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Med-Surg set 1

An example of a nursing activity that reflects the American Nurses Association’s definition of nursing is:

A. diagnosing a patient with a feeding tube as being at risk for aspiration
B. Establishing protocols for treating patients in the emergency department.
C. Providing antianxiety drugs for a patient who has disturbed sleep patterns
D. Identifying and treating dysrhythmias that occur in a patient in the coronary care unit.

(Chapter 1:Professional nursing practice – Bridge to NCLEX exam chapter questions pp 16-17)

A. diagnosing a patient with a feeding tube as being at risk for aspiration

Rationale: The American Nurses Association (ANA) defines nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.” The nursing activity described in option a is related to the prevention of injury.

A nurse working on the medical-surgical unit at an urban hospital would like to become certified in a medical-surgical specialty. The nurse knows that this process would most likely require:

A. A bachelor’s degree in nursing.
B. Formal education in advanced nursing practice.
C. Experience for a specific period in medical-surgical nursing.
D. Membership in a medical-surgical nursing specialty organization.

(Chapter 1:Professional nursing practice – Bridge to NCLEX exam chapter questions pp 16-17)

C. Experience for a specific period in medical-surgical nursing.

Rationale: Certification in nursing specialties usually requires a certain amount of clinical experience.

A nurse is providing care to a patient after right hip surgery. Within a pay-for-performance system, a critical role of the nurse is to:
A. Ensure that care is provided using a minimal amount of supplies
B. Discharge the patient at completion of the number of approved days of care.
C. Implement measures to decrease the risk of the patient acquiring an infection.
D. Assess the patient’s ability to pay for health care services at the time of admission.

(Chapter 1:Professional nursing practice – Bridge to NCLEX exam chapter questions pp 16-17)

C. Implement measures to decrease the risk of the patient acquiring an infection.

Rationale: Pay-for-performance programs reimburse hospitals for performance on quality-of-care measures. Payment for care can be withheld if a patient develops certain health conditions during the hospital stay or if something happens to the patient that is considered preventable.

The nurse is assigned to care for a newly admitted patient. Number in order the steps for using the nursing process to prioritize care. (Number 1 is the first step, and number 5 is the last step)
____Evaluate whether the plan was effective.
____Identify any health problems
____Collect patient information.
____Carry out the plan
____Determine the plan of action.

(Chapter 1:Professional nursing practice – Bridge to NCLEX exam chapter questions pp 16-17)

4. Correct answer: 5, 2, 1, 4, 3

_1__Collect patient information.
_2__Identify any health problems
_3__Determine the plan of action.
_4__Carry out the plan
_5__Evaluate whether the plan was effective.

Rationale: The basic order of the nursing process is assessment, problem identification, planning, implementation, and evaluation.

The linkages among NANDA-1 nursing diagnosis, NOC patient outcomes, and NIC nursing interventions can be used to:
A. Evaluate patient outcomes.
B. Provide guides for planning care.
C. Predict the results of nursing care.
D. Shorten written care plans for individual patients.

(Chapter 1:Professional nursing practice – Bridge to NCLEX exam chapter questions pp 16-17)

B. Provide guides for planning care.

Rationale: Standardized care plans offered by the North American Nursing Diagnosis Association (NANDA), Nursing Outcomes Classification (NOC), and Nursing Interventions Classification (NIC) groups may be used as guides for routine nursing care.

Advantages of the use of informatics in health care delivery are (Select all that apply):

A. Reduced need for home care nurses in rural areas
B. Increased patient anonymity and confidentiality
C. The ability to achieve and maintain high standards of care.
D. Improved communication of the patient’s health status to the health care team.
E. Access to standardized plans of care that are available for most types of health problems.

(Chapter 1:Professional nursing practice – Bridge to NCLEX exam chapter questions pp 16-17)

Correct answers:

C. The ability to achieve and maintain high standards of care.
D. Improved communication of the patient’s health status to the health care team.
E. Access to standardized plans of care that are available for most types of health problems.

Rationale: Informatics can improve the ability of the health care team to deliver high-quality care through facilitating communication of the patient’s health status among the team members and enhancing access to standardized plans of care. With the increased use of informatics are new concerns regarding best practices for maintaining patient anonymity and confidentiality.

When using evidenced-based practice, the nurse:

A. Must use clinical practice guidelines developed by national health agencies.
B. Should use findings from randomized controlled trials to plan care for all patient problems.
C. Uses clinical decision making and judgement to determine what evidence is appropriate for a specific clinical situation.
D. Statistically analyze the relationship of nursing interventions to patient outcomes to establish evidence for the most appropriate patient interventions.

(Chapter 1:Professional nursing practice – Bridge to NCLEX exam chapter questions pp 16-17)

C. Uses clinical decision making and judgement to determine what evidence is appropriate for a specific clinical situation.

Rationale: Evidence-based practice is the consistent use of the best evidence in combination with clinicians’ expertise and patients’ preferences and values to support clinical decision making.

The nurse’s role in addressing the national patient safety goals established by The Joint Commission includes (Select all that apply):

A. Using side rails and alarm systems as necessary to prevent patient falls.
B. Memorizing and implementing all the rules published by The Joint Commission.
C. Verifying telephone and verbal orders using the “write down and read back procedure.”
D. Encourage patients to be actively involved in and question their own health care.
E. Obtaining a complete list of the patient’s medications and monitoring their use throughout the continuum of care.

(Chapter 1:Professional nursing practice – Bridge to NCLEX exam chapter questions pp 16-17)

Correct answers: a, c, e

A. Using side rails and alarm systems as necessary to prevent patient falls.
C. Verifying telephone and verbal orders using the “write down and read back procedure.”
E. Obtaining a complete list of the patient’s medications and monitoring their use throughout the continuum of care.

Rationale: Review the National Patient Safety Goals in Table 1-5. The goals related to the correct options are to reduce the risk of patient harm resulting from falls, to improve the effectiveness of communication among caregivers, and to accurately and completely reconcile medications across the continuum of care.

The nurse is caring for a diabetic patient in the ambulatory surgical unit who has just undergone debridement of an infected toe. Which task is most appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

A. Check patient’s vital signs.
B. Evaluate the patient’s awareness.
C. Monitor the site of the patient’s IV catheter.
D. Evaluate the patient’s tibial and pedal pulses.

(Chapter 1:Professional nursing practice – Bridge to NCLEX exam chapter questions pp 16-17)

A. Check patient’s vital signs.

Rationale: Specific activities that may be delegated to unlicensed assistive personnel (UAP) include routine measurement of vital signs on stable patients, feeding or assisting patients at mealtime, helping stable patients ambulate, and helping patients with bathing and hygiene. Nursing interventions that require independent nursing knowledge, skill, or judgment, such as assessment and evaluation of care, cannot be delegated.

A nurse with an associate or baccalaureate degree who meets licensing requirements is qualified to practice as

A. a nurse practitioner.
B. a certified specialist.
C. an entry-level generalist.
D. an advanced practice nurse.

(Chapter 1: Professional nursing practice – Evolve PRE-TEST questions)

c. An entry level generalist,

Rationale: Entry-level nurses with an associate or baccalaureate degree are prepared to function as generalists. With experience and continued study, nurses may specialize in an area of practice and may obtain certification in nursing specialties. Certification usually requires clinical experience and successful completion of an examination. A nurse practitioner is an example of an advanced practice nurse. An advanced practice nurse has a minimum of a master’s degree with advanced education in pharmacology and physical assessment as well as expertise in a specialized area of practice.

When nurses disagree about the effectiveness of a commonly used nursing intervention, the best evidence for solving the question related to an intervention is

A. a systematic review of randomized controlled trials.
B. a qualitative research study with a large sample size.
C. a methodological Internet search using key medical terms.
D. anecdotal evidence retrieved from two or more case studies.

(Chapter 1: Professional nursing practice – Evolve PRE-TEST questions)

A. a systematic review of randomized controlled trials.

Rationale: Systematic reviews of randomized controlled trials (RCTs) are considered the strongest level of evidence to answer questions about interventions (i.e., cause and effect).

The nurse establishes priorities and determines outcomes for an individual patient during the

A. analysis phase of the nursing process.
B. planning phase of the nursing process.
C. evaluation phase of the nursing process.
D. assessment phase of the nursing process.

(Chapter 1: Professional nursing practice – Evolve PRE-TEST questions)

B. Planning phase of the nursing process

Rationale: During the planning phase of the nursing process, patient outcomes or goals are developed and nursing interventions are identified to accomplish the outcomes. The assessment phase of the nursing process includes the collection of subjective and objective patient information on which to base the plan of care. The evaluation phase of the nursing process determines if the patient outcomes have been met as a result of nursing interventions. Nursing diagnosis is the act of analyzing the assessment data and making a judgment about the nature of the data.

A nurse is monitoring all of the patients in an outpatient procedure area for complications of IV fluid administration. What type of function is the nurse demonstrating?

A. Dependent nursing function
B. Independent nursing function
C. Autonomous nursing function
D. Collaborative nursing function

(Chapter 1: Professional nursing practice – Evolve PRE-TEST questions)

D. Collaborative nursing function

Rationale: A collaborative nursing function is demonstrated when the nurse monitors patients for complications of acute illness, administers IV fluids and medications per physician or nurse practitioner orders, and implements nursing interventions such as providing emotional support or teaching about specific procedures. Nursing functions may be dependent, collaborative, or independent. The nurse functions dependently when carrying out medical orders. Physician-initiated nursing functions may include administering medications, performing or assisting with certain medical treatments, and assisting with diagnostic tests and procedures. Independent nursing functions include interventions such as promotion and optimization of health, prevention of illness, and patient advocacy.

A 40-year-old female patient is being prepared for discharge home after a laparoscopic cholecystectomy. Which team member can be assigned to complete a discharge assessment and provide patient teaching for post-discharge care?

A. Registered nurse (RN)
B. Nursing technician (NT)
C. Unlicensed assistive personnel (UAP)
D. Licensed practical/vocational nurse (LPN/LVN)

(Chapter 1: Professional nursing practice – Evolve PRE-TEST questions)

A. Registered Nurse (RN)

Rationale: Nursing interventions that require independent nursing knowledge, skill, or judgment such as assessment, patient teaching, and evaluation of care cannot be delegated. These interventions are the responsibility of the RN. The scope of practice for LPN/LVNs is determined by each state board of nursing. The RN must know the legal scope of practical/vocational nursing practice and delegates and assigns nursing functions appropriately. In most states LPN/LVNs may administer medications, perform sterile procedures, and provide a wide variety of interventions planned by the RN. UAP are unlicensed individuals who serve in an assistive role to the RN and may include nursing assistants or technicians. The RN may delegate specific activities such as obtaining routine vital signs on stable patients, feeding/assisting patients at mealtimes, ambulating stable patients, and helping patients with bathing and hygiene.

When the nurse encourages a patient with heart failure to alternate rest and activity periods to reduce cardiac workload, what phase of the nursing process is being used?

A. Planning
B. Diagnosis
C. Evaluation
D. Implementation

(Chapter 1: Professional nursing practice – Evolve NCLEX questions)

D. Implementation

Rationale: Carrying out a specific, individualized plan constitutes the implementation phase of the nursing process. The nurse’s action of encouragement and instruction to the patient is part of carrying out a plan of action

When planning care for a patient, the nurse may use a visual diagram of patient problems and interventions to illustrate the relationships among pertinent clinical data. What is this format called?

A. Concept map
B. Critical pathway
C. Clinical pathway
D. Nursing care plan

(Chapter 1: Professional nursing practice – Evolve NCLEX questions)

A. Concept map

Rationale: A concept map is another method of recording a nursing care plan. In a concept map, the nursing process is recorded in a visual diagram of patient problems and interventions. A clinical (critical) pathway is a prewritten plan that directs the entire health care team in the daily care goals for select health care problems.

A nurse is providing care for a patient who had transurethral resection of his prostate this morning. The patient is receiving continuous bladder irrigation, but his urinary catheter is now occluded. The nurse is now planning to phone the patient’s health care provider and communicate using the SBAR (Situation-Background-Assessment-Recommendation) format. Which statement is a component of communication using SBAR?

A. “What do you think could be causing this occlusion?”
B. “I think that we should manually irrigate his catheter.”
C. “What do you know about this patient and his history?”
D. “Could you please provide some direction for his care?”

(Chapter 1: Professional nursing practice – Evolve NCLEX questions)

B: “I think we should mannually irrigate his catheter.”

Rationale: Proposing a recommendation is a component of the “R” component of SBAR communication. Asking the health care provider for possible contributing factors to the problem or for general direction may be appropriate in some circumstances, but these are not explicit components of SBAR. The nurse should briefly identify the patient and his circumstances, not ask an open-ended question regarding the physician’s familiarity

What factor has been most clearly identified as an influence on the future of nursing practice?

A. Aging of the American population and increases in chronic illnesses
B. Increasing birth rates coupled with decreased average life expectancy
C. Increased awareness of determinants of health and improved self-care
D. Apathy around health behaviors and the relationship of lifestyle to health

(Chapter 1: Professional nursing practice – Evolve NCLEX questions)

A. Aging of the American population and increases in chronic illnesses

Rationale: The American population is aging at the same time that the incidence of chronic health conditions is increasing. There is no noted increase in the overall awareness of the determinants of health, but at the same time, observers have not identified apathy as a predominant attitude. Life expectancy is increasing, not decreasing.

A group of nurses have a plan to implement evidence-based practice (EBP) for care of patients with pressure ulcers. What will this change in practice encompass (select all that apply)?

A. Consulting with the wound care and ostomy nurse
B. The preferences of patients and their particular circumstances
C. Nurses’ expertise and their bodies of experience and knowledge
D. The traditions that surround pressure ulcer practices on the unit
E. Journal articles that address the care of patients with pressure ulcers

(Chapter 1: Professional nursing practice – Evolve NCLEX questions)

Correct answers: A, B, C, E

A. Consulting with the wound care and ostomy nurse
B. The preferences of patients and their particular circumstances
C. Nurses’ expertise and their bodies of experience and knowledge
E. Journal articles that address the care of patients with pressure ulcers

Rationale: EBP draws on research, data from local quality improvement, professional organization standards, patient preferences, and clinical expertise. The particular traditions on the nursing unit are not part of EBP.

A registered nurse (RN) has delegated the administration of IV medications to a licensed practical/vocational nurse (LPN/LVN). Which statement accurately describes delegation?

A. The RN should first teach the LPN how to administer IV medications.
B. Ultimate responsibility for the execution of the task now lies with the LPN.
C. The RN is still accountable for the quality of care and procedures that the patient receives.
D. The RN is responsible for observing and evaluating the administration of IV medications by the LPN.

(Chapter 1: Professional nursing practice – Evolve NCLEX questions)

C. The RN is still accountable for the quality of care and procedures that the patient receives.

Rationale: Delegation entails a redistribution of nursing work, but the RN remains ultimately responsible and accountable for the execution of the task. It would be inappropriate to delegate if the LPN was unfamiliar with the task. The RN is not obliged to observe the LPN’s execution of the task.

Nurses deliver patient-centered care in collaboration with the interdisciplinary health care team within the framework of a care delivery model. In which care delivery model does the nurse plan and coordinate the aspects of patient care with other disciplines with a focus on continuity of care and interdisciplinary collaboration even when the nurse is absent?

A. Team nursing model
B. Primary nursing model
C. Total patient care model
D. Case management nursing model

(Chapter 1: Professional nursing practice – Evolve NCLEX questions).

B. Primary nursing model

Rationale: Primary nursing model includes planning the patient’s care, coordinating and communicating all aspects of care with other disciplines and those providing care in the nurse’s absence. The focus is on continuity of care and interdisciplinary collaboration. Team nursing uses the RN as the team leader to organize and manage the care for a group of patients with other ancillary workers. The RN has authority and accountability for the quality of care delivered by the team only during the work period. In a total patient care model, the nurse is accountable for the complete care of the patient during the assigned shift. Case management is not a model of care delivery, but a collaborative process that involves assessing, planning, facilitating, and advocating for health services with a variety of resources to promote cost-effective outcomes.

Which interventions are independent nursing actions (select all that apply)?

A. IV reinsertion
B. Assessing lung sounds
C. Medication administration
D. First postoperative dressing change
E. Obtaining informed consent from the patient

(Chapter 1: Professional nursing practice – Evolve NCLEX questions)

Correct answers: A, B

A. IV reinsertion
B. Assessing lung sounds

Rationale: Independent nursing actions are those that a nurse is legally able to order or begin independently (e.g., turn every two hours, monitor for complications). Dependent interventions are physician-initiated. Medication administration is collaborative care as the health care provider must order the medication. Surgeons usually do the first postoperative dressing change. The health care provider legally must obtain informed consent from the patient, although the nurse may witness the consent.

Telehealth includes using devices to provide which types of care for the patient (select all that apply)?

A. Administering medications
B. Evaluation of weight loss
C. Video assessment of wounds
D. Monitoring peak flow meter results
E. Real-time blood pressure assessment

(Chapter 1: Professional nursing practice – Evolve NCLEX questions)

Correct answers: B, C, D, E

B. Evaluation of weight loss
C. Video assessment of wounds
D. Monitoring peak flow meter results
E. Real-time blood pressure assessment

Rationale: Telehealth enables the nurse to provide distance assessment, planning, intervention, and evaluation of outcomes of nursing care using technologies such as the Internet, digital assessment tools, and telemonitoring equipment.

You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A bowel obstruction is suspected. You assess this patient for which anticipated primary acid-base imbalance if the obstruction is high in the intestine?

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

B. Metabolic alkalosis

Rationale: Because gastric secretions are rich in hydrochloric acid, the patient who is vomiting will lose a significant amount of gastric acid and be at an increased risk for metabolic alkalosis.

Which serum potassium result best supports the rationale for administering a stat dose of potassium chloride 20 mEq in 250 mL of normal saline over 2 hours?

A. 3.1 mEq/L
B. 3.9 mEq/L
C, 4.6 mEq/L
D. 5.3 mEq/L

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

A. 3.1 mEq/L

Rationale: The normal range for serum potassium is 3.5 to 5.0 mEq/L. This IV order provides a substantial amount of potassium. Thus the patient’s potassium level must be low. The only low value shown is 3.1 mEq/L.

You receive a physician’s order to change a patient’s IV from D5½ NS with 40 mEq KCl/L to D5NS with 20 mEq KCl/L. Which serum laboratory values on this same patient best support the rationale for this IV order change?

A. Sodium 136 mEq/L, potassium 4.5 mEq/L
B. Sodium 145 mEq/L, potassium 4.8 mEq/L
C. Sodium 135 mEq/L, potassium 3.6 mEq/L
D. Sodium 144 mEq/L, potassium 3.7 mEq/L

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

A. Sodium 136 mEq/L, potassium 4.5 mEq/L

Rationale: The normal range for serum sodium is 135 to 145 mEq/L, and the normal range for potassium is 3.5 to 5.0 mEq/L. The change in the IV order decreases the amount of potassium and increases the amount of sodium. Therefore for this order to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective ranges.

You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, and O2 saturation of 99%. You interpret these results as

A. Slight metabolic acidosis.
B. Slight respiratory acidosis.
C. Slight respiratory alkalosis.
D. Within normal limits.

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

D. Within normal limits

Rationale: The normal pH is 7.35 to 7.45. Normal PaCO2 levels are 35 to 45 mm Hg, and HCO3 is 22 to 26 mEq/L. Normal PaO2 is >80 mm Hg. Normal oxygen saturation is >95%. Since the patient’s results all fall within these normal ranges, the nurse can conclude that the patient’s blood gas results are within normal limits.

You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results?

A. Fully compensated respiratory alkalosis
B. Partially compensated respiratory acidosis
C. Normal acid-base balance with hypoxemia
D. Normal acid-base balance with hypercapnia

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

B. Partially compensated respiratory acidosis

Rationale: A low pH (normal 7.35-7.45) indicates acidosis. In the patient with respiratory disease such as COPD, the patient retains carbon dioxide (normal 35-45 mm Hg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis. The elevated HCO3 indicates a partial compensation for the elevated CO2.

You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy?

A. Sodium falling to 138 mEq/L
B. Potassium rising to 4.1 mEq/L
C. Magnesium rising to 2.9 mg/dL
D. Phosphorus falling to 2.1 mg/dL

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

D. Phosphorus falling to 2.1 mg/dL

Rationale: Calcium has an inverse relationship with phosphorus in the body. When phosphorus levels fall, calcium rises, and vice versa. Since hypercalcemia rarely occurs as a result of calcium intake, the patient’s phosphorus falling to 2.1 mg/dL (normal 2.4-4.4 mg/dL) may be a result of the phosphate-binding effect of calcium carbonate.

You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the physician?

A. AntibioticS
B. Loop diuretics
C. Bronchodilators
D. Antihypertensives

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

B. Loop diuretics

Rationale: Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing physician should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range.

You are caring for a patient admitted with diabetes mellitus, malnutrition, and massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient (select all that apply)?

A. The potassium level may be increased if the patient has renal nephropathy.
B. The patient may be excreting extra sodium and retaining potassium because of malnutrition.
C. The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels.
D. There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood.
E. The patient has been overeating raisins, baked beans, and salt substitute that increase the potassium level.

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

Correct answers: A, C, D

A. The potassium level may be increased if the patient has renal nephropathy.
C. The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels.
D. There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood.

Rationale: Hyperkalemia may result from hyperglycemia, renal insufficiency, and/or cell death. Diabetes mellitus, along with the stress of hospitalization and illness, can lead to hyperglycemia. Renal insufficiency is a complication of diabetes. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus it is not a contributing factor to this patient’s potassium level. Stored hemolyzed blood can cause hyperkalemia when large amounts are transfused rapidly. The patient with a massive GI bleed would have an NG tube and not be eating.

You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention?

A. Notify the physician and complete an incident report.
B. Slow the rate to keep vein open until next bag is due at noon.
C. Obtain a new bag of IV solution to maintain patency of the site.
D. Listen to the patient’s lung sounds and assess respiratory status.

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

D. Listen to the patient’s lung sounds and assess respiratory status.

Rationale: After 4 hours of infusion time, 500 mL of IV solution should have infused, not 950 mL. This patient is at risk for fluid volume excess, and you should assess the patient’s respiratory status and lung sounds as the priority action and then notify the physician for further orders.

When assessing a patient admitted with nausea and vomiting, which finding supports the nursing diagnosis of deficient fluid volume?

A. Polyuria
B. Decreased pulse
C. Difficulty breathing
D. General restlessness

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

D. General restlessness

Rationale: Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma.

Which nursing intervention is most appropriate when caring for a patient with dehydration?

A. Auscultate lung sounds every 2 hours.
B. Monitor daily weight and intake and output.
C. Monitor diastolic blood pressure for increases.
D. Encourage the patient to reduce sodium intake.

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

B. Monitor daily weight and intake and output

Rationale: Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume. Recall that a 1-kg weight gain indicates a gain of approximately 1000 mL of body water.

When planning the care of a patient with dehydration, what would the nurse instruct the unlicensed assistive personnel (UAP) to report?

A. 60 mL urine output in 90 minutes
B. 1200 mL urine output in 24 hours
C. 300 mL urine output per 8-hour shift
D. 20 mL urine output for 2 consecutive hours

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

D. 20 mL urine output for 2 consecutive hours

Rationale: The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for 2 consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.
Awarded 1.0 points out of 1.0 possible points.

When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit?

A. Fluid movement from the blood vessels into the cells
B. Fluid movement from the interstitial spaces into the cells
C. Fluid movement from the blood vessels into interstitial spaces
D. Fluid movement from the interstitial space into the blood vessels

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

D. Fluid movement from the interstitial space into the blood vessels

Rationale: In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.

When planning care for adult patients, which oral intake is adequate to meet daily fluid needs of a stable patient?

A. 500 to 1500 mL
B. 1200 to 2200 mL
C. 2000 to 3000 mL
D. 3000 to 4000 mL

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

C. 2000 to 3000 mL

Rationale: Daily fluid intake and output is usually 2000 to 3000 mL. This is sufficient to meet the needs of the body and replace both sensible and insensible fluid losses. These would include urine output and fluids lost through the respiratory system, skin, and GI tract.

While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient?

A. Weakness
B. Paresthesia
C. Facial spasms
D. Muscle tremors

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

A. Weakness

Rationale: Signs of hypercalcemia are lethargy, headache, weakness, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial spasms, and muscle tremors are symptoms of hypocalcemia.

While performing patient teaching regarding hypercalcemia, which statements are appropriate (select all that apply)?

A. Have patient restrict fluid intake to less than 2000 mL/day.
B. Renal calculi may occur as a complication of hypercalcemia.
C. Weight-bearing exercises can help keep calcium in the bones.
D. The patient should increase daily fluid intake to 3000 to 4000 mL.
E. Treatment of heartburn can best be managed with Tums as needed.

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

Correct answers: B, C, and D

B. Renal calculi may occur as a complication of hypercalcemia.
C. Weight-bearing exercises can help keep calcium in the bones.
D. The patient should increase daily fluid intake to 3000 to 4000 mL.

Rationale: A daily fluid intake of 3000 to 4000 mL is necessary to enhance calcium excretion and prevent the formation of renal calculi, a potential complication of hypercalcemia. Tums are a calcium-based antacid that should not be used in patients with hypercalcemia. Weight-bearing exercise does enhance bone mineralization.

The patient has chronic kidney disease and ate a lot of nuts, bananas, peanut butter, and chocolate. The patient is admitted with loss of deep tendon reflexes, somnolence, and altered respiratory status. What treatment should the nurse expect for this patient?

A. Renal dialysis
B. IV potassium chloride
C. IV furosemide (Lasix)
D. IV normal saline at 250 mL per hour

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

A. Renal Dialysis

Rationale: Renal dialysis will need to be administered to remove the excess magnesium that is in the blood from the increased intake of foods high in magnesium. If renal function was adequate, IV potassium chloride would oppose the effects of magnesium on the cardiac muscle. IV furosemide and increased fluid would increase urinary output which is the major route of excretion for magnesium.

The patient is admitted with metabolic acidosis. Which system is not functioning normally?

A. Buffer system
B. Kidney system
C. Hormone system
D. Respiratory system

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

B. Kidney system

Rationale: When the patient has metabolic acidosis, the kidneys are not combining H+ with ammonia to form ammonium or eliminating acid with secretion of free hydrogen into the renal tubule. The buffer system neutralizes hydrochloric acid by forming a weak acid. The hormone system is not directly related to acid-base balance. The respiratory system releases CO2 that combines with water to form hydrogen ions and bicarbonate. The hydrogen is then buffered by the hemoglobin.

The dehydrated patient is receiving a hypertonic solution. What assessments must be done to avoid risk factors of these solutions (select all that apply)?

A. Lung sounds
B. Bowel sounds
C. Blood pressure
D. Serum sodium level
E. Serum potassium level

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

Correct answers: A, C, and D

A. Lung sounds
C. Blood pressure
D. Serum sodium level

Rationale: BP, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions.

When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress, and the vital signs show hypotension and tachycardia. What is the nurse’s priority action?

A. Administer oxygen.
B. Notify the physician.
C. Rapidly administer more IV fluid.
D. Reposition the patient to the right side.

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

A. Administer Oxygen

Rationale: The cap off the central line could allow entry of air into the circulation. For an air emboli, oxygen is administered; the catheter is clamped; the patient is positioned on the left side with the head down. Then the physician is notified.

The patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid was removed. What IV solution may be used to pull fluid into the intravascular space after the paracentesis?

A. 0.9% sodium chloride
B. 25% albumin solution
C. Lactated Ringer’s solution
D. 5% dextrose in 0.45% saline

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve NCLEX questions)

B. 25% albumin solution

Rationale: After a paracentesis of 5 L or greater of ascites fluid, 25% albumin solution may be used as a volume expander. Normal saline, lactated Ringer’s, and 5% dextrose in 0.45% saline will not be effective for this action.

A 50-year-old woman with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which type of order, if written by the health care provider, should be questioned by the nurse?

A. Limit foods high in potassium
B. Spironolactone (Aldactone) daily
C. Calcium gluconate IV piggyback
D. Administer intravenous insulin and glucose

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve PRE-TEST questions)

B. Spironolactone (Aldactone) daily

Rationale: Spironolactone (Aldactone) is a potassium-sparing diuretic that inhibits the exchange of sodium for potassium in the distal renal tubule and helps to prevent potassium loss. Spironolactone is contraindicated in a patient with hyperkalemia (serum potassium >5.0 mEq/L). Collaborative management for patients with hyperkalemia may include limiting foods high in potassium, IV insulin and glucose, administration of calcium gluconate, potassium-wasting diuretics (e.g., furosemide [Lasix]), hemodialysis, sodium polystyrene sulfonate (Kayexalate), and IV fluid administration.

The nurse is caring for a 76-year-old woman admitted to the clinical unit with hypernatremia and dehydration after prolonged fever. Which beverage would be safest for the nurse to offer the patient?

A. Malted milk
B. Orange juice
C. Tomato juice
D. Hot chocolate

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve PRE-TEST questions)

B. Orange juice

Rationale: Orange juice has the least amount of sodium (approximately 2 mg in 8 ounces). Hot chocolate has approximately 75 mg sodium in 8 ounces. Tomato juice has approximately 650 mg sodium in 8 ounces. Malted milk has approximately 625 mg sodium in 8 ounces.

The nurse on a medical-surgical unit identifies that which patient has the highest risk for metabolic alkalosis?

A. A patient with a traumatic brain injury
B. A patient with type 1 diabetes mellitus
C. A patient with acute respiratory failure
D. A patient with nasogastric tube suction

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve PRE-TEST questions)

D. A patient with nasogastric tube suction

Rationale: Excessive nasogastric suctioning may cause metabolic alkalosis. Brain injury may cause hyperventilation and respiratory alkalosis. Type 1 diabetes mellitus (diabetic ketoacidosis) is associated with metabolic acidosis. Acute respiratory failure may lead to respiratory acidosis.

A 22-year-old male is admitted to the emergency department with a stab wound to the abdomen. The patient’s vital signs are blood pressure 82/56 mm Hg, pulse 132 beats/minute, respirations 28 breaths/minute, and temperature 97.9° F (36.6° C). Which fluid, if ordered by the health care provider, should the nurse question?

A. 0.9% saline
B. 0.45% saline
C. Packed red blood cells
D. Lactated Ringer’s solution

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve PRE-TEST questions)

B. 0.45% saline

Rationale: IV administration of 0.45% saline is hypotonic and is used for maintenance fluid replacement and dilutes the extracellular fluid. Intravenous solutions used for volume expansion for hypovolemic shock include lactated Ringer’s solution and 0.9% saline. If hypovolemia is due to blood loss, blood may be administered.

A 46-year-old woman with a subclavian triple-lumen catheter is transferred from a critical care unit after an extended stay for respiratory failure. Which action is important for the nurse to take?

A. Change the injection cap after the administration of IV medications.
B. Use a 5-mL syringe to flush the catheter between medications and after use.
C. During removal of the catheter, have the patient perform the Valsalva maneuver.
D. If resistance is met when flushing, use the push-pause technique to dislodge the clot.

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – Evolve PRE-TEST questions)

C. During removal of the catheter, have the patient perform the Valsalva maneuver.

Rationale: The nurse should withdraw the catheter while the patient performs the Valsalva maneuver to prevent an air embolism. Injection caps should be changed at regular intervals but not routinely after medications. Flushing should be performed with at least a 10-mL syringe to avoid excess pressure on the catheter. If resistance is encountered during flushing, force should not be applied. The push-pause method is preferred for flushing catheters but not used if resistance is encountered during flushing.

During the postoperative care of a 76-year-old patient, the nurse monitors the patient’s intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because:

A. Older adults have an impaired thirst mechanism and need reminding to drink fluids
B. Water accounts for a greater percentage of body weight in the older adult than in younger adults.
C. Older adults are more likely than younger adults to lose extracellular fluid during surgical procedures.
D. Small losses of fluid are more significant because body fluids account for only about 50% of body weight in older adults.

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – – Bridge to NCLEX exam chapter questions pp 313-314)

D. Small losses of fluid are more significant because body fluids account for only about 50% of body weight in older adults.

Rationale: In the older adult, body water content averages 45% to 55% of body weight.

During administration of hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cell is:

A. Osmosis
B. Diffusion
C. Active transport
D. Facilitated diffusion

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – – Bridge to NCLEX exam chapter questions pp 313-314-314)

A. Osmosis

Rationale: Osmosis is the movement of water between two compartments separated by a semipermeable membrane. Water moves through the membrane from an area of low solute concentration to an area of high solute concentration.

An older woman was admitted to the medical unit with dehydration. Clinical indications of this problem are (select all that apply):

A. Weight loss
B. Dry oral mucosa.
C. Full bounding pulse.
D. Engorged neck veins.
E. Decreased central venous pressure.

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – – Bridge to NCLEX exam chapter questions pp 313-314-314)

Correct answers: A, B, E

A. Weight loss
B. Dry oral mucosa.
E. Decreased central venous pressure.

Rationale: Body weight loss, especially sudden change, is an excellent indicator of overall fluid volume loss. Other clinical manifestations of dehydration include dry mucous membranes and a decreased central venous pressure, which reflect fluid volume loss.

The nursing care for a patient with hyponatremia includes:

A. Fluid restrictions
B. Administration of hypotonic IV fluids.
C. Administration of a cation-exchange resin.
D. increased water intake for patients on NG suction

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – – Bridge to NCLEX exam chapter questions pp 313-314)

A. Fluid restrictions

Rationale: In hyponatremia that is caused by water excess, fluid restriction often is all that is needed to treat the problem.

The nurse should be alert for which manifestations in a patient receiving loop diuretic?

A. Restlessness and agitation.
B. Paresthesias and irritability
C. Weak, irregular pulse and poor muscle tone
D. Increased blood pressure and muscle spasms.

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – – Bridge to NCLEX exam chapter questions pp 313-314)

C. Weak, irregular pulse and poor muscle tone

Rationale: Loop diuretics may result in renal loss of potassium (i.e., hypokalemia). Clinical manifestations of hypokalemia include fatigue, muscle weakness, leg cramps, nausea, vomiting, paralytic ileus, soft, muscle flab, paresthesias, decreased reflexes, weak, irregular pulse, polyuria, hyperglycemia, and electrocardiographic changes.

Which patient would be greatest risk for the potential development of hypermagnesemia?

A. 83-year-old man with lung cancer and hypertension
B. 65-year-old woman with hypertension taking Beta-adrenergic blockers
C. 42-year-old woman ith systemic lupus erythematosus and renal failure
D. 50-year-old man with benign prostatic hyperplasia and a urinary tract infection.

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – – Bridge to NCLEX exam chapter questions pp 313-314)

C. 42-year-old woman ith systemic lupus erythematosus and renal failure

Rationale: Causes of hypermagnesemia include renal failure (especially if the patient is given magnesium products), excessive administration of magnesium for treatment of eclampsia, and adrenal insufficiency.

It is especially important for the nurse to assess for which clinical manifestation(s) in a patient who has just undergone a total thyroidectomy (select all that apply)?:

A. Confusion
B. Weight gain
C. Depressed reflexes
D. Circumoral numbness
E. Positive Chvostek’s sign

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – – Bridge to NCLEX exam chapter questions pp 313-314)

Correct answers: A, D, E

A. Confusion
D. Circumoral numbness
E. Positive Chvostek’s sign

Rationale: Inadvertent removal of a portion of or injury to the parathyroid glands during thyroid or neck surgery can result in a lack of parathyroid hormone, leading to hypocalcemia. A positive Chvostek sign, confusion, and circumoral numbness are manifestations of low serum calcium levels.

The nurse anticipates that the treatment of the patient with hyperphosphatemia secondary to renal failure will include:

A. Fluid restrictions
B. Calcium supplements
C. Loop diuretic therapy
D. Magnesium supplements

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – – Bridge to NCLEX exam chapter questions pp 313-314)

B. Calcium supplements

Rationale: The major conditions that can lead to hyperphosphatemia are acute kidney injury and chronic kidney disease that alter the ability of the kidneys to excrete phosphate. For the patient with renal failure, measures to reduce serum phosphate levels include calcium supplements, phosphate-binding agents or gels, fluid replacement therapy, and dietary phosphate restrictions.

The lungs act as an acid-base buffer by:

A. Increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load.
B. Increasing respiratory rate and depth when CO2 level in the blood are low, reducing the base load.
C. Decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load.
D. Decreasing respiratory rate and depth when CO2 levels are low, increasing acid load.

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – – Bridge to NCLEX exam chapter questions pp 313-314)

A. Increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load.

Rationale: As a compensatory mechanism, the respiratory system acts on the CO2 + H2O side of the reaction by altering the rate and depth of breathing to “blow off” (through hyperventilation) or “retain” (through hypoventilation) CO2.

A patient has the following arterial blood gas results: pH 7.52; PaCO2 30 mm Hg; HCO3 24 mEq/L. The nurse determins that these results indicate:

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory Alkalosis

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – – Bridge to NCLEX exam chapter questions pp 313-314)

D. Respiratory Alkalosis

Rationale: Respiratory alkalosis (carbonic acid deficit) occurs with hyperventilation. The primary cause of respiratory alkalosis is hypoxemia from acute pulmonary disorders. Anxiety, central nervous system (CNS) disorders, and mechanical overventilation also increase ventilation rate and decrease the partial pressure of arterial carbon dioxide (PaCO2). This leads to a decrease in carbonic acid level and to alkalosis.

The typical fluid replacement for the patient with a fluid volume deficit is:

A. Dextran.
B. 0.45% saline
C. Lactated Ringer’s
D. 5% dextrose in 0.45% saline.

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – – Bridge to NCLEX exam chapter questions pp 313-314)

C. Lactated Ringer’s

Rationale: Administration of an isotonic solution expands only the extracellular fluid (ECF). There is no net loss or gain from the intracellular fluid (ICF). An isotonic solution is the ideal fluid replacement for a patient with an ECF volume deficit. Examples of isotonic solutions include lactated Ringer’s solution and 0.9% NaCl.

The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to:

A. Apply warm moist compress to the insertion site.
B. Attempt to force 10mL of normal saline into the device.
C. Place the patient on the left side with head-down position.
D. Instruct the patient to change positions, raise arm, and cough.

(Chapter 17: Fluid, electrolyte, and Acid-base imbalances – – Bridge to NCLEX exam chapter questions pp 313-314)

D. Instruct the patient to change positions, raise arm, and cough.

Rationale: Interventions for catheter occlusion include instructing the patient to change position, raise an arm, and cough; assessing for and alleviating clamping or kinking of the tube; flushing the catheter with normal saline through a 10-mL syringe (do not force flush); using fluoroscopy to determine cause and site of occlusion; and instilling anticoagulant or thrombolytic agents.

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