level 4 nursing theory final questions with complete solutions
A 27-yr-old patient admitted with diabetic ketoacidosis (DKA)
has a serum glucose level of 732 mg/dL and serum potassium
level of 3.1 mEq/L. Which action prescribed by the health care
provider should the nurse take first? Correct Answers Place the
patient on a cardiac monitor.
A massive gastrointestinal bleed has resulted in hypovolemic
shock in an older patient. What is a priority nursing diagnosis?
a. Impaired Skin Integrity
b. Acute Pain
c. Ineffective tissue perfusion
d. Decreased Cardiac Output Correct Answers c. Ineffective
tissue perfusion
A nurse is caring for a patient with second- and third-degree
burns to 50% of the body. The nurse prepares fluid resuscitation
based on knowledge of the Parkland (Baxter) formula that
includes which recommendation?
a. One third of the total 24-hour fluid requirement should be
administered in the first 4 hours.
b. One half of the total 24-hour fluid requirement should be
administered in the first 8 hours.
c. The total 24-hour fluid requirement should be administered in
the first 8 hours.
d. One half of the total 24-hour fluid requirement should be
administered in the first 4 hours Correct Answers b. One half of
the total 24-hour fluid requirement should be administered in the
first 8 hours.
,A nurse is learning how to manage patients with substance abuse
disorders. Which step should the nurse apply as a first-line
intervention in such cases?
a. Providing safety and sleep
b. Secluding the patients
c. Sedating the patients
d. Encouraging strenuous activities Correct Answers a.
Providing safety and sleep
A patient admitted with heart failure is anxious and reports
shortness of breath. Which nursing actions would be appropriate
to alleviate this patient's anxiety (select all that apply.)?
a. Administer ordered morphine sulfate.
b. Position patient in a semi-Fowler's position.
c. Position patient on left side with head of bed flat.
d. Instruct patient on the use of relaxation techniques.
e. Use a calm, reassuring approach while talking to patient.
f. Tripod positioning prn Correct Answers a. Administer
ordered morphine sulfate.
b. Position patient in a semi-Fowler's position.
d. Instruct patient on the use of relaxation techniques.
e. Use a calm, reassuring approach while talking to patient.
f. tripod positioning prn
A patient has anemia related to inadequate intake of essential
nutrients. Which intervention would be appropriate for the nurse
to include in the plan of care for this patient?
, a. Give the patient a list of medications that inhibit iron
absorption.
b. Instruct the patient to select soft, bland, and nonacidic foods.
c. Plan for 30 minutes of rest before and after every meal.
d. Encourage foods high in protein, iron, vitamin C, and folate.
Correct Answers d. Encourage foods high in protein, iron,
vitamin C, and folate.
A patient is sitting up in bed and talking while the bedside
electrocardiogram tracing shows a rhythm that looks like
tombstones ( /\/\/\/\/\/\/\/\/\/\/\ )Which action would the nurse take
first?
a. Perform rapid defibrillation
b. Palpate for a pulse
c. Check patients blood pressure
d. Perform CPR Correct Answers b. Palpate for a pulse
A patient states " I feel tired all the time and am having trouble
doing activities of daily living". The patient has an irregular
heart rate around 120 bpm. What rhythm is the nurse
anticipating on the EKG?
a. Asystole
b. Atrial Fibrillation
c. Sinus Bradycardia
d. Ventricular Fibrillation Correct Answers b. Atrial Fibrillation
* IRREGULAR *
* 90 - 120 *
A 27-yr-old patient admitted with diabetic ketoacidosis (DKA)
has a serum glucose level of 732 mg/dL and serum potassium
level of 3.1 mEq/L. Which action prescribed by the health care
provider should the nurse take first? Correct Answers Place the
patient on a cardiac monitor.
A massive gastrointestinal bleed has resulted in hypovolemic
shock in an older patient. What is a priority nursing diagnosis?
a. Impaired Skin Integrity
b. Acute Pain
c. Ineffective tissue perfusion
d. Decreased Cardiac Output Correct Answers c. Ineffective
tissue perfusion
A nurse is caring for a patient with second- and third-degree
burns to 50% of the body. The nurse prepares fluid resuscitation
based on knowledge of the Parkland (Baxter) formula that
includes which recommendation?
a. One third of the total 24-hour fluid requirement should be
administered in the first 4 hours.
b. One half of the total 24-hour fluid requirement should be
administered in the first 8 hours.
c. The total 24-hour fluid requirement should be administered in
the first 8 hours.
d. One half of the total 24-hour fluid requirement should be
administered in the first 4 hours Correct Answers b. One half of
the total 24-hour fluid requirement should be administered in the
first 8 hours.
,A nurse is learning how to manage patients with substance abuse
disorders. Which step should the nurse apply as a first-line
intervention in such cases?
a. Providing safety and sleep
b. Secluding the patients
c. Sedating the patients
d. Encouraging strenuous activities Correct Answers a.
Providing safety and sleep
A patient admitted with heart failure is anxious and reports
shortness of breath. Which nursing actions would be appropriate
to alleviate this patient's anxiety (select all that apply.)?
a. Administer ordered morphine sulfate.
b. Position patient in a semi-Fowler's position.
c. Position patient on left side with head of bed flat.
d. Instruct patient on the use of relaxation techniques.
e. Use a calm, reassuring approach while talking to patient.
f. Tripod positioning prn Correct Answers a. Administer
ordered morphine sulfate.
b. Position patient in a semi-Fowler's position.
d. Instruct patient on the use of relaxation techniques.
e. Use a calm, reassuring approach while talking to patient.
f. tripod positioning prn
A patient has anemia related to inadequate intake of essential
nutrients. Which intervention would be appropriate for the nurse
to include in the plan of care for this patient?
, a. Give the patient a list of medications that inhibit iron
absorption.
b. Instruct the patient to select soft, bland, and nonacidic foods.
c. Plan for 30 minutes of rest before and after every meal.
d. Encourage foods high in protein, iron, vitamin C, and folate.
Correct Answers d. Encourage foods high in protein, iron,
vitamin C, and folate.
A patient is sitting up in bed and talking while the bedside
electrocardiogram tracing shows a rhythm that looks like
tombstones ( /\/\/\/\/\/\/\/\/\/\/\ )Which action would the nurse take
first?
a. Perform rapid defibrillation
b. Palpate for a pulse
c. Check patients blood pressure
d. Perform CPR Correct Answers b. Palpate for a pulse
A patient states " I feel tired all the time and am having trouble
doing activities of daily living". The patient has an irregular
heart rate around 120 bpm. What rhythm is the nurse
anticipating on the EKG?
a. Asystole
b. Atrial Fibrillation
c. Sinus Bradycardia
d. Ventricular Fibrillation Correct Answers b. Atrial Fibrillation
* IRREGULAR *
* 90 - 120 *
