1.) A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the
following findings as a manifestation of fluid volume excess?
a. Decreased bowel sounds
b. Distended neck veins
Bilateral muscle weakness
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 findings should indicate to the nurse that the treatment is effective? a. Absent
Chvostek’s sign
b. Improved cognition
Decreased vomiting
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?
“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.”
d. “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 to the provider? a. 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 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
The client tests negative for HIV
The client has a positive purified protein derivative test
The client’s liver function test results are within the expected reference range
6.) A client is caring for a client who develops an anaphylactic reaction to IV administration. After assessing the
client’s respiratory status and stopping the medication infusion. Which of the following actions should the nurse
take next?
Replace the infusion with 0.9% sodium chloride
Give diphenhydramine IM
Elevate the client’s legs and feet
d. Administer epinephrine IM
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