WCU FINAL EXAM (NURS 100)
QUESTIONS WITH CORRECT
ANSWERS
What are some fluid volume deficits that can lead to hypovolemic shock? - Answer-
Vomiting, NG tube suction, diarrhea, diabetes inspidius, kidney disease, adrenal
insufficiency, hemorrhage, hyperventilation, prolonged fever, enteral feedings w/o
sufficent water intake
What are some clinical manifestations that present with FVD? - Answer-
Hypothermia/hyperthermia, tachycardia, thready pulse, hypotension, hypoxia,
tachypnea, dizziness, syncope, thirst, dry mucous membranes, vomiting, oliguria, acute
weight loss, diminishes capillary refill, clammy skin, sunken eyeballs, flattened neck
veins, decreased skin turgor
OLIGURIA - Answer- Less than 400ml of urine output in a 24 hr period
ANURIA - Answer- Less than 100ml of urine per hour in a 24 hour period
What kind of patients will we see anuria in? - Answer- Renal patients
What is the urine specific gravity range? - Answer- 1.010-1.030
BUN, creatinine, and urine specific gravity labs will tell us? - Answer- If the kidneys are
functioning properly
A doctor orders a BUN and creatinine lab to determine if the patient is dehydrated, a
urine specific lab will confirm what? - Answer- Dehydration
Acidosis - Answer- ph<7.35
CO2>45
HCO3<22
Alkalosis - Answer- ph>7.45
CO2<35
HCO3>26
Fully compensated - Answer- if pH is normal, then ABG is
Partially compensated - Answer- If all 3 values in ABG is abnormal then it is
,Uncompensated - Answer- If paCO2 or HCO3 is normal and the other is abnormal, then
the ABG is
Metabolic - Answer- If pH and HCO3 are in the same category, then the ABG is
Respiratory - Answer- if pH and paCO2 are in the same category, then the ABG is
Aspiration - Answer- The most important consideration when managing a patient with
swallowing difficulty
136-145 mEq/L is the therapeutic range for which electrolyte? - Answer- Sodium
3.5-5 mEq/L is the therapeutic range for which electrolyte? - Answer- Potassium
9-10.5 mg/dl is the therapeutic range for which electrolyte? - Answer- Calcium
1.3-1.2 mEq/L is the therapeutic range for which electrolyte? - Answer- Magnesium
What are the nursing interventions for patients who are suffering from hyponatremia? -
Answer- restrict water intake, administer hypertonic soln, monitor I&O's
Incontinence
Stress Incontinence
Functional Incontinence
Urge Incontinence
Overflow Incontinence
Total (reflex) Incontinence - Answer- loss of voluntary control of urination
leakage when coughing, sneezing, or increased intra-abdominal pressure
inability to get to toilet in time or inability to recognize need to urinate
inability to delay need to urinate
retention with leakage that exceeds bladder capacity
complete lack of control over urination
Enuresis
Frequency
,Dysuria
Noctura
Hesistancy
Retention
Urgency
Neurogenic - Answer- incontinence in child after toilet control expected
voiding too often but normal total amounts
difficulty or painful urination
frequency that occurs during sleeping hours
delay or problem starting urinary stream
inability to empty bladder
need to void without ability to hold or delay
bladder-nervous system damage0.l
Surgical Asepsis - Answer- Sterile technique; practices that render & keep objects &
areas free from microorganisms
Surgical classifications: Urgent - Answer- Must be done within a reasonably short time
frame to preserve health, but is not an emergency.
Surgicale Classification- elective - Answer- Procedure that is preplanned & based on
the patient's choice & availability of scheduling for the patient, surgeon, & facility; Non-
urgent; does not have to be done immediately
Surgical Classification -emergent - Answer- Must be done immediately to preserve life,
a body part, or function
Catheter Urine Specimen procedure - Answer- •Collect from specimen port on drainage
tubing
•Cleanse with alcohol & use sterile syringe to pull out urine
•Collect urine only from upper tubing, never from drainage bag
•Urinalysis - collect 30 mL; Culture & Sensitivity (C&S) - collect 10 mL
•Label & send specimen to lab within 30 min. or refrigerate until sent
, Timed specimen collections (24-hour specimen): - Answer- Timed specimen collections
(24-hour specimen):
•obtain correct container & preservative or ice if needed
•Instruct patient/family about collection
•Begin with empty bladder, end with empty bladder
-Have patient void before beginning
-Have patient void & add to collection at end of test
•Keep all urine for designated time frame
Clean Catch Specimen Collection - Answer- -collected during midstream
-first small amount of urine voided helps to flush away any organisms near the meatus
-urine voided at midstream is most characteristic of urine body is producing
-patient voids & discards a small amount of urine; continues voiding in a sterile
specimen container; stops voiding into container; removes container & continues
voiding; then discards the last amount of urine in the bladder
What are some clinical manifestations of hyponatremia? - Answer- Hypothermia,
tachycardia, thready pulse, hypotension, confusion, seizures, coma, decreased deep
tendon reflex
What are some clinical manifestations that present with hypernatremia? - Answer-
Hyperthermia, tachycardia, orthostatic hypotension, muscle twitching, muscle
weakness, dry mouth, absent deep tendon reflex
What are some nursing interventions for patients suffering from hypernatremia? -
Answer- Monitor level of consciousness, provide oral care, I&O's encourage water
intake and discourage sodium intake, diuretics, administer hypotonic soln
Whenever we see a potassium imbalance we are thinking which organ is being
affected? - Answer- Heart
What is an adverse effect for taking furosemide (loop diuretic) to treat hyperkalemia? -
Answer- Use to treat hyperkalemia but can cause HYPOKALEMIA
Nursing intervention for potassium imbalance? - Answer- Cardiac monitoring
What are some risks involved with hypocalcemia? - Answer- Chronic diarrhea,
malabsorption syndromes (chron's disease)
What are some clinical manifestations that present with hypocalcemia? - Answer-
Numbness, tingling, hyperactive deep tendon reflex, positive chvostek's sign (tapping on
facial nerve and triggering a twitch), positive trousseau sign (blood pressure cuff causes
hand to contract), seizures
QUESTIONS WITH CORRECT
ANSWERS
What are some fluid volume deficits that can lead to hypovolemic shock? - Answer-
Vomiting, NG tube suction, diarrhea, diabetes inspidius, kidney disease, adrenal
insufficiency, hemorrhage, hyperventilation, prolonged fever, enteral feedings w/o
sufficent water intake
What are some clinical manifestations that present with FVD? - Answer-
Hypothermia/hyperthermia, tachycardia, thready pulse, hypotension, hypoxia,
tachypnea, dizziness, syncope, thirst, dry mucous membranes, vomiting, oliguria, acute
weight loss, diminishes capillary refill, clammy skin, sunken eyeballs, flattened neck
veins, decreased skin turgor
OLIGURIA - Answer- Less than 400ml of urine output in a 24 hr period
ANURIA - Answer- Less than 100ml of urine per hour in a 24 hour period
What kind of patients will we see anuria in? - Answer- Renal patients
What is the urine specific gravity range? - Answer- 1.010-1.030
BUN, creatinine, and urine specific gravity labs will tell us? - Answer- If the kidneys are
functioning properly
A doctor orders a BUN and creatinine lab to determine if the patient is dehydrated, a
urine specific lab will confirm what? - Answer- Dehydration
Acidosis - Answer- ph<7.35
CO2>45
HCO3<22
Alkalosis - Answer- ph>7.45
CO2<35
HCO3>26
Fully compensated - Answer- if pH is normal, then ABG is
Partially compensated - Answer- If all 3 values in ABG is abnormal then it is
,Uncompensated - Answer- If paCO2 or HCO3 is normal and the other is abnormal, then
the ABG is
Metabolic - Answer- If pH and HCO3 are in the same category, then the ABG is
Respiratory - Answer- if pH and paCO2 are in the same category, then the ABG is
Aspiration - Answer- The most important consideration when managing a patient with
swallowing difficulty
136-145 mEq/L is the therapeutic range for which electrolyte? - Answer- Sodium
3.5-5 mEq/L is the therapeutic range for which electrolyte? - Answer- Potassium
9-10.5 mg/dl is the therapeutic range for which electrolyte? - Answer- Calcium
1.3-1.2 mEq/L is the therapeutic range for which electrolyte? - Answer- Magnesium
What are the nursing interventions for patients who are suffering from hyponatremia? -
Answer- restrict water intake, administer hypertonic soln, monitor I&O's
Incontinence
Stress Incontinence
Functional Incontinence
Urge Incontinence
Overflow Incontinence
Total (reflex) Incontinence - Answer- loss of voluntary control of urination
leakage when coughing, sneezing, or increased intra-abdominal pressure
inability to get to toilet in time or inability to recognize need to urinate
inability to delay need to urinate
retention with leakage that exceeds bladder capacity
complete lack of control over urination
Enuresis
Frequency
,Dysuria
Noctura
Hesistancy
Retention
Urgency
Neurogenic - Answer- incontinence in child after toilet control expected
voiding too often but normal total amounts
difficulty or painful urination
frequency that occurs during sleeping hours
delay or problem starting urinary stream
inability to empty bladder
need to void without ability to hold or delay
bladder-nervous system damage0.l
Surgical Asepsis - Answer- Sterile technique; practices that render & keep objects &
areas free from microorganisms
Surgical classifications: Urgent - Answer- Must be done within a reasonably short time
frame to preserve health, but is not an emergency.
Surgicale Classification- elective - Answer- Procedure that is preplanned & based on
the patient's choice & availability of scheduling for the patient, surgeon, & facility; Non-
urgent; does not have to be done immediately
Surgical Classification -emergent - Answer- Must be done immediately to preserve life,
a body part, or function
Catheter Urine Specimen procedure - Answer- •Collect from specimen port on drainage
tubing
•Cleanse with alcohol & use sterile syringe to pull out urine
•Collect urine only from upper tubing, never from drainage bag
•Urinalysis - collect 30 mL; Culture & Sensitivity (C&S) - collect 10 mL
•Label & send specimen to lab within 30 min. or refrigerate until sent
, Timed specimen collections (24-hour specimen): - Answer- Timed specimen collections
(24-hour specimen):
•obtain correct container & preservative or ice if needed
•Instruct patient/family about collection
•Begin with empty bladder, end with empty bladder
-Have patient void before beginning
-Have patient void & add to collection at end of test
•Keep all urine for designated time frame
Clean Catch Specimen Collection - Answer- -collected during midstream
-first small amount of urine voided helps to flush away any organisms near the meatus
-urine voided at midstream is most characteristic of urine body is producing
-patient voids & discards a small amount of urine; continues voiding in a sterile
specimen container; stops voiding into container; removes container & continues
voiding; then discards the last amount of urine in the bladder
What are some clinical manifestations of hyponatremia? - Answer- Hypothermia,
tachycardia, thready pulse, hypotension, confusion, seizures, coma, decreased deep
tendon reflex
What are some clinical manifestations that present with hypernatremia? - Answer-
Hyperthermia, tachycardia, orthostatic hypotension, muscle twitching, muscle
weakness, dry mouth, absent deep tendon reflex
What are some nursing interventions for patients suffering from hypernatremia? -
Answer- Monitor level of consciousness, provide oral care, I&O's encourage water
intake and discourage sodium intake, diuretics, administer hypotonic soln
Whenever we see a potassium imbalance we are thinking which organ is being
affected? - Answer- Heart
What is an adverse effect for taking furosemide (loop diuretic) to treat hyperkalemia? -
Answer- Use to treat hyperkalemia but can cause HYPOKALEMIA
Nursing intervention for potassium imbalance? - Answer- Cardiac monitoring
What are some risks involved with hypocalcemia? - Answer- Chronic diarrhea,
malabsorption syndromes (chron's disease)
What are some clinical manifestations that present with hypocalcemia? - Answer-
Numbness, tingling, hyperactive deep tendon reflex, positive chvostek's sign (tapping on
facial nerve and triggering a twitch), positive trousseau sign (blood pressure cuff causes
hand to contract), seizures
