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1. The nurse obtains all of the following assessment data about a patient with fluid-volume deficit caused by a massive burn injury. Which of the following assessment data will be of greatest concern?
a. Oral fluid intake is 100 ml for the last 8 hours.
b. The blood pressure is 90/40 mm Hg.
c. Urine output is 30 ml over the last hour.
d. There is prolonged skin tenting over the sternum.

B
Rationale: The blood pressure indicates that the patient may be developing hypovolemic shock as a result of fluid loss. This will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension.

Cognitive Level: Application Text Reference: pp. 322-323
Nursing Process: Assessment NCLEX: Physiological Integrity

2. A recently admitted patient has a small-cell carcinoma of the lung, which is causing the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully for
a. rapid and unexpected weight loss.
b. increased total urinary output.
c. decreased serum sodium level.
d. elevation of serum hematocrit.

C
Rationale: SIADH causes water retention and a decrease in serum sodium level. Weight loss, increased urine output, and elevated serum hematocrit may be associated with excessive loss of water, but not with SIADH and water retention.

Cognitive Level: Application Text Reference: pp. 319, 322, 325-326
Nursing Process: Assessment NCLEX: Physiological Integrity

3. Following bowel surgery 2 days ago, a patient has been receiving normal saline intravenously at 100 ml/hr, has a nasogastric tube to low, intermittent suction, and is NPO. An assessment finding that indicates a need to contact the health care provider immediately is a
a. weight gain of 2 pounds above the preoperative weight.
b. an oral temperature of 100.1° F with bibasilar lung crackles.
c. gradually decreasing level of consciousness (LOC).
d. serum sodium level of 138 mEq/L (138 mmol/L).

C
Rationale: The patient's history and change in LOC could be indicative of several fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information will be ordered by the health care provider to determine the cause of the change in LOC and the appropriate interventions. A weight gain of 2 pounds (<1 kg) since surgery would not be clinically significant unless associated with other symptoms. The oral temperature elevation and crackles would initially be addressed by having the patient cough and deep breathe. The sodium level is within the normal range of 135 to 145 mEq/L.

Cognitive Level: Application Text Reference: pp. 322-325, 338
Nursing Process: Assessment NCLEX: Physiological Integrity

4. When evaluating the response to treatment for a patient with a fluid imbalance, the most important assessment to include is
a. skin turgor.
b. presence of edema.
c. hourly urine output.
d. daily weight.

D
Rationale: Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age; considerable fluid-volume excess may be present before fluid moves into the interstitial space and causes edema; and hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.

Cognitive Level: Application Text Reference: p. 323
Nursing Process: Evaluation NCLEX: Physiological Integrity

5. When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake
a. when the patient feels thirsty.
b. in the late evening hours.
c. as soon as changes in LOC occur.
d. if the oral mucosa feels dry.

D
Rationale: An alert elderly patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age, and is not an accurate indicator of volume depletion. Many prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in LOC occur.

Cognitive Level: Application Text Reference: p. 321
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance

6. A patient is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as
a. generalized weakness.
b. facial muscle spasms.
c. frequent loose stools.
d. personality changes.

A
Rationale: Generalized weakness progressing to flaccidity is a manifestation of hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia. Personality changes are not associated with electrolyte disturbances, although changes in mental status are common manifestations with sodium excess or deficit.

Cognitive Level: Application Text Reference: p. 327
Nursing Process: Implementation NCLEX: Physiological Integrity

7. A patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. The laboratory data that will be of most concern to the nurse is
a. K+ 3.4 mEq/L (3.4 mmol/L).
b. Ca+2 7.8 mg/dl (1.95 mmol/L).
c. Na+ 154 mEq/L (154 mmol/L).
d. HPO4- 3 4.8 mg/dl (1.55 mmol/L).

C
Rationale: The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from the normal but do not require any immediate action by the nurse. The phosphate level is within the normal parameters.

Cognitive Level: Application Text Reference: pp. 325-326
Nursing Process: Assessment NCLEX: Physiological Integrity

8. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic. Which statement by the patient indicates that the teaching about this medication has been effective?
a. "I can have low-fat cheese."
b. "I will have apple juice instead of orange juice."
c. "I will drink at least 8 glasses of water every day."
d. "I can use a salt substitute."

B
Rationale: Spironolactone is a potassium-sparing diuretic. Patients should be taught to choose low-potassium foods such as apple juice rather than foods that have higher levels of potassium, such as citrus fruits. Cheese is high in sodium; the fat content of the cheese is not relevant. Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Patients are taught to avoid salt substitutes, which are high in potassium.

Cognitive Level: Application Text Reference: pp. 326-327
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance

9. When assessing a patient with increased extracellular fluid (ECF) osmolality, the priority assessment for the nurse to obtain is
a. mental status.
b. skin turgor.
c. capillary refill.
d. heart sounds.

A
Rationale: Changes in ECF osmolality lead to swelling or shrinking of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds may also be affected by ECF osmolality changes and resultant fluid shifts, these are signs that occur later and do not have as immediate an impact on patient outcomes.

Cognitive Level: Application Text Reference: pp. 322-323
Nursing Process: Assessment NCLEX: Physiological Integrity

10. When developing a care plan for a patient with syndrome of inappropriate antidiuretic hormone (SIADH), an intervention that will be important for the nurse to include is
a. monitor intake and output hourly.
b. restrict oral free water intake.
c. ambulate patient at least once per shift.
d. use incentive spirometer every 2 hours.

B
Rationale: SIADH causes water retention, which leads to hyponatremia, so water intake is restricted. Intake and output are measured, but hourly monitoring is not required. Ambulation and incentive spirometer use may be included in the care plan but are not indicated for the diagnosis of SIADH.

Cognitive Level: Application Text Reference: p. 326
Nursing Process: Planning NCLEX: Physiological Integrity

11. Intravenous potassium chloride (KCl) 40 mEq is ordered for treatment of a patient with hypokalemia. In administering the potassium solution, the nurse is aware that
a. the KCl should be administered as an IV bolus so that the hypokalemia will be corrected before complications occur.
b. the amount of KCl added to IV fluids should not exceed 20 mEq/L to prevent hyperkalemia from developing.
c. the KCl should be given only through central lines to avoid venospasm and inflammation at the IV insertion site.
d. to reduce the risk for cardiac dysrhythmia, the maximum amount of KCl to be administered in 1 hour is 20 mEq.

D
Rationale: Rapid IV administration of KCl can cause cardiac arrest; KCl is administered at a maximal rate of 20 mEq/hr. Bolus administration of KCl is contraindicated. The rate of administration, not the amount of KCl added to IV fluids, is important. KCl can cause inflammation of peripheral veins, but it can be administered by this route.

Cognitive Level: Application Text Reference: p. 329
Nursing Process: Implementation NCLEX: Physiological Integrity

12. To prevent laryngeal spasms and respiratory arrest in a patient who is at risk for hypocalcemia, an early sign of hypocalcemia the nurse should assess for is
a. weak hand grips.
b. confusion.
c. constipation.
d. lip numbness.

D
Rationale: Numbness and tingling around the lips or in the fingers are early signs of hypocalcemia. Muscle weakness, confusion, and constipation may also occur, but these are later signs of low calcium levels.

Cognitive Level: Comprehension Text Reference: p. 331
Nursing Process: Assessment NCLEX: Physiological Integrity

13. A patient who has been NPO with gastric suction and IV fluid replacement for 3 days following surgery develops nausea and vomiting, weakness, and confusion and has a serum sodium level of 125 mEq/L (125 mmol/L). The nurse reviews the health care provider's postoperative medication and IV orders. Which health care provider order should the nurse question?
a. Administer 3% saline if serum sodium drops to less than 128 mEq/L.
b. IV morphine sulfate 4 mg every 2 hours prn.
c. Infuse 5% dextrose in water at 125 ml/hr.
d. Give IV metoclopramide (Reglan) 10 mg every 6 hours prn nausea.

C
Rationale: Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.

Cognitive Level: Analysis Text Reference: pp. 326, 338-340
Nursing Process: Diagnosis NCLEX: Physiological Integrity

14. A patient with renal insufficiency develops lethargy and somnolence with a blood pressure of 100/60, pulse 62, and respirations 10. The nurse notes that the patient has been taking an aluminum hydroxide/magnesium hydroxide suspension (Maalox) for indigestion. The nurse anticipates that management of the patient will include IV administration of
a. magnesium sulfate.
b. potassium chloride.
c. calcium gluconate.
d. sodium chloride.

C
Rationale: The patient has a history and symptoms consistent with hypermagnesemia, so calcium gluconate or calcium chloride will be the initial therapy to oppose the effects of excess magnesium on cell function. Magnesium sulfate infusion is contraindicated because it will increase the serum magnesium level. Potassium chloride and sodium chloride will not impact the patient's symptoms and should be avoided in a patient with renal insufficiency.

Cognitive Level: Analysis Text Reference: pp. 332-333
Nursing Process: Diagnosis NCLEX: Physiological Integrity

15. A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse interprets these results as
a. metabolic acidosis.
b. metabolic alkalosis.
c. respiratory acidosis.
d. respiratory alkalosis.

D
Rationale: The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

Cognitive Level: Application Text Reference: p. 335
Nursing Process: Diagnosis NCLEX: Physiological Integrity

16. A diabetic patient with poor glucose control develops diabetic ketoacidosis. The nurse notes that a patient with diabetic ketoacidosis has rapid, deep respirations. Which collaborative intervention will the nurse anticipate implementing?
a. Oxygen at 2 to 4 L/min
b. IV sodium bicarbonate 50 mEq
c. IV 50% dextrose 50 ml
d. IV lorazepam (Ativan) 1 mg

B
Rationale: The rapid, deep (Kussmaul) respirations are a compensatory mechanism to "blow off" excessive CO2 generated by the high levels of ketoacids. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. Administration of 50% dextrose will increase serum glucose level. Ativan administration will slow the respiratory rate and increase the level of acidosis.

Cognitive Level: Application Text Reference: pp. 334-335
Nursing Process: Implementation NCLEX: Physiological Integrity

17. The home health nurse notes that an elderly patient has a low serum protein level. The nurse will plan to assess for
a. confusion.
b. restlessness.
c. edema.
d. pallor.

C
Rationale: Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.

Cognitive Level: Application Text Reference: p. 319
Nursing Process: Assessment NCLEX: Physiological Integrity

18. A postoperative patient with a nasogastric tube connected to low, intermittent suction is complaining of anxiety and severe incisional pain. The patient has a respiratory rate of 32 breaths per minute. The arterial blood gases (ABG) are pH 7.50, PaO2 90 mm Hg, PaCO2 30 mm Hg, and HCO3 23 mm Hg. Which intervention is most appropriate for the nurse to implement?
a. Disconnect the nasogastric tube until the pH is within the normal range.
b. Administer the prescribed sodium bicarbonate 50 mEq intravenously.
c. Teach the patient about the importance of taking slow, deep breaths.
d. Give the patient the ordered morphine sulfate 4 mg intravenously.

D
Rationale: The ABGs indicate respiratory alkalosis, which is caused by the increased respiratory rate. Because the increased respirations are most likely caused by the incisional pain, the first action by the nurse should be to medicate the patient for pain. The nasogastric tube is needed for postoperative gastric decompression and should remain connected to suction. Sodium bicarbonate administration will further increase the pH. Teaching the patient to take slow, deep breaths may be helpful, but it is unlikely to be effective until the pain level is decreased.

Cognitive Level: Application Text Reference: p. 335
Nursing Process: Implementation NCLEX: Physiological Integrity

19. A patient is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, the most important assessment for the nurse to monitor is
a. peripheral pulses.
b. lung sounds.
c. peripheral edema.
d. urinary output.

B
Rationale: Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are the most serious of the symptoms of fluid excess listed. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

Cognitive Level: Application Text Reference: pp. 339-340
Nursing Process: Assessment NCLEX: Physiological Integrity

20. Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." The nurse will immediately check for
a. elevated serum potassium level.
b. decreased thyroid hormone level.
c. bleeding on the patient's dressing.
d. the presence of Chvostek's sign.

D
Rationale: The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.

Cognitive Level: Analysis Text Reference: pp. 330-331
Nursing Process: Assessment NCLEX: Physiological Integrity

21. The long-term-care nurse is evaluating the effectiveness of protein supplements on a patient who has low serum total protein level. Which of these data indicate that the patient's condition has improved?
a. Absence of peripheral edema
b. Good skin turgor
c. Hematocrit 28%
d. Blood pressure 110/72 mm Hg

A
Rationale: Edema is caused by low oncotic pressure in individuals with low serum protein levels; the absence of edema indicates an improvement in the patient's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.

Cognitive Level: Application Text Reference: pp. 318-319
Nursing Process: Evaluation NCLEX: Physiological Integrity

22. A patient has the following ABG results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. The nurse interprets these results as
a. respiratory acidosis.
b. respiratory alkalosis.
c. metabolic acidosis.
d. metabolic alkalosis.

C
Rationale: The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.

Cognitive Level: Application Text Reference: pp. 335-336
Nursing Process: Assessment NCLEX: Physiological Integrity

23. The nurse working in the emergency department (ED) admits a patient with renal failure and a serum potassium level of 8.0 mEq/L. All these orders are received from the health care provider. Which order will the nurse implement first?
a. Place the patient on a cardiac monitor.
b. Insert a retention catheter.
c. Administer Kayexalate 15 g orally.
d. Give IV furosemide (Lasix) 40 mg.

A
Rationale: Because cardiac dysrhythmias are a common and potentially fatal complication of hyperkalemia, the first action should be to initiate cardiac monitoring. The other orders are also appropriate and should be accomplished as quickly as possible.

Cognitive Level: Analysis Text Reference: pp. 327-328
Nursing Process: Implementation NCLEX: Physiological Integrity

24. A patient who has been receiving diuretic therapy is admitted to the ED with a serum potassium level of 3.1 mEq/L. Of the following medications that the patient has been taking at home, the nurse will be most concerned about
a. metoprolol (Lopressor) 12.5 mg orally daily.
b. lantus insulin 24 U subcutaneously every evening.
c. oral digoxin (Lanoxin) 0.25 mg daily.
d. ibuprofen (Motrin) 400 mg every 6 hours.

C
Rationale: Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but there is not as much concern with the potassium level.

Cognitive Level: Application Text Reference: p. 329
Nursing Process: Assessment NCLEX: Physiological Integrity

25. A patient with advanced lung cancer is admitted to the ED with urinary retention caused by renal calculi. Which of these laboratory values will require the most immediate action by the nurse?
a. Arterial oxygen saturation 91%
b. Serum potassium is 5.1 mEq/L
c. Arterial blood pH is 7.32
d. Serum calcium is 18 mEq/L

D
Rationale: The serum calcium is well above the normal level (4.5-5.5 mEq/L) and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they do not indicate the need for immediate intervention.

Cognitive Level: Analysis Text Reference: p. 330
Nursing Process: Assessment NCLEX: Physiological Integrity

26. A patient with hypercalcemia is being cared for on the medical unit. Nursing actions included on the care plan will include
a. maintaining the patient on bedrest to prevent pathologic fractures.
b. monitoring for Trousseau's and Chvostek's signs.
c. encouraging fluid intake up to 4000 ml every day.
d. auscultate breath sounds every 4 hours.

C
Rationale: To decrease the risk for renal calculi, the patient should have an intake of 3000 to 4000 ml daily. Ambulation helps to decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of breath sounds, although these would be assessed every shift.

Cognitive Level: Application Text Reference: p. 330
Nursing Process: Planning NCLEX: Physiological Integrity

27. When teaching a patient with renal failure about a low-phosphate diet, the nurse will include information to restrict
a. intake of green, leafy vegetables.
b. the amount of high-fat foods.
c. ingestion of dairy products.
d. the quantity of fruits and juices.

C
Rationale: Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables, high-fat foods, and fruits/juices are not high in phosphate and are not restricted.

Cognitive Level: Application Text Reference: p. 331
Nursing Process: Implementation NCLEX: Physiological Integrity

28. The nurse assesses a pregnant patient with eclampsia who is receiving IV magnesium sulfate and obtains all the following information. Which of these assessment data is most important to report to the health care provider immediately?
a. The patient reports feeling "sick to my stomach."
b. The patellar and triceps reflexes are absent.
c. The patient has been sleeping most of the day.
d. The bibasilar breath sounds are decreased.

B
Rationale: The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels. Nausea and lethargy are also side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.

Cognitive Level: Analysis Text Reference: pp. 332-333
Nursing Process: Assessment NCLEX: Physiological Integrity

29. The nurse in the outpatient clinic who notes that a patient has a decreased magnesium level will ask the patient about
a. intake of dietary protein.
b. use of OTC laxatives.
c. multivitamin/mineral use.
d. daily alcohol intake.

D
Rationale: Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamins mineral supplements would tend to increase magnesium level.

Cognitive Level: Application Text Reference: p. 332
Nursing Process: Assessment NCLEX: Physiological Integrity

30. The nurse has administered 3% saline to a patient with hyponatremia. Which one of these assessment data will require the most rapid response by the nurse?
a. There are crackles audible throughout both lung fields.
b. The patient's radial pulse is 105 beats/minute.
c. The blood pressure increases from 120/80 to 142/94.
d. There is sediment and blood in the patient's urine.

A
Rationale: Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine should also be reported, but they are not as dangerous as the presence of fluid in the alveoli.

Cognitive Level: Application Text Reference: pp. 339, 340
Nursing Process: Assessment NCLEX: Physiological Integrity

31. The IV therapy nurse is inserting a peripherally inserted central catheter (PICC) so that a patient can receive an IV solution containing 50% dextrose. When explaining the need for the PICC, the nurse will include the information that
a. to give adequate doses of IV insulin, a centrally located IV catheter is needed.
b. blood glucose testing is more accurate when samples are obtained from a central line.
c. infusion of the IV solution through a PICC line will allow rapid dilution of 50% dextrose.
d. the 50% dextrose is less likely to produce infection when given through a PICC line.

C
Rationale: Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered intravenously. Insulin can be administered intravenously through the peripheral catheter. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines.

Cognitive Level: Application Text Reference: p. 340
Nursing Process: Implementation NCLEX: Physiological Integrity

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