A nurse suspects a fluid and electrolyte imbalance in an older adult. Which assessment best indicates fluid and electrolyte balance?
- a. Intake and output results
- b. Serum laboratory values
- c. Condition of the skin
- d. Presence of tenting
A nurse is caring for a patient with an intestinal stoma. Which intervention is most important?
- a. Cleansing the stoma with cool water
- b. Spraying an air-freshening deodorant in the room
- c. Selecting a bag with an appropriate-size stomal opening
- d. Wearing sterile nonlatex gloves when caring for the stoma
A nurse is caring for a patient who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombophlebitis (DVT)?
- a. Utilization of compression stockings at night
- b. Deep breathing and coughing daily
- c. Leg exercises 10 times per hour when awake
- d. Elevation of the legs on 2 pillows
The nurse monitors a client with a nasogastric tube attached to low suction for manifestations of which disorder?
- a. Metabolic acidosis
- b. Metabolic alkalosis
- c. Respiratory acidosis
- d. Respiratory alkalosis
A client with broken ribs is likely to experience what type of acid-base imbalance?
- a. Respiratory acidosis from inadequate ventilation
- b. Respiratory alkalosis from anxiety and hyperventilation
- c. Metabolic acidosis from calcium loss due to broken bones
- d. Metabolic alkalosis from taking analgesics containing base products
A patient with diarrhea needs to replace potassium. Which nutrient selections indicate additional teaching on potassium-rich foods is needed? (Select all that apply.)
- a. Beef bouillon
- b. Orange juice
- c. Poached egg
- d. Warm tea
- e. Avocado
A 750-mL tap-water enema is ordered for a patient. Which approach best promotes acceptance of the volume?
- a. Administer the fluid slowly, and have the patient take shallow breaths
- b. Place the patient in the left lateral position, and slowly administer the fluid
- c. Have the patient take shallow breaths, and keep the fluid at body temperature
- d. Keep the fluid at body temperature, and place the patient in the left lateral position
Which information indicates a patient at highest risk for developing diarrhea?
- a. Is physically active
- b. Drinks a lot of fluid
- c. Eats whole-grain bread
- d. Is experiencing emotional problems
Sequential compression devices (SCD) are ordered for a postoperative patient. Which information should the nurse provide? (Select all that apply.)
- a. Keeps the lower extremities warm
- b. Helps prevent deep vein thrombosis
- c. Accelerates the rate of wound healing
- d. Promotes circulation of blood back to the heart
- e. Eliminates the need for leg and foot exercises after surgery
A patient in the post anesthesia care unit (PACU) has vital signs: BP 150/90 mm Hg, pulse 88 (bounding), respirations 24 with crackles. What is the patient likely experiencing?
- a. Hypoglycemia
- b. Hyponatremia
- c. Hyperkalemia
- d. Hypervolemia
A patient reports no bowel movement in 10 days. Which questions help assess for fecal impaction? (Select all that apply.)
- a. “How long has it been since you had a formed stool?”
- b. “Have you had small amounts of liquid stool?”
- c. “Do you notice a bad odor to your breath?”
- d. “Have you been eating food with fiber?”
- e. “Are you having any vomiting?”
A postoperative client becomes restless. What should the nurse do first?
- a. Notify the physician
- b. Medicate the patient for pain
- c. Check the client’s vital signs
- d. Talk to the client in a calm voice
A client scheduled for surgery expresses uncertainty about proceeding. What is the nurse’s best response?
- a. “It is your decision.”
- b. “Do not worry. Everything will be fine.”
- c. “Why do you not want to have this surgery?”
- d. “Tell me what concerns you have about the surgery.”
When explaining at-home fecal occult blood testing, which instructions should the nurse include?
- a. Eating more protein is optimal prior to testing
- b. Continue all scheduled medications, including aspirin, before the test
- c. A red color change indicates a positive result
- d. The specimen must not be contaminated with urine
A nurse assesses a client who has had diarrhea for 4 days. Which findings are expected? (Select all that apply.)
- a. Bradycardia
- b. Hypotension
- c. Elevated temperature
- d. Poor skin turgor
- e. Peripheral edema
A client receiving IV therapy reports arm pain, chills, and general malaise, with warmth, edema, and redness near the IV site. What is the nurse’s first action?
- a. Obtain a specimen for culture
- b. Apply a warm compress
- c. Administer analgesics
- d. Discontinue the infusion
During an admission assessment, which findings would the nurse not expect in a client with hypovolemia due to vomiting and diarrhea? (Select all that apply.)
- a. Flat neck veins
- b. Thready pulse
- c. Syncope
- d. Dark urine
- e. Postural hypotension
A client’s potassium level is 5.2 mEq/L. What should the nurse anticipate after notifying the provider?
- a. Starting an IV infusion of 0.9% sodium chloride
- b. Consulting with a dietician to increase potassium intake
- c. Initiating continuous cardiac monitoring
- d. Preparing the patient for gastric lavage
A nurse assesses a client with a calcium level of 10.8 mEq/L. Which findings are expected? (Select all that apply.)
- a. Hyperreflexia
- b. Muscle weakness
- c. Positive Chvostek’s sign
- d. Muscle cramps
- e. Kidney stones
