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WorksheetsReady, Set, 70!
Total questions: 70
Worksheet time: 38mins
Which assessment finding indicates that dehydration is progressing to hypovolemic shock?
Warm, flushed skin and bounding pulses
BP 88/54 mm Hg with delayed capillary refill
Bradycardia with increased urine output
Moist mucous membranes and clear lung sounds
Daniel Reed, a 45-year-old male, is admitted with severe diarrhea for three days. He reports weakness, confusion, and muscle cramps.
• Labs: ↓K⁺, ↓Ca²⁺, ↑Na⁺, ↓HCO₃⁻ Which assessment finding requires the nurse’s immediate intervention?
Irregular heart rhythm on ECG
Muscle cramping in the lower extremities
Mild confusion and dry mucous membranes
Serum sodium of 148 mEq/L
The patient has hypoxia and a fluid volume deficit
which action should the nurse take first?
Administer isotonic IV fluids
Place patient on 2 L/min oxygen via nasal cannula
Assess electrolyte levels
Obtain urine output
Which ECG change would the nurse anticipate due to a patient's low potassium?
Shortened QT interval
Flattened T waves and presence of U waves
Peaked T waves
ST-segment elevation
Which finding best indicates the need for cardiac monitoring?
Serum sodium of 150 mEq/L
SpO₂ 92% on 2 L oxygenr
Respiratory rate of 28/min
Serum potassium of 3.0 mEq/L
What electrolyte imbalance is most associated with confusion, seizures and coma
Hyponatremia
Hyperkalemia
Hypocalcemia
Hypercalcemia
What electrolyte imbalance is most commonly associated with muscle weakness, cramps, arrhythmias and metabolic alkalosis?
Hyperkalemia
Hypernatremia
Hypokalemia
Hypophosphatemia
All of the following symptoms can be seen in both hypokalemia and hypercalcemia except:
Fatigue
Muscle weakness
Diarrhea
Arrythmias
Both hypernatremia and hyponatremia primarily cause which of the following clinical manifestations?
Bradycardia and hypotension
A) Muscle weakness and arrhythmias
Confusion, irritability, and seizures
Increased bowel motility and diarrhea
What condition does this patient have?
Uncompensated respiratory acidosis
Compensated respiratory acidosis
Uncompensated metabolic acidosis
Compensated metabolic acidosis
What acid-base imbalance does this patient have?
Compensated metabolic alkalosis
Uncompensated metabolic alkalosis
Compensated respiratory alkalosis
Uncompensated respiratory alkalosis
Which client statement reflects understanding of HAART adherence teaching?
“If I miss a dose, I’ll take two the next day to catch up.”
“Taking my medications at the same time daily helps prevent resistance.”
“Stopping the drugs occasionally will help my body rest.”
“If I feel better, I can take a break from the medications.”
Both hypocalcemia and hypercalcemia affect the QT interval. Which of the following statements are true? (Select all that apply)
Hypocalcemia prolongs the QT interval.
Hypercalcemia shortens the QT interval.
Both hypocalcemia and hypercalcemia increase the risk of cardiac arrhythmias
Hypocalcemia shortens the QT interval.
Hypercalcemia can lead to ventricular arrhythmias.
Which assessment finding would alert the nurse to progression toward anaphylaxis in this client?
Mild pruritus around the mouth
Increasing throat tightness and hoarse voice
Nasal congestion and watery eyes
Transient abdominal cramping
Maria Lopez experiences oral itching and throat tightness after eating fruit salad. Which instruction should the nurse prioritize?
“Avoid kiwi, banana, and avocado since they can cross-react with latex.”
“Carry an oral antihistamine for future mild allergic symptoms.”
“You can safely consume fruits if cooked or blended.”
“Latex reactions do not usually involve foods, so no dietary changes are needed.”
After administering epinephrine, which nursing assessment finding would indicate the most effective response for a patient with anaphylaxis?
Rationale: Improved oxygen saturation shows successful reversal of bronchoconstriction. Mild tachycardia is expected; hypotension would signal ongoing anaphylaxis.
Heart rate increases to 110 bpm
Skin becomes flushed and warm
Oxygen saturation rises from 86% to 95%
Blood pressure remains 84/48 mm Hg
After eating peanuts, James Carter develops wheezing, hives, and hypotension. What is the priority nursing action?
Administer oxygen and prepare for intubation
Place the patient supine with legs elevated
Give IM epinephrine in the mid-anterolateral thigh
Administer IV diphenhydramine for histamine blockade
Hypotension and rapid breathing in a neutropenic patient with fever most likely indicate (a) .
David Kim has an ANC of 350. Which statement by the client indicates a need for further teaching?
“I’ll check my temperature every 4 hours and report anything above 100.4°F.”
“I’ll avoid crowds and anyone with colds or infections.”
“I can take aspirin if I develop a mild fever.”
“I’ll wash my hands before eating or touching my face.”
Q2. Which finding shows ART effectiveness?
HIV is eradicated
A decreasing CD4 count
A stable or increased CD4 count
A positive HIV antibody test
Which statement by David’s parents demonstrates a correct understanding of IVIG therapy?
“This treatment helps his body make antibodies for future infections.”
“The antibodies he’s receiving will protect him temporarily.”
“He won’t need vaccines after this treatment.”
“IVIG will permanently strengthen his immune system.”
Which room assignment is most appropriate for Maria Lopez who is on neutropenic precautions?
Semi-private room with curtain
Shared room with another neutropenic client
Private room with closed door
An isolation room with no visitors permitted
A neutropenic client has a temperature of 101.8. Which action should the nurse take first?
r
Administer acetaminophen for fever
Notify the provider and obtain ordered cultures
Begin oral hydration
Reassess temperature in one hour
Which statement by the client shows correct understanding of neutropenic precautions?
“I should avoid brushing my teeth.”
“I’ll avoid gardening and use stool softeners if needed.”
"I should wash my hands before meals"
"I should eat fresh salad and soft cheese"
Q2. Which preventive strategy will help to reduce asthma exacerbations?
Limiting exercise
Staying current on vaccinations
Avoiding exposure to fresh air
Using daily albuterol doses
Sarah reports using her albuterol inhaler several times daily. Which nursing action is priority?
Document use as “effective self-management.”
Assess for poor asthma control and need for maintenance therapy.
Encourage increasing inhaler use as needed.
Notify the provider to increase albuterol dose.
Which finding indicates progression from COPD to cor pulmonale?
Rationale: JVD and edema reflect systemic venous congestion from right-sided heart failure secondary to COPD.
Barrel chest
Clubbing of fingers
Jugular vein distention and peripheral edema
D. Dyspnea on exertion
Which assessment findings suggest the need to increase a patient’s fluid intake? (Select all that apply.)
Thick, tenacious sputum and dry oral mucosa
Decreased urine output and concentrated urine
Brisk capillary refill and JVD
Hypotension and tachycardia
Flat neck veins when the patient is supine
Linda refuses her influenza vaccine, stating she “never gets sick.” Which nursing response demonstrates therapeutic communication?
“Vaccines are required for COPD patients.”
Let’s discuss how vaccines can prevent COPD flare-ups.”
“Skipping vaccines increases your infection risk.”
D. “You should reconsider because it is for your health”
The nurse should question which order for a client with pneumonia?
Obtain sputum culture before antibiotics
Administer acetaminophen for fever
Start antibiotics immediately after cultures
Collect sputum after the first antibiotic dose
Which finding most strongly suggests hypoxia related to pneumonia?
Wheezing on auscultation
Confusion and disorientation
Crackles in the lower lobes
Fever and tachypnea
Mark is using accessory muscles, signaling increased respiratory effort and severe oxygen deprivation. Which nursing actions have the highest priority? (Select all that apply.)
Apply oxygen as prescribed and assess the patient’s response.
Elevate the head of the bed to promote lung expansion.
Stay with the patient and closely monitor respiratory status.
Prepare to obtain arterial blood gases (ABGs) to evaluate oxygenation and ventilation.
Administer an opioid to reduce anxiety and respiratory effort.
Which finding after sputum collection requires immediate follow-up?
Productive cough and thick yellow sputum
Hypoxia and absent breath sounds on one side
Rhonchi breath sound
Patient reports fatigue
Which symptom indicates early hypoxia rather than late?
=
Cyanosis
Bradypnea
Agitation
Coma
The nurse recognizes that diarrhea causes acidosis primarily through loss of:
Hydrogen ions
Bicarbonate ions
Potassium ions
Sodium ions
The patient has receive oxygen for hypoxemia. Which outcome best indicates improvement?
PaO₂ increased to 90 mmHg
pH decreased to 7.28
CO₂ increased to 50 mmHg
Oxygen saturation at 88%
Which clinical finding supports partial respiratory compensation for metabolic acidosis?
Rationale: The body hyperventilates to expel CO₂, compensating for metabolic acidosis.
Slow, shallow respirations
Rapid, deep respirations
Normal respiratory pattern
Irregular, gasping respirations
Which ABG pattern confirms partial compensation?
pH normal, low CO₂, low HCO₃⁻
pH low, low CO₂, low HCO₃⁻
pH high, high CO₂, normal HCO₃⁻
pH normal, normal CO₂, low HCO₃⁻
What is the primary reason hypokalemia occurs in metabolic alkalosis?
Potassium shifts out of cells and into the blood
Potassium shifts into cells
Increased renal potassium retention
Excessive dietary potassium intake
Which ECG finding requires related to metabolic alkalosis and potassium loss requires immediate intervention?
Flat T waves
Shortened PR interval
Prolonged QT interval
Sinus bradycardia
Which food choice shows effective understanding of potassium-rich foods?
Baked potato with skin
White rice
Applesauce
Cottage cheese
Which sign best confirms hypermagnesemia in a patient with adrenal insufficiency?
Hyperreflexia
Tachycardia
Decreased deep tendon reflexes
Muscle twitching and irritability
Which medication would reverse the effects of severe hypermagnesemia?
Potassium chloride
Calcium gluconate
Sodium bicarbonate
Magnesium sulfate
Which intervention prevents a dangerous complication during sodium correction in a patient with hypernatremia?
Rapid administration of hypotonic fluids
Gradual reduction of serum sodium
Encouraging sodium-rich foods
Avoiding all IV fluids
What is the physiologic cause of seizure risk in hypernatremia?
Neuronal swelling due to low sodium
Myelin sheath destruction
Increased potassium in cerebrospinal fluid
Brain cell shrinkage due to water loss
Which IV fluid order should the nurse question for a client with hypernatremia and seizure risk?
0.9% Normal saline
0.45% Normal saline
D5W (5% dextrose in water)
Oral water intake as tolerated
Which finding indicates hypocalcemia rather than hypercalcemia?
Bone pain
Dysrhythmias
Hyperreflexia
Dehydration
A patient who recently underwent a thyroidectomy has developed stridor. The nurse recognizes this may result from parathyroid gland damage leading to hypocalcemia. What is the nurse’s priority action?
Document the findings
Administer oral calcium
Prepare emergency airway equipment
Encourage deep breathing
A patient with hypercalcemia is at risk for ventricular arrhythmias due to a shortened QT interval. Which of the following nursing interventions are appropriate to prevent cardiac complications? (Select all that apply.)
Initiate IV isotonic fluid therapy
Monitor cardiac rhythm continuously
Encourage strict bedrest to reduce cardiac workload
Prepare to administer IV calcium gluconate if ordered
Restrict oral fluid intake to prevent overload
Which physiological alteration causes the symptoms of perioral tingling and positive Trousseau’s and Chvostek’s signs?
Decreased neuromuscular excitability
Increased neuromuscular excitability
Depressed central nervous system activity
Reduced sympathetic tone
Which meal choice indicates effective patient teaching about hypercalcemia diet?
Grilled salmon with spinach
Tofu with almond topping
Chicken salad with apple slices
Yogurt parfait with fortified cereal
Why is maintaining adequate hydration crucial in managing hypercalcemia?
It helps flush excess calcium through the kidneys.
It prevents gastrointestinal absorption of calcium.
It decreases bone resorption
It neutralizes calcium ions.
Which assessment finding would require prompt re-evaluation of a treatment plan for a patient with hypercalcemia?
Fatigue
Nausea and vomiting
Increased thirst
Mild constipation
Which finding best reflects effective treatment of a client with hypervolemia?
Persistent orthopnea
Decreasing serum osmolality
Rising serum osmolality
Stable weight but persistent edema
When monitoring a client for pulmonary edema, which assessment requires immediate intervention?
Weight gain
Fatigue with activity
Crackles at lung bases and new shortness of breath
Which laboratory trend would indicate worsening fluid volume excess in Karen Mitchell?
Rising hematocrit and BUN
Increasing serum sodium
Decreasing urine specific gravity
Elevated blood osmolality
Which order should be carried out first for a patient with pneumonia and hypoxia?
Administer IV antibiotics
Collect sputum culture
Apply oxygen therapy
Administer acetaminophen
Which parameter best reflects improved fluid volume status?
Rising blood pressure and improved perfusion
Clear lung sounds
Decreased temperature
Improved appetite
A patient presents with hypovolemia and low potassium levels. Which nursing action should be questioned?
Obtain blood cultures
Initiate isotonic fluid bolus
Administer spironolactone
Place on seizure precautions
Which electrolyte imbalance poses the greatest cardiac risk?
Hypernatremia
Hypocalcemia
Hypokalemia
Hypomagnesemia
Which lab result aligns with fluid volume excess?
Decreased serum osmolarity
Increased hematocrit
Increased BUN
Elevated sodium
Which assessment findings and laboratory results indicate fluid volume deficit? (Select all that apply)
Hypotension and weak peripheral pulses
Urine output <30 mL/hr
Elevated blood urea nitrogen (BUN) and hematocrit
E. Jugular vein distention
Decreased serum sodium
Which finding requires immediate nursing intervention in a client with fluid volume deficit?
Skin tenting
Fever 100.1 °F
BP 88/54 mm Hg and confusion
Dry mucous membranes
Which of the following parameters best indicate a client’s cardiac recovery? (Select all that apply)
Clear lung sounds without crackles
Consistent urine output greater than 30 mL/hr
Decreasing peripheral edema
Tachycardia
Rising BP
Which finding warrants immediate intervention post-MI?
Mild anxiety
Crackles in lung bases
140/90 mm Hg
Heart rate 88 bpm
A patient with dilutional hyponatremia is receiving care. Which healthcare provider order should the nurse question?
Daily weights to monitor fluid status
0.45% normal saline IV
Furosemide 40 mg PO
Sodium restriction in the diet
Which nursing action is most important for a client with hyponatremia risk?
Restrict sodium intake
Implement seizure precautions
Offer hypotonic fluids
Limit repositioning to conserve energy
Which lab result supports fluid volume deficit?
Sodium 130 mEq/L
BUN 25 mg/dL and hematocrit 50%
Serum osmolarity 270 mOsm/kg
Urine specific gravity 1.005
Which parameter best evaluates antibiotic effectiveness?
CRP
White blood cell count and temperature
Urine output
Heart rate
The nurse prepares IV potassium chloride. Which statement demonstrates safe practice?
Administer IV push at 10 mEq/min
Dilute in 10 mL normal saline
Infuse via pump using piggyback line
Administer via central line
