ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
A client on hemodialysis is complaining of muscle weakness and numbness in his legs. His lab results are: Na 136 mEq/L, K 5.9 mEq/L, Cl 100 mEq/L, ca 8.5 mg/dl. Which electrolyte imbalance is the client suffering from?
Correct Answer: A
Rationale: The client is experiencing muscle weakness and numbness in his legs, which are symptoms commonly associated with hyperkalemia (high potassium levels). The potassium level of 5.9 mEq/L is above the normal range (3.5-5.0 mEq/L), indicating hyperkalemia. Hyperkalemia can lead to muscle weakness, numbness, and potentially more severe complications like cardiac arrhythmias.
Question 2 of 5
Which of these signs suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?
Correct Answer: C
Rationale: In the context of syndrome of inappropriate antidiuretic hormone (SIADH), complications such as hyponatremia and fluid overload can lead to increased volume in the venous system, including the neck veins. Neck vein distention is a sign associated with fluid overload and can be indicative of worsening complications in a client with SIADH. Tetanic contractions are not typical manifestations of complications in SIADH. Weight loss and polyuria are not commonly associated with SIADH due to the increased water retention caused by the syndrome.
Question 3 of 5
A 40 year-old female nurse had a fecal impaction and was admitted to the hospital. The physician orders an oil retention enema followed by a cleansing enema. What is the rationale for administering the oiul enema first?
Correct Answer: B
Rationale: The rationale for administering the oil retention enema first in this case is to help soften the fecal mass and lubricate the walls of the rectum and colon. This will make it easier for the impacted stool to be passed, reducing the risk of injury or discomfort during the procedure. The oil enema acts as a lubricant, making it easier for the hardened fecal mass to be expelled from the body without causing damage to the intestinal walls. Additionally, the oil enema helps to soften the fecal mass, further aiding in its removal.
Question 4 of 5
A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client's care, the nurse should focus on his need for:
Correct Answer: C
Rationale: In a client with end-stage acquired immunodeficiency syndrome (AIDS) manifesting with profound Cryptosporidium infection, fluid replacement is crucial for managing the symptoms and complications. Cryptosporidium infection can cause severe diarrhea and dehydration, leading to significant fluid loss. Therefore, the primary focus of care in this situation should be on maintaining adequate hydration through fluid replacement. This is essential for preventing further complications and supporting the client's overall health and well-being. Pain management, antiretroviral therapy, and high-calorie intake may be important aspects of care in other situations but are not the priority in managing a client with severe Cryptosporidium infection and dehydration.
Question 5 of 5
A client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?
Correct Answer: B
Rationale: Increased urine osmolarity would best support the nursing diagnosis of Deficient fluid volume in a client with hyperglycemia. Hyperglycemia can lead to osmotic diuresis, where the body excretes excessive amounts of water to help eliminate glucose. This results in concentrated urine with a higher osmolarity. A high urine osmolarity indicates that the kidneys are conserving water due to decreased fluid volume in the body, supporting the diagnosis of Deficient fluid volume. The other assessment findings (cool, clammy skin, distended neck veins, serum sodium level) are not specific to the diagnosis of Deficient fluid volume in this context.