‭ .

Question‬
1 ‭ ecessary. Adjust and monitor environmental factors like room temperature and bed‬
n
‭1 point(s)‬ ‭linens as indicated. Room temperature may be accustomed to near normal body‬
‭Patient X is diagnosed with constipation. As a knowledgeable nurse, which nursing‬ ‭temperature and blankets and linens may be adjusted as indicated to regulate the‬
‭intervention is appropriate for maintaining normal bowel function?‬ ‭temperature of the patient.‬
‭●‬ ‭A. Assessing dietary intake‬ ‭●‬ ‭Option B:‬‭Fluids should be encouraged, not restricted to compensate for‬
‭insensible losses. Monitor fluid intake and urine output. If the patient is‬
‭●‬ ‭B. Decreasing fluid intake‬
‭unconscious, central venous pressure or pulmonary artery pressure‬
‭●‬ ‭C. Providing limited physical activity‬ ‭should be measured to monitor fluid status. Fluid resuscitation may be‬
‭●‬ ‭D. Turning, coughing, and deep breathing‬ ‭required to correct dehydration. The patient who is significantly‬
‭ orrect‬
C ‭dehydrated is no longer able to sweat, which is necessary for evaporative‬
‭Correct Answer: A. Assessing dietary intake‬ ‭cooling.‬
‭Assessing dietary intake provides a foundation for the client’s usual practices and may‬ ‭●‬ ‭Option C:‬‭Tympanic or rectal temperature measurements are generally‬
‭help determine if the client is prone to constipation or diarrhea. Check out usual dietary‬ ‭accepted and are more accurate than axillary measurements. Monitor the‬
‭habits, eating habits, eating schedule, and liquid intake. Irregular mealtime, type of food,‬ ‭patient’s HR, BP, and especially the tympanic or rectal temperature. HR‬
‭and interruption of the usual schedule can lead to constipation. Assist the patient to take‬ ‭and BP increase as hyperthermia progresses. Tympanic or rectal‬
‭at least 20 g of dietary fiber (e.g., raw fruits, fresh vegetables, whole grains) per day.‬ ‭temperature gives a more accurate indication of core temperature.‬
‭●‬ ‭Option B:‬‭Fluid intake should be increased to aid bowel elimination.‬ ‭●‬ ‭Option D:‬‭Antipyretics, and not antiemetics, are indicated to reduce‬
‭Encourage the patient to take in fluid 2000 to 3000 mL/day, if not‬ ‭fever. Give antipyretic medications as prescribed. Antipyretic medications‬
‭contraindicated medically. Sufficient fluid is needed to keep the fecal‬ ‭lower body temperature by blocking the synthesis of prostaglandins that‬
‭mass soft. But take note of some patients or older patients having‬ ‭act in the hypothalamus.‬
‭cardiovascular limitations requiring less fluid intake.‬ ‭3. Question‬
‭●‬ ‭Option C:‬‭Limited physical activity may contribute to constipation due to‬ ‭1 point(s)‬
‭decreased peristalsis. Assess the patient’s activity level. Sedentary‬ ‭Tom is ready to be discharged from the medical-surgical unit after 5 days of‬
‭lifestyles such as sitting all day, lack of exercise, prolonged bed rest, and‬ ‭hospitalization. Which client statement indicates to the nurse that Tom understands the‬
‭inactivity contribute to constipation.‬ ‭discharge teaching about cellular injury?‬
‭●‬ ‭Option D:‬‭Turning, coughing and deep breathing help promote gas‬ ‭●‬ ‭A. "I do not have to see my doctor unless I have problems."‬
‭exchange. Urge the patient for some physical activity and exercise.‬ ‭●‬ ‭B. "I can stop taking my antibiotics once I am feeling better."‬
‭Consider isometric abdominal and gluteal exercises. Movement‬
‭●‬ ‭C. "If I have redness, drainage, or fever, I should call my healthcare‬
‭promotes peristalsis. Abdominal exercises strengthen abdominal‬
‭ rovider."‬
p
‭muscles that facilitate defecation.‬
‭2. Question‬ ‭●‬ ‭D. "I can return to my normal activities as soon as I go home."‬
‭1 point(s)‬ ‭ orrect‬
C
‭A 12-year-old boy was admitted to the hospital two days ago due to hyperthermia. His‬ ‭Correct Answer: C. “If I have redness, drainage, or fever, I should call my‬
‭attending nurse, Dennis, is quite unsure about his plan of care. Which of the following‬ ‭healthcare provider.”‬
‭nursing interventions should be included in the care plan for the client?‬ ‭The knowledge that redness, drainage, or fever — signs of infection associated with‬
‭●‬ ‭A. Room temperature reduction‬ ‭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
‭●‬ ‭B. Fluid restriction of 2,000 ml/day‬
‭injury is reversible until a certain threshold where it progresses to cell death. Historically,‬
‭●‬ ‭C. Axillary temperature measurements every 4 hours‬ ‭cell death has been designated into two classes: necrosis and apoptosis. Necrosis is‬
‭●‬ ‭D. Antiemetic agent administration‬ ‭often coined as accidental death as it is generally seen as not controlled by the cell.‬
‭ orrect‬
C ‭Apoptosis, on the other hand, is typically viewed as programmed cell death, regulated‬
‭Correct Answer: A. Room temperature reduction‬ ‭and controlled.‬
‭For the patient with hyperthermia, reducing the room temperature may help decrease‬ ‭●‬ ‭Option A:‬‭Follow-up checkups should be encouraged. Cell growth,‬
‭the body temperature. Tepid baths, cool compresses, and cooling blankets may also be‬ ‭division, and death are all important parts of this regulation, and each is‬
 ‭ ighly regulated. Loss of this balance is seen in tumor cells where‬
h ‭●‬ O ‭ ption D:‬‭Use a footboard or pillows to keep the feet in the correct‬
‭mechanisms of cell death are avoided, resulting in uncontrolled cell‬
‭growth. Conversely, conditions where extensive cell death is seen also‬
‭result in loss of homeostasis, such as in the case of neuronal loss in‬
‭Alzheimer’s disease.‬
‭●‬ ‭Option B:‬‭The nurse should place an emphasis on antibiotic compliance‬
‭even if the client feels better. The understanding of cell death and the‬
‭players involved is a subject of constant research. The better one‬
‭understands the mechanism of cell death, the more likely it is that‬
‭knowledge can be integrated into clinical medicine.‬
‭ ‬ ‭Option D:‬‭There are usually activity limitations after cellular injury.‬
● ‭surgery. Which intervention should be included in the home health care nurse’s‬
‭Chemotherapy treatments with radiation can manipulate these pathways‬
‭more directly by causing DNA damage that drives the cell to apoptosis.‬
‭Understanding the basics of cell death allows for a better understanding‬
‭of how tumor cells may evade death and counter-evade clinically.‬
‭4. Question‬
‭1 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.‬
‭ orrect‬
C
‭Correct Answers: B, D, & E‬
‭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.‬
‭●‬ ‭Option A:‬‭Provide the patient with rest periods in between activities.‬
‭Consider energy-saving techniques. Rest periods are essential to‬
‭conserve energy. The patient must learn and accept his/her limitations.‬
‭●‬ ‭Option B:‬‭Help the patient develop sitting balance and standing balance.‬
‭This helps out in retraining neural pathways, promoting proprioception‬
‭and motor response. Keep limbs in functional alignment with one or more‬
‭of the following: pillows, sandbags, wedges, or prefabricated splints.‬
‭●‬ ‭Option C:‬‭Assess input and output record and nutritional pattern.‬
‭Pressure ulcers build up more rapidly in patients with nutritional‬
‭insufficiency. Encourage a diet high in fiber and liquid intake of 2000 to‬
‭3000 ml per day unless contraindicated.‬
‭position. This avoids foot drop and too much plantar flexion or tightness.‬
‭Maintain feet in a dorsiflexed position.‬
‭●‬ ‭Option E:‬‭Assess the strength to perform ROM to all joints. This‬
‭assessment provides data on the extent of any physical problems and‬
‭guides therapy. Testing by a physical therapist may be needed. Execute‬
‭passive or active assistive ROM exercises to all extremities.‬
‭5. Question‬
‭1 point(s)‬
‭A 36-year-old male client is about to be discharged from the hospital after 5 days due to‬
‭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
‭ limination.‬
e
‭●‬ ‭C. Instructing the client to establish a bowel evacuation schedule that changes‬
‭ very day.‬
e
‭●‬ ‭D. Instructing the client to fill a 2-L bottle with water every night and drink‬
i‭t the next day.‬
‭ orrect‬
C
‭Correct Answer: 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.‬
‭●‬ ‭Option A:‬‭High fiber or roughage foods are encouraged. Assist the‬
‭patient to take at least 20 g of dietary fiber (e.g., raw fruits, fresh‬
‭vegetables, whole grains) per day. Fiber adds bulk to the stool and‬
‭makes defecation easier because it passes through the intestine‬
‭essentially unchanged.‬
‭●‬ ‭Option B:‬‭Laxatives should not be used routinely for bowel elimination.‬
‭They should be used only as a last resort, because clients may become‬
‭dependent on them. The use of laxatives or enemas is indicated for the‬
‭short-term management of constipation.‬
‭●‬ ‭Option C:‬‭A regular bowel evacuation schedule should be established.‬
‭Encourage a regular period for elimination. Most people defecate‬
‭following the first daily meal or coffee, as a result of the gastrocolic reflex.‬
‭6. Question‬
‭1 point(s)‬
‭ r. McPartlin suffered abrasions and lacerations after a vehicular accident. He was‬
M ‭ nti-inflammatory agents help reduce edema and relieve pressure on nerve endings,‬
‭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.‬
‭ orrect‬
C ‭Cover wounds as soon as possible unless an open-air exposure burn‬
‭Correct Answer: C. The presence of infection may slow the healing process.‬
‭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.‬
‭●‬ ‭Option A:‬‭Nutritional needs, including protein and caloric needs,‬
‭increase for all clients undergoing cellular repair because adequate‬
‭protein and caloric intake is essential to optimal cellular repair. Nutritional‬
‭deficiencies, excesses, and imbalances all predispose the cell to injury.‬
‭●‬ ‭Option B:‬‭Elderly clients may have decreased blood flow to the skin,‬
‭organ atrophy and diminished function, and altered immunity. These‬
‭conditions slow cellular repair and increase the risk of infection. Cells and‬
‭tissues age because of accumulated damage to their proteins, lipids, and‬
‭nucleic acids. Much of the damage of aging is attributed to ROS, DNA‬
‭mutations, and cellular senescence‬
‭●‬ ‭Option D:‬‭Anything that decreases the supply of oxygen and other‬
‭nutrients to the cell or that damages mitochondria directly halts oxidative‬
‭phosphorylation, leading to rapid depletion of ATP, even in those cells‬
‭that can switch to anaerobic glycolysis. The ATP depletion results in‬
‭additional cell damage by causing failure of energy-dependent enzymes,‬
‭in particular, the cell membrane adenosine triphosphatase ion pumps that‬
‭control cell volume and electrolyte balance.‬
‭7. Question‬
‭1 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.‬
‭ orrect‬
C ‭is helpful for developing an individual plan of care to meet a patient’s‬
‭Correct Answer: A. Administering anti-inflammatory agents as prescribed‬
A
‭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.‬
‭●‬ ‭Option B:‬‭Elevating the injured area increases venous return to the‬
‭heart. Elevation may be required initially to reduce edema formation;‬
‭thereafter, changes in position and elevation reduce discomfort and risk‬
‭of joint contractures.‬
‭●‬ ‭Option C:‬‭Maintaining clean, dry skin aids in preventing skin breakdown.‬
‭care method is required. Temperature changes and air movement can‬
‭cause great pain to exposed nerve endings.‬
‭●‬ ‭Option D:‬‭Cool packs, not warm packs, should be used initially to cause‬
‭vasoconstriction and reduce edema. Altered tissue perfusion and edema‬
‭formation impair drug absorption. Injections into potential donor sites may‬
‭render them unusable because of hematoma formation.‬
‭8. Question‬
‭1 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.‬
‭ orrect‬
C
‭Correct Answer: B. Having the client perform Kegel exercises.‬
‭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.‬
‭●‬ ‭Option A:‬‭Inserting an indwelling Foley catheter increases the risk for‬
‭infection and should be avoided. Begin bladder retraining per protocol‬
‭when appropriate (fluids between certain hours, digital stimulation of‬
‭trigger area, contraction of abdominal muscles, Credé’s maneuver).‬
‭●‬ ‭Option C:‬‭Proper perineal hygiene decreases the risk of skin irritation or‬
‭breakdown and the development of ascending infection. The nurse‬
‭should encourage the client to develop a toileting schedule based on‬
‭normal urinary habits. However, suggesting bathroom use every 8 hours‬
‭may be too long an interval to wait.‬
‭●‬ ‭Option D:‬‭Pads or diapers should be used only as a resort. Refer to the‬
‭urinary continence specialist as indicated. Collaboration with specialists‬
‭specific needs using the latest techniques, continence products.‬
‭ . Question‬
9 ‭ edications, diet, therapy, and follow-up appointments, must be explained in detail to all‬
m
‭1 point(s)‬ ‭patients and then presented in written form to take home upon discharge.‬
‭Jeron is admitted to the hospital due to bacterial pneumonia. He is febrile, diaphoretic,‬ ‭●‬ ‭Option A:‬‭The discharge plan begins at the admission time and includes‬
‭and has shortness of breath and asthma. Which goal is the‬‭most‬‭important for the‬ ‭the patients and their families’ needs prediction, and a plan to fulfill their‬
‭client?‬ ‭requirements after discharge from the hospital. A practical discharge plan‬
‭●‬ ‭A. Prevention of fluid volume excess‬ ‭helps to provide continuous care with the least amount of stress for‬
‭patients.‬
‭●‬ ‭B. Maintenance of adequate oxygenation‬
‭●‬ ‭Option C:‬‭Nurses, as key members of the treatment team, play a critical‬
‭●‬ ‭C. Education about infection prevention‬ ‭role in training and taking care of the patients. One of the most basic‬
‭●‬ ‭D. Pain reduction‬ ‭nursing responsibilities is to provide continuous care. In this regard, the‬
‭ orrect‬
C ‭inclusion of a discharge plan for all admitted patients could be a symbol‬
‭Correct Answer: B. Maintenance of adequate oxygenation‬ ‭of such care.‬
‭For the client with asthma and infection, oxygenation is the priority. Maintaining adequate‬ ‭●‬ ‭Option D:‬‭Basically, any significant change or poor performance requires‬
‭oxygenation reduces the risk of physiologic injury from cellular hypoxia, which is the‬ ‭physical, social, and psychological adjustment. Patients are concerned‬
‭leading cause of cell death. The purpose of oxygen therapy is to maintain PaO2 above‬ ‭about their discharge and are preoccupied with their ability in performing‬
‭60 mmHg. Oxygen is administered by the method that provides appropriate delivery‬ ‭their own duties and the way to handle themselves as well as joining the‬
‭within the patient’s tolerance.‬ ‭family. Therefore, self-care training is of utmost importance for the‬
‭●‬ ‭Option A:‬‭A fluid volume deficit resulting from fever and diaphoresis, not‬ ‭patients and their families.‬
‭excess, is more likely for this client. Assess respirations: note quality,‬ ‭11. Question‬
‭rate, rhythm, depth, use of accessory muscles, ease, and position‬ ‭1 point(s)‬
‭assumed for easy breathing.‬ ‭Mrs. dela Riva is in her first trimester of pregnancy. She has been lying all day because‬
‭●‬ ‭Option C:‬‭Teaching about infection control is not appropriate at this time‬ ‭her OB-GYN requested her to have a complete bed rest. Which nursing intervention is‬
‭but would be appropriate before discharge. Observe the color of skin,‬ ‭appropriate when addressing the client’s need to maintain skin integrity?‬
‭mucous membranes, and nail beds, noting the presence of peripheral‬ ‭●‬ ‭A. Monitoring intake and output accurately.‬
‭cyanosis (nail beds) or central cyanosis (circumoral).‬ ‭●‬ ‭B. Instructing the client to cough and deep breathe every 2 hours.‬
‭●‬ ‭Option D:‬‭No information regarding pain is provided in this scenario.‬
‭●‬ ‭C. Keeping the linens dry and wrinkle-free.‬
‭Monitor body temperature, as indicated. Assist with comfort measures to‬
‭reduce fever and chills: addition or removal of bedcovers, comfortable‬ ‭●‬ ‭D. Using a footboard to maintain correct anatomic position.‬
‭room temperature, tepid or cool water sponge bath.‬ ‭ orrect‬
C
‭10. Question‬ ‭Correct Answer: C. Keeping the linens dry and wrinkle-free.‬
‭1 point(s)‬ ‭Keeping the linens dry and wrinkle-free aids in preventing moisture and pressure from‬
‭Rogelio, a 32-year-old patient, is about to be discharged from the acute care setting.‬ ‭interfering with adequate blood supply to the tissues, helping to maintain skin integrity.‬
‭Which nursing intervention is the‬‭most‬‭important to include in the plan of care?‬ ‭Encourage the implementation of a turning schedule, restricting time in one position to 2‬
‭●‬ ‭A. Stress-reduction techniques‬ ‭hours or less, if the patient is restricted to bed.‬
‭●‬ ‭Option A:‬‭Monitoring intake and output aids in assessing and‬
‭●‬ ‭B. Home environment evaluation‬
‭maintaining bladder function. Assess patient’s nutritional status, including‬
‭●‬ ‭C. Skin-care measures‬ ‭weight, weight loss, and serum albumin levels. An albumin level less than‬
‭●‬ ‭D. Participation in activities of daily living‬ ‭2.5 g/dL is a grave sign, indicating severe protein depletion and at high‬
‭ orrect‬
C ‭risk of skin breakdown.‬
‭Correct Answer: B. Home environment evaluation‬ ‭●‬ ‭Option B:‬‭Coughing and deep breathing help promote gas exchange.‬
‭After discharge, the client is responsible for his own care and health maintenance‬ ‭Reinforce the importance of turning, mobility, and ambulation. These will‬
‭management. Discharge includes assessing the home environment for determining the‬ ‭enhance their sense of efficacy and can improve compliance with the‬
‭client’s ability to maintain his health at home. All instructions for care at home, including‬ ‭prescribed interventions.‬
 ‭●‬ O
‭ ption D:‬‭Using a footboard is appropriate for maintaining a normal‬ ‭●‬ ‭C. Using therapeutic conversation to try to discourage pain medication.‬
‭body function position. Encourage the patient to change position every‬
‭●‬ ‭D. Attempting to rule out complications before administering pain‬
‭15 minutes and change chair-bound positions every hour. Use pillows or‬
‭ edication.‬
m
‭foam wedges to keep bony prominences from direct contact with each‬
‭ orrect‬
C
‭other. Keep pillows under the heels to raise off the bed.‬
‭Correct Answer: D. Attempting to rule out complications before administering pain‬
‭12. Question‬
‭medication.‬
‭1 point(s)‬
‭When intervening with a client complaining of pain, the nurse must always determine if‬
‭Maya, who is admitted to a hospital, is scheduled to have her general checkup and‬
‭the pain is expected pain or a complication that requires immediate nursing intervention.‬
‭physical assessment. Nurse Timothy observed a reddened area over her left hip. Which‬
‭This must be done before administering the medication. Perform a comprehensive‬
‭should the nurse do‬‭first‬‭?‬
‭assessment of pain. Determine via assessment the location, characteristics, onset,‬
‭●‬ ‭A. Massage the reddened area for a few minutes.‬
‭duration, frequency, quality, and severity of pain.‬
‭●‬ ‭B. Notify the physician immediately.‬ ‭●‬ ‭Option A:‬‭Perform a history assessment of pain. Additionally, the nurse‬
‭●‬ ‭C. Arrange for a pressure-relieving device.‬ ‭should ask the following questions during pain assessment to determine‬
‭its history: (1) effectiveness of previous pain treatment or management;‬
‭●‬ ‭D. Turn the client to the right side for 2 hours.‬
‭(2) what medications were taken and when; (3) other medications being‬
‭ orrect‬
C
‭taken; (4) allergies or known side effects to medications.‬
‭Correct Answer: D. Turn the client to the right side for 2 hours‬
‭●‬ ‭Option B:‬‭Guided imagery should be used along with, not instead of,‬
‭Turning the client to the right side relieves the pressure and promotes adequate blood‬
‭administration of pain medication. Guided imagery involves the use of‬
‭supply to the left hip. Encourage the patient to change position every 15 minutes and‬
‭mental pictures or guiding the patient to imagine an event to distract from‬
‭change chair-bound positions every hour. During sitting, the pressure over the sacrum‬
‭the pain.‬
‭may exceed 100 mm Hg. The pressure needed to close capillaries is around 32 mm Hg;‬
‭●‬ ‭Option C:‬‭The nurse should medicate the client and not discourage‬
‭any pressure above 32 mm Hg leads to ischemia.‬
‭medication. Nurses have the duty to ask their clients about their pain and‬
‭●‬ ‭Option A:‬‭A reddened area is never massaged, because this may‬
‭believe their reports of pain. Challenging or undermining their pain‬
‭increase the damage to the already reddened, damaged area. Massage‬
‭reports results in an unhealthy therapeutic relationship that may hinder‬
‭only around the affected area. This is to increase tissue perfusion.‬
‭pain management and deteriorate rapport.‬
‭Massaging the actual reddened area may damage the skin further.‬
‭14. Question‬
‭●‬ ‭Option B:‬‭The health care provider does not need to be notified‬
‭1 point(s)‬
‭immediately. However, the health care provider should be informed of‬
‭Nurse Martha is teaching her students about bacterial control. Which intervention is the‬
‭this finding the next time he is on the unit. Educate the patient and‬
‭most‬‭important factor in preventing the spread of microorganisms?‬
‭caregiver about the causes of pressure. This information can assist the‬
‭●‬ ‭A. Maintenance of asepsis with indwelling catheter insertion.‬
‭patient or caregiver in finding methods to prevent skin breakdown.‬
‭●‬ ‭Option C:‬‭Arranging for a pressure-relieving device is appropriate, but‬ ‭●‬ ‭B. Use of masks, gowns, and gloves when caring for clients with infection.‬
‭this is done after the client has been turned. Use pillows or foam wedges‬ ‭●‬ ‭C. Correct handwashing technique.‬
‭to keep bony prominences from direct contact with each other. Keep‬
‭●‬ ‭D. Cleanup of blood spills with sodium hydrochloride.‬
‭pillows under the heels to raise off bed. These measures reduce‬
‭ orrect‬
C
‭shearing forces on the skin.‬
‭Correct Answer: C. Correct handwashing technique.‬
‭13. Question‬
‭Handwashing remains the most effective procedure for controlling microorganisms and‬
‭1 point(s)‬
‭the incidence of nosocomial infections. According to the Centers for Disease Control and‬
‭Pierro was noted to be displaying facial grimaces after nurse Kara assessed his‬
‭Prevention (CDC), hand hygiene is the single most important practice in the reduction of‬
‭complaints of pain rated as 8 on a scale of 1 (no pain) 10 10 (worst pain). Which‬
‭the transmission of infection in the healthcare setting. According to the CDC, hand‬
‭intervention should the nurse do?‬
‭hygiene encompasses the cleansing of your hands with soap and water, antiseptic hand‬
‭●‬ ‭A. Administering the client's ordered pain medication immediately.‬
‭washes, antiseptic hand rubs such as alcohol-based hand sanitizers, foams or gels, or‬
‭●‬ ‭B. Using guided imagery instead of administering pain medication.‬ ‭surgical hand antisepsis.‬
 ‭●‬ O ‭ ption A:‬‭Aseptic technique is essential with invasive procedures,‬
‭including indwelling catheters. The purpose of creating a sterile field is to‬
‭reduce the number of microbes present to as few as possible. The sterile‬
‭field is used in many situations outside the operating room as well as‬
‭inside the operating room when performing surgical cases.‬
‭●‬ ‭Option B:‬‭Masks, gowns, and gloves are necessary only when the‬
‭likelihood of exposure to blood or body fluids is high. Personal protective‬
‭equipment serves as a barrier to protect the skin, mucous membranes,‬
‭airway, and clothing. It includes gowns, gloves, masks, and face shields‬
‭or goggles.‬
‭●‬ ‭Option D:‬‭Spills of blood from clients with acquired immunodeficiency‬
‭syndrome should be cleaned with sodium hydrochloride. Standard‬
‭precautions apply to the care of all patients, irrespective of their disease‬
‭state. These precautions apply when there is a risk of potential exposure‬
‭to blood; all body fluids, secretions, and excretions, except sweat,‬
‭regardless of whether or not they contain visible blood; non-intact skin,‬
‭and mucous membranes.‬
‭15. Question‬
‭1 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.‬
‭ orrect‬
C ‭●‬ ‭Option A:‬‭Whole grains and nuts would be encouraged for the client with‬
‭Correct Answer: A. Administering I.V. and oral fluids‬
‭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.‬
‭●‬ ‭Option B:‬‭Clustering activities help with energy conservation and‬
‭promote rest. Aid the patient if he or she is unable to eat without‬
‭assistance, and encourage the family or SO to assist with feedings, as‬
‭necessary. Dehydrated patients may be weak and unable to meet‬
‭prescribed intake independently.‬
‭●‬ ‭Option C:‬‭Assessing sputum would be appropriate for a client with‬
‭problems associated with impaired gas exchange or ineffective airway‬
‭clearance. Assess skin turgor and oral mucous membranes for signs of‬
‭dehydration. Signs of dehydration are also detected through the skin.‬
‭ kin of elderly patients loses elasticity, hence skin turgor should be‬
S
‭assessed over the sternum or on the inner thighs. Longitudinal furrows‬
‭may be noted along the tongue.‬
‭●‬ ‭Option D:‬‭Monitoring albumin and protein levels are appropriate for‬
‭clients experiencing inadequate nutrition. Monitor and document‬
‭hemodynamic status including CVP, pulmonary artery pressure (PAP),‬
‭and pulmonary capillary wedge pressure (PCWP) if available in a‬
‭hospital setting. These direct measurements serve as an optimal guide‬
‭for therapy.‬
‭16. Question‬
‭1 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
‭ orrect‬
C
‭Correct Answer: 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.‬
‭hypomagnesemia. Encourage intake of dairy products, meat, fish, green‬
‭leafy vegetables, and whole grains. Provides an oral replacement for mild‬
‭magnesium deficits; may prevent a recurrence.‬
‭●‬ ‭Option B:‬‭Milk products and green, leafy vegetables are good sources of‬
‭calcium for the client with hypocalcemia. Encourage the client to eat‬
‭foods high in calcium such as dark leafy greens, cheese, low-fat milk,‬
‭yogurt, eggs, oranges, green beans, and sardines. Avoid intake of‬
‭phosphorus-rich foods such as bran, chocolates, nuts, whole wheat, and‬
‭barley.‬
‭●‬ ‭Option C:‬‭Pork products and canned vegetables are high in sodium and‬
‭are encouraged for the client with hyponatremia. Encourage fluids and‬
‭foods high in sodium such as meat, milk, beets, celery, eggs, and carrots.‬
‭Use fruit juices and bouillon instead of water. Unless sodium deficit‬
‭causes serious symptoms requiring immediate IV replacement, the client‬
‭may benefit from slower replacement by oral method or removal of‬
‭previous salt restriction.‬
‭ 7. Question‬
1 ‭ he fluid intake includes 8 oz (240 ml) of apple juice, 850 ml of water, 2 cups (480 ml) of‬
‭1 point(s)‬
‭Mary Jean, a first year nursing student, was rushed to the clinic department due to‬
‭hyperventilation. Which nursing intervention is the‬‭most‬‭appropriate 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.‬
‭ orrect‬
C ‭carpopedal spasm after the blood-pressure cuff is inflated?‬
‭Correct Answer: B. Encouraging slow, deep breaths.‬
‭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.‬
‭●‬ ‭Option A:‬‭Administering sodium chloride is appropriate for metabolic‬
‭alkalosis. Demonstrate appropriate breathing patterns, if appropriate, and‬
‭assist with respiratory aids or a rebreathing mask/bag. Decreasing the‬
‭rate of respiration can halt the “blowing off” of CO2, elevating Pco2 level‬
‭and normalizing pH.‬
‭●‬ ‭Option C:‬‭Administering sodium bicarbonate is appropriate for treating‬
‭metabolic acidosis. Provide comfort measures; encourage the use of‬
‭meditation and visualization. Use a tepid sponge bath/cool cloths.‬
‭Promotes relaxation and reduces stress. Control and reduction of fever‬
‭reduce the potential for seizures and helps reduce respiration rate.‬
‭●‬ ‭Option D:‬‭Administering low-flow oxygen therapy is appropriate for‬
‭chronic respiratory acidosis. Administer CO2, or use a rebreathing mask‬
‭as indicated. Reduce respiratory rate and tidal volume, or add additional‬
‭dead space (tubing) to a mechanical ventilator.‬
‭18. Question‬
‭1 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 answer‬‭as a whole number.‬
‭●‬ ‭Answer:‬ ‭mL.‬
‭ orrect‬
C ‭Lab tests revealed that patient Z’s [Na+] is 170 mEq/L. Which clinical manifestation‬
‭Correct answer:‬‭2470 mL.‬
‭Rationale:‬
T
‭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.‬
‭ 9. Question‬
1
‭1 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
‭●‬ ‭A. Positive Trousseau's sign‬
‭●‬ ‭B. Positive Chvostek's sign‬
‭●‬ ‭C. Tetany‬
‭●‬ ‭D. Paresthesia‬
‭ orrect‬
C
‭Correct Answer: A. Positive Trousseau’s sign‬
‭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.‬
‭●‬ ‭Option B:‬‭Chvostek’s sign refers to twitching of the facial nerve when‬
‭tapping below the earlobe. In the late 1800s, Dr. Chvostek noticed that‬
‭mechanical stimulation of the facial nerve (as with the fingertip of the‬
‭examiner, for example) could lead to twitching of the ipsilateral facial‬
‭muscles. The long-accepted explanation is that this resulted from‬
‭hypocalcemia, and this relationship became known as the Chvostek sign.‬
‭●‬ ‭Option C:‬‭Tetany is a clinical manifestation of hypocalcemia denoted by‬
‭tingling in the tips of the fingers around the mouth and muscle spasms in‬
‭the extremities and face. Tetany is generally induced by a rapid decline in‬
‭serum ionized calcium. Tetany is usually most dangerous and most‬
‭commonly seen in the presence of respiratory alkalosis causing‬
‭hypocalcemia.‬
‭●‬ ‭Option D:‬‭Paresthesia refers to numbness or tingling. Paresthesia is an‬
‭abnormal sensation of the skin (tingling, pricking, chilling, burning,‬
‭numbness) with no apparent physical cause. Paresthesia may be‬
‭transient or chronic and may have any of dozens of possible underlying‬
‭causes.‬
‭20. Question‬
‭1 point(s)‬
‭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
‭ orrect‬
C ‭●‬ ‭Option A:‬‭The inability to fully exhale also causes elevations in carbon‬
‭Correct Answer: A. Tented skin turgor and thirst‬
‭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.‬
‭●‬ ‭Option B:‬‭Muscle twitching and tetany may be seen with hypercalcemia‬
‭or hyperphosphatemia. CNS features include delirium, coma, seizures,‬
‭neuromuscular hyperexcitability, (Chvostek’s sign and Trousseau’s‬
‭phenomenon), hyperreflexia, muscle cramping (e.g., carpopedal spasm),‬
‭or tetany.‬
‭●‬ ‭Option C:‬‭Fruity breath and Kussmaul’s respirations are associated with‬
‭diabetic ketoacidosis. Kussmaul breathing, which is labored, deep, and‬
‭tachypneic, may occur. Some providers may appreciate a fruity scent to‬
‭the patient’s breath, indicative of the presence of acetone. Patients may‬
‭have signs of dehydration, including poor capillary refill, skin turgor, and‬
‭dry mucous membranes.‬
‭●‬ ‭Option D:‬‭Muscle weakness and paresthesia are associated with‬
‭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.‬
‭21. Question‬
‭1 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)‬
‭ orrect‬
C ‭serum electrolyte levels would most likely be evaluated. Monitor serum‬
‭Correct Answer: B. Low PO2‬
‭ chronically elevated PCO2 level (above 50 mmHg) is associated with inadequate‬
A
‭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.‬
‭dioxide (CO2) levels. As the disease progresses, impairment of gas‬
‭exchange is often seen. The reduction in ventilation or increase in‬
‭physiologic dead space leads to CO2 retention. Pulmonary hypertension‬
‭may occur due to diffuse vasoconstriction from hypoxemia.‬
‭●‬ ‭Option C:‬‭An acid-base disturbance arises when arterial pH lies outside‬
‭that range. If pH is less than 7.35 an acidosis is present, if pH is greater‬
‭than 7.45 the alkalosis is present. Tight control on blood pH is achieved‬
‭by a combination of blood buffers and the respiratory and renal systems‬
‭which make adjustments to return pH toward its normal levels.‬
‭●‬ ‭Option D:‬‭Acidosis can be caused by either a rise in PaCO2 or a fall in‬
‭HCO3. Alkalosis can be caused by either a fall in PaCO2 or a rise in‬
‭HCO3. When the primary change is in CO2 we name the disturbance‬
‭respiratory, and when the primary change is in bicarbonate, we name the‬
‭disturbance metabolic.‬
‭22. Question‬
‭1 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.‬
‭ orrect‬
C
‭Correct Answer: A. Assessing urinary intake and output.‬
‭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.‬
‭●‬ ‭Option B:‬‭The client should be weighed daily, not weekly, and at the‬
‭same time each day, usually in the morning. 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.‬
‭●‬ ‭Option C:‬‭Monitoring ABGs is not necessary for this client. Rather,‬
‭electrolytes and urine osmolality, and report abnormal values. Elevated‬
 ‭ lood urea nitrogen suggests fluid deficit. Urine-specific gravity is‬
b ‭●‬
‭likewise increased.‬
‭●‬ ‭Option D:‬‭The client also would have an I.V. rate of at least 75 ml/hour, if‬
‭not higher, to correct the fluid volume deficit. Administer parenteral fluids‬
‭as prescribed. Consider the need for an IV fluid challenge with an‬
‭immediate infusion of fluids for patients with abnormal vital signs.‬
‭23. Question‬
‭1 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.‬
‭ orrect‬
C ‭●‬ ‭Option C:‬‭Avoiding the use of a tight tourniquet when drawing blood‬
‭Correct Answer: 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.‬
‭●‬ ‭Option A:‬‭A client receiving diuretics may be hypokalemic. 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.‬
‭●‬ ‭Option B:‬‭Patients with ileostomies may have hypokalemia. Potassium‬
‭may be replaced and level maintained through the diet when the client is‬
‭allowed oral food and fluids. Dietary replacement of 40 to 60 mEq/L/day‬
‭is usually sufficient if no abnormal losses are happening.‬
‭●‬ ‭Option C:‬‭Patients with metabolic disease may be hypokalemic. Note for‬
‭signs of metabolic alkalosis such as tachycardia, dysrhythmias,‬
‭hypoventilation, tetany, and changes in mentation. These are usually‬
‭associated with hypokalemia.‬
‭24. Question‬
‭1 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.‬
‭ orrect‬
C
‭Correct Answer: A. Instituting seizure precaution to prevent injury.‬
‭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.‬
‭●‬ ‭Option B:‬‭Hypophosphatemia may produce changes in granulocytes,‬
‭which would require the nurse to instruct the client about measures to‬
‭prevent infection. Mild hypophosphatemia will not be clinically apparent.‬
‭Severe hypophosphatemia may have the clinical presence of altered‬
‭mental status, neurological instability including seizures and focal‬
‭neurologic findings such as numbness or reflexive weakness, a cardiac‬
‭manifestation of possible heart failure, muscle pain, and muscular‬
‭weakness.‬
‭helps prevent pseudohyperkalemia. Assess the level of consciousness‬
‭and neuromuscular function, including sensation, strength, and‬
‭movement. The client is usually conscious and alert; however, muscular‬
‭paresthesia, weakness, and flaccid paralysis may occur.‬
‭●‬ ‭Option D:‬‭Early ambulation is recommended to reduce calcium loss from‬
‭bones during hospitalization. Encourage frequent repositioning and‬
‭range-of-motion (ROM) and/or muscle-setting exercises with caution.‬
‭Promote ambulation as tolerated. Muscle activity may reduce calcium‬
‭shifting from the bones that occur during immobilization.‬
‭25. Question‬
‭1 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
‭ orrect‬
C
‭Correct Answer: 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.‬
 ‭●‬ O ‭ ption A:‬‭Potassium (a cation) is a major electrolyte in the intracellular‬
‭fluid. Potassium is mainly an intracellular ion. The sodium-potassium‬
‭adenosine triphosphatase pump has the primary responsibility for‬
‭regulating the homeostasis between sodium and potassium, which‬
‭pumps out sodium in exchange for potassium, which moves into the‬
‭cells.‬
‭●‬ ‭Option B:‬‭Phosphate (an anion) is a major electrolyte in the intracellular‬
‭fluid. Phosphate is an essential electrolyte in the human body as it‬
‭constitutes about 1% of the total body weight. In an adult, the normal‬
‭serum phosphate level ranges between 2.5 to 4.5 mg/d L. The normal‬
‭serum levels of phosphate tend to decrease with age and its highest‬
‭levels i.e., 4.5 to 8.3 mg/dL are seen in infants, about 50% higher than‬
‭adults; this is because infants and children need more phosphate for their‬
‭growth and development.‬
‭●‬ ‭Option C:‬‭Chloride, an anion (e.g., negatively charged ion), is also‬
‭present in extracellular fluid, but to a lesser extent. 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.‬
‭26. Question‬
‭1 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
‭ orrect‬
C ‭neurologic findings such as numbness or reflexive weakness, a cardiac‬
‭Correct Answer: B. Kayexalate‬
‭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.‬
‭●‬ ‭Option A:‬‭Because the client’s potassium level is already elevated,‬
‭potassium supplements would not be given. Patients with neuromuscular‬
‭weakness, paralysis, or ECG changes and elevated potassium of more‬
‭than 5.5 mEq/L in patients at risk for ongoing hyperkalemia, or confirmed‬
‭hyperkalemia of 6.5 mEq/L should have aggressive treatment.‬
‭Exogenous sources of potassium should be immediately discontinued.‬
‭●‬ ‭Option C:‬‭Neither calcium gluconate nor sodium tablets would address‬
‭the client’s elevated potassium level. Calcium therapy will stabilize the‬
‭cardiac response to hyperkalemia and should be initiated first in the‬
s‭ etting of cardiac toxicity. Calcium does not alter the serum concentration‬
‭of potassium but is a first-line therapy in hyperkalemia-related‬
‭arrhythmias and ECG changes.‬
‭●‬ ‭Option D:‬‭Sodium bicarbonate infusion may be helpful in patients with‬
‭metabolic acidosis. Bolus dosing of sodium bicarbonate is less effective.‬
‭Loop or thiazide diuretics may be helpful in enhancing potassium‬
‭excretion. They may be used in non-oliguric, volume overloaded patients‬
‭but should not be used as monotherapy in symptomatic patients.‬
‭27. Question‬
‭1 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
‭ orrect‬
C
‭Correct Answer: B. Hot, flushed skin and diaphoresis‬
‭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.‬
‭●‬ ‭Option A:‬‭Muscle pain and acute rhabdomyolysis are indicative of‬
‭hypophosphatemia. Mild hypophosphatemia will not be clinically‬
‭apparent. Severe hypophosphatemia may have the clinical presence of‬
‭altered mental status, neurological instability including seizures and focal‬
‭manifestation of possible heart failure, muscle pain, and muscular‬
‭weakness.‬
‭●‬ ‭Option C:‬‭Soft-tissue calcification and hyperreflexia are indicative of‬
‭hyperphosphatemia. Calcifications can also be present in skin, soft‬
‭tissue, and periarticular regions. Prolonged bone demineralization can‬
‭lead to bone fractures. CNS features include delirium, coma, seizures,‬
‭neuromuscular hyperexcitability, (Chvostek’s sign and Trousseau’s‬
‭phenomenon), hyperreflexia, muscle cramping (e.g., carpopedal spasm)‬
‭or tetany.‬
‭●‬ ‭Option D:‬‭Increased respiratory rate and depth are associated with‬
‭metabolic acidosis. The physical exam reveals signs unique to each‬
‭cause such as dry mucous membranes in the patient with diabetic‬
‭ketoacidosis. Hyperventilation may also be present as a compensatory‬
‭respiratory alkalosis to assist with PCO2 elimination and correction of the‬
 ‭ cidemia. Compensatory reactions do not completely correct a‬
a ‭ m Hg, and a bicarbonate level of 24 mEq/L. Based on these results, which intervention‬
m
‭disturbance to the normal pH range.‬ ‭should the nurse implement?‬
‭ 8. Question‬
2 ‭●‬ ‭A. Instructing the client to breathe slowly into a paper bag.‬
‭1 point(s)‬
‭●‬ ‭B. Administering low-flow oxygen.‬
‭Joshua is receiving furosemide and Digoxin, which laboratory data would be the‬‭most‬
‭important to assess in planning the care for the client?‬ ‭●‬ ‭C. Encouraging the client to cough and deep breathe.‬
‭●‬ ‭A. Sodium level‬ ‭●‬ ‭D. Nothing, because these ABG values are within normal limits.‬
‭●‬ ‭B. Magnesium level‬ ‭ orrect‬
C
‭Correct Answer: C. Encouraging the client to cough and deep breathe.‬
‭●‬ ‭C. Potassium level‬
‭The ABG results indicate respiratory acidosis requiring improved ventilation and‬
‭●‬ ‭D. Calcium level‬ ‭increased oxygen to the lungs. Coughing and deep breathing can accomplish this.‬
‭ orrect‬
C ‭Encourage and assist with deep-breathing exercises, turning, and coughing. Suction as‬
‭Correct Answer: C. Potassium level‬ ‭necessary. Provide airway adjunct as indicated. Place in semi-Fowler’s position. These‬
‭Diuretics such as furosemide may deplete serum potassium, leading to hypokalemia.‬ ‭measures improve lung ventilation and reduce or prevent airway obstruction associated‬
‭When the client is also taking digoxin, the subsequent hypokalemia may potentiate the‬ ‭with the accumulation of mucus.‬
‭action of digoxin, placing the client at risk for digoxin toxicity. Most cases of hypokalemia‬ ‭●‬ ‭Option A:‬‭Breathing into a paper bag is appropriate for a client‬
‭result from gastrointestinal (GI) or renal losses. Renal potassium losses are associated‬ ‭hyperventilating and experiencing respiratory alkalosis. Provide‬
‭with increased mineralocorticoid-receptor stimulation such as occurs with primary‬ ‭appropriate chest physiotherapy, including postural drainage and‬
‭hyperreninism and primary aldosteronism.‬ ‭breathing exercises. Aids in clearing secretions, which improves‬
‭●‬ ‭Option A:‬‭Diuretic therapy may lead to the loss of other electrolytes such‬ ‭ventilation, allowing excess CO2 to be eliminated.‬
‭as sodium, but the loss of potassium in association with digoxin therapy‬ ‭●‬ ‭Option B:‬‭The nurse would administer high oxygen levels because the‬
‭is most important. Increased delivery of sodium and/or non-absorbable‬ ‭client does not have chronic obstructive pulmonary disease. Administer‬
‭ions (diuretic therapy, magnesium deficiency, genetic syndromes) to the‬ ‭oxygen as indicated. Increase respiratory rate or tidal volume of the‬
‭distal nephron can also result in renal potassium wasting. GI losses are a‬ ‭ventilator, if used. Prevents and corrects hypoxemia and respiratory‬
‭common cause of hypokalemia with severe or chronic diarrhea being the‬ ‭failure.‬
‭most common extrarenal cause of hypokalemia.‬ ‭●‬ ‭Option D:‬‭Some action is necessary because the ABG results are not‬
‭●‬ ‭Option B:‬‭Hypomagnesemia generally is associated with poor nutrition,‬ ‭within normal limits. Monitor and graph serial ABGs, pulse oximetry‬
‭alcoholism, and excessive GI or renal losses, not diuretic therapy.‬ ‭readings; Hb, serum electrolyte levels. Evaluates therapy need and‬
‭Magnesium homeostasis involves the kidney (primarily through the‬ ‭effectiveness. Note: Bedside pulse oximetry monitoring is used to show‬
‭proximal tubule, the thick ascending loop of Henle, and the distal tubule),‬ ‭early changes in oxygenation before other signs or symptoms are‬
‭small bowel (primarily through the jejunum and ileum), and bone.‬ ‭observed.‬
‭Hypomagnesemia occurs when something, whether a drug or a disease‬ ‭30. Question‬
‭condition, alters the homeostasis of magnesium.‬ ‭1 point(s)‬
‭●‬ ‭Option D:‬‭Hypocalcemia is usually associated with inadequate vitamin D‬ ‭A client is diagnosed with metabolic acidosis, which would the nurse expect the health‬
‭intake or synthesis, renal failure, or the use of drugs, such as‬ ‭care provider to order?‬
‭aminoglycosides and corticosteroids. Calcitonin on the other hand lowers‬ ‭●‬ ‭A. Potassium‬
‭levels of calcium. Hypocalcemia is a common cause of tetany and‬
‭●‬ ‭B. Sodium bicarbonate‬
‭neuromuscular irritability. An alkaline environment lowers calcium levels‬
‭and induces tetany, whereas an acidic environment is protective.‬ ‭●‬ ‭C. Serum sodium level‬
‭29. Question‬ ‭●‬ ‭D. Bronchodilator‬
‭1 point(s)‬ ‭ orrect‬
C
‭Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34, partial‬ ‭Correct Answer: B. Sodium bicarbonate‬
‭pressure of arterial oxygen of 80 mm Hg, partial pressure of arterial carbon dioxide of 49‬ ‭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.‬
‭●‬ ‭Option A:‬‭The chief indication for potassium administration is potassium‬
‭deficiency or hypokalemia, a condition in which serum potassium level‬
‭falls below a critical range. Hypokalemia can occur due to multiple‬
‭reasons, mainly inadequate intake of potassium. Metabolic alkalosis can‬
‭also cause hypokalemia by shifting potassium from the extracellular to‬
‭the intracellular compartment.‬
‭●‬ ‭Option C:‬‭Among the electrolyte disorders, hyponatremia is the most‬
‭frequent. Diagnosis is when the serum sodium level less than 135‬
‭mmol/L. Hyponatremia has neurological manifestations. Patients may‬
‭present with headache, confusion, nausea, delirium. Hypernatremia‬
‭presents when the serum sodium levels greater than145 mmol/L.‬
‭Symptoms of hypernatremia include tachypnea, sleeping difficulty, and‬
‭feeling restless. Rapid sodium corrections can have serious‬
‭consequences like cerebral edema and osmotic demyelination‬
‭syndrome.‬
‭●‬ ‭Option D:‬‭Bronchodilators are indicated for individuals that have lower‬
‭than optimal airflow through the lungs. The mainstay of treatment is‬
‭beta-2 agonists that target the smooth muscles in the bronchioles of the‬
‭lung. Various respiratory conditions may require bronchodilators,‬
‭including asthma and chronic obstructive pulmonary disease.‬