1.) A nurse is assessing a client who is receiving intravenous therapy. The nurse should idenfy
which of the following ndings as a manifestaon of uid 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 prescribed
hypertonic soluon. Which of the following ndings should indicate to the nurse that the
treatment is e&ecve?
a. Absent Chvostek’s sign
b. Improved cognion
c. Decreased voming
d. Cardiac arrhythmias absent
3.) A nurse is teaching a client who has a new prescripon for a nitroglycerin transdermal patch.
Which of the following instrucons should the nurse include?
a. “Disconnue 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 prescripon for sodium
polystyrene sulfonate (Kayexalate) every 6 hr. which of the following should the nurse report to
the provider?
a. Creanine 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 of
the following outcomes indicates that the client is adhering to the medicaon regimen?
a. The client has a negave sputum culture
b. The client tests negave for HIV
c. The client has a posive puried protein derivave test
d. The client’s liver funcon test results are within the expected reference range
6.) A client is caring for a client who develops an anaphylacc reacon to IV administraon. A=er
assessing the client’s respiratory status and stopping the medicaon infusion. Which of the
following acons 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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