A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming
procedure. What action by the nurse is best? -ask the client to describe current feelings
2. A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery,
which resul...
1. A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming
procedure. What action by the nurse is best? -ask the client to describe current feelings
2. A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery,
which result warrants immediate communication with the surgical team? -potassium 2.9 mEq/L
3. A nurse Is caring for a client who is experiencing moderate metabolic alkalosis. Which action
should the nurse take? -teach the client fall prevention measures
4. Which newly written prescription does the nurse administer first? -oral potassium chloride to a
client whose serum potassium is 3 mEq/L
5. A postoperative client has an abdominal drain. What assessment by the nurse indicates that
foals for the priority client problems related to the drain are being met? -there is no redness,
warmth, or drainage at the insertion site
6. A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98mm Hg,
PaCO2 28 mm Hg, and HCO3 -22 mEq/L, which client condition should the nurse correlate with
these results? -anxiety induced hyperventilation
7. An older adult client is admitted with dehydration. Which nursing assessment data identify that
the client is at risk for falling? -orthostatic blood pressure changes
8. When caring for a client with a pulse oximetry level of 89%, which action does the nurse take
first? -apply oxygen as prescribed
9. A preoperative client smokes a pack of cigarettes a day. What is the nurses teaching priority for
the best physical outcomes? -teach the importance of incentive spirometry
10. The charge nurse on a medical surgical unit is completing assignments for the day shift. Which
client is assigned to the LPN/LVN? -a 76 year old with poor skin turgor who has a serum
osmolarity of 300 mOsm/L
11. A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse
assess first for potential hyponatremia? – a 34-year-old on NPO status who is receiving
intravenous D5W
12. During a preoperative assessment, which statement by a client requires further investigation by
the nurse to asses’ surgical risks? – “I had a heart attack 4 months ago”
13. In going through the preoperative checklist, the nurse notices that the clients armband does not
match the handwritten name on the informed consent, but it matches the stamped name. what
does the nurse do first? -talk to the operating team
14. A 90-year-old client with hypermagnesemia is seen in the emergency department (ED). The ED
nurse prepares the client for admission to which inpatient unit? -telemetry/cardiac stepdown
15. After teaching a client to increase dietary potassium intake, a nurse assesses the clients
understanding. Which dietary meal selection indicates the client correctly understands the
teaching? -sausage, one slice of whole wheat toast, half cup of raisins and a glass of milk
16. After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the clients
understanding. Which food choice for lunch indicates the client correctly understood the
teaching? -grilled chicken breast with glazed carrots
17. A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas
values are pH 7.28, PaO2 45 mm Hg, and HCO3 -16 mEq/L. which provider order should the
nurse expect to receive? – sodium bicarbonate 100 mEq/L diluted in 1 L of D5W
,18. A nurse assesses a client who is experiencing an acid-base imbalance. The client’s arterial blood
gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 -19 mEq/L. which
assessment should the nurse perform first? -cardiac rate and rhythm
19. An inpatient nurse brings an informed consent form to a client for an operation scheduled for
tomorrow. The client asks about possible complications from the operation. What response by
the nurse is best? -do not have the client sign the consent and call the surgeon
20. Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist?
-creatinine 1.9 mEq/L
21. The nurse is instructing a client who is being discharged with a diagnosis of congestive heart
failure (CHF). Which client statement indicates a correct understanding of CHF? –“weighing
myself daily can reveal increased fluid retention.”
22. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which
intervention should the nurse implement to prevent injury while in the hospital? -dangle the
client on the bedside before ambulating
23. A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse
is giving this drug when the client has no history of ulcers. What response by the nurse is best? –
“it helps prevent ulcers from the stress of surgery”
24. A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2
56 mm Hg, PaCO2 65 mm Hg, and HCO3 -22 mEq/L. which clinical situation should the
nurse correlate with these values? -bronchial obstruction related to aspiration of a hot
dog
25. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base
imbalance. For which manifestation of this acid-base imbalance should the nurse
assess? -kussmaul respirations
26. To decrease the risk of acid-base imbalance, what goal must the client with diabetes
mellitus strive for? -Maintaining blood glucose level within normal limits
27. A nurse assesses a client who is prescribed a mediation that inhibits angiotensin I from
converting into angiotensin II(Angiotensin-converting enzyme[ACE] inhibitor). For which
expected therapeutic effect should the nurse assess? -blood pressure decreases from
180/72 mm Hg to 144/50 mm Hg
28. The nurse is teaching a group of unlicensed assistive personnel (UAP) about fluid intake
principles for older adults. What does the nurse tell them? –“offer fluids that they prefer
frequently and on a regular schedule
29. A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting
cardiovascular changes. Which prescription should the nurse implement first? -prepare
to administer dextrose 20% and 10 units of regular insulin IV push
30. A 77-year-old woman is brought to the emergency department by her family after she
has had diarrhea for 3 days. The family tells the nurse that she has not been eating or
drinking well, but that she has been taking her diuretics for congestive heart failure. Her
laboratory results include a potassium level of 7.0 mEq/L. What is the primary goal of
drug therapy for this client? -Restoring fluid balance by controlling the causes of
dehydration
31. A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm hg,
PaCO2 55 mm Hg, and HCO3 22 mEq/L. which intervention should the nurse implement
first? -assess the airway
32. A 70-year-old woman is admitted to the hospital with heart failure, shortness of breath,
and 3+ pitting edema in her lower extremities. Her medications are furosemide (Lasix),
, digoxin (Lanoxin), and an angiotensin-converting enzyme inhibitor (Lotensin). She states
that she stopped taking her Lasix because she did not think that it was helping her heart
failure. Her health care provider orders furosemide (Lasix) 5 mg IV push. Ten hours after
receiving the Lasix, the client's potassium (K+) level is 2.5 mEq/L. Knowing all of the
client's medications, what problem does the nurse anticipate in this client? -clinical
manifestations of digoxin toxicity
33. A nurse is evaluating a client who Is being treated for dehydration. Which assessment result
should the nurse correlate with a therapeutic response to the treatment plan? -decreased
orthostatic light-headedness and dizziness
34. A nurse teaches a client who is at risk for mild hypernatremia. Which statement should
the nurse include in this clients teaching? –“read food labels to determine sodium
content.”
35. A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by
the nurse is most important for this client? -raise the siderails on the bed
36. The nurse is planning care for a client with hypocalcemia. Which nursing action is
appropriate to delegate to unlicensed assistive personnel (UAP)? -transferring the client
from the bed to the stretcher using a lift sheet
37. A client is being prepared for gastrointestinal surgery and undergoes a bowel
preparation. Why is this preoperative procedure done? -Reduce the number of intestinal
bacteria
38. A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse
identify as being at greatest risk for insensible water loss? -anxious client who has tachypnea
39. The perioperative nurse manager and the postoperative unit manager are concerned
about the increasing number of surgical infections in their hospital. What action by the
managers is best? -audit charts to see if the surgical care improvement project (SCIP)
outcomes were met
40. The RN is caring for a client admitted with dehydration who requires a blood transfusion.
Which nursing action does the RN delegate to unlicensed assistive personnel (UAP)?
-Obtaining baseline vital signs before blood administration
41. Which acid-base disturbance does the nurse anticipate the client with morbid obesity
may develop?: -respiratory acidosis
42. Colostomy surgery is categorized as what type of surgery? -palliative
43. A client who collapsed during dinner in a restraint arrives in the emergency department.
The client is going to surgery to repair an abdominal aortic aneurysm. What medication
does the nurse prepare to administer as a priority for this client? -metoclopramide
(Reglan)
44. A preoperative nurse is assessing a client prior to surgery. Which information would be most
important for the nurse to relay to the surgical team? -use of multiple herbs and supplements
45. A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For
which acid-base imbalance should the nurse assess to prevent complications of this
therapy? -metabolic alkalosis
46. A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a
client whose heart rate is 120 beats/min. after consulting with the surgeon, the nurse
administers a beta blocker to the client. The student asks why this was needed. What response
by the nurse is best? – “a rapid heart rate requires more effort by the heart.”
47. Which of these clients would be appropriate to assign to the new nurse working on the
unit? -A client with emphysema and cellulitis with a PaCO2 level of 58 mm Hg
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