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?

• Decreased bowel sounds

• Distended neck veins

• Bilateral muscle weakness

• Thread pulse

• 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 effective?

• Absent Chvostek’s sign

• Improved cognition

• Decreased vomiting

• Cardiac arrhythmias absent

• 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?

• “Discontinue the patch if you experience a headache.”

• “Apply a new patch if you have chest pain.”

• “Cover the patch with dry gauze when taking a shower.”

• “Remove the patch prior to going to bed.”

• 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?

• Creatinine 0.72 mg/dL

• Sodium 138 mEq/L

• Magnesium 2 mEq/L

• Potassium 5.2 mEq/L - Hyperkalemia (serum potassium level

greater than 5.0 mEq/L) increases the client risk for fatal cardiac