Question 1

Neonatal Hypothermia Concern A preterm newborn has a temperature of 96.8°F (36°C). What is the priority action?

Accepted Answer

Answer reason: A preterm newborn is at high risk for cold stress due to limited brown fat, thin skin, and immature thermoregulation, so the safest immediate intervention is active external warming in a controlled neutral thermal environment. An incubator provides consistent heat (and often humidity) to reduce ongoing heat loss and oxygen/glucose consumption. Skin-to-skin can help in stable infants but may be insufficient as the primary measure for a hypothermic preterm newborn and is less controlled. Checking glucose is important because hypothermia can cause hypoglycemia, but stabilizing temperature is the priority action to prevent further metabolic deterioration; oral feeds are not first-line in an unstable preterm infant.

Question 2

A nurse is reviewing lab results for a client with SIADH. Which finding requires immediate intervention?

Accepted Answer

Answer reason: SIADH causes excess water retention leading to dilutional hyponatremia, and a level this low represents severe hyponatremia with high risk for cerebral edema. This can rapidly progress to neurologic deterioration such as confusion, seizures, and coma, making it an urgent, time-sensitive abnormality. The other values are within normal or only mildly abnormal ranges and are less likely to cause immediate life-threatening complications.
Category reason: This question asks the nurse to recognize a dangerous electrolyte abnormality in a clinical context and determine urgency of intervention, which is nursing judgment about fluid/electrolyte imbalance management.

Question 3

A client has a sodium level of 126 mEq/L. Which symptom is the most concerning?

Accepted Answer

Answer reason: New-onset headache with confusion suggests significant CNS involvement and risk for seizures, decreased level of consciousness, and respiratory compromise. Neurologic findings are prioritized because they signal potential rapid deterioration and require urgent evaluation and controlled correction of sodium. In contrast, dry mouth and cramping symptoms are generally less immediately life-threatening and do not indicate impending neurologic catastrophe.

Question 4

The Nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention?

Accepted Answer

Answer reason: Once insulin is started (with appropriate fluids), serum glucose falls and ketogenesis halts, allowing acidosis to resolve as a downstream effect rather than a separate primary target. Dextrose infusion is not a first-step intervention in the acute phase; it is added later when glucose approaches ~200–250 mg/dL to permit continued insulin while preventing hypoglycemia. ECG monitoring is important due to potassium shifts, but it does not correct the life-threatening metabolic derangement and therefore is not the single priority over initiating insulin therapy.

Question 5

Best method to check Fluid replacement in adults is ?

Accepted Answer

Answer reason: Adequate resuscitation in adults is commonly reflected by urine output around 0.5 mL/kg/hr (about 30 mL/hr for many adults), indicating sufficient circulating volume to perfuse the kidneys. Blood pressure can remain normal despite significant hypovolemia due to compensatory vasoconstriction, so it may lag behind true volume status. Respiration and pulse pressure are less direct and are influenced by many non-volume factors, making them less reliable as primary measures of replacement adequacy.

Question 6

A diabetic client becomes confused and diaphoretic. Blood glucose is 52 mg/dL. What is the nurse’s priority action?

Accepted Answer

Answer reason: If the client can safely swallow, the priority is a rapid-acting oral carbohydrate (about 15 g), which this option provides. Glucagon is reserved for clients who are unconscious, having seizures, or unable to take oral glucose safely. Rechecking glucose is done after treatment (typically in 15 minutes), not before correcting the low value, and notifying the provider is not the first action in an acute, readily treatable emergency.

Question 7

A nurse is assessing a client with a serum sodium level of 125 mEq/L. Which assessment finding is most concerning?

Accepted Answer

Answer reason: A sodium of 125 mEq/L is significantly low and symptoms such as headache and confusion can signal rising intracranial pressure and risk of seizures and coma, requiring urgent evaluation and careful sodium correction. Findings like dry mucous membranes and poor skin turgor suggest volume depletion but are not immediately life-threatening compared with acute neurologic changes. Hypotension can indicate hypovolemia, yet without signs of shock, altered mental status in the setting of hyponatremia is the higher priority concern.

Question 8

Most important aspect of management of burn injury in firs 24 hours is?

Accepted Answer

Answer reason: Immediate IV crystalloid replacement (e.g., guided by urine output and burn size) is the key life-saving intervention to restore perfusion and prevent acute kidney injury and multi-organ failure. Dressings and wound care are important but do not address the early lethal problem of intravascular volume depletion. Prophylactic systemic antibiotics are generally not prioritized initially without evidence of infection, and reconstructive surgery is a later-phase concern.

Question 9

Which of the following clinical finding indicates the patient is experiencing hypokalemia?

Accepted Answer

Answer reason: This commonly presents as constipation, hypoactive bowel sounds, and abdominal bloating or distention. Muscle spasms are more characteristic of hypocalcemia (tetany) rather than low potassium, where weakness/cramps are more typical. Kussmaul respirations indicate metabolic acidosis (e.g., DKA) and are not a hallmark sign of hypokalemia, and edema more often reflects fluid overload states than isolated potassium depletion.

Question 10

A nurse is caring for a postoperative client with hypokalemia. Which findings should the nurse anticipate?

Accepted Answer

Answer reason: This commonly presents as a weak pulse with irregular rhythm due to ectopy or conduction abnormalities. Postoperative patients are also at higher risk from fluid shifts, diuretics, or GI losses, making cardiac monitoring findings particularly expected. By contrast, hyperactive bowel sounds and neuromuscular irritability findings like Chvostek’s sign are more consistent with other electrolyte disturbances rather than low potassium, which more often causes decreased GI motility and muscle weakness.

Question 11

The nurse cares for a group of clients with acid-base imbalances. Which client does the nurse assess closely for risk of respiratory acidosis?

Accepted Answer

Answer reason: Postoperative clients are at risk because sedatives/opioids, residual anesthesia, and pain-related splinting can reduce ventilation and respiratory rate. Decreased respirations therefore directly increase PaCO2 and can rapidly produce hypercapnia with acidemia. In contrast, vomiting more typically causes metabolic alkalosis from loss of gastric acid, while chronic kidney disease and diabetic ketoacidosis are primary metabolic acidosis conditions.

Question 12

Which of the following best describes the following ABG values? pH: 7.32 CO2: 31 HCO3: 19?

Accepted Answer

Answer reason: The pH 7.32 indicates acidemia, and the bicarbonate of 19 is low, which directly produces metabolic acidemia. The PaCO2 of 31 is low, which represents respiratory compensation via hyperventilation (blowing off CO2) rather than the primary problem. A common trap is choosing respiratory alkalosis because PaCO2 is low, but that would typically raise the pH, not lower it.

Question 13

A parents bring infant seeking treatment for vomiting and diarrhea for two days on assessment students finds dry mucus membrane and lethargy what other findings suggest fluid volume deficit?

Accepted Answer

Answer reason: Fluid volume deficit lowers circulating volume and triggers a compensatory sympathetic response to maintain cardiac output and perfusion, producing tachycardia. In an infant with vomiting/diarrhea, dry mucous membranes and lethargy already suggest dehydration; an increased pulse rate is a common early vital-sign change. Increased blood pressure would be inconsistent because dehydration more typically leads to normal-to-low BP with possible orthostatic changes. Decreased urine specific gravity would not fit, since dehydration causes the kidneys to conserve water, leading to more concentrated urine and higher specific gravity.

Question 14

A Client Had Extensive, Prolonged Surgery. Which Electrolyte Level Should The Nurse Monitor Most Closely?

Accepted Answer

Answer reason: Potassium abnormalities are immediately life-threatening because they directly affect cardiac conduction and skeletal/respiratory muscle function, making early detection critical in the post-op period. Additionally, perioperative factors such as insulin/dextrose administration, blood transfusions, and renal hypoperfusion can precipitate rapid hypo- or hyperkalemia. In contrast, sodium and chloride more commonly reflect overall fluid balance trends and typically evolve less abruptly into arrhythmogenic emergencies than potassium. Closely monitoring potassium helps prevent and rapidly address dangerous dysrhythmias after extensive surgery.

Question 15

Which of the following intravenous (IV) fluid solutions would be the best choice for a patient who is experiencing dehydration due to loss of bile?

Accepted Answer

Answer reason: An isotonic crystalloid is needed to expand intravascular volume effectively without shifting water into cells. Lactated Ringer’s provides sodium and chloride similar to plasma plus lactate, which is metabolized to bicarbonate and helps buffer acid-base disturbances associated with GI losses. D5W and the dextrose-containing hypotonic saline options become effectively hypotonic after dextrose metabolism and are less effective for rapid intravascular volume replacement and can worsen hyponatremia.

Question 16

Parents bring their infant to the clinic seeking treatment for vomiting and diarrhea that has lasted for 2 days. In assessment, you notice dry mucous membranes, and lethargy. Which other finding suggests a fluid volume deficit in the infant?

Accepted Answer

Answer reason: A depressed anterior fontanel is a particularly relevant pediatric indicator of significant dehydration because the soft tissue overlying the cranial sutures loses turgor with volume loss. Increased blood pressure and decreased pulse rate are inconsistent with dehydration, which more typically causes tachycardia and possible hypotension as losses progress. Low urine specific gravity suggests dilute urine, whereas dehydration more often results in concentrated urine with increased specific gravity.

Question 17

A client with adrenal insufficiency has a potassium level of 7.2 mEq/L. Which of the following signs or symptoms might the client exhibit with this result?

Accepted Answer

Answer reason: A potassium level of 7.2 mEq/L is high enough to cause tall, peaked T waves as an early electrical manifestation. By contrast, a prominent U wave is classically associated with hypokalemia rather than hyperkalemia. Muscle spasms more often point to hypocalcemia or alkalosis, and constipation is more typical of hypokalemia-related decreased GI motility.

Question 18

A nurse is reinforcing teaching with a client about nutrition. The client has hypertension and is taking a potassium-wasting diuretic. Which of the following dietary instructions should the nurse include in the teaching?

Accepted Answer

Answer reason: g., thiazides, loop diuretics) increase renal potassium excretion, creating risk for hypokalemia. Teaching should therefore emphasize increasing dietary potassium to support normal neuromuscular and cardiac conduction. Oranges and bananas are classic high-potassium foods that directly address this medication effect. Options that restrict potassium-containing foods or focus on unrelated foods do not mitigate the primary electrolyte risk associated with these diuretics.

Question 19

A client who is postoperative is receiving IV fluids and a unit of whole blood. The nurse should observe the client for which of the following as an early sign of circulatory overload?

Accepted Answer

Answer reason: An early and common manifestation is respiratory compromise from pulmonary congestion, which presents as new or worsening shortness of breath. This finding should prompt immediate assessment for crackles, oxygen saturation decline, and increasing work of breathing because it can rapidly progress to pulmonary edema. Bradycardia is not an expected early response; patients more often develop tachycardia and hypertension as the body responds to increased volume.

Question 20

A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client's temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Accepted Answer

Answer reason: Urine specific gravity 1.034 Dehydration causes the kidneys to conserve water, producing more concentrated urine and raising urine specific gravity. A value of 1.034 is abnormally high and is consistent with fluid volume deficit after vomiting and fever-related insensible losses. In contrast, bounding pulses and distended neck veins are more suggestive of fluid volume excess or increased preload rather than dehydration. Elevated blood pressure is not a reliable dehydration marker and can be influenced by pain, stress, or baseline hypertension.

Question 21

A nurse is caring for a 4-year-old child who has dehydration. Which of the following findings should the nurse identify as the priority?

Accepted Answer

Answer reason: Potassium 2.5 mEq/L Severe hypokalemia is an immediate safety threat because it can precipitate life-threatening cardiac dysrhythmias and respiratory muscle weakness. A value of 2.5 mEq/L is markedly low and requires prompt provider notification and careful replacement with cardiac monitoring. The other findings are either within expected limits (glucose 110 mg/dL and sodium 142 mEq/L) or only mildly suggest concentration from dehydration without indicating imminent instability (urine specific gravity 1.025). In dehydration, correcting electrolytes that pose acute cardiopulmonary risk takes priority over routine indicators of hydration status.

Question 22

A client with hypertension who has been taking labetalol for two weeks, reports a five-pound (2.2 kg) weight gain. Which follow up assessment is most important for the nurse to obtain?

Accepted Answer

Answer reason: Assessing lung sounds helps detect early crackles and decreased aeration consistent with pulmonary edema, guiding immediate intervention and provider notification. Labetalol can worsen or unmask heart failure in susceptible patients, so evaluating for respiratory compromise is the priority. The other assessments are less sensitive for acute volume overload and do not directly evaluate a potentially life-threatening complication.

Question 23

A nurse reviewing the laboratory of a client who had a total thyroidectomy discovers that his calcium level is 7mg/dL. Which of the following client findings should the nurse expect?

Accepted Answer

Answer reason: This leads to manifestations such as perioral numbness/tingling, muscle cramps, hyperreflexia, and tetany (including possible laryngospasm or seizures if severe). Hypertension and increased thirst are not characteristic primary findings of hypocalcemia; increased thirst more often aligns with hypercalcemia or hyperglycemia. Diaphoresis is nonspecific and does not directly reflect the electrolyte-driven neuromuscular irritability expected with hypocalcemia.

Question 24

A nurse on the telemetry unit is caring for a client with a potassium of 5.6 mEq/L. The nurse anticipates changes in the ECG which would include the following finding?

Accepted Answer

Answer reason: A potassium of 5.6 mEq/L is mild-to-moderate hyperkalemia, where peaked T waves are a common expected ECG change. As potassium rises further, progressive conduction slowing can occur (PR prolongation, QRS widening, sine-wave pattern) and bradyarrhythmias may develop. In contrast, prolonged QT interval and prominent/inverted U waves are more typical of hypokalemia due to delayed repolarization.

Question 25

The nurse would expect which eating disorder to have the greatest fluctuations in potassium?

Accepted Answer

Answer reason: Bulimia is characterized by recurrent binge episodes followed by compensatory purging behaviors, making electrolyte variability more pronounced and episodic. These patients are at particular risk for cardiac dysrhythmias due to fluctuating potassium and associated alkalosis from vomiting. In contrast, anorexia nervosa more often causes chronic malnutrition-related abnormalities that may be persistent rather than markedly fluctuating.

Question 26

The nurse is caring for a 4 year-old admitted after receiving burns to more than 50% of his body. Which laboratory data should be reviewed by the nurse as a priority in the first 24 hours?

Accepted Answer

Answer reason: Hematocrit is a rapid indicator of intravascular volume status and adequacy of early fluid resuscitation, making it a priority lab to trend during the acute phase. An elevated value suggests insufficient circulating volume and ongoing third spacing, while a falling value after resuscitation can indicate hemodilution or bleeding. Blood urea nitrogen can rise later with renal hypoperfusion but is less immediate than hematocrit for guiding early resuscitation. White blood count commonly elevates from stress/inflammation and is not as directly actionable for acute volume management in the initial burn period.

Question 27

A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find?

Accepted Answer

Answer reason: A new S3 is a classic assessment finding in fluid overload and developing heart failure physiology. Flattened neck veins would suggest low volume rather than overload, making it an opposite finding. A thready pulse is more consistent with hypovolemia or shock states than with an IV-related fluid excess, where bounding pulses and JVD are more typical early signs.

Question 28

The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?

Accepted Answer

Answer reason: Sodium restriction helps reduce water retention and control edema and hypertension risk. With oliguria and decreased renal clearance, potassium can accumulate and precipitate dysrhythmias, so limiting dietary intake is a safety-focused intervention. Options that increase sodium/fluids would worsen volume overload, and increasing potassium/protein would increase hyperkalemia risk and nitrogenous waste burden.

Question 29

Which serum blood findings with diabetic ketoacidosis alerts the nurse that immediate action is required?

Accepted Answer

Answer reason: pH below 7.3 DKA causes a high–anion gap metabolic acidosis from ketone accumulation, and worsening acidemia is an immediate threat to cardiac function, hemodynamics, and mental status. A pH under 7.3 confirms clinically significant acidosis consistent with DKA and signals urgent need for rapid IV fluids, insulin infusion, and close electrolyte monitoring. In contrast, a potassium of 5.0 can be seen initially from insulin deficiency and acidosis-driven extracellular shift and is not, by itself, the most urgent trigger compared with severe acidemia. HCT elevation reflects dehydration but is managed through fluid resuscitation, and a PaO2 of 79% is only mildly low and not the primary life-threatening derangement in DKA.

Question 30

The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5. Which of the following would the nurse anticipate?

Accepted Answer

Answer reason: A total protein of 4.5 g/dL is markedly low and supports the need for aggressive nutritional support to promote wound healing and reduce complications. TPN provides complete nutrition when the GI tract cannot be used effectively or when fistula output needs to be minimized. Potassium replacement may be needed depending on specific electrolyte results, but the key anticipated intervention based on cachexia and hypoproteinemia is initiation of parenteral nutrition. Coagulation studies and lipase testing do not directly address the primary problem of profound nutritional deficiency from fistula losses.

Question 31

A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs?

Accepted Answer

Answer reason: A gain of at least 2 lb over 48 hours suggests the need for prompt assessment and possible adjustment of diuretics, sodium/fluid restrictions, or evaluation for decompensation. Urinating 4–5 times daily can be within normal range depending on intake and diuretic timing and is not, by itself, an urgent warning sign. Non-pitting ankle edema is less typical of heart-failure-related dependent edema (usually pitting), and decreased appetite can occur but is less specific and less time-sensitive than rapid weight gain.

Question 32

Which Assessment Finding Best Supports A Nursing Diagnosis Of deficient Fluid Volume?

Accepted Answer

Answer reason: A higher urine osmolality reflects this renal compensation and is a classic assessment/lab correlate of dehydration/hypovolemia. Distended neck veins are more consistent with fluid volume excess or elevated central venous pressure rather than depletion. Cool, clammy skin can occur with shock states but is less specific for simple fluid volume deficit, and hyponatremia is not a typical direct finding of dehydration (more often sodium is normal or elevated unless there is disproportionate sodium loss).

Question 33

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy via nasal cannula at 4 L/min. The patient is drowsy and has a respiratory rate of 8 breaths per minute. What is the nurse's priority action?

Accepted Answer

Answer reason: In some COPD patients, excessive supplemental oxygen can worsen hypercapnia by reducing hypoxic respiratory drive and increasing V/Q mismatch, leading to CO2 retention and somnolence. A respiratory rate of 8/min with new drowsiness signals dangerous hypoventilation, so the immediate, nurse-controlled step is to titrate oxygen down while maintaining adequate oxygenation (typically targeting SpO2 88–92%). Increasing flow could further depress ventilation and exacerbate CO2 narcosis. After reducing oxygen and reassessing (including pulse oximetry and ideally ABGs), escalation/notification is appropriate if ventilation remains inadequate.

Question 34

The nurse provides care to a pediatric client in the emergency department (ED) who presents with symptoms of a vaso-occlusive sickle cell crisis. Which prescribed intervention does the nurse implement first?

Accepted Answer

Answer reason: Rapid IV hydration is a priority to improve plasma volume, decrease viscosity, and support tissue perfusion while other therapies are initiated. Oxygen is appropriate if hypoxemia is present, but it does not correct the common precipitating problem of dehydration and is not universally needed first in an otherwise stable child. Heat and oral analgesics may help pain, but pain control is typically achieved with prompt, titratable parenteral opioids in the ED and should not delay immediate hydration to reduce ongoing ischemia.

Question 35

A patient has had diarrhea for the past 72 hours. Which of the symptoms would support a diagnosis of hypovolemia?

Accepted Answer

Answer reason: This finding is consistent with compensatory sympathetic activation and possible orthostatic hypotension. In contrast, hypovolemia typically causes tachycardia rather than a decreased pulse rate. It also more often leads to concentrated, low-volume urine and dry mucous membranes, not light-colored urine or wet mucosa.

Question 36

Which of the following clients should be assessed for hypovolemic shock? 1. A 77-year old client with cellulitis of the leg who received vancomycin. 2. A 25-year old client who came in for vomiting with last emesis 12 hours ago. 3. A 60-year old client with a lupus flare up receiving NS at 125ml/hr. 4. A 45-year old client with +2 pitting edema receiving furosemide?

Accepted Answer

Answer reason: Hypovolemic shock results from inadequate circulating volume leading to decreased preload, reduced cardiac output, and tissue hypoperfusion. Ongoing or recent significant GI losses place a patient at risk for intravascular volume depletion, especially if intake has been poor and replacement has not occurred. This client therefore warrants focused assessment for dehydration and early shock indicators such as tachycardia, orthostatic hypotension, delayed capillary refill, decreased urine output, and altered mentation. By contrast, receiving isotonic IV fluids tends to support circulating volume, and localized infection treated with an antibiotic does not by itself suggest volume loss. Although diuretics can contribute to volume depletion, the presence of edema suggests fluid excess as the dominant issue rather than current hypovolemia.

Question 37

The nurse is caring for a 2-year-old infant who is diagnosed with diabetes insipidus. Which of the following interventions should the nurse include in the client’s plan of care?

Accepted Answer

Answer reason: A primary nursing priority is maintaining adequate free-water replacement to match losses and prevent hypovolemia. Giving isotonic sodium chloride would not correct free-water deficit and can worsen hypernatremia if used indiscriminately. Blood glucose monitoring addresses diabetes mellitus, not diabetes insipidus, and hypertension is not the typical expected finding with untreated DI (hypotension/tachycardia from volume depletion is more likely).

Question 38

The nurse is reviewing the assignment for the shift and will be caring for the following clients. Which client is at risk for hypokalemia? A client with?

Accepted Answer

Answer reason: Persistent vomiting causes direct gastrointestinal potassium losses and volume depletion, which drives renal potassium wasting via secondary hyperaldosteronism. This combination makes potassium depletion and hypokalemia a common electrolyte risk in severe pregnancy-related emesis. In contrast, end-stage renal failure typically impairs potassium excretion and more often leads to hyperkalemia. Major burns and DKA can produce early hyperkalemia from cellular shifts, even when total-body potassium is depleted.

Question 39

A nurse cares for a client who has had prolonged nasogastric intubation with gastric suctioning. The client reports new leg cramping, and the nurse finds the client has 4+ deep-tendon reflexes. Based on these findings, what is the priority nursing action?

Accepted Answer

Answer reason: Prolonged gastric suctioning can cause metabolic alkalosis and electrolyte losses (notably chloride and potassium) and can also contribute to neuromuscular irritability when electrolytes shift. New muscle cramps with markedly hyperactive reflexes indicate increased neuromuscular excitability and escalating risk of tetany and seizures, so immediate safety measures take priority. Seizure precautions reduce harm from potential acute neurologic deterioration while the underlying imbalance is evaluated and corrected. Further assessment for classic hypocalcemia signs is appropriate but is not as urgent as preventing injury if a seizure occurs.

Question 40

A healthcare provider is caring for a 3-month-old infant diagnosed with infectious gastroenteritis. The infant is lethargic, and the mucous membranes are dry. Which additional finding would support a diagnosis of moderate dehydration?

Accepted Answer

Answer reason: A sunken fontanelle is a classic infant-specific physical sign indicating significant fluid deficit beyond mild dehydration. Anuria suggests severe dehydration/renal hypoperfusion rather than moderate disease and is a later, more critical finding. Increased thirst is more typical in older children and adults and is less reliable in a 3-month-old, who cannot express thirst effectively.

Question 41

A client with end-stage renal disease is scheduled for hemodialysis tomorrow. Which lab value does the nurse discuss with the healthcare provider?

Accepted Answer

Answer reason: potassium level of 6.8 mEq/L Severe hyperkalemia is an immediate, life-threatening electrolyte abnormality because it can precipitate malignant dysrhythmias and cardiac arrest. A value of 6.8 mEq/L is critically high and requires prompt provider notification and rapid interventions (e.g., ECG monitoring and temporizing therapies) while preparing for dialysis to remove potassium. In end-stage renal disease, elevated BUN and creatinine are expected and typically improve with scheduled dialysis, but they are not as acutely dangerous as marked hyperkalemia. A sodium of 145 mEq/L is within normal limits and does not require urgent escalation in this context.

Question 42

The client has a sodium level of 125 mEq/L. Which nursing assessment supports the diagnosis of hyponatremia related to fluid volume overload?

Accepted Answer

Answer reason: Objective findings of hypervolemia include dependent peripheral edema from increased hydrostatic pressure and fluid shift into interstitial spaces. This assessment finding directly supports the “fluid volume overload” etiology rather than sodium loss alone. In contrast, hypotension, weak thready pulse, and lightheadedness are more consistent with hypovolemia or poor perfusion, which would not support an overload-related cause of hyponatremia.

Question 43

The nurse is caring for a child experiencing a celiac crisis. The nurse should anticipate which prescription from the primary healthcare provider (PHCP)?

Accepted Answer

Answer reason: A celiac crisis can cause profuse diarrhea and vomiting leading to acute dehydration, hypovolemia, and electrolyte derangements, so rapid intravascular volume replacement is a priority. IV fluids support perfusion while ongoing GI losses and poor absorption limit the effectiveness of oral rehydration. Fluid restriction would worsen circulatory compromise and increase risk for shock. An enema is not indicated for this diarrheal illness, and NGT insertion is not a routine first-line order unless there is severe vomiting/ileus requiring decompression.

Question 44

The home care nurse cares for a 70-year-old male client who reports feeling hungry, weak, and “shaky,” and is found to have a low blood glucose level. Which action by the nurse is appropriate at this time?

Accepted Answer

Answer reason: A small serving of juice provides quick absorption of glucose, aligning with the immediate correction needed for low blood sugar. Crackers with cheese contain fat and protein that slow gastric emptying and glucose absorption, making them better for follow-up stabilization after the initial quick sugar. Glucagon IM is typically reserved for severe hypoglycemia when the client cannot safely take oral carbohydrates (eg, unconscious, unable to swallow) due to aspiration risk.

Question 45

A client with acute renal failure has an increase in the serum potassium level. The nurse should monitor the client for?

Accepted Answer

Answer reason: In acute renal failure, potassium excretion falls, so rising serum potassium can quickly progress from ECG changes (peaked T waves, widened QRS) to ventricular fibrillation or asystole. This makes close monitoring for life-threatening arrhythmias and arrest the most urgent concern. Pulmonary edema is more directly tied to fluid overload, not the direct physiologic effect of elevated potassium. Hemorrhage and circulatory collapse are not characteristic primary complications of isolated hyperkalemia.

Question 46

In a client with renal failure, which assessment finding may indicate hypocalcemia?

Accepted Answer

Answer reason: In renal failure, decreased vitamin D activation and phosphate retention can lower ionized calcium, making symptomatic hypocalcemia a relevant complication. A serum calcium of 10 mg/dL is within the normal total calcium range and therefore does not suggest hypocalcemia. Increased blood coagulation is not a typical manifestation of low calcium, and headache is nonspecific compared with a compatible electrolyte-related GI symptom.

Question 47

A client is diagnosed with hypokalemia. The nurse knows the electrolyte that must be corrected in this situation is?

Accepted Answer

Answer reason: Hypokalemia is often difficult to correct when magnesium is low because magnesium deficiency increases renal potassium wasting and impairs cellular potassium uptake. Repleting potassium without addressing concurrent magnesium depletion can lead to persistent or recurrent low potassium and ongoing symptoms. Clinically, this matters because both abnormalities raise the risk of dysrhythmias, so correcting the underlying driver improves stabilization. Calcium, manganese, and zinc are not the typical co-deficiencies that physiologically prevent potassium repletion in this setting.

Question 48

Which is manifested by an increase in weight and peripheral edema or ascites?

Accepted Answer

Answer reason: Fluid volume excess increases total body water, leading to rapid weight gain and third-spacing of fluid into interstitial or peritoneal spaces. Peripheral edema and ascites reflect increased hydrostatic pressure and/or decreased oncotic pressure causing fluid to shift out of the vascular space. In contrast, dehydration and volume depletion typically present with weight loss, poor skin turgor, hypotension, and concentrated urine rather than edema. Hyperosmolality more commonly produces cellular dehydration and neurologic symptoms, not generalized fluid accumulation.

Question 49

The nurse cares for a client diagnosed with metabolic alkalosis. Metabolic alkalosis occurs in?

Accepted Answer

Answer reason: Metabolic alkalosis results from a primary increase in serum bicarbonate or a loss of hydrogen ions, often accompanied by volume depletion and electrolyte shifts. Glucocorticoids with mineralocorticoid activity can increase renal sodium retention while promoting hydrogen and potassium excretion, which raises bicarbonate and predisposes to alkalosis. In contrast, hypoxia and head trauma more typically drive respiratory alkalosis through hyperventilation, not a primary metabolic process. Uremia is classically associated with metabolic acidosis due to impaired renal acid excretion and retention of organic acids.

Question 50

Which assessment is important for a child in sickle cell crisis?

Accepted Answer

Answer reason: Sickle cell crisis is worsened by dehydration because hemoconcentration increases blood viscosity and promotes sickling and vaso-occlusion. Assessing hydration status is therefore a key priority, and skin turgor is a rapid bedside indicator to help detect volume depletion. Maintaining adequate hydration helps reduce pain episodes and risk of complications such as acute chest syndrome. By contrast, absence of bruising or bladder control does not directly reflect the physiologic trigger that commonly precipitates or intensifies a crisis.

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