Question 1 of 5

A nurse is reviewing the medical records of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess.

A. Urine specific gravity 1.015B. Hematocrit 42%C. Urine pH 6.5D. BUN 5 mg/dL

Correct Answer: D

Rationale: A urine specific gravity of 1.015 is within the normal range (1.005-1.030). While fluid volume excess may lead to a lower specific gravity due to urine dilution, this value does not indicate fluid overload and is considered normal. A hematocrit level of 42% is within the normal range for adults (men: 38-50%, women: 35-45%). Hematocrit levels tend to decrease in fluid volume excess due to hemodilution, but this value does not suggest fluid overload. A urine pH of 6.5 is within the normal range (4.5-8.0). Urine pH reflects the acid-base balance rather than fluid status and is not a reliable indicator of fluid volume excess. A BUN level of 5 mg/dL is below the normal range (10-20 mg/dL). In fluid volume excess, the dilution of blood plasma can lead to decreased BUN levels. This low BUN value, in conjunction with clinical symptoms, supports the diagnosis of fluid volume excess.

Question 2 of 5

A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client?

A. Nasal cannulaB. Simple face maskC. Venturi maskD. Nonrebreather mask

Correct Answer: D

Rationale: A nasal cannula provides a low to moderate concentration of oxygen and is not suitable for a client experiencing severe difficulty breathing. A simple face mask provides a higher concentration of oxygen than a nasal cannula but may not deliver a high enough concentration for a client experiencing severe respiratory distress. A Venturi mask can provide a precise and adjustable concentration of oxygen but may not deliver the highest concentration needed in this scenario. A nonrebreather mask can deliver the highest concentration of oxygen (up to 100%) and is the most appropriate choice for a client experiencing severe difficulty breathing.

Question 3 of 5

A nurse is calculating the intake and output for a client over the last 8 hr. The client is receiving a continuous IV infusion at 150 mL/hr and had 4 oz of juice and 0.5 L of water. How many mL of fluid should the nurse document as the client’s intake for the last 8 hr? (Round your answer to the nearest whole number.)

Correct Answer: 1820 mL

Rationale: 1. IV fluids: 150 mL/hr * 8 hr = 1200 mL. 2. Juice: 4 oz * 30 mL/oz = 120 mL. 3. Water: 0.5 L * 1000 mL/L = 500 mL.
Total intake: 1200 mL + 120 mL + 500 mL = 1820 mL.

Question 4 of 5

A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider?

A. The client has smooth, brown, irregular lesions on the back of each hand.B. The client has glossy, white arches around the periphery of the corneas.C. The client reports urinary incontinence.D. The client reports a decreased sense of taste.

Correct Answer: C

Rationale: The client has smooth, brown, irregular lesions on the back of each hand - These are likely seborrheic keratoses, which are benign, age-related lesions and do not usually require reporting unless changes suggest malignancy. The presence of glossy, white arches around the periphery of the corneas is a normal finding, known as arcus senilis, which is commonly seen in older adults and not typically a cause for concern. The client reports urinary incontinence - Urinary incontinence can be a sign of underlying issues such as a urinary tract infection or neurological disorder, necessitating further evaluation by the provider. A decreased sense of taste is a common age-related change and may not require immediate reporting unless it is associated with other symptoms or significant nutritional issues.

Question 5 of 5

A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take?

A. Explain the negative consequences of the refusal.B. Discuss with the client’s partner why the treatment is necessary.C. Document the client’s refusal of the treatment.D. Try to convince the client that the treatment is needed.

Correct Answer: C

Rationale: While explaining the negative consequences of refusal is important, it may not change the client’s decision, and respect for the client’s autonomy must be upheld. Discussing the treatment with the client’s partner without the client’s consent may breach patient confidentiality and privacy. Correct. The nurse should document the client’s refusal of the medical treatment in the client’s medical record. This documentation is essential for legal and ethical purposes and to ensure that the refusal is adequately communicated to the healthcare team. Trying to convince the client to undergo the treatment is not appropriate and may violate the principle of informed consent. The client has the right to refuse treatment after being adequately informed of the risks and benefits.