Fluids And Electrolytes Quiz Questions And Answers

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  • 1/52 Questions

    Which laboratory result indicates hyperkalemia?

    • Serum potassium level of 3.8 mEq/L
    • Serum potassium level of 7.8 mEq/L
    • Serum sodium level of 138 mEq/L
    • Serum sodium level of 148 mEq/L
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About This Quiz

This quiz assesses key nursing competencies in managing fluids and electrolytes, focusing on patient care scenarios such as handling hyperkalemia, scabies precautions, and discoid lupus erythematosus. It is essential for healthcare professionals to enhance patient safety and treatment efficacy.

Fluids And Electrolytes Quiz Questions And Answers - Quiz

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  • 2. 

    Prior to discharge, the nurse confirms that the patient understands antibiotic therapy for a wound infection by which statement?

    • I should take the antibiotic until my temperature is normal

    • If my temperature elevates, I should increase my dose of antibiotic

    • In my drainage is clear, I do not need the antibiotic

    • I need to take the medication until the prescription is finished

    Correct Answer
    A. I need to take the medication until the prescription is finished
    Explanation
    The correct answer is "I need to take the medication until the prescription is finished." This statement indicates that the patient understands the importance of completing the full course of antibiotics as prescribed by their healthcare provider. Taking the medication until the prescription is finished helps to ensure that all the bacteria causing the infection are eliminated and prevents the development of antibiotic resistance.

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  • 3. 

    The client is on intake and output and daily weights. When the night nurse asks for the morning weight from the nursing assistant before the morning shift report, the assistant says "She was sleeping so well, I didn't want to wake her to get her up for weight" What is the best reponse for the nurse?

    • That was a good idea. She needs her rest.

    • Get the information before I write you up for not doing your job.

    • I will do it myself.

    • Please get the information. It is important that it be done at the same time each day.

    Correct Answer
    A. Please get the information. It is important that it be done at the same time each day.
    Explanation
    The best response for the nurse is to ask the nursing assistant to get the information because it is important that it be done at the same time each day. This ensures consistency and accuracy in monitoring the client's intake and output and daily weights. It also emphasizes the importance of following the established protocol and responsibilities of the nursing assistant's job.

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  • 4. 

    Which patient is at greatest risk for pressure ulcer development?

    • Patient who has pneumonia

    • Patient who requires assistance with ambulation

    • Older patient with hypertension

    • Incontinent patient with limited mobility

    Correct Answer
    A. Incontinent patient with limited mobility
    Explanation
    An incontinent patient with limited mobility is at the greatest risk for pressure ulcer development because they are unable to move or change positions frequently, which can lead to prolonged pressure on certain areas of the body. Additionally, incontinence can increase the risk of skin breakdown and moisture-related skin damage, further increasing the risk of pressure ulcers.

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  • 5. 

    The older adult client is placed on Lasix for peripheral edema. Which assessment most directly identifies a risk for falls?

    • Oral membranes

    • Orthostatic blood pressure

    • Pulse rate

    • Serum potassium

    Correct Answer
    A. Orthostatic blood pressure
    Explanation
    Orthostatic blood pressure is the most direct assessment that identifies a risk for falls in an older adult client on Lasix for peripheral edema. Orthostatic hypotension, a sudden drop in blood pressure when standing up, can cause dizziness and increase the risk of falls. By measuring blood pressure in different positions (lying, sitting, and standing), orthostatic hypotension can be detected. This assessment helps healthcare professionals identify individuals who may be at an increased risk of falls and take appropriate measures to prevent them.

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  • 6. 

    In reviewing serum electrolyte levels, for a newly admitted client, the nurse is most concerned with which result?

    • Glucose, 97

    • Magnesium, 2.1

    • Potassium, 5.9

    • Sodium, 143

    Correct Answer
    A. Potassium, 5.9
    Explanation
    The nurse is most concerned with the result of Potassium, 5.9. This is because a potassium level of 5.9 is higher than the normal range (3.5-5.0 mEq/L), indicating hyperkalemia. Hyperkalemia can lead to serious complications such as cardiac arrhythmias and can be life-threatening. Therefore, the nurse should closely monitor the client's potassium level and take appropriate actions to prevent further complications.

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  • 7. 

    A patient has angioedema of the lower face. what will the nurse assess next?

    • Pulse oximetry

    • Airway patency

    • Breath sounds

    • Chest wall symmetry

    Correct Answer
    A. Airway patency
    Explanation
    In a patient with angioedema of the lower face, the nurse would assess airway patency next. Angioedema is a condition characterized by swelling beneath the skin, which can potentially obstruct the airway. Therefore, it is crucial to assess the patency of the airway to ensure that the patient can breathe without any difficulty. This assessment should be prioritized to prevent any respiratory compromise or distress.

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  • 8. 

    After drug therapy for hyperkalemia, the nurse hopes to see which potassium level result in the client indicating the therapy was effective?

    • 7.6 mEq/L

    • 5.6 mEq/L

    • 4.6 mEq/L

    • 2.6 mEq/L

    Correct Answer
    A. 4.6 mEq/L
    Explanation
    The normal range for potassium levels in the blood is typically between 3.5 to 5.0 mEq/L. Hyperkalemia refers to abnormally high levels of potassium in the blood. Therefore, the nurse would hope to see a decrease in potassium levels after drug therapy for hyperkalemia. Among the given options, 4.6 mEq/L is the closest to the normal range, indicating that the therapy was effective in reducing the elevated potassium levels.

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  • 9. 

    What action is most important for the nurse to teach the patient who is at continuing risk for mild hypernatremia to take to prevent hypernatremia?

    • Weigh yourself every morning and every night

    • Check your pulse and rhythm every morning and every night

    • Read the labels of all packaged foods to determine the sodium content

    • When you prepare meals, try to bake or grill the food rather than frying it.

    Correct Answer
    A. Read the labels of all packaged foods to determine the sodium content
    Explanation
    Reading the labels of all packaged foods to determine the sodium content is the most important action for the nurse to teach the patient to prevent hypernatremia. Hypernatremia is a condition characterized by high levels of sodium in the blood. By reading the labels of packaged foods, the patient can make informed choices and avoid consuming foods that are high in sodium. This can help prevent further increases in sodium levels and reduce the risk of developing or worsening hypernatremia. Weighing oneself, checking pulse and rhythm, and choosing healthier cooking methods are important for overall health but may not directly address the prevention of hypernatremia.

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  • 10. 

    The nurse instructs the older adult client to increase intake of dietary potassium when the client is prescribed which classification of drugs?

    • Alpha antagonists

    • Beta Blockers

    • Corticosteroids

    • Loop diurectics

    Correct Answer
    A. Loop diurectics
    Explanation
    Loop diuretics are a type of medication that increase the excretion of water and electrolytes, including potassium, from the body. This can lead to low levels of potassium in the blood, known as hypokalemia. To prevent this, the nurse instructs the older adult client to increase their intake of dietary potassium when taking loop diuretics. Alpha antagonists, beta blockers, and corticosteroids do not have the same effect on potassium levels and therefore do not require increased intake of dietary potassium.

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  • 11. 

    Which patient will the nurse consider to be at increased risk for infection as a result of a chronic health problem?

    • A young adult who wears contact lenses

    • An adult with type 1 diabetes mellitus

    • An adult with a known hypersensitivity to latex

    • An adolescent using analgesics for migraine headaches

    Correct Answer
    A. An adult with type 1 diabetes mellitus
    Explanation
    An adult with type 1 diabetes mellitus is at increased risk for infection due to their chronic health problem. Diabetes can weaken the immune system, making it harder for the body to fight off infections. Additionally, high blood sugar levels can create a favorable environment for bacteria and fungi to grow. Therefore, this patient would be considered to be at increased risk for infection compared to the other options given.

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  • 12. 

    Which community-dwelling healthy person has the greatest risk for dehydration when exposed to a hot, dry enviornment for several hours?

    • 50 year old man

    • 50 year old woman

    • 80 year old man

    • 80 year old woman

    Correct Answer
    A. 80 year old woman
    Explanation
    Older adults, especially those over 80 years old, have a higher risk of dehydration due to physiological changes that occur with aging. These changes include a decreased sense of thirst and a reduced ability to conserve water. Additionally, older adults may have underlying health conditions or take medications that can further increase their risk of dehydration. Therefore, the 80 year old woman in this scenario has the greatest risk for dehydration when exposed to a hot, dry environment for several hours.

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  • 13. 

    The nurse is instructing the client being discharged with a diagnosis of congestive heart failure. Which statement by the client indicates understanding of the disorder?

    • I can gain 2 pounds of water a day without risk

    • I should call my provider if I gain more than 1 pound per week

    • Weighing myself daily can determine if my diet is effective

    • Weighing myself daily can indicate increased fluid retention

    Correct Answer
    A. Weighing myself daily can indicate increased fluid retention
    Explanation
    Weighing myself daily can indicate increased fluid retention. This statement indicates that the client understands that daily weighing can help monitor fluid retention, which is a common symptom of congestive heart failure. This is important because fluid retention can worsen the condition and lead to further complications. By monitoring their weight daily, the client can identify any sudden or significant weight gain, which may indicate an increase in fluid accumulation. This understanding shows that the client is aware of the importance of managing fluid retention and seeking medical attention if necessary.

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  • 14. 

    Which patient is at greatest risk for the development of hyperkalemia?

    • 60 year old man with heart failure using a salt substitute

    • 60 year old woman taking a thiazide diuretic for hypertension

    • 40 year old woman taking NSAIDs daily for rheumatoid arthritis

    • 40 year old man with type 2 diabetes taking an oral antidiabetic agent

    Correct Answer
    A. 60 year old man with heart failure using a salt substitute
    Explanation
    The 60-year-old man with heart failure using a salt substitute is at the greatest risk for the development of hyperkalemia. Heart failure can lead to impaired kidney function, which can result in the retention of potassium in the body. Salt substitutes often contain potassium chloride, which can further increase the levels of potassium in the body. Therefore, the combination of heart failure and the use of a salt substitute can significantly increase the risk of hyperkalemia in this patient.

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  • 15. 

    An African-American woman had a breast biopsy 1 year ago. The incision site is elevated, dark, and protruding. Which is the nurse's interpretations for these findings?

    • The patient has formed a keloid

    • There is a high probability that skin cancer has developed

    • The benign breast disease has undergone malignant transformation

    • Chronic inflammatory of deep infection has occured

    Correct Answer
    A. The patient has formed a keloid
    Explanation
    The nurse's interpretation for the elevated, dark, and protruding incision site is that the patient has formed a keloid.

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  • 16. 

    The patient has scabies. In addition to standard precautions, which information is most important to communicate to visitors and health care providers?

    • Do not allow children to visit

    • Wear gloves when entering the room

    • Wear a mask when within 3 feet of the patient

    • Keep head covered when providing patient care

    Correct Answer
    A. Wear gloves when entering the room
    Explanation
    When a patient has scabies, it is crucial to communicate to visitors and healthcare providers that they should wear gloves when entering the room. Scabies is a highly contagious skin condition caused by mites, and direct skin-to-skin contact can easily transmit the mites. Wearing gloves acts as a barrier and helps prevent the spread of the mites from the patient to others. This precaution is essential to protect both visitors and healthcare providers from contracting scabies.

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  • 17. 

    What intervention will the nurse implement to provide for patient safety during intradermal allergy testing?

    • Ensure that emergency equipment is in the room

    • Pretreat the skin area to be tested with a cortisone-based cream

    • Apply oxygen by mask or nasal cannula before injecting the test again

    • Cover the examination table and pillow with plastic or an ultrafine mesh

    Correct Answer
    A. Ensure that emergency equipment is in the room
    Explanation
    To ensure patient safety during intradermal allergy testing, the nurse should ensure that emergency equipment is in the room. This is important because allergic reactions can occur during the testing, such as anaphylaxis, which can be life-threatening. Having emergency equipment readily available allows for immediate intervention and treatment in case of an adverse reaction.

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  • 18. 

    The patient, who has chronic conditions that increase the risk for dehydration, is going home. What intervention is most important to teach this patient about identifying the onset of dehydration?

    • Measuring abdominal girth

    • Converting ounces to milliliters

    • Obtaining and charting accurate weight

    • Selecting food items with high water content

    Correct Answer
    A. Obtaining and charting accurate weight
    Explanation
    Obtaining and charting accurate weight is the most important intervention to teach the patient about identifying the onset of dehydration. This is because weight loss is one of the earliest signs of dehydration. By regularly weighing themselves and keeping a record of their weight, the patient can monitor any significant changes that may indicate dehydration. This intervention allows for early detection and prompt intervention to prevent further complications. Measuring abdominal girth, converting ounces to milliliters, and selecting food items with high water content may be helpful in managing dehydration but are not the most important interventions for identifying its onset.

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  • 19. 

    Which intervention is most important to teach the patient who develops thrombocytopenia secondary to chemotherapy?

    • Eat a low-bacteria diet

    • Take your temperature daily

    • Use a soft-bristled toothbrush and do not floss

    • Avoid using mouthwashes that contain alcohol

    Correct Answer
    A. Use a soft-bristled toothbrush and do not floss
    Explanation
    Patients who develop thrombocytopenia secondary to chemotherapy have a decreased platelet count, which impairs their ability to clot blood properly. Using a soft-bristled toothbrush and avoiding flossing can help prevent gum bleeding and minimize the risk of injury to the oral mucosa, which could lead to bleeding. Therefore, this intervention is the most important to teach the patient in order to prevent complications associated with thrombocytopenia.

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  • 20. 

    The nurse is assessing a cut on the patient's hand. Which assessment finding will the nurse report to the patient's health care provider right away?

    • The wound is puffy and pink

    • The wound has purulent drainage

    • The wound is tender to the touch

    • The patient's temperature is 99.0 degrees F

    Correct Answer
    A. The wound has purulent drainage
    Explanation
    The nurse will report the finding of purulent drainage from the wound to the patient's healthcare provider right away. Purulent drainage indicates the presence of infection in the wound, which requires immediate attention and appropriate treatment to prevent further complications.

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  • 21. 

    The client develops fluid overload while in the intensive care unit. Which intervention does the nurse perform?

    • Draws blood for lab tests

    • Elevates the head of bed

    • Lowers the head of bed

    • Places the extremeties in dependent positions

    Correct Answer
    A. Elevates the head of bed
    Explanation
    Elevating the head of the bed is the appropriate intervention for a client who develops fluid overload in the intensive care unit. This position helps to promote drainage of fluid from the lungs and reduces the workload on the heart. By elevating the head of the bed, gravity assists in reducing the accumulation of fluid in the lungs, making it easier for the client to breathe and improving oxygenation. This intervention can help to alleviate symptoms of fluid overload and prevent further complications.

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  • 22. 

    Which intervention is mose important for the nurse to teach the patient who is recovering from an allergic reaction to a bee sting?

    • How to use an Epi Pen

    • Obtaining and wearing a medical alert bracelet

    • Avoiding direct contact with the offending allergen

    • Keeping diphendydramine available

    Correct Answer
    A. How to use an Epi Pen
    Explanation
    The most important intervention for the nurse to teach the patient recovering from an allergic reaction to a bee sting is how to use an Epi Pen. An Epi Pen is a device that delivers a dose of epinephrine, which can quickly reverse the symptoms of an allergic reaction and prevent anaphylaxis. Knowing how to properly use an Epi Pen is crucial in case of future bee stings or exposure to other allergens. This intervention can potentially save the patient's life by providing immediate treatment in emergency situations.

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  • 23. 

    Which lab result in a patient with cancer siggests the possibility of syndrome of inappropriate diuretic hormone (SIADH)

    • Serum potassium 5.2 mmol/L

    • Serum sodium of 120 mmol/L

    • Hematocrit of 40%

    • Blood urea nitrogen (BUN) of 10mg/dL

    Correct Answer
    A. Serum sodium of 120 mmol/L
    Explanation
    A serum sodium level of 120 mmol/L suggests the possibility of syndrome of inappropriate antidiuretic hormone (SIADH) because SIADH is characterized by excessive release of antidiuretic hormone (ADH), resulting in water retention and dilutional hyponatremia. In SIADH, the kidneys retain water, leading to a decrease in serum sodium levels. A serum sodium level of 120 mmol/L is significantly lower than the normal range (135-145 mmol/L), indicating dilutional hyponatremia and suggesting the possibility of SIADH in a patient with cancer.

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  • 24. 

    When teaching a patient who has a penicillin-resistant infection, which instruction is most important for the nurse to include in the discharge teaching plan?

    • You have an allergy to penicillin

    • You will not need to take an antibiotic for this infection

    • You are being discharged on an antibiotic that is not a penicillin

    • You are at high risk for other infections

    Correct Answer
    A. You are being discharged on an antibiotic that is not a penicillin
    Explanation
    The most important instruction for the nurse to include in the discharge teaching plan is that the patient is being discharged on an antibiotic that is not a penicillin. This is important because the patient has a penicillin-resistant infection, meaning that penicillin will not be effective in treating the infection. Therefore, it is crucial for the patient to understand that they are being prescribed a different antibiotic that will target the specific bacteria causing the infection. This instruction ensures that the patient is aware of the appropriate medication to take and can effectively manage their infection.

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  • 25. 

    The nurse notes that the handgrip of the patient with hypokalemia has dimished since the previous assessment 1 hour ago. What is the nurse's first best action?

    • Assess the patient's rate, rhythm, and depth of respiration

    • Measure the patient's pulse and blood pressure

    • Document the findings as the only action

    • Call the emergency team

    Correct Answer
    A. Assess the patient's rate, rhythm, and depth of respiration
    Explanation
    The nurse's first best action should be to assess the patient's rate, rhythm, and depth of respiration. Hypokalemia, which is a low level of potassium in the blood, can cause muscle weakness and affect the respiratory muscles. Diminished handgrip strength could indicate respiratory distress, so assessing the patient's breathing is crucial to determine if immediate intervention is needed.

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  • 26. 

    The patient with a prostate cancer is taking estrogen dailt to control tumor growth. He reports that his left calf is swollen and painful. Which is the nurse's best action?

    • Instruct the patient to keep the leg elevated

    • Measure the calf circumference and compare with right calf

    • Apply ice to the calf after massaging it

    • Document this expected response

    Correct Answer
    A. Measure the calf circumference and compare with right calf
    Explanation
    The nurse's best action is to measure the calf circumference and compare it with the right calf. This is because swelling and pain in the calf can be a sign of deep vein thrombosis (DVT), which is a potential complication of estrogen therapy. By measuring and comparing the calf circumference, the nurse can assess for any significant differences between the two calves, which could indicate the presence of DVT. This action allows for early detection and appropriate intervention to prevent further complications.

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  • 27. 

    Which common physiologic change resulting from the aging process alters hydration status in the older adult?

    • Adrenal growth

    • Decreased muscle mass

    • Increased thirst reflex

    • Poor skin turgor

    Correct Answer
    A. Decreased muscle mass
    Explanation
    As individuals age, they tend to experience a decrease in muscle mass, which can alter their hydration status. Muscle tissue contains a significant amount of water, and a decrease in muscle mass means there is less water available in the body. This can lead to a decrease in overall hydration levels in older adults.

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  • 28. 

    The patient's radiation implant has become dislodged overnight, and the nurse finds it in the patient's bed. What will the nurse do first?

    • Asses the patient's mental status

    • Use tongs to place the implant into the radiation container

    • Notify the physician and move the patient to a different room

    • Don gloves and attempt to reposition the implant and position-holding device

    Correct Answer
    A. Use tongs to place the implant into the radiation container
    Explanation
    The nurse will use tongs to place the implant into the radiation container to ensure safety and prevent any potential harm from radiation exposure. This is the first priority to protect both the patient and the healthcare team. Assessing the patient's mental status, notifying the physician, and attempting to reposition the implant can be done after ensuring the safe containment of the implant.

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  • 29. 

    What is the priority nursing diagnosis for the patient experiencing chemotherapy-induced anemia?

    • Risk for Injury related to poor blood clotting

    • Fatigue related to decreased cellular oxygenation

    • Disturbed Body Image related to skin color changes

    • Imbalanced Nutrition, Less than Body Requirements related to anorexia

    Correct Answer
    A. Fatigue related to decreased cellular oxygenation
    Explanation
    The priority nursing diagnosis for a patient experiencing chemotherapy-induced anemia is "Fatigue related to decreased cellular oxygenation." Chemotherapy can cause a decrease in red blood cells, leading to anemia. Anemia results in decreased oxygen-carrying capacity, which can cause fatigue. Addressing the patient's fatigue and implementing interventions to improve cellular oxygenation should be the priority to improve the patient's quality of life and overall well-being.

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  • 30. 

    The patient is admitted with hypokalemia and skeletal muscle weakness. Which assessment does the nurse prioritize?

    • Temperature

    • Pulse

    • Respirations

    • Blood Pressure

    Correct Answer
    A. Respirations
    Explanation
    In this scenario, the nurse would prioritize assessing the patient's respirations. Hypokalemia can lead to respiratory muscle weakness, which can result in respiratory distress or failure. Therefore, monitoring the patient's breathing is crucial to ensure adequate oxygenation and prevent further complications. Assessing the patient's temperature, pulse, and blood pressure are also important, but respiratory assessment takes priority in this case.

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  • 31. 

    Which characteristics are common to all types of hypersensitivity reactions?

    • Decreased inflammatory responses

    • Presence of tissue damaging reactions

    • Enhances natural killer cell activity

    • Inability to recognize extraneous cells

    Correct Answer
    A. Presence of tissue damaging reactions
    Explanation
    The correct answer is "Presence of tissue damaging reactions." This means that all types of hypersensitivity reactions involve some form of damage to the body's tissues. This can occur through various mechanisms, such as the release of inflammatory mediators or the activation of immune cells that directly damage the tissues. The other options, including decreased inflammatory responses, enhancing natural killer cell activity, and inability to recognize extraneous cells, are not characteristics that are common to all types of hypersensitivity reactions.

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  • 32. 

    When taking the blood pressure of a very ill patient, the nurse observes that the patient's hand undergoes flexion contractions. what is the nurse's best first action?

    • Place the patient in the high-Fowlers position and increase the IV flow rate

    • Deflate the blood pressure cuff and give the patient oxygen

    • Document the finding as the only action

    • Notify the emergency team

    Correct Answer
    A. Deflate the blood pressure cuff and give the patient oxygen
    Explanation
    The nurse's best first action would be to deflate the blood pressure cuff and give the patient oxygen. Flexion contractions in the hand during blood pressure measurement may indicate pain or discomfort, and it is important to alleviate any potential harm or distress to the patient. Deflating the cuff would relieve any pressure on the patient's arm, while providing oxygen would help improve their breathing and overall condition. Documenting the finding as the only action may delay necessary interventions, and notifying the emergency team may not be required unless the patient's condition worsens or additional assistance is needed.

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  • 33. 

    The client with which condition is at greatest risk for hypernatremia?

    • Excessive sweating

    • Hyperglycemia

    • On hypotonic fluids

    • Low-salt diet

    Correct Answer
    A. Excessive sweating
    Explanation
    Excessive sweating can lead to dehydration, which in turn can cause an imbalance in electrolytes, including sodium. Hypernatremia is a condition characterized by high levels of sodium in the blood, and it is more likely to occur in individuals who lose large amounts of fluid through excessive sweating. Therefore, clients who experience excessive sweating are at the greatest risk for developing hypernatremia.

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  • 34. 

    When evaluating the hydration status, the nurse observes tenting of the skin on the back of the 87-year old patients hand when testing skin turgor. What is the nurse's best action?

    • Notify the physician

    • Examine dependent body areas

    • Assess turgor on the patient's forehead

    • Document the finding as the only action

    Correct Answer
    A. Assess turgor on the patient's forehead
    Explanation
    The nurse should assess turgor on the patient's forehead. Tenting of the skin on the back of the hand indicates dehydration, and assessing turgor on the forehead is a reliable method to evaluate hydration status. The nurse should gently pinch the skin on the forehead and observe how quickly it returns to its normal position. If the skin takes longer to return, it suggests dehydration. This finding should be documented, but further action may be needed to address the patient's hydration status.

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  • 35. 

    The patient has dry skin and a history of cardiovascular disease. Which is the best intervention for the nurse to teach the patient?

    • Wear pajamas to cover your legs at night

    • Avoid wearing stockings

    • Increase your fluid intake to 3 L per day

    • Bathe in warm water and then apply lotion immediately.

    Correct Answer
    A. Bathe in warm water and then apply lotion immediately.
    Explanation
    The patient's dry skin can be addressed by bathing in warm water as it helps to retain moisture in the skin. Applying lotion immediately after bathing helps to lock in the moisture and prevent further dryness. This intervention is particularly beneficial for patients with dry skin, as it can help alleviate discomfort and prevent complications such as itching and cracking.

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  • 36. 

    In providing care to the client with hyponatremia, which finding requires immediate action by the nurse?

    • Diminished bowel sounds

    • Heightened acuity

    • Muscular weakness

    • Urine output of 35mL/hr

    Correct Answer
    A. Muscular weakness
    Explanation
    Muscular weakness in a client with hyponatremia requires immediate action by the nurse because it can be a sign of severe electrolyte imbalance. Hyponatremia is a condition characterized by low sodium levels in the blood, which can lead to neurological symptoms such as muscle weakness, confusion, and seizures. If left untreated, severe hyponatremia can be life-threatening. Therefore, the nurse should prioritize addressing the muscular weakness by notifying the healthcare provider, initiating appropriate interventions, and closely monitoring the client's condition to prevent further complications.

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  • 37. 

    The nurse is told that a patient has been admitted whi is infected with measles (rubeola). How will the nurse begin to plan for the patient's care?

    • Implementation of contact precautions

    • Implementation of airborne precautions

    • Implementation of droplet precautions

    • Implementation of reverse isolation

    Correct Answer
    A. Implementation of airborne precautions
    Explanation
    The nurse will begin to plan for the patient's care by implementing airborne precautions. Measles (rubeola) is a highly contagious viral infection that spreads through the air when an infected person coughs or sneezes. Airborne precautions are necessary to prevent the transmission of the virus to other patients and healthcare workers. These precautions include placing the patient in a negative pressure room, using personal protective equipment such as masks, and ensuring proper ventilation in the room.

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  • 38. 

    What is the priority nursing diagnosis for the patient who has Sjogrens syndrome?

    • Fatigue related to anemia

    • Disturbed Body Image related to excessive weight gain

    • Risk for Infection related to dryness of mucous membranes

    • Ineffective Breathing Pattern related to progressive pulmonary fibrosis

    Correct Answer
    A. Risk for Infection related to dryness of mucous membranes
    Explanation
    The priority nursing diagnosis for a patient with Sjogren's syndrome is "Risk for Infection related to dryness of mucous membranes." Sjogren's syndrome is an autoimmune disorder that primarily affects the salivary and lacrimal glands, leading to dryness of the mucous membranes in the eyes, mouth, and other areas. Dryness of the mucous membranes can increase the risk of infections, as the normal protective barrier provided by moist membranes is compromised. Therefore, the priority nursing diagnosis is to address and prevent infections in these vulnerable areas.

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  • 39. 

    A patient has numerous skin lesions. Which one will the nurse evaluate first?

    • Beige freckles on the backs of both hands

    • Irregular blue mole with white specks on the lower leg

    • Large cluster of pustules in the right axilla

    • Raised, tubular, white, snake-like areas on the inner aspects of the wrists

    Correct Answer
    A. Irregular blue mole with white specks on the lower leg
    Explanation
    The nurse will evaluate the irregular blue mole with white specks on the lower leg first because it could potentially be a sign of skin cancer or melanoma. Melanoma is a type of skin cancer that can be deadly if not caught and treated early. The irregular shape and the presence of white specks could indicate an abnormality in the mole that requires immediate evaluation and further investigation.

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  • 40. 

    The patient is taking a medication for an endocrine problem that inhibits aldosterone secretion and release. For what complications of this therapy should the nurse be alert?

    • Dehydration, hypokalemia

    • Dehydration, hyperkalemia

    • Overhydration, hyponatremia

    • Overhydration, hypernatremia

    Correct Answer
    A. Dehydration, hyperkalemia
    Explanation
    The patient is taking a medication that inhibits aldosterone secretion and release. Aldosterone is responsible for promoting sodium and water reabsorption and potassium excretion in the kidneys. Therefore, inhibiting aldosterone can lead to decreased sodium and water reabsorption, resulting in dehydration. Additionally, since aldosterone also promotes potassium excretion, inhibiting its secretion can cause hyperkalemia, an excessive buildup of potassium in the blood. Therefore, the nurse should be alert for dehydration and hyperkalemia as potential complications of this therapy.

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  • 41. 

    The nurse is instructing the patient about the management of systemic sclerosis. Which statement indicates that the patient needs additional teaching?

    • I will let my doctor know right away if I develop a fever

    • I will use ice packs to help relieve the aching pain in my hips and knees

    • I will put mittens on when I am in the freezer section of the grocery store

    • I will apply a rich moisturizer to my skin every morning after my shower

    Correct Answer
    A. I will use ice packs to help relieve the aching pain in my hips and knees
    Explanation
    The statement "I will use ice packs to help relieve the aching pain in my hips and knees" indicates that the patient needs additional teaching. Systemic sclerosis is a condition characterized by thickening and hardening of the skin and connective tissues, which can lead to decreased blood flow and sensitivity to cold temperatures. Using ice packs may worsen the symptoms and should be avoided.

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  • 42. 

    Which statement by a patient with psoriasis indicates a need for further teaching?

    • At the next family reunion, I am going to ask if any of my relatives have psoriasis

    • I have to make sure I have this covered so I do not spread it to others

    • I expect that these patches will get smaller when I lay out in the sun

    • I should continue to use the cortisone ointment as the patches shrink and dry out

    Correct Answer
    A. I have to make sure I have this covered so I do not spread it to others
    Explanation
    The patient's statement suggests a misunderstanding about the transmission of psoriasis. Psoriasis is not contagious and cannot be spread to others. This indicates a need for further teaching to clarify that psoriasis is a chronic autoimmune condition and is not contagious.

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  • 43. 

    The nurse is teaching a community health class about health promotion techniques. Which statement by a student indicates a strategy to help prevent the development of osteoarthritis?

    • I will keep my BMI under 24

    • I will switch to low-tar cigarettes

    • I will start jogging twice a week

    • I will check my blood pressure weekly

    Correct Answer
    A. I will keep my BMI under 24
    Explanation
    Keeping one's BMI under 24 is a strategy to help prevent the development of osteoarthritis because maintaining a healthy weight can reduce stress on the joints, particularly the weight-bearing joints like the knees and hips. Excess weight puts extra pressure on these joints, increasing the risk of developing osteoarthritis. By keeping the BMI under 24, the student is indicating an intention to maintain a healthy weight, which can help prevent the development of osteoarthritis.

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  • 44. 

    The nurse is instructing the patient about management of discoid lupus erythematosus (DLE). Which statement indicates that the patient needs additional teaching?

    • I will be sure to apply sunscreen whenever I am outside

    • I will apply small amounts of the steroid cream to my face twice a day

    • I will take the Plaquenil (hydroxychloroquine sulfate) with breakfast each morning

    • I will wash my hands often and get a flu shot because the steroids will weaken my immune system

    Correct Answer
    A. I will wash my hands often and get a flu shot because the steroids will weaken my immune system
    Explanation
    The patient's statement about washing hands often and getting a flu shot because the steroids will weaken their immune system indicates a need for additional teaching. Steroids do not weaken the immune system in the same way as immunosuppressive medications, so the patient's understanding of the medication's effects on their immune system is incorrect. They should be educated about the specific effects of steroids and the importance of hand hygiene and flu vaccination for general infection prevention.

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  • 45. 

    The patient with hypermagnesemia has a blood pressure of 90/40, compared with the 108/80 reading obtained 1 hour earlier. What is the nurse's best first action?

    • Assess bowel sounds and measure abdominal girth

    • Increase the intravenous infusion rate

    • Document the finding as the only action

    • Notify the emergency team

    Correct Answer
    A. Notify the emergency team
    Explanation
    The patient's significant drop in blood pressure within a short period of time indicates a potential emergency situation. Hypermagnesemia can cause muscle weakness, including the muscles that control blood vessels, leading to low blood pressure. Therefore, notifying the emergency team is the best first action to ensure prompt intervention and appropriate management of the patient's condition. Assessing bowel sounds and measuring abdominal girth, increasing the intravenous infusion rate, or simply documenting the finding would not address the immediate concern of the patient's dropping blood pressure.

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  • 46. 

    The nurse assesses a cut that is 24 hours old and fines that the site is swollen, red, and tender to the touch. Which cell types are responsible for these assessment findings?

    • Erythrocytes and platelets

    • Basophils and eosinophils

    • Plasma cells and B-lymphocytes

    • Natural killer cells

    Correct Answer
    A. Basophils and eosinophils
    Explanation
    Basophils and eosinophils are responsible for the assessment findings of a swollen, red, and tender cut. Basophils release histamine, which causes blood vessels to dilate and become more permeable, leading to swelling and redness. Eosinophils are involved in the inflammatory response and release substances that contribute to tissue damage and pain. Therefore, the presence of these cell types suggests an ongoing inflammatory response at the site of the cut.

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  • 47. 

    What statement indicates that the patient understands teaching about neutropenia and bone marrow suppresion?

    • I need to use a soft toothbrush to prevent gum trauma and bleeding

    • I have to wear a mask at all times

    • My grandchildren may get an infection from me because they are so young

    • I should call my health provider with any increase in my body temperature

    Correct Answer
    A. I should call my health provider with any increase in my body temperature
    Explanation
    The statement "I should call my health provider with any increase in my body temperature" indicates that the patient understands teaching about neutropenia and bone marrow suppression because an increase in body temperature can be a sign of infection, which is a serious concern for patients with compromised immune systems. This shows that the patient has been educated about the importance of monitoring their temperature and contacting their healthcare provider promptly if there is any indication of infection.

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  • 48. 

    A patient presents with painful, inflamed fingers with small, hard, yellow nodules that have sandy yellow drainage. Which medication will the nurse prepare to administer?

    • Lasix (Furosemide)

    • Allopurinol (Zyloprim)

    • Methotrexate (Rheumatrex)

    • Aspirin (acetysalicylic acid)

    Correct Answer
    A. Allopurinol (Zyloprim)
    Explanation
    The correct answer is Allopurinol (Zyloprim). Allopurinol is a medication commonly used to treat gout, a form of arthritis that causes painful inflammation in the joints. The presence of painful, inflamed fingers with small, hard, yellow nodules suggests the possibility of tophi, which are deposits of uric acid crystals that can form in the joints of individuals with gout. Allopurinol works by reducing the production of uric acid in the body, helping to prevent the formation of tophi and alleviate symptoms.

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  • 49. 

    The client has a serum potassium of 3.1 mEq/L. What is the safe way to administer parenteral potassium-containing solution to this client?

    • Administer KCI, 5 mEq/L, given intramuscularly

    • Dilute KCI, 200 mEq/L, in 1 liter of normal saline and infuse at 100mL/hr

    • Infuse KCI, 10mEq, over 1 hour

    • Push KCI, 5mEq, through a central line

    Correct Answer
    A. Infuse KCI, 10mEq, over 1 hour
    Explanation
    The client has a low serum potassium level, indicating hypokalemia. Infusing KCI, 10mEq, over 1 hour is the safest way to administer parenteral potassium-containing solution to this client. This allows for a slow and controlled infusion, minimizing the risk of complications such as hyperkalemia or cardiac arrhythmias. Pushing KCI through a central line or administering a higher concentration of KCI could lead to rapid potassium shifts and potential adverse effects. Diluting KCI in normal saline and infusing at a slower rate is a safer option to prevent rapid potassium shifts.

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Quiz Review Timeline (Updated): Jul 26, 2024 +

Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Jul 26, 2024
    Quiz Edited by
    ProProfs Editorial Team
  • Nov 12, 2009
    Quiz Created by
    Samanthakc05
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