Question 1

The nurse admitting a 5 month-old who vomited nine times in the past six hours should observe for signs of?

Accepted Answer

Answer reason: Repeated vomiting causes loss of gastric hydrochloric acid, leading to a metabolic alkalosis.

Question 2

A nurse is caring for a patient with acute kidney injury caused by hypovolemia. Which finding is most consistent with this condition?

Accepted Answer

Answer reason: Hypovolemia reduces renal perfusion, causing oliguria. Rising BUN and creatinine typically accompany AKI; alkalosis and hypokalemia are not characteristic.

Question 3

A nurse is caring for a patient with severe dehydration. Which finding indicates effective rehydration?

Accepted Answer

Answer reason: Improved renal perfusion results in increased urine output, making it one of the earliest signs of successful rehydration.

Question 4

What acid base imbalance should the nurse suspect in a patient with fentanyl overdose?

Accepted Answer

Answer reason: Fentanyl is an opioid that depresses the central nervous system and the respiratory drive, causing hypoventilation. Hypoventilation leads to CO2 retention, elevating PaCO2 and lowering blood pH, which is respiratory acidosis. Respiratory alkalosis would occur with hyperventilation, and metabolic disturbances are not the primary effect of opioid overdose.

Question 5

What acid-base imbalance should the nurse suspect in a patient with 38 breaths/minute due to anxiety?

Accepted Answer

Answer reason: A respiratory rate of 38/min due to anxiety indicates hyperventilation, which blows off CO2 and decreases PaCO2, raising blood pH. This is the classic mechanism of respiratory alkalosis. Metabolic acidosis/alkalosis are primary bicarbonate disturbances rather than ventilation problems. Respiratory acidosis occurs with hypoventilation and CO2 retention, not with anxiety-induced tachypnea.

Question 6

Patient with peptic ulcer disease takes excessive amount of antacids. Which acid-base imbalance should the nurse assess for?

Accepted Answer

Answer reason: Excessive intake of antacids (e.g., calcium carbonate or sodium bicarbonate) increases systemic bicarbonate, raising serum HCO3− and producing a primary metabolic alkalosis. The respiratory system compensates with hypoventilation, not with a primary respiratory disorder. Antacid overuse does not cause metabolic acidosis. Therefore, the nurse should assess for metabolic alkalosis.

Question 7

Signs of severe dehydration include?

Accepted Answer

Answer reason: Severe dehydration reduces intravascular volume, leading to lethargy from decreased cerebral perfusion. Tissue fluid loss produces sunken eyes. A very slow skin pinch (markedly decreased skin turgor) indicates significant interstitial fluid depletion. Therefore, all listed findings are signs of severe dehydration.

Question 8

The best nursing intervention in diarrhoea is?

Accepted Answer

Answer reason: Diarrhoea causes increased loss of water and electrolytes, making dehydration and hypovolemia the most immediate and common risks. Nursing priorities focus on maintaining hydration status through oral rehydration (or IV fluids if needed), monitoring intake/output, and assessing for signs of dehydration. Headache prevention and sleep promotion are secondary comfort measures. Antibiotics are not routinely indicated for all diarrhoea and should be used only when a bacterial cause is suspected/confirmed and prescribed.

Question 9

What is the priority for a patient with diabetic ketoacidosis (DKA)?

Accepted Answer

Answer reason: In DKA, the immediate life-threatening problem is severe dehydration and hypovolemia from osmotic diuresis, which can progress to shock and impaired perfusion. Initial priority is rapid isotonic IV fluid resuscitation (e.g., 0.9% normal saline) to restore circulating volume and support renal perfusion. Insulin is started after initial fluids and assessment/correction of potassium because insulin can drive potassium into cells and precipitate dangerous hypokalemia. Acidosis typically improves with fluids and insulin; bicarbonate is rarely first-line unless severe acidemia.

Question 10

The nurse is assessing a client with acute renal failure. Which of the following electrolyte imbalances should be the priority concern for the nurse?

Accepted Answer

Answer reason: In acute renal failure, impaired potassium excretion commonly leads to hyperkalemia, which can rapidly cause life-threatening cardiac dysrhythmias and cardiac arrest. Therefore, potassium elevation is the most immediate safety priority compared with calcium or phosphate abnormalities. Hypocalcemia and hyperphosphatemia can occur with renal failure, but they are typically less immediately fatal than severe hyperkalemia. Hypokalemia is not the expected primary imbalance in acute renal failure.

Question 11

A client with type 2 diabetes is scheduled for surgery in the morning. The nurse notes the client's blood glucose is 55 mg/dL after receiving insulin. What should the nurse do NEXT?

Accepted Answer

Answer reason: A blood glucose of 55 mg/dL indicates clinically significant hypoglycemia, which requires immediate treatment before any further preoperative steps. For a conscious patient who can swallow safely, rapid-acting carbohydrates (e.g., orange juice or glucose tablets) are first-line to quickly raise blood glucose. Giving more insulin would worsen hypoglycemia, and proceeding with pre-op activities delays urgent treatment. Surgery may be delayed if hypoglycemia persists, but the next nursing priority is to correct the low glucose.

Question 12

A school-age child with type 1 diabetes is brought to the nurse with irritability, fatigue, and sweating. The child ate breakfast but skipped their morning snack. Blood glucose is 58 mg/dL. What is the nurse's best action?

Accepted Answer

Answer reason: A blood glucose of 58 mg/dL with sweating and irritability indicates symptomatic hypoglycemia, which requires immediate treatment. The priority is to give 15 g of rapid-acting carbohydrate (e.g., glucose tablets/juice) to quickly raise blood glucose and prevent seizure or loss of consciousness. Waiting for lunch, resting, or calling the parent first delays urgent care and increases risk of clinical deterioration. After treatment, glucose should be rechecked in about 15 minutes and repeated if still low, followed by a longer-acting snack when stable.

Question 13

A client with type 2 diabetes is scheduled for surgery in the morning. The nurse notes the client's blood glucose is 55 mg/dL after receiving insulin. What should the nurse do NEXT?

Accepted Answer

Answer reason: A blood glucose of 55 mg/dL indicates hypoglycemia, which requires immediate treatment to prevent neuroglycopenic symptoms, seizures, or loss of consciousness. For a patient who can take oral carbohydrates, fast-acting glucose (e.g., glucose tablets or juice) is the appropriate first intervention. Giving more insulin would worsen hypoglycemia, and proceeding with pre-op tasks delays urgent treatment. Canceling surgery is not the next step; the priority is rapid correction and reassessment of blood glucose.

Question 14

A client with type 2 diabetes is scheduled for surgery in the morning. The nurse notes the client’s blood glucose is 55 mg/dL after receiving insulin. What should the nurse do NEXT?

Accepted Answer

Answer reason: A blood glucose of 55 mg/dL indicates hypoglycemia, which requires immediate treatment to prevent neurologic deterioration and potential loss of consciousness. For a conscious patient who can swallow safely, fast-acting oral carbohydrates such as glucose tablets or juice are the appropriate first-line intervention. Giving more insulin or proceeding with pre-op care delays treatment and worsens hypoglycemia, and canceling surgery is not the immediate priority before stabilizing the patient.

Question 15

A patient with SIADH presents with confusion and seizures. Which IV solution should the nurse anticipate administering?

Accepted Answer

Answer reason: SIADH causes water retention leading to dilutional hyponatremia; neurologic symptoms like confusion and seizures indicate severe, symptomatic hyponatremia. The appropriate IV therapy to rapidly raise serum sodium and reduce cerebral edema risk is hypertonic saline (3% sodium chloride), administered carefully with close monitoring. Hypotonic fluids (D5W, 0.45% NS) would worsen hyponatremia, and isotonic saline (0.9% NS) is typically insufficient for acute severe neurologic symptoms.

Question 16

A patient receiving IV furosemide (Lasix) shows muscle weakness and a flattened T wave on ECG. Which electrolyte should be replaced first?

Accepted Answer

Answer reason: IV furosemide commonly causes potassium wasting, leading to hypokalemia. Hypokalemia classically presents with muscle weakness and ECG changes such as flattened T waves (and can progress to U waves and dysrhythmias). Because potassium abnormalities can rapidly precipitate life-threatening cardiac arrhythmias, potassium replacement is the priority. Magnesium can contribute to refractory hypokalemia, but the findings given most directly indicate potassium deficit as the first replacement.

Question 17

Which acid-base imbalance is associated with diarrhea?

Accepted Answer

Answer reason: Diarrhea causes loss of bicarbonate (HCO3−)-rich intestinal fluids, which lowers serum bicarbonate and leads to a primary metabolic acidosis. The body may compensate with increased respiratory rate (blowing off CO2), but the primary disturbance remains metabolic. In contrast, vomiting is classically associated with metabolic alkalosis due to loss of gastric acid.

Question 18

What IV fluid is best for a patient with cerebral edema?

Accepted Answer

Answer reason: Cerebral edema involves increased brain water content and elevated intracranial pressure; hypertonic saline creates an osmotic gradient that pulls water from the cerebral tissue into the intravascular space, helping reduce edema and ICP. D5W becomes hypotonic after metabolism and can worsen cerebral edema by shifting free water into cells. Hypotonic saline (0.45% NaCl) similarly lowers serum osmolality and can exacerbate brain swelling. Normal saline is isotonic and may be used for volume resuscitation, but it does not actively reduce cerebral edema as effectively as 3% hypertonic saline when hyperosmolar therapy is indicated.

Question 19

First step in management of severe dehydration?

Accepted Answer

Answer reason: Severe dehydration can rapidly progress to hypovolemia and shock, so immediate restoration of intravascular volume is the priority. IV fluid therapy (typically isotonic crystalloids such as normal saline or lactated Ringer’s) provides rapid, reliable rehydration when oral intake is inadequate or unsafe. Oral fluids are appropriate for mild to moderate dehydration but may be too slow or impossible in severe cases due to altered mental status or vomiting. Antibiotics and blood transfusion do not address the primary problem of fluid volume deficit unless a separate indication exists.

Question 20

Preferred IV fluid in severe dehydration due to diarrhea?

Accepted Answer

Answer reason: Severe dehydration from diarrhea causes extracellular fluid volume depletion and often metabolic acidosis from bicarbonate loss. Ringer’s lactate is an isotonic crystalloid that expands intravascular volume and provides lactate, which is metabolized to bicarbonate and helps correct acidosis. 5% dextrose is not appropriate for initial resuscitation because it becomes hypotonic after metabolism and does not effectively restore intravascular volume. Plasma expanders are not first-line for dehydration from gastrointestinal fluid loss, and normal saline lacks a buffer and can worsen hyperchloremic acidosis when given in large volumes.

Question 21

A nurse is monitoring the fluid replacement of a client who has sustained burns. Which of the following fluids is used in the first 24 hours following a burn injury?

Accepted Answer

Answer reason: In the first 24 hours after a major burn, capillary leak causes large fluid shifts from the intravascular space into the interstitium, so aggressive isotonic crystalloid resuscitation is required. Lactated Ringer’s is the preferred initial fluid because it is isotonic and its electrolyte composition is closer to plasma, supporting intravascular volume expansion. D5W is hypotonic in effect and does not adequately expand intravascular volume, and dextrose-containing solutions are generally avoided early in resuscitation. Normal saline can be used, but large volumes increase risk of hyperchloremic metabolic acidosis, making LR the standard choice.

Question 22

A client with type 2 diabetes is scheduled for surgery in the morning. The nurse notes the client blood glucose is 55 mg/dl after receiving insulin. What should the nurse do NEXT?

Accepted Answer

Answer reason: A blood glucose of 55 mg/dL indicates clinically significant hypoglycemia requiring immediate treatment to prevent neuroglycopenic symptoms, seizures, or loss of consciousness. If the client can safely swallow, the priority action is rapid oral carbohydrate such as glucose tablets or juice (the “15 g fast-acting carbohydrate” approach), followed by reassessment. Giving more insulin or proceeding with routine pre-op tasks delays correction of an acute physiologic emergency. Canceling surgery is not the immediate priority; stabilize glucose first and then notify the provider/anesthesia as appropriate.

Question 23

The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. What is the priority intervention?

Accepted Answer

Answer reason: Diabetes insipidus causes large free-water losses leading to dehydration, hypernatremia, and potential hypovolemia, which can present with mental status changes. The immediate priority is to assess for hemodynamic instability by checking vital signs (especially blood pressure, heart rate, and orthostatics) to identify shock risk and guide urgent fluid replacement. Measuring urine output and daily weights are important monitoring interventions but are secondary to immediate assessment of circulation. Encouraging oral fluids may be insufficient or unsafe if the client is significantly altered or unstable and should follow assessment and provider-directed fluid therapy.

Question 24

A client with type 1 diabetes reports shakiness, hunger, and dizziness. Blood glucose is 58 mg/dL. What is the nurse's first action?

Accepted Answer

Answer reason: A blood glucose of 58 mg/dL with adrenergic/neuroglycopenic symptoms indicates symptomatic hypoglycemia requiring immediate treatment. The priority is to rapidly raise glucose with the "15-15 rule" by giving 15 g of fast-acting carbohydrate, then reassessing in about 15 minutes. Administering insulin would worsen hypoglycemia, and waiting 30 minutes to recheck delays treatment. Notifying the provider is not the first action because hypoglycemia is an urgent, nurse-managed emergency intervention.

Question 25

A nurse is monitoring a client with diabetes mellitus and notes a blood glucose of 58 mg/dL. What is the first nursing action?

Accepted Answer

Answer reason: A blood glucose of 58 mg/dL indicates hypoglycemia, which requires immediate treatment to prevent neuroglycopenic symptoms, seizures, or loss of consciousness. The priority first action for a conscious client who can swallow is the “15-15 rule”: give 15 g of rapid-acting carbohydrate (e.g., glucose tablets/juice). Rechecking in 15 minutes is the next step after treatment, and notifying the provider is not the initial priority in an acute correctable hypoglycemic episode. Administering long-acting insulin would worsen hypoglycemia and is unsafe.

Question 26

Which IV solution is commonly used to treat hyponatremia, a condition characterized by low levels of sodium in the blood?

Accepted Answer

Answer reason: Hypertonic saline (3% NaCl) is used to raise serum sodium in clinically significant or symptomatic hyponatremia because it provides a higher sodium concentration than plasma, increasing extracellular osmolality and sodium level. D5W would dilute serum sodium further and can worsen hyponatremia. Lactated Ringer’s has less sodium than normal saline and is not the typical corrective fluid for hyponatremia. While 0.9% normal saline may be used in some hypovolemic hyponatremia, the commonly tested IV treatment for hyponatremia (especially severe/symptomatic) is 3% hypertonic saline.

Question 27

After a blood transfusion, a patient develops shortness of breath and crackles in the lungs. Which medication would the nurse expect to administer?

Accepted Answer

Answer reason: Shortness of breath with crackles after a blood transfusion most strongly suggests transfusion-associated circulatory overload (TACO) with pulmonary edema from volume overload. The expected treatment includes stopping/slowing the transfusion, positioning upright, oxygen as needed, and administering a loop diuretic to remove excess fluid. Furosemide reduces intravascular volume and pulmonary congestion, improving dyspnea and crackles. Paracetamol and diphenhydramine are used for febrile/allergic reactions, and hydrocortisone is for severe allergic/anaphylactoid reactions, not volume overload.

Question 28

A nurse reviews discharge instructions for a client with heart failure. Which statement indicates a need for further teaching?

Accepted Answer

Answer reason: Clients with heart failure are commonly prescribed fluid and/or sodium restrictions to reduce volume overload and prevent worsening edema and pulmonary congestion. Drinking at least 3 liters of water daily would likely increase preload, promote fluid retention, and exacerbate dyspnea and weight gain. The other statements reflect appropriate self-management: daily weights help detect fluid retention early, calling the provider for breathing difficulty signals possible decompensation, and continuing medications even when asymptomatic supports ongoing control.

Question 29

Newborn Hypoglycemia Concern A newborn of a diabetic mother has a blood glucose of 38 mg/dL and is jittery. What is the priority action?

Accepted Answer

Answer reason: An infant of a diabetic mother is at high risk for neonatal hypoglycemia due to hyperinsulinemia, and jitteriness is a symptomatic sign requiring prompt treatment. For mild-to-moderate symptomatic hypoglycemia (e.g., glucose 38 mg/dL) in a stable newborn, the first-line priority is immediate feeding (breastfeeding or formula) to raise glucose quickly and safely. IV dextrose is typically reserved for severe hypoglycemia, inability to feed, persistent symptoms, or failure to respond to oral feeding. Waiting an hour to recheck delays treatment and risks progression to seizures or neurologic injury.

Question 30

Which electrolyte imbalance is most commonly associated with prolonged nasogastric suctioning?

Accepted Answer

Answer reason: Prolonged nasogastric suction removes gastric secretions rich in hydrochloric acid and electrolytes, leading to volume depletion and metabolic alkalosis. The alkalosis and associated renal compensatory mechanisms increase urinary potassium losses, making hypokalemia a common electrolyte imbalance. Clinically, hypokalemia is a key risk because it can cause ileus and dysrhythmias, so potassium levels should be monitored and replaced as indicated. Hyperkalemia, hypernatremia, and hypocalcemia are not the typical primary electrolyte abnormalities from NG suction.

Question 31

A patient with hypokalemia is at risk for which of the following complications?

Accepted Answer

Answer reason: Hypokalemia increases myocardial excitability and impairs normal cardiac conduction, predisposing the patient to dysrhythmias (e.g., PVCs, atrial/ventricular arrhythmias) and characteristic ECG changes (flattened T waves, U waves). These arrhythmias can be life-threatening, especially in patients on digoxin or with underlying heart disease. Seizures and hyperreflexia are more consistent with other electrolyte disturbances, and hypokalemia more often causes hypotension than hypertension due to muscle weakness and decreased smooth muscle tone.

Question 32

A nurse reviews lab values for a client with pneumonia. The nurse reports which priority lab value to the healthcare provider (HCP)?

Accepted Answer

Answer reason: An arterial pH of 7.27 indicates clinically significant acidemia, which can rapidly impair cardiac function, hemodynamics, and oxygen delivery and therefore warrants prompt provider notification and intervention. In pneumonia, worsening ventilation/perfusion mismatch and hypoventilation can lead to respiratory acidosis; the pH reflects the severity of physiologic decompensation better than a mildly low PaO2. A PaO2 of 78 mmHg is only mildly decreased and is often expected with pneumonia and may be managed with oxygen titration per protocol. Leukocytosis (14,000/mm3) is common with infection, and mild thrombocytopenia (125,000/mm3) is less immediately life-threatening than significant acid-base derangement.

Question 33

Diarrhoea is treated with?

Accepted Answer

Answer reason: Acute diarrhea primarily risks dehydration and electrolyte loss, so first-line treatment is oral rehydration solution (ORS) to replace water, sodium, and glucose for optimal intestinal absorption. Insulin treats hyperglycemia/diabetes, not diarrhea. Paracetamol treats pain/fever, and cetirizine is an antihistamine for allergies—neither corrects dehydration from diarrhea. Therefore, ORS is the best answer.

Question 34

A patient with chronic kidney disease(ckd) is experiencing hyperkalemia. Which of the following interventions should the nurse anticipate?

Accepted Answer

Answer reason: In CKD, potassium excretion is reduced, increasing the risk of life-threatening dysrhythmias from hyperkalemia. Sodium polystyrene sulfonate (Kayexalate) is a potassium-binding resin that removes potassium through the GI tract, so it is an anticipated therapy when prescribed. Encouraging potassium-rich foods would worsen hyperkalemia, and Lactated Ringer’s contains potassium and can further increase serum K+. Sodium restriction may be appropriate for fluid management in CKD but does not directly treat hyperkalemia.

Question 35

In a patient with fluid overload, the nurse will likely assess all of the following except?

Accepted Answer

Answer reason: Fluid overload increases intravascular volume, which typically raises blood pressure rather than causing hypotension. Patients commonly show signs of volume excess such as jugular venous distention (JVD) from elevated venous pressures and possible dilutional effects like low serum osmolality (often related to dilutional hyponatremia). Bradycardia is not a classic hallmark of fluid overload (tachycardia is more common with physiologic stress), but among the choices, hypotension is the clear “except” because it contradicts expected hemodynamics in hypervolemia.

Question 36

The oncoming nurse learns that a new client is suffering from syndrome of inappropriate antidiuretic hormone (SIADH) secretion. Which of the following nursing actions is the most important?

Accepted Answer

Answer reason: SIADH causes water retention leading to dilutional hyponatremia, which can rapidly affect the brain and progress to confusion, decreased level of consciousness, seizures, and coma. Therefore, frequent assessment of mental status is the priority to detect worsening neurologic impairment early and trigger urgent intervention. Accurate intake/output is important for monitoring fluid balance, but it does not identify the most immediately life-threatening complication as directly as neurologic assessment. Oral hygiene and stress reduction are supportive but not priority compared with monitoring for hyponatremic encephalopathy.

Question 37

A nurse is assessing a client with hypoglycemia. Which of the following findings should the nurse expect? Select 4 to be prioritized?

Accepted Answer

Answer reason: Hypoglycemia typically produces adrenergic/neuroglycopenic findings such as shakiness (tremor), diaphoresis, irritability, and confusion due to sympathetic activation and inadequate glucose delivery to the brain. Polyuria and fruity breath odor are more consistent with hyperglycemia/diabetic ketoacidosis rather than hypoglycemia. Therefore, the prioritized expected findings in hypoglycemia would be shakiness, irritability, diaphoresis, and confusion, not polyuria or fruity breath odor.

Question 38

A client with hyponatremia is admitted. Which lab value confirms this condition?

Accepted Answer

Answer reason: Hyponatremia is defined as a serum sodium level below the normal range (typically

Question 39

A patient’s ECG shows a new onset of peaked T waves. What lab result should the nurse check immediately?

Accepted Answer

Answer reason: New onset peaked T waves on ECG are a classic early sign of hyperkalemia, which can rapidly progress to life-threatening dysrhythmias. The most urgent lab to verify is the serum potassium level to confirm the suspected electrolyte abnormality and guide immediate treatment. Sodium, calcium, and magnesium disturbances have different typical ECG patterns and are less directly linked to peaked T waves. Prompt potassium assessment supports rapid risk mitigation for cardiac instability.

Question 40

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?

Accepted Answer

Answer reason: A sodium of 130 mEq/L indicates hyponatremia. Many diuretics—especially thiazides—can cause renal sodium loss and/or dilutional hyponatremia due to increased free-water retention relative to sodium. In contrast, hyperaldosteronism, Cushing’s syndrome, and corticosteroid therapy tend to promote sodium retention (mineralocorticoid effect), making hyponatremia less likely.

Question 41

A nurse is caring for a patient diagnosed with acute kidney injury (AKI) due to hypovolemia. Which of the following findings should the nurse expect?

Accepted Answer

Answer reason: Hypovolemia causes decreased renal perfusion leading to prerenal AKI, which reduces glomerular filtration rate and results in retention of nitrogenous wastes. Therefore BUN and creatinine rise, often with a disproportionately higher BUN compared with creatinine in prerenal states. Urine output is typically decreased (oliguria), not increased, and creatinine would not be decreased. While hypovolemia can cause hypotension, bradycardia is not the expected compensatory response (tachycardia is more typical).

Question 42

A 2-year-old is admitted to the hospital with a diagnosis of dehydration due to gastroenteritis. Which of the following would be the highest priority nursing intervention?

Accepted Answer

Answer reason:  Administering an oral rehydration solution (ORS) In pediatric gastroenteritis, the immediate priority is restoring circulating volume and correcting electrolyte losses, and oral rehydration solution is first-line for mild to moderate dehydration. ORS provides an appropriate glucose-sodium ratio to maximize intestinal water absorption and prevent worsening dehydration. Antidiarrheals are generally avoided in young children due to limited benefit and potential adverse effects, and antibiotics are only indicated for specific bacterial etiologies. Antiemetics may reduce vomiting but do not replace the essential intervention of rehydration.

Question 43

A nurse is assessing a 2-year-old with dehydration. Which finding requires immediate intervention?

Accepted Answer

Answer reason: Capillary refill of 5 seconds A capillary refill time of 5 seconds indicates significantly decreased peripheral perfusion and can be a sign of hypovolemia progressing toward shock in a dehydrated child, requiring prompt intervention (e.g., rapid assessment and fluid resuscitation per protocol). Dry mucous membranes are common in dehydration but are not as immediately life-threatening as evidence of poor perfusion. A heart rate of 110 bpm can be within normal limits for a 2-year-old, depending on context and activity level. Sunken fontanels are less applicable at age 2 because fontanels are typically closed, and therefore is not the best urgent finding here.

Question 44

A patient’s potassium level is 2.8 mEq/L. Which assessment finding would the nurse expect?

Accepted Answer

Answer reason: Irregular heart rhythm A potassium of 2.8 mEq/L indicates hypokalemia, which increases the risk of cardiac conduction abnormalities and dysrhythmias (e.g., ventricular ectopy, U waves, ST depression). Therefore an irregular heart rhythm is an expected and high-priority assessment finding. Moist lung crackles point more toward fluid overload/heart failure, increased deep tendon reflexes is more consistent with hypocalcemia, and bradycardia with hypotension is not the typical primary presentation of hypokalemia.

Question 45

Which finding indicates fluid overload?

Accepted Answer

Answer reason: Crackles in the lungs Crackles (rales) suggest fluid in the alveoli/interstitial spaces, commonly seen with fluid volume excess and pulmonary edema. Fluid overload increases hydrostatic pressure in the pulmonary capillaries, pushing fluid into lung tissue and impairing gas exchange. In contrast, dry mucous membranes and decreased skin turgor are typical dehydration findings, and low blood pressure more often suggests hypovolemia rather than overload.

Question 46

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing?

Accepted Answer

Answer reason: The client with diabetes mellitus. Third-spacing is fluid shifting from the intravascular space into the interstitial/third space due to increased capillary permeability or low oncotic pressure. Sepsis commonly causes capillary leak, cirrhosis leads to hypoalbuminemia/portal hypertension with ascites, and kidney failure is associated with fluid overload and edema. Diabetes mellitus alone is not a classic primary cause of third-spacing compared with the other conditions listed, making it the least likely risk.

Question 47

A client has the following laboratory values: a pH of 7.55, an HCO3− level of 22 mm Hg, and a Pco2 of 30 mm Hg. Which action should the nurse take?

Accepted Answer

Answer reason: Encourage the client to slow down breathing. The pH is alkalemic (7.55) and the PaCO2 is low (30), indicating primary respiratory alkalosis, most often from hyperventilation. HCO3− is near normal (22), consistent with an acute process with minimal metabolic compensation. Nursing management focuses on addressing hyperventilation by coaching slower breathing (and treating the underlying cause such as anxiety or pain). The other options do not address the acid–base disturbance described by these ABG values.

Question 48

A nurse is assessing a client with fluid volume overload. Which sound is most likely heard during auscultation?

Accepted Answer

Answer reason: Crackles. Fluid volume overload can cause pulmonary congestion/edema as fluid leaks into the alveoli and interstitial spaces, producing inspiratory crackles (rales) on auscultation. Wheezes are more typical of bronchospasm or narrowed airways, stridor indicates upper airway obstruction, and a pleural friction rub is associated with pleural inflammation rather than excess intravascular volume. Therefore crackles are the most expected finding.

Question 49

A patient with severe vomiting and diarrhea is admitted to the emergency department. The nurse notes that the patient is experiencing muscle weakness, lethargy, and characteristic ECG changes like flattened T waves and prominent U waves. Which electrolyte imbalance should the nurse anticipate?

Accepted Answer

Answer reason: Hypokalemia Severe vomiting and diarrhea commonly cause potassium losses, leading to hypokalemia. Hypokalemia produces neuromuscular symptoms such as muscle weakness and lethargy due to impaired membrane excitability. The ECG findings of flattened T waves and prominent U waves are classic for low potassium and help distinguish it from hyperkalemia (which causes peaked T waves).

Question 50

A patient presents with nausea, confusion, and muscle cramps. Lab results show a serum sodium of 124 mEq/L. Which nursing intervention is the priority?

Accepted Answer

Answer reason: Restrict fluid intake and monitor it A sodium of 124 mEq/L with confusion indicates symptomatic hyponatremia, commonly worsened by excess free water. The priority nursing action is to prevent further dilution by restricting fluids and closely monitoring intake (and associated outputs/neurologic status) while collaborating for additional therapy as ordered. Administering hypotonic fluids or encouraging more water would further lower serum sodium and increase risk of cerebral edema/seizures. Potassium supplementation does not address the primary electrolyte abnormality driving the symptoms.

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The nurse admitting a 5 month-old who vomited nine times in the past six hours should observe for signs of?

A nurse is caring for a patient with acute kidney injury caused by hypovolemia. Which finding is most consistent with this condition?

A nurse is caring for a patient with severe dehydration. Which finding indicates effective rehydration?

What acid base imbalance should the nurse suspect in a patient with fentanyl overdose?

What acid-base imbalance should the nurse suspect in a patient with 38 breaths/minute due to anxiety?

Patient with peptic ulcer disease takes excessive amount of antacids. Which acid-base imbalance should the nurse assess for?

Signs of severe dehydration include?

The best nursing intervention in diarrhoea is?

What is the priority for a patient with diabetic ketoacidosis (DKA)?

The nurse is assessing a client with acute renal failure. Which of the following electrolyte imbalances should be the priority concern for the nurse?

A client with type 2 diabetes is scheduled for surgery in the morning. The nurse notes the client's blood glucose is 55 mg/dL after receiving insulin. What should the nurse do NEXT?

A school-age child with type 1 diabetes is brought to the nurse with irritability, fatigue, and sweating. The child ate breakfast but skipped their morning snack. Blood glucose is 58 mg/dL. What is the nurse's best action?

A client with type 2 diabetes is scheduled for surgery in the morning. The nurse notes the client's blood glucose is 55 mg/dL after receiving insulin. What should the nurse do NEXT?

A client with type 2 diabetes is scheduled for surgery in the morning. The nurse notes the client’s blood glucose is 55 mg/dL after receiving insulin. What should the nurse do NEXT?

A patient with SIADH presents with confusion and seizures. Which IV solution should the nurse anticipate administering?

A patient receiving IV furosemide (Lasix) shows muscle weakness and a flattened T wave on ECG. Which electrolyte should be replaced first?

Which acid-base imbalance is associated with diarrhea?

What IV fluid is best for a patient with cerebral edema?

First step in management of severe dehydration?

Preferred IV fluid in severe dehydration due to diarrhea?

A nurse is monitoring the fluid replacement of a client who has sustained burns. Which of the following fluids is used in the first 24 hours following a burn injury?

A client with type 2 diabetes is scheduled for surgery in the morning. The nurse notes the client blood glucose is 55 mg/dl after receiving insulin. What should the nurse do NEXT?

The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. What is the priority intervention?

A client with type 1 diabetes reports shakiness, hunger, and dizziness. Blood glucose is 58 mg/dL. What is the nurse's first action?

A nurse is monitoring a client with diabetes mellitus and notes a blood glucose of 58 mg/dL. What is the first nursing action?

Which IV solution is commonly used to treat hyponatremia, a condition characterized by low levels of sodium in the blood?

After a blood transfusion, a patient develops shortness of breath and crackles in the lungs. Which medication would the nurse expect to administer?

A nurse reviews discharge instructions for a client with heart failure. Which statement indicates a need for further teaching?

Newborn Hypoglycemia Concern A newborn of a diabetic mother has a blood glucose of 38 mg/dL and is jittery. What is the priority action?

Which electrolyte imbalance is most commonly associated with prolonged nasogastric suctioning?

A patient with hypokalemia is at risk for which of the following complications?

A nurse reviews lab values for a client with pneumonia. The nurse reports which priority lab value to the healthcare provider (HCP)?

Diarrhoea is treated with?

A patient with chronic kidney disease(ckd) is experiencing hyperkalemia. Which of the following interventions should the nurse anticipate?

In a patient with fluid overload, the nurse will likely assess all of the following except?

The oncoming nurse learns that a new client is suffering from syndrome of inappropriate antidiuretic hormone (SIADH) secretion. Which of the following nursing actions is the most important?

A nurse is assessing a client with hypoglycemia. Which of the following findings should the nurse expect? Select 4 to be prioritized?

A client with hyponatremia is admitted. Which lab value confirms this condition?

A patient’s ECG shows a new onset of peaked T waves. What lab result should the nurse check immediately?

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?

A nurse is caring for a patient diagnosed with acute kidney injury (AKI) due to hypovolemia. Which of the following findings should the nurse expect?

A 2-year-old is admitted to the hospital with a diagnosis of dehydration due to gastroenteritis. Which of the following would be the highest priority nursing intervention?

A nurse is assessing a 2-year-old with dehydration. Which finding requires immediate intervention?

A patient’s potassium level is 2.8 mEq/L. Which assessment finding would the nurse expect?

Which finding indicates fluid overload?

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing?

A client has the following laboratory values: a pH of 7.55, an HCO3− level of 22 mm Hg, and a Pco2 of 30 mm Hg. Which action should the nurse take?

A nurse is assessing a client with fluid volume overload. Which sound is most likely heard during auscultation?

A patient with severe vomiting and diarrhea is admitted to the emergency department. The nurse notes that the patient is experiencing muscle weakness, lethargy, and characteristic ECG changes like flattened T waves and prominent U waves. Which electrolyte imbalance should the nurse anticipate?

A patient presents with nausea, confusion, and muscle cramps. Lab results show a serum sodium of 124 mEq/L. Which nursing intervention is the priority?

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