1.) A nurse is assessing a client who is receiving intravenoustherapy. The nurse should identify
which of the following ;ndings as a manifestation 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 solution. Which of the following ;ndings should indicate to the nurse that the
treatment is eFective?
a. Absent Chvostek’ssign
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
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 medication regimen?
a. The client has a negative sputum culture
b. The client tests negative for HIV
c. The client has a positive puri;ed protein derivative test
d. The client’sliver function test results are within the expected reference range
A client is caring for a client who develops an anaphylactic reaction to IV administration. A]er
assessing 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’slegs and feet
d. Administer epinephrine IM
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