Foundation Exam #5 Summer 2025 at Denver College of Nursing
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Free Foundation Exam #5 Summer 2025 at Denver College of Nursing Questions
The health care provider (HCP) asks the nurse to monitor the fluid volume status of a client diagnosed with heart failure and a second client at risk for clinical dehydration. The nurse knows that which task is the most effective nursing intervention for monitoring both of these clients?
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Assess each client's self-charting of I/Os.
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Administer extra IV fluids to both clients.
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Weigh each client every morning.
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Assess calcium levels for both clients now.
Explanation
Daily weight measurement is the most reliable and effective indicator of fluid volume status in both heart failure and dehydration. A sudden weight gain indicates fluid retention (as seen in heart failure), while weight loss suggests fluid deficit (as in dehydration). Monitoring weights at the same time each day, on the same scale, and under similar conditions provides consistent data to evaluate fluid balance accurately.
When clients use certain sleep aids, either prescribed medications or some herbal products, they most likely experience which of the following adverse effects?
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Diarrhea
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High blood pressure
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Immunosuppression
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Daytime drowsiness
Explanation
Many sleep aids, including prescription sedative-hypnotics and herbal products such as valerian root or melatonin, can cause daytime drowsiness or residual sedation as an adverse effect. These substances depress the central nervous system to promote sleep, but their effects can persist into the next day, leading to fatigue, impaired alertness, and decreased concentration. Clients should be advised to avoid driving or operating machinery until they know how the medication affects them.
A nurse is caring for a client with a potassium of 2.9 mmol/L. The nurse should anticipate the following order from the healthcare provider (HCP):
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Assess respiratory status every 2 hours.
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Perform GI/GU assessments hourly.
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Conduct neurological assessments Q2H.
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Start cardiac monitoring immediately.
Explanation
A potassium level of 2.9 mmol/L indicates hypokalemia, which can cause serious cardiac dysrhythmias due to altered electrical conduction in the heart. The nurse should anticipate an order to initiate continuous cardiac monitoring to detect arrhythmias such as premature ventricular contractions (PVCs), ventricular tachycardia, or cardiac arrest. Monitoring allows for prompt recognition and intervention if cardiac instability occurs.
Some self-care techniques that promote relaxation and stress relief that nurses can teach their clients include:
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Rest, exercise, and spending time with friends and family
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Staying up all night
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Drinking caffeine in the evening
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Working as much as possible
Explanation
Healthy self-care techniques such as getting adequate rest, engaging in regular exercise, and maintaining social connections are proven ways to reduce stress and promote overall well-being. These activities support both physical and emotional health, lower stress hormone levels, and improve resilience. Teaching clients these habits helps them develop long-term coping strategies for relaxation and balance.
When teaching a client, it would be ideal for the nurse to ensure the following for an optimal teaching environment: Select all that apply. One, some, or all options may be correct.
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A well-lit space
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An area free of distractions
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In the cafeteria
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Meeting at the nurse’s station to talk
Explanation
A student nurse is working on a busy medical/surgical floor. When asked by the client how much fluid the client should be taking daily, the student nurse knows the correct answer would be:
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3000 mL daily
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2300 mL daily
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1800 mL daily
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1000 mL daily
Explanation
The average adult requires about 2300 mL (2.3 liters) of fluid per day to maintain proper hydration and support normal physiological functions such as circulation, temperature regulation, and waste elimination. Fluid needs may vary depending on age, activity level, and health status, but 2 to 3 liters daily is the general guideline for healthy adults without fluid restrictions.
A nurse is taking care of a 24-year-old client. The client exhibits signs of muscle weakness and paralysis through the day. The nurse suspects which complication?
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Drowsiness
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Narcolepsy
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Sleep apnea
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Cataplexy
Explanation
Cataplexy is a sudden and temporary episode of muscle weakness or paralysis triggered by strong emotions such as laughter, anger, or surprise. It is often associated with narcolepsy, a sleep disorder that causes excessive daytime sleepiness. During cataplexy, the client remains conscious but unable to move, and muscle tone is suddenly lost. The nurse should assess for additional symptoms of narcolepsy and ensure safety during these episodes.
A nurse on a medical/surgical floor is caring for a client with admitted sleep issues. When providing client education, the nurse should explain that a normal sleep cycle has ________ complete cycles of REM and NREM sleep per night.
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0–1
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7–9
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1–2
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4–5
Explanation
A normal sleep cycle consists of alternating periods of non-rapid eye movement (NREM) and rapid eye movement (REM) sleep. Each cycle lasts approximately 90 to 110 minutes, and most adults experience 4 to 5 complete cycles per night, depending on total sleep time. These cycles are essential for physical restoration (NREM) and mental and emotional recovery (REM).
A client with fluid volume deficit has oxygen saturation level of 90%, serum sodium of 142 mEq/L, serum chloride 106 mEq/L, serum magnesium 2.2 mg/dL, albumin 4 g/dL, AST 30 U/L, and serum potassium of 2.9 mEq/L from daily labs. The nurse reports to the healthcare provider her assessment and lab findings. Which laboratory result is critical and should the nurse have the HCP repeat back?
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Chloride 106 mEq/L
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Magnesium 2.2 mg/dL
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Potassium 2.9 mEq/L
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Sodium 142 mEq/L
Explanation
A potassium level of 2.9 mEq/L indicates hypokalemia, which is a critical electrolyte imbalance. Potassium is essential for cardiac electrical conduction and muscle contraction. Low levels can cause life-threatening arrhythmias, muscle weakness, and respiratory compromise. This finding must be reported immediately, and the nurse should have the provider repeat back the value to confirm understanding and ensure prompt intervention, such as potassium replacement and cardiac monitoring.
Which of the following scenarios demonstrate that client learning has taken place?
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A client listens to a nurse's review of the warning signs of a stroke.
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A client demonstrates how to take his blood pressure at home.
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A client reviews written information about resources for cancer survivors.
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A client attends a spinal cord injury support group.
Explanation
Learning is demonstrated by a change in behavior or the application of knowledge. When the client demonstrates how to take his blood pressure at home, it shows that he has not only received information but also understood and applied it correctly, reflecting effective teaching and learning. Psychomotor skill demonstration is a clear, observable indicator that learning has occurred.
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