Question: A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings as a manifestation of fluid volume excess?

1. Decreased bowel sounds

2. b. Distended neck veins

3. c. Bilateral muscle weakness

4. d. Thread pulse

5. Answer: b. Distended neck veins

6. Question:

7. Answer: b. Improved cognition

8. Question:

9. Answer: d. “Remove the patch prior to going to bed.”

10. Question: A nurse is reviewing he laboratory results of a client who has a prescription for sodium polystyrene sulfonate (Kayexalate) every 6 hr. which of the following should the nurse report to the provider?

11. a. Creatinine 0.72 mg/dL

12. b. Sodium 138 mEq/L

13. c. Magnesium 2 mEq/L

14. d. Potassium 5.2 mEq/L

15. Answer: d. Potassium 5.2 mEq/L - Hyperkalemia (serum potassium level greater than 5.0 mEq/L) increases the client risk for fatal cardiac dysrhythmias. Kayexalate is used to decrease the serum potassium level so the PN should monitor the client’s serum potassium level

16. Question:

17. Answer: a. The client has a negative sputum culture

18. Question:

19. Answer: d. Administer epinephrine IM

20. Question: A nurse is caring for a client who is taking sertraline and reports a desire to begin taking supplements. Which of the following supplements should the nurse advise the client to avoid?

21. a. St. John’s Wort

22. b. Ginger root

23. c. Black cohosh

24. d. Coenzyme Q10

25. Answer: a. St. John’s Wort

26. Question: A nurse is caring for a client who has heart failure and a new prescription for lisinopril. For which of the following adverse effects should the nurse monitor when administering lisinopril?

27. a. Bradycardia

28. b. Hypokalemia

29. c. Tinnitus

30. d. Hypotension

31. Answer: d. Hypotension

32. Question:

33. Answer: d. Increased blood pressure

34. Question:

35. Answer: b. The nurse who identifies the error