MED SURG chapters 13,14 and 15 nclex f&e
practice Exam
The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse is most
appropriate?
a. Notify the physician.
b. Examine dependent body areas.
c. Assess turgor on the client's forehead.
d. Document the finding and continue to monitor.
C
The client is taking a medication that inhibits aldosterone secretion and release. The nurse assesses for what
potential complication?
a. Fluid retention
b. Hyperkalemia
c. Hyponatremia
d. Hypervolemia
B
Which assessment does the nurse use to determine the adequacy of circulation in a client whose blood osmolarity is
250 mOsm/L?
a. Measuring urine output
b. Measuring abdominal girth
c. Monitoring fluid intake
d. Comparing radial versus apical pulses
A
Which statement made by the older adult client alerts the nurse to assess specifically for fluid and electrolyte
imbalances?
a. "My skin is always so dry, especially here in the Southwest."
b. "I often use a glycerin suppository for constipation."
c. "I don't drink liquids after 5 PM so I don't have to get up at night."
d. "In addition to coffee, I drink at least one glass of water with each meal."
C
A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that
teaching has been effective?
,a. Chinese take-out, including steamed rice
b. A grilled cheese sandwich with tomato soup
c. Slices of ham and cheese on whole grain crackers
d. A chicken leg, one slice of bread with butter, and steamed carrots
D
A client is on a potassium-restricted diet. Which protein choice by the client indicates a good understanding of the
dietary regimen?
a. 1% or 2% milk
b. Grilled salmon
c. Poached eggs
d. Baked chicken
C
Which assessment finding obtained while taking the history of an older adult client alerts the nurse that the client
needs further assessment for fluid or electrolyte imbalance?
a. "I am often cold and need to wear a sweater."
b. "I seem to urinate more when I drink coffee."
c. "In the summer, I feel thirsty more often."
d. "My rings seem to be tighter this week."
D
Which client is at greatest risk for dehydration?
a. Younger adult client on bedrest
b. Older adult client receiving hypotonic IV fluid
c. Younger adult client receiving hypertonic IV fluid
d. Older adult client with cognitive impairment
D
Which question does the nurse ask the client who has isotonic dehydration to determine a possible cause?
a. "Do you take diuretics, or 'water pills'?"
b. "What do you normally eat over a day's time?"
c. "How many bowel movements do you have daily?"
d. "Have you been diagnosed with diabetes mellitus?"
A
Which intervention in a client with dehydration-induced confusion is most likely to relieve the confusion?
a. Measuring intake and output every four hours
b. Applying oxygen by mask or nasal cannula
c. Increasing the IV flow rate to 250 mL/hr
d. Placing the client in a high Fowler's position
B
, A client is being treated for dehydration. Which statement made by the client indicates understanding of this
condition?
a. "I must drink a quart of water or other liquid each day."
b. "I will weigh myself each morning before I eat or drink."
c. "I will use a salt substitute when making and eating my meals."
d. "I will not drink liquids after 6 PM so I won't have to get up at night."
B
What intervention is most important to teach the client about identifying the onset of dehydration?
a. Measuring abdominal girth
b. Converting ounces to milliliters
c. Obtaining and charting daily weight
d. Selecting food items with high water content
C
A nurse is caring for several clients with dehydration. The nurse assesses the client with which finding as needing
oxygen therapy?
a. Tenting of skin on the back of the hand
b. Increased urine osmolarity
c. Weight loss of 10 pounds
d. Pulse rate of 115 beats/min
D
Which action does the nurse teach a client to reduce the risk for dehydration?
a. Restricting sodium intake to no greater than 4 g/day
b. Maintaining an oral intake of at least 1500 mL/day
c. Maintaining a daily oral intake approximately equal to daily fluid loss
d. Avoiding the use of glycerin suppositories to manage constipation
C
Which item of assessment data obtained by the home care nurse suggests that an older adult client may be
dehydrated?
a. The client has dry, scaly skin on bilateral upper and lower extremities.
b. The client states that he gets up three or more times during the night to urinate.
c. The client states that he feels lightheaded when he gets out of bed or stands up.
d. The nurse observes tenting on the back of the hand when testing skin turgor.
C
A client is being discharged with mild dehydration. Which statement by the client indicates an understanding of
measures to prevent mild dehydration from becoming more severe?
a. "I will weigh myself at the same time daily wearing the same clothes."
b. "When I feel lightheaded, I will drink a full glass of water."
practice Exam
The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse is most
appropriate?
a. Notify the physician.
b. Examine dependent body areas.
c. Assess turgor on the client's forehead.
d. Document the finding and continue to monitor.
C
The client is taking a medication that inhibits aldosterone secretion and release. The nurse assesses for what
potential complication?
a. Fluid retention
b. Hyperkalemia
c. Hyponatremia
d. Hypervolemia
B
Which assessment does the nurse use to determine the adequacy of circulation in a client whose blood osmolarity is
250 mOsm/L?
a. Measuring urine output
b. Measuring abdominal girth
c. Monitoring fluid intake
d. Comparing radial versus apical pulses
A
Which statement made by the older adult client alerts the nurse to assess specifically for fluid and electrolyte
imbalances?
a. "My skin is always so dry, especially here in the Southwest."
b. "I often use a glycerin suppository for constipation."
c. "I don't drink liquids after 5 PM so I don't have to get up at night."
d. "In addition to coffee, I drink at least one glass of water with each meal."
C
A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that
teaching has been effective?
,a. Chinese take-out, including steamed rice
b. A grilled cheese sandwich with tomato soup
c. Slices of ham and cheese on whole grain crackers
d. A chicken leg, one slice of bread with butter, and steamed carrots
D
A client is on a potassium-restricted diet. Which protein choice by the client indicates a good understanding of the
dietary regimen?
a. 1% or 2% milk
b. Grilled salmon
c. Poached eggs
d. Baked chicken
C
Which assessment finding obtained while taking the history of an older adult client alerts the nurse that the client
needs further assessment for fluid or electrolyte imbalance?
a. "I am often cold and need to wear a sweater."
b. "I seem to urinate more when I drink coffee."
c. "In the summer, I feel thirsty more often."
d. "My rings seem to be tighter this week."
D
Which client is at greatest risk for dehydration?
a. Younger adult client on bedrest
b. Older adult client receiving hypotonic IV fluid
c. Younger adult client receiving hypertonic IV fluid
d. Older adult client with cognitive impairment
D
Which question does the nurse ask the client who has isotonic dehydration to determine a possible cause?
a. "Do you take diuretics, or 'water pills'?"
b. "What do you normally eat over a day's time?"
c. "How many bowel movements do you have daily?"
d. "Have you been diagnosed with diabetes mellitus?"
A
Which intervention in a client with dehydration-induced confusion is most likely to relieve the confusion?
a. Measuring intake and output every four hours
b. Applying oxygen by mask or nasal cannula
c. Increasing the IV flow rate to 250 mL/hr
d. Placing the client in a high Fowler's position
B
, A client is being treated for dehydration. Which statement made by the client indicates understanding of this
condition?
a. "I must drink a quart of water or other liquid each day."
b. "I will weigh myself each morning before I eat or drink."
c. "I will use a salt substitute when making and eating my meals."
d. "I will not drink liquids after 6 PM so I won't have to get up at night."
B
What intervention is most important to teach the client about identifying the onset of dehydration?
a. Measuring abdominal girth
b. Converting ounces to milliliters
c. Obtaining and charting daily weight
d. Selecting food items with high water content
C
A nurse is caring for several clients with dehydration. The nurse assesses the client with which finding as needing
oxygen therapy?
a. Tenting of skin on the back of the hand
b. Increased urine osmolarity
c. Weight loss of 10 pounds
d. Pulse rate of 115 beats/min
D
Which action does the nurse teach a client to reduce the risk for dehydration?
a. Restricting sodium intake to no greater than 4 g/day
b. Maintaining an oral intake of at least 1500 mL/day
c. Maintaining a daily oral intake approximately equal to daily fluid loss
d. Avoiding the use of glycerin suppositories to manage constipation
C
Which item of assessment data obtained by the home care nurse suggests that an older adult client may be
dehydrated?
a. The client has dry, scaly skin on bilateral upper and lower extremities.
b. The client states that he gets up three or more times during the night to urinate.
c. The client states that he feels lightheaded when he gets out of bed or stands up.
d. The nurse observes tenting on the back of the hand when testing skin turgor.
C
A client is being discharged with mild dehydration. Which statement by the client indicates an understanding of
measures to prevent mild dehydration from becoming more severe?
a. "I will weigh myself at the same time daily wearing the same clothes."
b. "When I feel lightheaded, I will drink a full glass of water."
