Adult Care Exam 2 – Questions & Accurate A+ Answers
Symptoms of excess fluid volume Right Ans - - dyspnea
- crackles audible on auscultation
- increase in BP / respirations
*may be present in someone w/ heart failure
The nurse is preparing to care for a client with a potassium deficit. The nurse
reviews the client's record and determines that the client is at risk for
developing the potassium deficit because of which situation? Right Ans - A.
Sustained tissue damage
B. Requires nasogastric suction
C. Has a history of Addison's disease
D. Uric acid level of 9.4 mg/dL (559 mmol/L)
B.
The nurse reviews a client's electrolyte laboratory report and notes that the
potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse
watch for on the electrocardiogram (ECG) as a result of the laboratory value?
Select all that apply. Right Ans - 1. U waves
2. Absent P waves
3. Inverted T waves
4. Depressed ST segment
5. Widened QRS complex
1, 3, 4
Foods high in potassium Right Ans - raisins
potatoes
cantaloupe
strawberries
The nurse is assessing a client with a suspected diagnosis of hypocalcemia.
Which clinical manifestation would the nurse expect to note in the client?
Right Ans - 1. Twitching
2. Hypoactive bowel sounds
3. Negative Trousseau's sign
4. Hypoactive deep tendon reflexes
,1
The nurse is caring for a client with hypocalcemia. Which patterns would the
nurse watch for on the electrocardiogram as a result of the laboratory value?
Select all that apply. Right Ans - 1. U waves
2. Widened T wave
3. Prominent U wave
4. Prolonged QT interval
5. Prolonged ST segment
4, 5
The nurse reviews the electrolyte results of an assigned client and notes that
the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the
nurse watch for on the cardiac monitor as a result of the laboratory value?
Select all that apply. Right Ans - 1. ST depression
2. Prominent U wave
3. Tall peaked T waves
4. Prolonged ST segment
5. Widened QRS complexes
3, 5
Which client is at risk for the development of a sodium level at 130 mEq/L
(130 mmol/L)? Right Ans - 1. The client who is taking diuretics
2. The client with hyperaldosteronism
3. The client with Cushing's syndrome
4. The client who is taking corticosteroids
1
The nurse is caring for a client with heart failure who is receiving high doses
of a diuretic. On assessment, the nurse notes that the client has flat neck veins,
generalized muscle weakness, and diminished deep tendon reflexes. The
nurse suspects hyponatremia. What additional signs would the nurse expect
to note in a client with hyponatremia? Right Ans - 1. Muscle twitches
2. Decreased urinary output
3. Hyperactive bowel sounds
, 4. Increased specific gravity of the urine
3
The nurse reviews a client's laboratory report and notes that the client's
serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which
condition most likely caused this serum phosphorus level? Right Ans - 1.
Malnutrition
2. Renal insufficiency
3. Hypoparathyroidism
4. Tumor lysis syndrome
1, normal range in adults = 2.4 to 4.5 mg/dL
The nurse is reading a health care provider's (HCP's) progress notes in the
client's record and reads that the HCP has documented "insensible fluid loss of
approximately 800 mL daily." The nurse makes a notation that insensible fluid
loss occurs through which type of excretion? Right Ans - 1. Urinary output
2. Wound drainage
3. Integumentary output
4. The gastrointestinal tract
3
The nurse is assigned to care for a group of clients. On review of the clients'
medical records, the nurse determines that which client is most likely at risk
for a fluid volume deficit? Right Ans - 1. A client with an ileostomy
2. A client with heart failure
3. A client on long-term corticosteroid therapy
4. A client receiving frequent wound irrigations
1
The nurse caring for a client who has been receiving intravenous (IV)
diuretics suspects that the client is experiencing a fluid volume deficit. Which
assessment finding would the nurse note in a client with this condition?
Right Ans - 1. Weight loss and poor skin turgor
2. Lung congestion and increased heart rate
3. Decreased hematocrit and increased urine output
Symptoms of excess fluid volume Right Ans - - dyspnea
- crackles audible on auscultation
- increase in BP / respirations
*may be present in someone w/ heart failure
The nurse is preparing to care for a client with a potassium deficit. The nurse
reviews the client's record and determines that the client is at risk for
developing the potassium deficit because of which situation? Right Ans - A.
Sustained tissue damage
B. Requires nasogastric suction
C. Has a history of Addison's disease
D. Uric acid level of 9.4 mg/dL (559 mmol/L)
B.
The nurse reviews a client's electrolyte laboratory report and notes that the
potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse
watch for on the electrocardiogram (ECG) as a result of the laboratory value?
Select all that apply. Right Ans - 1. U waves
2. Absent P waves
3. Inverted T waves
4. Depressed ST segment
5. Widened QRS complex
1, 3, 4
Foods high in potassium Right Ans - raisins
potatoes
cantaloupe
strawberries
The nurse is assessing a client with a suspected diagnosis of hypocalcemia.
Which clinical manifestation would the nurse expect to note in the client?
Right Ans - 1. Twitching
2. Hypoactive bowel sounds
3. Negative Trousseau's sign
4. Hypoactive deep tendon reflexes
,1
The nurse is caring for a client with hypocalcemia. Which patterns would the
nurse watch for on the electrocardiogram as a result of the laboratory value?
Select all that apply. Right Ans - 1. U waves
2. Widened T wave
3. Prominent U wave
4. Prolonged QT interval
5. Prolonged ST segment
4, 5
The nurse reviews the electrolyte results of an assigned client and notes that
the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the
nurse watch for on the cardiac monitor as a result of the laboratory value?
Select all that apply. Right Ans - 1. ST depression
2. Prominent U wave
3. Tall peaked T waves
4. Prolonged ST segment
5. Widened QRS complexes
3, 5
Which client is at risk for the development of a sodium level at 130 mEq/L
(130 mmol/L)? Right Ans - 1. The client who is taking diuretics
2. The client with hyperaldosteronism
3. The client with Cushing's syndrome
4. The client who is taking corticosteroids
1
The nurse is caring for a client with heart failure who is receiving high doses
of a diuretic. On assessment, the nurse notes that the client has flat neck veins,
generalized muscle weakness, and diminished deep tendon reflexes. The
nurse suspects hyponatremia. What additional signs would the nurse expect
to note in a client with hyponatremia? Right Ans - 1. Muscle twitches
2. Decreased urinary output
3. Hyperactive bowel sounds
, 4. Increased specific gravity of the urine
3
The nurse reviews a client's laboratory report and notes that the client's
serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which
condition most likely caused this serum phosphorus level? Right Ans - 1.
Malnutrition
2. Renal insufficiency
3. Hypoparathyroidism
4. Tumor lysis syndrome
1, normal range in adults = 2.4 to 4.5 mg/dL
The nurse is reading a health care provider's (HCP's) progress notes in the
client's record and reads that the HCP has documented "insensible fluid loss of
approximately 800 mL daily." The nurse makes a notation that insensible fluid
loss occurs through which type of excretion? Right Ans - 1. Urinary output
2. Wound drainage
3. Integumentary output
4. The gastrointestinal tract
3
The nurse is assigned to care for a group of clients. On review of the clients'
medical records, the nurse determines that which client is most likely at risk
for a fluid volume deficit? Right Ans - 1. A client with an ileostomy
2. A client with heart failure
3. A client on long-term corticosteroid therapy
4. A client receiving frequent wound irrigations
1
The nurse caring for a client who has been receiving intravenous (IV)
diuretics suspects that the client is experiencing a fluid volume deficit. Which
assessment finding would the nurse note in a client with this condition?
Right Ans - 1. Weight loss and poor skin turgor
2. Lung congestion and increased heart rate
3. Decreased hematocrit and increased urine output
