1.) A nurse is assessing a client who is receiving intravenous therapy.
The nurse should identify which 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 prescribed hypertonic solution. Which of
the following findings should indicate to the nurse that the
treatment is effective?
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 to the 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
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