Question

A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia?

Answer 1

Correct Answers:

Urine specific gravity 1.001 (1.005to 1.03)

Rationale :

💧 A low urine specific gravity (below 1.005) indicates dilute urine, which can occur in hypervolemia because excess fluid intake or retention reduces urine concentration.

💧 In hypervolemia, the kidneys excrete more water, leading to low solute concentration in urine.

💧 The other values—serum calcium, serum sodium, and urine pH—are all within normal range and do not directly indicate fluid volume excess.

💧 Causes of hypervolemia include heart failure, kidney failure, excessive IV fluids, and sodium retention.

💧 Early recognition via lab findings helps prevent complications such as pulmonary edema.

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Answer 2

Correct Answers:

Diphenhydramine

Rationale :

💊 The client is showing signs of an acute dystonic reaction, a type of extrapyramidal symptom (EPS), which can occur after taking metoclopramide due to its dopamine antagonist effects.

💊 Diphenhydramine, an antihistamine with anticholinergic properties, is effective in rapidly reversing dystonia by restoring the balance between dopamine and acetylcholine in the CNS.

💊 Hydromorphone is an opioid analgesic and will not treat EPS.

💊 Albuterol sulfate is a bronchodilator for asthma or bronchospasm, unrelated to EPS.

💊 Amitriptyline is a tricyclic antidepressant and not indicated for acute dystonia.

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Answer 3

Correct Answers:

Phenytoin for seizure disorder

Rationale :

⚠️ Phenytoin is an anticonvulsant that is known to be teratogenic, meaning it can cause developmental abnormalities in the fetus if taken during pregnancy.

⚠️ Fetal hydantoin syndrome—characterized by growth deficiencies, craniofacial anomalies, and limb defects—is a documented risk with phenytoin exposure.

⚠️ While seizure control is important during pregnancy, alternative or safer anticonvulsants may be considered, and close monitoring is essential.

⚠️ Levothyroxine, magnesium oxide, and ferrous sulfate are generally considered safe during pregnancy and are often necessary for maternal health.

⚠️ Teratogenic risk is highest during the first trimester when organogenesis occurs.

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Answer 4

Correct Answers:

Administer the medication with a glass of orange juice.

Rationale :

🍊 Vitamin C in orange juice enhances the absorption of oral iron supplements like ferrous sulfate by converting ferric iron to its more absorbable ferrous form.

🍊 Iron should be given on an empty stomach if tolerated, but orange juice helps improve absorption and reduce the metallic taste.

🍊 Avoid giving iron with milk, dairy, or calcium-containing foods, as calcium can inhibit iron absorption.

🍊 Opening capsules and mixing with food may alter absorption and stain teeth; if necessary, liquid forms can be given through a straw to prevent staining.

🍊 Administering at bedtime is not necessary unless it helps with tolerance; timing should focus on maximizing absorption.

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Answer 5

Correct Answers:

Infuse 0.9% sodium chloride IV.

Rationale :

💉 A hemolytic transfusion reaction is a medical emergency caused by incompatible blood, leading to destruction of transfused red blood cells.

💉 The first step is to immediately stop the transfusion and keep the IV line open with 0.9% sodium chloride to maintain venous access and prevent clotting of the line.

💉 Normal saline is the only compatible fluid for blood transfusions; it is used to flush the line and maintain circulation while further treatment is initiated.

💉 Administering an antipyretic may help with fever but is not the priority—the transfusion must be stopped first and the line kept patent.

💉 Simply reducing the rate will not stop the reaction, and positioning changes are not relevant for treating hemolysis.

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Answer 6

Correct Answers:

Lead

Rationale :

⚠️ Older homes may have lead pipes or lead-based solder, which can leach into the water supply and cause lead poisoning.

⚠️ Lead exposure is particularly dangerous for children and pregnant women, as it can impair neurological development and cause long-term health issues.

⚠️ Testing the water for lead is a key safety measure in home hazard assessments, especially for residences built before the 1980s.

⚠️ Magnesium, potassium, and copper are naturally occurring minerals in water, and while excessive levels can cause problems, they are not the primary concern in older homes compared to lead.

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Answer 7

Correct Answers:

Magnesium 9 mEq/L (1.3 mEq/L to 2.1 mEq'L)

Rationale :

⚠️ A magnesium level of 9 mEq/L is dangerously high and indicates magnesium toxicity. This is a serious complication of magnesium sulfate therapy in preeclampsia and requires immediate provider notification.

⚠️ Signs of toxicity include loss of deep tendon reflexes, respiratory depression, hypotension, cardiac arrhythmias, and in severe cases, cardiac arrest.

⚠️ The therapeutic range for seizure prevention in preeclampsia is typically 4–7 mEq/L; anything above this increases risk for severe complications.

⚠️ A respiratory rate of 14/min and elevated blood pressure do not indicate magnesium toxicity; however, the high magnesium level is an urgent safety concern.

⚠️ Ongoing monitoring of respirations, reflexes, urine output, and serum magnesium levels is essential when administering magnesium sulfate.

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Answer 8

Correct Answers:

Serum alpha-fetoprotein levels can assist in identifying neural tube defects.

Rationale :

🧬 Serum alpha-fetoprotein (AFP) testing is a prenatal blood test typically performed between 15–20 weeks of gestation to help detect neural tube defects (e.g., spina bifida, anencephaly) and certain chromosomal abnormalities.

🧬 Elevated AFP levels may suggest open neural tube defects, while low levels may be associated with chromosomal abnormalities such as Down syndrome.

🧬 A Coombs test detects Rh incompatibility, not cystic fibrosis.

🧬 Chorionic villus sampling (CVS) is performed earlier in pregnancy, between 10–13 weeks, not at week 34.

🧬 Amniotic fluid screening (amniocentesis) can detect genetic disorders, neural tube defects, and fetal lung maturity, but not specifically “bladder anomalies.”

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Answer 9

Correct Answers:

Pertussis

Rationale :

😷 Droplet precautions are required for infections spread by large respiratory droplets that travel up to about 3 feet and are generated when a person coughs, sneezes, or talks.

😷 Pertussis (whooping cough) is a highly contagious bacterial infection transmitted through these droplets; precautions include wearing a surgical mask when within close contact and placing the client in a private room.

😷 Varicella-zoster requires airborne and contact precautions.

😷 VRE requires contact precautions because it is spread by direct and indirect contact with contaminated surfaces.

😷 Rotavirus also requires contact precautions due to its fecal–oral transmission route.

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Answer 10

Correct Answers:

Hospice care improves quality of life through palliative care.

Rationale :

🌿 Hospice care focuses on comfort, dignity, and symptom management for clients with a life expectancy of 6 months or less when curative treatment is no longer pursued.

🌿 The goal is to improve quality of life through palliative interventions, which address pain control, symptom relief, and emotional and spiritual support for both the client and family.

🌿 Hospice does not aim to postpone death; rather, it supports a natural dying process while minimizing suffering.

🌿 It does not provide continuous 24-hour in-home care, though staff are available for urgent needs and scheduled visits.

🌿 Hospice coordinates care with the family but does not expect the family alone to organize all services—this is handled by the hospice team.

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QLexNursing

1 :
A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia?

2 :
A nurse administers a dose of metoclopramide to a client prior to a chemotherapy treatment. The client develops uncontrolled contractions of the head and neck muscles. Which of the following medications should the nurse administer?

3 :
A nurse in the labor and delivery unit is reviewing medications for a group of clients. Which of the following medications places the fetus at risk for teratogenic effects?

4 :
A nurse is providing teaching to the guardian of a school-age child who has a new prescription for ferrous sulfate capsules PO. Which of the following instructions should the nurse include in the teaching?

5 :
A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform?

6 :
A nurse is performing a home hazard assessment for a client who lives in an older home. The nurse should instruct the client to have the water tested for which of the following elements?

7 :
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider?

8 :
A nurse is discussing various options for prenatal testing with a client who is at 7 weeks of gestation and has a family history of chromosomal abnormalities. Which of the following information should the nurse include?

9 :
A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?

10 :
A nurse is teaching a client and their family about home hospice care. Which of the following information should the nurse include in the teaching?

QLexNursing

1 : A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia?

2 : A nurse administers a dose of metoclopramide to a client prior to a chemotherapy treatment. The client develops uncontrolled contractions of the head and neck muscles. Which of the following medications should the nurse administer?

3 : A nurse in the labor and delivery unit is reviewing medications for a group of clients. Which of the following medications places the fetus at risk for teratogenic effects?

4 : A nurse is providing teaching to the guardian of a school-age child who has a new prescription for ferrous sulfate capsules PO. Which of the following instructions should the nurse include in the teaching?

5 : A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform?

6 : A nurse is performing a home hazard assessment for a client who lives in an older home. The nurse should instruct the client to have the water tested for which of the following elements?

7 : A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider?

8 : A nurse is discussing various options for prenatal testing with a client who is at 7 weeks of gestation and has a family history of chromosomal abnormalities. Which of the following information should the nurse include?

9 : A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?

10 : A nurse is teaching a client and their family about home hospice care. Which of the following information should the nurse include in the teaching?

1 :
A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia?

2 :
A nurse administers a dose of metoclopramide to a client prior to a chemotherapy treatment. The client develops uncontrolled contractions of the head and neck muscles. Which of the following medications should the nurse administer?

3 :
A nurse in the labor and delivery unit is reviewing medications for a group of clients. Which of the following medications places the fetus at risk for teratogenic effects?

4 :
A nurse is providing teaching to the guardian of a school-age child who has a new prescription for ferrous sulfate capsules PO. Which of the following instructions should the nurse include in the teaching?

5 :
A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform?

6 :
A nurse is performing a home hazard assessment for a client who lives in an older home. The nurse should instruct the client to have the water tested for which of the following elements?

7 :
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider?

8 :
A nurse is discussing various options for prenatal testing with a client who is at 7 weeks of gestation and has a family history of chromosomal abnormalities. Which of the following information should the nurse include?

9 :
A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?

10 :
A nurse is teaching a client and their family about home hospice care. Which of the following information should the nurse include in the teaching?