1. After receiving IV fluids in the emergency department, an elderly client is
admitted to the acute care unit with a medical diagnosis of dehydration. The
client is receiving 0.9% normal saline at 125 ml/hour via saline lock and has
a bounding pulse, tachycardia, and pedal edema. When contacting the
healthcare provider, the nurse anticipates a prescription what intervention?
A) Remove the saline lock from the client’s arm.
B) Increase the rate of the normal saline infusion.
C) Decrease the rate of the normal saline infusion.
D) Change the IV solution to 0.45% saline solution.
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2. A client who is admitted to the care unit with syndrome of inappropriate
antidiuretic hormone (SIADH) has developed osmotic demyelination. Which
intervention should the nurse implement first?
A) Patch one
eye. B) Evaluate
swallow.
C) Reorient often.
D) Range of motion.
3. The nurse is preparing a client who had a below-the-knee (BKA)
amputation for discharge to home. Which recommendations should the
nurse provide this client? (Select all that apply)
A) Wash the stump with soap and water.
B) Avoid range of motion exercise.
C) Apply alcohol to the stump after
bathing. D) Inspect skin for redness.
E) Use a residual limb shrinker.
4. After 2 days treatment for dehydration, a child continues to vomit and
have diarrhea. Normal saline is infusing and the child’s urine output is
50ml/hour. During morning assessment, the nurse determines that the
child is lethargic and difficult to arouse. Which should the nurse implement?
A) Increase the IV fluid flow rate.
B) Review 24-hour intake and output.
C) Obtain arterial blood gases.
D) Perform a finger stick glucose test.
5. A client with bleeding esophageal varices receives vasopressin IV. What
should the nurse monitor for during the IV infusion of this medication?
A) Vasodilatation of the
extremities. B) Chest pain and
dysrhythmia.
C) Hypotension and tachycardia.
D) Decreasing GI cramping and nausea.
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6. A male client with an antisocial personality disorder is admitted to an
inpatient mental health unit for multiple substance dependency. When
providing a history, the client justifies to the nurse his use of illicit drugs.
Based on this pattern of behavior, this client’s history is most likely to
include which finding?
A) Multiple convictions for misdemeanors and Class B felonies.
B) Delusions of grandiosity and persecution.
C) Suicidal ideations and multiple attempts.
D) Photos and panic attacks when confronted by authority figures.
7. An older client is admitted for repair of a broken hip. To reduce the risk
postoperative period., which nursing care intervention should the nurse
client’s plan of care? (Select all that
A) Administer low molecular weight heparin as prescribed.
B) Teach client to use incentive spirometer every 2 hours while
awake. C) Remove urinary catheter as soon as possible and
encourage voiding.
D) Maintain sequential compression devices while in bed.
E) Assess pain level and medicate PRN as prescribed.
8. The nurse is preparing a 50 ml dose of 50% Dextrose IV for a client
with insulin shock. How should the nurse administer the medication?
A. Dilute the dextrose in one liter of 0.9% Normal Saline
solution. B. Push undiluted slowly though the currently
infusing IV.
C. Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml.
D. Ask the pharmacist to add the Dextrose to a TPN solution.
9. A client with arthritis has been receiving treatment with naproxen and
now reports ongoing stomach pain, increasing weakness, and fatigue.
Which laboratory test should the nurse monitor?
A) Serum Calcium.
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