NURS 3000 2024 UPDATE COMPREHENSIVE QUESTIONS
AND VERIFIED ANSWERS (100% CORRECT) APPROVED
FOR SUCCESS GRADE A+
The nurse is caring for a client who is taking a potassium-wasting diuretic for
treatment of hypertension. Which of the following assessment data would the
nurse include in the teaching plan?
a. Personality changes
b. Frequent loose stools
c. Facial muscle spasms
d. Lower extremity weakness
ANS: D
Lower extremity weakness progressing to flaccidity is a manifestation of hypokalemia.
Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with
hyperkalemia. Personality changes are not associated with electrolyte disturbances,
although changes in mental status are common manifestations with sodium excess or
deficit.
The nurse is teaching a client about spironolactone as a diuretic. Which
statement by the client indicates that the teaching about this medication has been
effective?
a. "I will try to drink at least 8 glasses of water every day."
b. "I will use a salt substitute to decrease my sodium intake."
c. "I will increase my intake of potassium-containing foods."
d. "I will drink apple juice instead of orange juice for breakfast."
ANS: D
The nurse is caring for a client with deficient fluid volume caused by a massive
burn injury. Which of the following assessment data will be of greatest concern to
the nurse?
a. The blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL over the last hour.
c. Oral fluid intake is 100 mL for the last 8 hours.
d. There is prolonged skin tenting over the sternum.
ANS: A
The blood pressure indicates that the client may be developing hypovolemic shock as a
result of fluid loss. This will require immediate intervention to prevent the complications
associated with systemic hypoperfusion. The poor oral intake, decreased urine output,
and skin tenting all indicate the need for increasing the client's fluid intake but not as
urgently as the hypotension.
The nurse is caring for a client recently admitted with small cell carcinoma of the
lung and the syndrome of inappropriate antidiuretic hormone (SIADH). Which of
the following assessments should the nurse carefully monitor?
a. Increased total urinary output
,b. Elevation of serum hematocrit
c. Decreased serum sodium level
d. Rapid and unexpected weight loss
ANS: C
SIADH causes water retention and hyponatremia—a decrease in serum sodium level.
Weight loss, increased urine output, and elevated serum hematocrit may be associated
with excessive loss of water, but not with SIADH and water retention.
The nurse is evaluating the fluid balance for a client admitted for hypovolemia
associated with multiple draining wounds. Which of the following assessments is
the most accurate to evaluate volume status in this client?
a. Skin turgor
b. Daily weight
c. Presence of edema
d. Hourly urine output
ANS: B
Daily weight is the most easily obtained and accurate means of assessing volume
status. Skin turgor varies considerably with age. Considerable excess fluid volume may
be present before fluid moves into the interstitial space and causes edema. Hourly urine
outputs do not take account of fluid intake or of fluid loss through insensible loss,
sweating, or loss from the gastrointestinal tract or wounds
The nurse is caring for an alert and oriented older-adult client with a history of
dehydration. Which of the following information should the home health nurse
teach the client as to when to increase fluid intake?
a. In the late evening hours
b. If the oral mucosa feels dry
c. When the client feels thirsty
d. As soon as changes in level of consciousness (LOC) occur
ANS: B
An alert, elderly client will be able to self-assess for signs of oral dryness such as thick
oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and
is not an accurate indicator of volume depletion. Many older clients prefer to restrict
fluids slightly in the evening to improve sleep quality. The client will not be likely to
notice and act appropriately when changes in LOC occur.
Since spironolactone is a potassium-sparing diuretic, clients should be taught to choose
low potassium foods such as apple juice rather than foods that have higher levels of
potassium, such as citrus fruits. Because the client is using spironolactone as a diuretic,
the nurse would not encourage the client to increase fluid intake. Teach clients to avoid
salt substitutes, which are high in potassium.
The nurse is caring for a client admitted with hyponatremia. Which of the
following actions should the nurse anticipate implementing?
a. Restrict client's oral free water intake.
b. Avoid use of electrolyte-containing drinks.
,c. Infuse a solution of 5% dextrose in 0.45% saline.
d. Administer vasopressin (antidiuretic hormone, ADH).
ANS: A
To help improve serum sodium levels, water intake is restricted. Electrolyte-containing
beverages will improve the client's sodium level. Administration of vasopressin or
hypotonic IV solutions will decrease the serum sodium level further.
The nurse is caring for a client with severe hypokalemia and is preparing to
administer intravenous potassium chloride (KCl) 40 mmol as prescribed by the
health care provider. Which of the following actions should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 20 mEq/hour.
c. Give the KCl only through a central venous line.
d. Add no more than 40 mEq/L to a litre of IV fluid.
ANS: B
Intravenous KCl is administered at a maximal rate of 20 mEq/hour. Rapid IV infusion of
KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more
than 40 mmol, concentrations up to 60 mmol may be used for some clients. KCl can
cause inflammation of peripheral veins, but it can be administered by this route.
The nurse is caring for a client who has required prolonged mechanical
ventilation and has the following arterial blood gas results: pH 7.48, PaO2 85 mm
Hg, PaCO2 32 mm Hg, and HCO3 25 mmol/L. Which of the following
interpretations would the nurse document?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
ANS: D
The pH indicates that the client has alkalosis and the low PaCO2 indicates a respiratory
cause. The other responses are incorrect based on the pH and the normal HCO3.
The nurse is caring for a client who was admitted with diabetic ketoacidosis and
has rapid, deep respirations. Which of the following actions should the nurse
implement?
a. Notify the client's health care provider.
b. Give the prescribed PRN lorazepam.
c. Start the prescribed PRN oxygen at 2-4 L/min.
d. Encourage the client to take deep, slow breaths.
ANS: A
The rapid, deep (Kussmaul's) respirations indicate a metabolic acidosis and the need
for actions such as administration of sodium bicarbonate, which will require a
prescription by the health care provider. Oxygen therapy is not indicated because there
is no indication that the increased respiratory rate is related to hypoxemia. The
respiratory pattern is compensatory, and the client will not be able to slow the
, respiratory rate. Lorazepam administration will slow the respiratory rate and increase
the level of acidosis.
The home health nurse is visiting an older-adult client who has a low serum
protein level. Which of the following assessment areas should the nurse assess?
a. Pallor
b. Edema
c. Confusion
d. Restlessness
ANS: B
Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid
to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are
not associated with low serum protein levels.
The nurse is caring for a client who is receiving 3% NaCl solution for correction
of hyponatremia. During administration of the solution, which of the following
assessments is a priority for the nurse to monitor?
a. Lung sounds
b. Urinary output
c. Peripheral pulses
d. Peripheral edema
ANS: A
Hypertonic solutions cause water retention, so the client should be monitored for
symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary
edema and are the most serious of the symptoms of fluid excess listed. Bounding
peripheral pulses, peripheral edema, or changes in urine output also are important to
monitor when administering hypertonic solutions, but they do not indicate acute
respiratory or cardiac decompensation.
The nurse is caring for a client who has a low serum total protein level and is
taking protein supplements. Which of the following data indicate that the client's
condition has improved?
a. Hematocrit 28%
b. Good skin turgor
c. Absence of peripheral edema
d. Blood pressure 110/72 mm Hg
ANS: C
Edema is caused by low oncotic pressure in individuals with low serum protein levels;
the absence of edema indicates an improvement in the client's protein status. Good skin
turgor is an indicator of fluid balance, not protein status. A low hematocrit could be
caused by poor protein intake. Blood pressure does not provide a useful clinical tool for
monitoring protein status.
The nurse is caring for a client who has the following arterial blood gas (ABG)
results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mmol/L. Which
of the following interpretations would the nurse document?
a. Metabolic acidosis
AND VERIFIED ANSWERS (100% CORRECT) APPROVED
FOR SUCCESS GRADE A+
The nurse is caring for a client who is taking a potassium-wasting diuretic for
treatment of hypertension. Which of the following assessment data would the
nurse include in the teaching plan?
a. Personality changes
b. Frequent loose stools
c. Facial muscle spasms
d. Lower extremity weakness
ANS: D
Lower extremity weakness progressing to flaccidity is a manifestation of hypokalemia.
Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with
hyperkalemia. Personality changes are not associated with electrolyte disturbances,
although changes in mental status are common manifestations with sodium excess or
deficit.
The nurse is teaching a client about spironolactone as a diuretic. Which
statement by the client indicates that the teaching about this medication has been
effective?
a. "I will try to drink at least 8 glasses of water every day."
b. "I will use a salt substitute to decrease my sodium intake."
c. "I will increase my intake of potassium-containing foods."
d. "I will drink apple juice instead of orange juice for breakfast."
ANS: D
The nurse is caring for a client with deficient fluid volume caused by a massive
burn injury. Which of the following assessment data will be of greatest concern to
the nurse?
a. The blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL over the last hour.
c. Oral fluid intake is 100 mL for the last 8 hours.
d. There is prolonged skin tenting over the sternum.
ANS: A
The blood pressure indicates that the client may be developing hypovolemic shock as a
result of fluid loss. This will require immediate intervention to prevent the complications
associated with systemic hypoperfusion. The poor oral intake, decreased urine output,
and skin tenting all indicate the need for increasing the client's fluid intake but not as
urgently as the hypotension.
The nurse is caring for a client recently admitted with small cell carcinoma of the
lung and the syndrome of inappropriate antidiuretic hormone (SIADH). Which of
the following assessments should the nurse carefully monitor?
a. Increased total urinary output
,b. Elevation of serum hematocrit
c. Decreased serum sodium level
d. Rapid and unexpected weight loss
ANS: C
SIADH causes water retention and hyponatremia—a decrease in serum sodium level.
Weight loss, increased urine output, and elevated serum hematocrit may be associated
with excessive loss of water, but not with SIADH and water retention.
The nurse is evaluating the fluid balance for a client admitted for hypovolemia
associated with multiple draining wounds. Which of the following assessments is
the most accurate to evaluate volume status in this client?
a. Skin turgor
b. Daily weight
c. Presence of edema
d. Hourly urine output
ANS: B
Daily weight is the most easily obtained and accurate means of assessing volume
status. Skin turgor varies considerably with age. Considerable excess fluid volume may
be present before fluid moves into the interstitial space and causes edema. Hourly urine
outputs do not take account of fluid intake or of fluid loss through insensible loss,
sweating, or loss from the gastrointestinal tract or wounds
The nurse is caring for an alert and oriented older-adult client with a history of
dehydration. Which of the following information should the home health nurse
teach the client as to when to increase fluid intake?
a. In the late evening hours
b. If the oral mucosa feels dry
c. When the client feels thirsty
d. As soon as changes in level of consciousness (LOC) occur
ANS: B
An alert, elderly client will be able to self-assess for signs of oral dryness such as thick
oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and
is not an accurate indicator of volume depletion. Many older clients prefer to restrict
fluids slightly in the evening to improve sleep quality. The client will not be likely to
notice and act appropriately when changes in LOC occur.
Since spironolactone is a potassium-sparing diuretic, clients should be taught to choose
low potassium foods such as apple juice rather than foods that have higher levels of
potassium, such as citrus fruits. Because the client is using spironolactone as a diuretic,
the nurse would not encourage the client to increase fluid intake. Teach clients to avoid
salt substitutes, which are high in potassium.
The nurse is caring for a client admitted with hyponatremia. Which of the
following actions should the nurse anticipate implementing?
a. Restrict client's oral free water intake.
b. Avoid use of electrolyte-containing drinks.
,c. Infuse a solution of 5% dextrose in 0.45% saline.
d. Administer vasopressin (antidiuretic hormone, ADH).
ANS: A
To help improve serum sodium levels, water intake is restricted. Electrolyte-containing
beverages will improve the client's sodium level. Administration of vasopressin or
hypotonic IV solutions will decrease the serum sodium level further.
The nurse is caring for a client with severe hypokalemia and is preparing to
administer intravenous potassium chloride (KCl) 40 mmol as prescribed by the
health care provider. Which of the following actions should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 20 mEq/hour.
c. Give the KCl only through a central venous line.
d. Add no more than 40 mEq/L to a litre of IV fluid.
ANS: B
Intravenous KCl is administered at a maximal rate of 20 mEq/hour. Rapid IV infusion of
KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more
than 40 mmol, concentrations up to 60 mmol may be used for some clients. KCl can
cause inflammation of peripheral veins, but it can be administered by this route.
The nurse is caring for a client who has required prolonged mechanical
ventilation and has the following arterial blood gas results: pH 7.48, PaO2 85 mm
Hg, PaCO2 32 mm Hg, and HCO3 25 mmol/L. Which of the following
interpretations would the nurse document?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
ANS: D
The pH indicates that the client has alkalosis and the low PaCO2 indicates a respiratory
cause. The other responses are incorrect based on the pH and the normal HCO3.
The nurse is caring for a client who was admitted with diabetic ketoacidosis and
has rapid, deep respirations. Which of the following actions should the nurse
implement?
a. Notify the client's health care provider.
b. Give the prescribed PRN lorazepam.
c. Start the prescribed PRN oxygen at 2-4 L/min.
d. Encourage the client to take deep, slow breaths.
ANS: A
The rapid, deep (Kussmaul's) respirations indicate a metabolic acidosis and the need
for actions such as administration of sodium bicarbonate, which will require a
prescription by the health care provider. Oxygen therapy is not indicated because there
is no indication that the increased respiratory rate is related to hypoxemia. The
respiratory pattern is compensatory, and the client will not be able to slow the
, respiratory rate. Lorazepam administration will slow the respiratory rate and increase
the level of acidosis.
The home health nurse is visiting an older-adult client who has a low serum
protein level. Which of the following assessment areas should the nurse assess?
a. Pallor
b. Edema
c. Confusion
d. Restlessness
ANS: B
Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid
to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are
not associated with low serum protein levels.
The nurse is caring for a client who is receiving 3% NaCl solution for correction
of hyponatremia. During administration of the solution, which of the following
assessments is a priority for the nurse to monitor?
a. Lung sounds
b. Urinary output
c. Peripheral pulses
d. Peripheral edema
ANS: A
Hypertonic solutions cause water retention, so the client should be monitored for
symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary
edema and are the most serious of the symptoms of fluid excess listed. Bounding
peripheral pulses, peripheral edema, or changes in urine output also are important to
monitor when administering hypertonic solutions, but they do not indicate acute
respiratory or cardiac decompensation.
The nurse is caring for a client who has a low serum total protein level and is
taking protein supplements. Which of the following data indicate that the client's
condition has improved?
a. Hematocrit 28%
b. Good skin turgor
c. Absence of peripheral edema
d. Blood pressure 110/72 mm Hg
ANS: C
Edema is caused by low oncotic pressure in individuals with low serum protein levels;
the absence of edema indicates an improvement in the client's protein status. Good skin
turgor is an indicator of fluid balance, not protein status. A low hematocrit could be
caused by poor protein intake. Blood pressure does not provide a useful clinical tool for
monitoring protein status.
The nurse is caring for a client who has the following arterial blood gas (ABG)
results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mmol/L. Which
of the following interpretations would the nurse document?
a. Metabolic acidosis
