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

- 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