NR 226: Exam 2 Review Questions

Fluid and Electrolyte Balance

A nurse suspects a fluid and electrolyte imbalance in an older adult. Which assessment best indicates fluid and electrolyte balance?

• a. Intake and output results

• b. Serum laboratory values

• c. Condition of the skin

• d. Presence of tenting

Care of a Patient with an Intestinal Stoma

A nurse is caring for a patient with an intestinal stoma. Which intervention is most important?

• a. Cleansing the stoma with cool water

• b. Spraying an air-freshening deodorant in the room

• c. Selecting a bag with an appropriate-size stomal opening

• d. Wearing sterile nonlatex gloves when caring for the stoma

Prevention of Postoperative Thrombophlebitis

A nurse is caring for a patient who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombophlebitis (DVT)?

• a. Utilization of compression stockings at night

• b. Deep breathing and coughing daily

• c. Leg exercises 10 times per hour when awake

• d. Elevation of the legs on 2 pillows

Monitoring Patients with a Nasogastric Tube

The nurse monitors a client with a nasogastric tube attached to low suction for manifestations of which disorder?

• a. Metabolic acidosis

• b. Metabolic alkalosis

• c. Respiratory acidosis

• d. Respiratory alkalosis

Acid-Base Imbalance in Rib Fractures

A client with broken ribs is likely to experience what type of acid-base imbalance?

• a. Respiratory acidosis from inadequate ventilation

• b. Respiratory alkalosis from anxiety and hyperventilation

• c. Metabolic acidosis from calcium loss due to broken bones

• d. Metabolic alkalosis from taking analgesics containing base products

Potassium Replacement for Diarrhea

A patient with diarrhea needs to replace potassium. Which nutrient selections indicate additional teaching on potassium-rich foods is needed? (Select all that apply.)

• a. Beef bouillon

• b. Orange juice

• c. Poached egg

• d. Warm tea

• e. Avocado

Administering a Tap-Water Enema

A 750-mL tap-water enema is ordered for a patient. Which approach best promotes acceptance of the volume?

• a. Administer the fluid slowly, and have the patient take shallow breaths

• b. Place the patient in the left lateral position, and slowly administer the fluid

• c. Have the patient take shallow breaths, and keep the fluid at body temperature

• d. Keep the fluid at body temperature, and place the patient in the left lateral position

Risk Factors for Diarrhea

Which information indicates a patient at highest risk for developing diarrhea?

• a. Is physically active

• b. Drinks a lot of fluid

• c. Eats whole-grain bread

• d. Is experiencing emotional problems

Sequential Compression Devices (SCD)

Sequential compression devices (SCD) are ordered for a postoperative patient. Which information should the nurse provide? (Select all that apply.)

• a. Keeps the lower extremities warm

• b. Helps prevent deep vein thrombosis

• c. Accelerates the rate of wound healing

• d. Promotes circulation of blood back to the heart

• e. Eliminates the need for leg and foot exercises after surgery

Post-Anesthesia Care Monitoring

A patient in the post-anesthesia care unit (PACU) has vital signs: BP 150/90 mm Hg, pulse 88 (bounding), respirations 24 with crackles. What is the patient likely experiencing?

• a. Hypoglycemia

• b. Hyponatremia

• c. Hyperkalemia

• d. Hypervolemia

Fecal Impaction Assessment

A patient reports no bowel movement in 10 days. Which questions help assess for fecal impaction? (Select all that apply.)

• a. “How long has it been since you had a formed stool?”

• b. “Have you had small amounts of liquid stool?”

• c. “Do you notice a bad odor to your breath?”

• d. “Have you been eating food with fiber?”

• e. “Are you having any vomiting?”

Postoperative Restlessness

A postoperative client becomes restless. What should the nurse do first?

• a. Notify the physician

• b. Medicate the patient for pain

• c. Check the client’s vital signs

• d. Talk to the client in a calm voice

Patient Uncertainty About Surgery

A client scheduled for surgery expresses uncertainty about proceeding. What is the nurse’s best response?

• a. “It is your decision.”

• b. “Do not worry. Everything will be fine.”

• c. “Why do you not want to have this surgery?”

• d. “Tell me what concerns you have about the surgery.”

At-Home Fecal Occult Blood Testing

When explaining at-home fecal occult blood testing, which instructions should the nurse include?

• a. Eating more protein is optimal prior to testing

• b. Continue all scheduled medications, including aspirin, before the test

• c. A red color change indicates a positive result

• d. The specimen must not be contaminated with urine

Assessment of Diarrhea

A nurse assesses a client who has had diarrhea for 4 days. Which findings are expected? (Select all that apply.)

• a. Bradycardia

• b. Hypotension

• c. Elevated temperature

• d. Poor skin turgor

• e. Peripheral edema

IV Therapy Complications

A client receiving IV therapy reports arm pain, chills, and general malaise, with warmth, edema, and redness near the IV site. What is the nurse’s first action?

• a. Obtain a specimen for culture

• b. Apply a warm compress

• c. Administer analgesics

• d. Discontinue the infusion

Hypovolemia Assessment

During an admission assessment, which findings would the nurse not expect in a client with hypovolemia due to vomiting and diarrhea? (Select all that apply.)

• a. Flat neck veins

• b. Thready pulse

• c. Syncope

• d. Dark urine

• e. Postural hypotension

Hyperkalemia Management

A client’s potassium level is 5.2 mEq/L. What should the nurse anticipate after notifying the provider?

• a. Starting an IV infusion of 0.9% sodium chloride

• b. Consulting with a dietician to increase potassium intake

• c. Initiating continuous cardiac monitoring

• d. Preparing the patient for gastric lavage

NR 226 Exam 2

Hypercalcemia Assessment

A nurse assesses a client with a calcium level of 10.8 mEq/L. Which findings are expected? (Select all that apply.)

• a. Hyperreflexia

• b. Muscle weakness

• c. Positive Chvostek’s sign

• d. Muscle cramps

• e. Kidney stones