FLUIDS AND ELECTROLYTES
Placing cl in high
1.When teaching a client with hypokalemia, which foods should
the nurse instruct the client to increase? Orange juice and
bananas
2. Which intervention is most appropriate for the client who is
hyperventilating and developing respiratory alkalosis?
Encouraging slow, deep breaths
3. The nurse is totaling the I/O for a client diagnosed with
septicemia who is on a clear liquid diet. The client intakes 8 oz
apple juice, 850 ml water, 2 cups beef broth, and 900 ml of half
normal saline solution and outputs 1500 ml urine during the
shift. How many ml should the nurse document as the client’s
intake? 2470 – 8 oz=240 ml + 850 ml + 2cups=480 ml +
900 ml
4. Which assessment data does the nurse document when a
client diagnosed with hypocalcemia develops a carpopedal
spasm after the BP cuff is inflated? Positive Trousseau’s sign
5. Which clinical manifestation would the nurse expect to assess
in a client with hypernatremia? Tented skin turgor and thirst
6. A client with a hx of COPD has the following ABG results:
PO2-55 mmHg, PCO2-60 mmHg. When attempting to improve
the client’s blood gas values through improved ventilation and
oxygen therapy, which is the client’s primary stimulus for
breathing? Low PO2
7. Which intervention should the nurse perform when caring for
a client diagnosed with fluid volume deficit? Assessing urinary
I/O with a urometer
8. Which client situation requires the nurse to discuss the
importance of avoiding foods high in potassium? Renal dse
9. For the client diagnosed with hypomagnesemia, which nsg
intervention would be appropriate? Instituting seizure
precautions to prevent injury
10. Which electrolyte would the nurse identify as the major
electrolyte responsible for determining the concentration of the
extracellular fluid? Sodium
11. Which medication would the nurse anticipate administering
for a client with a potassium level of 6.2 mEq/L? Kayexalate
12. Which clinical manifestation would lead the nurse to suspect
that a client is experiencing hypermagnesemia? Hot, flushed
skin and diuresis
13. In planning the care for a client receiving furosemide and
digoxin, which lab data would be the most impt to assess?
Potassium level
14. A client has the ff ABG values: PO2-80 mmHg, PCO2-49
mmHg and HCO3-24mEq/L. based on these results, which
intervention should the nurse implement? Encouraging client
to cough and deep breathe
15. Which would the nurse expect the health care provider to
order for the client diagnosed with metabolic acidosis? Sodium
bicarbonate
16. Which electrolyte abnormality would the nurse suspect if the client’s ECG
showed a shortened QT interval and bradycardia? Hypercalcemia
RESPIRATORY DISORDERS
1. During the nsg hx, which client statement would lead the nurse to
Suspect pneumoconiosis? “Ihave worked in the coal mines
for over 25 years.”
2. A client is admitted to the emergency department with an acute
excacerbation of COPD. Which interventions should the nurse
implement while caring for the client?
fowler’s/obtaining a stat pulse oximeter reading/notifying
the respi therapist
3. Which data would the nurse expect to assess in a febrile client
complaining of a hacking cough and generalized malaise? Bronchial
breath sounds over lung fields with consolidation
4. Which nsg intervention would be impt to include in the discharge
teaching plan for the client diagnosed with pulmonary embolism?
Maintaining peripheral circulation with leg exercises
5. Which long-term goal would the nurse identify for a client
diagnosed with COPD? Improving pulmonary ventilation and
gas exchange
6. Which intervention would the nurse implement for a client with
COPD who develops acute respiratory failure? Managing oxygen
therapy
7. Which intervention would be most helpful in assisting the client
diagnosed with COPD to develop ways to cope with the disease?
Teaching the client relaxation techniques and breathing
retraining exercises
8. A client hospitalized for acute bacterial pneumonia is recovering
after a course of therapy with pen G. Which outcome demonstrates
the effectiveness of care? The client has PaO2 of 85 mmHg or
higher
9. Which nsg intervention should be included in the care plan for a
client receiving mechanical ventilation? Assessing the ventilator
settings as prescribed by the health care provider
10. Which should the nurse expect to observe in the water seal
chamber of the chest tube drainage system for a client with a
hemothorax 4 hrs after chest tube insertion? Fluctuation with
inspiration and expiration
11. Which discharge instruction is most appropriate to prevent or
control respi infections for the client diagnosed with respiratory
insufficiency resulting from long standing restrictive lung dse?
Receiving influenza injections
12. Which procedure would the nurse anticipate preparing for the
client who develops a large pleural effusion? Thoracentesis
13. The nurse would suspect ARDS in a client diagnosed with
hypovolemic shock secondary to multiply trauma when he exhibits
which clinical manifestation? PaO2 of 62 mmHg after 2 hrs of
oxygen at 10 L/min
14. Which assessment findings would the nurse expect in a client
with a right-sided pneumothorax? Dyspnea and asymmetric
chest expansion
15. Which nsg intervention should be included in the care plan for a
client diagnosed with ARDS? Monitoring ABG levels and cardiac
status
16. A client with a pulmonary embolism who is receiving
anticoagulation therapy with warfarin has an International
Normalized Ratio of 2.5, a prothrombin time of 23, and a partial
thromboplastin time of 39. Based on these test results, which
intervention should the nurse implement? Administering the
prescribed dose