Title RECALLS 13 - NP4 - KEY ✅

1-5. Situation. Nurse Kim cares for a 40-year-old male with electrolyte imbalance. On assessment, the nurse observes the client to be confused, restless and lethargic. 1. Nurse Kim carries out the order for the client to have a diagnostic test. Which of the following values indicate hyponatremia? A sodium level _____ A. Below 8.5 to 10.5 mg/dL B. Between 3.5 and 5.5 mEgL C. Above 145 mEg/L D. Below 135 mEg/L 2. Nurse Kim is aware that the MOST common electrolyte abnormality in hospitalized patient is ______ A. Hyperkalemia B. Hyponatremia C. Hypernatremia D. Hypokalemia 3. Nurse Kim writes a nursing diagnosis. Which of the following diagnoses is MOST appropriate for the client? A. Excess Fluid Volume B. Ineffective Breathing Pattern C. Deficient Fluid Volume D. Disturbed Thought Processes 4. The physician prescribes intravenous solutions for the client. Which of the following solutions is appropriate? A. 0.9 % Sodium Chloride B. Dextran 6 % in sterile water C. 0.3 % Sodium Chloride D. Dextrose 5 % in water 5. An appropriate nursing intervention for the client is for Nurse Kim to________ A. Maintain body alignment and assist with movement B. Monitor level of consciousness C. Administer oral hygiene D. Monitor laboratory findings 6-10. Situation. The nurse cares for a group of clients with allergies. 6. The nurse assesses the client who says he is highly allergic to many food items and medications. Which of the following hypersensitivity reactions would be responsible for this type of clinical manifestation? A. Type 4, delayed sensitivity B. Type 1, IgE mediated hypersensitivity C. Type 2, cytotoxic hypersensitivity D. Type 3, immune complex-mediated hypersensitivity 7. The nurse assesses an atopic client who had serious Type 1 hypersensitivity reactions. The nurse is aware that the most severe form of a Type 1 hypersensitivity reaction is which of the following conditions? A. Cell-mediated sensitivity B. Dermatitis C. Anaphylaxis D. Bronchial asthma 8. A client is experiencing anaphylaxis. Which of the following actions by the nurse takes HIGHEST priority? A. Administer epinephrine injection B. Place the client in Trendelenburg position C. Maintain an open airway D. Administer emergency oxygen 9. The nurse develops a care plan for a client with a past history of anaphylaxis. Which drug should the nurse instruct the client to always have it readily available to treat possible allergic reaction? A. Diphenhydramine B. Acetaminophen C. Epinephrine D. Acetyl Salicylic Acid 10. A client with a history of Type 1 hypersensitivity reaction is receiving immunotherapy. The nurse administers the allergen injection and asks the client to wait for how many minutes so that the immediate reactions can be treated? A. 5 – 15 minutes B. 30 – 40 minutes C. 60 minutes D. 15 – 25 minutes 11-15. Situation. Nurse Em cares for a 30 year old male who suffered a spinal cord injury sustained in a sporting accident which resulted in paraplegia. The following questions relate to the care of a client with a paraplegia. 11.The client is fortunate that the level of his injury did not affect his respiratory function. The nurse understands that the cord segments involved in maintaining respiratory function are: A. C1-2 B. C3-4 C. C5 D. C6 12. Nurse Em understands that the LEAST effective method of preventing contractures of the joints of the lower extremities would be to: A. Passively move the extremities through range of motion exercises. B. Provide the client with active exercise instructions. C. Maintain proper alignment in bed. D. Change the client’s position every two hours. 13. Nurse Em plans care for the client which includes turning the client every two hours. This nursing measure is necessary to: 1 | Page