Chapter 25 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 25

Question 1

Type: MCSA

The nurse is planning the care of a 50-year-old patient with the risk of developing fluid volume deficit. Which assessment finding would have the greatest contribution to this risk?

1. Loose bowel movement one per day

2. First-degree steam burn on hand and forearm

3. Temperature of 99.6 F

4. Diuretic therapy two doses per day

Correct Answer: 4

Rationale 1: Diarrhea does contribute to fluid volume deficit, but one loose bowel movement per day does not constitute diarrhea.

Rationale 2: Burns also can cause a fluid volume deficit but it is unlikely that a first-degree burn on the hand forearm will produce a significant amount of fluid loss.

Rationale 3: Fever does increase fluid loss, but this is a low-grade temperature whose affect would be minimal.

Rationale 4: The patient receiving two doses of diuretic therapy per day is at risk for high volumes of urine output that could increase the risk of developing a fluid volume deficit.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-1

Question 2

Type: MCSA

A patient in the intensive care unit has developed gastrointestinal hemorrhage. The nurse would prepare to fluid resuscitate this patient with which intravenous fluid?

1. 5% dextrose and 0.45% normal saline

2. 2.5% dextrose

3. 0.45% normal saline

4. 0.9% normal saline

Correct Answer: 4

Rationale 1: The solution 5% dextrose and 0.45% normal saline is a hypertonic solution and is not the best choice for expanding the patients blood volume.

Rationale 2: The 2.5% dextrose is a hypotonic solution and would not help expand the patients blood volume.

Rationale 3: The 0.45% normal saline is a hypotonic solution and would not help expand the patients blood volume.

Rationale 4: The patient needs an isotonic solution to expand the blood volume. The appropriate intravenous solution is 0.9% normal saline.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 25-1

Question 3

Type: MCMA

The nurse is assessing the effectiveness of fluid replacement therapy in a patient with the nursing diagnosis of Fluid Volume Deficit. Which assessment findings would indicate the therapy is effective?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Blood pressure 90/48 mm Hg

2. Weight gain of 2 pounds since yesterday

3. Urine output increase to 40 mL per hour

4. Tenting of skin

5. Serum osmolality of 284 mOm/kg

Correct Answer: 2,3,5

Rationale 1: Low blood pressure indicates that the therapy has not been effective.

Rationale 2: Increase in weight of 2 pounds in 1 day indicates a change in fluid balance.

Rationale 3: Increase in urine output indicates improvement of fluid balance status.

Rationale 4: Tenting of skin indicates poor skin turgor and fluid volume deficit.

Rationale 5: Normal serum osmolality is 280300 mOm/kg. Presence of normal serum osmolality indicates normal fluid volume status.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-1

Question 4

Type: MCSA

A patient with fluid volume excess has a hemoglobin level of 9.0 mg/dL. How would the nurse explain the more likely cause of this laboratory value?

1. An undiagnosed bleeding disorder exists.

2. The patient has chronic anemia.

3. The patient has iron deficiency anemia.

4. Plasma dilution has occurred due to excess fluid.

Correct Answer: 4

Rationale 1: While this may be the case it is not the most likely reason for this lab value.

Rationale 2: While this may be the case it is not the most likely reason for this lab value.

Rationale 3: While this may be the case it is not the most likely reason for this lab value.

Rationale 4: Since this patient has fluid volume excess the most likely etiology of a low hemoglobin level is plasma dilution from excess extracellular fluid volume.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-2

Question 5

Type: MCSA

A patient being treated for fluid volume excess has blood glucose elevation. The nurse would review the patients medication history for which medication?

1. Furosemide (Lasix)

2. Spironolactone (Aldactone)

3. Potassium chloride (K-Dur)

4. Hydrochlorothiazide (Esidrix)

Correct Answer: 4

Rationale 1: Furosemide does not cause hyperglycemia.

Rationale 2: Spironolactone does not result in hyperglycemia.

Rationale 3: Potassium supplements do not cause hyperglycemia.

Rationale 4: Hydrochlorothiazide has hyperglycemia as a major side effect.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-2

Question 6

Type: MCSA

A patient comes into the emergency department with complaints of feeling weak, confused, and having abdominal cramps after spending several hours in the hot sun attending a baseball game. The patients blood pressure is 96/58 mm Hg. The nurse would conduct additional assessment for which condition?

1. Hyponatremia

2. Hypercalcemia

3. Hypernatremia

4. Hypocalcemia

Correct Answer: 1

Rationale 1: Manifestations of hyponatremia include hypotension, confusion, headache, lethargy, seizures, decreased muscle tone, muscle twitching, tremors, vomiting, diarrhea, and cramping. The patient is complaining of feeling weak and confused with abdominal cramps, which are symptoms associated with hyponatremia. The blood pressure of 96/58 mm Hg is another indication of hyponatremia. Because of these findings and the patient history the nurse should assess for additional symptoms of hyponatremia.

Rationale 2: The symptoms and the patient history do not suggest hypercalcemia.

Rationale 3: Manifestations of hypernatremia include hypertension, thirst, nausea, and vomiting. Hypernatremia would be unlikely in the patient with this history.

Rationale 4: These symptoms and this history do not support a diagnosis of hypocalcemia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-3

Question 7

Type: MCSA

The nurse is preparing intravenous fluids for a patient whose serum sodium is 156 mmol/L. Which types of fluid would the nurse select?

1. 10% dextrose in water

2. Lactated Ringers

3. 0.45% normal saline

4. 5% dextrose and 0.45% normal saline

Correct Answer: 3

Rationale 1: Hypertonic solutions such as 10% dextrose in water are not used to treat hypernatremia.

Rationale 2: Lactated Ringers is an isotonic solution and would not be effective when treating hypernatremia.

Rationale 3: To effectively treat hypernatremia, the patient will need to be provided with hypotonic intravenous fluids. The fluid 0.45% normal saline is a hypotonic fluid.

Rationale 4: Hypertonic fluids such as 5% dextrose and 0.45% normal saline would not be used to treat hypernatremia.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-3

Question 8

Type: MCSA

A patient is receiving several units of packed red blood cells over several days to replace the blood lost during an active gastrointestinal bleed. The nurse would assess this patient for findings associated with which electrolyte imbalance?

1. Hyponatremia

2. Hypercalcemia

3. Hypokalemia

4. Hypomagnesaemia

Correct Answer: 4

Rationale 1: Blood is administered with normal saline so hypernatremia would be a more likely condition.

Rationale 2: Blood administration is not a primary cause of hypercalcemia.

Rationale 3: Blood transfusion is not a likely cause of hypokalemia.

Rationale 4: Hypomagnesaemia can be induced by the administration of large amounts of stored blood because stored blood is preserved with citrate. Citrate is added to stored blood as a preservative.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-6

Question 9

Type: MCMA

A patient has a serum calcium level of 7.9 mg/dL. Which nursing interventions would be appropriate for this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Treat tachycardia.

2. Monitor for the development of hypertension.

3. Place on seizure precautions.

4. Strain all urine.

5. Reorient as indicated.

Correct Answer: 3,5

Rationale 1: Bradycardia is the expected result of this calcium level.

Rationale 2: Hypotension is the expected effect of this calcium level.

Rationale 3: A serum calcium level of less than 8.5 mg/dL is indicative of hypocalcemia. Nursing interventions appropriate for the patient would include monitoring the patient for seizures.

Rationale 4: Straining urine is associated with the possibility of kidney stones. This calcium level is not associated with kidney stone development.

Rationale 5: This calcium level indicates hypocalcemia. Reduce cognitive ability is a common finding associated with hypocalcemia. The nurse should reorient this patient as needed.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-4

Question 10

Type: MCMA

A patient has a serum calcium level of 11.0 mg/dL. The nurse would review this patients medical record for which conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. History of taking thiazide diuretics

2. Diagnosis of hyperparathyroidism

3. Diagnosis of acute pancreatitis

4. Low serum magnesium level

5. Long term bedrest

Correct Answer: 1,2,5

Rationale 1: Hypercalcemia may result from use of thiazide diuretics.

Rationale 2: Primary hyperparathyroidism is associated with hypercalcemia.

Rationale 3: The diagnosis acute pancreatitis is associated with hypocalcemia.

Rationale 4: A low serum magnesium level is also seen in hypocalcemia.

Rationale 5: Immobility can cause hypercalcemia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-4

Question 11

Type: MCSA

The nurse caring for a patient receiving digoxin plans to monitor which electrolyte because of increased risk of digitalis toxicity?

1. Potassium

2. Chloride

3. Calcium

4. Sodium

Correct Answer: 1

Rationale 1: In patients receiving digoxin therapy, low serum potassium levels can increase the risk for development of dysrhythmias.

Rationale 2: Chloride levels do not increase risk for digitalis toxicity.

Rationale 3: Calcium levels do not increase risk for digitalis toxicity.

Rationale 4: Sodium levels do not increase risk for digitalis toxicity.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 25-5

Question 12

Type: MCSA

The nurse is concerned that a patients arterial blood carbon dioxide level is increasing because this can contribute to the development of which electrolyte imbalance?

1. Hyperkalemia

2. Hypokalemia

3. Hypercalcemia

4. Hypocalcemia

Correct Answer: 1

Rationale 1: A rise in arterial blood carbon dioxide is a diagnostic indicator of acidosis. Acidosis contributes to hyperkalemia because excess hydrogen ions shift into the cells, forcing potassium out into the serum. The nurse should be concerned about the patient developing hyperkalemia.

Rationale 2: Acidosis does not contribute to the development of hypokalemia.

Rationale 3: Acidosis does not contribute to the development of hypercalcemia.

Rationale 4: Acidosis does not contribute to the development of hypocalcemia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-5

Question 13

Type: MCSA

A patients electrocardiogram reveals a prolonged P-R interval and ST segment depression. The nurse should review laboratory results for which electrolyte imbalance?

1. Hypokalemia

2. Hyperkalemia

3. Hypocalcemia

4. Hypernatremia

Correct Answer: 2

Rationale 1: Prolongation of the PR interval is not an ECG finding associated with hypokalemia.

Rationale 2: Cardiovascular manifestations of hyperkalemia include prolonged P-R interval; flat or absent P wave; slurring of QRS; tall peaked T wave; and ST segment depression.

Rationale 3: Hypocalcemia causes prolongation of the QT interval and a long ST segment.

Rationale 4: Cardiovascular manifestations of hypernatremia include hypertension and tachycardia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-5

Question 14

Type: MCSA

A patient is demonstrating tremors and a positive Chvosteks sign even though the serum calcium level is low normal. The nurse would review the medical record for which electrolyte imbalance?

1. Low phosphate

2. Low potassium

3. Low magnesium

4. Elevated sodium

Correct Answer: 3

Rationale 1: A positive Chvosteks sign is associated with hyperphosphatemia.

Rationale 2: Potassium levels are not associated with a positive Chvosteks sign.

Rationale 3: The symptoms associated with a low magnesium level are similar to those seen in a low calcium level. Therefore, the nurse should suspect that the patient is experiencing a low magnesium level since tremors and a positive Chvosteks sign is also seen with a low calcium level.

Rationale 4: Sodium level is not associated with a positive Chvosteks sign.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-6

Question 15

Type: MCSA

A patient diagnosed with chronic renal failure has a magnesium level of 6.0 mg/dL. Which history data would the nurse evaluate as contributing to this electrolyte imbalance?

1. The patient had an episode of nasal congestion last week and took decongestant.

2. The patient had a resent sprain injury treated with rest and compression wrapping.

3. The patient has been trying to reduce intake of caffeine-containing fluids.

4. The patient has been taking over-the-counter laxative for chronic constipation.

Correct Answer: 4

Rationale 1: Taking a decongestant would not contribute to hypermagnesemia.

Rationale 2: A sprain injury treated with rest and compression would not cause hypermagnesemia.

Rationale 3: Reduction of caffeine-containing beverages would not contribute to hypermagnesemia.

Rationale 4: Many over-the-counter laxatives contain magnesium. Chronic overuse of these laxatives may result in hypermagnesemia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-6

Question 16

Type: MCMA

A patient who was admitted to the intensive care unit has a magnesium level of 8.4 mg/dL. The nurse would prepare for which interventions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Maintenance of strict bedrest

2. Administration of calcium gluconate

3. Observation for tetany

4. Intravenous administration of magnesium

5. Initiation of dialysis

Correct Answer: 2,5

Rationale 1: While ambulation may not be indicated for this patient due to changes in neuromuscular function, strict bedrest is not required. The patient may be able to sit on the side of the bed, use a bedside commode, or sit in a bedside chair.

Rationale 2: The neuromuscular and cardiac toxicity of hypermagnesemia can be antagonized by the administration of 1020 mL of calcium gluconate over 10 minutes.

Rationale 3: Tetany is seen in hypomagnesaemia and not hypermagnesemia.

Rationale 4: This magnesium level is elevated, so additional magnesium is not indicated.

Rationale 5: Dialysis may be required to remove magnesium in severe cases.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 25-6

Question 17

Type: MCSA

A patient with a history of heart failure is admitted with dehydration, malnutrition, and fatigue. The nurse learns that the patient has been taking multiple doses of a thiazide diuretic. The nurse would review laboratory reports for which electrolyte imbalance?

1. Hypernatremia

2. Hypophosphatemia

3. Hypocalcemia

4. Hypermagnesemia

Correct Answer: 2

Rationale 1: Hypernatremia is not associated with dehydration.

Rationale 2: Hypophosphatemia is associated with malnourished states and is a relatively common imbalance in the high-acuity patient. Other conditions that can cause hypophosphatemia include those disorders that cause hypercalcemia, such as taking thiazide diuretics.

Rationale 3: Thiazide diuretics can cause hypercalcemia.

Rationale 4: Dehydration, malnutrition, and fatigue are not directly linked to hypermagnesemia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-7

Question 18

Type: MCMA

A hospitalized patient has a phosphorus level of 4.8 mg/dL. The nurse would review this patients history for the presence of which conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Chronic kidney failure

2. Hyperthyroidism

3. Recent cardiac surgery

4. Alcoholism

5. Treatment for gram-negative sepsis

Correct Answer: 1,2

Rationale 1: Hyperphosphatemia is predominantly associated with chronic kidney failure.

Rationale 2: Hyperthyroidism can precipitate hypocalcemia, which leads to hyperphosphatemia.

Rationale 3: Cardiac surgery is associated with hypophosphatemia.

Rationale 4: Alcoholism is associated with hypophosphatemia.

Rationale 5: Gram-negative sepsis is associated with hypophosphatemia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25-7

Question 19

Type: MCSA

A patient admitted with hyperphosphatemia is to be treated with the administration of intravenous fluids. Which fluid would the nurse anticipate providing?

1. 0.9% normal saline

2. Lactated Ringers solute

3. 5% dextrose and 0.25% normal saline

4. 5% dextrose and water

Correct Answer: 1

Rationale 1: Treatment of hyperphosphatemia is directed at lowering serum levels. This is accomplished by either administering agents that bind phosphate in the gastrointestinal tract or administering an intravenous solution with saline since saline promotes the renal excretion of phosphate. The intravenous solution of choice for this patient would be 0.9% normal saline.

Rationale 2: Lactated Ringers solution does not provide the most benefit to this patient.

Rationale 3: 5% dextrose and 0.25% normal saline is not the best fluid choice as it has insufficient amounts of an essential ingredient.

Rationale 4: 5% dextrose and water is not the best fluid choice as it lacks an essential ingredient.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-7

Question 20

Type: MCSA

Potassium phosphate IV has been prescribed for a patient who has hypophosphatemia. Which nursing interventions are indicated when administering this medication?

1. Dilute the dose in 100 mL of normal saline and administer over 20 minutes.

2. Monitor the patient for respiratory distress.

3. Monitor for the development of hypotension.

4. Ensure that pharmacy has mixed the medication with a local anesthetic.

Correct Answer: 2

Rationale 1: The dose should be diluted in 500 mL of 0.45 NS and given over 6 hours.

Rationale 2: Replacement of phosphorus may cause respiratory changes. The patient should be monitored for respiratory distress.

Rationale 3: Hypotension is not an expected effect of phosphorus replacement.

Rationale 4: There is no indication that mixing this medication with a local anesthetic is required.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25-7

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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