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b. Distended neck veins
1. A nurse is assessing a client who is receiving intra-
venous therapy. The nurse should identify which of
the following findings as a manifestation of fluid
volume excess?
a. Decreased bowel sounds
b. Distended neck veins
c. Bilateral muscle weakness
d. Thread pulse
b. Improved cognition
2. A nurse is caring for a client who has hyponatremia
and is receiving an infusion of a prescribed hypertonic
solution. Which of the following findings should indi-
cate to the nurse that the treatment is effective?
a. Absent Chvostek's sign
b. Improved cognition
c. Decreased vomiting
d. Cardiac arrhythmias absent
3. A nurse is teaching a client who has a new prescription d. "Remove the patch prior
for a nitroglycerin transdermal patch. Which of the should the
following instructions should the nurse include? nurse report
a. "Discontinue the patch if you experience a to the
headache." provider?
b. "Apply a new patch if you have chest pain."
c. "Cover the patch with dry gauze when taking a
shower."
d. "Remove the patch prior to going to bed."
4. A nurse is reviewing he laboratory results of a client
who has a prescription for sodium polystyrene sul-
fonate (Kayexalate) every 6 hr. which of the following
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to going to bed."
d. Potassium 5.2 mEq/L
- Hyperkalemia (serum potassium level greater than 5.0 mEq/L) increases
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a. Creatinine 0.72 mg/dL the client risk for fatal car-
b. Sodium 138 mEq/L diac dysrhythmias. Kayex-
c. Magnesium 2 mEq/L alate is used to decrease
the serum potassium level
d. Potassium 5.2 mEq/L
so the PN should monitor
the client's serum potassi-
um level
5. A nurse is caring for a client who has tuberculosis and a. The client has a negative
is taking isoniazid and rifampin. Which of the follow- sputum culture
ing outcomes indicates that the client is adhering to
the medication regimen?
a. The client has a negative sputum culture
b. The client tests negative for HIV
c. The client has a positive purified protein derivative
test
d. The client's liver function test results are within the
expected reference range
6. A client is caring for a client who develops an ana- d. Administer epinephrine
phylactic reaction to IV administration. After assessing IM
the client's respiratory status and stopping the med-
ication infusion. Which of the following actions should
the nurse take next?
a. Replace the infusion with 0.9% sodium chloride
b. Give diphenhydramine IM
c. Elevate the client's legs and feet
d. Administer epinephrine IM
7. A nurse is caring for a client who is taking sertraline Which of the
and reports a desire to begin taking supplements. following
supplements
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should the nurse a. St. John's Wort
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