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Worksheets1111 exam 5 outcome.1
Total questions: 99
Worksheet time: 52mins
Which finding indicates circulatory overload?
Decreased blood pressure
Crackles in the lungs
Slow heart rate
Warm, dry skin
Which assessment finding should the nurse report for suspected fluid overload?
Jugular vein distention
Flat neck veins
Sunken eyes
Dry mucous membranes
Which client statement supports fluid volume overload?
I feel dizzy when I stand up.
My mouth feels dry.
I have swelling in my ankles.
I’m always thirsty.
Which task can be safely delegated to an assistive personnel (AP)?
Obtaining vital signs for a stable postoperative client
Teaching use of an incentive spirometer
Assessing pain level
Evaluating IV site
The nurse can delegate which activity to an AP?
Administering an enema to an unstable client
Assisting with ambulation after surgery
Assessing a dressing
Explaining a diet
Which action must the nurse perform, not the AP?
Evaluating effectiveness of pain medication
Measuring urine output
Making a bed
Obtaining weight
Which finding is expected with paralytic ileus?
Hyperactive bowel sounds
Absent bowel sounds
Frequent stools
Active peristalsis
Which intervention is priority for paralytic ileus?
Maintain NPO status and insert NG tube
Increase oral fluids
Administer laxatives
Encourage ambulation only
Which diagnostic test confirms paralytic ileus?
CT brain scan
Abdominal x-ray
Chest x-ray
Colonoscopy
The nurse should take which action for a malfunctioning electrical pump?
Attempt repair
Remove it and tag for inspection
Continue use if minor issue
Cover the cord with tape
To prevent electrical shock, the nurse should:
Plug cords into extension outlets
Use grounded electrical outlets
Overload sockets
Pull cords to disconnect
Which finding requires removing electrical equipment from service?
Frayed or exposed wires
Slight discoloration
Label missing
Long cord length
Which food is highest in calcium?
Apples
Chicken breast
Yogurt
Rice
Which statement shows correct understanding of calcium intake?
I will include more dairy and leafy greens.
I will drink more soda.
I will cut down on milk.
I will avoid fish.
The nurse teaches that calcium absorption improves with:
Vitamin D intake
Low sodium intake
Vitamin C
Fiber supplements
Which client is most at risk for wound dehiscence?
A. A 22-year-old with appendectomy
B. An obese client after abdominal surgery
C. A 40-year-old with ankle sprain
D. A young adult with mild burn
Which postoperative practice increases dehiscence risk?
Which postoperative practice increases dehiscence risk?
Coughing forcefully without splinting
Wearing an abdominal binder
Using an incentive spirometer
Adequate protein intake
Which lab finding increases risk for wound separation?
Sodium 140 mEq/L
Albumin 2.8 g/dL
Potassium 4.0 mEq/L
Calcium 9.5 mg/dL
What is the nurse’s priority during the first hour after surgery?
Assess airway and breathing
Assess urine output
Measure temperature
Inspect incision
Which nursing action prevents DVT post-surgery?
Elevate head of bed
Encourage leg exercises
Restrict fluids
Keep bed flat
Which finding requires immediate intervention?
Mild nausea
Small amount of drainage
O₂ saturation of 85%
Pain 4/10
Kayexalate is prescribed for which condition?
Hypokalemia
Hyponatremia
Hyperkalemia
Hypercalcemia
What should the nurse monitor for after giving kayexalate?
Frequent loose stools
Constipation
Decreased bowel sounds
Bradycardia
Which finding shows effectiveness of kayexalate?
Potassium 6.2 mEq/L
Potassium 4.0 mEq/L
Sodium 136 mEq/L
Calcium 9.0 mg/dL
Which adverse effect may occur from excess calcium?
Diarrhea
Hypotension
Which adverse effect may occur from excess calcium?
Diarrhea
Hypotension
Constipation
Hypocalcemia
Which client statement indicates a side effect of calcium supplements?
I feel dizzy when I stand.
I bruise easily.
I’m having frequent kidney stones.
My vision is blurry.
Which medication increases risk for hypercalcemia when taken with calcium?
Iron
Thiazide diuretics
Loop diuretics
Beta blockers
Which vitamin deficiency is most associated with chronic alcohol use?
Vitamin D
Thiamine (B1)
Vitamin E
Vitamin K
Which withdrawal symptom requires immediate attention?
Tremors and hallucinations
Nausea
Mild anxiety
Insomnia
Which intervention promotes recovery in alcohol use disorder?
Administer caffeine
Refer to Alcoholics Anonymous
Encourage isolation
Limit nutrition
Which statement demonstrates correct understanding of diffusion?
“It’s the movement of molecules from high to low concentration.”
“It’s the pumping of ions using energy.”
“It’s water movement only.”
“It’s passive filtration.”
Which body process uses diffusion?
Blood clotting
Gas exchange in alveoli
Peristalsis
Active transport
Which factor affects diffusion rate?
pH levels only
Membrane thickness
Blood pressure only
Which ECG finding indicates hypokalemia?
Peaked T waves
Prolonged PR interval
Flattened T waves
Short QT interval
Which clinical sign suggests low potassium?
Muscle twitching
Weak, irregular pulse
Rapid respirations
Hypertension
The nurse expects which finding in hypokalemia?
Muscle weakness and leg cramps
Tremors
Hyperreflexia
Sweating
Which action should the nurse take first before starting an IV infusion?
Verify provider’s prescription
Choose the largest catheter available
Ask AP to start IV
Apply sterile gloves
The nurse should select which vein for adult IV initiation?
Femoral
Neck
Dorsal hand or forearm
Foot
Which solution requires the nurse to check for infiltration most frequently?
Isotonic
Hypertonic
Hypotonic
Dextrose
During a continuous IV infusion, which nursing action is essential?
Measure blood glucose every hour
Monitor infusion rate and site condition regularly
Flush IV every 30 minutes
Apply warm compress to site
Which sign indicates an air embolism during IV therapy?
Sudden shortness of breath and chest pain
Low-grade fever
Bradycardia
Local redness at site
What is the priority nursing action for suspected air embolism?
Start chest compressions
Elevate client’s legs
Place client on left side in Trendelenburg position
Administer oral fluids
Which finding is a complication of spinal anesthesia?
Severe headache from CSF leak
Fever and chills
Hyperglycemia
Constipation
The nurse recognizes which symptom as spinal anesthesia complication?
Restlessness
Vomiting
Hypotension and bradycardia
Hypertension
Which nursing action minimizes post-spinal headache?
Ambulate immediately
Encourage supine position and fluids
Limit fluid intake
Apply ice to incision
Which complication may occur with central venous catheter placement?
Urinary retention
Pneumothorax
Hypoglycemia
Constipation
Which finding indicates a problem with a central line?
Clear, dry dressing
Stable oxygen level
Swelling or pain at insertion site
Clean connections
To prevent catheter-related infection, the nurse should:
Use sterile technique for dressing changes
Replace line weekly
Avoid flushing line
Use tap water
Which factor increases risk for surgical complications?
Regular exercise
Balanced diet
Smoking history
Normal BMI
Which client condition poses increased perioperative risk?
Diabetes mellitus
Iron deficiency
Lactose intolerance
Nearsightedness
The nurse identifies which as a surgical risk factor?
Age 25, healthy
Normal labs
Obesity and hypertension
Stable vital signs
A client receives 250 mL IV fluid over 4 hours. How many mL per hour should the pump deliver?
50 mL/hr
63 mL/hr
70 mL/hr
80 mL/hr
If a client receives 1,000 mL of fluid over 8 hours, what is the hourly rate?
100 mL/hr
125 mL/hr
75 mL/hr
90 mL/hr
How much total intake is recorded for 6 hours if the client drinks 480 mL and receives 600 mL IV?
900 mL
950 mL
1,080 mL
1,000 mL
Which instruction is appropriate for a client scheduled for a colonoscopy?
You may eat a light breakfast the morning of your test.
You will be on clear liquids and take a bowel prep before the procedure.
You will need to fast for 48 hours.
Avoid walking after the test.
Which finding requires notifying the provider before colonoscopy?
Active rectal bleeding
Mild nausea
Anxiety about procedure
Past appendectomy
Which action is appropriate after colonoscopy?
Begin solid diet immediately
Encourage bed rest
Monitor for signs of perforation
Remove IV immediately
The nurse recognizes which postoperative complication risk for a client who smokes?
Hypokalemia
Constipation
Delayed wound healing
Hyperglycemia
A nurse should prioritize which intervention for a post-op smoker?
Encourage sugar intake
Restrict fluids
Monitor oxygen saturation closely
Limit ambulation
Smoking increases a client’s risk for which complication?
A. Respiratory depression after anesthesia
B. High blood calcium
C. Low platelet count
D. Hypothermia
When administering oral potassium supplements, which action is correct?
Give on empty stomach
Crush before giving
Administer with full glass of water
Skip if client has nausea
Which route is used for severe hypokalemia requiring rapid replacement?
Oral
Subcutaneous
Intravenous (diluted)
Topical
What is a safe nursing action for IV potassium administration?
Use infusion pump and never give as IV bolus
Push IV quickly for immediate effect
Mix with antibiotics
Inject into muscle
Which instruction should be included when teaching about DVT prevention?
Limit leg movement
Cross legs often
Perform ankle flexion exercises
Avoid fluids
Which finding suggests deep vein thrombosis?
Pallor and cold skin
Calf pain and warmth
Equal leg size
No pulse changes
Which medication helps prevent DVT after surgery?
Acetaminophen
Enoxaparin
Ibuprofen
Vitamin D
Which instruction should the nurse give for using an incentive spirometer?
Inhale slowly and hold breath for 3–5 seconds
Exhale forcefully into the device
Use once daily
Sit flat in bed
Which statement indicates correct understanding of incentive spirometry?
It helps lower my blood pressure.
It clears my throat.
It prevents pneumonia after surgery.
It measures my oxygen level.
The nurse teaches that the client should use an incentive spirometer how often?
Once daily
10 times every hour while awake
Every 4 hours
Only before meals
The nurse knows the antidote for magnesium sulfate toxicity is:
Vitamin K
Calcium gluconate
Potassium chloride
Sodium phosphate
Which finding indicates magnesium sulfate toxicity?
Depressed deep tendon reflexes
Hypertension
Restlessness
Tachycardia
Which intervention should the nurse anticipate for magnesium toxicity?
Increase magnesium dose
Restrict fluids
Stop infusion and administer calcium gluconate
Apply warm compresses
Which nursing action ensures accuracy when calculating IV intake?
Record all oral fluids only
Include all IV fluids and piggybacks administered
Count irrigation fluids only
Exclude flushes
A client received 500 mL normal saline and 250 mL antibiotics. How much intake should be documented?
500 mL
750 mL
600 mL
800 mL
Which should the nurse do when documenting IV fluid intake?
Record total volume on intake/output sheet every shift
Record intake only at end of day
Estimate hourly rate
Combine oral and IV volumes together without separation
When planning preoperative care, which instruction should be given?
Eat breakfast before surgery
Wear jewelry to surgery
Remove nail polish and makeup
Continue all home medications
The nurse includes which point in preoperative teaching?
Demonstrate deep-breathing and coughing exercises
Restrict all fluids for 24 hours
Avoid explaining procedure
Omit incentive spirometer teaching
Which teaching should the nurse provide preoperatively?
Ambulate every 8 hours post-op
Avoid any leg movements
Perform leg and ankle exercises frequently
Expect to remain in bed for 2 days
Which finding indicates wound dehiscence postoperatively?
Sudden opening of the incision with drainage
Mild redness around edges
Slight pain at site
Intact staples with no drainage
What should the nurse do first if wound dehiscence occurs?
Remove sutures
Cover with sterile saline-soaked dressing
Apply dry gauze
Tape wound closed
Which client is at highest risk for dehiscence?
Obese client after abdominal surgery
Child after tonsillectomy
Elderly client after cataract surgery
Adult after dental procedure
Which food is the best dietary source of potassium?
White rice
Bananas
Cheese
Applesauce
The nurse should teach which statement about potassium?
Potassium keeps my blood sugar normal.
Potassium helps my muscles contract and heart beat regularly.
It builds strong bones.
It controls my temperature.
Which condition increases potassium loss?
Kidney failure
Diuretic therapy
Hypovolemia
Increased sodium intake
Which nursing action is essential during continuous IV infusion?
Check IV site and infusion rate every hour
Add medications without orders
Allow air bubbles to enter line
Flush only once per shift
When regulating an IV pump, the nurse should:
Ensure the roller clamp is open and monitor flow rate closely
Let gravity control flow
Keep pump alarms off
Ignore air-in-line warnings
Which client statement shows understanding of continuous IV therapy?
It will run until my pain goes away.
I can disconnect the line for a walk.
The nurse will check the site frequently for swelling or redness.
I can adjust the pump if it beeps.
What is the first action when a client develops air embolism signs?
Notify the physician only
Sit client upright
Turn client on left side and lower head of bed
Increase IV rate
Which symptom indicates air embolism during infusion?
Dyspnea, tachycardia, and hypotension
Fever and chills
Local swelling
Slow respirations
Which measure prevents air embolism in central line removal?
Have client cough repeatedly
Instruct client to perform Valsalva maneuver during removal
Remove during inspiration
Clamp line after removal
Which finding indicates complication of spinal anesthesia?
Numbness at incision site
Persistent headache and back pain
Normal reflexes
Stable blood pressure
What should the nurse monitor closely after spinal anesthesia?
Skin turgor
Pupil size
Blood pressure and sensation level
Bowel sounds
Which nursing action helps prevent spinal anesthesia complications?
Encourage client to remain flat for several hours
Ambulate immediately
Restrict fluids
Avoid monitoring vitals
Which complication can result from central venous catheter use?
Hypertension
Catheter-related bloodstream infection
Hypoglycemia
Hypernatremia
Which assessment finding after central line insertion is most concerning?
Cough
Sudden shortness of breath
Clear breath sounds
Slight bruising
To prevent central line infection, the nurse should:
Change transparent dressing every 7 days or when damp
Use clean gloves for insertion
Flush with tap water
Avoid hand hygiene
Which factor increases the client’s risk for surgical complications?
Advanced age and obesity
Stable vital signs
Balanced nutrition
Limited medication use
