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 2 . Providing limited physical activity 4d. Turning, coughing, and deep breathing ‘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? a, Room temperature reduction b. Fluid restriction of 2,000 mi/day c. Axillary temperature measurements every 4 8 hours 4d. Antiemetic agent administration “Tom is ready to be discharged from the medical-surgical unit after 5 days of hospitalization. Which dient statement indicates to the nurse that Tom understands the discharge teaching about cellular injury? a. “Ido not have to see my doctor unless i have problems.” 9. “L-can stop taking my antibiotics once I am feeling better.” ¢. “If Ihave redness, drainage, or fever, I should call my healthcare provider.” “T-can return to my normal activities as soon as T go home.” Nurse Katee is caring for Adam, a 22-year-old client, in a long-term facility. All of the following nursing 10, interventions would be appropriate in promoting and preventing contractures except: a. Maintaining correct body alignment b. Using a footboard for correct foot alignment ‘c._Performing active and passive range of motion d. Weighing client at the same ‘everyday wearing the same clothes ‘A 36-year-old male client is about to be discharged from 11 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? ‘a. Discouraging the client from eating large ‘amounts of roughage-containing foods in the det. 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. 12 4. Instructing the client to fill a 2-L bottle with water every night and drink it the next day, Mr. MePartiin suffered abrasions and lacerations after 2 vehicular accident. He was hospitalized and was treated for a couple of weeks. When planning care for a client with celular injury, the nurse should consider which scientific rationale? ‘a. Nutritional needs remain unchanged for the well-nourished adutt, ‘Age is an insignificant factor in cellular repair. The presence of infection may slow the healing process. d. Tissue with inadequate blood supply may heal faster. AA 22-year-old lady is displaying facial grimaces during her treatment in the hospital due to burn trauma. Which ‘ursing intervention should be included for reducing pain due to cellular injury? a. Administering anti-inflammatory agents as prescribed . Elevating the injured area to decrease venous return to the heart & _ Keeping the skin clean and dry 6. Applying warm packs intially to reduce edema isa, a client with altered urinary function, is under the care of nurse Tine. Which intervention is appropriate to Incude 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 Keeping the skin clean and dry . Using pads or diapers on the client 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? ‘a. Prevention of fluid volume excess b. Maintenance of adequate oxygenation Education about infection prevention Pain reduction 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? ‘a. Stress-reduction techniques b. Home environment evaluation &Skin-care measures . Participation in activities of daily living 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 Keeping the linens dry and wrinkle free 6. Using a foot board to maintain correct anatomic Position 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 lft hip. Which should the nurse do first? ‘a, Massage the reddened are for a few minutes b. Notify the physician immediately Arrange for a pressure-relieving device . Turn the client to the right side for 2 hours13, 14, 15, 16, 17, 18, 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 Using guided imagery instead of administering pain medication Using therapeutic conversation to try to discourage pain medication d. Attempting to rule out complications before administering pain medication ‘Nurse Martha is teaching her students about bacterial Control. Which intervention is the most important factor in preventing the spread of microorganism? ‘a. Maintenance of asepsis with indwelling catheter Insertion Use of masks, gowns, and gloves when caring for dlients with infection Correct handwashing technique 4d. Cleanup of blood spils with sodium hydrochloride 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? a. Administering LV. and oral fluids . Clustering necessary activities throughout the day &_ Assessing color, odor, and amount of sputum 4. Monitoring serum albumin and total protein levels khaleesi is admitted in the hospital due to having lower than normal potassium level in her bloodstream. Her ‘medical history reveals vomiting and diarthea prior to hospitalization. Which foods should the nurse instruct the lent to increase? Whole grains and nuts . Milk products and green, leafy vegetables Pork products and canned vegetables d. Orange juice and bananas Mary Jean, a first year nursing student, was rushed to the clinic department due to hyperventilation. Which ‘ursing intervention is the most appropriate for the client who is subsequentiy developing respiratory alkalosis? a. Administering sodium chloride LV. b. Encouraging stow, deep breaths Preparing to administer sodium bicarbonate . Administer low-flow oxygen therapy ‘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 mililiters should the rhurse document as the client's intake. 2,230 b. 2,740 < 2470 4. 2,320 19, 21. 24, 25. ‘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? 2. Positive Trousseau's sign b. Positive Chvostek’s sign . Tetany d. Paresthesia Lab tests revealed that patient 2'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 ‘Mang Teban has a history of chronic obstructive pulmonary disease and has the following arterial blood {gas results: partial pressure of oxygen (P02), 55 mm Hg, and partial pressure of carbon dioxide (PCO2), 60 mm Hg. When attempting to improve the clent’s blood gas values through improved ventilation and oxygen therapy, which is the clients primary stimulus for breathing? ‘a. High PCO b. Low Po2 Normal pH d. Normal bicarbonate (HCO3) ‘A dient with very dry mouth, skin and mucous ‘membranes Is diagnosed of having dehydration. Which intervention should the nurse perform when caring for a lent 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 LV. therapy at the keep-vein-open rate Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium? ‘a. 14-year-old Elena who is taking diuretics . 16-year-old John Joseph with ileostomy 16-year-old Gabriel with metabolic acidosis, d. 18-year-old Albert who has renal disease Genevieve is diagnosed with hyperkalemia, which ‘hursing intervention would be appropriate? ‘a. _Instituting seizure precaution to prevent injury . Instructing the client on the importance of Preventing infection c. Checking that the blood to be administered is fresh d. Teaching the client the importance of early ambulation Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid? ‘a. Potassium b. Phosphate Chloride d. Sodium26. 2. 28. 29. 30. a. 22 3B. Jon has a potassium level of 6.5 mEq/L, which ‘medication would nurse Wilma anticipate? ‘a. Potassium supplements, b. Kayexalate Calum gluconate d. Sodium tablets \Which clinica finding would be seen in a patient having fluid volume excess? ‘a. Decreased urine output b. CVP reading of 15 cmH20 c.Specfic gravity of 1.050, d. Dry skin Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to assess in planning the care for the cent? 2. Sodium level b. Magnesium level Potassium level d. Calcium level Mr. Salcedo has the folowing 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 fn these results, which intervention should the nurse Implement? ‘2. Instructing the client to breathe slowly into a paper bag ‘Administering low-flow oxygen Encouraging the client to cough and deep breathe d. Nothing, because these ABG values are within ‘normal limits ‘A dient is diagnesed 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 ‘A nurse is reading a physician’s progress notes in the client's record and reads that the physician has documented "Insensibe fluid loss of approximately 800m! dally.” The nurse understands that this type of fluid loss can occur through: a. The skin b. Urinary output Wound drainage 4d. The gastrointestinal tract ‘A nurse Is assigned to care for a group of clients. On review of the dent's medical records, the nurse determines that which client is at risk for deficient fuid volume? ‘a. Adiient with a colostomy b. Aclent with congestive heart failure c.Aclient with decreased kidney function d.__Aciient receiving frequent wound irrigation ‘A nurse caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition? 35, 36. 37, ‘Lung congestion Decreased hematocrit Increased blood pressure |. Decreased central venous pressure ‘A nurse is assigned to care for a group of clients. On review of the clients medical records, the nurse determines that which client is at risk for excess fluid volume? ‘a. The client taking diuretics b. Client with renal failure c. Gient with ileostomy d. The dient requiring GIT suctioning The nurse is caring for a cient with congestive heart failure. On assessment, the nurse notes that the client is dyspnetc and crackles are aucible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if ‘excess fluid volume is present? ‘a Weight loss b. Flat neck and hand veins cAnincrease in BP 4d. A decrease CVP ‘A nurse is preparing to care for a client with Potassium deficit. The nurse reviews the dients record and determines that the dient was at risk for developing the potassium deficit because the dient: ‘a. Has renal falure b. Requires NG suction c History of addisons disease d. Is taking a potassium sparing diuretic A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2 meg/L. Which ofthe following would the nurse note on the electrocardiogram as a result ofthe laboratory value? a. Uwaves b. Absent P waves c. Elevated T waves d. Elevated ST segment ‘A nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure ifthe student states that Which ofthe following is part ofthe plan for preparation ‘and administration of the potassium? 2. Obtaining a controled IV infusion pump b. Monitoring urine output during administration ‘c_Diluting inappropriate amount of normal saline 1d. Preparing the medication for bolus administration ‘A nurse instructs a cient at risk for hypokalemia about the foods high in potassium that should be included in the dally diet. The nurse determines that the client Understands the food sources of potassium ifthe client states that the food item lowest in potassium is: pose a. Apples b. Carrots Spinach 4. Avocado40. at 42, 43. 45, ‘A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level (of 5.5 meqjl. on 1 clients laboratory report. The nurse understands that which client is at highest risk for the development of a potassium value at this level? a. The dient with colts . Client with Cushing's syndrome ._Acdlient who has been overusing laxatives d. Aclient who has sustained a traumatic burn’ ‘A nurse reviews the electrolyte results of an assigned cent and notes that the potassium level is 5:4 meq/L. Which of the following would the nurse expect to nate on the ECG as a result of the laboratory value? a. ST depression b. Inverted T wave Prominent U wave d, Tall peak T waves ‘A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 meg/l. on one client's lab report. The nurse understands that which client is at highest risk for the development of a sodium value at this level? ‘a. The dlent with renal falure b. The client who is taking diuretics The lent with hyperaidosteronism 4d. The dient taking corticosteroids ‘A nurse is caring for a client with acute congestive heart fallure who is receiving high doses of diuretics. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes, The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present? a. Dry skin b. Decrease urinary output c. Hyperactive bowel sounds 4. Increase urine specfic gravity ‘A nurse is caring for a client with a nasogastric tube. "Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte results indicate a potassium level of 4.5, ‘meq/L and a sodium level of 132 mea/L. Based on these lab findings, the nurse selcects which solution to use for the nasogastric tube Irigation? a. Tap water b. Sterile water Sodium Chloride d. Distilled water ‘A nurse is reviewing lab results and notes that the client's serum sodium level is 150 meq/L. The nurse reports the serum sodium level to the physician and the physician prescribes dietary instructions based on the sodium level. Which food itern does the nurse instruct the client to avoid a. Peas b. Caulifower Low fat yogurt d. Processed oat cerials 47, 50. “The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which ofthe following clinical ‘manifestation would the nurse suspect to note in the lent? a. Twitching b. (-) Trosseau’s sign cc Hypoactive bowel sounds d. _Hypoactive deep tendon reflexes ‘Annurse reviews a client's lab report and reports the lent’s serum phosphorus level is 2.0 mg/dl. Which condition most likely caused this phosphorus level? a Alcoholism . Renal insufficiency &Hypoparathyroidism . Tumor lysis syndrome A nurse is reviewing an ABG result of a patient and notes the following values: pH - 7.36, PCO2 ~ 50, HCO3 — 29. Which of the following interpretations is fit for the given values? a. Partially compensated respiratory acidosis, b. Fully compensated metabolic acidosis Fully compensated respiratory acidosis. 4d. Partialy compensated respiratory acidosis \Which of the following values is expected from a patient who is constantly vomiting? a. HCO3-24 b. pH-7.30 & Pco2-49 d. HCO3-20 Which of the following should be assessed from a patient Who has @ pH of 7.297 a. Anxiety b. Diarrhea Vomiting d. Intermittent NGT suctioning