Nur 235 Exam 3: Questions With Step-by-Step
Solutions (Scored A+)
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?
A. Muscle twitches
B. Decreased Urinary output
C. Hyperactive bowel sounds
D. Increased specific gravity of the urine Right Ans - C. Hyperactive bowel
sounds
A nurse is caring for a client with a nasogastric tube (NGT) who has a
prescription for NGT irrigation once every 8 hours. To maintain homeostasis,
which solution should the nurse use to irrigate the NGT?
A. Tap wate
rB. Sterile Water
C. 0.9% Sodium Chloride
D. 0.45% Sodium Chloride Right Ans - C. 0.9% Sodium Chloride
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 was at risk for
developing the potassium deficit because of which situation?
A. Sustained tissue damage
B. Requires Nasogastric suction
C. Has a history of Addison's disease
D. Is taking a potassium-retaining diuretic Right Ans - B. Requires
Nasogastric suction
During an assessment of a newly admitted client, the nurse notes that the
client's heart rate is 110 beats/minute, his blood pressure shows orthostatic
changes when he stands up, and his tongue has a sticky, paste-like coating.
The client's spouse tells the nurse that he seems a little confused and unsteady
on his feet. Based on these assessment findings, the nurse suspects that the
client has which condition?
A. Dehydration
, B. Hypokalemia
C. Fluid Overload
D. Hypernatremia Right Ans - A. Dehydration
The nurse is performing an assessment on a client admitted to the hospital
with a diagnosis of dehydration. Which assessment finding should the nurse
expect to note?
A. Bradycardia
B. Elevated blood pressure
C. Changes in mental status
D. Bilateral crackles in the lung Right Ans - C. Changes in mental status
A nurse is planning care for a client with hypokalemia. Which interventions
should be included in the plan of care? Select all that apply.
A. Ensure adequate fluid intake.
B. Implement safety measures to prevent falls
C. Encourage low fiber foods to prevent diarrhea
.D. Instruct the client about foods that contain potassium.
E. Encourage the client to obtain assistance to ambulate. Right Ans - A.
Ensure adequate fluid intake.
B. Implement safety measures to prevent falls
.D. Instruct the client about foods that contain potassium.
E. Encourage the client to obtain assistance to ambulate.
The nurse is reading a health care provider's (HCP) progress notes in the
client's record and reads that the HCP has documented "insensible fluid loss of
approximately 800 mL daily." The nurse interprets that this type of fluid loss
can occur through which route?A. The Skin
B. Urinary Output
C. Wound Drainage
D. The gastrointestinal trac Right Ans - A. The Skin
The nurse is assessing a client with a suspected diagnosis of hypocalcemia.
Which cardiovascular manifestation would the nurse expect to note?
A. Hypotension
B. Increased heart rate
C. Bounding peripheral pulses
D. Shortened QT interval on electrocardiography (ECG) Right Ans - A.
Hypotension
Solutions (Scored A+)
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?
A. Muscle twitches
B. Decreased Urinary output
C. Hyperactive bowel sounds
D. Increased specific gravity of the urine Right Ans - C. Hyperactive bowel
sounds
A nurse is caring for a client with a nasogastric tube (NGT) who has a
prescription for NGT irrigation once every 8 hours. To maintain homeostasis,
which solution should the nurse use to irrigate the NGT?
A. Tap wate
rB. Sterile Water
C. 0.9% Sodium Chloride
D. 0.45% Sodium Chloride Right Ans - C. 0.9% Sodium Chloride
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 was at risk for
developing the potassium deficit because of which situation?
A. Sustained tissue damage
B. Requires Nasogastric suction
C. Has a history of Addison's disease
D. Is taking a potassium-retaining diuretic Right Ans - B. Requires
Nasogastric suction
During an assessment of a newly admitted client, the nurse notes that the
client's heart rate is 110 beats/minute, his blood pressure shows orthostatic
changes when he stands up, and his tongue has a sticky, paste-like coating.
The client's spouse tells the nurse that he seems a little confused and unsteady
on his feet. Based on these assessment findings, the nurse suspects that the
client has which condition?
A. Dehydration
, B. Hypokalemia
C. Fluid Overload
D. Hypernatremia Right Ans - A. Dehydration
The nurse is performing an assessment on a client admitted to the hospital
with a diagnosis of dehydration. Which assessment finding should the nurse
expect to note?
A. Bradycardia
B. Elevated blood pressure
C. Changes in mental status
D. Bilateral crackles in the lung Right Ans - C. Changes in mental status
A nurse is planning care for a client with hypokalemia. Which interventions
should be included in the plan of care? Select all that apply.
A. Ensure adequate fluid intake.
B. Implement safety measures to prevent falls
C. Encourage low fiber foods to prevent diarrhea
.D. Instruct the client about foods that contain potassium.
E. Encourage the client to obtain assistance to ambulate. Right Ans - A.
Ensure adequate fluid intake.
B. Implement safety measures to prevent falls
.D. Instruct the client about foods that contain potassium.
E. Encourage the client to obtain assistance to ambulate.
The nurse is reading a health care provider's (HCP) progress notes in the
client's record and reads that the HCP has documented "insensible fluid loss of
approximately 800 mL daily." The nurse interprets that this type of fluid loss
can occur through which route?A. The Skin
B. Urinary Output
C. Wound Drainage
D. The gastrointestinal trac Right Ans - A. The Skin
The nurse is assessing a client with a suspected diagnosis of hypocalcemia.
Which cardiovascular manifestation would the nurse expect to note?
A. Hypotension
B. Increased heart rate
C. Bounding peripheral pulses
D. Shortened QT interval on electrocardiography (ECG) Right Ans - A.
Hypotension
