Quiz 2

Question 1

a client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the client’s nose and around the intravenous catheter. What action by the nurse is the priority?

Answer 1

prepare protamine sulfate for administration

Question 2

what is the client’s MAP if the BP is 98/50 mm Hg?

Answer 2

66

Question 3

the charge nurse is orienting a float nurse to an assigned client with an AV fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe?

Answer 3

administering IV fluids through the AV fistula

Question 4

a client is place on fluid restrictions because of chronic kidney disease. Which assessment finding would alert the nurse that the client’s fluid balance is stable at this time?

Answer 4

no adventitious sounds in the lungs

Question 5

today the client weighs 186.4 pounds. Six months ago the client weighed 211.8 pounds. What action by the nurse is best?

Answer 5

ask the client if the weight loss was intentional

Question 6

a nurse is caring for four clients receiving enteral tube feedings, which client should the nurse see first?

Answer 6

client with a potassium level of 2.6 mg/dL

Question 7

Several nurses have just helped a morbidly obese client get out of bed. One nurse accesses the client’s record because she “just has to know how much she weighs”. What action by the client’s nurse is most appropriate?

Answer 7

state that is a violation of client confidentiality

Question 8

a nurse cares for an older adult client who has salmonella food poisoning. the client’s VS are HR 102, BP 98/55, RR 22, and O2 95%. Which action should the nurse complete first?

Answer 8

administer IV fluids

Question 9

a client is taking furosemide (Lasix) 40 mg/day for management of chronic kidney disease. To detect the positive effect of the medication, what action of the nurse is best?

Answer 9

obtain daily weights

Question 10

a client has a serum potassium of 6, a serum creatinine of 2 and urine output of 350 mL/day. What is the best next action by the nurse?

Answer 10

place the client on a cardiac monitor

Question 11

a nurse reviews lab results for a client with DM, who presents with polyuria, lethargy, and BG of 560. Which lab result would the nurse correlate with the client’s polyuria?

Answer 11

serum osmolarity 375 mOsm/kg

Question 12

a nurse teaches a client with type 2 DM who is prescribed glipizide. Which statement should the nurse include in this client’s teaching?

Answer 12

avoid taking NSAIDs

Question 13

a nurse assesses a client who is being treated for hyperglycemic hyperosmolar state. Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted?

Answer 13

glascow coma scale score is unchanged

Question 14

after teaching a client with type 2 DM the nurse assess the client’s understanding. Which statement made by the client indicates a need for additional teaching?

Answer 14

since my diabetes is controlled with diet and exercise I must be seen only if I am sick

Question 15

a nurse reviews the medication list of client recovering from CT scan with IV contrast to rule out small bowel obstruction. Which med should alert the nurse to contact the provider and withhold the prescribed dose?

Answer 15

metformin (glucophage)

Question 16

after teaching a client who is newly diagnosed with type 2 DM the nurse assess the client’s understanding. Which statement made by the client indicates a need for additional teaching?

Answer 16

I should decrease my intake of protein and eliminate carbs from my diet

Question 17

a nurse collaborates with an UAP to provide care for a client who is prescribed 24 hr urine specimen collection. Which statement should the nurse include when delegating this activity to the UAP.

Answer 17

note the time of the client’s first void and collect urine for the following 24 hrs

Question 18

a nurse cares for a teenage girl with a new ileostomy. The client states I cannot go to prom with an ostomy. How should the nurse respond?

Answer 18

let’s talk to the enterostomal therapist about options for ostomy supplies and dress styles

Question 19

after teaching a client who is prescribed adalimumab (Humira) for severe UC, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?

Answer 19

N and V are common side effects of this drug

Question 20

the nurse is completing a nutritional assessment on a patient with glomerulonephritis. What foods would be recommended for this patient?

Answer 20

low protein