1. A female client is admitted with a diagnosis of acute renal failure.

She is awake, alert, oriented, and complaining of severe back pain, nausea and vomiting and abdominal cramps. Her vital signs are blood pressure 100/70 mm Hg, pulse 110, respirations 30, and oral temperature 100.4F (38C). Her electrolytes are sodium 120 mEq/L, potassium 5.2 mEq/L; her urinary output for the first 8 hours is 50 ml. The client is displaying signs of which electrolyte imbalance? A. Hyponatremia B. Hyperkalemia C. Hyperphosphatemia D. Hypercalcemia 2. Assessing the laboratory findings, which result would the nurse most likely expect to find in a client with chronic renal failure? A. BUN 10 to 30 mg/dl, potassium 4.0 mEq/L, creatinine 0.5 to 1.5 mg/dl B. Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L C. BUN 15 mg/dl, increased serum calcium, creatinine l.0 mg/dl D. BUN 35 to 40 mg/dl, potassium 3.5 mEq/L, pH 7.35, decreased serum calcium 3. Treatment with hemodialysis is ordered for a client and an external shunt is created. Which nursing action would be of highest priority with regard to the external shunt? A. Heparinize it daily. B. Avoid taking blood pressure measurements or blood samples from the affected arm. C. Change the Silastic tube daily. D. Instruct the client not to use the affected arm. 4. Romeo Diaz, age 78, is admitted to the hospital with the diagnosis of benign prostatic hyperplasia (BPH). He is scheduled for a transurethral resection of the prostate (TURP). It would be inappropriate to include which of the following points in the preoperative teaching? A. TURP is the most common operation for BPH. B. Explain the purpose and function of a two-way irrigation system. C. Expect bloody urine, which will clear as healing takes place. D. He will be pain free. 5. Roxy is admitted to the hospital with a possible diagnosis of appendicitis. On physical examination, the nurse should be looking for tenderness on palpation at McBurneys point, which is located in the A. left lower quadrant B. left upper quadrant C. right lower quadrant D. right upper quadrant 6. Mr. Valdez has undergone surgical repair of his inguinal hernia. Discharge teaching should include A. telling him to avoid heavy lifting for 4 to 6 weeks B. instructing him to have a soft bland diet for two weeks C. telling him to resume his previous daily activities without limitations D. recommending him to drink eight glasses of water daily 7. A 30-year-old homemaker fell asleep while smoking a cigarette. She sustained severe burns of the face,neck, anterior chest, and both arms and hands. Using the rule of nines, which is the best estimate of total body-surface area burned?

A. 18% B. 22% C. 31% D. 40% 8. Nursing care planning is based on the knowledge that the first 24-48 hours post-burn are characterized by: A. An increase in the total volume of intracranial plasma B. Excessive renal perfusion with diuresis C. Fluid shift from interstitial space D. Fluid shift from intravascular space to the interstitial space 9. If a client has severe bums on the upper torso, which item would be a primary concern? A. Debriding and covering the wounds B. Administering antibiotics C. Frequently observing for hoarseness, stridor, and dyspnea D. Establishing a patent IV line for fluid replacement 10. Contractures are among the most serious long-term complications of severe burns. If a burn is located on the upper torso, which nursing measure would be least effective to help prevent contractures? A. Changing the location of the bed or the TV set, or both, daily B. Encouraging the client to chew gum and blow up balloons C. Avoiding the use of a pillow for sleep, or placing the head in a position of hyperextension D. Helping the client to rest in the position of maximal comfort 11. An adult is receiving Total Parenteral Nutrition (TPN). Which of the following assessment is essential? A. evaluation of the peripheral IV site B. confirmation that the tube is in the stomach C. assess the bowel sound D. fluid and electrolyte monitoring 12. Which drug would be least effective in lowering a clients serum potassium level? A. Glucose and insulin B. Polystyrene sulfonate (Kayexalate) C. Calcium glucomite D. Aluminum hydroxide 13. A nurse is directed to administer a hypotonic intravenous solution. Looking at the following labeled solutions, she should choose A. 0.45% NaCl B. 0.9% NaCl C. D5W D. D5NSS 14. A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms EXCEPT A. hypertension B. oliguria

C. tachycardia D. tachypnea 15. Maria Sison, 40 years old, single, was admitted to the hospital with a diagnosis of Breast Cancer. She was scheduled for radical mastectomy. Nursing care during the preoperative period should consist of A. assuring Maria that she will be cured of cancer B. assessing Marias expectations and doubts C. maintaining a cheerful and optimistic environment D. keeping Marias visitors to a minimum so she can have time for herself 16. Maria refuses to acknowledge that her breast was removed. She believes that her breast is intact under the dressing. The nurse should A. call the MD to change the dressing so Kathy can see the incision B. recognize that Kathy is experiencing denial, a normal stage of the grieving process C. reinforce Kathys belief for several days until her body can adjust to stress of surgery. D. remind Kathy that she needs to accept her diagnosis so that she can begin rehabilitation exercises. 17. A chemotherapeutic agent 5FU is ordered as an adjunct measure to surgery. Which of the ff. statements about chemotherapy is true? A. it is a local treatment affecting only tumor cells B. it affects both normal and tumor cells C. it has been proven as a complete cure for cancer D. it is often used as a palliative measure. 18. Which is an incorrect statement pertaining to the following procedures for cancer diagnostics? A. Biopsy is the removal of suspicious tissue and the only definitive method to diagnose cancer B. Ultrasonography detects tissue density changes difficult to observe by X-ray via sound waves. C. CT scanning uses magnetic fields and radio frequencies to provide cross-sectional view of tumor D. Endoscopy provides direct view of a body cavity to detect abnormality. 19. A post-operative complication of mastectomy is lymphedema. This can be prevented by A. ensuring patency of wound drainage tube B. placing the arm on the affected side in a dependent position C. restricting movement of the affected arm D. frequently elevating the arm of the affected side above the level of the heart. 20. Which statement by the client indicates to the nurse that the patient understands precautions necessary during internal radiation therapy for cancer of the cervix? A. I should get out of bed and walk around in my room. B. My 7 year old twins should not come to visit me while Im receiving treatment. C. I will try not to cough, because the force might make me expel the application. D. I know that my primary nurse has to wear one of those badges like the people in the x ray department, but they are not necessary for anyone else who comes in here. 21. High uric acid levels may develop in clients who are receiving chemotherapy. This is caused by:

A. The inability of the kidneys to excrete the drug metabolites B. Rapid cell catabolism C. Toxic effect of the antibiotic that are given concurrently D. The altered blood ph from the acid medium of the drugs 22. Which of the following interventions would be included in the care of plan in a client with cervical implant? A. Frequent ambulation B. Unlimited visitors C. Low residue diet D. Vaginal irrigation every shift 23. Which nursing measure would avoid constriction on the affected arm immediately after mastectomy? A. Avoid BP measurement and constricting clothing on the affected arm B. Active range of motion exercises of the arms once a day. C. Discourage feeding, washing or combing with the affected arm D. Place the affected arm in a dependent position, below the level of the heart 24. A client suffering from acute renal failure has an unexpected increase in urinary output to 150ml/hr. The nurse assesses that the client has entered the second phase of acute renal failure. Nursing actions throughout this phase include observation for signs and symptoms of A. Hypervolemia, hypokalemia, and hypernatremia. B. Hypervolemia, hyperkalemia, and hypernatremia. C. Hypovolemia, wide fluctuations in serum sodium and potassium levels. D. Hypovolemia, no fluctuation in serum sodium and potassium levels. 25. An adult has just been brought in by ambulance after a motor vehicle accident. When assessing the client, the nurse would expect which of the following manifestations could have resulted from sympathetic nervous system stimulation? A. A rapid pulse and increased RR B. Decreased physiologic functioning C. Rigid posture and altered perceptual focus D. Increased awareness and attention 26. Ms. Sy undergoes surgery and the abdominal aortic aneurysm is resected and replaced with a graft. When she arrives in the RR she is still in shock. The nurses priority should be : A. placing her in a trendeleburg position B. putting several warm blankets on her C. monitoring her hourly urine output D. assessing her VS especially her RR 27. A major goal for the client during the first 48 hours after a severe bum is to prevent hypovolemic shock. The best indicator of adequate fluid balance during this period is A. Elevated hematocrit levels. B. Urine output of 30 to 50 ml/hr. C. Change in level of consciousness. D. Estimate of fluid loss through the burn eschar. 28. A thoracentesis is performed on a chest-injured client, and no fluid or air is found. Blood and fluids is administered intravenously (IV), but the clients vital signs do not improve. A

central venous pressure line is inserted, and the initial reading is 20 cm H^O. The most likely cause of these findings is which of the following? A. Spontaneous pneumothorax B. Ruptured diaphragm C. Hemothorax D. Pericardial tamponade 29. Intervention for a pt. who has swallowed a Muriatic Acid includes all of the following except; A. administering an irritant that will stimulate vomiting B. aspirating secretions from the pharynx if respirations are affected C. neutralizing the chemical D. washing the esophagus with large volumes of water via gastric lavage 30. Which initial nursing assessment finding would best indicate that a client has been successfully resuscitated after a cardio-respiratory arrest? A. Skin warm and dry B. Pupils equal and react to light C. Palpable carotid pulse D. Positive Babinskis reflex 31. Chemical burn of the eye are treated with A. local anesthetics and antibacterial drops for 24 36 hrs. B. hot compresses applied at 15-minute intervals C. Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water D. cleansing the conjunctiva with a small cotton-tipped applicator 32. The Heimlich maneuver (abdominal thrust), for acute airway obstruction, attempts to: A. Force air out of the lungs B. Increase systemic circulation C. Induce emptying of the stomach D. Put pressure on the apex of the heart 33. John, 16 years old, is brought to the ER after a vehicular accident. He is pronounced dead on arrival. When his parents arrive at the hospital, the nurse should: A. ask them to stay in the waiting area until she can spend time alone with them B. speak to both parents together and encourage them to support each other and express their emotions freely C. Speak to one parent at a time so that each can ventilate feelings of loss without upsetting the other D. ask the MD to medicate the parents so they can stay calm to deal with their sons death. 34. An emergency treatment for an acute asthmatic attack is Adrenaline 1:1000 given hypodermically. This is given to: A. increase BP B. decrease mucosal swelling C. relax the bronchial smooth muscle D. decrease bronchial secretions 35. A nurse is performing CPR on an adult patient. When performing chest compressions, the nurse understands the correct hand placement is located over the

A. upper half of the sternum B. upper third of the sternum C. lower half of the sternum D. lower third of the sternum 36. The nurse is performing an eye examination on an elderly client . The client states My vision is blurred, and I dont easily see clearly when I get into a dark room. The nurse best response is: A. You should be grateful you are not blind. B. As one ages, visual changes are noted as part of degenerative changes. This is normal. C. You should rest your eyes frequently. D. You maybe able to improve you vision if you move slowly. 37. Which of the following activities is not encouraged in a patient after an eye surgery? A. sneezing, coughing and blowing the nose B. straining to have a bowel movement C. wearing tight shirt collars D. sexual intercourse 38. Which of the following indicates poor practice in communicating with a hearing-impaired client? A. Use appropriate hand motions B. Keep hands and other objects away from your mouth when talking to the client C. Speak clearly in a loud voice or shout to be heard D. Converse in a quiet room with minimal distractions 39. A client is to undergo lumbar puncture. Which is least important information about LP? A. Specimens obtained should be labeled in their proper sequence. B. It may be used to inject air, dye or drugs into the spinal canal. C. Assess movements and sensation in the lower extremities after the D. Force fluids before and after the procedure. 40. A client diagnosed with cerebral thrombosis is scheduled for cerebral angiography. Nursing care of the client includes the following EXCEPT A. Inform the client that a warm, flushed feeling and a salty taste may be B. Maintain pressure dressing over the site of puncture and check for C. Check pulse, color and temperature of the extremity distal to the site of D. Kept the extremity used as puncture site flexed to prevent bleeding. 41. Which is considered as the earliest sign of increased ICP that the nurse should closely observed for? A. abnormal respiratory pattern B. rising systolic and widening pulse pressure C. contralateral hemiparesis and ipsilateral dilation of the pupils D. progression from restlessness to confusion and disorientation to lethargy 42. Which is irrelevant in the pharmacologic management of a client with CVA? A. Osmotic diuretics and corticosteroids are given to decrease cerebral edema B. Anticonvulsants are given to prevent seizures C. Thrombolytics are most useful within three hours of an occlusive CVA D. Aspirin is used in the acute management of a completed stroke.

43. What would be the MOST therapeutic nursing action when a clients expressive aphasia is severe? A. Anticipate the client wishes so she will not need to talk B. Communicate by means of questions that can be answered by the client shaking the head C. Keep us a steady flow rank to minimize silence D. Encourage the client to speak at every possible opportunity. 44. A client with head injury is confused, drowsy and has unequal pupils. Which of the following nursing diagnosis is most important at this time? A. altered level of cognitive function B. high risk for injury C. altered cerebral tissue perfusion D. sensory perceptual alteration 45. Which nursing diagnosis is of the highest priority when caring for a client with myasthenia gravis? A. Pain B. High risk for injury related to muscle weakness C. Ineffective coping related to illness D. Ineffective airway clearance related to muscle weakness 46. The client has clear drainage from the nose and ears after a head injury. How can the nurse determine if the drainage is CSF? A. Measure the ph of the fluid B. Measure the specific gravity of the fluid C. Test for glucose D. Test for chlorides 47. The nurse includes the important measures for stump care in the teaching plan for a client with an amputation. Which measure would be excluded from the teaching plan? A. Wash, dry, and inspect the stump daily. B. Treat superficial abrasions and blisters promptly. C. Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb. D. Toughen the stump by pushing it against a progressively harder substance (e.g., pillow on a foot-stool). 48. A 70-year-old female comes to the clinic for a routine checkup. She is 5 feet 4 inches tall and weighs 180 pounds. Her major complaint is pain in her joints. She is retired and has had to give up her volunteer work because of her discomfort. She was told her diagnosis was osteoarthritis about 5 years ago. Which would be excluded from the clinical pathway for this client? A. Decrease the calorie count of her daily diet. B. Take warm baths when arising. C. Slide items across the floor rather than lift them. D. Place items so that it is necessary to bend or stretch to reach them. 49. A client is admitted from the emergency department with severe-pain and edema in the right foot. His diagnosis is gouty arthritis. When developing a plan of care, which action would have the highest priority?

A. Apply hot compresses to the affected joints. B. Stress the importance of maintaining good posture to prevent deformities. C. Administer salicylates to minimize the inflammatory reaction. D. Ensure an intake of at least 3000 ml of fluid per day. 50. A client had a laminectomy and spinal fusion yesterday. Which statement is to be excluded from your plan of care? A. Before log rolling, place a pillow under the clients head and a pillow between the clients legs. B. Before log rolling, remove the pillow from under the clients head and use no pillows between the clients legs. C. Keep the knees slightly flexed while the client is lying in a semi-Fowlers position in bed. D. Keep a pillow under the clients head as needed for comfort.
Answer: (A) Hyponatremia The normal serum sodium level is 135 145 mEq/L. The clients serum sodium is below normal. Hyponatremia also manifests itself with abdominal cramps and nausea and vomiting 2. Answer: (B) Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L Chronic renal failure is usually the end result of gradual tissue destruction and loss of renal function. With the loss of renal function, the kidneys ability to regulate fluid and electrolyte and acid base balance results. The serum Ca decreases as the kidneys fail to excrete phosphate, potassium and hydrogen ions are retained. 3. Answer: (B) Avoid taking blood pressure measurements or blood samples from the affected arm. In the client with an external shunt, dont use the arm with the vascular access site to take blood pressure readings, draw blood, insert IV lines, or give injections because these procedures may rupture the shunt or occlude blood flow causing damage and obstructions in the shunt. 4. Answer: (D) He will be pain free. Surgical interventions involve an experience of pain for the client which can come in varying degrees. Telling the pain that he will be pain free is giving him false reassurance. 5. Answer: (C) right lower quadrant To be exact, the appendix is anatomically located at the Mc Burneys point at the right iliac area of the right lower quadrant. 6. Answer: (A) telling him to avoid heavy lifting for 4 to 6 weeks The client should avoid lifting heavy objects and any strenuous activity for 4-6 weeks after surgery to prevent stress on the inguinal area. There is no special diet required. The fluid intake of eight glasses a day is good advice but is not a priority in this case. 7. Answer: (C) 31% Using the Rule of Nine in the estimation of total body surface burned, we allot the following: 9% head; 9% each upper extremity; 18%- front chest and abdomen; 18% entire back; 18% each lower extremity and 1% perineum. 8. Answer: (D) Fluid shift from intravascular space to the interstitial space This period is the burn shock stage or the hypovolemic phase. Tissue injury causes vasodilation that results in increase capillary permeability making fluids shift from the intravascular to the interstitial space. This can lead to a decrease in circulating blood volume or hypovolemia which decreases renal perfusion and urine output. 9. Answer: (C) Frequently observing for hoarseness, stridor, and dyspnea Burns located in the upper torso, especially resulting from thermal injury related to fires can lead to inhalation burns. This causes swelling of the respiratory mucosa and blistering which can lead to airway obstruction manifested by hoarseness, noisy and difficult breathing. Maintaining a patent airway is a primary concern.

10. Answer: (D) Helping the client to rest in the position of maximal comfort Mobility and placing the burned areas in their functional position can help prevent contracture deformities related to burns. Pain can immobilize a client as he seeks the position where he finds less pain and provides maximal comfort. But this approach can lead to contracture deformities and other complications. 11. Answer: (D) fluid and electrolyte monitoring Total parenteral nutrition is a method of providing nutrients to the body by an IV route. The admixture is made up of proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals and sterile water based on individual client needs. It is intended to improve the clients nutritional status. Because of its composition, it is important to monitor the clients fluid intake and output including electrolytes, blood glucose and weight. 12. Answer: (D) Aluminum hydroxide Aluminum hydroxide binds dietary phosphorus in the GI tract and helps treat hyperphosphatemia. All the other medications mentioned help treat hyperkalemia and its effects. 13. Answer: (A) 0.45% NaCl Hypotonic solutions like 0.45% NaCl has a lower tonicity that the blood; 0.9% NaCl and D5W are isotonic solutions with same tonicity as the blood; and D5NSS is hypertonic with a higher tonicity thab the blood. 14. Answer: (A) hypertension In hypovolemia, one of the compenasatory mechanisms is activation of the sympathetic nervous system that increases the RR & PR and helps restore the BP to maintain tissue perfusion but not cause a hypertension. The SNS stimulation constricts renal arterioles that increases release of aldosterone, decreases glomerular filtration and increases sodium & water reabsorption that leads to oliguria. 15. Answer: (B) assessing Marias expectations and doubts Assessing the clients expectations and doubts will help lessen her fears and anxieties. The nurse needs to encourage the client to verbalize and to listen and correctly provide explanations when needed. 16. Answer: (B) recognize that Kathy is experiencing denial, a normal stage of the grieving process A person grieves to a loss of a significant object. The initial stage in the grieving process is denial, then anger, followed by bargaining, depression and last acceptance. The nurse should show acceptance of the patients feelings and encourage verbalization. 17. Answer: (B) it affects both normal and tumor cells Chemotherapeutic agents are given to destroy the actively proliferating cancer cells. But these agents cannot differentiate the abnormal actively proliferating cancer cells from those that are actively proliferating normal cells like the cells of the bone marrow, thus the effect of bone marrow depression. 18. Answer: (C) CTscanning uses magnetic fields and radio frequencies to provide cross-sectional view of tumor CT scan uses narrow beam x-ray to provide cross-sectional view. MRI uses magnetic fields and radio frequencies to detect tumors. 19. Answer: (D) frequently elevating the arm of the affected side above the level of the heart. Elevating the arm above the level of the heart promotes good venous return to the heart and good lymphatic drainage thus preventing swelling. 20. Answer: (B) My 7 year old twins should not come to visit me while Im receiving treatment. Children have cells that are normally actively dividing in the process of growth. Radiation acts not only against the abnormally actively dividing cells of cancer but also on the normally dividing cells thus affecting the growth and development of the child and even causing cancer itself.

21. Answer: (B) Rapid cell catabolism One of the oncologic emergencies, the tumor lysis syndrome, is caused by the rapid destruction of large number of tumor cells. . Intracellular contents are released, including potassium and purines, into the bloodstream faster than the body can eliminate them. The purines are converted in the liver to uric acid and released into the blood causing hyperuricemia. They can precipitate in the kidneys and block the tubules causing acute renal failure. 22. Answer: (C) Low residue diet It is important for the nurse to remember that the implant be kept intact in the cervix during therapy. Mobility and vaginal irrigations are not done. A low residue diet will prevent bowel movement that could lead to dislodgement of the implant. Patient is also strictly isolated to protect other people from the radiation emissions 23. Answer: (A) Avoid BP measurement and constricting clothing on the affected arm A BP cuff constricts the blood vessels where it is applied. BP measurements should be done on the unaffected arm to ensure adequate circulation and venous and lymph drainage in the affected arm 24. Answer: (C) Hypovolemia, wide fluctuations in serum sodium and potassium levels. The second phase of ARF is the diuretic phase or high output phase. The diuresis can result in an output of up to 10L/day of dilute urine. Loss of fluids and electrolytes occur. 25. Answer: (A) A rapid pulse and increased RR The fight or flight reaction of the sympathetic nervous system occurs during stress like in a motor vehicular accident. This is manifested by increased in cardiovascular function and RR to provide the immediate needs of the body for survival. 26. Answer: (D) assessing her VS especially her RR Shock is characterized by reduced tissue and organ perfusion and eventual organ dysfunction and failure. Checking on the VS especially the RR, which detects need for oxygenation, is a priority to help detect its progress and provide for prompt management before the occurrence of complications. 27. Answer: (B) Urine output of 30 to 50 ml/hr. Hypovolemia is a decreased in circulatory volume. This causes a decrease in tissue perfusion to the different organs of the body. Measuring the hourly urine output is the most quantifiable way of measuring tissue perfusion to the organs. Normal renal perfusion should produce 1ml/kg of BW/min. An output of 30-50 ml/hr is considered adequate and indicates good fluid balance. 28. Answer: (D) Pericardial tamponade Pericardial tamponade occurs when there is presence of fluid accumulation in the pericardial space that compresses on the ventricles causing a decrease in ventricular filling and stretching during diastole with a decrease in cardiac output. . This leads to right atrial and venous congestion manifested by a CVP reading above normal. 29. Answer: (A) administering an irritant that will stimulate vomiting Swallowing of corrosive substances causes severe irritation and tissue destruction of the mucous membrane of the GI tract. Measures are taken to immediately remove the toxin or reduce its absorption. For corrosive poison ingestion, such as in muriatic acid where burn or perforation of the mucosa may occur, gastric emptying procedure is immediately instituted, This includes gastric lavage and the administration of activated charcoal to absorb the poison. Administering an irritant with the concomitant vomiting to remove the swallowed poison will further cause irritation and damage to the mucosal lining of the digestive tract. Vomiting is only indicated when non-corrosive poison is swallowed. 30. Answer: (C) Palpable carotid pulse Presence of a palpable carotid pulse indicates the return of cardiac function which, together with the return of breathing, is the primary goal of CPR. Pulsations in arteries indicates blood flowing in the blood vessels with each cardiac contraction. Signs of effective tissue perfusion will be noted after.

31. Answer: (C) Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water Prompt treatment of ocular chemical burns is important to prevent further damage. Immediate tap-water eye irrigation should be started on site even before transporting the patient to the nearest hospital facility. In the hospital, copious irrigation with normal saline, instillation of local anesthetic and antibiotic is done. 32. Answer: (A) Force air out of the lungs The Heimlich maneuver is used to assist a person choking on a foreign object. The pressure from the thrusts lifts the diaphragm, forces air out of the lungs and creates an artificial cough that expels the aspirated material. 33. Answer: (B) speak to both parents together and encourage them to support each other and express their emotions freely Sudden death of a family member creates a state of shock on the family. They go into a stage of denial and anger in their grieving. Assisting them with information they need to know, answering their questions and listening to them will provide the needed support for them to move on and be of support to one another. 34. Answer: (C) relax the bronchial smooth muscle Acute asthmatic attack is characterized by severe bronchospasm which can be relieved by the immediate administration of bronchodilators. Adrenaline or Epinephrine is an adrenergic agent that causes bronchial dilation by relaxing the bronchial smooth muscles. 35. Answer: (C) lower half of the sternum The exact and safe location to do cardiac compression is the lower half of the sternum. Doing it at the lower third of the sternum may cause gastric compression which can lead to a possible aspiration. 36. Answer: (B) As one ages, visual changes are noted as part of degenerative changes. This is normal. Aging causes less elasticity of the lens affecting accommodation leading to blurred vision. The muscles of the iris increase in stiffness and the pupils dilate slowly and less completely so that it takes the older person to adjust when going to and from light and dark environment and needs brighter light for close vision. 37. Answer: (D) sexual intercourse To reduce increases in IOP, teach the client and family about activity restrictions. Sexual intercourse can cause a sudden rise in IOP. 38. Answer: (C) Speak clearly in a loud voice or shout to be heard Shouting raises the frequency of the sound and often makes understanding the spoken words difficult. It is enough for the nurse to speak clearly and slowly. 39. Answer: (D) Force fluids before and after the procedure. LP involves the removal of some amount of spinal fluid. To facilitate CSF production, the client is instructed to increase fluid intake to 3L, unless contraindicated, for 24 to 48 hrs after the procedure. 40. Answer: (D) Kept the extremity used as puncture site flexed to prevent bleeding. Angiography involves the threading of a catheter through an artery which can cause trauma to the endothelial lining of the blood vessel. The platelets are attracted to the area causing thrombi formation. This is further enhanced by the slowing of blood flow caused by flexion of the affected extremity. The affected extremity must be kept straight and immobilized during the duration of the bedrest after the procedure. Ice bag can be applied intermittently to the puncture site. 41. Answer: (D) progression from restlessness to confusion and disorientation to lethargy The first major effect of increasing ICP is a decrease in cerebral perfusion causing hypoxia that produces a progressive alteration in the LOC. This is initially manifested by restlessness.

42. Answer: (D) Aspirin is used in the acute management of a completed stroke. The primary goal in the management of CVA is to improve cerebral tissue perfusion. Aspirin is a platelet deaggregator used in the prevention of recurrent or embolic stroke but is not used in the acute management of a completed stroke as it may lead to bleeding. 43. Answer: (D) Encourage the client to speak at every possible opportunity. Expressive or motor aphasia is a result of damage in the Brocas area of the frontal lobe. It is amotor speech problem in which the client generally understands what is said but is unable to communicate verbally. The patient can best he helped therefore by encouraging him to communicate and reinforce this behavior positively. 44. Answer: (C) altered cerebral tissue perfusion The observations made by the nurse clearly indicate a problem of decrease cerebral perfusion. Restoring cerebral perfusion is most important to maintain cerebral functioning and prevent further brain damage. 45. Answer: (D) Ineffective airway clearance related to muscle weakness Myasthenia gravis causes a failure in the transmission of nerve impulses at the neuromuscular junction which may be due to a weakening or decrease in acetylcholine receptor sites. This leads to sporadic, progressive weakness or abnormal fatigability of striated muscles that eventually causes loss of function. The respiratory muscles can become weak with decreased tidal volume and vital capacity making breathing and clearing the airway through coughing difficult. The respiratory muscle weakness may be severe enough to require and emergency airway and mechanical ventilation. 46. Answer: (C) Test for glucose The CSF contains a large amount of glucose which can be detected by using glucostix. A positive result with the drainage indicate CSF leakage. 47. Answer: (C) Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb. The shrinker bandage is applied to prevent swelling of the stump. It should be applied with the distal end with the tighter arms. Applying the tighter arms at the proximal end will impair circulation and cause swelling by reducing venous flow. 48. Answer: (D) Place items so that it is necessary to bend or stretch to reach them. Patients with osteoarthritis have decreased mobility caused by joint pain. Over-reaching and stretching to get an object are to be avoided as this can cause more pain and can even lead to falls. The nurse should see to it therefore that objects are within easy reach of the patient. 49. Answer: (D) Ensure an intake of at least 3000 ml of fluid per day. Gouty arthritis is a metabolic disease marked by urate deposits that cause painful arthritic joints. The patient should be urged to increase his fluid intake to prevent the development of urinary uric acid stones. 50. Answer: (B) Before log rolling, remove the pillow from under the clients head and use no pillows between the clients legs. Following a laminectomy and spinal fusion, it is important that the back of the patient be maintained in straight alignment and to support the entire vertebral column to promote complete healing.

1. A client with hypoparathyroidism complains of numbness and tingling in his fingers

and around the mouth. The nurse would assess for what electrolyte imbalance? A.Hyponatremia B.Hypocalcemia C.Hyperkalemia D.Hypermagnesemia 2. The nurse evaluates which of the following clients to be at risk for developing hypernatremia? A.50-year-old with pneumonia, diaphoresis, and high fevers B.62-year-old with congestive heart failure taking loop diuretics

C.39-year-old with diarrhea and vomiting 60-year-old with lung cancer and syndrome of inappropriate antidiuretic hormone D. (SIADH) 3. A client is admitted with diabetic ketoacidosis who, with treatment, has a normal blood glucose, pH, and serum osmolality. During assessment, the client complains of weakness in the legs. Which of the following is a priority nursing intervention? A.Request a physical therapy consult from the physician B.Ensure the client is safe from falls and check the most recent potassium level C.Allow uninterrupted rest periods throughout the day D.Encourage the client to increase intake of dairy products and green leafy vegetables. 4. A client with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor A.urine output. B.blood pressure. C.bowel movements. D.ECG for tall, peaked T waves. 5. The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client's serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action? A.Call the physician and report results B.Question the results and redraw the specimen C.Encourage the client to increase the intake of bananas D.Initiate seizure precautions 6. A client is receiving an intravenous magnesium infusion to correct a serum level of 1.4 mEq/L. Which of the following assessments would alert the nurse to immediately stop the infusion? A.Absent patellar reflex B.Diarrhea C.Premature ventricular contractions D.Increase in blood pressure 7. A client with chronic renal failure reports a 10 pound weight loss over 3 months and has had difficulty taking calcium supplements. The total calcium is 6.9 mg/dl. Which of the following would be the first nursing action? A.Assess for depressed deep tendon reflexes B.Call the physician to report calcium level C.Place an intravenous catheter in anticipation of administering calcium gluconate D.Check to see if a serum albumin level is available 8. A client with heart failure is complaining of nausea. The client has received IV furosemide (Lasix), and the urine output has been 2500 ml over the past 12 hours. The client's home drugs include metoprolol (Lopressor), digoxin (Lanoxin), furosemide, and multivitamins. Which of the following are the appropriate nursing actions before administering the digoxin? Select all that apply. A.Administer an antiemetic prior to giving the digoxin B.Encourage the client to increase fluid intake C.Call the physician D.Report the urine output E.Report indications of nausea 9. The nurse is caring for a bedridden client admitted with multiple myeloma and a serum calcium level of 13 mg/dl. Which of the following is the most appropriate nursing action? A.Provide passive ROM exercises and encourage fluid intake B.Teach the client to increase intake of whole grains and nuts C.Place a tracheostomy tray at the bedside

D.Administer calcium gluconate IM as ordered 10. An older adult client admitted with heart failure and a sodium level of 113 mEq/L is behaving aggressively toward staff and does not recognize family members. When the family expresses concern about the client's behavior, the nurse would respond most appropriately by stating "The client may be suffering from dementia, and the hospitalization has worsened the A. confusion." B."Most older adults get confused in the hospital." C."The sodium level is low, and the confusion will resolve as the levels normalize." D."The sodium level is high and the behavior is a result of dehydration." 11. A client with a serum sodium of 115 mEq/L has been receiving 3% NS at 50 ml/hr for 16 hours. This morning the client feels tired and short of breath. Which of the following interventions is a priority? A.Turn down the infusion B.Check the latest sodium level C.Assess for signs of fluid overload D.Place a call to the physician 12. A client with chronic renal failure receiving dialysis complains of frequent constipation. When performing discharge teaching, which over-the-counter products should the nurse instruct the client to avoid at home? A.Bisacodyl (Dulcolax) suppository B.Fiber supplements C.Docusate sodium D.Milk of magnesia 13. A client is receiving intravenous potassium supplementation in addition to maintenance fluids. The urine output has been 120 ml every 8 hours for the past 16 hours and the next dose is due. Before administering the next potassium dose, which of the following is the priority nursing action? A.Encourage the client to increase fluid intake B.Administer the dose as ordered C.Draw a potassium level and administer the dose if the level is low or normal D.Notify the physician of the urine output and hold the dose 14. The nurse should monitor for clinical manifestations of hypophosphatemia in which of the following clients? A.A client with osteoporosis taking vitamin D and calcium supplements B.A client who is alcoholic receiving total parenteral nutrition C.A client with chronic renal failure awaiting the first dialysis run D.A client with hypoparathyroidism secondary to thyroid surgery 15. A client admitted with squamous cell carcinoma of the lung has a serum calcium level of 14 mg/dl. The nurse should instruct the client to avoid which of the following foods upon discharge? Select all that apply. A.Eggs B.Broccoli C.Organ meats D.Nuts E.Canned salmon 16. A client with pancreatitis has been receiving potassium supplementation for four days since being admitted with a serum potassium of 3.0 mEq/L. Today the potassium level is 3.1 mEq/L. Which of the following laboratory values should the nurse check before notifying the physician of the client's failure to respond to treatment? A.Sodium B.Phosphorus C.Calcium D.Magnesium

17. The nurse should include which of the following instructions to assist in controlling

phosphorus levels for a client in renal failure? A.Increase intake of dairy products and nuts Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after B. meals C.Reduce intake of chocolate, meats, and whole grains D.Avoid calcium supplements 18. A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45, which of the following is the most appropriate nursing intervention? A.Administer a sedative B.Place client in left lateral position C.Place client in high-Fowler's position D.Assist the client to breathe into a paper bag 19. A client with COPD feels short of breath after walking to the bathroom on 2 liters of oxygen nasal cannula. The morning's ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse's first intervention? A.Call the physician and report the change in client's condition B.Turn the client's O2 up to 4 liters nasal cannula C.Encourage the client to sit down and to take deep breaths D.Encourage the client to rest and to use pursed-lip breathing technique 20. A client who had a recent surgery has been vomiting and becomes dizzy while standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the pulse is 140. The nurse hangs which of the following IV fluids to correct this condition? A.D5.45 NS at 50 ml/hr B.0.9 NS at an open rate C.D5W at 125 ml/hr D.0.45 NS at open rate 21. A client with renal failure enters the emergency room after skipping three dialysis treatments to visit family out of town. Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis? A.pH of 7.43, PCO2 of 36, HCO3 of 26 B.pH of 7.41, PCO2 of 49, HCO3 of 30 C.pH of 7.33, PCO2 of 35, HCO3 of 17 D.pH of 7.25, PCO2 of 56, HCO3 of 28 22. A client with a small bowel obstruction has had an NG tube connected to low intermittent suction for two days. The nurse should monitor for clinical manifestations of which acid-base disorder? A.Respiratory alkalosis B.Respiratory acidosis C.Metabolic alkalosis D.Metabolic acidosis 23. A client who suffers from an anxiety disorder is very upset, has a respiratory rate of 32, and is complaining of lightheadedness and tingling in the fingers. ABG values are pH of 7.48, PaCO2 of 29, HCO3 of 24, and O2 is at 93% on room air. The nurse performs which of the following as a priority nursing intervention? A.Monitor intake and output B.Encourage client to increase activity C.Institute deep breathing exercises every hour D.Provide reassurance to the client and administer sedatives 24. Which of the following assessment findings would indicate to the nurse that a client's diabetic ketoacidosis is deteriorating? A.Deep tendon reflexes decreasing from +2 to +1

B.Bicarbonate rising from 20 mEq/L to 22 mEq/L C.Urine pH less than 6 D.Serum potassium decreasing from 6.0 mEq/L to 4.5 mEq/L 25. A client who is admitted with malnutrition and anorexia secondary to chemotherapy is also exhibiting generalized edema. The client asks the nurse for an explanation for the edema. Which of the following is the most appropriate response by the nurse? A."The fluid is an adverse reaction to chemotherapy." B."A decrease in activity has allowed extra fluid to accumulate in the tissues." "Poor nutrition has caused decreased blood protein levels, and fluid has moved from C. the blood vessels into the tissues." "Chemotherapy has increased your blood pressure, and fluid was forced out into the D. tissues." 26. A client with a recent thyroidectomy complains of numbness and tingling around the mouth. Which of the following findings indicates the serum calcium is low? A.Bone pain B.Depressed deep tendon reflexes C.Positive Chvostek's sign D.Nausea 27. A client recently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) complains of headache, weight gain, and nausea. Which of the following is an appropriate nursing diagnosis for this client? A.Deficient fluid volume related to decreased fluid intake B.Excess fluid volume related to increased water retention C.Deficient fluid volume related to excessive fluid loss D.Risk for injury related to fluid volume loss 28. The registered nurse is delegating nursing tasks for the day. WHich of the following tasks may the nurse delegate to a licensed practical nurse? A.Assess a client for metabolic acidosis B.Evaluate the blood gases of a client with respiratory alkalosis C.Obtain a glucose level on a client admitted with diabetes mellitus D.Perform a neurological assessment on a client suspected of having hypocalcemia 29. A client who is post-gallbladder surgery has a nasogastric tube, decreased reflexes, pulse of 110 weak and irregular, and blood pressure of 80/50 and is weak, mildly confused, and has a serum of potassium of 3.0 mEq/L. Based on the assessment data, which of the following is the priority intervention? A.Withhold furosemide (Lasix) B.Notify the physician C.Administer the prescribed potassium supplement D.Instruct the client on foods high in potassium 30. The nurse is admitting a client with a potassium level of 6.0 mEq/L. The nurse reports this finding as a result of A.acute renal failure. B.malabsorption syndrome. C.nasogastric drainage. D.laxative abuse 31. Which of the following should the nurse include in the diet teaching for a client with a sodium level of 158 mEq/L? A.Pretzels B.Baked chicken C.Chicken bouillon D.Baked potato E.Baked ham 32. The nurse assesses a client to be experiencing muscle cramps, numbness, and tingling of the extremities, and twitching of the facial muscle and eyelid when the

facial nerve is tapped. THe nurse reports this assessment as consistent with which of the following? A.Hypokalemia B.Hypernatremia C.Hypermagnesemia D.Hypocalcemia 33. Which of the following should the nurse include when preparing to teach a class on the regulation and functions of electrolytes? A.Sodium is essential to maintain intracellular fluid water balance Magnesium is essential to the function of muscle, red blood cells, and nervous B. system C.Less calcium is excreted with aging D.Chloride is lost in hydrochloride acid 34. The nurse assists a client with a serum potassium of 3.2 mEq/L to make which of the following menu selections? Select all that apply. A.Baked cod B.Ham and cheese omelet C.Fried eggs D.Baked potato E.Spinach 35. The nurse evaluates which of the following clients to have hypermagnesemia? A.A client who has chronic alcoholism and a magnesium level of 1.3 mEq/L B.A client who has hyperthyroidism and a magnesium level of 1.6 mEq/L A client who has renal failure, takes antacids, and has a magnesium level of 2.9 C. mEq/L A client who has congestive heart disease, takes a diuretic, and has a magnesium D. level of 2.3 mEq/L 36. The nurse is evaluating the serum laboratory results on the following four clients. Which of the following laboratory results is a priority for the nurse to report first? A.A client with osteoporosis and a calcium level of 10.6 mg/dl B.A client with renal failure and a magnesium level of 2.5 mEq/L C.A client with bulimia and a potassium level of 3.6 mEq/L D.A client with dehydration and a sodium level of 149 mEq/L 37. The registered nurse is delegating client assignments to unlicensed assistive personnel. Which of the following clients does not require additional monitoring and assessment and may be delegated to unlicensed assistive personnel? A client who has been experiencing diarrhea and has a serum chloride level of 100 A. mEq/L B.A client with renal failure who has a serum magnesium level of 3.0 mEq/L A client who has experienced a fracture of the femur and has a serum phosphate of C. 5.0 mg/dl D.A client with dehydration who has a serum sodium level of 128 mEq/L 38. The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition would be a cause for these findings? A.Overhydration. B.Anemia. C.Dehydration. D.Renal failure. 39. The client who has undergone an exploratory laparotomy and subsequent removal of a large intestinal tumor has a nasogastric tube (NGT) in place and an IV running at 150 mL/hr via an IV pump. Which data should be reported to the health care provider? A.The pump keeps sounding an alarm that the high pressure has been reached. B.Intake is 1800 mL, NGT output is 550 mL, and Foley output 950 mL.

C.On auscultation, crackles and rales in all lung fields are noted. D.Client has negative pedal edema and an increasing level of consciousness. 40. The client diagnosed with diabetes insipidus weighed 180 pounds when the daily weight was taken yesterday. This morning's weight is 175.6 pounds. One liter of fluid weighs approximately 2.2 pounds. How much fluid has the client lost (in milliliters)? A.500 mL B.1000 mL C.2000 mL D.4400 mL 41. The nurse writes the nursing problem of "fluid volume excess" (FVE). Which intervention should be included in the plan of care? A.Change the IV fluid from 0.9% NS to D5W. B.Restrict the client's sodium in the diet. C.Monitor blood glucose levels. D.Prepare the client for hemodialysis. 42. The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented? A.Encourage fluids orally. B.Administer 10% saline solution IVPB. C.Administer antidiuretic hormone intranasally. D.Place on seizure precautions. 43. The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first? A.The client in normal sinus rhythm with a peaked T wave. B.The client diagnosed with atrial fibrillation with a rate of 100. C.The client diagnosed with a myocardial infarction who has occasional PVC. D.The client with a first-degree AV block and a rate of 92. 44. The client post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should be implemented first? A.Notify the health care provider immediately. B.Tap the cheek about two (2) centimeters anterior to the ear lobe. C.Check the serum calcium and magnesium levels. D.Prepare to administer calcium gluconate IVP. 45. Which statement best explains the scientific rationale for Kussmaul's respirations in the client diagnosed with diabetic ketoacidosis (DKA)? A.The kidneys produce excess urine and the lungs try to compensate. B.The respirations increase the amount of carbon dioxide in the bloodstream. C.The lungs speed up to release carbon dioxide and increase the pH. D.The shallow and slow respirations will increase the HCO3 in the serum. 46. The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply. A.Place the solution on an IV pump at the prescribed rate. B.Monitor blood glucose every six (6) hours. C.Weigh the client weekly, first thing in the morning. D.Change the IV tubing every three (3) days. E.Monitor intake and output every shift. 47. The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds the nurse notes the IV site is tender to palpation and a red streak has formed. Which action should the nurse implement first? A.Start a new IV in the right hand. B.Discontinue the intravenous line. C.Complete an incident record. D.Place a warm washrag over the site.

48. The nurse and an unlicensed nursing assistant are caring for a group of clients.

Which nursing intervention should the nurse perform? A.Measure the client's output from the indwelling catheter. B.Record the client's intake and output on the I & O sheet. C.Instruct the client on appropriate fluid restrictions. D.Provide water for a client diagnosed with diabetes insipidus. 49. The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor? A.Serum calcium. B.Serum phosphorus. C.Serum potassium. D.Serum sodium. 50. A nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse understands that this type of fluid loss can occur through: A.The skin B.Urinary output C.Wound drainage D.The gastrointestinal tract 51. A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for deficient fluid volume? A.A client with a colostomy B.A client with congestive heart failure C.A client with decreased kidney function D.A client receiving frequent wound irrigations 52. A nurse caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition? A.Lung congestion B.Decreased hematocrit C.Increased blood pressure D.Decreased central venous pressure (CVP) 53. A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for excess fluid volume? A.The client taking diuretics B.The client with renal failure C.The client with an ileostomy D.The client who requires gastrointestinal suctioning 54. The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present? A.Weight loss B.Flat neck and hand veins C.An increase in blood pressure D.A decreased central venous pressure (CVP) 55. A 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 the client: A.Has renal failure. B.Requires nasogastric suction. C.Has a history of Addison's disease. D.Is taking a potassium-sparing diuretic. 56. A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the

electrocardiogram as a result of the laboratory value? A.U waves B.Absent P waves C.Elevated T waves D.Elevated ST segment 57. A nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium? A.Obtaining a controlled IV infusion pump B.Monitoring urine output during administration C.Diluting in appropriate amount of normal saline D.Preparing the medication for bolus administration 58. A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that the food item lowest in potassium is: A.Apples B.Carrots C.Spinach D.Avocado 59. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a potassium value at this level? A.The client with colitis B.The client with Cushing's syndrome C.The client who has been overusing laxatives D.The client who has sustained a traumatic burn 60. A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value? A.ST depression B.Inverted T wave C.Prominent U wave D.Tall peaked T waves 61. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level? A.The client with renal failure B.The client who is taking diuretics C.The client with hyperaldosteronism D.The client who is taking corticosteroids 62. A nurse is caring for a client with acute congestive 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 this client if hyponatremia were present? A.Dry skin B.Decreased urinary output C.Hyperactive bowel sounds D.Increased specific gravity of the urine 63. A nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte

results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L. Based on these laboratory findings, the nurse selects which solution to use for the nasogastric tube irrigation? A.Tap water B.Sterile water C.Sodium chloride D.Distilled water 64. A nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the physician and the physician prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid? A.Peas B.Cauliflower C.Low-fat yogurt D.Processed oat cereals 65. A nurse is reviewing a client's laboratory report and notes that the serum calcium level is 4.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level? A.Prolonged bed rest B.Renal insufficiency C.Hyperparathyroidism D.Excessive ingestion of vitamin D 66. A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client? A.Twitching B.Negative Trousseau's sign C.Hypoactive bowel sounds D.Hypoactive deep tendon reflexes 67. A nurse caring for a client with hypocalcemia would expect to note which of the following changes on the electrocardiogram? A.Widened T wave B.Prominent U wave C.Prolonged QT interval D.Shortened ST segment 68. A nurse caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which electrocardiographic change would the nurse expect to note based on the magnesium level? A.Prominent U waves B.Prolonged PR interval C.Depressed ST segment D.Widened QRS complexes 69. A nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level? A.Alcoholism B.Renal insufficiency C.Hypoparathyroidism D.Tumor lysis syndrome 70. The nurse provides instructions to a client with a low magnesium level about the foods that are high in magnesium and tells the client to consume which foods? Select all that apply. A.Peas B.Oranges C.Cauliflower D.Peanut butter

E.Canned white tuna