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Download NSG 3100 exam 4: 50 Questions and 100% Verified Answers Graded A+ Galen College of Nursin and more Exams Nursing in PDF only on Docsity!
Graded At Galen Solkee i Nursing tl The nurse is providing teaching to clients regarding intake of dietary potassium. The nurse recognizes that the client at risk of developing an electrolyte imbalance of potassium is the client who a. _ has fatty stools from taking an over-the-counter (OTC) weight loss product. b. experiences anorexia. rc) has chronic heart failure (HF) that is being treated with diuretics. takes very large doses of vitamin D as a chemotherapy supplement. The nurse is caring for a client who has had diarrhea for 48 hours and has developed fatigue, muscle weakness, and an irregular pulse. Which of the following laboratory results should the nurse correlate to these signs and symptoms? a. Serum phosphate of 4 mEq/L. b. Serum magnesium of 2 mEq/L. c. Serum calcium of 9.5 mEq/L. \ Fy) Serum potassium of 2.8 mEq/L. The nurse is caring for a client who has multiple draining wounds and has been admitted for hypovolemia. Which of the following assessment findings is consistent with hypovolemia? a. Increased urine output. (ais) Decreased skin turgor. c. Hypertension. d. Bounding peripheral pulses. The nurse is caring for assigned clients. The nurse should see the client with which of the following symptoms first? a. | Serum potassium concentration is decreasing; abdominal distention, but denies any difficulty breathing. b. Serum calcium concentration is increasing; reports constipation; is alert and denies any discomfort. Serum potassium concentration is increasing; has developed cardiac dysrhythmias, but denies any difficulty breathing. d. Serum calcium concentration is decreasing; reports constipation; is alert and reports a pain level of 3 on a scale of 0 (no pain) to 10 (severe pain). The nurse is caring for the following clients. The nurse identifies which client as being at risk for developing metabolic acidosis? a. Theclient whois extremely anxious. coy The client who has had diarrhea for over a week. The client who has a nasogastric (NG) tube. The client who has newly diagnosed pneumonia. Page 2/12 6. The nurse is reviewing laboratory results for assigned clients. The nurse should follow-up with a client who has a a. serum chloride of 100 mEq/dL. b. specific gravity of 1.025. ce. blood sugar of 125 mg/dL. serum potassium of 6 mEq/L. 7. The nurse is caring for a client who has fluid overload. Which of the following should the nurse include in the client’s plan of care? a. Measure the client’s intake and output (I/O) every 24 hours. b. Provide the client with unlimited low-sodium liquids. 1 c. ) Assess lung sounds at least every 2 hours. Maintain the client’s head of bed (HOB) at a 90-degree angle. 8. The nurse is assessing a client who is at risk for fluid volume overload. Which of the following, assessment findings indicates hypotonic fluid volume overload? Ye) Decreased level of consciousness (LOC). b> ~=Drymucous membranes. c.. Adecreasein capillary refill. d. _ Postural hypotension. 9. The nurse is caring for a client who has severe fatigue and confusion. Which of the following laboratory values requires immediate action by the nurse? a. SaQ2 is 95%. b. Arterial blood pH is’7.32. w, Serum calcium is 18 mg/dL. Serum potassium is 5.1 mEq/L. 10. Thenurseis caring for the following clients. Which client should the nurse seefirst? a. Amiddle-aged adult who has no place to live and is ready for discharge. bX An older adult who has a decreased oral intake and has just taken a diuretic. c. Ateenager who has a sprained ankle and severe edema of the area. d. Ateenager who has a temperature (T) of 99.2° F and a decreased appetite. 11. | The nurse is caring for a client who was admitted with sepsis. Which of the following acid-base imbalances should the nurse expect to observe in this client? a. Respiratory alkalosis. b. Metabolic acidosis. | ) Metabolic alkalosis. d. 2) Respiratory acidosis. Page 3/12 17. The nurse is calculating intake and output (I/O) on a client for the end-of-shift report. The client has taken in the following: Breakfast: Lunch: 2 scrambled eggs Chicken salad sandwich 8 oz of coffee 1 bag of chips 1 piece of toast 16 oz can of diet cola 6 oz of ice cream Water for the shift: 3 glasses of water, 8 oz each The nurse should calculate the total intake as a. 1,320mL. 1,440 mL. (o 1,620 mL. = 1,560 mL. 18. The nurse is caring for a client who has a secondary diagnosis of hypermagnesemia. Which of the following assessment findings is consistent with this diagnosis? a... Hypertension. b. | Kussmaul respirations. c. ) Shallow respirations. . _ Increased deep tendon reflexes. AS) The nurse is caring for a client who complains of nausea, vomiting, bone pain, and polyuria. Which of the following assessment questions is most important for the nurse to ask? a. “Do you have a family history of these sorts of problems or any cancers?” “When you last saw your primary health care provider, did they mention low potassium?” | ¢] “Doyou take a multivitamin with both calcium and vitamin D every day?” “When was the last time that you had a bone density scan performed?” 20. The nurse is caring for a client who is 5-days postoperative and has been on bed rest. Which of the following interventions should the nurse implement to decrease the client's possibility of developing hypercalcemia? \ a) Assist the client to ambulate around the room at least 3 times daily. b. Assist the client to turn, cough, and deep breathe every 2 hours. c. Measure vital signs (VS) every 4 hours. d. __ Irrigate the client's nasogastric (NG) tube every 2 hours. Page 5/12 21. The nurse is assessing a client who is receiving intravenous (IV) magnesium sulfate. Which of the following assessment findings should the nurse report to the primary health care provider (PHCP) immediately? a. The client reports feeling “sick to my stomach.” b. Theclient has been sleeping most of the day. © The client has decreased respirations (R) of 8. The client has an increased pulse (P) of 102. 22. The nurse is caring fora client who was admitted to the acute care unit with a phosphorus level of 1.8 mg/dL. Which of the following nursing interventions supports this client's homeostasis? a. Restrict foods from outside the healthcare facility. Strain all urine. Encourage consumption of a high-calorie carbohydrate diet. 7: Encourage consumption of milk and yogurt. 23. The nurse is caring for a client who has the following arterial blood gas (ABG) results. Which laboratory value requires follow-up by the nurse? a. HCOs- 25 mEq/L. 1D _-Paco2 54mm Hg. . pil 7.35. d. SaOQ2 97%. 24. The nurse is administering a hypotonic intravenous (IV) solution toa client. The nurse understands that this type of fluid will cause shifting from a. intracellular to extracellular. intravascular to interstitial. intravascular to intracellular. ci ee, extracellular to intracellular. 25. Thenurseis caring for a client who has developed respiratory alkalosis. Which of the following should the nurse identify as the cause for this acid-base imbalance? a. Pulmonary edema. Ne] Hyperventilation. Aspiration. Hypercapnia. Page 6/12 31. | The nurse is caring for a client who is postoperative following abdominal surgery. The surgeon has initially prescribed a clear-liquid diet. Which of the following items is appropriate for the nurse to include on the client's lunch tray? a. Carrot juice. 7) Cranberry juice. c. Lemon sherbet. d. Plain yogurt. 32. The nurse is caring for a client who is obese and is receiving a 1,500-calorie weight-reduction diet in a long-term care (LTC) facility. The client has not lost weight in the past 2 weeks. Which of the following actions should the nurse take first? a. Inform the primary health care provider (PHCP) of the client’s lack of progress. > Instruct the client to keep a food diary for 3 days. SD Schedule a multidisciplinary team conference. d. Instruct the client to limit intake to 1,000 calories per day. 33. The nurse is caring for a client who is to receive multiple medications via a nasogastric (NG) tube. The nurse is concerned that the tube may become clogged. Which of the following actions is appropriate for the nurse to take? a. Mixall medications together to decrease the number of administrations. b. Check with the pharmacy for availability of the liquid forms of medications. 4c irrigate the tube with.60 mL of water after all medications are given. d. Combine all medications together and dilute with 100 mL to decrease risk of clogs. 34. The nurse is preparing to teach a client about foods that are high in vitamin C. Which of the following foods should the nurse include in the teaching? a. Milk, yogurt, and cheese. (oapayas and broccoli. c. Fish and spinach. d. Nuts and bananas. 35. The nurse is performing an admission assessment on a client. Which of the following tools provides the most information to the nurse to assess the client’s dietary intake during the interview process? a. Comprehensive diet history. 24-hour recall. Food diary. d. Calorie count. Page 8/12 36. The nurse is implementing aspiration precautions while feeding a client who recently had a stroke. Which of the following actions by the nurse requires intervention? a. ‘The nurse encourages slow eating and careful swallowing. b. Thenurse has the client alternate between food and sips of fluid. Nuc ) The nurse raises the head of the bed (HOB) to at least 25 degrees for safety. d. The nurse uses thickening in all liquids, including water. 37. The nurse is caring for a client who is receiving supplemental nutrition 2 times per day via a gastrointestinal tube (G-tube). The nurse correctly identifies this as a pureed diet. an enteral feeding. a parenteral feeding. a full-liquid diet. a 9 (.)» 38. The nurse is performing nutritional health assessments on various clients. Which of the following clients should the nurse identify as being at greatest risk for malnutrition? a. The client who works at a desk all day and has a body mass index (BMI) of 26. b. Theclient who is widowed, lives with adult children, and eats out once a week with friends. c. The client who is 16 years old, pregnant and frequently takes antacids for heartburn. d. ‘The client who isa vegetarian and includes whole grains and fruits in their dict. 39. Aclient tells the nurse that they try to keep their fat intake at less than 15% of their total caloric intake per day. Which of the following is an appropriate response by the nurse? " a ™ “Limiting fat prevents some diseases, but your fat intake is much lower than the 25% recommended.” b. “Eating fat is essential for good health, and you should consume about 40% of your fats as monounsaturated fat.” ce. “Ifyou want to bring your fat intake down further, you might want to eliminate eating fast foods.” d. “That is admirable; it would be great if more people could accomplish fat intake that low ona daily basis.” 40. The nurse is attempting to open an occluded percutaneous endoscopic gastrostomy (PEG) tube. Which of the following actions by the nurse requires follow-up? a. Flushing the tube with a special enzyme solution. a) Reinserting the stylet to break up the clot. Flushing the tube using a 50- to 60-mL syringe and 20 to 30 mL of warm water. Flushing the tube with a small amount of air. Page 9/12 45. The nurse is confirming the placement of a newly inserted nasogastric (NG) tube for a client. Which of the following is the most reliable action for the nurse to take to confirm placement of the tube? Apply a drop of aspirate onto a pH test paper to measure acidity of the aspirate. a b. ) Request a prescription for a radiograph (x-ray) to confirm placement of the tube. C. Assess the appearance of aspirate from the tube. d Auscultate for placement by inserting air into the tube. 46. The nurse is educating a client who has osteoporosis. In addition to calcium, which of the following vitamin supplements does the nurse anticipate the primary health care provider (PHCP) will prescribe for the client? a. Vitamin B. Vitamin D. c. Vitamin K. d. Vitamin E. 47. The nurse is caring for a client who has a pereutancous endoscopic gastrostomy (PEG) tube and is scheduled to receive a bolus feeding. Which of the following actions should the nurse take prior to administering the feeding? a) Aspirate and measure the gastric residual. Inject air into the stomach via the tube and auscultate. ce. Ensure the feeding is at refrigerator temperature. d. Change the dressing around the tube insertion site. 48. The nurse is feeding an 80-year-old client who is diagnosed with dysphagia. Which of the following actions should the nurse take? a. Allow the client to eat dessert first if preferred allowing the client to get some nutrition. (Ee allew the client sips of thickened liquids between bites of food to assist with swallowing. Combine the client’s pureed food in a single cup to promote swallowing. d. Provide more simple carbohydrates to allow the bady to easily absorb the carbohydrates. 49. The nurse is reviewing nutritional risk factors for assigned clients. Which of the following clients should the nurse identify as being at risk for nutritional deficiency? a. The client who is being discharged with a prescription for an oral antibiotic for the treatment of pneumonia. b. The client who is taking an occasional antacid for indigestion. Nea The client who is starting a pureed diet for the development of dysphagia. d. The cclient who is tolerating the advancement of diet following bowel surgery. Page 11/12 50. Thenurse is caring fora client who has iron-deficiency anemia. Which of the following foods isbest for the nurse to recommend? a ) Spinach. b. Milk. c. Soy products. d. Raisins. Page 12/12 
