Unit III: Nursing Sciences

Question 1

The nurse is caring for a client for a client with renal failure notes that the client is dyspneic and crackles are heard when listening to breath sounds in the lungs. Which additional signs and symptoms would the nurse expect to note in this client?
A. Rapid weight loss
B. Flat hand and neck veins
C. A weak and thready pulse
D. An increase in blood pressure

Answer 1

D

Question 2

The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that the client is at risk for a potassium deficit?
A. The client with Addison’s disease
B. The client with metabolic acidosis
C. The client with intestinal obstruction
D. The client with receiving nasogastric suction

Answer 2

D

Question 3

The nurse reviews a client’s electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level would be noted with which condition?
A. Diarrhea
B. Traumatic burn
C. Cushing’s syndrome
D. Overuse of laxative

Answer 3

B

Question 4

The nurse reviews a client’s electrolyte results and notes that the potassium level is 5.4 mEq/L. What would the nurse look for on the cardiac monitor as a result of the laboratory value?
A. ST elevation
B. Peaked P waves
C. Prominent U waves
D. Narrow, peaked T waves

Answer 4

D

Question 5

The nurse is reading the primary health care provider’s (PHCP’s) progress notes in the clients record and sees that the PHCP has documented “insensible fluid loss of approx. 800ml daily”
A. The client with a draining wound
B.The client with a urinary catheter
C. The client with a fast respiratory rate
D. The client with the nasogastric tube to low situations

Answer 5

C

Question 6

The client is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at the LEAST LIKELY risk for the development of third-spacing?
A. The client with septic
B. The client with cirrhosis
C. The client with kidney failure
D. The client with diabetes mellitus

Answer 6

D

Question 7

The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for fluid volume deficit?
A. The client with cirrhosis
B. The client with ileostomy
C. The client with heart failure
D. The client with decreased renal failure

Answer 7

B

Question 8

The nurse is caring for a client who has been taking diuretics on a long term basics. Which finding would the nurse expect to note as a result of this long term care?
A. Gurgling respirations
B. Increased BP
C. Decreased HCT level
D. Increased specific gravity of the urine

Answer 8

D

Question 9

The nurse reviews electrolyte values and notes a sodium level of 130mEq/L. The nurse expects that this sodium level would be noted in a client with which condition?
A. The client with watery diarrhea
B. The client with diabetes insipidus
C. The client with an inadequate daily water intake
D. The client with the syndrome of inappropriate secretion of antidiuretic hormone

Answer 9

D

Question 10

The nurse is caring for a client with leukaemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which S/S would the nurse expect to note in this client if hyponatremia is present?
A. Intense thirst
B. Slow bounding pulse
C. Dry mucous membranes
D. Postural BP changes

Answer 10

D

Question 11

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Lab studies are performed and the serum calcium level is 12 mg/dL. Based on this lab value, the nurse would take which action?
A. Document the value in the clients record
B. Inform the RN of the lab value
C. Place the lab result form in the clients record
D. Reassure the client that the lab value is normal

Answer 11

B

Question 12

The nurse reviews the clients serum calcium level and notes that the level is 8 mg/Dl. The nurse understands that which condition would cause this serum calcium level?
A. Prolonged bed rest
B. Adrenal insufficiency
C. Hyperparathyroidism
D. Excessive indigestion of vit. D

Answer 12

A

Question 13

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which S/S would be an indication of this electrolyte imbalance?
A. Twitching
B. Positive Trousseau’s sign
C. Hyperactive bowel sounds
D. Generalized muscle weakness

Answer 13

D

Question 14

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse would tell the client that which food item is LEAST LIKELY to contain calcium?
A. Milk
B. Butter
C. Spinach
D. Collard greens

Answer 14

B

Question 15

The nurse caring for a client with hyperparathyroidism and notes that the clients serum calcium level is 13 mg/dL. Which prescribed medication would the nurse plan to assist in administering to the client?
A. Calcitonin
B. Calcium chloride
C. Calcium gluconate
4. Large doses of Vitamin D

Answer 15

A

Question 16

A client has the following lab values: pH of 7.55, HCO3 level of 22 mEq/L, and Pco2 of 30 mm Hg. Which action would the nurse plan to take?
A. Perform an Allen’s test
B. Prepare the client of dialysis
C. Administer insulin as prescribed
D. Encourage the client to slow down breathing

Answer 16

D

Question 17

The nurse is told that the ABG results indicate a pH of 7.5 and a PCO2 of 32 mm Hg. The nurse determines that these results are indicative of which acid-base disturbances?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

Answer 17

D

Question 18

A client is scheduled for blood to be drawn form the radial artery for an ABG determination. The nurse assists with performing an Allen’s test before drawing the blood to determine the adequacy of what?
A. Ulnar circulation
B. Carotid circulation
C. Femoral circulation
D. Brachial circulation

Answer 18

A

Question 19

The nurse is caring for a client with a nasogastric tube that is attached too low suction. The nurse monitors the client closely for which acid-base disorder that is MOST LIKELY to occur in this situation?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

Answer 19

B

Question 20

The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

Answer 20

A

Question 21

The nurse observes that a client with diabetic ketoacidosis is experiencing abnormally deep, regular, rapid respirations. How would the nurse correctly document this observation in the medical record?
A. Apnea
B. Bradypnea
C. Cheyne-stone
D. Kussmaul’s respiration

Answer 21

D

Question 22

The nurse is caring for a client with a diagnosis of COPD. The nurse would monitor the client for which acid-base imbalance?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

Answer 22

C

Question 23

Which clients would the nurse determine to be at risk for development of metabolic alkalosis? SELECT ALL THAT APPLIES
A. Client with emphysema
B. Client who is hyperventilating
C. Client with chronic kidney disease
D. Client admitted with aspirin overdose
E. Client who has been vomitting for 2 days
F. Client receiving oral furosemide for 40 mg daily

Answer 23

D, F

Question 24

The nurse is caring for a client with respiratory insufficiency. The ABG results indicate a pH of 7.5 and a PCO2 of 30 mm Hg and the nurse is told that the client is experiencing respiratory alkalosis. Which additional lab value would the nurse expect to note?
A. Sodium level of 145 mEq/L
B. Potassium level of 3 mEq/L
C. Magnesium level of 1.3 mEq/L
D. Phosphorus level of 3 mg/dL

Answer 24

B

Question 25

The RN reviews the results of the ABG values with the LPN and tells the LPN that the client is experiencing respiratory acidosis. The LPN would expect to note which of the lab result report?
A. pH 7.5, Pco2 52 mm Hg
B. pH 7.35, Pco2 40 mm Hg
C. pH 7.25, Pco2 50 mm Hg
D. pH 7.5, Pco2 30 mm Hg

Answer 25

C

Question 26

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these lab values, the nurse anticipates which prescription?
A. Adding a dose of heparin sodium
B. Holding the next dose of warfarin
C. Increasing the next dose of warfarin
D. Administering the next dose of warfarin

Answer 26

B

Question 27

An RPN is precepting a student assigned to care for a client with chronic pain. Which statement, if made by the student, indicates the NEED FOR FURTHER TEACHING regarding pain management?
A. “I will be sure to ask my client what their pain level is on a scale of 0 to 10”
B. “ I know that I need to follow up after giving medication to make sure it is effective”
C. “ I know that pain in the older client might manifest as sleep disturbance or depression”
D. “ I will be sure to cue in to any indicators that the client may be exaggerating their pain”

Answer 27

D

Question 28

A client has been admitted to the hospital for UTI and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?
A. 3 mg/dL
B. 15 mg.dL
C. 29 mg/dL
D. 35 mg/dL

Answer 28

B

Question 29

An RPN is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the AP as being an appropriate method, indicates the NEED FOR FURTHER TEACHING?
A. Taking a rectal temperature for a client who has undergone nasal surgery
B. Taking an oral temperature for a client with a cough and nasal congestion
C. Taking an axillary temperature on a client who has just consumed hot coffee
D. Taking a temporal temperature on the neck behind the ear on a client who is diaphoretic

Answer 29

B

Question 30

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client’s activated partial thromboplastin (aPTT) time is 65 seconds. The licensed practical nurse reviews the lab results with the registered nurse, anticipating that which action is needed?
A. Discontinuing the heparin infusion
B. Increasing the rate of heparin infusion
C. Decreasing the rate of heparin infusion
D. Leaving the rate of the heparin infusion as it

Answer 30

B

Question 31

A client with a. history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client’s lab report, would be reported before administering the dose of furosemide?
A. 3.2 mEq/L
B. 3.8 mEq/L
C. 4.3 mEq/L
D. 4.8 mEq/L

Answer 31

D

Question 32

Several lab tests are prescribed for a client, and the nurse reviews the results of the tests. Which lab test results would the nurse report? SELECT ALL THAT APPLY?
A. Platelets 35,000 mm3
B. Sodium 150 mEq/L
C. Potassium 5 mEq/L
D. Segmented neutrophils 40%
E. Serum creatinine, 1 mg/dL
F. WBC 3000 mm3

Answer 32

A

Question 33

The nurse is caring for a client who takes ibuprofen for the pain. The nurse is gathering information on the client’s medication history and determines it is necessary to consult with the RN if the client is also taking which medications? SELECT ALL THE APPLY
A. Warfarin
B. Glimepiride
C. Amlodipine
D. Simvastatin
E. Hydrochlorothiazide

Answer 33

A,B,D,F

Question 34

A client with DM has a glycosylated hemoglobin A1C level of 9%. On the basis of the test result, the nurse plans to reinforce teaching the client about the need for which measures?
A. Avoiding infections
B. Taking in adequate fluids
C. Preventing and recognizing hypoglycemia
D. Preventing and recognizing hyperglycemia

Answer 34

A,B,C

Question 35

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would suggest to the RN the need for implementing neutropenic precautions if the clients WBC count was which value?
A. 2000 mm3
B. 5800 mm3
C. 8400 mm3
D. 11,500 mm3

Answer 35

D

Question 36

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to assist the RN with which action?
A. Administering antidote
B. Drawing a sample for type and crossmatching and transfusing the client
C. Drawing a sample for an activated partial thromboplastin time (aPTT) level
D. Drawing a sample for prothrombin time (PT) and international normalized ratio (INR)

Answer 36

A

Question 37

An RPN is caring for a postoperative client who is receiving demand-dose hydro morphone via a patient-controlled analgesia (PCA). The nurse enters the client room and finds the client drowsy and records the following vital signs: temp 36.2 C (97.2 F) orally, pulse 52 BPM, BP 101/58 mm HG, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 litres of oxygen via nasal cannula. Which action must the nurse take FIRST?
A. Document the findings
B. Attempt to arouse the client
C. Contract the RN immediately
D. Check the medication administration history on the PCA pump

Answer 37

D

Question 38

An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this results is MOST LIKELY caused by which condition noted in the client’s history?
A.Dehydration
B. Heart failure
C. Iron deficiency anemia
D. COPD

Answer 38

B

Question 39

A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3. The nurse needs to take which action after seeing the lab results?
A. Report the abnormally low count
B. Report the abnormally high count
C. Place the client on bleeding precautions
D. Place the normal report in the client’s medical record

Answer 39

C

Question 40

A client with DM has a blood sample drawn for the determination of a fasting blood glucose level. Which reviewing the client’s results, the nurse determines that which requires a call to the primary health care provider for intervention?
A. 75 mg/dL
B. 92 mg/dL
C. 120 mg/dL
D. 240 mg/dL

Answer 40

D

Question 41

A client with DM has a blood sample drawn for the determination of a fasting blood glucose level. Which reviewing the client’s results, the nurse determines that which requires a call to the primary health care provider for intervention?
A. 75 mg/dL
B. 92 mg/dL
C. 120 mg/dL
D. 240 mg/dL

Answer 41

D

Question 42

A client is having problems with blood clotting. Which food item would the nurse encourage the client to eat?
A. Legumes
B. Citrus fruits
C. Vegetable oils
D. Green, leafy vegetables

Answer 42

D

Question 43

When reinforcing dietary instructions to a client with irritable bowel syndrome whose primary symptom is alternating constipation and diarrhea, the nurse would tell the client that which foods are BEST to include in there diet for this disorder? SELECT ALL THAT APPLY
A. Beans
B. Apples
C. Cabbage
D. Brussels sprouts
E. Whole-grain bread

Answer 43

B,E

Question 44

A hospitalized client is a lacto- vegatarian. Which food item would the nurse remove from the meal tray?
A. Eggs
B. Milk
C. Cheese
D. Broccoli

Answer 44

A

Question 45

A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet?
A. Baked turkey
B. Tomato soup
C. Boiled shrimp
D. Chicken gumbo

Answer 45

A

Question 46

The nurse is providing dietary instructions to a client with gout. The nurse needs to tell the client that which food item will exacerbate the condition?
A. Scallops
B. Chocolate
C. Cornbread
D. Macaroni products

Answer 46

A

Question 47

A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client?
A. Soft custards
B. Orange juice
C. Clam chowder
D. Fat-free beef broth

Answer 47

D

Question 48

A client with heart disease is instructed regarding a low fat diet. The nurse determines that the client understands the diet if the client states it is acceptable to eat which food item?
A. Steak
B. Apples
C. Cheese
D. Pizza without pepperoni

Answer 48

B

Question 49

The nurse reinforces instructions to increase the amount of riboflavin in the diet. The nurse would tell the client to select which food item that is high in riboflavin?
A. Milk
B. Tomatoes
C. Citrus fruits
D. Green, leafy vegetables

Answer 49

A

Question 50

A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing?
A. veal, potatoes, gelatin, and orange juice
B. Chicken breast, broccoli, strawberries, and milk
C. Peanut butter and jelly sandwich, cantaloupe, and tea
D. Spaghetti with tomato sauce, garlic bread, and ginger ale

Answer 50

B

Question 51

The nurse has completed diet teaching for a client who has been prescribed a low sodium diet to treat hypertension. The nurse determines that there is a NEED FOR FURTHER TEACHING when the client make which statements?
A. “This diet will help lower my BP”
B. “Fresh foods such as fruits and vegetables are high in sodium”
C. “This diet is not a replacement for my antihypertensive medications”
D. “The reason I need to lower my salt intake is to reduce fluid retention”

Answer 51

B

Question 52

The nurse is assisting with care for a client who will receive a unit of blood. Just before the infusion, it is MOST IMPORTANT for then nurse to check which item?
A. Vital signs
B. Skin colour
C. Oxygen saturation
D. Latest hematocrit level

Question 53

A client who is receiving blood transfusion pushes the call light for the nurse. When entering the room the nurse notes that the patient is flushed, dyspneic, an dis complaining if generalized itching. How would the nurse correctly interpret these findings?
A. Bacteremia
B. Fluid overload
C. Hypovolemic shock
D. Transfusion reaction

Answer 53

D

Question 54

A client who is receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area?
A. Pharmacy
B. Lab
C. Blood bank
D. Risk management department

Answer 54

C

Question 55

The nurse takes a client’s temperature before given a blood transfusion. The temperature is 100F (37C) orally. The nurse reports the finding to the RN and anticipates that which action will take place?
A. The transfusion will begin as prescribed
B. The transfusion will begin after the administration of an antihistamine
C. The transfusion will begin after the administration of 650 mg of acetaminophen
D. The blood will be held, and the primary health care provided will be notified

Answer 55

D

Question 56

Which of these clients is/are MOST LIKELY to develop fluid(circulatory) overload? SELECT ALL THAT APPLIES
A. Premature infant
B. 101 year old man
C. Client with heart failure
D. Client with diabetes mellitus
E. Client receiving renal dialysis
F. 29 year old client with pneumonia

Answer 56

A,B,C,E

Question 57

A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the intravenous (IV) bag with the tubing?
A. Uncaps the distal end of the tubing
B. Uncaps the spike portion of the bag
C. Opens the roller clamp on the IV tubing
D. Closes the roller clamp on the IV tubing

Answer 57

D

Question 58

The nurse is doing a routine assessment of a clients peripheral intravenous(IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which complication has probably occurred?
A. Phlebitis
B. Infection
C. Infiltration
D. Thrombosis

Answer 58

C

Question 59

The nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would take which actions while changing the clients hospital gown? SELECT ALL THAT APPLIES
A. Using a hospital gown with snaps at the sleeves
B. Disconnecting the IV tubing from the catheter in the vein
C. Checking the IV flow rate immediately after changing the hospital gown
D. Putting the bag and tubing through the sleeve, followed by the clients arm
E.Cutting the sleeves of the hospital gown and using safety pins to hold the sleeve together

Answer 59

A,C,D

Question 60

The nurse is making a worksheet and listing the tasks that needs to be performed for the assigned adult clients during the shifts. The nurse writes on the plan to check the IV of an assigned client who is receiving fluid replacement therapy how frequently?
A. Every hour
B. Every 2 hours
C. Every 3 Hours
D. Every 4 hours

Answer 60

A

Question 61

The nurse is checking the insertion site of a peripheral IV catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is most likely the result of which complication?
A. Phlebitis of the vein
B. Infiltration of the IV line
C. Hypersensitivity to the IV solution
D. An allergic reaction to the IV solution

Answer 61

A

Question 62

The nurse has been instructed to remove an IV line. The nurse removed the catheter by withdrawing the catheter while applying pressure ti the site with which item?
A. Band-aid
B. Alcohol swab
C. Betadine swab
D. Sterile 2 X 2 gauze

Answer 62

D

Question 63

The nurse is preparing for an IV solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse would plan to take which action?
A. Change the IV tubing
B. Wipe the tubing with Betadine
C. Scrub the tubing with an alcohol swab
D. Scrub the ruing before attaching it to the iv bag

Answer 63

A

Question 64

A client is going to be transfused with a unit of packed RBCs. The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started?
A. 5 mins
B. 15 mins
C. 30 mins
D. 45 mins

Answer 64

B

Question 65

The nurse is assisting with caring for a client who is receiving a unit of packed RBCs. The nurse would tell the client that it is MOST IMPORTANT to report which signs IMMEDIATELY?
A. Sore throat or earache
B. Chills, itching, or rash
C. Unusual sleepiness or fatigue
D. Mild discomfort at the catheter site

Answer 65

B

Question 66

The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy id the client exits which findings?
A. Increased hematocrit level
B. Increased hemoglobin level
C. Decline of the temperature to normal
D. Decrease in boxing from puncture sites and gums

Answer 66

D