Saunder's Comprehensive NCLEX Review Practice Questions with correct answers graded A+ alr, Exams of Nursing

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Which teaching method is most effective when providing instruction to members of special populations?

1. Teach-back
2. video instruction
3. written materials

4. verbal explanation - correct answer 1. Teach-back

Rationale: When providing education to members of special populations, return explanation and demonstration (teach-back) of are particular importance to ensure safety and mutual understanding. This method is the most reliable in confirming the client understands the instructions. Which health concerns should the nurse be aware of as risk factors when caring for clients of African American descent? Select all that apply:

1. cancer
2. obesity
3. hypertension
4. heart disease
5. hypothyroidism

6. diabetes mellitus - correct answer 1, 2, 3, 4, 6

Rationale: obesity, diabetes mellitus, hypertension, heart disease, asthma, and cancer are prevalent among African Americans. The nurse is planning care for a client of Native Hawaiian descent who recently had a baby. The nurse develops a teaching plan and includes info about which measure that's related to a newborn complication within this ethnic group?

1. safe sleeping 2. car seat safety 3. breast-feeding

4. baby-proofing - correct answer 1. Safe sleeping

Rationale: The native Hawaiian population has a disproportionately higher rate of infant mortality compared with other ethnic groups. Sudden Infant Death Syndrome (SIDS) is a major cause of infant mortality. Safe sleeping is an important measure to prevent this newborn complication. The nurse is planning care for an assigned client. The nurse should include info in the plan of care about the prevention of HIV for which individuals specifically at risk?

Saunder's Comprehensive NCLEX

Review Practice Questions with correct

answers graded A+ already passed!.....

1. lesbian persons
2. men-who-have-sex-with-men (MSM)
3. women-who-have-sex-with-women (WSW)

4. Female-To-Male (FTM) transgender persons - correct answer 2.

MSM

Rationale: MSM (men who have sex with men) are at a higher risk for HIV and AIDS. Which therapeutic communication technique is most helpful when working with transgender persons?

1. using open-ended questions
2. using their first name to address them 3. using pronouns associated with birth sex

4. anticipating the client's needs and making suggestions - correct

answer 1. Using open-ended questions

Rationale: The use of open-ended questions is the most helpful in communicating with transgender persons because it assists in refraining from judgment and allows the client the opportunity to express their thoughts and feelings. Which special population should be targeted for breast cancer screening by way of mammography? Select all that apply:

1. male-to-female (MTF)
2. female-to-male (FTM)
3. men-who-have-sex-with-men (MSM)
4. women-who-have-sex-with-men (WSM)

5. women-who-have-sex-with-women (WSW) - correct answer 1, 2, 4,

Rationale: Transgender persons who have undergone sexual reassignment surgery should have the respective preventive screenings. WSW and WSM should also have screenings. The nurse is volunteering with an outreach program to provide basic healthcare for homeless people. Which finding, if noted, should be addressed first?

1. BP 154/
2. visual acuity of 20/200 in both eyes 3. random blood glucose level of 206
3. complaints of pain associated with numbness and tingling in both feet - correct answer 4. complaints of pain associated with numbness and tingling in both feet Rationale: With this population, the complaints of pain associated with

numbness and tingling should be addressed first. If the client perceives value to the service provided, they will be likely to provide follow-up care. While the bp, blood glucose, and vision are concerning, the client's stated concern should be addressed first.

The nurse is preparing discharge resources for a client being discharged to the homeless shelter. When looking at the discharge medication reconciliation form, the nurse determines there is a need for follow-up if which medication was prescribed? 1. Glipizide

2. Lisinopril
3. Metformin

4. Beclomethasone - correct answer 1. Glipizide

Rationale: Glipizide is an oral hypoglycemic medication and is classified as a sulfonylurea. A major side effect of this medication is hypoglycemia, which is a safety risk to the homeless population. Lisinopril is an angiotensin- converting enzyme inhibitor. Although there are side effects that should be included in discharge instructions, there is less of a threat to safety with this medication and the benefits to it are important. Metformin is an oral biguanide and is used for type 2 diabetes mellitus. Hypoglycemia is less of a concern with this medication compared with other oral hypoglycemics. Beclomethasone is an inhaled corticosteroid used for obstructive lung disease, and although there are side effects the client should know about, there is not a particular safety risk associated with this medication for the homeless person. The nurse is completing the admission assessment for a client who is intellectually disabled. Which part of the client encounter may require more time to complete?

1. the history
2. the physical assessment 3. the nursing plan of care

4. the readmission risk assessment - correct answer 1. the history

Rationale: intellectually disabled clients tend to be poor historians, and it may take more time to ask questions in different ways when collecting the history data. The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How should the nurse respond?

1. "health care is very limited in the prison setting"
2. "living in a prison isn't different than living at home"
3. "living in a prison can predispose a person to different health conditions"
4. "living in a prison is similar to living in a condominium complex or

dorm" - correct answer 3. "living in a prison can predispose a

person to different health conditions" Rationale: the environment of a prison can predispose a person to different health conditions. Option 1 does not address the client's question and options 2 and 4 convey incorrect information.

A nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? Select all that apply:

1. asthma
2. claustrophobia

3. sleep problems
4. bipolar disorder
5. aggressive behavior

6. ADHD - correct answer 3, 4, 5, 6

Rationale: foster children are at risk for a variety of health conditions later in life, including ADHD, aggressive behavior, anxiety disorder, bipolar disorder, depression, mood disorder, PTSD, reactive detachment disorder, sleep problems, prenatal drug and alcohol exposure, and personality disorder. Claustrophobia and asthma are not specifically associated with foster children. The nurse is caring for a female client in the ED who presents with a complaint of fatigue and SOB. Which physical assessment findings, if noted by the nurse, warrant a need for follow up?

1. reddened sclera of the eyes 2. dry flaking noted on the scalp
2. a reddish-purple mark on the neck

4. a scaly rash noted on the elbows and knees - correct answer

3. a reddish-purple mark on the neck Rationale: The client should be screened for abuse. Battered women experience bruises, particularly around the eyes, red or purple marks on the neck, sprained or broken wrists, chronic fatigue, SOB, muscle tension, involuntary shaking, changes in eating and sleeping, sexual dysfunction, and fertility issues. Mental health issues can also arise including PTSD, nightmares, anxiety, uncontrollable thoughts, depression, anxiety, low self- esteem, and alcohol and drug abuse. Reddened sclera, a dry rash on the elbows, and flaking of the scalp do not indicate abuse. The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population?
4. hypertension
5. hyperlipidemia
6. substance abuse disorder

4. PTSD - correct answer 4. PTSD

Rationale: PTSD is extremely common in this population. Identifying and treating mental health disorders assists in lowering the suicide risk. Treatment of comorbid conditions such as PTSD may also help address any substance abuse disorder. Use of screening tools in identifying substance use disorder is helpful. Treatment of PTSD includes exposure therapy, psychotherapy, and family/group therapy. Hypertension and hyperlipidemia are important but not priority; the risk of suicide and other safety concerns associated with PTSD are the priority for this population. The nurse caring for a refugee considers which health care need a

priority for this client?

1. access to housing
2. access to clean water 3. access to transportation

4. access to mental health care services - correct answer 4. access

to mental health care services Rationale: Mental health problems are the primary issue for this population as a result of tortuous events. While all the other options are important, they do not address the specific needs of this special population. Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness?

1. arranging for home health care
2. focusing on managing a single illness at a time
3. communicating with one provider only to avoid confusion for the client
4. allowing the client to teach a support person about their treatment

regimen - correct answer 1. arranging for home health care

Rationale: Nursing follow-up visits are important in promoting health for individuals with chronic illness, therefore, arranging for home health care is an important strategy. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report?

1. The client fell out of bed.
2. The client climbed over the side rails. 3. The client was found lying on the floor.

4. The client became restless and tried to get out of bed. - correct

answer 3. the client was found lying on the floor

Rationale: The occurrence report should contain a factual description of the occurrence, any injuries experienced by those involved, and the outcome of the situation. The other options are interpretations of the situation, not facts. A client is brought to the ED by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?

1. obtain a court order for the surgical procedure 2. ask the EMS team to sign the informed consent
2. transport the victim to the operating room for surgery

4. call the police to identify the client and notify the family - correct

answer 3. transport the victim to the operating room for surgery

Rationale: two situations where informed consent is not needed are when an emergency is present and delaying treatment in order to get informed consent would result in injury or death to the client, or when the client waives the right to get informed consent. A nurse has just assisted a client back to bed after a fall. The nurse and primary healthcare provider have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse should implement which action next?

1. reassess the client
2. conduct a staff meeting to describe the fall
3. contact the nursing supervisor to update info regarding the fall
4. document in the nurse's notes that an occurrence report was

completed - correct answer 1. reassess the client

Rationale: after a client's fall, the nurse must frequently reassess the client. Their fall should be treated as private information and given on a "need to know" basis. The nurse does not need to put the completion of the occurrence report in the nurse's notes. A nurse arrives at work and is told to float to the ICU for the day because they're understaffed and need additional nurses to care for clients. The nurse has never worked in the ICU. The nurse should take which best action?

1. refuse to float to the ICU because of lack of unit orientation
2. clarify the ICU client assignment with the team leader to ensure it's a safe assignment 3. ask the nursing supervisor to review the hospital policy on floating
3. submit a written protest to nursing administration, and then call the

hospital lawyer - correct answer 2. clarify the ICU client assignment

with the team leader to ensure it's a safe assignment Rationale: Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can only work in a specified area or the nurse can prove the lack of knowledge for the performed tasks. The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around her upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?

1. call security
2. call police
3. call the nursing supervisor

4. lock the coworker in the medication room until help is obtained -

correct answer 3. call the nursing supervisor

Rationale: the nurse practice act requires reporting impaired nurses. The nurse should report it to the nursing supervisor.

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client?

1. "I will sign as a witness to your signature" 2. "you will need to find a witness on your own"
2. "whoever is available at the time will sign as a witness for you"
3. "I will call the nursing supervisor to seek assistance regarding your

request" - correct answer 4. "I will call the nursing supervisor to

seek assistance regarding your request" Rationale: Living wills are required to be in writing and signed by the client, and their signature must be witnessed or notarized. Laws regarding living wills vary by state to state, and many states inhibit any employee from being a witness. The nurse has made an error in documentation of dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another RN witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the MAR that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which actions to correct the MAR? Select all that apply:

1. complete and file an occurrence report
2. right-click on the entry and modify it to reflect the correct information
3. document the correct information and end with the nurse'e signature and title
4. obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg 5. document in a nurse's note in the client's record

detailing the corrected information. - correct answer 2, 3, 4, 5

Rationale: Electronic health records will have a time date stamp that indicates an amendment has been entered. If the nurse makes an error, they should follow agency protocols to correct the error. In the MAR the nurse can right click on the entry and modify it to correct it. Since this is an opioid medication, the nurse should obtain a cosignature from the RN who witnessed the wasting of the excess medication. A nurse's note should be used to detail the event and the corrections made, and the nurse's name and title will be stamped on the entry in the record. An occurrence report is not needed in this situation. Which identifies accurate nursing documentation notations? Select all that apply: 1. The client slept through the night

2. Abdominal wound dressing is dry and intact without drainage
3. The client seemed angry when awakened for vital sign measurement
4. The client appears to become anxious when it is time for respiratory treatments
5. The client's left lower medial leg wound is 3cm in length without redness,

• drainage, or edema - correct answer 1, 2,

Rationale: Factual documentation has descriptive, objective information about what the nurse sees, feels, hears, or smells. Inferences and vague terms are not acceptable because its an opinion/not factual. A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of this client right?

1. performing a procedure without consent 2. threatening to give a client medication
2. telling the client that he or she cannot leave the hospital

4. observing care provided to the client without the client's permission -

correct answer 4. observing care provided to the client without the

client's permission Rationale: invasion of privacy occurs with unreasonable intrusion into an individual's private affairs. Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the UAP violated?

1. Libel
2. Slander
3. Assault

4. Negligence - correct answer 2. Slander

Rationale: Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation either in writing (libel) or verbally (slander). An older woman is brought to the ED for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he gets home from work. Which is the most appropriate nursing response? 1. "Oh, really? I will discuss this situation with your son"

2. "Lets talk about ways you can manage your time to prevent this from happening"
3. "Do you have any friends who could help you out until you resolve these issues with your son?"
4. "As a nurse, I am legally bound to report abuse. I will stay with you while

you give the report and help find a safe place for you to stay" - correct

answer 4. "As a nurse, I am legally bound to report abuse. I will stay with

you while you give the report and help find a safe place for you to stay" Rationale: The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases.

The nurse calls the primary hc provider regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the primary hc provider, and the medication is due to be administered. Which action should the nurse take?

1. contact the nursing supervisor 2. administer the dose prescribed
2. hold the medication until the primary hc provider can be contacted
3. administer the recommended does until the primary hc provider can

be located - correct answer 1. contact the nursing supervisor

Rationale: If the primary care provider writes a prescription that requires clarification, it is the nurse's responsibility to contact them. If that is not able to happen, the nurse should contact the nursing supervisor or nurse manager for further clarification as to what the next step should be. The nurse employed in a hospital is waiting to receive a report from the lab from the fax machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photo. Which is the most appropriate nursing action?

1. call the police
2. cut up the photo and throw it away
3. call the nursing supervisor and report the occurrence

4. call the lab and ask for the name of the individual who sent the photo -

correct answer 3. call the nursing supervisor and report the

occurrence The nurse is assigned to care for 4 client. In planning client rounds, which client should the nurse assess first?

1. a post-op client preparing for discharge with a new medication
2. a client requiring daily dressing changes of a recent surgical incision
3. a client scheduled for a chest x-ray after an insertion of a nasogastric tube
4. a client with asthma who requested a breathing treatment during the

previous shift - correct answer 4. a client with asthma who

requested a breathing treatment during the previous shift Rationale: airway is always the highest priority, and since the client had difficulty breathing during the previous shift they should assess them first. The nurse employed in an ED is assigned to triage clients coming to the ED for treatment on the evening shift. The nurse should assign priority to which client? 1. a client complaining of muscle aches, headache, and a history of seizures

2. a client who twisted her ankle when rollerblading and is requesting medication for pain
3. a client with a minor laceration on the index finger sustained while cutting an eggplant 4. a client with chest pain who states that he just ate pizza that

was made with a very spicy sauce - correct answer 4. a client with

chest pain who states that he just ate pizza that was made with a very spicy sauce

Rationale: clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, acute neurological defects, or who have sustained chemical splashes to the eyes are classified as emergent and are priority. A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the hc facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice?

1. each staff member is assigned a specific task for a group of clients
2. a staff member is assigned to determine the client's needs at home and begin discharge planning
3. a single RN is responsible for providing care to a group of 6 clients with the help of assistive personnel
4. an RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing

care to a group of 12 clients - correct answer 4. an RN leads 2

licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients Rationale: in team nursing, nursing personnel are led by a RN leader in providing care to a group of clients. The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1. a client who is ambulatory demonstrating steady gait

2. a post-op client who has just received an opioid pain med
3. a client scheduled for PT for their first crutch-walking session

4. a client with a WBC count of 14,000 mm and a temp of 38.4 C -

correct answer 4. a client with a WBC count of 14,000 and a temp

of 38.4 C Rationale: The nurse should plan to care for the client who has an elevated WBC count and a fever first because their needs are the priority. The nurse is giving a bed bath to an assigned client when an AP enters the client's room and tells the nurse another assigned client is in pain and needs pain meds. Which is the most appropriate nursing action?

1. finish the bed bath and then administer the pain med to the other client 2. ask the AP to find out when the last pain med was given to the client
2. ask the AP to tell the client in pain the med will be administered as soon as the bed bath is done
3. cover the client, raise the side rails, tell the client you'll return soon, and

give the pain med to the other client - correct answer 4. cover the

client, raise the side rails, tell the client you'll return soon, and give the pain med to the other client

Rationale: the nurse should provide safety to the client receiving the bed bath and prepare to give the pain med.

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An AP is resistive to the change and is not taking an active part to facilitate the process of change. Which is the best approach in dealing with the AP?

1. Ignore the resistance
2. exert coercion on the AP
3. provide a positive reward system for the AP
4. confront the AP to encourage verbalization of feelings regarding the

change - correct answer 4. confront the AP to encourage

verbalization of feelings regarding the change Rationale: confrontation is an important strategy to meet resistance head-on. The RN is planning client assignments for the day. Which is the most appropriate assignment for an AP?

1. a client requiring a colostomy irrigation
2. a client receiving continuous tube feedings
3. a client who requires urine specimen collections

4. a client with difficulty swallowing food and fluids - correct

answer 3. a client who requires urine specimen collections

Rationale: The AP is skilled in the procedure of a urine specimen collection. Colostomy irrigations and tube feedings are not performed by APs because they're invasive procedures, and the client with difficulty swallowing is at risk for aspiration. The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply:

1. open doors to client rooms
2. move beds away from windows 3. close window shades and curtains
3. place blankets over client confined to beds

5. relocate ambulatory clients from the hallways back into their rooms -

correct answer 2, 3, 4

The nurse employed in a LTC facility is planning assignments for the clients in a nursing unit. The nurse needs to assign 4 clients and has a LPN and 3 APs on a nursing team. Which client would the nurse most appropriately assign to the LPN?

1. a client who requires a bed bath
2. an older client requiring frequent ambulation
3. a client who needs hourly vital sign measurements
4. a client requiring abdominal wound irrigations and dressing changes

every 3 hours - correct answer 4. a client requiring abdominal

wound irrigations and dressing changes every 3 hours

Rationale: giving a bed bath, assisting with frequent ambulation, and taking vitals can be done by an AP. The LPN is trained in wound irrigations and dressing changes so this is an appropriate assignment for them. The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply:

1. the acuity level of the clients
2. specific responses from the staff
3. the clustering of the rooms on the unit
4. the number of anticipated client discharges

5. client needs and worker needs and abilities - correct answer 1, 5

Rationale: staff requests, convenience in clustering of rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

1. weight loss and dry skin
2. flat neck and hand veins and decreased urinary output 3. an increase in bp and increased respirations

4. weakness and decreased central venous pressure (CVP) - correct

answer 3. an increase in bp and increased respirations

Rationale: Assessment findings associated with fluid volume excess are cough, dyspnea, crackles, tachypnea, tachycardia, elevated bp, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered LOC, and decreased hematocrit. The nurse reviews a client's record and determines that the client is at risk for developing a K+ deficit if which situation is documented?

1. sustained tissue damage 2. requires nasogastric suction
2. has a history of addison's disease

4. uric acid level of 9.4 mg/dl (557 mcmol/L) - correct answer 2.

requires nasogastric suction Rationale: the normal serum K+ level is 3.5 to 5.0. K+-rich GI fluids are lost through GI suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The nurse reviews a client's electrolyte lab report and notes the client's K+ level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for

on the ECG as a result of the lab value? Select all that apply:

1. U waves
2. absent P waves 3. inverted T waves
3. depressed ST segment

5. widened QRS complex - correct answer 1, 3, 4

Rationale: A serum K+ level lower than 3.5 indicates hypokalemia. K+ deficit is an electrolyte imbalance that can be potentially life-threatening. ECG changes include shallow, flat, or inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not present in hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and hypermagnesemia. Potassium chloride intravenously is prescribed for a client with HF experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the K+? Select all that apply:

1. obtain an IV infusion pump
2. monitor urine output during administration
3. prepare the medication for bolus administration
4. monitor the IV site for signs of infiltration or phlebitis
5. ensure the medication is diluted in the appropriate volume of fluid

6. ensure the bag is labeled so it reads the volume of K+ in the solution -

correct answer 1, 2, 4, 5, 6

Rationale: potassium chloride administered IV must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). The IV bag containing the potassium chloride should always be labeled with the amount of potassium it contains. The IV site is monitored closely, because it's irritating to the veins and there's a risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors for urine output during administration and should contact the doctor if urinary output is less than 30 mL/hour. The nurse is assessing a client with lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

1. twitching
2. hypoactive bowel sounds 3. negative Trousseau's sign

4. hypoactive deep tendon reflexes - correct answer 1. twitching

Rationale: A client with lactose intolerance is at risk for developing hypocalcemia, because food products that contain calcium also contain lactose. The normal serum calcium level is 9 to 10.5. A serum calcium level under 9 indicates hypocalcemia. 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 neuromuscular excitability, muscle cramps, twitching, tetany,

seizures, irritability, and anxiety. GI symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dl (2mmol/L). Which patterns would the nurse watch for on the ECG? Select all that apply: 1. U waves

2. widened T waves 3. Prominent U wave
3. Prolonged QT interval

5. Prolonged ST segment - correct answer 4, 5

Rationale: A client with Chron's disease is at risk for hypocalcemia. The normal serum calcium level is 9 to 10.5, and a serum calcium level lower than 9 indicates hypocalcemia. ECG changes that occur in a client with hypocalcemia include a prolonged QT interval, and prolonged ST segment. A shortened ST segment and wider T wave occur with hypercalcemia. ST segment depression and prominent U wave occurs with hypokalemia. The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the K+ level is 5.7 mEq/L. Which patterns would the nurse watch for on the cardiac monitor as a result of the lab value? Select all that apply:

1. ST depression
2. prominent U wave 3. tall peaked T waves
3. prolonged ST segment

5. widened QRS complexes - correct answer 3, 5

Rationale: The client with chronic kidney disease is at risk for hyperkalemia. The normal K+ level is 3.5 to 5. A serum K+ level greater than 5 indicates hyperkalemia. ECG changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave are signs of hypokalemia. A prolonged ST segment occurs in hypocalcemia. Which client is at risk for the development of a Na+ level of 130 mEq/L? 1. the client who is taking diuretics

2. the client with hyperaldosteronism 3. the client with Cushing's syndrome

4. the client who's taking corticosteroids - correct answer 1. the

client who is taking diuretics Rationale: The normal serum sodium level is 135 to 145. A serum sodium level of 130 indicates hyponatremia. Hyponatremia can occur in a client taking diuretics. The client taking corticosteroids and the client with

hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.