Question 1

The nurse knows respiratory acidosis occurs in?

Accepted Answer

Answer reason: Respiratory acidosis results from hypoventilation, which leads to carbon dioxide (CO₂) retention and decreased blood pH. Oversedation depresses the respiratory center in the brain, reducing ventilation and causing CO₂ buildup. Diuretic therapy and potassium deficit are associated with metabolic disturbances, while hypoxia alone does not directly cause respiratory acidosis unless it leads to hypoventilation.

Question 2

A nurse is caring for a client with a traumatic brain injury who is now voiding large volumes of clear urine (up to 500 mL/hour). The client reports excessive thirst, and the nurse notes the following labs: • Sodium: 152 mmol/L • Serum osmolality: 310 mOsm/kg • Urine specific gravity: 1.002 Which of the following provider orders should the nurse question?

Accepted Answer

Answer reason: The pattern of very high urine output with low urine specific gravity plus hypernatremia and elevated serum osmolality after brain injury is most consistent with central diabetes insipidus, where free water is being lost due to inadequate ADH. In this setting, restricting fluids would worsen the existing free-water deficit, further increasing sodium/osmolality and raising the risk of dehydration, hypotension, and neurologic deterioration. Appropriate management includes ADH replacement (desmopressin) and cautious hypotonic fluid replacement (e.g., 0.45% NaCl) while monitoring volume status and electrolytes closely. Strict I&O and daily weights are essential to guide therapy and detect rapid shifts in water balance.

Question 3

A patient is experiencing decreased deep tendon reflexes (DTRs). The nurse expects which electrolyte imbalance?

Accepted Answer

Answer reason: As magnesium rises, patients can progress from lethargy and hyporeflexia to respiratory depression and cardiac conduction abnormalities, making this a key assessment finding. In contrast, hypocalcemia typically causes neuromuscular irritability (e.g., hyperreflexia, tetany, Trousseau/Chvostek signs) rather than decreased reflexes. Hyperphosphatemia and hyponatremia do not most characteristically present with isolated hyporeflexia as the hallmark finding.

Question 4

A patient with hyperkalemia is at risk for cardiac dysrhythmias. Which order should the nurse implement first?

Accepted Answer

Answer reason: In hyperkalemia, the first priority when cardiac instability is a concern is to protect the myocardium. IV calcium gluconate does not lower the serum potassium level, but it rapidly stabilizes the cardiac membrane and reduces the immediate risk of lethal dysrhythmias. Kayexalate and loop diuretics help remove potassium more slowly, and monitoring alone does not treat the urgent danger.

Question 5

A nurse is caring for an infant diagnosed with intussusception. What should be the nurse's priority goal of management?

Accepted Answer

Answer reason: Stabilizing circulation with IV fluids and correcting electrolytes is the immediate, life-preserving priority before diagnostic/therapeutic procedures. Hydrostatic (air/contrast) reduction is definitive treatment, but it should follow initial stabilization to reduce peri-procedural risk. Monitoring temperature and infection prevention are important but do not address the most imminent threat to life in the acute phase.

Question 6

The earliest sign of fluid volume deficit is?

Accepted Answer

Answer reason: This makes weight loss an early and objective indicator of developing hypovolemia, often preceding more overt perfusion-related signs. Thirst is a compensatory sensation and can be blunted in older adults or those with altered sensorium, so it is less reliable as an earliest finding. Low urine output is typically a later compensatory response after renal perfusion/ADH-mediated conservation has become more pronounced, and weakness is nonspecific.

Question 7

Following a unilateral adrenalectomy, nurse Betty would assess for hyperkalemia shown by which of the following?

Accepted Answer

Answer reason: After adrenalectomy, reduced aldosterone effect can decrease renal potassium excretion, increasing risk for elevated serum potassium. Tremors and diaphoresis are more typical of sympathetic activation or hypoglycemia rather than potassium excess. Constipation is more consistent with hypokalemia (reduced GI smooth muscle activity) than hyperkalemia.

Question 8

A nurse is caring for a client who presents with abdominal pain, loose stools, and postprandial vomiting for 2 days. What is the priority nursing diagnosis?

Accepted Answer

Answer reason: Priority nursing diagnoses focus on immediate threats to circulation and physiologic stability before comfort or longer-term needs. This presentation implies active GI fluid losses and reduced intake due to postprandial emesis, making volume depletion the most urgent and actionable concern. Pain control is important but does not supersede stabilization of intravascular volume. Malnutrition and skin integrity are typically longer-term risks and are not the most immediate priority in an acute 48-hour GI illness.

Question 9

A nurse is caring for a client with diabetes on metformin who reports muscle twitching. On assessment, blood glucose level is 70 mg/dL (3.9 mmol/L). Which of the following acid-base imbalance would the nurse suspect?

Accepted Answer

Answer reason: The nurse should suspect an acid-base problem driven by excess fixed acid (lactate) rather than a primary ventilatory problem. Muscle twitching can occur with acid–base/electrolyte derangements that accompany systemic illness and acidosis, and hypoglycemia does not point toward respiratory alkalosis. Respiratory acidosis/alkalosis would be primarily linked to hypoventilation/hyperventilation patterns rather than a medication-associated metabolic process.

Question 10

The nurse cares for an adult female client who reports weakness in all extremities. Bowel sounds are hypoactive. The client’s electrocardiogram (ECG) features a flattened T wave, prolonged PR interval, and a prominent U wave is noted. Which of the following electrolyte imbalances should the nurse expect?

Accepted Answer

Answer reason: Neuromuscular hypopolarization also leads to generalized weakness and decreased GI smooth muscle activity, consistent with hypoactive bowel sounds/ileus. Hypocalcemia more typically prolongs the QT interval with neuromuscular excitability (e.g., tetany), not U waves. Hypernatremia and hypermagnesemia do not match the characteristic U-wave pattern described here and would be less directly tied to the listed ECG triad.

Question 11

An 18-month-old child is brought to the emergency department with irritability, lethargy for 2 days, dry skin, and an increased pulse rate. Based on these findings, the nurse should assess for which additional condition?

Accepted Answer

Answer reason: Dry skin, lethargy, irritability, and tachycardia are classic signs of dehydration in young children. These findings indicate fluid volume deficit and warrant further assessment for additional signs such as decreased urine output, sunken eyes, and poor skin turgor.

Question 12

Which patient is at more risk for an electrolyte imbalance?

Accepted Answer

Answer reason: An 8 month old with a fever of 102.3 °F and diarrhea Infants are at high risk for rapid fluid and electrolyte shifts because they have a higher total body water percentage, higher metabolic rate, and limited renal ability to conserve water and sodium. Diarrhea causes direct gastrointestinal losses of water, sodium, potassium, and bicarbonate, and fever increases insensible losses, compounding dehydration risk. This combination can quickly lead to clinically significant hypo/hypernatremia and potassium abnormalities with signs like lethargy, poor perfusion, and decreased urine output. While vomiting can also cause electrolyte disturbances, the most vulnerable patient with the greatest risk of rapid decompensation here is the young infant with ongoing diarrheal losses and fever.

Question 13

Which patient below would have a potassium level of 5.5?

Accepted Answer

Answer reason: A potassium of 5.5 mEq/L indicates hyperkalemia, most commonly from reduced renal potassium excretion or hypoaldosteronism. In Addison’s disease (primary adrenal insufficiency), aldosterone deficiency decreases sodium reabsorption and potassium secretion in the distal nephron, leading to hyperkalemia. In contrast, loop diuretics like furosemide and prolonged vomiting typically cause potassium loss and hypokalemia. Liver failure can cause multiple metabolic abnormalities, but it is not a classic primary cause of isolated hyperkalemia compared with adrenal mineralocorticoid deficiency.

Question 14

Which patient is at most risk for fluid volume deficient?

Accepted Answer

Answer reason: Fluid volume deficit occurs when fluid losses exceed intake, commonly from gastrointestinal losses or external drainage/suction. Prolonged vomiting and diarrhea produce large isotonic losses, reducing intravascular volume and increasing risk for dehydration and electrolyte disturbances. Continuous nasogastric suction removes gastric fluids and can cause ongoing volume depletion as well as metabolic alkalosis and hypochloremia. Intermittent wound vac therapy can also remove serosanguinous fluid, and if output is significant it contributes to negative fluid balance, so each scenario increases risk.

Question 15

The nurse is caring for a client who has normal glucose levels at bedtime, hypoglycemia at 2am and hyperglycemia in the morning. What is this client likely experiencing?

Accepted Answer

Answer reason: A normal bedtime glucose with a low value around 2 AM strongly supports overnight overinsulinization as the trigger. In contrast, dawn phenomenon causes morning hyperglycemia without preceding overnight hypoglycemia, typically with normal or elevated 2–3 AM glucose. Recognizing this distinction guides safer insulin adjustments (often reducing nighttime insulin or adding a bedtime snack rather than increasing insulin).

Question 16

A patient with Delirium Tremens is receiving intravenous fluids. Which electrolyte imbalance is most critical to monitor?

Accepted Answer

Answer reason: Chronic alcohol use commonly leads to hypomagnesemia, which increases risk of arrhythmias and seizures, especially in delirium tremens. Monitoring and correcting magnesium is critical.

Question 17

The nurse is teaching a child and her parents about managing diabetes during illness. The nurse determines the parents understand the instruction when they indicate that, when the child is ill, they will provide?

Accepted Answer

Answer reason: Acute illness triggers a stress-hormone response (e.g., cortisol, catecholamines) that increases hepatic glucose production and causes relative insulin resistance. As a result, children with diabetes typically need continued—and often increased—insulin to prevent hyperglycemia and ketosis/DKA even if oral intake is reduced. Decreasing insulin is a common unsafe mistake because it can rapidly precipitate ketone formation during illness. Sick-day management also emphasizes frequent glucose/ketone monitoring and maintaining hydration, but the key teaching here is that insulin usually must not be withheld and may need to be increased.

Question 18

The nurse is monitoring a child with burns during treatment. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation?

Accepted Answer

Answer reason: Capillary refill is a rapid bedside indicator of peripheral perfusion that worsens with hypovolemia/shock and improves as circulation is restored. Skin turgor and local burn-site edema are unreliable in burns because tissue injury and third spacing distort these findings. The amount of fluid “tolerated” does not confirm effective circulating volume or tissue perfusion and can be misleading if ongoing losses are high.

Question 19

A nurse is caring for a patient with the following symptoms: positive Chvostek’s sign, positive Trousseau’s sign, and muscle spasms. Which of the following electrolyte imbalances is this patient likely to have?

Accepted Answer

Answer reason: Chvostek’s sign and Trousseau’s sign are classic bedside indicators of hypocalcemia/tetany and are commonly accompanied by cramps or muscle spasms. Sodium abnormalities more typically produce altered mental status and seizure risk rather than these specific tetany signs. In contrast, hypercalcemia tends to decrease neuromuscular excitability and is associated with weakness, constipation, and diminished reflexes rather than carpopedal spasm.

Question 20

Which of these signs suggests that a male client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?

Accepted Answer

Answer reason: Neuromuscular irritability and severe electrolyte derangements can progress to muscle cramps/spasms and seizure activity, making tetany an alarming complication indicator. Neck vein distention suggests volume overload/heart failure, which is not the classic early complication being monitored in SIADH compared with neurologic signs. Weight loss and polyuria are more consistent with water deficit states (e.g., diabetes insipidus) rather than SIADH-related water retention.

Question 21

A rapid response is called on a patient who is experiencing acute shortness of breath. Which action is most appropriate?

Accepted Answer

Answer reason: Stopping the IV infusion is an immediate nursing action to prevent worsening alveolar flooding while additional interventions (upright positioning, oxygen escalation, provider notification/diuretics) are initiated. Titrating oxygen down solely because SpO2 is 96% can be unsafe in an actively dyspneic patient because work of breathing and ventilation may still be failing. Subcutaneous epinephrine is reserved for anaphylaxis/bronchospasm scenarios and is not the best fit for crackles indicating fluid in the lungs.

Question 22

Which outcome indicates that treatment of a male client with diabetes insipidus has been effective?

Accepted Answer

Answer reason: Effective management of diabetes insipidus reduces free-water losses by decreasing polyuria and polydipsia, leading to more normalized hydration needs and urine volume. A daily fluid intake under about 2.5 L suggests thirst and excessive replacement drinking are no longer driving intake, consistent with improved ADH effect or response to therapy. In contrast, urine output >200 mL/hr reflects ongoing large-volume diuresis typical of uncontrolled disease. Hypotension and tachycardia are signs of hypovolemia from persistent fluid loss, indicating inadequate control rather than effective treatment.

Question 23

SITUATION: A 55-year-old male client visits the cardiovascular clinic after an ECG reveals T wave inversion, ST segment depression, and prominent U waves. Based on these findings, the nurse anticipates a prescription for which of the following medications?

Accepted Answer

Answer reason: Replacing potassium addresses the underlying electrolyte deficit and helps normalize repolarization abnormalities seen on ECG. Calcium gluconate and sodium polystyrene sulfonate are therapies aimed at hyperkalemia (membrane stabilization and potassium removal, respectively), which would more typically cause peaked T waves and QRS widening. Magnesium sulfate is primarily used for torsades de pointes or significant hypomagnesemia, and while magnesium can be related, the described hallmark U waves point most directly to low potassium.

Question 24

The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse would plan to implement which measure?

Accepted Answer

Answer reason: Anuria in hemolytic-uremic syndrome reflects severe acute kidney injury with inability to excrete water and solutes, creating high risk for fluid overload, hypertension, and pulmonary edema. Fluid intake is typically limited to insensible losses plus any ordered allowances and is adjusted based on weight trends and dialysis prescription. Peritoneal dialysis helps remove fluid and wastes, but nursing care still prioritizes strict intake/output and preventing volume excess between exchanges. An arteriovenous fistula pertains to hemodialysis access, and promoting high-potassium foods is unsafe when renal potassium excretion is impaired.

Question 25

SITUATION: The nurse reviews a client's ECG and notes tall, peaked T waves, a widened QRS complex, and a prolonged PR interval. Based on these findings, which medication is the healthcare provider most likely to prescribe?

Accepted Answer

Answer reason: The immediate priority is membrane stabilization to reduce the risk of lethal dysrhythmias, which is achieved with intravenous calcium. This intervention does not lower serum potassium, but it rapidly antagonizes potassium’s effect on the myocardium. Potassium chloride would worsen the problem, and magnesium sulfate is primarily used for torsades de pointes rather than hyperkalemic ECG changes.

Question 26

A 48-year-old client with a history of type 1 diabetes mellitus presents to the emergency department with abdominal pain, vomiting, and rapid deep respirations. Vital signs are: BP 88/56 mmHg, HR 128 bpm, RR 32, Temp 37.4°C. The client reports feeling extremely thirsty and reports no insulin use for the past 24 hours due to running out of supply. Laboratory results reveal: blood glucose 480 mg/dL, serum ketones positive, arterial pH 7.18, bicarbonate 14 mEq/L. Which of the following should the nurse do first?

Accepted Answer

Answer reason: Start an IV infusion of 0.9% normal saline. This presentation is diabetic ketoacidosis with shock-level hypotension, indicating severe intravascular volume depletion requiring immediate circulatory support. The first priority is restoring perfusion with isotonic fluids to improve blood pressure, renal perfusion, and tissue oxygen delivery before other therapies. Insulin is essential but can worsen hypotension and precipitate dangerous electrolyte shifts (especially potassium) if started before adequate volume resuscitation. Oral fluids are unsafe/ineffective in an acutely ill vomiting client, and notifying the provider does not replace initiating the time-critical standing emergency intervention of IV isotonic fluids.

Question 27

Your patient is complaining of muscle cramps while undergoing hemodialysis. Which intervention is effective in relieving muscle cramps?

Accepted Answer

Answer reason: Intradialytic muscle cramps are most commonly caused by excessive fluid removal leading to acute intravascular volume depletion and reduced muscle perfusion. An isotonic normal saline bolus helps restore circulating volume and blood pressure, improving tissue perfusion and relieving cramping. Increasing the dialysis rate typically worsens fluid shifts and can aggravate hypotension and cramps. D5W becomes hypotonic after dextrose metabolism and is less effective for rapid intravascular expansion during dialysis.

Question 28

A male client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?

Accepted Answer

Answer reason: SIADH causes excess ADH effect, leading to water retention, dilutional hyponatremia, and risk for neurologic complications such as confusion and seizures. The priority nursing action is to limit free water to reduce further dilution of serum sodium and help restore osmolality. Increasing oral intake or rapidly infusing IV fluids worsens water overload and can further drop sodium. Glucose-containing IV fluids become hypotonic after metabolism and can also exacerbate hyponatremia in SIADH.

Question 29

Which of the following factors should be the primary focus of nursing management in a patient with acute pancreatitis?

Accepted Answer

Answer reason: Nursing priorities therefore center on aggressive monitoring and support of intravascular volume, electrolytes (especially calcium), urine output, and hemodynamic status to prevent organ hypoperfusion. While pain control is essential, it does not mitigate the immediate life-threatening risk of circulatory collapse if volume deficits are not corrected. Nutrition is typically held initially (NPO) and addressed after stabilization, and hypoglycemia is not the most characteristic early metabolic threat compared with fluid shifts and electrolyte derangements.

Question 30

Daniel who is a marathon runner is at high risk for fluid volume deficit. Which one of the following is a related factor?

Accepted Answer

Answer reason: Endurance running increases respiratory rate and sweating for thermoregulation, creating substantial water (and some electrolyte) loss. This mechanism directly explains why marathon runners are prone to dehydration if fluids are not replaced. Decreased urine output is more consistent with a compensatory response to dehydration rather than a cause. The other options either reduce fluid loss or are nonspecific compared with the key exercise-related driver here.

Question 31

Which finding indicates that fluid resuscitation has been successful for a client with a burn injury?

Accepted Answer

Answer reason: A urine output around 0.5 mL/kg/hr in adults (often targeted as ~30–50 mL/hr) suggests sufficient intravascular volume and renal perfusion. A hematocrit of 60% indicates hemoconcentration from ongoing plasma losses, implying under-resuscitation. Tachycardia at 130 beats/min can reflect hypovolemia or stress response, and increasing peripheral edema reflects capillary leak/third spacing rather than effective circulating volume.

Question 32

Which finding is characteristic during the emergent period after a deep full-thickness burn injury?

Accepted Answer

Answer reason: A hallmark finding is oliguria, and urine output becomes critically low if resuscitation is inadequate. A urine output of 10 mL/hr indicates significant underperfusion/shock risk in an adult compared with typical targets (about 30–50 mL/hr). Foul-smelling drainage is more consistent with later wound infection, and deep full-thickness burns may have reduced local pain because nerve endings are destroyed.

Question 33

A 19-year-old client with a 2-year history of type 1 diabetes mellitus is admitted to the emergency department experiencing confusion, diaphoresis, and palpitations. Her blood glucose testing is 30 mg/dL. The client has been taking regular insulin injections as prescribed but reports feeling unwell for the past few hours and neglecting to eat due to nausea. The nurse anticipates the patient is most likely experiencing?

Accepted Answer

Answer reason: Neuroglycopenic and adrenergic symptoms occur when plasma glucose drops significantly, especially in patients using insulin. A glucose of 30 mg/dL is critically low and directly explains confusion, diaphoresis, and palpitations. The history of taking regular insulin while not eating due to nausea strongly supports insulin-related low blood sugar rather than hyperglycemic crises. Diabetic ketoacidosis typically presents with hyperglycemia, dehydration, and metabolic acidosis (e.g., Kussmaul respirations), which is inconsistent with the measured value.

Question 34

The nurse is caring for a diabetic patient who becomes diaphoretic. When reaching for his water, the patient’s hands tremble. What action by the nurse is least helpful?

Accepted Answer

Answer reason: Giving insulin in this context can further lower blood glucose and worsen neuroglycopenia, potentially leading to seizure or loss of consciousness. Immediate bedside capillary glucose testing and providing fast-acting carbohydrate (e.g., juice) are appropriate initial actions while evaluating contributing factors such as timing and carbohydrate content of the last meal. A common pitfall is treating presumed hyperglycemia by protocol without first verifying the glucose level when hypoglycemia symptoms are present.

Question 35

The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem?

Accepted Answer

Answer reason: Immediate priorities follow ABCs and circulation, so restoring/maintaining intravascular volume and monitoring fluid status outweigh longer-term needs. Client education and coping are important but are not the most urgent threats to physiologic stability in acute hyperglycemia. Nutrition problems contribute to glycemic control, but they do not address the immediate risk of fluid deficit from ongoing diuresis.

Question 36

A client who is receiving chemotherapy reports having prolonged diarrhea at home without adequate management. The nurse should become concerned about which risk to this client regarding chemotherapy?

Accepted Answer

Answer reason: Clients receiving chemotherapy are often more vulnerable due to poor intake, nausea, and concurrent nephrotoxic exposures, so dehydration can progress quickly to kidney impairment if not corrected. This option reflects a serious systemic complication requiring prompt assessment of hydration status, urine output, and labs (BUN/creatinine, electrolytes). Malnutrition is a longer-term concern, but it is typically less immediately life-threatening than acute kidney injury from uncontrolled fluid loss.

Question 37

A mother brings her daughter to the emergency department. The daughter was at a dance party for the last few hours, but now she is sweating and does not look well. Assessment reveals temperature of 103°F (39.4°C), weight loss, and teeth grinding. What should be the nurse’s greatest concern?

Accepted Answer

Answer reason: g., MDMA/amphetamines) exposure, which can rapidly cause dangerous fluid shifts. Ongoing sweating and hyperthermia increase insensible losses and can precipitate hypovolemia, tachycardia, and shock if not corrected promptly. Stimulant-associated overheating can also be complicated by sodium disturbances (including hyponatremia if excessive free water is consumed), raising seizure and cerebral edema risk. Compared with longer-term concerns like nutrition or an eating disorder, immediate threats to perfusion and neurologic stability from fluid/electrolyte derangements require urgent nursing prioritization. Influenza is less consistent with the sudden onset during a dance party and does not best explain bruxism and acute weight loss.

Question 38

A patient is admitted to the ER with the following findings: heart rate of 110 (thready upon palpation), 80/62 blood pressure, 25 ml/hr urinary output, and Sodium level of 160. What interventions do you expect the medical doctor to order for this patient?

Accepted Answer

Answer reason: Administer isotonic IV fluid (0.9% Sodium Chloride) and monitor urinary output. The key principle is that severe hypernatremia with signs of hypovolemia (hypotension, tachycardia with thready pulse, oliguria) requires rapid isotonic fluid resuscitation to restore circulating volume, followed by gradual correction of serum sodium to avoid rapid osmotic shifts and neurologic injury. This option addresses both circulatory compromise and ongoing renal perfusion by providing IV fluids and emphasizing urine-output monitoring as a response marker. Fluid restriction would worsen hypovolemia and kidney hypoperfusion, and giving sodium tablets would further increase an already critically elevated sodium level. Doing nothing is unsafe given shock physiology and end-organ hypoperfusion indicators.

Question 39

The nurse is caring for a patient whose blood glucose level is 55mg/dL. What is the likely nursing response?

Accepted Answer

Answer reason: A blood glucose of 55 mg/dL indicates clinically significant hypoglycemia requiring rapid correction with fast-acting glucose. The standard first intervention for a conscious patient who can swallow is the “15-15 rule”: give 10–15 g of rapid carbohydrate and recheck in about 15 minutes, repeating if still low. A small meal or high-protein snack acts more slowly and is better used after initial correction to prevent recurrence, not as the immediate treatment. Glucagon is typically reserved for severe hypoglycemia when the patient cannot take oral carbohydrates due to altered mental status, seizure, or inability to swallow.

Question 40

An adolescent client with type I diabetes mellitus is admitted to the emergency department after treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note as sweating and tremors?

Accepted Answer

Answer reason: This produces diaphoresis with cool/clammy skin and neurobehavioral changes such as irritability. These findings fit early hypoglycemia and are important for rapid bedside recognition and prompt glucose administration. Fruity breath and declining consciousness are more consistent with ongoing ketoacidosis and worsening hyperglycemia rather than post-treatment hypoglycemia.

Question 41

The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client’s urine output for the previous shift was 3000 mL. The nurse implements a new physician order to administer?

Accepted Answer

Answer reason: Desmopressin is a synthetic ADH analog that increases renal water reabsorption in the collecting ducts, decreasing urine volume and increasing urine concentration. A loop diuretic such as ethacrynic acid would worsen polyuria and volume depletion rather than correct the underlying problem. Mannitol is an osmotic diuretic used to reduce intracranial pressure and would also increase urine output, making it unsafe in this presentation.

Question 42

The nurse is caring for a patient who has a chloride level of 115 mEq/L. Which of the following medications does she prepare to administer?

Accepted Answer

Answer reason: Sodium bicarbonate provides base to buffer hydrogen ions and can help correct clinically significant hyperchloremic metabolic acidosis when indicated. Normal saline would tend to worsen hyperchloremia because it has a high chloride content. Lactated Ringer’s has less chloride than normal saline and may be preferred for resuscitation, but it does not directly provide bicarbonate and is not the targeted corrective therapy for the chloride-driven acidosis implied here. Lasix promotes renal chloride loss but is not the primary, direct correction for the acid–base problem and can create additional electrolyte losses.

Question 43

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?

Accepted Answer

Answer reason: Major burns cause extensive tissue injury and cell lysis, releasing intracellular potassium into the bloodstream, which can raise serum potassium to 5.5 mEq/L or higher, especially early after injury. In contrast, colitis and laxative overuse typically cause gastrointestinal potassium losses leading to hypokalemia. Cushing’s syndrome produces mineralocorticoid effects that promote sodium retention and potassium wasting, also making hypokalemia more likely than hyperkalemia.

Question 44

While at the park, the nurse witnesses an elderly woman fall. Upon evaluation, the woman complains of severe pain and an inability to move her left leg. The nurse also notes that the woman's left leg appears shorter than the right but no visible wound. A femoral fracture is suspected. Which of the following is the greatest immediate risk for the client?

Accepted Answer

Answer reason: A femoral fracture can cause major occult blood loss into the thigh even without an open wound, making hemorrhagic shock the most time-critical early complication. Proximal long-bone fractures can sequester large volumes of blood, so the immediate nursing priority is recognizing and preventing hypovolemia through rapid assessment and stabilization. Fat embolism is a serious complication of long-bone fractures, but it typically develops after a latency period rather than being the most immediate threat at the scene. Infection is less immediate in a closed fracture, and neurogenic shock is associated with spinal cord injury rather than an isolated femur fracture.

Question 45

A full-term newborn of a mother with gestational diabetes is slightly jittery with a blood glucose level of 45 mg/dL. What is the nurse's first action?

Accepted Answer

Answer reason: A glucose of 45 mg/dL in a term infant is at the threshold where feeding and recheck is the immediate nursing intervention before escalation if the infant can safely feed. Oral glucose gel/solution protocols vary and typically follow facility orders, while notifying the provider is appropriate if the glucose remains low or symptoms persist despite feeding. Warming the room addresses cold stress but does not rapidly correct the primary problem of low serum glucose in an infant of a diabetic mother.

Question 46

A nurse is caring for a client with type 1 diabetes who is light headed, begins sweating profusely, and loses consciousness. Which action should the nurse take?

Accepted Answer

Answer reason: Loss of consciousness with diaphoresis in a client with type 1 diabetes most strongly indicates severe hypoglycemia, which requires rapid correction to prevent neurologic injury. An unconscious client cannot safely take oral carbohydrates due to aspiration risk, so orange juice is inappropriate. IV dextrose provides immediate glucose availability and is the fastest bedside reversal when IV access is available. Giving fast-acting insulin would worsen hypoglycemia, and raising the legs does not treat the underlying low serum glucose driving the symptoms.

Question 47

A nurse is caring for an adolescent client who has diabetes mellitus. Which of the following findings indicates that the client is experiencing hyperglycemia?

Accepted Answer

Answer reason: Thirst reflects the body’s compensatory drive to replace fluid losses from polyuria. In contrast, shakiness and diaphoresis are adrenergic signs more typical of hypoglycemia due to counterregulatory catecholamine release. Pallor is nonspecific and does not strongly indicate elevated blood glucose compared with the dehydration pattern seen in hyperglycemia.

Question 48

You are taking care of a 10-year-old with a GJ tube. Which electrolyte deficit is this patient at risk for?

Accepted Answer

Answer reason: Patients with gastrostomy/jejunostomy tubes can have significant GI losses from drainage, high-output feeds, diarrhea, or vomiting, which commonly depletes potassium. Potassium is predominantly an intracellular ion and is easily lost in stool and gastric/intestinal secretions, making hypokalemia a frequent risk with ongoing GI loss or poor intake. Hypokalemia is clinically important because it predisposes to weakness, ileus, and cardiac dysrhythmias, so it is a key electrolyte to monitor in enteral-tube patients. Sodium disturbances can occur too, but potassium is the most classically associated deficit with sustained GI losses. Chloride loss is more specific to gastric suction/vomiting metabolic alkalosis patterns, not the broader GJ-tube risk profile.

Question 49

A diabetic woman has a precipitous delivery in the emergency department. Which initial neonate assessment finding is not expected and is a priority for a nursing response?

Accepted Answer

Answer reason: Jitteriness is an abnormal neurologic sign consistent with hypoglycemia (and can also indicate hypocalcemia) and requires immediate bedside glucose assessment and prompt feeding or IV dextrose per protocol to prevent seizures. An Apgar of 7 at 1 minute can be a normal transition finding, and a heart rate of 160/min is within the normal newborn range (120–160/min). Mild circumoral duskiness can be seen during early transition and is less immediately concerning than a symptom suggesting metabolic instability.

Question 50

A nurse is caring for a 4 year-old child admitted after being burned over more than 50% of the body. Which laboratory data should be reviewed by the nurse as a priority in the initial 24 hours?

Accepted Answer

Answer reason: Trending this value helps evaluate the severity of plasma loss and the adequacy of early fluid resuscitation alongside urine output and vital signs. An elevated result early suggests ongoing intravascular depletion, while a falling value after resuscitation can indicate hemodilution or bleeding, both clinically important. In contrast, leukocytosis is common from stress/inflammation and is less useful as an immediate resuscitation guide in the first day. Renal markers such as BUN can lag behind the acute volume shift and are more supportive than primary for early burn-shock management.

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