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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
c. Bilateral muscle weakness
d. Thread pulse
Ans>> b. Distended neck veins
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
c. Decreased vomiting
d. Cardiac arrhythmias absent
Ans>> b. Improved cognition
,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 in-
clude?
a. "Discontinue the patch if you experience a headache."
b. "Apply a new patch if you have chest pain."
c. "Cover the patch with dry gauze when taking a shower."
d. "Remove the patch prior to going to bed."
Ans>> d. "Remove the patch prior to going to bed."
4. 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 follow-
ing should the nurse report to the provider?
a. Creatinine 0.72 mg/dL
b. Sodium 138 mEq/L
c. Magnesium 2 mEq/L
d. Potassium 5.2 mEq/L
Ans>> d. Potassium 5.2 mEq/L - Hyperkalemia (serum potassi- um level greater
than 5.0 mEq/L) increases the client risk for fatal cardiac dysrhyth- mias.
Kayexalate is used to decrease the serum potassium level so the PN should
monitor the client's serum potassium level
5. 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
b. The client tests negative for HIV
c. The client has a positive purified protein derivative test