NURS 3000 Midterm Exam Questions With Verified Answers.
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Course
NURS 3000
Institution
NURS 3000
NURS 3000 Midterm Exam Questions With
Verified Answers.
The nurse is caring for a client with deficient fluid volume caused by a massive burn injury.
Which of the following assessment data will be of greatest concern to the nurse?
a. The blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL ...
NURS 3000 Midterm Exam Questions With
Verified Answers.
The nurse is caring for a client with deficient fluid volume caused by a massive burn injury.
Which of the following assessment data will be of greatest concern to the nurse?
a. The blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL over the last hour.
c. Oral fluid intake is 100 mL for the last 8 hours.
d. There is prolonged skin tenting over the sternum. - answer✔ANS: A
The blood pressure indicates that the client may be developing hypovolemic shock as a result of
fluid loss. This will require immediate intervention to prevent the complications associated with
systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all
indicate the need for increasing the client's fluid intake but not as urgently as the hypotension.
The nurse is caring for a client recently admitted with small cell carcinoma of the lung and the
syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following assessments
should the nurse carefully monitor?
a. Increased total urinary output
b. Elevation of serum hematocrit
c. Decreased serum sodium level
d. Rapid and unexpected weight loss - answer✔ANS: C
SIADH causes water retention and hyponatremia—a decrease in serum sodium level. Weight
loss, increased urine output, and elevated serum hematocrit may be associated with excessive
loss of water, but not with SIADH and water retention.
The nurse is evaluating the fluid balance for a client admitted for hypovolemia associated with
multiple draining wounds. Which of the following assessments is the most accurate to evaluate
volume status in this client?
a. Skin turgor
b. Daily weight
c. Presence of edema
d. Hourly urine output - answer✔ANS: B
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin
turgor varies considerably with age. Considerable excess fluid volume may be present before
fluid moves into the interstitial space and causes edema. Hourly urine outputs do not take
account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the
gastrointestinal tract or wounds
The nurse is caring for an alert and oriented older-adult client with a history of dehydration.
Which of the following information should the home health nurse teach the client as to when to
increase fluid intake?
a. In the late evening hours
b. If the oral mucosa feels dry
c. When the client feels thirsty
d. As soon as changes in level of consciousness (LOC) occur - answer✔ANS: B
An alert, elderly client will be able to self-assess for signs of oral dryness such as thick oral
secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an
accurate indicator of volume depletion. Many older clients prefer to restrict fluids slightly in the
evening to improve sleep quality. The client will not be likely to notice and act appropriately
when changes in LOC occur.
The nurse is caring for a client who is taking a potassium-wasting diuretic for treatment of
hypertension. Which of the following assessment data would the nurse include in the teaching
plan?
a. Personality changes
b. Frequent loose stools
c. Facial muscle spasms
d. Lower extremity weakness - answer✔ANS: D
Lower extremity weakness progressing to flaccidity is a manifestation of hypokalemia. Facial
muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia.
Personality changes are not associated with electrolyte disturbances, although changes in mental
status are common manifestations with sodium excess or deficit.
The nurse is teaching a client about spironolactone as a diuretic. Which statement by the client
indicates that the teaching about this medication has been effective?
a. "I will try to drink at least 8 glasses of water every day."
b. "I will use a salt substitute to decrease my sodium intake."
c. "I will increase my intake of potassium-containing foods."
d. "I will drink apple juice instead of orange juice for breakfast." - answer✔ANS: D
Since spironolactone is a potassium-sparing diuretic, clients should be taught to choose low
potassium foods such as apple juice rather than foods that have higher levels of potassium, such
as citrus fruits. Because the client is using spironolactone as a diuretic, the nurse would not
encourage the client to increase fluid intake. Teach clients to avoid salt substitutes, which are
high in potassium.
The nurse is caring for a client admitted with hyponatremia. Which of the following actions
should the nurse anticipate implementing?
a. Restrict client's oral free water intake.
b. Avoid use of electrolyte-containing drinks.
c. Infuse a solution of 5% dextrose in 0.45% saline.
d. Administer vasopressin (antidiuretic hormone, ADH). - answer✔ANS: A
To help improve serum sodium levels, water intake is restricted. Electrolyte-containing
beverages will improve the client's sodium level. Administration of vasopressin or hypotonic IV
solutions will decrease the serum sodium level further.
The nurse is caring for a client with severe hypokalemia and is preparing to administer
intravenous potassium chloride (KCl) 40 mmol as prescribed by the health care provider. Which
of the following actions should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 20 mEq/hour.
c. Give the KCl only through a central venous line.
d. Add no more than 40 mEq/L to a litre of IV fluid. - answer✔ANS: B
Intravenous KCl is administered at a maximal rate of 20 mEq/hour. Rapid IV infusion of KCl
can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mmol,
concentrations up to 60 mmol may be used for some clients. KCl can cause inflammation of
peripheral veins, but it can be administered by this route.
The nurse is caring for a client who has required prolonged mechanical ventilation and has the
following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25
mmol/L. Which of the following interpretations would the nurse document?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis - answer✔ANS: D
The pH indicates that the client has alkalosis and the low PaCO2 indicates a respiratory cause.
The other responses are incorrect based on the pH and the normal HCO3.
The nurse is caring for a client who was admitted with diabetic ketoacidosis and has rapid, deep
respirations. Which of the following actions should the nurse implement?
a. Notify the client's health care provider.
b. Give the prescribed PRN lorazepam.
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