1. The nurse is attending to a client who was diagnosed 8.

Which client will most likely experience a serum

with heart failure. During the examination, the nurse sodium concentration of 127 mEq/L (127 mmol/L)?
observes that the client is dyspneic with crackles upon A. A client who has Cushing’s syndrome
auscultation. Which symptoms would manifest for a B. A client who has hyperaldosteronism
client with excess fluid volume? C. A client who is taking thiazide diuretics
A. Decreased central venous pressure D. A client who uses corticosteroids
B. Flat neck and hand veins
C. Hypertension 9. The client was diagnosed with heart failure and is
D. Weight loss currently taking high doses of diuretics. During the
assessment, the nurse noted generalized weakness, flat
neck veins, and diminished deep tendon reflexes. Which
2. During the client’s medical records review, what
of the following symptoms would indicate that the client
condition can put the client at risk for developing
has hyponatremia?
hypokalemia?
A. Decreased urinary output
A. Has a history of Addison’s disease
B. Hyperactive bowel sounds
B. Nasogastric suction
C. Increased urine specific gravity
C. Burn
D. Tremors
D. Uric acid level of 10.2 mg/dL (59.48 µmol/L)
10. After the nurse reviewed the client’s lab results, the
3. The nurse analyzes the electrolyte test results for a
client’s serum phosphorus (phosphate) level was found
client and notes that the potassium level is 2.2 mEq/L
to be at 1.8 mg/dL (0.58 mmol/L) level. What condition is
(2.2 mmol/L). Based on the laboratory result, which ECG
most likely to cause the serum phosphorus level?
pattern is not expected?
A. Hypoparathyroidism
A. Absent P waves
B. Kidney failure
B. Depressed ST segment
C. Malnutrition
C. Inverted T waves
D. Tumor lysis syndrome
D. Presence of U waves
11. After reading the doctor’s progress reports, the
4. An intravenous dose of potassium chloride is
nurse plans to monitor the client, which states that the
prescribed for a client with hypokalemia. Which action
patient has “insensible fluid loss of approximately 800
of the nurse indicates a need for further teaching in the
mL daily.” The nurse is aware that one way insensible
preparation and administration of potassium?
fluid loss happens is through which form of excretion?
A. Administer potassium through IV bolus.
A. Gastrointestinal tract
B. Check if the label of the bag indicates the volume of the
B. Sweat
potassium in the solution.
C. Urinary output
C. Infuse potassium through an intravenous (IV) infusion
D. Wound drainage
pump.
D. Monitor urine output during infusion.
12. The nurse reviewed the medical records of the four
clients assigned to her. Which client has the highest risk
5. A client with hypoparathyroidism is suspected of
for a fluid volume deficit?
having hypocalcemia. Upon assessment, the nurse
A. A client with an ileostomy
notes which clinical symptom would indicate
B. A client with heart failure
hypocalcemia.
C. A client on long-term corticosteroid therapy
A. Diminished deep tendon reflexes
D. A client with SIADH
B. Hypoactive bowel sounds
C. Negative Trousseau’s sign
13. A client diagnosed with heart failure has been
D. Twitching
receiving intravenous (IV) diuretics. Which finding
would the nurse expect to assess from this client
6. A client diagnosed with Crohn’s disease has a
suspected of experiencing fluid volume deficit?
calcium level of 7 mg/dL (1.75 mmol/L). Which ECG
A. Decreased hematocrit
patterns would the nurse monitor?
B. Increased blood pressure
A. Peaked T wave
C. Lung congestion
B. Prolonged QT interval
D. Poor skin turgor
C. Prominent U wave
D. Widened T wave
14. Which client is at risk for fluid volume excess?
A. The client with intermittent gastrointestinal suctioning
B. The client who is on diuretics and has skin tenting
7. A client diagnosed with Cushing’s disease has a
C. The client with an ileostomy from a recent abdominal
potassium level of 2.3 mEq/L (2.3 mmol/L). Based on the
surgery
result, which pattern would the nurse be monitoring for
D. The client with kidney disease developed as a
on the cardiac monitor?
complication of diabetes mellitus
A. Prolonged ST segment
B. Prominent U wave
C. ST elevation
D. Tall peaked T waves
15. Which client is most likely to develop a potassium 22. A nosocomial infection of Methicillin-resistant
level of 6.2 mEq/L (6.2 mmol/L)? Staphylococcus aureus was detected in the client, who
A. The client who abuses laxatives has been put on contact precautions as a result (MRSA).
B. The client who had a traumatic burn What protective equipment should a nurse prepare
C. The client with colitis before providing colostomy care?
D. The client with Cushing’s syndrome A. Gloves and gown
B. Gloves and goggles
16. Immunosuppression is noted in the client. Which C. Gloves, gown, and shoe protectors
WBC value would cause the nurse to consider using D. Gloves, gown, goggles, and a mask or face shield
neutropenic precautions?
A. 2000 mm3 (2.0 × 109/L)
B. 5800 mm3 (5.8 × 109/L) 23. The responsibility of taking a 47-year-old female
C. 8400 mm3 (8.4 × 109/L) client’s vital signs who was diagnosed with right breast
D. 9,500 mm3 (9.5 × 109/L) cancer post-mastectomy has been assigned to the
newly graduated nurse. Which of the following vital sign
17. The client’s blood has a platelet count of 300,000 procedures should be considered?
mm3 (300 x 109/L). What should the nurse do when she A. Attaching pulse oximeter on the left index finger.
receives this laboratory result? B. Attaching pulse oximeter on the right index finger.
A. Advise the primary healthcare provider about the C. Taking BP on the left arm.
unusually increased value. D. Taking BP on the right arm.
B. Document the report as normal in the client’s medical file.
C. Notify the primary healthcare provider about the unusually
decreased value. 24. The nurse is preparing to give a bed bath to a client
D. Put the client on platelet boosting medication. diagnosed with tuberculosis. Which equipment should
the nurse include when administering this procedure?
18. After undergoing abdominal perineal excision for a A. Particulate respirator and protective eyewear
colon tumor, a 55-year-old male patient is admitted for B. Particulate respirator, gown, and gloves
colostomy placement. The nurse will evaluate the newly C. Surgical mask and gloves
inserted colostomy. Which of the following assessments D. Surgical mask, gown, and protective eyewear
indicates a functional colostomy?
A. Absent bowel sounds upon auscultation 25. The client is getting ready for a thoracentesis. Which
B. Bloody drainage coming out of the colostomy drainage position should the client be placed in for the
C. Presence of flatus procedure?
D. Client’s food tolerance A. Lie on the affected side
B. Lay on the unaffected side.
C. Prone with the head turned to the side with a pillow
19. The nurse observes the stoma to be red and supporting the head
edematous. Based on this finding, what should the D. Sims’ position with the head flat on the bed
nurse do?
A. Immediately apply ice.
B. Record the findings.
C. Elevate the client’s buttocks.
D. Notify the primary healthcare provider.

20. The client started passing foul-smelling flatus from

the colostomy stoma after two days of the insertion.
What is the correct interpretation for the nurse?
A. It is a sign of ischemic bowel disease.
B. The client’s nasogastric tube should stay inserted with the
client.
C. It is an expected outcome.
D. The intestinal preparation before surgery is not adequate.

21. Which of the following findings must be immediately

reported to the primary healthcare provider?
A. Beefy red and shiny stoma.
B. Excoriation of the skin around the stoma
C. A semi-formed stool in the ostomy.
D. The stoma is purple in appearance.
1. Correct: prolonged QT interval and a prolonged ST segment are
C. Hypertension is a sign of fluid volume excess or fluid electrocardiographic alterations in clients with hypocalcemia.
overload. The increase in fluid volume causes an increase in Incorrect:
blood pressure in the vessels. A. Myocardial infarction results in peaked T waves.
Incorrect: C. Hypokalemia results in ST depression and prominent U
A., B., D. Decreased central venous pressure, flat neck and waves.
hand veins, and weight loss are all signs of fluid volume D. Hypercalcemia causes a narrowed ST segment and a
deficit. widened T wave.

2. Correct: 7. Correct:
B. The client is at risk for hypokalemia due to losing B. A potassium level of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)
potassium-rich gastrointestinal fluids during nasogastric is considered normal. Hypokalemia is indicated by a blood
suction. potassium level of less than 3.5 mEq/L (3.5.0 mmol/L). In
Incorrect: Cushing’s syndrome, the increase in cortisol causes
A., C., D. Clients with tissue damage (such as from severe hypokalemia.
burns), hyperuricemia, and Addison’s disease are at risk for Incorrect:
developing hyperkalemia. The normal uric acid level ranges A. Hypocalcemia causes the prolonged ST segment.
from 2.7 to 8.5 mg/dL (160 to 501 µmol/L). C. In hypokalemia, there is ST depression and NOT
elevation.
3. Correct: D. Hyperkalemia causes tall peaked T waves, enlarged QRS
A. A serum potassium level of 3.5 – 5.0 mEq/L (3.5-5.0 complexes, longer PR intervals, and flat P waves.
mmol/L) is considered normal. Hypokalemia is a serum
potassium level below 3.5 mEq/L (3.5 mmol/L). Absent P 8. Correct:
waves are not a sign of hypokalemia. However, it can be C. A serum sodium level of 135 to 145 mEq/L (or 135 to 145
seen in a patient with ventricular rhythms, junctional mmol/L) is considered normal. Hyponatremia is indicated by
rhythms, or atrial fibrillation. a serum sodium level of 127 mEq/L (127 mmol/L). The client
Incorrect: who is taking diuretics may experience hyponatremia.
B., C., D. Shallow, flat, or inverted T waves, ST segment Incorrect:
depression, and the presence of U waves are A., B., and D. Risk factors for hypernatremia include using
electrocardiographic alterations in hypokalemia. corticosteroids, having hyperaldosteronism, or having
Cushing’s syndrome.
4. Correct: 9. Correct:
A. Never administer potassium chloride through bolus (IV B. A serum sodium level of 135 to 145 mEq/L (or 135 to 145
push). Cardiac arrest may occur when potassium chloride is mmol/L) is considered normal. A serum sodium level of less
injected intravenously as a bolus. The nurse needs to ensure than 135 mEq/L (135 mmol/L) indicates hyponatremia.
that the potassium is diluted in the correct fluid or diluent. Hyperactive bowel movements indicate hyponatremia.
Incorrect: Incorrect:
B. The amount of potassium chloride in the IV bag is always A., C., and D. Hypernatremia symptoms include decreased
noted on the label. urine output, increased urine specific gravity, and tremors.
C. Potassium chloride must always be diluted with IV fluid
and infused using an infusion pump before being delivered 10. Correct:
intravenously. C. The normal serum phosphorus (phosphate) level is 3.0 to
D. During administration, the nurse closely monitors the 4.5 mg/dL (0.97 to 1.45 mmol/L). There is
urinary output and reports to the healthcare provider if it hypophosphatemia in the client. Malnutrition and using
decreases below 30 mL/hr. antacids with aluminum hydroxide or magnesium base are
contributing factors.
5. Correct: Incorrect:
D. Low parathyroid levels in hypoparathyroidism cause A., B., and D. The three leading causes of
hypocalcemia by disrupting the calcium balance.The normal hyperphosphatemia are renal insufficiency,
serum calcium is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). It is hypoparathyroidism, and tumor lysis syndrome.
known as hypocalcemia when the serum calcium level is
less than 9 mg/dL (2.25 mmol/L). Twitching is a sign of 11. Correct:
neuromuscular excitability in hypocalcemia. B. Insensible fluid losses are fluid losses that are not easily
Incorrect: measured and include fluids from the respiratory system,
A., B., and C. Hyperactive deep tendon reflexes,and a skin, and water in the excreted stool.
positive Trousseau’s or Chvostek’s sign indicate Incorrect:
hypocalcemia. Increased neuromuscular excitability, muscle A., C., and D. Sensible losses can be measured by the
cramps, twitching, tetany, seizures, irritability, and anxiety nurse, including those caused by urination, wound drainage,
are symptoms of hypocalcemia. and gastrointestinal losses.

6. Correct: 12. Correct:

B. A Crohn’s disease patient is susceptible to A. Vomiting, diarrhea, conditions that increase respiration or
hypocalcemia.The normal serum calcium is 9–10.5 mg/dL urine output, inadequate intravenous fluid replacement,
(2.25–2.75 mmol/L). Hypocalcemia manifests by a blood draining fistulas, and the presence of an ileostomy or
calcium level of less than 9 mg/dL (2.25 mmol/L). A
colostomy are among the factors that cause fluid volume
deficit.
Incorrect: 18. Correct:
B., C., and D. The most vulnerable patients to fluid volume C. The colostomy should begin working within 72 hours of
excess are those with heart failure, those taking long-term surgery, but it could take up to 5 days. Bowel sounds and
corticosteroid therapy, and those with Syndrome of flatus should be present to confirm that the peristalsis has
Inappropriate Antidiuretic Hormone (SIADH). returned.
Incorrect:
A. Absent bowel sounds indicate that peristalsis has not yet
13. Correct: returned.
D. Poor skin turgor is when the skin is pulled up and does B. A colostomy is expected not to produce bloody drainage.
not return to its original state within a few seconds. If there is D. The client would be kept on NPO (nothing by mouth) until
a wrinkle in the skin for more than 20 seconds, the patient peristalsis has returned.
has poor skin turgor. This is a late sign of dehydration or
fluid volume deficit. 19. Correct:
Incorrect: B. A new colostomy stoma will initially look red and
A., B., and C. Excessive fluid intake includes elevated blood edematous. However, this will eventually subside. After
pressure, decreased hematocrit, and congested lungs. some time, the colostomy site turns pink and should not
manifest abnormal drainage, edema, or skin collapse. The
14. Correct: nurse should record the assessment findings since this is an
D. Reduced renal function is one of the leading causes of expected finding, and there is no need for interventions.
excess fluid volume. Diabetes mellitus is complicated by Incorrect:
renal disease, which affects the body’s ability to eliminate A., C., and D. These interventions are not necessary to be
fluid and causes the patient to retain fluid. implemented.
Incorrect:
A, B, and C. Clients who use diuretics, have ileostomies, or 20. Correct:
need suctioning of their gastrointestinal tract are at risk for C. After a colostomy, the client is expected to pass foul-
fluid volume deficit. smelling flatus as peristalsis starts returning. Foul-smelling
flatus is a normal finding indicating that gastrointestinal
15. Correct: function has returned. The patient should pass feces through
B. A potassium level of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L) the colostomy within 72 hours of surgery.
is considered normal. Indicative of hyperkalemia is a blood Incorrect:
potassium level of more than 5.0 mEq/L (5.0 mmol/L). A, B, and D. These are incorrect interpretations for passing
Clients who encounter cellular shifting of potassium during foul-smelling flatus after the colostomy insertion.
the initial phases of extensive cell death, such as trauma,
burns, sepsis, or metabolic or respiratory acidosis, are at risk 21. Correct:
for hyperkalemia. D. The stoma manifests a dark, bluish, or purple appearance
Incorrect: when it is ischemic or lacks oxygenated blood supply.
A., C., and D. Hypokalemia is dangerous for clients with Incorrect:
colitis, Cushing’s syndrome, or who have abused laxatives. A. A stoma that is beefy red, and shiny is normal and
expected.
16. Correct: B. Skin excoriation must be addressed and treated, but it
A. Normal WBC counts range from 5000 to 10,000 mm3 (5 - does not need the same level of attention as purple stoma
10 x 109/L). A decrease in the quantity of WBCs in discoloration.
circulation is called immunosuppression. The nurse takes C. A semi-formed stool is expected.
neutropenic precautions when the client’s levels fall
significantly below the usual range. The policy of the 22. Correct:
healthcare institution typically determines the specific value D. Splashes of bodily secretions are possible when doing
for using neutropenic precautions. colostomy care. Goggles, a mask, or a face shield are worn
Incorrect: to protect the face and eye mucous membranes during
B., C., and D. All values are within the normal range. No procedures that could cause splashes of blood, body fluids,
intervention (such as implementing neutropenic precautions) secretions, or excretions. Additionally, gloves are necessary
is needed. for contact precautions, and a gown should be worn for
direct client contact.
17. Correct: Incorrect:
B. A normal range for platelet count is 150,000 to 400,000 A. Goggles and a mask or face shield should be worn to
mm3 (150 to 400 x 109/L). A 300,000 mm3 (300 x 109/L) protect the face and mucous membranes of the eyes.
platelet count is within the normal range. The nurse needs to B. Colostomy care necessitates wearing a gown and a
enter the report with the normal laboratory value in the mask/ face shield.
client’s medical file. C. Shoe protectors are not required.
Incorrect:
A., C., and D. These interventions are unnecessary since the 23. Correct:
platelet count falls within the normal range. Precautions C. Regardless of the type or timing of the surgery, most
against bleeding are not necessary because the count is not facilities will impose limb restrictions on anyone who has
low. undergone breast cancer surgery. These limb restrictions
are applied to clients who need to have their blood pressure
taken or have a venipuncture performed in the ipsilateral or
the same side of the affected arm.
Incorrect:
A. and B. There are no known contraindications for pulse
oximetry. A pulse oximeter comprises a microprocessor unit
and a peripheral probe. It is safe to use in all client
monitoring.
D. Taking BP on the same arm where the surgical site is not
recommended for this client. BP should be done on the
opposite arm.

24. Correct:
B. If a nurse encounters a client with tuberculosis, they
should wear a fitted particulate respirator. The nurse would
also put on gloves as part of standard precautions. The
nurse should also wear a gown when giving a bed bath since
there is a possibility that the clothing will become
contaminated.
Incorrect:
A., C., and D. A particulate respirator, gown, and gloves
should be worn.

25. Correct:
B. If they are able to sit, the client should be seated at the
edge of the bed. They are instructed to lean over the
bedside table with their feet on a stool. The client can also
be placed on the unaffected side with the head elevated 30
to 45 degrees to enable fluid drainage from the chest.
Incorrect:
A. The client should be placed on the unaffected side.
C. Prone position is not recommended for thoracentesis.
D. Sim’s position is not recommended for thoracentesis.