Fluid & Electrolytes and Eyes and Ears NCLEX questions

Fluid & Electrolytes and Eyes and Ears NCLEX questions Leave the first rating Students also studied Terms in this set (46) Science MedicineNursing Save Drugs on Test 1 Med Surg 107 terms marissaa0Preview Mental Health Exam 1 114 terms marissaa0Preview LPN Unit Exam 1 97 terms vlambert21Preview

Ch. 6: A

76 terms mar The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

• Blood pressure is 90/40 mm Hg.
• Urine output is 30 mL over the last hour.
• Oral fluid intake is 100 mL for the last 8 hours.
• There is prolonged skin tenting over the sternum.

blood pressure is 90/40

• multiple choice options

A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?

• Skin turgor
• Daily weight
• Presence of edema
• Hourly urine output

daily weight

• multiple choice options

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?

• Increase fluids if your mouth feels dry.
• More fluids are needed if you feel thirsty.
• Drink more fluids in the late evening hours.
• If you feel lethargic or confused, you need more to

drink.increase fluids if your mouth feels dry

• multiple choice options

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action?

• Assess for facial muscle spasms
• Ask the patient about loose stools
• Suggest that the patient avoid orange juice with meals.
• Ask the health care provider to order a basic metabolic

panel ask the health care provider to order a basic metabolic panel

• multiple choice options

A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?

• assign the patient to a room near the nurses station.
• place the patient in a room nearest to the water

fountain.

• place the patient on telemetry to monitor for peaked T

waves.

• assign the patient to a semi-private room and place an

order for a low-salt diet.assign the patient to a room near the nurses station

• multiple choice options

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?

• Administer the KCl as a rapid IV bolus.
• Infuse the KCl at a rate of 10 mEq/hour.
• Only give the KCl through a central venous line.
• Discontinue cardiac monitoring during the infusion.

infuse the KCl at a rate of 10 mEq/hour

• multiple choice options

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?

• Infuse 5?xtrose in water at 125 mL/hr. b. Administer

IV morphine sulfate 4 mg every 2 hours PRN.

• Give IV metoclopramide (Reglan) 10 mg every 6 hours

PRN for nausea.

• Administer 3% saline if serum sodium decreases to less

than 128 mEq/L.infuse 5?xtrose in water at 125 mL/hr

• multiple choice options

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?a.Pallor b.Edema c.Confusion d.Restlessness edema

• multiple choice options

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?a.Lung sounds b.Urinary output c.Peripheral pulses d.Peripheral edema lung sounds

• multiple choice options

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?

• Oral digoxin (Lanoxin) 0.25 mg daily b.Ibuprofen

(Motrin) 400 mg every 6 hours c. Metoprolol (Lopressor) 12.5 mg orally daily.

• Lantus insulin 24 U subcutaneously every evening

oral digoxin (lanoxin) 0.25 mg daily

• multiple choice options

A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make?

• Daily alcohol intake
• Intake of dietary protein
• Multivitamin/mineral use
• Use of over-the-counter (OTC) laxatives

daily alcohol intake

• multiple choice options

A patient has a parenteral nutrition infusion of 25?xtrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate?

• There is a decreased risk for infection when 25%

dextrose is infused through a central line.

• The prescribed infusion can be given much more

rapidly when the patient has a central line.

• The 25?xtrose is hypertonic and will be more

rapidly diluted when given through a central line.

• The required blood glucose monitoring is more

accurate when samples are obtained from a central line.the 25?xtrose is hypertonic and will be more rapidly diluted when given through a central line

• multiple choice options

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?

• Oral temperature of 100.1 F
• Serum sodium level of 138 mEq/L (138mmol/L)
• Gradually decreasing level of consciousness (LOC)
• Weight gain of 2 pounds (1 kg) above the admission

weight gradually decreasing level of consciousness (LOC)

• multiple choice options

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of just blowing up and has peripheral edema and shortness of breath. Which assessment should the nurse complete first?

• Skin turgor
• Heart sounds
• Mental status
• Capillary refill

mental status

• multiple choice options

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?

• The patient's radial pulse is 105 beats/minute.
• There is sediment and blood in the patient's urine.
• The blood pressure increases from 120/80 to 142/94.
• There are crackles audible throughout both lung fields.

there are crackles audible throughout both lung fields

• multiple choice options

The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing?

• A Tono-pen will be applied to the surface of the eye.
• The test involves reading a Snellen chart from 20 feet.
• Medications will be used to dilate the pupils for the

test.d .The examination involves checking the pupils reaction to light.a tono-pen will be applied to the surface of the eye

• multiple choice options

The nurse is performing an eye examination on a 76-year- old patient. The nurse should refer the patient for a more extensive assessment based on which finding?

• The patients sclerae are light yellow.
• The patient reports persistent photophobia.
• The pupil recovers slowly after responding to a bright

light.

• There is a whitish gray ring encircling the periphery of

the iris.the patient reports persistent photophobia

• multiple choice options

The nurse performing an eye examination will document normal findings for accommodation when

• shining a light into the patient's eye causes pupil

constriction in the opposite eye.

• a blink reaction follows touching the patient's pupil with

a piece of sterile cotton.

• covering one eye for 1 minute and noting pupil

constriction as the cover is removed. d. the pupils constrict while fixating on an object being moved closer to the patient's eyes.the pupils constrict while fixating on an object being moved closer to the patient's eyes

• multiple choice options