Nur 235 Exam 3 Study Questions and Correct Answers
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Course
NUR 235
Institution
NUR 235
The nurse is caring for a client with 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...
Nur 235 Exam 3 Study Questions and
Correct Answers
The nurse is caring for a client with 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 a client with
hyponatremia?
A. Muscle twitches
B. Decreased Urinary output
C. Hyperactive bowel sounds
D. Increased specific gravity of the urine ✅C. Hyperactive bowel sounds
A nurse is caring for a client with a nasogastric tube (NGT) who has a prescription for
NGT irrigation once every 8 hours. To maintain homeostasis, which solution should the
nurse use to irrigate the NGT?
A. Tap wate
rB. Sterile Water
C. 0.9% Sodium Chloride
D. 0.45% Sodium Chloride ✅C. 0.9% Sodium Chloride
The 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 of which situation?
A. Sustained tissue damage
B. Requires Nasogastric suction
C. Has a history of Addison's disease
D. Is taking a potassium-retaining diuretic ✅B. Requires Nasogastric suction
During an assessment of a newly admitted client, the nurse notes that the client's heart
rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands
up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse
that he seems a little confused and unsteady on his feet. Based on these assessment
findings, the nurse suspects that the client has which condition?
A. Dehydration
B. Hypokalemia
C. Fluid Overload
D. Hypernatremia ✅A. Dehydration
The nurse is performing an assessment on a client admitted to the hospital with a
diagnosis of dehydration. Which assessment finding should the nurse expect to note?
A. Bradycardia
B. Elevated blood pressure
C. Changes in mental status
, D. Bilateral crackles in the lung ✅C. Changes in mental status
A nurse is planning care for a client with hypokalemia. Which interventions should be
included in the plan of care? Select all that apply.
A. Ensure adequate fluid intake.
B. Implement safety measures to prevent falls
C. Encourage low fiber foods to prevent diarrhea
.D. Instruct the client about foods that contain potassium.
E. Encourage the client to obtain assistance to ambulate. ✅A. Ensure adequate fluid
intake.
B. Implement safety measures to prevent falls
.D. Instruct the client about foods that contain potassium.
E. Encourage the client to obtain assistance to ambulate.
The nurse is reading a health care provider's (HCP) progress notes in the client's record
and reads that the HCP has documented "insensible fluid loss of approximately 800 mL
daily." The nurse interprets that this type of fluid loss can occur through which route?A.
The Skin
B. Urinary Output
C. Wound Drainage
D. The gastrointestinal trac ✅A. The Skin
The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which
cardiovascular manifestation would the nurse expect to note?
A. Hypotension
B. Increased heart rate
C. Bounding peripheral pulses
D. Shortened QT interval on electrocardiography (ECG) ✅A. Hypotension
The nurse is planning care for a pt with severe burns. Which of the following is this pt at
risk for developing?
1. intracellular fluid deficit
2. intracellular fluid overload
3. extracellular fluid deficit
4. interstitial fluid deficit ✅1. intracellular fluid deficit
A pt recovering from surgery has an indwelling urinary catheter. The nurse would
contact the pt's primary healthcare provider with which of the following 24-hour urine
output volumes?
1. 600 mL
2. 750 mL
3. 1000 mL
4. 1200 mL ✅1. 600 mL
A pt is receiving intravenous fluids postoperatively following cardiac surgery. Nursing
assessments should focus on which postoperative complication?
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