Correct

Q.1) A client with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth. The nurse would assess for what electrolyte imbalance?

A. Hyponatremia

B. Hypocalcemia (Your Answer)

C. Hyperkalemia

D. Hypermagnesemia

Explanation

Hypoparathyroidism can cause low serum calcium levels. Numbness and tingling in extremities and in the circumoral area around the mouth are the hallmark signs of hypocalcemia. Normal calcium level is 9 to 11 mg/dl.

Incorrect

Q.2) The nurse evaluates which of the following clients to be at risk for developing hypernatremia?

A. 50-year-old with pneumonia, diaphoresis, and high fevers (Correct Answer)

B. 62-year-old with congestive heart failure taking loop diuretics

C. 39-year-old with diarrhea and vomiting

D. 60-year-old with lung cancer and syndrome of inappropriate antidiuretic hormone (SIADH)

(Your Answer)

Explanation

Diaphoresis and a high fever can lead to free water loss through the skin, resulting in hypernatremia. Loop diuretics are more likely to result in a hypovolemic hyponatremia. Diarrhea and vomiting cause both sodium and water losses. Clients with syndrome of inappropriate antidiuretic hormone (SIADH) have hyponatremia, due to increased water reabsorption in the renal tubules.

Correct

Q.3) A client is admitted with diabetic ketoacidosis who, with treatment, has a normal blood glucose, pH, and serum osmolality. During assessment, the client complains of weakness in the legs. Which of the following is a priority nursing intervention?

A. Request a physical therapy consult from the physician

B. Ensure the client is safe from falls and check the most recent potassium level (Your

Answer)

C. Allow uninterrupted rest periods throughout the day

D. Encourage the client to increase intake of dairy products and green leafy vegetables.

Explanation

In the treatment of diabetic ketoacidosis, the blood sugar is lowered, the pH is corrected, and potassium moves back into the cells, resulting in low serum potassium. Client safety and the correction of low potassium levels are a priority. The weakness in the legs is a clinical manifestation of the hypokalemia. Dairy products and green, leafy vegetables are a source of calcium.

Incorrect

Q.4) A client with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor

A. urine output.

B. blood pressure.

C. bowel movements. (Correct Answer)

D. ECG for tall, peaked T waves. (Your Answer)

Explanation

Kayexalate causes potassium to be exchanged for sodium in the intestines and excreted through bowel movements. If client does not have stools, the drug cannot work properly. Blood pressure

and urine output are not of primary importance. The nurse would already expect changes in T waves with hyperkalemia. Normal serum potassium is 3.5 to 5.5 mEq/L.

Correct

Q.5) The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client's serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action?

A. Call the physician and report results

B. Question the results and redraw the specimen (Your Answer)

C. Encourage the client to increase the intake of bananas

D. Initiate seizure precautions

Explanation

A client who has been in good health up to the present is admitted for cellulitis of the hands. When the serum potassium goes from 4.5 mEq/L to 7.0 mEq/L with no risk factors for hyperkalemia, false high results should be suspected because of hemolysis of the specimen. The physician would likely question results as well. Bananas are a food high in potassium. Seizures are not a clinical manifestation of hyperkalemia.

Incorrect

Q.6) A client is receiving an intravenous magnesium infusion to correct a serum level of 1.4 mEq/L. Which of the following assessments would alert the nurse to immediately stop the infusion?

A. Absent patellar reflex (Correct Answer)

B. Diarrhea

C. Premature ventricular contractions (Your Answer)

D. Increase in blood pressure

Explanation

An intravenous magnesium infusion may be used to treat a low serum magnesium level. Normal serum magnesium is 1.5 to 2.5 mEq/L. Clinical manifestations of hypermagnesemia are the result of depressed neuromuscular transmission. Absent reflexes indicate a magnesium level around 7 mEq/L. Diarrhea and PVCs are not clinical manifestations of high magnesium levels. Hypermagnesemia causes hypotension.

Incorrect

Q.7) A client with chronic renal failure reports a 10 pound weight loss over 3 months and has had difficulty taking calcium supplements. The total calcium is 6.9 mg/dl. Which of the following would be the first nursing action?

A. Assess for depressed deep tendon reflexes (Your Answer)

B. Call the physician to report calcium level

C. Place an intravenous catheter in anticipation of administering calcium gluconate

D. Check to see if a serum albumin level is available (Correct Answer)

Explanation

A client with chronic renal failure who reports a 10 pound weight loss over 3 months and has difficulty taking calcium supplements is poorly nourished and likely to have hypoalbuminemia. A drop in serum albumin will result in a false low total calcium level. Placing an IV is not a priority action. Depressed reflexes are a sign of hypercalcemia. Normal serum calcium is 9 to 11 mg/dl.

Incorrect

Q.8) A client with heart failure is complaining of nausea. The client has received IV furosemide (Lasix), and the urine output has been 2500 ml over the past 12 hours. The client's home drugs include metoprolol (Lopressor), digoxin (Lanoxin), furosemide, and multivitamins. Which of the following are the appropriate nursing actions before administering the digoxin? Select all that apply.

A. Administer an antiemetic prior to giving the digoxin

B. Encourage the client to increase fluid intake

C. Call the physician (Missed)

D. Report the urine output (Your Answer)

E. Report indications of nausea (Missed)

Explanation

Potassium is lost during diuresis with a loop diuretic such as furosemide (Lasix). Hypokalemia can cause digitalis toxicity, which often results in nausea. The physician should be notified, and digoxin should be held until potassium levels and digoxin levels are checked. Peaked T waves and widened QRS are manifestations of hyperkalemia.

Correct

Q.9) The nurse is caring for a bedridden client admitted with multiple myeloma and a serum calcium level of 13 mg/dl. Which of the following is the most appropriate nursing action?

A. Provide passive ROM exercises and encourage fluid intake (Your Answer)

B. Teach the client to increase intake of whole grains and nuts

C. Place a tracheostomy tray at the bedside

D. Administer calcium gluconate IM as ordered

Explanation

A client who has a serum calcium of 13 mg/dl has hypercalcemia. Normal serum calcium is 9 to 11 mg/dl. Fluid intake promotes renal excretion of excess calcium. ROM exercises promote reabsorption of calcium into bone. Placing a tracheostomy at the bedside is a nursing intervention for hypocalcemia. Although calcium gluconate may be administered in hypocalcemia, it is never administered IM.

Correct

Q.10) An older adult client admitted with heart failure and a sodium level of 113 mEq/L is behaving aggressively toward staff and does not recognize family members. When the family expresses

concern about the client's behavior, the nurse would respond most appropriately by stating

A. "The client may be suffering from dementia, and the hospitalization has worsened the

confusion."

B. "Most older adults get confused in the hospital."

C. "The sodium level is low, and the confusion will resolve as the levels normalize." (Your

Answer)

D. "The sodium level is high and the behavior is a result of dehydration."

Explanation

Normal serum level is 135 to 145 mEq/L. Neurological symptoms occur when sodium levels fall below 120 mEq/L. The confusion is an acute condition that will go away as the sodium levels normalize. Dementia is an irreversible condition.

Incorrect

Q.11) A client with a serum sodium of 115 mEq/L has been receiving 3% NS at 50 ml/hr for 16 hours. This morning the client feels tired and short of breath. Which of the following interventions is a priority?

A. Turn down the infusion (Your Answer)

B. Check the latest sodium level

C. Assess for signs of fluid overload (Correct Answer)

D. Place a call to the physician

Explanation

A complication of hypertonic sodium solution administration is fluid overload. While turning down the infusion, checking the latest sodium level, and notifying the physician may all be reasonable, the priority intervention is to assess for manifestations of fluid overload. Assessment is always the priority to determine what action to take next.

Incorrect

Q.12) A client with chronic renal failure receiving dialysis complains of frequent constipation. When performing discharge teaching, which over-the-counter products should the nurse instruct the client to avoid at home?

A. Bisacodyl (Dulcolax) suppository

B. Fiber supplements

C. Docusate sodium (Your Answer)

D. Milk of magnesia (Correct Answer)

Explanation

Milk of magnesia contains magnesium, an electrolyte that is excreted by kidneys. Clients with renal failure are at risk for hypermagnesemia, since their bodies cannot excrete the excess magnesium. The client should avoid magnesium-containing laxatives.

Correct

Q.13) A client is receiving intravenous potassium supplementation in addition to maintenance fluids. The urine output has been 120 ml every 8 hours for the past 16 hours and the next dose is due. Before administering the next potassium dose, which of the following is the priority nursing action?

A. Encourage the client to increase fluid intake

B. Administer the dose as ordered

C. Draw a potassium level and administer the dose if the level is low or normal

D. Notify the physician of the urine output and hold the dose (Your Answer)

Explanation

Urine output is an indication of renal function. Normal urine output is at least 30 ml/hour. Clients with impaired renal function are at risk for hyperkalemia. Initiating a lab draw requires a physician order.

Incorrect

Q.14) The nurse should monitor for clinical manifestations of hypophosphatemia in which of the following clients?

A. A client with osteoporosis taking vitamin D and calcium supplements

B. A client who is alcoholic receiving total parenteral nutrition (Correct Answer)

C. A client with chronic renal failure awaiting the first dialysis run

D. A client with hypoparathyroidism secondary to thyroid surgery (Your Answer)

Explanation

A client with osteoporosis taking vitamin and calcium supplements, a client with chronic renal failure awaiting dialysis, and a client with hypoparathyroidism secondary to thyroid surgery are at risk for hyperphosphatemia. Alcoholics and clients receiving TPN are at risk for low phosphorus levels, due to poor intestinal absorption and shifting of phosphorus into cells along with insulin and glucose.

Correct

Q.15) A client admitted with squamous cell carcinoma of the lung has a serum calcium level of 14 mg/dl. The nurse should instruct the client to avoid which of the following foods upon discharge? Select all that apply.

A. Eggs

B. Broccoli (Your Answer)

C. Organ meats

D. Nuts (Your Answer)

E. Canned salmon (Your Answer)

Explanation

Fish, eggs, and organ meats are high in phosphorus. Broccoli, nuts, and canned salmon are high in calcium. Clients with lung or breast cancer often have elevated calcium levels due to tumor-induced hyperparathyroidism.

Incorrect

Q.16) A client with pancreatitis has been receiving potassium supplementation for four days since being admitted with a serum potassium of 3.0 mEq/L. Today the potassium level is 3.1 mEq/L. Which of the following laboratory values should the nurse check before notifying the physician of the client's failure to respond to treatment?

A. Sodium

B. Phosphorus (Your Answer)

C. Calcium

D. Magnesium (Correct Answer)

Explanation

Low serum magnesium levels can inhibit potassium ions from crossing cell membranes, resulting in potassium loss through the urine. Generally, low magnesium levels must be corrected before potassium replacement is effective.

Correct

Q.17) The nurse should include which of the following instructions to assist in controlling phosphorus levels for a client in renal failure?

A. Increase intake of dairy products and nuts

B. Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals

(Your Answer)

C. Reduce intake of chocolate, meats, and whole grains

D. Avoid calcium supplements

Explanation

Aluminum-based antacids are often prescribed in the treatment of renal failure to bind with phosphate and increase elimination through the GI tract. Dairy products and nuts are foods high in phosphorus. Chocolate, meats, and whole grains are foods high in magnesium. Clients with renal failure often require calcium supplements as a result of poor vitamin D metabolism and in order to prevent hyperphosphatemia.

Correct

Q.18) A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45, which of the following is the most appropriate nursing intervention?

A. Administer a sedative

B. Place client in left lateral position

C. Place client in high-Fowler's position (Your Answer)

D. Assist the client to breathe into a paper bag

Explanation

The client with a pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45 is in a state of respiratory acidosis. Placing the client in high-Fowler's position will facilitate the expansion of the lungs and help the client blow off the excess CO2. Sedatives would impede respirations. The question does not indicate which is the affected lung, so left lateral position would not be a first choice. Breathing into a paper bag will cause the PCO2 to rise higher.

Correct

Q.19) A client with COPD feels short of breath after walking to the bathroom on 2 liters of oxygen nasal cannula. The morning's ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse's first intervention?

A. Call the physician and report the change in client's condition

B. Turn the client's O2 up to 4 liters nasal cannula

C. Encourage the client to sit down and to take deep breaths

D. Encourage the client to rest and to use pursed-lip breathing technique (Your Answer)

Explanation

Clients with COPD, especially those who are in a chronic compensated respiratory acidosis, are very sensitive to changes in O2 flow, because hypoxemia rather than high CO2 levels stimulates respirations. Deep breaths are not helpful, because clients with COPD have difficulty with air trapping in alveoli. There is no need to call the physician, since this client is presently most likely at baseline.

Correct

Q.20) A client who had a recent surgery has been vomiting and becomes dizzy while standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the pulse is 140. The nurse hangs which of the following IV fluids to correct this condition?

A. D5.45 NS at 50 ml/hr

B. 0.9 NS at an open rate (Your Answer)

C. D5W at 125 ml/hr

D. 0.45 NS at open rate

Explanation

A client who recently had surgery, is vomiting, becomes dizzy when standing up, has a blood pressure of 55/30, and has a pulse of 140 is hypovolemic and requires plasma volume expansion. Isotonic fluids such as 0.9 NS will expand volume. Hypotonic fluids such as 0.45 NS will leave the intravascular space. D5W will metabolize into free water and leave the intravascular space. D5.45 NS is a good maintenance fluid but a rate of 50 ml per hour is not sufficient to expand the vascular volume quickly.

Incorrect

Q.21) A client with renal failure enters the emergency room after skipping three dialysis treatments to visit family out of town. Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis?

A. pH of 7.43, PCO2 of 36, HCO3 of 26

B. pH of 7.41, PCO2 of 49, HCO3 of 30

C. pH of 7.33, PCO2 of 35, HCO3 of 17 (Correct Answer)

D. pH of 7.25, PCO2 of 56, HCO3 of 28 (Your Answer)

Explanation

A pH of 7.33, PCO2 of 35, and HCO3 of 17 and a pH of 7.25, PCO2 of 56, and HCO3 of 28 both indicate acidosis. The pH of 7.25 is a respiratory acidosis. A pH of 7.41, PCO2 of 49, and HCO3 of 30 is a compensated metabolic alkalosis. A pH of 7.43, PCO2 of 36, and HCO3 of 26 is normal.

Correct

Q.22) A client with a small bowel obstruction has had an NG tube connected to low intermittent suction for two days. The nurse should monitor for clinical manifestations of which acid-base disorder?

A. Respiratory alkalosis

B. Respiratory acidosis

C. Metabolic alkalosis (Your Answer)

D. Metabolic acidosis

Explanation

Clients with gastric suctioning can lose hydrogen ions resulting in a metabolic alkalosis.

Correct

Q.23) A client who suffers from an anxiety disorder is very upset, has a respiratory rate of 32, and is complaining of lightheadedness and tingling in the fingers. ABG values are pH of 7.48, PaCO2 of

29, HCO3 of 24, and O2 is at 93% on room air. The nurse performs which of the following as a priority nursing intervention?

A. Monitor intake and output

B. Encourage client to increase activity

C. Institute deep breathing exercises every hour

D. Provide reassurance to the client and administer sedatives (Your Answer)

Explanation

A client who is anxious and upset, gets lightheaded, and has tingling in the fingers is in respiratory alkalosis. The arterial blood gases include a pH of 7.48, PaCO2 of 29, and HCO3 of 24. Administering sedatives will assist the client to slow breathe and retain more CO2, thus bringing the pH back into normal range. Deep breathing exercises may worsen the client's condition. Encouraging the client to increase activity is contraindicated because clients are often exhausted and require rest after expending so much energy breathing. Monitoring intake and output is not a priority.

Correct

Q.24) Which of the following assessment findings would indicate to the nurse that a client's diabetic ketoacidosis is deteriorating?

A. Deep tendon reflexes decreasing from +2 to +1 (Your Answer)

B. Bicarbonate rising from 20 mEq/L to 22 mEq/L

C. Urine pH less than 6

D. Serum potassium decreasing from 6.0 mEq/L to 4.5 mEq/L

Explanation

A decrease in deep tendon reflexes is a sign that pH is dropping and that metabolic acidosis is worsening to diabetic ketoacidosis. An increase in bicarbonate would indicate that the acidosis is being corrected. A urine pH less than 6 indicates the kidneys are excreting acid. Serum potassium levels are expected to fall because acidosis is corrected and potassium moves back into the intracellular space.

Correct

Q.25) A client who is admitted with malnutrition and anorexia secondary to chemotherapy is also exhibiting generalized edema. The client asks the nurse for an explanation for the edema. Which of the following is the most appropriate response by the nurse?

A. "The fluid is an adverse reaction to chemotherapy."

B. "A decrease in activity has allowed extra fluid to accumulate in the tissues."

C. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the

blood vessels into the tissues." (Your Answer)

D. "Chemotherapy has increased your blood pressure, and fluid was forced out into the

tissues."

Explanation

Generalized edema, or anasarca, is often seen in clients with low albumin levels secondary to poor nutrition. Decreased oncotic pressure within the blood vessels allows fluid to move from the intravascular space to the interstitial space.

Correct

Q.26) A client with a recent thyroidectomy complains of numbness and tingling around the mouth. Which of the following findings indicates the serum calcium is low?

A. Bone pain

B. Depressed deep tendon reflexes

C. Positive Chvostek's sign (Your Answer)

D. Nausea

Explanation

Numbness and tingling around the mouth indicate hypocalcemia, which results in neuromuscular irritability. A positive Chvostek's sign is the contraction of facial muscles when the facial nerve in

front of the ear is tapped. Bone pain, nausea, and depressed deep tendon reflexes are signs of hypercalcemia.

Correct

Q.27) A client recently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) complains of headache, weight gain, and nausea. Which of the following is an appropriate nursing diagnosis for this client?

A. Deficient fluid volume related to decreased fluid intake

B. Excess fluid volume related to increased water retention (Your Answer)

C. Deficient fluid volume related to excessive fluid loss

D. Risk for injury related to fluid volume loss

Explanation

The client exhibits signs of excess fluid volume. Syndrome of inappropriate antidiuretic hormone (SIADH) is the release of excess ADH by the pituitary gland, which results in hypervolemic hyponatremia and clinical manifestations of headache, weight gain, and nausea.

Correct

Q.28) The registered nurse is delegating nursing tasks for the day. WHich of the following tasks may the nurse delegate to a licensed practical nurse?

A. Assess a client for metabolic acidosis

B. Evaluate the blood gases of a client with respiratory alkalosis

C. Obtain a glucose level on a client admitted with diabetes mellitus (Your Answer)

D. Perform a neurological assessment on a client suspected of having hypocalcemia

Explanation

A licensed practical nurse may obtain a finger-stick glucose on a client with diabetes mellitus. A licensed practical nurse may not assess a client for metabolic acidosis, evaluate blood gases on a client with respiratory alkalosis, or perform a neurological assessment on a client suspected of hypocalcemia.

Incorrect

Q.29) A client who is post-gallbladder surgery has a nasogastric tube, decreased reflexes, pulse of 110 weak and irregular, and blood pressure of 80/50 and is weak, mildly confused, and has a serum of potassium of 3.0 mEq/L. Based on the assessment data, which of the following is the priority intervention?

A. Withhold furosemide (Lasix) (Your Answer)

B. Notify the physician (Correct Answer)

C. Administer the prescribed potassium supplement

D. Instruct the client on foods high in potassium

Explanation

The priority intervention for a client who had gallbladder surgery, has a nasogastric tube, decreased reflexes, pulse of 110 weak and irregular, and blood pressure of 80/50 and is weak, mildly confused, and has a serum potassium of 3.0 mEq/L would be to notify the physician that the potassium level is low. After notifying the physician, the furosemide (Lasix) may be withheld and potassium supplement should be administered as prescribed and may even be increased after talking with the physician. The client may also be instructed on foods high in potassium. These are all appropriate interventions but not the priority.

Correct

Q.30) The nurse is admitting a client with a potassium level of 6.0 mEq/L. The nurse reports this finding as a result of

A. acute renal failure. (Your Answer)

B. malabsorption syndrome.

C. nasogastric drainage.

D. laxative abuse

Explanation

A serum potassium level of 6.0 mEq/L is indicative of acute renal failure. Malabsorption syndrome, nasogastric drainage, and laxative abuse may result in a low serum potassium level, because output may be greater than input. Diarrhea results in malabsorption syndrome and can come from laxative abuse. Fluids and electrolytes may be lost in the nasogastric drainage. Normal serum potassium is 3.5 to 5.5 mEq/L.

Incorrect

Q.31) Which of the following should the nurse include in the diet teaching for a client with a sodium level of 158 mEq/L?

A. Pretzels

B. Baked chicken (Missed)

C. Chicken bouillon (Your Answer)

D. Baked potato (Missed)

E. Baked ham

Explanation

Normal serum sodium is between 135 and 145 mEq/L. A sodium level of 158 mEq/L is elevated and a low sodium diet should be prescribed. A peanut butter sandwich, pretzels, chicken bouillon, and baked ham are all foods high in sodium content. Baked chicken and baked potato are low-sodium food choices.

Correct

Q.32) The nurse assesses a client to be experiencing muscle cramps, numbness, and tingling of the extremities, and twitching of the facial muscle and eyelid when the facial nerve is tapped. THe

nurse reports this assessment as consistent with which of the following?

A. Hypokalemia

B. Hypernatremia

C. Hypermagnesemia

D. Hypocalcemia (Your Answer)

Explanation

Normal serum calcium is 9 to 11 mg/dl. A client who has hypocalcemia would experience muscle cramps, numbness, and twitching of the facial muscles and eyelid when the facial nerve is tapped. Hypocalcemia may result from renal failure, hypothyroidism, acute pancreatitis, liver disease, malabsorption syndrome, and vitamin D deficiency. Normal serum potassium level is 3.5 to 5.5 mEq/L. Normal serum sodium is 135 to 145 mEq/L. Normal serum magnesium is 1.5 to 2.5 mEq/L.

Incorrect

Q.33) Which of the following should the nurse include when preparing to teach a class on the regulation and functions of electrolytes?

A. Sodium is essential to maintain intracellular fluid water balance (Your Answer)

B. Magnesium is essential to the function of muscle, red blood cells, and nervous system

C. Less calcium is excreted with aging

D. Chloride is lost in hydrochloride acid (Correct Answer)

Explanation

Sodium is essential to maintain extracellular fluid water balance. Phosphate is the major anion in intracellular fluid water balance that is essential in the function of muscle, red blood cells, and nervous system. A person tends to excrete more calcium with age. Chloride is lost through hydrochloride acid.

Incorrect

Q.34) The nurse assists a client with a serum potassium of 3.2 mEq/L to make which of the following menu selections? Select all that apply.

A. Baked cod (Missed)

B. Ham and cheese omelet (Your Answer)

C. Fried eggs

D. Baked potato (Missed)

E. Spinach (Your Answer)

Explanation

Normal serum potassium is 3.5 to 5.5 mEq/L. A client who has a potassium of 3.2 mEq/L would benefit from a diet high in potassium. Baked cod, baked potato, and spinach are all food selections high in potassium. A ham and cheese omelet is high in sodium. Fried eggs are high in cholesterol. A whole grain muffin is high in grains.

Incorrect

Q.35) The nurse evaluates which of the following clients to have hypermagnesemia?

A. A client who has chronic alcoholism and a magnesium level of 1.3 mEq/L

B. A client who has hyperthyroidism and a magnesium level of 1.6 mEq/L (Your Answer)

C. A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L

(Correct Answer)

D. A client who has congestive heart disease, takes a diuretic, and has a magnesium level of

2.3 mEq/L (Your Answer)

Explanation

Normal serum magnesium is 1.5 to 2.5 mEq/L. Clients who have chronic alcoholism and hyperthyroidism are prone to hypomagnesemia. A client who has congestive heart failure, takes a

diuretic, and has a magnesium level of 2.3 mEq/L falls within the normal magnesium range.

Incorrect

Q.36) The nurse is evaluating the serum laboratory results on the following four clients. Which of the following laboratory results is a priority for the nurse to report first?

A. A client with osteoporosis and a calcium level of 10.6 mg/dl

B. A client with renal failure and a magnesium level of 2.5 mEq/L

C. A client with bulimia and a potassium level of 3.6 mEq/L (Your Answer)

D. A client with dehydration and a sodium level of 149 mEq/L (Correct Answer)

Explanation

Although a client with acute osteoporosis may have a high serum calcium, a level of 10.6 mg/dl is normal. Normal serum calcium is 9 to 11 mg/dl. Normal serum magnesium is 1.5 to 2.5 mEq/L. A client who has renal failure is prone to hypermagnesemia, but a level of 2.5 mEq/L is at the upper limit of normal. A client who has bulimia generally vomits enough to result in a low potassium level, but a potassium level of 3.6 mEq/L is low normal. Normal serum potassium is 3.5 to 5.5 mEq/L. Normal serum sodium is 135 to 145 mEq/L. The sodium level generally goes up with dehydration. A sodium level of 149 mEq/L is elevated.

Incorrect

Q.37) The registered nurse is delegating client assignments to unlicensed assistive personnel. Which of the following clients does not require additional monitoring and assessment and may be delegated to unlicensed assistive personnel?

A. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L

(Correct Answer)

B. A client with renal failure who has a serum magnesium level of 3.0 mEq/L

C. A client who has experienced a fracture of the femur and has a serum phosphate of 5.0

mg/dl

D. A client with dehydration who has a serum sodium level of 128 mEq/L (Your Answer)

Explanation

Normal serum chloride is 95 to 105 mEq/L. A client with diarrhea may experience a low chloride level, but 100 mEq/L is within the normal range and may be delegated to unlicensed assistive personnel. Normal serum magnesium is 1.5 to 2.5 mEq/L. A magnesium level of 3.0 mEq/L is elevated and may occur in renal failure. Phosphate levels may be elevated with healing fractures. A phosphate level of 5.0 mg/dl is elevated. Normal serum phosphate is 2.8 to 4.5 mg/dl. A sodium level of 128 mEq/L is decreased and may be found with dehydration. Normal serum sodium is 135 to 145 mEq/L.

Correct

Q.38) The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition would be a cause for these findings?

A. Overhydration.

B. Anemia.

C. Dehydration. (Your Answer)

D. Renal failure.

Explanation

A. (incorrect) Clients who are overhydrated or have fluid volume excess would experience dilutional values of sodium (135-145 mEq/L) and red blood cells (44% to 52%). The levels would be lower than normal, not higher.B. (incorrect) Anemia is a low red blood cell count for a variety of reasons.C. (correct) Dehydration results in concentrated serum that causes lab values to increase because the blood has normal constituents but not enough volume to dilute the values to within normal range or possibly lower.D. (incorrect) In renal failure, the kidneys cannot excrete, and this results in too much fluid in the body.

TEST-TAKING HINT: The test taker must decide first if the values are high or low and then determine what is happening with body fluids in each process. Overhydration and renal failure

result in the same fluid shift, so these two options (A and D) could be excluded.

Correct

Q.39) The client who has undergone an exploratory laparotomy and subsequent removal of a large intestinal tumor has a nasogastric tube (NGT) in place and an IV running at 150 mL/hr via an IV pump. Which data should be reported to the health care provider?

A. The pump keeps sounding an alarm that the high pressure has been reached.

B. Intake is 1800 mL, NGT output is 550 mL, and Foley output 950 mL.

C. On auscultation, crackles and rales in all lung fields are noted. (Your Answer)

D. Client has negative pedal edema and an increasing level of consciousness.

Explanation

A. (incorrect) The pump is alerting the nurse that there is resistance distal to the pump; this does not require notifying the health care provider.B. (incorrect) The client has an 1800 mL intake and total output of 1500 mL. The body has an insensible loss of approximately 400 mL per day through the skin, respirations, and other body functions. This would not warrant notifying the health care provider.C. (correct) Crackles and rales in all lung fields indicate that the body is not able to process the amounts of fluids being infused. This should be brought to the health care provider's attention.D. (incorrect) Negative pedal edema and an increasing level of consciousness indicate that the client is not experiencing a problem.

TEST-TAKING HINT: The question requires the test taker to distinguish nursing problems from client problems. Option A is a nursing problem and options B and D are expected results, so the health care provider does not need to be notified. Only one option, C, contains abnormal or life-threatening information.

Correct

Q.40) The client diagnosed with diabetes insipidus weighed 180 pounds when the daily weight was taken yesterday. This morning's weight is 175.6 pounds. One liter of fluid weighs approximately 2.2 pounds. How much fluid has the client lost (in milliliters)?

A. 500 mL

B. 1000 mL

C. 2000 mL (Your Answer)

D. 4400 mL

Explanation

First, determine how many pounds the client has lost:

180 - 175.6 = 4.4 pounds lost

Then, based on the fact that 1 liter of fluid weighs 2.2 pounds, determine how many liters of fluid have been lost.

4.4 / 2.2 = 2 liters lost

Then, because the question asks for the answer in milliliters, convert 2 liters into milliliters.

2 x 1000 = 2000 mL

TEST-TAKING HINT: The test taker must be able to work basic math problems. This problem has several steps. Sometimes it is helpful to write out what is occurring at each step, such as 4.4 divided by 2.2 kg per pound. This can help the test taker realize if a step has been overlooked.

Correct

Q.41) The nurse writes the nursing problem of "fluid volume excess" (FVE). Which intervention should be included in the plan of care?

A. Change the IV fluid from 0.9% NS to D5W.

B. Restrict the client's sodium in the diet. (Your Answer)

C. Monitor blood glucose levels.

D. Prepare the client for hemodialysis.

Explanation

A. (incorrect) The nursing plan of care does not include changing the health care provider's orders.B. (correct) Fluid volume excess refers to an isotonic expansion of the extracellular fluid by an abnormal expansion of water and sodium. Therefore sodium is restricted to allow the body to excrete the extra volume.C. (incorrect) High blood glucose levels result in viscous blood and cause the kidneys to try and fix the problem by excreting the glucose through increasing the urine output, which results in fluid volume deficits.D. (incorrect) If the FVE is the result of renal failure, then hemodialysis may be ordered, but this information was not provided in the stem of the question.

TEST-TAKING HINT: Option A is not a nursing prerogative. The test taker should not read into the question.

Incorrect

Q.42) The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented?

A. Encourage fluids orally. (Your Answer)

B. Administer 10% saline solution IVPB.

C. Administer antidiuretic hormone intranasally.

D. Place on seizure precautions. (Correct Answer)

Explanation

A. (incorrect) The client probably will be placed on fluid restriction. Fluids should not be encouraged for a client with a low sodium level (135-145 mEq/L).B. (incorrect) Hypertonic solutions of saline are 3% to 5%, not 10%, because of the extreme nature of hypertonic solutions. Hypertonic solutions of saline may be used but very cautiously because if the sodium levels are increased too rapidly, a massive fluid shift can occur in the body, resulting in neurological damage and heart failure.C. (incorrect) THe antidiuretic hormone (vasopressin) would cause water retention in the body and increase the problem.D. (correct) Clients with sodium levels less than 120 mEq/L are at risk for seizures as a complication. The lower the sodium level, the greater the risk of a seizure.

TEST-TAKING HINTS: The test taker must memorize certain common lab values and understand how deviations in the electrolytes affect the body.

Correct

Q.43) The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first?

A. The client in normal sinus rhythm with a peaked T wave. (Your Answer)

B. The client diagnosed with atrial fibrillation with a rate of 100.

C. The client diagnosed with a myocardial infarction who has occasional PVC.

D. The client with a first-degree AV block and a rate of 92.

Explanation

A. (correct) A client with a peaked wave could be experiencing hyperkalemia. Changes in potassium levels can initiate cardiac dysrhythmias and instability.B. (incorrect) Fluctuations in rate are expected in clients diagnosed with atrial fibrillation, and a heart rate of 100 is at the edge of a normal rate.C. (incorrect) Most people experience an occasional premature ventricular contraction (PVC); this would not warrant the nurse assessing this client first.D. (incorrect) A first-degree block is not an immediate problem.

TEST-TAKING HINT: The test taker must know the normal data so that the abnormal will be apparent. Normal heart rate is 60-100. The nurse should assess the client who has an abnormal or life-threatening condition.

Incorrect

Q.44) The client post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should be implemented first?

A. Notify the health care provider immediately. (Your Answer)

B. Tap the cheek about two (2) centimeters anterior to the ear lobe. (Correct Answer)

C. Check the serum calcium and magnesium levels.

D. Prepare to administer calcium gluconate IVP.

Explanation

A. (incorrect) The health care provider may need to be notified, but the nurse should perform assessment first.B. (correct) These are signs and symptoms of hypocalcemia, and the nurse can confirm this by tapping the cheek to elicit the Chvostek's sign. If the muscles of the cheek begin to twitch, then the health care provider should be notified immediately because hypocalcemia is a medical emergency.C. (incorrect) A positive Chvostek's sign can indicate a low calcium or magnesium level, but serum lab levels may have been drawn hours previously or may not be available.D. (incorrect) If the client does have hypocalcemia, this may be ordered, but it is not implemented prior to assessment.

TEST-TAKING HINT: Assessment is the first step in the nursing process and is an appropriate option to select if the test taker has difficulty when trying to decide between two options.

Correct

Q.45) Which statement best explains the scientific rationale for Kussmaul's respirations in the client diagnosed with diabetic ketoacidosis (DKA)?

A. The kidneys produce excess urine and the lungs try to compensate.

B. The respirations increase the amount of carbon dioxide in the bloodstream.

C. The lungs speed up to release carbon dioxide and increase the pH. (Your Answer)

D. The shallow and slow respirations will increase the HCO3 in the serum.

Explanation

A. (incorrect) Kussmaul's respirations are the lung's attempt to maintain the narrow range of pH that is compatible with human life. The respiratory system reacts rapidly to changes in pH.B. (incorrect) Respiration is the act of moving oxygen and carbon dioxide. Kussmaul's respirations are rapid and deep and allow the client to exhale carbon dioxide.

C. (correct) The lungs attempt to increase the blood pH level by blowing off the carbon dioxide (carbonic acid).D. (incorrect) HCO3 (sodium bicarbonate) is an alkaline (base) substance that is a metabolic buffer system, not a respiratory system buffer. The excretion and retention of sodium bicarbonate is regulated by the kidneys; therefore, it is a metabolic buffer system. The excretion and retention of carbon dioxide (CO2) are regulated by the lungs and therefore is a respiratory buffer system.

TEST-TAKING HINT: Homeostasis is a delicate balance between acids and bases. The test taker can discard option A by realizing that production of urine does not affect the respirations.

Incorrect

Q.46) The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply.

A. Place the solution on an IV pump at the prescribed rate. (Missed)

B. Monitor blood glucose every six (6) hours. (Your Answer)

C. Weigh the client weekly, first thing in the morning.

D. Change the IV tubing every three (3) days. (Your Answer)

E. Monitor intake and output every shift. (Your Answer)

Explanation

A. (correct) TPN is a hypertonic solution that has enough calories, proteins, lipids, electrolytes, and trace elements to sustain life. It is administered via a pump to prevent too rapid infusion.B. (correct) TPN contains 50% dextrose solution; therefore, the client is monitored to ensure that the pancreas is adapting to the high glucose levels.C. (incorrect) The client is weighed daily, not weekly, to monitor for fluid overload.D. (incorrect) The IV tubing is changed with every bag because the high glucose level can cause bacterial growth.E. (correct) Intake and output are monitored to observe for fluid balance.

TEST-TAKING HINT: Options C and E refer to the same factor--namely, fluid level. The test taker should then determine if the time factors are appropriate. Weekly weighing is not appropriate so C can be eliminated.

Correct

Q.47) The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds the nurse notes the IV site is tender to palpation and a red streak has formed. Which action should the nurse implement first?

A. Start a new IV in the right hand.

B. Discontinue the intravenous line. (Your Answer)

C. Complete an incident record.

D. Place a warm washrag over the site.

Explanation

A. (incorrect) A new IV will be started in the right hand after the IV is discontinued.B. (correct) The client has signs of phlebitis and the IV must be removed to prevent further complications.C. (incorrect) Depending on the health-care facility, this may or may not be done, but client care comes before documentation.D. (incorrect) A warm washrag placed on an IV site sometimes provides comfort to the client. If this is done, it should be done for 20 minutes four (4) times a day.

TEST-TAKING HINT: The question is asking for a first action, which means all of the options may be actions the nurse would implement, but only one is priority. In general, priority actions are to stop the problem, continue treatment, treat the problem, and then document.

Incorrect

Q.48) The nurse and an unlicensed nursing assistant are caring for a group of clients. Which nursing intervention should the nurse perform?

A. Measure the client's output from the indwelling catheter.

B. Record the client's intake and output on the I & O sheet.

C. Instruct the client on appropriate fluid restrictions. (Correct Answer)

D. Provide water for a client diagnosed with diabetes insipidus. (Your Answer)

Explanation

A. (incorrect) An assistant can empty the catheter and measure the amount.B. (incorrect) The assistant can record intake and output on the I & O sheet.C. (correct) The nurse cannot delegate teaching.D. (incorrect) The client has a disease, but all the assistant is being asked to do is take water to the client.

TEST-TAKING HINT: This is an example of an "except" question. Frequently questions ask which tasks can be assigned to the assistant, but this question asks which action the nurse should implement. If the test taker does not read carefully, it is easy to jump to the first option for actions that the assistant can perform.

Correct

Q.49) The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor?

A. Serum calcium.

B. Serum phosphorus.

C. Serum potassium. (Your Answer)

D. Serum sodium.

Explanation

A. (incorrect) Serum calcium is decreased in conditions such as osteoporosis or post-thyroid surgery, but not in vomiting and diarrhea.B. (incorrect) Serum phosphorus levels are altered in acute and chronic renal failure or diabetic ketoacidosis, among other conditions, but not with acute fluid losses from the gastrointestinal tract.C. (correct) Clients lose potassium from the GI tract or through the use of diuretic medications. Potassium imbalances can lead to cardiac arrhythmias.D. (incorrect) The body is not at risk from losing sodium from these sources as it is with potassium.

TEST-TAKING HINT: The nurse must recognize basic fluids and electrolytes in the body and the implications of excess or loss. The body holds onto sodium and releases potassium.

Correct

Q.50) A nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse understands that this type of fluid loss can occur through:

A. The skin (Your Answer)

B. Urinary output

C. Wound drainage

D. The gastrointestinal tract

Explanation

Rationale: Sensible losses are those of which the person is aware, such as through wound drainage, gastrointestinal tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs.

Test-Taking Strategy: Note that the subject of the question is insensible fluid loss. Use the process of elimination, noting that options B, C, and D are comparative or alike. In options B, C, and D, these types of losses can be measured for accurate output. Fluid loss through the skin cannot be measured accurately, only approximated. If you had difficulty with this question, review the difference between sensible and insensible fluid loss.

Incorrect

Q.51) 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 deficient fluid volume?

A. A client with a colostomy (Correct Answer)

B. A client with congestive heart failure

C. A client with decreased kidney function

D. A client receiving frequent wound irrigations (Your Answer)

Explanation

Rationale: Causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with congestive heart failure or decreased kidney function, or a client receiving frequent wound irrigations, is at risk for excess fluid volume.

Test-Taking Strategy: Read the question carefully, noting that it asks for the client at risk for a deficit. Read each option and think about the fluid imbalance that can occur in each. The clients presented in options B, C, and D retain fluid. The only condition that can cause a deficit is the condition noted in option A. If you had difficulty with this question, review the causes of deficient fluid volume.

Correct

Q.52) 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?

A. Lung congestion

B. Decreased hematocrit

C. Increased blood pressure

D. Decreased central venous pressure (CVP) (Your Answer)

Explanation

Rationale: Assessment findings in a client with a deficient fluid volume include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H2O. A client with dehydration has a low CVP. The assessment findings in options A, B, and C are seen in a client with excess fluid volume.

Test-Taking Strategy: Use the process of elimination and focus on the subject, deficient fluid

volume. Eliminate options A and C first. Lung congestion is noted in excess fluid volume, as is increased blood pressure. From the remaining options, recall that central venous pressure reflects the pressure under which blood is returned to the superior vena cava and right atrium. Therefore, pressure (volume) would be decreased in a deficient fluid volume. If you had difficulty with this question, review the assessment findings noted in deficient fluid volume.

Correct

Q.53) 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. The client with renal failure (Your Answer)

C. The client with an ileostomy

D. The client who requires gastrointestinal suctioning

Explanation

Rationale: The causes of excess fluid volume include decreased kidney function, congestive heart failure, the use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for deficient fluid volume.

Test-Taking Strategy: Use the process of elimination and focus on the subject, excess fluid volume. Read each option and think about the fluid imbalance that can occur in each. The clients presented in options A, C, and D lose fluid. The only condition that can cause an excess is the condition noted in option B. If you had difficulty with this question, review the causes of excess fluid volume.

Correct

Q.54) The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible 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

C. An increase in blood pressure (Your Answer)

D. A decreased central venous pressure (CVP)

Explanation

Rationale: Assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, an elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and a decreased hematocrit. Options A, B, and D identify signs noted in deficient fluid volume.

Test-Taking Strategy: Use the process of elimination and knowledge regarding the assessment findings in excess fluid volume. Note that options A, B, and D are similar or alike in that each of these signs reflects a decrease. Option C reflects an increase. If you had difficulty with this question, review the assessment findings noted in excess fluid volume.

Correct

Q.55) A nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because the client:

A. Has renal failure.

B. Requires nasogastric suction. (Your Answer)

C. Has a history of Addison's disease.

D. Is taking a potassium-sparing diuretic.

Explanation

Rationale: Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with renal failure or Addison's disease and the client

taking a potassium-sparing diuretic are at risk for hyperkalemia.

Test-Taking Strategy: Use the process of elimination. Note that the subject of the question is a potassium deficit. Option B is the only option that identifies a loss of body fluid. If you had difficulty with this question, review the causes of hypokalemia.

Correct

Q.56) A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value?

A. U waves (Your Answer)

B. Absent P waves

C. Elevated T waves

D. Elevated ST segment

Explanation

Rationale: A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life-threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia.

Test-Taking Strategy: From the information in the question, you need to determine that the client is experiencing hypokalemia. From this point, you must know the electrocardiographic changes that are expected when hypokalemia exists. If you had difficulty with this question, review the electrocardiographic changes that occur in hypokalemia.

Correct

Q.57) 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 if the student states that which of the following is part of the plan for preparation and administration of the potassium?

A. Obtaining a controlled IV infusion pump

B. Monitoring urine output during administration

C. Diluting in appropriate amount of normal saline

D. Preparing the medication for bolus administration (Your Answer)

Explanation

Rationale: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via a pump or controller. The usual concentration of IV potassium chloride is 20 to 40 mEq/L. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, but dextrose solution is avoided because this type of solution increases intracellular potassium shifting. The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored closely because potassium chloride is irritating to the veins and the risk of phlebitis exists. The nurse monitors urinary output during administration and contacts the physician if the urinary output is less than 30 mL/hr.

Test-Taking Strategy: Use the process of elimination and knowledge regarding the administration of potassium chloride intravenously. Noting the strategic word UNPREPARED in the question and BOLUS in option D will direct you to the correct option. Review the administration of potassium chloride if you had difficulty with this question.

Incorrect

Q.58) A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that the food item lowest in potassium is:

A. Apples (Correct Answer)

B. Carrots

C. Spinach (Your Answer)

D. Avocado

Explanation

Rationale: A medium apple provides about 159 mg of potassium. A large carrot provides 341 mg, spinach (3 1/2 oz) provides 470 mg, and a medium avocado provides 1097 mg of potassium.

Test-Taking Strategy: Note the strategic words LOWEST IN POTASSIUM. Recalling the potassium content of the foods identified in the options will direct you to option A. Review the foods that are high and low in potassium content if you had difficulty with this question.

Correct

Q.59) A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a potassium value at this level?

A. The client with colitis

B. The client with Cushing's syndrome

C. The client who has been overusing laxatives

D. The client who has sustained a traumatic burn (Your Answer)

Explanation

Rationale: A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

Test-Taking Strategy: Use the process of elimination. Eliminate option A and C first because they are similar or alike, with both reflecting a gastrointestinal loss. From the remaining options, recalling that cell destruction causes potassium shifts will assist in directing you to the correct option. Remember that Cushing's syndrome presents a risk for hypokalemia and that Addison's disease presents a risk for hyperkalemia. If you had difficulty with this question, review the risk factors associated with hyperkalemia.

Correct

Q.60) A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is

5.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value?

A. ST depression

B. Inverted T wave

C. Prominent U wave

D. Tall peaked T waves (Your Answer)

Explanation

Rationale: A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Electrocardiographic changes include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves.

Test-Taking Strategy: From the information in the question, you need to determine that this condition is a hyperkalemic one. From this point, you must know the electrocardiographic changes that are expected when hyperkalemia exists. If you had difficulty with this question, review the normal serum potassium level and the electrocardiographic changes that occur in hyperkalemia.

Incorrect

Q.61) A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level?

A. The client with renal failure

B. The client who is taking diuretics (Correct Answer)

C. The client with hyperaldosteronism (Your Answer)

D. The client who is taking corticosteroids

Explanation

Rationale: Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with renal failure or hyperaldosteronism are at risk for hypernatremia.

Test-Taking Strategy: Use the process of elimination. First, determine that the client is experiencing hyponatremia. Next, you must know the causes of hyponatremia to direct you to option B. Review the normal serum sodium level and the causes of hyponatremia if you had difficulty with this question.

Incorrect

Q.62) A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. 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 (Your Answer)

B. Decreased urinary output

C. Hyperactive bowel sounds (Correct Answer)

D. Increased specific gravity of the urine

Explanation

Rationale: Hyperactive bowel sounds indicate hyponatremia. Options A, B, and D are signs of hypernatremia. In hyponatremia, increased urinary output and decreased specific gravity of the urine would be noted. Dry skin occurs in deficient fluid volume.

Test-Taking Strategy: Focus on the data in the question and the subject of the question. Recalling the signs of hyponatremia will direct you to option C. If you had difficulty with this question, review the assessment signs associated with hyponatremia and hypernatremia.

Incorrect

Q.63) 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 mEq/L. Based on these laboratory findings, the nurse selects

which solution to use for the nasogastric tube irrigation?

A. Tap water (Your Answer)

B. Sterile water

C. Sodium chloride (Correct Answer)

D. Distilled water

Explanation

Rationale: A potassium level of 4.5 mEq/L is within normal range. A sodium level of 132 mEq/L is low, indicating hyponatremia. In clients with hyponatremia, sodium chloride (isotonic) should be used rather than water for gastrointestinal irrigations.

Test-Taking Strategy: Use the process of elimination. Eliminate options A, B, and D because they are comparative or alike (sterile water, tap water, and distilled water). Also, recalling that the serum sodium level identified in the question indicates hyponatremia will direct you to option C. If you had difficulty with this question, review the care of the client experiencing hyponatremia.

Incorrect

Q.64) A nurse is reviewing laboratory results and notes that a 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 item does the nurse instruct the client to avoid?

A. Peas

B. Cauliflower (Your Answer)

C. Low-fat yogurt

D. Processed oat cereals (Correct Answer)

Explanation

Rationale: The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L indicates hypernatremia. Based on this finding, the nurse would instruct the client to avoid foods high in sodium. Low-fat yogurt, cauliflower, and peas are good food sources of phosphorus. Processed foods are high in sodium content.

Test-Taking Strategy: First, you must determine that the client has hypernatremia. Next, note the strategic word AVOID in the question. Eliminate options A and B first because these are vegetables. From the remaining options, note the word PROCESSED in option D. Processed foods tend to be higher in sodium content. Review foods high in sodium content if you had difficulty with this question.

Incorrect

Q.65) A nurse is reviewing a client's laboratory report and notes that the serum calcium level is 4.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level?

A. Prolonged bed rest (Correct Answer)

B. Renal insufficiency (Your Answer)

C. Hyperparathyroidism

D. Excessive ingestion of vitamin D

Explanation

Rationale: The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 4.0 mg/dL is experiencing hypocalcemia. The excessive ingestion of vitamin D and hyperparathyroidism are causative factors associated with hypercalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia.

Test-Taking Strategy: Note the strategic words MOST LIKELY. First, you must determine that the client is experiencing hypocalcemia. This should assist in eliminating option D. Next, you must recall the causative factors associated with hypocalcemia to direct you to option A. If you had difficulty with the question, review the causative factors associated with hypocalcemia.

Correct

Q.66) A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client?

A. Twitching (Your Answer)

B. Negative Trousseau's sign

C. Hypoactive bowel sounds

D. Hypoactive deep tendon reflexes

Explanation

Rationale: Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and ansiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

Test-Taking Strategy: Use the process of elimination, noting that options B, C, and D are comparative or alike in that they reflect a hypoactivity. The option that is different is option A. Review the assessment signs and symptoms noted in hypocalcemia if you had difficulty with this question.

Correct

Q.67) A nurse caring for a client with hypocalcemia would expect to note which of the following changes on the electrocardiogram?

A. Widened T wave

B. Prominent U wave

C. Prolonged QT interval (Your Answer)

D. Shortened ST segment

Explanation

Rationale: Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with hypokalemia.

Test-Taking Strategy: Use knowledge regarding the electrocardiographic changes that occur in a calcium imbalance to answer the question. Remember that hypocalcemia causes a prolonged ST or QT interval. If you had difficulty with this question, review the electrocardiographic changes that occur in these conditions.

Incorrect

Q.68) A nurse caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which electrocardiographic change would the nurse expect to note based on the magnesium level?

A. Prominent U waves

B. Prolonged PR interval (Your Answer)

C. Depressed ST segment (Correct Answer)

D. Widened QRS complexes

Explanation

Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL indicates hypomagnesemia. In hypomagnesemia, the nurse would note tall T waves and a depressed ST segment. Options B and D would be noted in a client experiencing hypermagnesemia. Prominent U waves occur with hypokalemia.

Test-Taking Strategy: First, you must determine that the client is experiencing hypomagnesemia. Next, identify the electrocardiographic changes that occur in this condition. If you had difficulty with this question, review the normal magnesium level and the electrocardiographic changes that occur in hypomagnesemia and hypermagnesemia.

Correct

Q.69) A nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level?

A. Alcoholism (Your Answer)

B. Renal insufficiency

C. Hypoparathyroidism

D. Tumor lysis syndrome

Explanation

Rationale: THe normal serum phosphorus level is 2.7 to 4.5 mg/dL. The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Malnutrition is associated with alcoholism. Hypoparathyroidism, tumor lysis syndrome, and renal insufficiency are causative factors of hyperphosphatemia.

Test-Taking Strategy: First you must determine that the client is experiencing hypophosphatemia. From this point, you must know the causes of hypophosphatemia. If you had difficulty with this question, review the causative factors associated with hypophosphatemia.

Incorrect

Q.70) The nurse provides instructions to a client with a low magnesium level about the foods that are high in magnesium and tells the client to consume which foods? Select all that apply.

A. Peas (Missed)

B. Oranges

C. Cauliflower (Missed)

D. Peanut butter (Missed)

E. Canned white tuna (Your Answer)

Explanation

Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. Common food sources of magnesium include avocado, canned white tuna, cauliflower, green leafy vegetables such as spinach and broccoli, milk, oatmeal, peanut butter, peas, pork, beef, chicken, potatoes, raisins, and yogurt. Bacon is high in sodium. Oranges are high in potassium.

Test-Taking Strategy: Focus on the subject, foods high in magnesium. Read each food item and recall that bacon is high in sodium and oranges are high in potassium. Review the food items high

in magnesium if you had difficulty with this question.

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