressures of gas in blood and
acid-base content. Understanding and use of blood gas
analysis enable providers to interpret respiratory,
circulatory, and metabolic disorders.
20. Question1 point(s)
Respiratory regulation of acids and bases involves:
A. Hydrogen
B. Hydroxide
C. Oxygen
D. Carbon dioxide
Respiratory regulation of acid-base balance involves
the elimination or retention of carbon dioxide. Arterial
blood gas interpretation is best approached
systematically. Interpretation leads to an
understanding of the degree or severity of
abnormalities, whether the abnormalities are acute or
chronic, and if the primary disorder is metabolic or
respiratory in origin.
21. Question1 point(s)
To determine if a patient’s respiratory system is
functioning, the nurse would assess which of the
following parameters:
A. Respiratory rate
B. Pulse
C. Arterial blood gas
D. Pulse oximetry
Arterial blood gases will indicate CO2 and O2 levels.
This is an indication that the respiratory system is
functioning. Blood gas analysis is a commonly used
diagnostic tool to evaluate the partial pressures of gas
in blood and acid-base content. Understanding and
use of blood gas analysis enable providers to interpret
respiratory, circulatory, and metabolic disorders.
22. Question1 point(s)
Which of the following conditions is an equal decrease
of extracellular fluid (ECF) solute and water volume?
A. Hypotonic FVD
B. Isotonic FVD
C. Hypertonic FVD
D. Isotonic FVE
Isotonic FVD involves an equal decrease in solute
concentration and water volume. ISOTONIC FLUID
VOLUME deficit is a proportionate loss of sodium and
water. Characterized by decreased extracellular fluid,
including decreased circulating blood volume, isotonic
fluid volume deficit results in signs and symptoms of
dehydration. Common causes include vomiting,
diarrhea, and polyuria.
23. Question1 point(s)
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:
A. 0.25 lb
B. 0.50 lb
C. 1 lb
D. 1 kg
Weight loss of more than 0.50 lb. is considered to be a
fluid loss. Weigh daily with the same scale, and
preferably at the same time of day. Weight is the best
assessment data for possible fluid volume imbalance.
An increase of 2 lbs a week is considered normal.
24. Question1 point(s)
Dietary recommendations for a patient with a
hypotonic fluid excess should include:
A. Decreased sodium intake
B. Increased sodium intake
C. Increased fluid intake
D. Intake of potassium-rich foods
Hypotonic fluid volume excess (FVE) involves an
increase in water volume without an increase in
sodium concentration. Increased sodium intake is part
of the management of this condition. Hypotonic
dehydration occurs when sodium loss is greater than
water loss, resulting in a decrease in serum osmolality.
This causes a shift of water from the extracellular space
into the intracellular space. The cells swell and
cerebral edema may occur.
25. Question1 point(s)
Osmotic pressure is created through the process of:
A. Osmosis
B. Diffusion
C. Filtration
D. Capillary dynamics
In diffusion, the solute moves from an area of higher
concentration to one of lower concentration, creating
osmotic pressure. There is a form of passive transport
called facilitated diffusion. It occurs when molecules
such as glucose or amino acids move from high
concentration to low concentration facilitated by
carrier proteins or pores in the membrane.
26. Question1 point(s)
A rise in arterial pressure causes the baroreceptors and
stretch receptors to signal an inhibition of the
sympathetic nervous system, resulting in:
A. Decreased sodium reabsorption
B. Increased sodium reabsorption
C. Decreased urine output
D. Increased urine output
Arterial baroreceptors and stretch receptors help
maintain fluid balance by increasing urine output in
response to a rise in arterial pressure. Baroreceptors
are sensitive to the rate of pressure change as well as
to the steady or mean pressure. Therefore, at a given
mean arterial pressure, decreasing the pulse pressure
(systolic minus diastolic pressure) decreases the
baroreceptor firing rate. This is important during
conditions such as hemorrhagic shock in which pulse
pressure, as well as mean pressure, decreases. The
combination of reduced mean pressure and reduced
pulse pressure amplifies the baroreceptor response.
27. Question1 point(s)
Normal serum sodium concentration ranges from:
A. 120 to 125 mEq/L
B. 125 to 130 mEq/L
C. 136 to 145 mEq/L
D. 140 to 148 mEq/L
Normal serum sodium level ranges from 136 to 145
mEq/L. Sodium, which is an osmotically active anion,
is one of the most important electrolytes in the
extracellular fluid. It is responsible for maintaining the
extracellular fluid volume, and also for regulation of
the membrane potential of cells. Sodium is exchanged
along with potassium across cell membranes as part of
active transport.
28. Question1 point(s)
When assessing a patient for electrolyte balance, the
nurse is aware that etiologies for hyponatremia
include:
A. Water gain
B. Diuretic therapy
C. Diaphoresis
D. All of the following
Water gain, diuretic therapy, and diaphoresis are
etiologies of hyponatremia. The etiology of
hyponatremia can be classified based upon the
volume status of the extracellular fluid. Sodium is the
major solute of extracellular fluid (ECF). Based upon
the volume of ECF, a patient can be classified into
hypovolemic, euvolemic, or hypervolemic.

29. Question1 point(s)

Nursing interventions for a patient with hyponatremia

include:
A. Administering hypotonic IV fluids.
B. Encouraging water intake.
C. Restricting fluid intake.
D. Restricting sodium intake.
Hyponatremia involves a decreased concentration of
sodium in relation to fluid volume, so restricting fluid
intake is indicated. In the presence of fluid excess or
SIADH, fluid restriction is indicated while in the
presence of hypovolemia, volume losses are replaced
with isotonic saline, or, on occasion, hypertonic
solution when hyponatremia is life-threatening.

30. Question1 point(s)

The nurse would analyze an arterial pH of 7.46 as

indicating:
A. Acidosis
B. Alkalosis
C. Homeostasis
D. Neutrality

Alkalosis is indicated by a pH above 7.45. A pH below

7.35 is an acidemia, and a pH above 7.45 is an
alkalemia. Due to the importance of sustaining a pH
level in the needed narrow range, the human body
contains compensatory mechanisms.