NCLEX MED SURG TEST BANK LATEST 2023 Questions Answers

NCLEX MED SURG TEST BANK LATEST 2023 – Questions & Answers

• 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 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

R: Causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with congestive heart failure or decreased kidney function, or a client receiving frequent wound irrigations, is at risk for excess fluid volume.

• 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

• Decreased central venous pressure (CVP)

R: Assessment findings in a client with a deficient fluid volume include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness.The normal CVP is between 4 and 11 cm H2O. A client with dehydration has a low CVP. The assessment findings in options 1, 2, and 3 are seen in a client with excess fluid volume.

• 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

• The client with renal failure

c) The client with an ileostomy

d) The client who requires gastrointestinal suctioning

R: The causes of excess fluid volume include decreased kidney function, congestive heart failure, the use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for deficient fluid volume.

• 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

• An increase in blood pressure

d) A decreased central venous pressure (CVP) 1 / 4

R: Assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, an elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and a decreased hematocrit. Options 1, 2, and 4 identify signs noted in deficient fluid volume.

• 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.

• Requires nasogastric suction.

c) Has a history of Addison’s disease.

d) Is taking a potassium-sparing diuretic.

R: Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with renal failure or Addison’s disease and the client taking a potassium-sparing diuretic are at risk for hyperkalemia.

• 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?

• U waves

b) Absent P waves

c) Elevated T waves

d) Elevated ST segment

R: A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia.

• 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

• Preparing the medication for bolus administration

R: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via a pump or controller. The usual concentration of IV potassium chloride is 20 to 40 mEq/L. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, but dextrose solution is avoided because this type of solution increases intracellular potassium shifting. The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored closely because potassium chloride is irritating to the veins and the risk of phlebitis exists.The nurse monitors urinary output during administration and contacts the physician if the urinary output is less than 30 mL/hr. 2 / 4

• 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

• The client who has sustained a traumatic burn

R: A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing’s syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

• 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

• Tall peaked T waves

R: A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Electrocardiographic changes include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves.

• 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

• The client who is taking diuretics

c) The client with hyperaldosteronism

d) The client who is taking corticosteroids

R: Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with renal failure or hyperaldosteronism are at risk for hypernatremia.

• 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

• Hyperactive bowel sounds

d) Increased specific gravity of the urine 3 / 4

R: Hyperactive bowel sounds indicate hyponatremia. Options 1, 2, and 4 are signs of hypernatremia. In hyponatremia, increased urinary output and decreased specific gravity of the urine would be noted. Dry skin occurs in deficient fluid volume.

• 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?

• Prolonged bed rest

b) Renal insufficiency

c) Hyperparathyroidism

d) Excessive ingestion of vitamin D

R: The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 4.0 mg/dL is experiencing hypocalcemia. The excessive ingestion of vitamin D and hyperparathyroidism are causative factors associated with hypercalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia.

• 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?

• Twitching

b) Negative Trousseau’s sign

c) Hypoactive bowel sounds

d) Hypoactive deep tendon reflexes

R: Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

• 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

• Prolonged QT interval

d) Shortened ST segment

R: Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with hypokalemia.

• 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

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