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1. What are the complications of untreated fluid overload?
- A. Pulmonary edema and congestive heart failure
- B. Hypertension and electrolyte imbalance
- C. Liver failure and electrolyte imbalance
- D. Pulmonary embolism and dehydration
Correct answer: A
Rationale: Corrected Rationale: Untreated fluid overload can lead to complications such as pulmonary edema and congestive heart failure. Pulmonary edema occurs when excess fluid accumulates in the lungs, leading to difficulty breathing and potentially life-threatening respiratory distress. Congestive heart failure can result from the heart's inability to pump effectively due to the excess fluid volume, leading to symptoms such as fatigue, shortness of breath, and fluid retention. Choices B, C, and D are incorrect because hypertension, liver failure, pulmonary embolism, and dehydration are not the primary complications directly associated with untreated fluid overload.
2. A nurse is caring for a client with an NG tube who reports nausea and a decrease in gastric secretions. What is the nurse's next step?
- A. Administer an antiemetic
- B. Irrigate the NG tube with sterile water
- C. Increase the suction setting
- D. Replace the NG tube
Correct answer: B
Rationale: The correct next step for the nurse is to irrigate the NG tube with sterile water. This action helps relieve blockages that may be causing the symptoms of nausea and decreased gastric secretions. Administering an antiemetic (Choice A) may mask the underlying issue without addressing the possible blockage. Increasing the suction setting (Choice C) is not indicated without first addressing the potential blockage. Replacing the NG tube (Choice D) is also premature before attempting to clear any obstructions.
3. A nurse at a long-term care facility is transcribing new prescriptions for four clients. Which of the following prescriptions is accurately transcribed by the nurse?
- A. KCl 10 mEq PO once daily
- B. KCl 20 mEq PO once daily
- C. Potassium gluconate PO
- D. Potassium chloride 20 mEq PO every morning
Correct answer: D
Rationale: The correct answer is D because it accurately transcribes the prescription by specifying the medication (Potassium chloride), the dose (20 mEq), the route (PO for by mouth), and the frequency (every morning). Choice A is incorrect as it specifies a lower dose compared to the correct prescription. Choice B is incorrect due to an inaccurate dose. Choice C is incorrect as it lacks specificity regarding the type of potassium prescribed and the dose.
4. A nurse is reinforcing teaching with a client about the client's recent diagnosis of multiple sclerosis. The client states, 'I am very upset and I want to be alone for a little while.' Which of the following responses should the nurse make?
- A. I see that you are feeling overwhelmed. I will come back when you are ready
- B. This is normal, and I will check on you later
- C. You are feeling frustrated. Let's talk about your concerns.
- D. You will feel better soon. Let me get you some water.
Correct answer: A
Rationale: Acknowledging the client's feelings and allowing them space demonstrates understanding and respect for their emotions.
5. A client is being taught about taking warfarin to treat atrial fibrillation. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will take this medication on an empty stomach.
- B. If I forget to take a dose, I can take it later on the same day.
- C. I will skip my dose if I forget to take it.
- D. I can take an additional dose if I miss one.
Correct answer: B
Rationale: The correct answer is B because taking warfarin later on the same day if a dose is missed helps maintain therapeutic levels. Choice A is incorrect because warfarin should be taken with food to enhance absorption. Choice C is incorrect as skipping a dose can lead to fluctuations in warfarin levels. Choice D is incorrect as taking an additional dose can increase the risk of bleeding.
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