• After receiving IV fluids in the emergency department, an elderly client is
admitted to
the acute care unit with a medical diagnosis of dehydration. The client is
receiving 0.9% normal saline at 125 ml/hour via saline lock and has a
bounding pulse, tachycardia, and pedal edema. When contacting the
healthcare provider, the nurse anticipates a prescription what intervention?
A) Remove the saline lock from the client’s arm.
B) Increase the rate of the normal saline infusion.
C) Decrease the rate of the normal saline infusion.
D) Change the IV solution to 0.45% saline solution.
• A client who is admitted to the care unit with syndrome of inappropriate
antidiuretic hormone (SIADH) has developed osmotic demyelination.
Which intervention should the nurse implement first?
A) Patch one eye.
B) Evaluate swallow.
C) Reorient often.
,D) Range of motion.
• The nurse is preparing a client who had a below-the-knee (BKA)
amputation for discharge to home. Which recommendations should
the nurse provide this client? (Select all that apply) A) Wash the stump
with soap and water.
B) Avoid range of motion exercise.
C) Apply alcohol to the stump after bathing. D) Inspect
skin for redness. E) Use a residual limb shrinker.
• After 2 days treatment for dehydration, a child continues to vomit and
have diarrhea. Normal saline is infusing and the child’s urine output is
50ml/hour. During morning assessment, the nurse determines that the child
is lethargic and difficult to arouse. Which should the nurse implement?
A) Increase the IV fluid flow rate.
B) Review 24-hour intake and output.
C) Obtain arterial blood gases.
D) Perform a finger stick glucose test.
• A client with bleeding esophageal varices receives vasopressin IV. What
should the nurse monitor for during the IV infusion of this medication?
A) Vasodilatation of the extremities.
B) Chest pain and dysrhythmia.
,C) Hypotension and tachycardia.
D) Decreasing GI cramping and nausea.
, • A male client with an antisocial personality disorder is admitted to an
inpatient mental health unit for multiple substance dependency. When
providing a history, the client justifies to the nurse his use of illicit drugs.
Based on this pattern of behavior, this client’s history is most likely to
include which finding?
A) Multiple convictions for misdemeanors and Class B felonies.
B) Delusions of grandiosity and persecution.
C) Suicidal ideations and multiple attempts.
D) Photos and panic attacks when confronted by authority figures.
• An older client is admitted for repair of a broken hip. To reduce the risk
for infection postoperative period., which nursing care intervention
should the nurse include the client’s plan of care? (Select all that apply)
A) Administer low molecular weight heparin as prescribed. B) Teach
client to use incentive spirometer every 2 hours while awake. C) Remove
urinary catheter as soon as possible and encourage voiding.
D) Maintain sequential compression devices while in bed.
E) Assess pain level and medicate PRN as prescribed.
• The nurse is preparing a 50 ml dose of 50% Dextrose IV for a client
with insulin shock. How should the nurse administer the medication?
admitted to
the acute care unit with a medical diagnosis of dehydration. The client is
receiving 0.9% normal saline at 125 ml/hour via saline lock and has a
bounding pulse, tachycardia, and pedal edema. When contacting the
healthcare provider, the nurse anticipates a prescription what intervention?
A) Remove the saline lock from the client’s arm.
B) Increase the rate of the normal saline infusion.
C) Decrease the rate of the normal saline infusion.
D) Change the IV solution to 0.45% saline solution.
• A client who is admitted to the care unit with syndrome of inappropriate
antidiuretic hormone (SIADH) has developed osmotic demyelination.
Which intervention should the nurse implement first?
A) Patch one eye.
B) Evaluate swallow.
C) Reorient often.
,D) Range of motion.
• The nurse is preparing a client who had a below-the-knee (BKA)
amputation for discharge to home. Which recommendations should
the nurse provide this client? (Select all that apply) A) Wash the stump
with soap and water.
B) Avoid range of motion exercise.
C) Apply alcohol to the stump after bathing. D) Inspect
skin for redness. E) Use a residual limb shrinker.
• After 2 days treatment for dehydration, a child continues to vomit and
have diarrhea. Normal saline is infusing and the child’s urine output is
50ml/hour. During morning assessment, the nurse determines that the child
is lethargic and difficult to arouse. Which should the nurse implement?
A) Increase the IV fluid flow rate.
B) Review 24-hour intake and output.
C) Obtain arterial blood gases.
D) Perform a finger stick glucose test.
• A client with bleeding esophageal varices receives vasopressin IV. What
should the nurse monitor for during the IV infusion of this medication?
A) Vasodilatation of the extremities.
B) Chest pain and dysrhythmia.
,C) Hypotension and tachycardia.
D) Decreasing GI cramping and nausea.
, • A male client with an antisocial personality disorder is admitted to an
inpatient mental health unit for multiple substance dependency. When
providing a history, the client justifies to the nurse his use of illicit drugs.
Based on this pattern of behavior, this client’s history is most likely to
include which finding?
A) Multiple convictions for misdemeanors and Class B felonies.
B) Delusions of grandiosity and persecution.
C) Suicidal ideations and multiple attempts.
D) Photos and panic attacks when confronted by authority figures.
• An older client is admitted for repair of a broken hip. To reduce the risk
for infection postoperative period., which nursing care intervention
should the nurse include the client’s plan of care? (Select all that apply)
A) Administer low molecular weight heparin as prescribed. B) Teach
client to use incentive spirometer every 2 hours while awake. C) Remove
urinary catheter as soon as possible and encourage voiding.
D) Maintain sequential compression devices while in bed.
E) Assess pain level and medicate PRN as prescribed.
• The nurse is preparing a 50 ml dose of 50% Dextrose IV for a client
with insulin shock. How should the nurse administer the medication?
