GUT
it can grow so large that an entire area, such as the
1. A nurse is caring for a burn client who has sustained
thoracic burns and smoke inhalation and is risk for
impaired gas exchange. The nurse avoids which action in
caring for this client?
1. repositioning the client from side to side every 2
hours
2. maintaining the client in a supine position with the
head of the bed elevated
3. suctioning the airway as needed
4. providing humidified oxygen as prescribed Aggressive
pulmonary measures are used to prevent respiratory
complications in the client who has impaired gas
exchange as a result of a burn injury. These include
turning and repositioning, positioning for comfort, using
humidified oxygen, providing incentive spirometry, and
suctioning the client on an as needed basis. The nurse
would avoid maintaining the client in one position. This
will ultimately lead to atelectasis and possible
pneumonia.
2. A client sustains a burn injury to the entire right arm,
entire right leg, and anterior thorax. According to the
rule of nine’s the nurse determines that what body
percent was injured? Answer: 45%
3. A nurse assesses a burn injury and determines that
the client sustained a full-thickness fourth-degree burn
if which of the following is noted at the site of injury?
1. a wet shiny weeping wound surface
2. a dry wound surface
3. charring at the wound site
4. blisters In a full-thickness fourth-degree burn injury,
charring is visible. Extremity movement is limited and
wound sensation is absent. Blisters and a wet shiny
weeping surface would be noted in a partial-thickness
second-degree burn injury. A dry wound surface would
be noted in a full-thickness third-degree burn injury.
4. A nurse reviews the record of a client scheduled for
removal of a skin lesion. The record indicates that the
lesion is an irregularly shaped, pigmented papule with a
blue-toned color. The nurse determines that this
description of the lesion is characteristic of:
1. melanoma
2. basal cell carcinoma
3. squamous cell carcinoma
4. actinic keratosis
A melanoma is an irregularly shaped pigmented papule
or plaque with a red, white or blue toned color. Basal
cell carcinoma appears as a pearly papule with a central
crater and rolled waxy border. Squamous cell carcinoma
is a firm nodular lesion topped with a crust or a central
area of ulceration. Actinic keratosis, a premalignant
lesion, appears as a small macule or papule with dry,
rough, adherent yellow or brown scale.
5. A client is seen in the health care clinic and a biopsy is
performed on a skin lesion that the physician suspects
malignant melanoma. The nurse prepares a plan of care
for the client based on which characteristics of this type
of skin cancer?
1. it is an aggressive cancer that requires aggressive
therapy to control its rapid spread
2. it is a slow-growing cancer and seldom metastasizes
3.
nose, the lip, or the ear must be removed and
reconstructed if it occurs on the face
4. it is the most common form of skin cancer Malignant
melanoma, commonly called melanoma, is cancer of the
melanocyte cells of the skin. It is an aggressive cancer
that requires aggressive therapy to control its spread.
Basal cell carcinoma, also known as basal cell
epithelioma, is the most common form of skin cancer. It
is a slow growing cancer and seldom metastasizes, but it
can grow so large that the entire area of the nose, the
lip, or the ear must be removed and reconstructed.
6. A nurse is caring for a client brought to the
emergency room following a burn injury that occurred
in the basement of the home. Which initial finding
would indicate the presence of inhalation injury?
a. expectoration of sputum tinged with blood
b. the presence of singed nasal hair
c. absent breath sounds in the lower lobes bilaterally
d. tachycardia
Inhalation injuries are most common when a fire occurs
in a closed space. The findings are facial burns, singed
nasal hairs, and sputum tinged with carbon.
Additionally, auscultation of wheezing and rales
suggests an inhalation injury. Tachycardia is not a
specific manifestation of a burn inhalation injury.
7. A nurse is caring for a client who arrives at the
emergency room with the emergency medical services
team following a severe burn injury from an explosion.
Once the initial assessment has been performed by the
physician and life-threatening dysfunctions have been
addressed, the nurse reviews the physician’s orders
anticipating that which pain medication will be
prescribed?
a. intravenous (IV) morphine sulfate
b. aspirin with oxycodone (percodan) via nasogastric
tube
c. acetaminophen (tylenol) with codeine sulfate
d. morphine sulfate by the subcutaneous route Once the
initial assessment has been made and life-threatening
dysfunctions have been addressed, pain medication can
be administered. Narcotics administered IV are the
initial medications of choice because absorption from
the musculature is erratic at this time, and an ileus can
be present in the burn client. The initial medication of
choice is morphine sulfate, although other medications
such as methadone, codeine, or hydromorphone may be
used also. Narcotics are given by the IV route until fluid
resuscitation is complete and gastric motility is restored.
8. The nurse is admitting a client diagnosed with acute
renal failure (ARF). Which question would be most
important for the nurse to ask during the admission
interview?
1. “Have you recently traveled outside the United
States?”
2. “Did you recently begin a vigorous exercise
program?”
3. “Is there a chance you have been exposed to a virus?”
4. “What over-the-counter medications do you take
regularly?”
9. The client is diagnosed with rule out ARF. Which
condition would predispose the client to developing pre-
renal failure?
1. Diabetes mellitus.
2. Hypotension.
3. Aminoglycosides.
4. Benign prostatic hypertrophy.
10. The client diagnosed with ARF is admitted to the
intensive care department and placed on a therapeutic
diet. Which diet would be not appropriate for the
client?
1. A high-potassium and low-calcium diet.
2. A low-fat and low-cholesterol diet.
3. A high carbohydrate and restricted-protein diet.
4. A regular diet with six (6) small feedings a day.
11. The client is admitted to the emergency department
after a gunshot wound to the abdomen. Which nursing
intervention would the nurse implement first to prevent
ARF?
1. Administer normal saline IV.
2. Take vital signs.
3. Place client on telemetry.
4. Assess abdominal dressing.
12. The client diagnosed with ARF is experiencing
hyperkalemia. Which medication should the nurse
prepare to administer to help decrease the potassium
level?
1. Erythropoietin.
2. Calcium gluconate.
3. Regular insulin.
4. Osmotic diuretic.
13. The nurse and unlicensed nursing assistant are
caring for clients on a medical floor.
Which nursing task would be most appropriate for the
nurse to delegate?
1. Collect a clean voided midstream urine specimen.
2. Evaluate the client’s 8 hour intake and output.
3. Assist in checking a unit of blood prior to hanging.
4. Administer a cation-exchange resin enema.
14. The unlicensed nursing assistant tells the nurse that
the client with ARF has a white layer on top of the skin
that looks like crystals. Which intervention should the
nurse implement?
1. Have the assistant apply a moisture barrier cream to
the skin.
2. Instruct the nursing assistant to bathe the client in
cool water.
3. Tell the nursing assistant not to turn the client in this
condition.
4. Explain that this is normal and do not do anything to
the client.
15. The client diagnosed with renal calculi is scheduled
for lithotripsy. Which post-procedure nursing task would
be most appropriate to delegate to the unlicensed
nursing assistant (NA)?
1. Monitor the amount, color, and consistency of urine
output.
2. Teach the client about care of the indwelling Foley
catheter.
3. Assist the client to the car when being discharged
home.
4. Take the client’s post-procedural signs.
16. In the oliguric phase of acute renal failure, the nurse
should anticipate the development of which of the
following complications?
1. Pulmonary edema.
2. Metabolic alkalosis.
3. Hypotension.
4. Hypokalemia.
Answer: 1. Pulmonary edema can develop during the
oliguric phase of acute renal failure because of
decreased urinary output and fluid retention. Metabolic
acidosis develops because the kidneys cannot excrete
hydrogen ions, and bicarbonate is used to buffer the
hydrogen. Hypertension may develop as a result of fluid
retention. Hyperkalemia develops as the kidneys lose
the ability to excrete potassium.
17. The nurse initiates the client's first hemodialysis
treatment. The client develops a headache, confusion,
and nausea. These symptoms indicate which of the
following potential complications?
1. Disequilibrium syndrome.
2. Myocardial infarction.
3. Air embolism.
4. Peritonitis.
Answer: 1. Common symptoms of disequilibrium syn-
drome include headache, nausea and vomiting, confu-
sion, and even seizures. Disequilibrium syndrome typi-
cally occurs near the end or after the completion of
hemodialysis treatment. It is the result of rapid changes
in solute composition and osmolality of the extracellular
fluid. These symptoms are not related to cardiac
function, air embolism, or peritonitis.
18. If disequilibrium syndrome occurs during dialysis,
which of the following would be the priority nursing
action?
1. Administer oxygen per nasal cannula.
2. Slow the rate of dialysis.
3. Reassure the client that the symptoms are normal.
4. Place the client in Trendelenburg's position.
Answer: 2. If disequilibrium syndrome occurs during
dialysis, the most appropriate intervention is to slow the
rate of dialysis. The syndrome is believed to result from
too-rapid removal of urea and excess electrolytes from
the blood: this causes transient cerebral edema, which
produces the symptoms. Administration of oxygen and
position changes do not affect the symptoms. It would
not be appropriate to reassure the client that the symp-
toms are normal.
19. Which of the following symptoms would most likely
indicate pyelonephritis?
1. Ascites.
2. Costovertebral angle (CVA) tenderness.
3. Polyuria.
4. Nausea and vomiting.
Answer: 2. Common symptoms of pyelonephritis include
CVA tenderness, burning, urinary urgency or frequency,
chills, fever, and fatigue. Ascites, polyuria, and nausea
and vomiting are not indicative of pyelonephritis.
20. Which of the following groups of laboratory tests is
most important for assessing the client's renal status?
1. Serum sodium and potassium levels.
2. Arterial blood gases and hemoglobin.
3. Serum blood urea nitrogen (BUN) and creatinine
levels.
4. Urinalysis and urine culture.
Answer: 3. Serum BUN and creatinine are the tests most
commonly used to assess renal function, with creatinine
being the most reliable indicator. Nonrenal factors may
affect BUN levels as well as serum sodium and potassium
levels. Arterial blood gases and hemoglobin are not used
to assess renal status. Urinalysis is a general screening
test, and a urine culture is used to detect urinary tract
infections.
21. The nurse is preparing a plan of care for the client
diagnosed with acute glomerulonephritis. Which would
be a long term goal?
1. The client will have a blood pressure within normal
limits.
2. The client will show no protein in the urine.
3. The client will maintain renal function.
4, The client will have clear lung sounds.
22. A client is admitted for treatment of
glomerulonephritis. On initial assessment, the nurse
detects one of the classic signs of acute
glomerulonephritis of sudden onset. Such signs include:
1. generalized edema, especially of the face and
periorbital area.
2. green-tinged urine.
3. moderate to severe hypotension.
4. polyuria.
RATIONALES: Generalized edema, especially of the face
and periorbital area, is a classic sign of acute
glomerulonephritis of sudden onset. Other classic signs
and symptoms of this disorder include hematuria (not
green-tinged urine), proteinuria, fever, chills, weakness,
pallor, anorexia, nausea, and vomiting. The client also
may have moderate to severe hypertension (not
hypotension), oliguria or anuria (not polyuria),
headache, reduced visual acuity, and abdominal or flank
pain.
23. The nurse helps the client with chronic renal failure
develop a home diet plan with the goal of helping the
client maintain adequate nutritional intake. Which of
the following diets would be most appropriate for a
client with chronic renal failure?
1. High carbohydrate, high protein.
2. High calcium, high potassium, high protein.
3. Low protein, low sodium, low potassium.
4. Low protein, high potassium.
Answer: 3. Dietary management for clients with chronic
renal failure is usually designed to restrict protein, sodi-
um, and potassium intake. Protein intake is reduced
because the kidney can no longer excrete the byprod-
ucts of protein metabolism. The degree of dietary re-
striction depends on the degree of renal impairment.
The client should also receive a high-carbohydrate diet
along with appropriate vitamin and mineral supple-
ments. Calcium requirements remain 1,000 to 2,000
mg/day.
24. The client is scheduled for an intravenous pyelogram
(IVP) to determine the location of the renal calculi.
Which of the following measures would be most
important for the nurse to include in pretest
preparation?
1. Ensuring adequate fluid intake on the day of the test.
2. Preparing the client for the possibility of bladder
spasms during the test.
3. Checking the client's history for allergy to iodine.
4. Determining when the client last had a bowel
movement.
25. . After an IVP, the nurse should anticipate incorpo-
rating which of the following measures into the
client's plan of care?
1. Maintaining bed rest.
2. Encouraging adequate fluid intake.
3. Assessing for hematuria.
4. Administering a laxative.
26. A client with end-stage renal failure receives
hemodialysis via an arteriovenous fistula (AV) placed in
the right arm. When caring for the client, the nurse
should:
1. Take the blood pressure in the right arm above the AV
fistula
2. Flush the AV fistula with IV normal saline to keep it
patent
3. Auscultate the AV fistula for the presence of a bruit
4. Perform needed venipunctures distal to the AV fistula
27. The client’s serum potassium is elevated in acute
renal failure, and the nurse administers sodium
polystyrene sulfonate (kayexalate). The drugs acts to
1. Increase potassium excretion from the colon.
2. Release of hydrogen ions for sodium ions.
3. Increase calcium absorption in the colon.
4. Exchange sodium for potassium ions in the colon.
28. In the diuretic phase of ARF, the nurse must be alert
for which of the following complications?
1. Respiratory acidosis
2. Hypertension
3. Hypokalemia
4. Hypernatremia
29. A client in ARF receives an IV infusion of 50 percent
dextrose in water with 20 units of regular insulin. The
nurse understands that the rational for this therapy is
to:
1. correct the hyperglycemia that occurs with acute
renal failure
2. facilitate the intracellular movement of potassium
3. provide calories to prevent tissue catabolism and
azotemia
4. force potassium into cells to prevent arrhythmias
30. The nurse is developing a nursing care plan for the
client diagnosed with ESRD. Which nursing problem
would have priority for the client?
1. Low self-esteem.
2. Knowledge deficit.
3. Activity Intolerance.
4. Excess fluid volume.
FABS
1. The nurse is caring for a client with heart failure. On
assessment, the nurse notes that the client is dyspneic,
and crackles are audible on auscultation. What
additional manifestations would the nurse expect to
note in this client if excess fluid volume is present?
1. Weight loss and dry skin
2. Flat neck and hand veins and decreased urinary
output
3. An increase in blood pressure and increased
respirations
4. Weakness and decreased central venous pressure
(CVP)
Rationale: A fluid volume excess is also known as over
hydration or fluid overload and occurs when fluid intake
or fluid retention exceeds the fluid needs of the body.
Assessment findings associated with fluid volume excess
include cough, dyspnea, crackles, tachypnea,
tachycardia, elevated blood pressure, bounding pulse,
elevated CVP, weight gain, edema, neck and hand vein
distention, altered level of consciousness, and
decreased hematocrit. Dry skin, flat neck and hand
veins, decreased urinary output, and decreased CVP are
noted in fluid volume deficit. Weakness can be present
in either fluid volume excess or deficit.
2. The nurse is preparing to care for a client with a
potassium deficit. The nurse reviews the client’s
record and determines that the client is at risk for
developing the potassium deficit because of which
situation?
1. Sustained tissue damage
2. Requires nasogastric suction
3. Has a history of Addison’s disease
4. Uric acid level of 9.4 mg/dL (559 μmol/L)
Rationale: The normal serum potassium level is 3.5 to
5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is
known as hypokalemia. Potassium-rich gastrointestinal
fluids are lost through gastrointestinal suction, placing
the client at risk for hypokalemia. The client with tissue
damage or Addison’s disease and the client with
hyperuricemia are at risk for hyperkalemia. The normal
uric acid level for a female is 2.7 to 7.3 mg/dL (0.16 to
0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL(0.24 to
0.51 mmol/L). Hyperuricemia is a cause of
hyperkalemia.
3. The nurse reviews a client’s electrolyte laboratory
report and notes that the potassium level is 2.5 mEq/L
(2.5 mmol/L). Which patterns should the nurse watch
for on the electrocardiogram (ECG) as a result of the
laboratory value? Select all that apply.
1. U waves
2. Absent P waves
3. Inverted T waves
4. Depressed ST segment
5. Widened QRS complex
4. Potassium chloride intravenously is prescribed for a
client with hypokalemia. Which actions should the
nurse take to plan for preparation and administration
of the potassium? Select all that apply.
1. Obtain an intravenous (IV) infusion pump.
2. Monitor urine output during administration.
3. Prepare the medication for bolus administration.
4. Monitor the IV site for signs of infiltration or
phlebitis.
5. Ensure that the medication is diluted in the
appropriate volume of fluid.
6. Ensure that the bag is labeled so that it reads the
volume of potassium in the solution.
Rationale: Potassium chloride administered
intravenously must always be diluted in IV fluid and
infused via an infusion pump. Potassium chloride is
never given by bolus (IV push). Giving potassium
chloride by IV push can result in cardiac arrest. The
nurse should ensure that the potassium is diluted
in the appropriate amount of diluent or fluid. The IV bag
containing the potassium chloride should always be
labeled with the volume of potassium it contains. The IV
site is monitored closely because potassium chloride is
irritating to the veins and there is risk of phlebitis. In
addition, the nurse should monitor for infiltration. The
nurse monitors urinary output during administration
and contacts the health care provider if the urinary
output is less than 30 mL/hour.
5. The nurse provides instructions to a client with a low
potassium level about the foods that are high in
potassium and tells the client to consume which foods?
Select all that apply.
1. Peas
2. Raisins
3. Potatoes
4. Cantaloupe
5. Cauliflower
6. Strawberries
Rationale: The normal potassium level is 3.5 to 5.0
mEq/L (3.5 to 5.0 mmol/L). Common food sources of
potassium include avocado, bananas, cantaloupe,
carrots, fish, mushrooms, oranges, potatoes, pork, beef,
veal, raisins, spinach, strawberries, and tomatoes. Peas
and cauliflower are high in magnesium.
6. The nurse is reviewing laboratory results and notes
that a client’s serum sodium level is 150 mEq/L (150
mmol/L). The nurse reports the serum sodium level to
the health care provider (HCP) and the HCP prescribes
dietary instructions based on the sodium level. Which
acceptable food items does the nurse instruct the client
to consume? Select all that apply.
1. Peas
2. Nuts
3. Cheese
4. Cauliflower
5. Processed oat cereals
Rationale: The normal serum sodium level is 135 to 145
mEq/L (135 to 145 mmol/L). A serum sodium level of
150 mEq/L (150 mmol/L) indicates hypernatremia. On
the basis of this finding, the nurse would instruct the
client to avoid foods high in sodium. Peas, nuts, and
cauliflower are good food sources of phosphorus and
are not high in sodium (unless they are canned or
salted). Peas are also a good source of magnesium.
Processed foods such as cheese and processed oat
cereals are high in sodium content.
7. The nurse is assessing a client with a suspected
diagnosis of hypocalcemia. Which clinical manifestation
would the nurse expect to note in the client?
1. Twitching
2. Hypoactive bowel sounds
3. Negative Trousseau’s sign
4. Hypoactive deep tendon reflexes
Rationale: The normal serum calcium level is 9 to 10.5
mg/dL (2.25 to 2.75 mmol/L). A serum calcium level
lower than 9 mg/dL (2.25 mmol/L) indicates
hypocalcemia. Signs of hypocalcemia include
paresthesias followed by numbness, hyperactive deep
tendon reflexes, and a positive Trousseau’s or
Chvostek’s sign. Additional signs of hypocalcemia
include increased neuromuscular excitability, muscle
cramps, twitching, tetany, seizures, irritability, and
anxiety. Gastrointestinal symptoms include increased
gastric motility, hyperactive bowel sounds, abdominal
cramping, and diarrhea.
8. The nurse is caring for a client with hypocalcemia.
Which patterns would the nurse watch for on the
electrocardiogram as a result of the laboratory value?
Select all that apply.
1. U waves
2. Widened T wave
3. Prominent U wave
4. Prolonged QT interval
5. Prolonged ST segment
9. The nurse reviews the electrolyte results of an
assigned client and notes that the potassium level is 5.7
mEq/L (5.7 mmol/L). Which patterns would the nurse
watch for on the cardiac monitor as a result of the
laboratory value? Select all that apply.
1. ST depression
2. Prominent U wave
3. Tall peaked T waves
4. Prolonged ST segment
5. Widened QRS complexes
10. Which client is at risk for the development of a
sodium level at 130 mEq/L (130 mmol/L)?
1. The client who is taking diuretics
2. The client with hyperaldosteronism
3. The client with Cushing’s syndrome
4. The client who is taking corticosteroids
11. The nurse is caring for a client with heart failure who
is receiving high doses of a diuretic. On assessment, the
nurse notes that the client has flat neck veins,
generalized muscle weakness, and diminished deep
tendon reflexes. The nurse suspects hyponatremia.
What additional signs would the nurse expect to note in
a client with hyponatremia?
1. Muscle twitches
2. Decreased urinary output
3. Hyperactive bowel sounds
4. Increased specific gravity of the urine
12. The nurse reviews a client’s laboratory report and
notes that the client’s serum phosphorus (phosphate)
level is 1.8 mg/dL (0.45 mmol/L). Which condition most
likely caused this serum phosphorus level?
1. Malnutrition
2. Renal insufficiency
3. Hypoparathyroidism
4. Tumor lysis syndrome
Rationale: The normal serum phosphorus (phosphate)
level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The
client is experiencing hypophosphatemia. Causative
factors relate to malnutrition or starvation and the use
of aluminum hydroxide– based or magnesium-based
antacids. Renal insufficiency, hypoparathyroidism, and
tumor lysis syndrome are causative factors of
hyperphosphatemia.
13. The nurse is reading a health care provider’s (HCP’s)
progress notes in the client’s record and reads that the
HCP has documented “insensible fluid loss of
approximately 800 mL daily.” The nurse makes a
notation that insensible fluid loss occurs through which
type of excretion?
1. Urinary output
2. Wound drainage
3. Integumentary output
4. The gastrointestinal tract
Rationale: Insensible losses may occur without the
person’s awareness. Insensible losses occur daily
through the skin and the lungs. Sensible losses are those
of which the person is aware, such as through urination,
wound drainage, and gastrointestinal tract losses.
14. The nurse is assigned to care for a group of clients.
On review of the clients’ medical records, the nurse
determines that which client is most likely at risk for a
fluid volume deficit?
1. A client with an ileostomy
2. A client with heart failure
3. A client on long-term corticosteroid therapy
4. A client receiving frequent wound irrigations
16. The nurse caring for a client who has been receiving
intravenous (IV) diuretics suspects that the client is
experiencing a fluid volume deficit. Which assessment
finding would the nurse note in a client with this
condition?
1. Weight loss and poor skin turgor
2. Lung congestion and increased heart rate
3. Decreased hematocrit and increased urine output
4. Increased respirations and increased blood pressure
17. On review of the clients’ medical records, the nurse
determines that which client is at risk for fluid volume
excess?
1. The client taking diuretics and has tenting of the skin
2. The client with an ileostomy from a recent abdominal
surgery
3. The client who requires intermittent gastrointestinal
suctioning
4. The client with kidney disease and a 12-year history
of diabetes mellitus
18. Which client is at risk for the development of a
potassium level of 5.5 mEq/L (5.5 mmol/L)?
1. The client with colitis
2. The client with Cushing’s syndrome
3. The client who has been overusing laxatives
4. The client who has sustained a traumatic burn
19. An elderly patient comes into the clinic with the
complaint of watery diarrhea for several days with
abdominal & muscle cramping. The nurse realizes that
this patient is demonstrating which of the following?
1. hypernatremia
2. hyponatremia
3. fluid volume excess
4. Hyperkalemia
20. The nurse is admitting a patient who was diagnosed
with acute renal failure. Which of the following
electrolytes will be most affected with this disorder?
1. calcium
2. magnesium
3. phosphorous
4. Potassium
21. A patient who is taking digoxin (Lanoxin) is admitted
with possible hypokalemia. Which of the following does
the nurse realize might occur with this patient?
1. Digoxin toxicity may occur.
2. A higher dose of digoxin (Lanoxin) may be needed.
3. A diuretic may be needed.
4. Fluid volume deficit may occur.
22. A patient is prescribed 40 mEq potassium as a
replacement. The nurse realizes that this replacement
should be administered
1. directly into the venous access line.
2. mixed in the prescribed intravenous fluid.
3. via a rectal suppository.
4. via intramuscular injection.
23. A 35-year-old female patient comes into the clinic
postoperative parathyroidectomy. Which of the
following should the nurse instruct this patient?
1. Drink one glass of red wine per day.
2. Avoid the sun.
3. Milk & milk-based products will ensure an adequate
calcium intake.
4. Red meat is the protein source of choice.
24. A patient is admitted for treatment of
hypercalcemia. The nurse realizes that this patient's
intravenous fluids will most likely be which of the
following?
1. dextrose 5% & water
2 dextrose 5% & ? normal saline
3. dextrose 5% & ? normal saline
4. normal saline
25. A patient is diagnosed with hyperphosphatemia. The
nurse realizes that this patient might also have an
imbalance of which of the following electrolytes?
1. calcium 3. potassium
2. sodium 4. Chloride
26. The nurse observes a patient's respirations & notes
that the rate is 30 per minute & the respirations are
very deep. The metabolic disorder this patient might be
demonstrating is which of the following?
1. hypernatremia
2. increasing carbon dioxide in the blood
3. hypertension
4. Pain
27. A pt's blood gases show a pH greater of 7.53 &
bicarbonate level of 36 mEq/L. The nurse realizes that
the acid-base disorder this pt is demonstrating is which
of the following?
1. respiratory acidosis 3. respiratory alkalosis
2. metabolic acidosis 4. metabolic alkalosis
28. The pt is receiving intravenous potassium (KCL).
Which nursing actions are required? Select all that
apply.
1. Administer the dose IV push over 3 minutes.
2. Monitor the injection site for redness.
3. Add the ordered dose to the IV hanging.
4. Use an infusion controller for the IV.
5. Monitor fluid intake & output.
29. Which pts are at risk for the development of
hypercalcemia? Select all that apply.
1. the pt with a malignancy
2. the pt taking lithium
3. the pt who uses sunscreen to excess
4. the pt with hyperparathyroidism
5. the pt who overuses antacids
30. The pt who has a serum magnesium level of 1.4
mg/dL is being treated with dietary modification. Which
foods should the nurse suggest for this pt? Select all that
apply.
1. bananas
2. seafood
3. white rice
4. lean red meat
5. Chocolate
31. pH 7.51, pCO2 40, HCO3- 31:
1. Normal
2. Uncompensated metabolic alkalosis
3. Compensated respiratory acidosis
4. Uncompensated respiratory alkalosis
32. pH 7.40, pCO2 40, HCO3- 24:
1. Normal
2. Uncompensated metabolic acidosis
3. Compensated respiratory acidosis
4. Compensated metabolic acidosis
33. pH 7.12, pCO2 60, HCO3- 29:
1. Uncompensated metabolic acidosis
2. Uncompensated respiratory acidosis
3. Compensated respiratory acidosis
4. Compensated metabolic acidosis
34. pH 7.48, pCO2 30, HCO3- 23:
1. Uncompensated metabolic alkalosis
2. Uncompensated respiratory alkalosis
3. Compensated respiratory alkalosis
4. Compensated metabolic alkalosis
35. pH 7.62, pCO2 47, HCO3- 30:
1. Uncompensated metabolic alkalosis
2. Uncompensated respiratory alkalosis
3. compensated respiratory alkalosis
4. compensated metabolic alkalosis
GIT
1. The nurse evaluates the client's most recent labo-
ratory data. Which laboratory finding would be
consistent with a diagnosis of acute pancreatitis?
1. Hyperglycemia.
2. Leukopenia.
3. Thrombocytopenia.
4. Hyperkalemia.
Answer: 1. Pancreatitis interferes with beta-cell
functioning, and clients must be monitored carefully for
hyperglycemia. The client may also develop
hypocalcemia and hyperlipidemia. Pancreatitis does not
decrease blood cell counts or affect platelet production
or potassium levels.
2. The initial treatment plan for a client with pancreatitis
most likely would focus on which of the following as a
priority?
1. Resting the gastrointestinal tract.
2. Ensuring adequate nutrition.
3. Maintaining fluid and electrolyte balance.
4. Preventing the development of an infection.
Answer: 1. There is little definitive treatment for pancre-
atitis. It is crucial to decrease pancreatic enzymes to re-
duce stimulation of the pancreas. This is done by keep-
ing the client NPO to rest the gastrointestinal tract and
thereby suppress pancreatic enzyme secretion. Ensuring
adequate nutrition, maintaining fluid and electrolyte
balance, and preventing the development of an
infection are issues for the client with pancreatitis but
are not the primary focus of treatment
3. When providing care for a client with acute pan-
creatitis, the nurse would anticipate which of the
following orders?
1. Increase oral intake to 3,000 mL every 24 hours.
2. Insert a nasogastric tube and connect it to low
suction.
3. Place the client in the reverse Trendelenburg position.
4. Place the client on enteric precautions.
Answer: 2. Nasogastric suction is frequently used in the
treatment of pancreatitis to decrease pancreatic secre-
tions and gastric distention. Foods and fluids are with-
held during the acute phase of pancreatitis to rest the
pancreas. Intravenous fluids are administered to provide
hydration. Placing the client in the reverse Trende-
lenburg position is not appropriate. Most clients will be
more comfortable if they are placed in a side-lying po-
sition with the head of the bed elevated to relieve ab-
dominal tension. There is no need to place the client on
enteric precautions.
4. Which of the following positions would be appro-
priate for a client with severe ascites?
1. Fowler's.
2. Side-lying.
3. Reverse Trendelenburg.
4. Sims
Answer: 1. Ascites can compromise the action of the di-
aphragm and increase the client's risk of respiratory
problems. Ascites also greatly increases the risk of skin
breakdown. Frequent position changes are important,
but the preferred position is Fowler's. Placing the client
in Fowler's position helps facilitate the client's breathing
by relieving pressure on the diaphragm. The other
positions do not relieve pressure on the diaphragm.
5. The physician orders oral neomycin as well as a
neomycin enema for a client with cirrhosis. The
nurse understands that the purpose of this therapy is to
1. reduce abdominal pressure.
2. prevent straining during defecation.
3. block ammonia formation.
4. reduce bleeding within the intestine.
Answer: 3. Neomycin is administered to decrease the
bacterial action on protein in the intestines, which
results in ammonia production. This ammonia, if not
detoxified by the liver, can result in hepatic
encephalopathy and coma. The antibiotic does not
reduce abdominal pressure, prevent straining during
defecation, or decrease hemorrhaging within the
intestine.
6. The nurse monitors a client with cirrhosis for the
development of hepatic encephalopathy. Which of
the following would be an indication that hepatic en-
cephalopathy is developing?
1. Decreased mental status.
2. Elevated blood pressure.
3. Decreased urinary output.
4. Labored respirations.
Answer: 1. The client should be monitored closely for
changes in mental status. Ammonia has a toxic effect on
central nervous system tissue and produces an altered
level of consciousness, marked by drowsiness and
irritability. If this process is unchecked, the client may
lapse into coma. Increasing ammonia levels are not de-
tected by changes in blood pressure, urinary output, or
respirations.
7. A client's serum ammonia level is elevated, and the
physician orders 30 mL of lactulose (Cephulac).
Which of the following side effects of this drug would
the nurse expect to see?
1. Increased urine output.
2. Improved level of consciousness.
3. Increased bowel movements.
4. Nausea and vomiting.
Answer: 3. Lactulose increases intestinal motility,
thereby trapping and expelling ammonia in the feces. An
increase in the number of bowel movements is expected
as a side effect. Lactulose does not affect urine output.
Any improvements in mental status would be the result
of increased ammonia elimination, not a side effect of
the drug. Nausea and vomiting are not common side
effects of lactulose.
8. The nurse is providing discharge instructions for a
client with cirrhosis. Which of the following statements
best indicates that the client has understood the teach-
ing?
1. "I should eat a high-protein, high-carbohydrate
diet to provide energy."
2. "It is safer for me to take
acetaminophen(Tylenol) for pain instead of
aspirin."
3. "I should avoid constipation to decrease chances of
bleeding."
4. "If I get enough rest and follow my diet, it is possible
for my cirrhosis to be cured."
Answer: 3. Clients with cirrhosis should be instructed to
avoid constipation and straining at stool to prevent he-
morrhage. The client with cirrhosis has bleeding ten-
dencies because of the liver's inability to produce clot-
ting factors. A low-protein and high-carbohydrate diet is
recommended. Clients with cirrhosis should not take
acetaminophen, which is potentially hepatotoxic. As-
pirin also should be avoided if esophageal varices are
present. Cirrhosis is a chronic disease.
9. The nurse is preparing a client for a paracentesis.
Which of the following activities would be appropriate
before the procedure?
1. Have the client void immediately before the
procedure.
2. Place the client in a side-lying position.
3. Initiate an intravenous line to administer sedatives.
4. Place client on NPO status 6 hours before the
procedure.
Answer: 1. Immediately before a paracentesis.'the client
should empty the bladder to prevent perforation. The
client will be placed in a high Fowler's position or seated
on the side of the bed for the procedure. Intravenous
sedatives are not usually administered. The client does
not need to be NPO.
10. Which of the following interventions would the
nurse anticipate incorporating into the client's plan of
care when hepatic encephalopathy initially develops?
1. Inserting a nasogastric tube.
2. Restricting fluids to 1,000 mL/day.
3. Administering intravenous salt-poor albumin.
4. Implementing a low-protein diet.
Answer: 4. When hepatic encephalopathy develops,
measures are taken to reduce ammonia formation.
Protein is restricted in the diet. A nasogastric tube is not
inserted initially but may be necessary as the disease
progresses. Fluid restriction and salt-poor albumin are
incorporated into the treatment of ascites, but not
hepatic encephalopathy.
11. A client with ascites and peripheral edema is at risk
for impaired skin integrity. Which of the following
interventions would be implemented to prevent skin
breakdown?
1. Range-of-motion exercise every 4 hours.
2. Massage of the abdomen once a shift.
3. Use of alternating air pressure mattress.
4. Elevation of the lower extremities.
Answer: 3. Edematous tissue is easily traumatized and
must receive meticulous care. An alternating air pres-
sure mattress will help decrease pressure on the ede-
matous tissue. Range-of-motion exercises are important
to maintain joint function, but they do not necessarily
prevent skin breakdown. When abdominal skin is
stretched taut due to ascites, it must be cleaned very
carefully. The abdomen should not be massaged.
Elevation of the lower extremities promotes venous re-
turn and decreases swelling
12. Which of the following lifestyle modifications should
the nurse encourage the client with a hiatal
hernia to include in activities of daily living?
1. Daily aerobic exercise.
2. Eliminating smoking and alcohol use.
3. Balancing activity and rest.
4. Avoiding high-stress situations.
Answer: 2. Smoking and alcohol use both reduce
esophageal sphincter tone and can result in reflux. They
therefore should be avoided by clients with hiatal
hernia. Daily aerobic exercise, balancing activity and
rest, and avoiding high-stress situations may increase
the client's general health and well-being, but they are
not directly associated with hiatal hernia.
13. The nurse instructs the client on health maintenance
activities to help control symptoms from her hiatal
hernia. Which of the following statements would
indicate that the client has understood the instruc-
tions?
1. "I'll avoid lying down after a meal."
2. "I can still enjoy my potato chips and cola at
bedtime."
3. "I wish I didn't have to give up swimming."
4. "If I wear a girdle, I'll have more support for my
stomach."
Answer: 1 A client with a hiatal hernia should avoid the
recumbent position immediately after meals to mini-
mize gastric reflux. Bedtime snacks, as well as high-fat
foods and carbonated beverages, should be avoided.
Excessive vigorous exercise also should be avoided, es-
pecially after meals, but there is no reason why the
client must give up swimming. Wearing tight constrictive
clothing, such as a girdle, can increase intra-abdominal
pressure and thus lead to reflux of gastric juices.
14. A client who has been diagnosed with gastroe-
sophageal reflux disease (GERD) complains of heart-
burn. To decrease the heartburn, the nurse should in-
struct the client to eliminate which of the following
items from the diet?
1. Lean beef.
2. Air-popped popcorn.
3. Hot chocolate.
4. Raw vegetables.
Answer: 1. With GERD, eating substances that decrease
lower esophageal sphincter pressure causes heartburn.
A decrease in the lower esophageal sphincter pressure
allows gastric contents to reflux into the lower end of .
the esophagus. Foods that can cause a decrease in
esophageal sphincter pressure include fatty foods,
chocolate, caffeinated beverages, peppermint, and al-
cohol. A diet high in protein and low in fat is recom-
mended for clients with GERD. Lean beef, popcorn, and
raw vegetables would be acceptable.
15. The client with GERD complains of a chronic cough.
The nurse understands that in a client with GERD this
symptom may be indicative of which of the following
conditions?
1. Development of laryngeal cancer.
2. Irritation of the esophagus.
3. Esophageal scar tissue formation.
4. Aspiration of gastric contents.
Answer: 4. Clients with GERD can develop pulmonary
symptoms such as coughing, wheezing, and dyspnea
that are caused by the aspiration of gastric contents.
GERD does not predispose the client to the develop-
ment of laryngeal cancer. Irritation of the esophagus
and esophageal scar tissue formation can develop as a
result of GERD. However, GERD is more likely to cause
painful and difficult swallowing.
Endocrine
1. A 9 yr.old with insulin dependent diabetes mellitus is
admitted to the hospital with deep rapid respirations,
flushed, dry cheeks, abdominal pain with nausea and
increased thirst. Laboratory test would be expected to
show:
1. A blood pH of 7.25 with a blood glucose level of 60
mg/dl
2. A blood pH of 7.50 with a blood glucose level of 60
mg/dl
3. A blood pH of 7.50 with a blood glucose level of 460
mg/dl
4. A blood pH of 7.25 with a blood glucose level of 460
mg/dl
2. A father has a child with type I Diabetes Mellitus.
Which of the following symptoms will indicate that his
child is hyperglycemic?
1. tremors
2. cheyne-stokes breathing
3. kussmauls breathing
4. hunger
3. A patient who has Cushing’s syndrome asks a nurse,
“Why has my face become so round?” The nurse’s
response is based on the knowledge that adrenal
hormone:
1. excess causes lymph edema
2. insufficiency results in hypervolemia
3. excess causes abnormal distribution of fat
4. insufficiency results in electrolyte imbalance
4. A patient who has undergone a thyroidectomy would
be predisposed to the development of:
1. hypocalcemia
2. hyponatremia
3. hyperkalemia
4. hypermagnesemia
5. When assessing a patient who has hypothyroidism, a
nurse should expect the patient to report which of the
following manifestations?
1. intolerance to cold
2. increased appetite
3. frequent stools
4. rapid heart rate
6. The nurse is assessing a client with Cushing's
syndrome. Which observation should the nurse report
to the physician immediately?
1. Pitting edema of the legs
2. An irregular apical pulse
3. Dry mucous membranes
4. Frequent urination
7. A client with type 1 diabetes mellitus is admitted to
an acute care facility with diabetic ketoacidosis. To
correct this acute diabetic emergency, which measure
should the health care team take first?
1. Initiate fluid replacement therapy.
2. Administer insulin.
3. Correct diabetic ketoacidosis.
4. Determine the cause of diabetic ketoacidosis.
8. A client diagnosed with hyperosmolar hyperglycemic
non-ketotic syndrome (HHNS) is stabilized and prepared
for discharge. When preparing the client for discharge
and home management, which of the following
statements
indicates that the client understands her condition and
how to control it?
1. "I can avoid getting sick by not becoming dehydrated
and by paying attention to my need to urinate, drink,
or eat more than usual."
2. "If I experience trembling, weakness, and headache, I
should drink a glass of soda that contains sugar."
3. "I will have to monitor my blood glucose level closely
and notify the physician if it's constantly elevated."
4. "If I begin to feel especially hungry and thirsty, I'll eat
a snack high in carbohydrates."
9. Which of the following would the nurse expect to
assess in an elderly client with Hashimoto's thyroiditis?
1. Weight loss, increased appetite, and hyperdefecation
2. Weight loss, increased urination, and increased thirst
3. Weight gain, decreased appetite, and constipation
4. Weight gain, increased urination, and purplish-red
striae
10. The nurse is performing an admission assessment on
a client diagnosed with diabetes insipidus. Which
findings should the nurse expect to note during the
assessment? Select all that apply:
1. Extreme polyuria
2. Excessive thirst
3. Elevated systolic blood pressure
4. Low urine specific gravity
5. Bradycardia
6. Elevated serum potassium level
11. After undergoing a subtotal thyroidectomy, a client
develops hypothyroidism. The physician prescribes
levothyroxine (Levothroid), 25 mcg P.O. daily. For which
condition is levothyroxine the preferred agent?
1. Primary hypothyroidism
2. Graves' disease
3. Thyrotoxicosis
4. Euthyroidism
12. When teaching a client with Cushing's syndrome
about dietary changes, the nurse should instruct the
client to increase intake of:
1. fresh fruits.
2. dairy products.
3. processed meats.
4. cereals and grains.
13. A client is diagnosed with the syndrome of
inappropriate antidiuretic hormone (SIADH). The nurse
should anticipate which laboratory test result?
1. Decreased serum sodium level
2. Decreased serum creatinine level
3. Increased hematocrit
4. Increased blood urea nitrogen (BUN) level
14. A 20-year-old client comes to the clinic because she
has experienced a weight loss of 20 lb over the last
month, even though her appetite has been "ravenous"
and she hasn't changed her activity level. She's
diagnosed with Graves' disease. Which other signs and
symptoms support the diagnosis of Graves' disease?
Select all that apply:
1. Rapid, bounding pulse
2. Bradycardia
3. Heat intolerance
4. Mild tremors
5. Nervousness
6. Constipation
15. A client with Addison's disease comes to the clinic
for a follow-up visit. When assessing this client, the
nurse should stay alert for signs and symptoms of:
1. calcium and phosphorus abnormalities.
2. chloride and magnesium abnormalities.
3. sodium and chloride abnormalities.
4. sodium and potassium abnormalities.
16. A client is admitted to the health care facility for
evaluation for Addison’s disease. Which laboratory test
result best supports a diagnosis of Addison’s disease?
1. Blood urea nitrogen (BUN) level of 12 mg/dl
2. Blood glucose level of 90 mg/dl
3. Serum sodium level of 134 mEq/L
4. Serum potassium level of 5.8 mEq/L
17. A nursing coordinator calls the intensive care unit
(ICU) to inform the department that a client with a
suspected pheochromocytoma will be admitted from
the emergency department. The ICU nurse should
prepare to administer which drug to the client?
1. Nitroprusside
2. Dopamine (Inotropin)
3. Insulin
4. Lidocaine

18. A client with a history of hypertension is diagnosed

with primary hyperaldosteronism. This diagnosis
indicates that the client’s hypertension is caused by
excessive hormone secretion from which gland?
1. Adrenal cortex
2. Pancreas
3. Adrenal medulla
4 Parathyroid

19. Which statement indicates that a client with

diabetes mellitus understands proper foot care?
1. “I’ll schedule an appointment with my physician if my
feet start to ache.”
2. “I’ll rotate insulin injection sites from my left foot to
my right foot.”
3. “I’ll go barefoot around the house to avoid pressure
areas on my feet.”
4. “I’ll wear cotton socks with well-fitting shoes.”

20. During a follow-up visit to the physician, a client with

hyperparathyroidism asks the nurse to explain the
physiology of the parathyroid glands. The nurse states
that these glands produce parathyroid hormone (PTH).
PTH maintains the balance between calcium and:
1. sodium.
2. potassium.
3. magnesium.
4. phosphorus.