Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 52
Question 1
Type: MCSA
The 154-pound adult client has had vomiting and diarrhea for 4 days secondary to a viral infection. What hourly
urine measurement would indicate that efforts to rehydrate this client have not yet been successful and should
continue?
1. 35 mL per hour
2. 80 mL per hour
3. 50 mL per hour
4. 30 mL per hour
Type: MCSA
The nurse suspects that a client’s body is attempting to correct an acid–base imbalance. How will this imbalance
be corrected?
1. Slow but efficient respiratory regulation will occur.
2. Primary regulation is through GI system losses.
3. Kidney regulation is powerfully effective.
4. The cardiovascular system is the major buffer.
Question 3
Type: MCSA
The nurse is caring for a client who is recovering from surgery. Which intervention should the nurse implement to
decrease the client’s possibility of developing hypercalcemia?
1. Measure vital signs every 4 hours.
2. Assist the client to turn, cough, and deep breathe every 2 hours.
3. Assist the client to ambulate around the room at least three times daily.
4. Irrigate the client’s nasogastric tube every 2 hours.
Question 4
Type: MCSA
The client is admitted to the acute care unit with a phosphorus level of 2.3 mg/dL. Which nursing intervention
would support this client’s homeostasis?
1. Encourage consumption of milk and yogurt.
2. Enforce strict isolation protocols.
3. Encourage consumption of a high-calorie carbohydrate diet.
4. Strain all urine.
Question 5
Type: MCSA
The mother of a 1-month-old infant is concerned because the infant has had vomiting and diarrhea for 2 days.
What instruction should the nurse give this infant’s mother?
1. Have the infant be seen by a physician
2. Give the infant at least 2 ounces of juice every 2 hours.
3. Measure the infant’s urine output for 24 hours.
4. Provide the infant with 50 mL of glucose water.
Question 6
Type: MCSA
A client has had a subclavian central venous catheter inserted. What should the nurse assess as a priority for this
client’s care?
1. Presence of bibasilar crackles
2. Tachycardia
3. Decreased pedal pulses
4. Headache
Question 7
Type: MCSA
The nurse is caring for a client who is receiving intravenous fluids that are not regulated on an electronic
controller. In order to calculate the rate of the IV flow in drops per minute, the nurse must know the number of
drops per milliliter of fluid the tubing delivers. Where should the nurse look for this information?
1. On the packaging of the tubing
2. In the charting from the nurse who started the infusion
3. In the drug reference book
4. On the roller clamp of the tubing
Question 8
Type: FIB
The physician has ordered 50 mL of an IV solution to infuse over the next 20 minutes. In order to accurately
infuse this solution, the nurse should set the electronic controller to deliver how many mL/hr?
Standard Text: Record your answer, rounding to the nearest whole number.
Question 9
Type: FIB
The nurse is to administer 75 mL of an antibiotic solution by IV over the next 30 minutes. The tubing has a drop
factor of 20. How many drops per minute should the nurse set the controller to deliver?
Standard Text: Record your answer, rounding to the nearest whole number.
Question 10
Type: MCSA
The nurse is caring for a client who is receiving IV therapy at a rate of 10 mL/hour. The 500-mL IV bottle was
hung at 0900 Monday morning when the IV catheter was initiated. It is now 0900 on Tuesday morning. What
nursing action should be taken?
1. Refigure the rate of the IV.
2. Infuse the remaining IV fluid before hanging a new bag.
3. Discard the remaining IV fluid and hang a new bag.
4. Discontinue the IV site and restart an IV in the opposite hand.
Question 11
Type: MCSA
A client tells the nurse about passing out after following a fasting diet for 5 days. Which acid–base imbalance
should the nurse expect to assess in this client?
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
Question 12
Type: MCSA
A client is admitted to the hospital after vomiting for 3 days. Which arterial blood gas results should the nurse
expect to find in this client?
1. pH 7.30; PaCO2 50; HCO3 27
2. pH 7.47; PaCO2 43; HCO3 28
3. pH 7.43; PaCO2 50; HCO3 28
4. pH 7.47; PaCO2 30; HCO3 23
Question 13
Type: MCSA
The client’s arterial blood gas report reveals a pH of 6.58. How does the nurse evaluate this value?
1. There is a slight elevation.
2. This value is incompatible with life.
3. This is a low normal value.
4. This value is extremely elevated.
Question 14
Type: MCSA
A client has experienced a narcotic overdose. What acid–base imbalance should the nurse expect to observe in
this client?
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
Question 15
Type: MCSA
Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client complains of a
headache. The nurse assesses that the client has slight shortness of breath and feels warm to the touch. What
action by the nurse is priority?
1. Notify the client’s physician.
2. Discontinue the transfusion.
3. Slow the rate of the transfusion.
4. Prepare to resuscitate the client.
Question 16
Type: MCSA
A client on diuretic therapy has a serum potassium level of 3.4 mg/dL. Which food should the nurse encourage
this client to choose from the dinner menu?
1. Baked chicken
2. Green beans
3. Cantaloupe
4. Iced tea
Question 17
Type: MCSA
A client has orders for the administration of IV fluid at a “keep vein open” rate in preparation for administration
of IV antibiotics starting at noon. When the nurse goes to the room to start the IV, the UAP is preparing to bathe
the client. What should the nurse do?
1. Instruct the UAP to wait until the IV is started to bathe the client.
2. Let the UAP start the bath on the opposite side of where the nurse will be starting the IV.
3. Tell the UAP to notify the nurse as soon as the bath is completed.
4. Give the UAP permission to skip the client’s bath for today.
Question 18
Type: MCSA
The nurse is preparing to start an IV in the hand of a client who has very small veins. Which actions would be
useful in dilating the veins?
1. Position the hand at heart level.
2. Stroke the vein.
3. Have the client clench and unclench the fist.
4. Slap the back of the client’s hand.
5. Massage the vein.