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Questions 149

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Question 1 of 5

The nurse is obtaining a history on a 74-year-old client. Which statement made by the client would alert the nurse to a possible fluid and electrolyte imbalance?

Correct Answer: B

Rationale: Frequent laxative use can cause fluid and electrolyte losses (e.g., potassium, sodium), leading to imbalances, unlike the other statements.

Question 2 of 5

The nurse is performing discharge teaching to a client newly diagnosed with hypertension and high cholesterol. Which statement by the client indicates that the nurse's teaching was effective?

Correct Answer: B

Rationale: Substituting lean sirloin for fried chicken reduces fat and cholesterol. Canned foods, soups, and frozen dinners are often high in sodium, unsuitable for hypertension.

Question 3 of 5

The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:

Correct Answer: A

Rationale: Adequate urinary output (at least 30 mL/hr) must be confirmed before adding potassium to IV fluids to prevent hyperkalemia.

Question 4 of 5

An RN delegates patient assignments to an LPN and nursing assistant. Later, the RN overhears a nursing assistant arguing with a patient regarding a late breakfast tray. The nursing assistant begins to raise his voice as the disagreement continues. The best action from the RN is

Correct Answer: A

Rationale: Addressing the nursing assistant privately de-escalates the situation, provides coaching, and maintains professionalism without immediate escalation.

Question 5 of 5

The nurse is caring for a client receiving supplemental oxygen. The effectiveness of the oxygen therapy is best determined by:

Correct Answer: C

Rationale: Arterial blood gases provide a direct measure of oxygenation and are the most accurate way to evaluate the effectiveness of oxygen therapy.

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