Question 1

A client has a serum sodium level of 129 mEq/L. The nurse should prepare to administer which of the following intravenous solutions?

Accepted Answer

Normal saline (0.9%) is commonly provided to restore extracellular fluid volume and increase sodium levels. Dextrose 5% and Lactated Ringers, Dextrose 5% and 0.45% Normal Saline, and Dextrose 5% and 0.9% Normal Saline are hypertonic solutions, and they will move water from the cells into the bloodstream.

Question 2

A client has a serum potassium level of 2.9 mEq/L. Which of the following should be done to assist this client? (Select all that apply.)

Accepted Answer

Interventions for a patient with hypokalemia are continuous cardiac monitoring; assessing forflattening T-waves; monitoring for digoxin toxicity, which may cause dysrhythmias; andassessing muscle strength, tone, and reflexes. Seizure activity is a sign of a sodium imbalance.

Question 3

A client is diagnosed with a serum calcium level of 11.2 mEq/L. Which of the following interventions would be appropriate for this client? (Select all that apply.)

Accepted Answer

Management of hypercalcemia is focused on removing calcium, which is accomplished byadministering diuretics, administering intravenous fluids, and administering intravenous sodium. Continuous cardiac monitoring is needed for clients at risk for developing dysrhythmias.Restricting fluids and changing to a low-fat diet are not used to treat hypercalcemia.

Question 4

The nurse is evaluating a client who is experiencing chest pain. Which of the following should be included in this assessment? (Select all that apply.)

Accepted Answer

When evaluating a clients chest pain, the following should be assessed: pain intensity with a pain scale; duration; characteristics to include precipitating factors, onset, pattern of disappearance; recurrence and time of day; what is used to treat the pain; other symptoms such as shortness of breath or sweating; and if the pain is related to an injury or surgery. Assessment for sleepdisturbance is not a part of the chest pain assessment.

Question 5

The nurse suspects a clients heart is failing when which of the following heart sounds is assessed?

Accepted Answer

An auscultated S3 is a sign that increased blood volume remains in the ventricle with each beatand that the heart is beginning to fail. S1 and S2 sounds are the first and second sounds heardwhen auscultating the heart. An S4 sound may indicate increased resistance to ventricular filling.

Question 6

The nurse is analyzing a clients electrocardiogram tracing and realizes that each small square on the paper is equal to:

Accepted Answer

The small square on the ECG graph paper equals 0.04 second. The large square equals 0.20second. The PR interval is 0.12 to 0.20 second. Two large squares would be equal to 0.40second.

Question 7

The nurse is reading an ECG rhythm strip and notes that there are nine QRS complexes in a 6-second strip. The heart rate is:

Accepted Answer

A heart rate can be determined by multiplying the QRS complexes in a 6-second strip by 10. The heart rate is 90. This method of calculating the heart rate is the most common method usedbecause it is quick and can be used when the heart rate is irregular.

Question 8

A clients electrocardiogram tracing shows a sawtooth pattern with F waves. The nurse realizes this client is demonstrating:

Accepted Answer

Atrial flutter is characterized by F waves that occur in a characteristic sawtooth pattern. Atrialfibrillation is characterized by coarse waves with the baseline between the QRS complexes asbeing rough and uneven. Premature atrial contractions occur when an electrical impulse isgenerated in an area of the atria outside of the SA node. Atrial tachycardia is three or morepremature atrial contractions. Neither premature atrial contractions or atrial tachycardia have an F wave on the tracing.

Question 9

A client is having laboratory tests conducted to confirm a diagnosis of arteriosclerosis. Which of the following laboratory values would support this clients medical diagnosis? (Select all thatapply.)

Accepted Answer

Diagnostic tests used to support the medical diagnosis of arteriosclerosis include cholesterol,LDL, HDL, and triglycerides. A serum cholesterol of 300 mg/dL, LDL of 125 mg/dL, HDL of45 mg/dL, and triglycerides of 400 mg/dL all support the diagnosis of arteriosclerosis. Blood glucose and potassium levels are not used to diagnose arteriosclerosis.

Question 10

A client is diagnosed as being obese. The nurse realizes that this clients body mass index (BMI) is most likely:

Accepted Answer

A BMI of 25 to 29 is considered overweight. A BMI greater than 30 is considered obese. A BMIless than 18.5 is considered underweight. A BMI between 18.5 and 24.9 is considered normalweight.

Question 11

The nurse is instructing a client on ways to reduce formation of future kidney stones. Which of the following should be included in these instructions? (Select all that apply.)

Accepted Answer

Instructions to reduce the formation of kidney stones in the future include: drink plenty of fluids;avoid soft drinks; limit the intake of spinach to reduce urinary oxalate levels; vitamin B6 helpsreduce the formation of kidney stones; magnesium citrate helps prevent the formation of kidneystones; and calcium intake should be adjusted to prevent the formation of kidney stones.

Question 12

A young adult female client is concerned that she does not have enough eggs since she has not yet become pregnant. The nurse should assure her that the number of ova available to produce a pregnancy would be around:

Accepted Answer

At birth the ovaries contain between 2 and 4 million ova. Most of the ova degenerate across time until there are only 300,000 to 400,000 ova present at puberty. A woman may release fewer that 500 mature ova during monthly ovulation.

Question 13

The nurse is preparing to administer medications to a client diagnosed with varicella. Which of the following personal protective equipment should the nurse use when entering the clientsroom?

Accepted Answer

A high-efficiency particulate air filter mask is required personal protective equipment for the care of a client with varicella. A mask may be worn for clients on droplet precautions, and the gown and gloves are for a client on contact precautions.

Question 14

During the assessment of a clients muscle status, the nurse notes the client is able to complete range of motion against gravity with some resistance. The nurse would document this assessment finding as being:

Accepted Answer

Complete range of motion against gravity with some resistance is graded as being 4 or good. Complete range of motion without gravity is graded as being 2 or poor. Complete range of motion against gravity without added resistance is graded as being 3 or fair. Complete range of motion against gravity with full resistance is graded as being 5 or normal.

Question 15

A client is going to have tender points examined to determine the diagnosis of fibromyalgia. The nurse should instruct the client the number of tender points that must be positive for the diagnosis would be:

Accepted Answer

The presence of at least 11 of 18 tender points is considered diagnostic for fibromyalgia. The other higher numbers would just be useful to confirm the diagnosis.

Question 16

A client is scheduled for surgery to fuse the vertebra in the lumbar region of the spine. Thenurse should instruct the client that the number of vertebra being affected by this surgery wouldbe:

Accepted Answer

There are 5 vertebra in the lumbar spine region. This is what the nurse should instruct the clientas being fused during the surgery. There are 7 cervical vertebra, 12 thoracic, and 4 coccygealfused into one.

Question 17

A client, being tested for a stroke, is not a candidate for tPA. Which of the following would be contraindicated for the use of tPA? (Select all that apply.)

Accepted Answer

Contraindications of tPA to treat an embolic stroke include minor ischemic stroke within the last30 days, blood pressure greater an 185 mmHg systolic or greater than 110 mmHg diastolic,lumbar puncture within the last 3 days, and onset of stroke greater than 3 hours. Glucose level of 120 mg/dL and INR of 1.0 would not be contraindications for tPA therapy.

Question 18

A client being treated for a spinal cord injury needs immediate ventilatory support. The nurse realizes that this clients level of injury is most likely:

Accepted Answer

High cervical injuries above C3 will result in loss of respiratory function and death unlessventilator support is immediately provided. Spinal cord injuries at C6, T3, or L3 do not need immediate ventilatory support.

Quiz 1: Assessment of Chest Pain