A client has a paracentesis, and the health care provider removes 1500 mL of fluid.
To monitor for a serious postprocedure complication, the nurse should assess for:
1
Dry mouth
Correct2
Tachycardia
3
Hypertensive crisis
4
Increased abdominal distention
Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to
hypovolemia and compensatory tachycardia. Dry mouth may occur with dehydration, but it
is not as vital or immediate as signs of shock. Dry mouth is a subjective symptom that
cannot be measured objectively. The fluid shift can cause hypovolemia with resulting
hypotension, not hypertension. A paracentesis decreases the degree of abdominal
distention.
A client admitted to the hospital with a diagnosis of malabsorption syndrome
exhibits signs of tetany. The nurse concludes that the tetany was precipitated by
the inadequate absorption of which electrolyte?
1
Sodium
Correct2
Calcium
3
Potassium
4
Phosphorus
The muscle contraction-relaxation cycle requires an adequate serum calcium-phosphorus
ratio; the reduction of the ionized serum calcium level associated with malabsorption
syndrome causes tetany (spastic muscle spasms). Sodium is the major extracellular cation.
Sodium's major route of excretion is the kidneys, under the control of aldosterone. Although
it plays a part in neuromuscular transmission, potassium is not related to the development
of tetany. Potassium is the major intracellular cation. Potassium is part of the sodium-
potassium pump and helps to balance the response of nerves to stimulation. Potassium is
not related to the development of tetany. Although phosphorus is closely related to calcium
because they exist in a specific ratio, phosphorus is not related to the development of
tetany.
A client reports severe pain two days after surgery. After assessing the
characteristics of the pain, which initial action should the nurse take next?
,1
Encourage rest.
Correct2
Obtain the vital signs.
3
Administer the prescribed analgesic.
4
Document the client's pain response.
Immediately before administration of an analgesic, an assessment of vital signs is
necessary to determine whether any contraindications to the medication exist (e.g.,
hypotension, respirations ≤12 breaths/min). Pain prevents both psychological and
physiological rest. Before administration of an analgesic, the nurse must check the health
care provider's prescription, the time of the last administration, and the client's vital signs. A
complete assessment including vital signs should be done before documenting.
The health care provider orders 1000 mL normal saline to be infused
over 8 hours for a client with a diagnosis of dehydration. The
intravenous (IV) tubing delivers 15 drops per milliliter (drop factor).
The nurse should administer the IV infusion at a rate of ____
gtts/minute. Record your answer using a whole number.
Administering 1,000 mL over 8 hours is equal to administering 125 mL over 1 hour (60
minutes). To find the number of milliliters per minute:
125/60 min = X/1 minute
60X = 125X = 2.1 mL/minute
To find the number of drops/minute:
2.1 mL/X gtts = 1 mL/15 gtts
X = 31 gtts/minute
A health care provider prescribes simvastatin (Zocor) 20 mg daily for elevated
cholesterol and triglyceride levels for a female client. Which is most important for
the nurse to teach when the client initially takes the medication?
1
Take the medication with breakfast.
2
Have liver function tests every six months.
3
Wear sunscreen to prevent photosensitivity reactions.
Correct4
Inform the health care provider if the client wishes to become pregnant.
Simvastatin is contraindicated in pregnancy because it is capable of causing fetal damage
(teratogenic). It is a Pregnancy Category X teratogen. Simvastatin should be taken in the
, evening because most cholesterol is synthesized between 12 midnight and 3:00 AM. Liver
function tests should be done at 6 to 12 weeks initially and only then every 6 months.
Although wearing sunscreen should be taught, sensitivity reactions are a rare occurrence; it
is not as important as an action in another option.
A client who weighs 176 pounds is receiving 8 mg/kg cyclosporine
(Sandimmune) each day to prevent organ transplant rejection. How
many milligrams should the nurse administer each day? Record
your answer using a whole number. _________ mg
First compute the client's weight in kilograms and then compute the dosage. Solve the
problem using ratio and proportion.
Desired 176 pounds = x kg
Have 2.2 pounds = 1 kg
2.2 x = 176
x = 176 ÷ 2.2
x = 80 kg
Desired 80 kg X x mg
Have 1 kg 8 mg
1x = 80 X 8
x = 640 mg
A client is being treated for Influenza A (H1N1). The nurse has provided instructions
to the client about how to decrease the risk of transmission to others. Which patient
statement indicates a need for further instruction/clarification?
1
"I should practice respiratory hygiene/cough etiquette."
2
"I should avoid contact with the elderly or children."
Correct3
"I should obtain a pneumococcal vaccination each year."
4
"I should allow visitors for short periods of time only."
The client should be encouraged to receive an influenza vaccine each year. Pneumococcal
vaccines will not prevent influenza. The nurse should stress the importance of practicing
respiratory hygiene/cough etiquette. The client should avoid contact with vulnerable
populations such as the elderly and children. Visitors for clients in isolation for influenza
should be limited to persons who are necessary for the patient's emotional well-being and
care. Visitors who have been in contact with the patient before and during hospitalization
are a possible source of influenza for other patients, visitors, and staff.
Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable
under ordinary circumstances and that the action can be carried out in the given situation.
To monitor for a serious postprocedure complication, the nurse should assess for:
1
Dry mouth
Correct2
Tachycardia
3
Hypertensive crisis
4
Increased abdominal distention
Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to
hypovolemia and compensatory tachycardia. Dry mouth may occur with dehydration, but it
is not as vital or immediate as signs of shock. Dry mouth is a subjective symptom that
cannot be measured objectively. The fluid shift can cause hypovolemia with resulting
hypotension, not hypertension. A paracentesis decreases the degree of abdominal
distention.
A client admitted to the hospital with a diagnosis of malabsorption syndrome
exhibits signs of tetany. The nurse concludes that the tetany was precipitated by
the inadequate absorption of which electrolyte?
1
Sodium
Correct2
Calcium
3
Potassium
4
Phosphorus
The muscle contraction-relaxation cycle requires an adequate serum calcium-phosphorus
ratio; the reduction of the ionized serum calcium level associated with malabsorption
syndrome causes tetany (spastic muscle spasms). Sodium is the major extracellular cation.
Sodium's major route of excretion is the kidneys, under the control of aldosterone. Although
it plays a part in neuromuscular transmission, potassium is not related to the development
of tetany. Potassium is the major intracellular cation. Potassium is part of the sodium-
potassium pump and helps to balance the response of nerves to stimulation. Potassium is
not related to the development of tetany. Although phosphorus is closely related to calcium
because they exist in a specific ratio, phosphorus is not related to the development of
tetany.
A client reports severe pain two days after surgery. After assessing the
characteristics of the pain, which initial action should the nurse take next?
,1
Encourage rest.
Correct2
Obtain the vital signs.
3
Administer the prescribed analgesic.
4
Document the client's pain response.
Immediately before administration of an analgesic, an assessment of vital signs is
necessary to determine whether any contraindications to the medication exist (e.g.,
hypotension, respirations ≤12 breaths/min). Pain prevents both psychological and
physiological rest. Before administration of an analgesic, the nurse must check the health
care provider's prescription, the time of the last administration, and the client's vital signs. A
complete assessment including vital signs should be done before documenting.
The health care provider orders 1000 mL normal saline to be infused
over 8 hours for a client with a diagnosis of dehydration. The
intravenous (IV) tubing delivers 15 drops per milliliter (drop factor).
The nurse should administer the IV infusion at a rate of ____
gtts/minute. Record your answer using a whole number.
Administering 1,000 mL over 8 hours is equal to administering 125 mL over 1 hour (60
minutes). To find the number of milliliters per minute:
125/60 min = X/1 minute
60X = 125X = 2.1 mL/minute
To find the number of drops/minute:
2.1 mL/X gtts = 1 mL/15 gtts
X = 31 gtts/minute
A health care provider prescribes simvastatin (Zocor) 20 mg daily for elevated
cholesterol and triglyceride levels for a female client. Which is most important for
the nurse to teach when the client initially takes the medication?
1
Take the medication with breakfast.
2
Have liver function tests every six months.
3
Wear sunscreen to prevent photosensitivity reactions.
Correct4
Inform the health care provider if the client wishes to become pregnant.
Simvastatin is contraindicated in pregnancy because it is capable of causing fetal damage
(teratogenic). It is a Pregnancy Category X teratogen. Simvastatin should be taken in the
, evening because most cholesterol is synthesized between 12 midnight and 3:00 AM. Liver
function tests should be done at 6 to 12 weeks initially and only then every 6 months.
Although wearing sunscreen should be taught, sensitivity reactions are a rare occurrence; it
is not as important as an action in another option.
A client who weighs 176 pounds is receiving 8 mg/kg cyclosporine
(Sandimmune) each day to prevent organ transplant rejection. How
many milligrams should the nurse administer each day? Record
your answer using a whole number. _________ mg
First compute the client's weight in kilograms and then compute the dosage. Solve the
problem using ratio and proportion.
Desired 176 pounds = x kg
Have 2.2 pounds = 1 kg
2.2 x = 176
x = 176 ÷ 2.2
x = 80 kg
Desired 80 kg X x mg
Have 1 kg 8 mg
1x = 80 X 8
x = 640 mg
A client is being treated for Influenza A (H1N1). The nurse has provided instructions
to the client about how to decrease the risk of transmission to others. Which patient
statement indicates a need for further instruction/clarification?
1
"I should practice respiratory hygiene/cough etiquette."
2
"I should avoid contact with the elderly or children."
Correct3
"I should obtain a pneumococcal vaccination each year."
4
"I should allow visitors for short periods of time only."
The client should be encouraged to receive an influenza vaccine each year. Pneumococcal
vaccines will not prevent influenza. The nurse should stress the importance of practicing
respiratory hygiene/cough etiquette. The client should avoid contact with vulnerable
populations such as the elderly and children. Visitors for clients in isolation for influenza
should be limited to persons who are necessary for the patient's emotional well-being and
care. Visitors who have been in contact with the patient before and during hospitalization
are a possible source of influenza for other patients, visitors, and staff.
Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable
under ordinary circumstances and that the action can be carried out in the given situation.
