1.) A nurse is assessing a client who is receiving intravenous therapy. The nurse should
identifywhich of the following findings as a manifestation of fluid volume excess?
a. Decreased bowel sounds
b. Distended neck veins
c. Bilateral muscle weakness
d. Thread pulse
2.) A nurse is caring for a client who has hyponatremia and is receiving an infusion of a
prescribedhypertonic solution. Which of the following findings should indicate to the
nurse that the treatment is e&ective?
a. Absent Chvostek’s sign
b. Improved cognition
c. Decreased vomiting
d. Cardiac arrhythmias absent
3.) A nurse is teaching a client who has a new prescription for a nitroglycerin transdermal
patch.
Which of the following instructions should the nurse include?
a. “Discontinue the patch if you experience a headache.”
b. “Apply a new patch if you have chest pain.”
c. “Cover the patch with dry gauze when taking a shower.”
d. “Remove the patch prior to going to bed.”
4.) A nurse is reviewing he laboratory results of a client who has a prescription for sodium
polystyrene sulfonate (Kayexalate) every 6 hr. which of the following should the nurse
report tothe provider?
a. Creatinine 0.72 mg/dL
b. Sodium 138 mEq/L
c. Magnesium 2 mEq/L
d. Potassium 5.2 mEq/L - Hyperkalemia (serum potassium level greater than 5.0
mEq/L) increases the client risk for fatal cardiac dysrhythmias. Kayexalate is
used to decrease the serum potassium level, so the PN should monitor the
client's serum potassium level
5.) A nurse is caring for a client who has tuberculosis and is taking isoniazid and rifampin.
Which ofthe following outcomes indicates that the client is adhering to the medication
regimen?
a. The client has a negative sputum culture
b. The client tests negative for HIV
c. The client has a positive purified protein derivative test
d. The client’s liver function test results are within the expected reference range
6.) A client is caring for a client who develops an anaphylactic reaction to IV
administration. Afterassessing the client’s respiratory status and stopping the medication
infusion. Which of the following actions should the nurse take next?
a. Replace the infusion with 0.9% sodium chloride
b. Give diphenhydramine IM
c. Elevate the client’s legs and feet
d. Administer epinephrine IM
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