UNIT 1 Complex
Elimination Disorders
1. A client is being monitored for daily weights. The night nurse asks the nursing assistant for
the morning weight, and the assistant replies, “She was sleeping so well, I didn’t want to
wake her to get her weight.” How does the nurse respond?
A. “Fast thinking! She really needs to rest after the night she had.”
B. “Get the information now, or I’ll report you for not doing your job.”
C. “Never mind—I will do it myself.”
D. “Weigh her now. We need her weight daily, at the same time.”
2. A client develops fluid overload while in the intensive care unit. Which nursing
intervention does the nurse perform first?
A. Draws blood for laboratory
tests B. Elevates the head of the
bed
C. Places the extremities in a dependent position
D. Puts the client in a side-lying position
3. Which newly written prescription does the nurse administer first?
A. Intravenous normal saline to a client with a serum sodium of 132 mEq/L
B. Oral calcium supplements to a client with severe osteoporosis
C. Oral phosphorus supplements to a client with acute
hypophosphatemia D. Oral potassium chloride to a client whose serum
potassium is 3 mEq/L
4. The health care provider writes orders for a client who is admitted with a serum
potassium level of 6.9 mEq/L. What does the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate) orally.
,B. Ensure that a potassium-restricted diet is ordered.
, C. Place the client on a cardiac monitor.
D. Teach the client about foods that are high in potassium.
5. After receiving change-of-shift report, which client does the RN assess first?
A. A 26-year-old with nausea and vomiting who complains of dizziness when standing
B. A 36-year-old with a nasogastric (NG) tube who has dry oral mucosa and is complaining
of thirst
C. A 46-year-old receiving intravenous (IV) diuretics whose blood pressure is 95/52 mm Hg
D. A 56-year-old with normal saline infusing at 150 mL/hr whose hourly urine output has
been averaging 75 mL
6. A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial
fibrillation, congestive heart failure, and hypertension. His current medications are digoxin
(Lanoxin), chlorothiazide (Diuril), and potassium supplements. He tells a nurse that he has had
flulike symptoms for the past week and has been unable to drink for the past 48 hours. The
nurse starts the client’s IV and receives laboratory results, which include a potassium level of
2.7 mEq/L. The physician orders an IV potassium supplement. How does the nurse administer
this medication?
A. Added to an IV, not to exceed 20 mEq/hr
B. Added to an IV, not to exceed 30 mEq/hr
C. Rapid IV push, a 25-mEq dose
D. Slow IV push, a 30-mEq dose
7. A new nurse graduate is caring for a postoperative client with the following arterial blood
gas values: pH, 7.30; PaCO2, 60 mm Hg; PaO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2
saturation, 96%. Which of these actions by the new graduate is indicated?
A. Encourage the client to use the incentive spirometer and cough.
B. Administer oxygen by nasal cannula.
C. Request a prescription for sodium bicarbonate from the health care provider.
D. Inform the charge nurse that no changes in therapy are needed.
Elimination Disorders
1. A client is being monitored for daily weights. The night nurse asks the nursing assistant for
the morning weight, and the assistant replies, “She was sleeping so well, I didn’t want to
wake her to get her weight.” How does the nurse respond?
A. “Fast thinking! She really needs to rest after the night she had.”
B. “Get the information now, or I’ll report you for not doing your job.”
C. “Never mind—I will do it myself.”
D. “Weigh her now. We need her weight daily, at the same time.”
2. A client develops fluid overload while in the intensive care unit. Which nursing
intervention does the nurse perform first?
A. Draws blood for laboratory
tests B. Elevates the head of the
bed
C. Places the extremities in a dependent position
D. Puts the client in a side-lying position
3. Which newly written prescription does the nurse administer first?
A. Intravenous normal saline to a client with a serum sodium of 132 mEq/L
B. Oral calcium supplements to a client with severe osteoporosis
C. Oral phosphorus supplements to a client with acute
hypophosphatemia D. Oral potassium chloride to a client whose serum
potassium is 3 mEq/L
4. The health care provider writes orders for a client who is admitted with a serum
potassium level of 6.9 mEq/L. What does the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate) orally.
,B. Ensure that a potassium-restricted diet is ordered.
, C. Place the client on a cardiac monitor.
D. Teach the client about foods that are high in potassium.
5. After receiving change-of-shift report, which client does the RN assess first?
A. A 26-year-old with nausea and vomiting who complains of dizziness when standing
B. A 36-year-old with a nasogastric (NG) tube who has dry oral mucosa and is complaining
of thirst
C. A 46-year-old receiving intravenous (IV) diuretics whose blood pressure is 95/52 mm Hg
D. A 56-year-old with normal saline infusing at 150 mL/hr whose hourly urine output has
been averaging 75 mL
6. A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial
fibrillation, congestive heart failure, and hypertension. His current medications are digoxin
(Lanoxin), chlorothiazide (Diuril), and potassium supplements. He tells a nurse that he has had
flulike symptoms for the past week and has been unable to drink for the past 48 hours. The
nurse starts the client’s IV and receives laboratory results, which include a potassium level of
2.7 mEq/L. The physician orders an IV potassium supplement. How does the nurse administer
this medication?
A. Added to an IV, not to exceed 20 mEq/hr
B. Added to an IV, not to exceed 30 mEq/hr
C. Rapid IV push, a 25-mEq dose
D. Slow IV push, a 30-mEq dose
7. A new nurse graduate is caring for a postoperative client with the following arterial blood
gas values: pH, 7.30; PaCO2, 60 mm Hg; PaO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2
saturation, 96%. Which of these actions by the new graduate is indicated?
A. Encourage the client to use the incentive spirometer and cough.
B. Administer oxygen by nasal cannula.
C. Request a prescription for sodium bicarbonate from the health care provider.
D. Inform the charge nurse that no changes in therapy are needed.
