Test Bank for Concepts for Nursing Practice, 4th Edition
(Giddens, 2024), Chapter 1-57 | All Chapters | 9780323809825
The nurse is admitting an older adult with decompensated congestive heart failure. The nursing
assessment reveals adventitious lung sounds, dyspnea, and orthopnea. Which physician order should
the nurse question?
a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
b. Furosemide (Lasix) 20 mg PO now
c. Oxygen via face mask at 8 L/min
d. KCl 20 mEq PO two times per day - ANSWER: a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
The nurse assessed four patients at the beginning of the shift. Which finding should the
nurse report immediately to the physician?
a. Swollen ankles in patient with compensated heart failure
b. Positive Chvostek sign in patient with acute pancreatitis
c. Dry mucous membranes in patient taking a new diuretic
d. Constipation in patient who has advanced breast cancer - ANSWER: b. Positive Chvostek sign in
patient with acute pancreatitis
The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it.
Which assessment finding should cause the nurse to hold the IV solution and contact the
physician?
a. Weight gain of 2 pounds since last week
b. Dry mucous membranes and skin tenting
c. Urine output 8 mL/hr
d. Blood pressure 98/58 - ANSWER: c. Urine output 8 mL/hr
At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which
patient should the nurse assess most carefully for development of hyponatremia?
a. Vomiting all day and not replacing any fluid
b. Tumor that secretes excessive antidiuretic hormone (ADH)
c. Tumor that secretes excessive aldosterone
d. Tumor that destroyed the posterior pituitary gland - ANSWER: b. Tumor that secretes excessive
antidiuretic hormone (ADH)
The patient is receiving tube feedings due to a jaw surgery. What change in assessment
findings should prompt the nurse to request an order for serum sodium concentration?
a. Development of ankle or sacral edema
b. Increased skin tenting and dry mouth
c. Postural hypotension and tachycardia
d. Decreased level of consciousness - ANSWER: d. Decreased level of consciousness
The patient with which diagnosis should have the highest priority for teaching regarding
foods that are high in magnesium?
a. Severe hemorrhage
b. Diabetes insipidus
c. Oliguric renal disease
d. Adrenal insufficiency - ANSWER: c. Oliguric renal disease
The patient's laboratory report today indicates severe hypokalemia, and the nurse has
notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the
priority nursing intervention?
a. Raise bed side rails due to potential decreased level of consciousness and
confusion.
,b. Examine sacral area and patient's heels for skin breakdown due to potential edema.
c. Establish seizure precautions due to potential muscle twitching, cramps, and
seizures.
d. Institute fall precautions due to potential postural hypotension and weak leg
muscles. - ANSWER: d. Institute fall precautions due to potential postural hypotension and weak leg
muscles.
The home health nurse is caring for a patient with a diagnosis of acute immunodeficiency
syndrome (AIDS) who has chronic diarrhea. Which assessments should the nurse use to
detect the fluid and electrolyte imbalances for which the patient has highest risk? (Select all
that apply.)
a. Bilateral ankle edema
b. Weaker leg muscles than usual
c. Postural blood pressure and heart rate
d. Positive Trousseau sign
e. Flat neck veins when upright
f. Decreased patellar reflexes - ANSWER: b. Weaker leg muscles than usual
c. Postural blood pressure and heart rate
d. Positive Trousseau sign
The patient has recent bilateral, above-the-knee amputations and has developed C. difficile
diarrhea. What assessments should the nurse use to detect ECV deficit in this patient?
(Select all that apply.)
a. Test for skin tenting.
b. Measure rate and character of pulse.
c. Measure postural blood pressure and heart rate.
d. Check Trousseau sign.
e. Observe for flatness of neck veins when upright.
f. Observe for flatness of neck veins when supine. - ANSWER: a. Test for skin tenting.
b. Measure rate and character of pulse.
f. Observe for flatness of neck veins when supine.
1. When an excess of body fluid exists in the intravascular compartment, all of the following signs can
be expected except:
1. Rales
2. A bounding pulse
3. Engorged peripheral veins
4. An elevated hematocrit level - ANSWER: 4. An elevated hematocrit level
A homeless client is brought into the emergency department with indications of extremely poor
nutrition. Arterial blood gas levels are assessed, and the nurse anticipates that this client will
demonstrate which of the following results?
1. pH 7.3, PaCO2 38 mm Hg, HCO3 19 mEq/L
2. pH 7.5, PaCO2 34 mm Hg, HCO3 20 mEq/L
3. pH 7.35, PaCO2 35 mm Hg, HCO3 24 mEq/L
4. pH 7.52, PaCO2 48 mm Hg, HCO3 28 mEq/ - ANSWER: 1. pH 7.3, PaCO2 38 mm Hg, HCO3 19 mEq/L
When a client's serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the
status of which body system?
1. Neurological
2. Gastrointestinal
3. Pulmonary
4. Hepatic - ANSWER: 1. Neurological
An 8-year-old is admitted to the pediatric unit with pneumonia. On assessment the nurse notes that
the child is warm and flushed, is lethargic, has difficulty breathing, and has moist rales. The nurse
determines that the child is suffering from:
,1. Metabolic acidosis
2. Respiratory acidosis
3. Respiratory alkalosis
4. Metabolic alkalosis - ANSWER: 2. Respiratory acidosis
Arterial blood gas levels are obtained for the client. If the client's results are pH 7.48, CO2 42 mm Hg,
and HCO3 32 mEq/L, the client is exhibiting which one of the following acid-base imbalances?
1. Metabolic acidosis
2. Respiratory acidosis
3. Respiratory alkalosis
4. Metabolic alkalosis - ANSWER: 4. Metabolic alkalosis
The nurse is aware that the compensating mechanism that is most likely to occur in the presence of
respiratory acidosis is:
1. Hyperventilation to decrease the CO2 levels
2. Hypoventilation to increase the CO2 levels
3. Retention of HCO3 by the kidneys to increase the pH level
4. Excretion of HCO3 by the kidneys to decrease the pH level - ANSWER: 3. Retention of HCO3 by the
kidneys to increase the pH level
Of all of the following clients, the nurse recognizes that the individual who is most at risk for a fluid
volume deficit is:
1. A 6-month-old learning to drink from a cup
2. A 12-year-old who is moderately active in 80° F weather
3. A 42-year-old with severe diarrhea
4. A 90-year-old with frequent headaches - ANSWER: 3. A 42-year-old with severe diarrhea
A client experiences a loss of intracellular fluid. The nurse anticipates that the intravenous (IV)
therapy that will be used to replace this type of loss is:
1. 0.45% normal saline (NS)
2. 10% dextrose
3. 5% dextrose in lactated Ringer's
4. Dextrose 5% in 1/2 NS - ANSWER: 1. 0.45% normal saline (NS)
The client has been experiencing right flank and lower back pain. Which of the following laboratory
values would be most desirable for the nurse to obtain based on the client's assessment?
1. Serum potassium
2. Serum sodium
3. Serum magnesium
4. Serum calcium - ANSWER: 4. Serum calcium
The health care provider orders 1000 mL of D5LR with 20 mEq KCl to run for 8 hours. Using an
infusion set with a drop factor of 15 gtt/mL, the nurse calculates the flow rate to be: 1. 12 gtt/min
2. 22 gtt/min
3. 32 gtt/min 41-4
4. 42 gtt/min - ANSWER: 3. 32 gtt/min 41-4
The nurse will be starting a new intravenous infusion and needs to select the site for the insertion. In
selection of a site, the nurse should: 1. Start with the most proximal site
2. Look for hard, cordlike veins
3. Use the dominant arm
4. Avoid sites on the extremity away from a dialysis graft - ANSWER: 4. Avoid sites on the extremity
away from a dialysis graft
A client has intravenous therapy for the administration of antibiotics and is stating that the "IV site
hurts and is swollen." Which of the following information assessed on the client indicates the
presence of phlebitis, as opposed to infiltration?
, 1. Intensity of the pain
2. Warmth of integument surrounding the IV site
3. Amount of subcutaneous edema
4. Skin discoloration of a bruised nature - ANSWER: 2. Warmth of integument surrounding the IV site
A client complains of a headache, nausea, and vomiting during a blood transfusion. Which one of the
following actions should the nurse take immediately?
1. Check the vital signs.
2. Stop the blood transfusion.
3. Slow down the rate of blood flow.
4. Notify the health care provider and blood bank personnel - ANSWER: 2. Stop the blood transfusion.
For a client with a nursing diagnosis of excess fluid volume, the nurse is alert to which one of the
following signs and symptoms?
1. Weak, thready pulse
2. Hypertension
3. Dry mucous membranes
4. Flushed skin - ANSWER: 2. Hypertension
A client is currently taking Lasix and digoxin. As a result of the medication regimen, the nurse is alert
to the presence of:
1. Cardiac dysrhythmias
2. Severe diarrhea
3. Hyperactive reflexes
4. Peripheral cyanosis - ANSWER: 1. Cardiac dysrhythmias
A rapid infusion of citrated blood has been given to the client. The nurse observes for:
1. Diaphoresis
2. Anxiety
3. Chvostek's sign
4. Nausea and vomiting - ANSWER: 3. Chvostek's sign
For a child who has ingested the remaining contents of an aspirin bottle, the nurse suspects signs and
symptoms consistent with:
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis - ANSWER: 4. Respiratory alkalosis
The single best indicator of fluid status is the nurse's assessment of the client's:
1. Skin turgor
2. Intake and output
3. Serum electrolyte levels
4. Daily weight - ANSWER: 4. Daily weight
An IV solution of 125 mL is to be infused over a 1-hour period. A microdrip infusion set will be used.
The nurse calculates the infusion rate as:
1. 32 gtt/min
2. 60 gtt/min
3. 125 gtt/min
4. 250 gtt/min - ANSWER: 3. 125 gtt/min
A client is admitted to the hospital with a diagnosis of adrenal insufficiency. In preparing to complete
the admission history, the nurse anticipates that the client will have experienced:
1. Decreased muscle tone
2. Hypertension
3. Diarrhea
(Giddens, 2024), Chapter 1-57 | All Chapters | 9780323809825
The nurse is admitting an older adult with decompensated congestive heart failure. The nursing
assessment reveals adventitious lung sounds, dyspnea, and orthopnea. Which physician order should
the nurse question?
a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
b. Furosemide (Lasix) 20 mg PO now
c. Oxygen via face mask at 8 L/min
d. KCl 20 mEq PO two times per day - ANSWER: a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
The nurse assessed four patients at the beginning of the shift. Which finding should the
nurse report immediately to the physician?
a. Swollen ankles in patient with compensated heart failure
b. Positive Chvostek sign in patient with acute pancreatitis
c. Dry mucous membranes in patient taking a new diuretic
d. Constipation in patient who has advanced breast cancer - ANSWER: b. Positive Chvostek sign in
patient with acute pancreatitis
The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it.
Which assessment finding should cause the nurse to hold the IV solution and contact the
physician?
a. Weight gain of 2 pounds since last week
b. Dry mucous membranes and skin tenting
c. Urine output 8 mL/hr
d. Blood pressure 98/58 - ANSWER: c. Urine output 8 mL/hr
At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which
patient should the nurse assess most carefully for development of hyponatremia?
a. Vomiting all day and not replacing any fluid
b. Tumor that secretes excessive antidiuretic hormone (ADH)
c. Tumor that secretes excessive aldosterone
d. Tumor that destroyed the posterior pituitary gland - ANSWER: b. Tumor that secretes excessive
antidiuretic hormone (ADH)
The patient is receiving tube feedings due to a jaw surgery. What change in assessment
findings should prompt the nurse to request an order for serum sodium concentration?
a. Development of ankle or sacral edema
b. Increased skin tenting and dry mouth
c. Postural hypotension and tachycardia
d. Decreased level of consciousness - ANSWER: d. Decreased level of consciousness
The patient with which diagnosis should have the highest priority for teaching regarding
foods that are high in magnesium?
a. Severe hemorrhage
b. Diabetes insipidus
c. Oliguric renal disease
d. Adrenal insufficiency - ANSWER: c. Oliguric renal disease
The patient's laboratory report today indicates severe hypokalemia, and the nurse has
notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the
priority nursing intervention?
a. Raise bed side rails due to potential decreased level of consciousness and
confusion.
,b. Examine sacral area and patient's heels for skin breakdown due to potential edema.
c. Establish seizure precautions due to potential muscle twitching, cramps, and
seizures.
d. Institute fall precautions due to potential postural hypotension and weak leg
muscles. - ANSWER: d. Institute fall precautions due to potential postural hypotension and weak leg
muscles.
The home health nurse is caring for a patient with a diagnosis of acute immunodeficiency
syndrome (AIDS) who has chronic diarrhea. Which assessments should the nurse use to
detect the fluid and electrolyte imbalances for which the patient has highest risk? (Select all
that apply.)
a. Bilateral ankle edema
b. Weaker leg muscles than usual
c. Postural blood pressure and heart rate
d. Positive Trousseau sign
e. Flat neck veins when upright
f. Decreased patellar reflexes - ANSWER: b. Weaker leg muscles than usual
c. Postural blood pressure and heart rate
d. Positive Trousseau sign
The patient has recent bilateral, above-the-knee amputations and has developed C. difficile
diarrhea. What assessments should the nurse use to detect ECV deficit in this patient?
(Select all that apply.)
a. Test for skin tenting.
b. Measure rate and character of pulse.
c. Measure postural blood pressure and heart rate.
d. Check Trousseau sign.
e. Observe for flatness of neck veins when upright.
f. Observe for flatness of neck veins when supine. - ANSWER: a. Test for skin tenting.
b. Measure rate and character of pulse.
f. Observe for flatness of neck veins when supine.
1. When an excess of body fluid exists in the intravascular compartment, all of the following signs can
be expected except:
1. Rales
2. A bounding pulse
3. Engorged peripheral veins
4. An elevated hematocrit level - ANSWER: 4. An elevated hematocrit level
A homeless client is brought into the emergency department with indications of extremely poor
nutrition. Arterial blood gas levels are assessed, and the nurse anticipates that this client will
demonstrate which of the following results?
1. pH 7.3, PaCO2 38 mm Hg, HCO3 19 mEq/L
2. pH 7.5, PaCO2 34 mm Hg, HCO3 20 mEq/L
3. pH 7.35, PaCO2 35 mm Hg, HCO3 24 mEq/L
4. pH 7.52, PaCO2 48 mm Hg, HCO3 28 mEq/ - ANSWER: 1. pH 7.3, PaCO2 38 mm Hg, HCO3 19 mEq/L
When a client's serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the
status of which body system?
1. Neurological
2. Gastrointestinal
3. Pulmonary
4. Hepatic - ANSWER: 1. Neurological
An 8-year-old is admitted to the pediatric unit with pneumonia. On assessment the nurse notes that
the child is warm and flushed, is lethargic, has difficulty breathing, and has moist rales. The nurse
determines that the child is suffering from:
,1. Metabolic acidosis
2. Respiratory acidosis
3. Respiratory alkalosis
4. Metabolic alkalosis - ANSWER: 2. Respiratory acidosis
Arterial blood gas levels are obtained for the client. If the client's results are pH 7.48, CO2 42 mm Hg,
and HCO3 32 mEq/L, the client is exhibiting which one of the following acid-base imbalances?
1. Metabolic acidosis
2. Respiratory acidosis
3. Respiratory alkalosis
4. Metabolic alkalosis - ANSWER: 4. Metabolic alkalosis
The nurse is aware that the compensating mechanism that is most likely to occur in the presence of
respiratory acidosis is:
1. Hyperventilation to decrease the CO2 levels
2. Hypoventilation to increase the CO2 levels
3. Retention of HCO3 by the kidneys to increase the pH level
4. Excretion of HCO3 by the kidneys to decrease the pH level - ANSWER: 3. Retention of HCO3 by the
kidneys to increase the pH level
Of all of the following clients, the nurse recognizes that the individual who is most at risk for a fluid
volume deficit is:
1. A 6-month-old learning to drink from a cup
2. A 12-year-old who is moderately active in 80° F weather
3. A 42-year-old with severe diarrhea
4. A 90-year-old with frequent headaches - ANSWER: 3. A 42-year-old with severe diarrhea
A client experiences a loss of intracellular fluid. The nurse anticipates that the intravenous (IV)
therapy that will be used to replace this type of loss is:
1. 0.45% normal saline (NS)
2. 10% dextrose
3. 5% dextrose in lactated Ringer's
4. Dextrose 5% in 1/2 NS - ANSWER: 1. 0.45% normal saline (NS)
The client has been experiencing right flank and lower back pain. Which of the following laboratory
values would be most desirable for the nurse to obtain based on the client's assessment?
1. Serum potassium
2. Serum sodium
3. Serum magnesium
4. Serum calcium - ANSWER: 4. Serum calcium
The health care provider orders 1000 mL of D5LR with 20 mEq KCl to run for 8 hours. Using an
infusion set with a drop factor of 15 gtt/mL, the nurse calculates the flow rate to be: 1. 12 gtt/min
2. 22 gtt/min
3. 32 gtt/min 41-4
4. 42 gtt/min - ANSWER: 3. 32 gtt/min 41-4
The nurse will be starting a new intravenous infusion and needs to select the site for the insertion. In
selection of a site, the nurse should: 1. Start with the most proximal site
2. Look for hard, cordlike veins
3. Use the dominant arm
4. Avoid sites on the extremity away from a dialysis graft - ANSWER: 4. Avoid sites on the extremity
away from a dialysis graft
A client has intravenous therapy for the administration of antibiotics and is stating that the "IV site
hurts and is swollen." Which of the following information assessed on the client indicates the
presence of phlebitis, as opposed to infiltration?
, 1. Intensity of the pain
2. Warmth of integument surrounding the IV site
3. Amount of subcutaneous edema
4. Skin discoloration of a bruised nature - ANSWER: 2. Warmth of integument surrounding the IV site
A client complains of a headache, nausea, and vomiting during a blood transfusion. Which one of the
following actions should the nurse take immediately?
1. Check the vital signs.
2. Stop the blood transfusion.
3. Slow down the rate of blood flow.
4. Notify the health care provider and blood bank personnel - ANSWER: 2. Stop the blood transfusion.
For a client with a nursing diagnosis of excess fluid volume, the nurse is alert to which one of the
following signs and symptoms?
1. Weak, thready pulse
2. Hypertension
3. Dry mucous membranes
4. Flushed skin - ANSWER: 2. Hypertension
A client is currently taking Lasix and digoxin. As a result of the medication regimen, the nurse is alert
to the presence of:
1. Cardiac dysrhythmias
2. Severe diarrhea
3. Hyperactive reflexes
4. Peripheral cyanosis - ANSWER: 1. Cardiac dysrhythmias
A rapid infusion of citrated blood has been given to the client. The nurse observes for:
1. Diaphoresis
2. Anxiety
3. Chvostek's sign
4. Nausea and vomiting - ANSWER: 3. Chvostek's sign
For a child who has ingested the remaining contents of an aspirin bottle, the nurse suspects signs and
symptoms consistent with:
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis - ANSWER: 4. Respiratory alkalosis
The single best indicator of fluid status is the nurse's assessment of the client's:
1. Skin turgor
2. Intake and output
3. Serum electrolyte levels
4. Daily weight - ANSWER: 4. Daily weight
An IV solution of 125 mL is to be infused over a 1-hour period. A microdrip infusion set will be used.
The nurse calculates the infusion rate as:
1. 32 gtt/min
2. 60 gtt/min
3. 125 gtt/min
4. 250 gtt/min - ANSWER: 3. 125 gtt/min
A client is admitted to the hospital with a diagnosis of adrenal insufficiency. In preparing to complete
the admission history, the nurse anticipates that the client will have experienced:
1. Decreased muscle tone
2. Hypertension
3. Diarrhea
