480 Exam 1
(detailed & elaborated)
QUESTIONS AND VERIFIED
CORRECT ANSWERS
GRADED A+ LATEST 100%
GUARANTEED PASS
The nurse is assessing a client with viral meningitis. Which of the following findings would the
nurse expect to observe? Select all that apply.
Nausea
Vomiting
Piloerection
Bradycardia
Photophobia- - CORRECT ANSWER-Nausea
Vomiting
Piloerection- goose bumps
Bradycardia- usually will see increase in HR (tachy)
Photophobia- headache will make bright light hurt (increase seizures, brain swelling, increased
ICP)
In a patient with prolonged vomiting, the nurse monitors for fluid volume deficit because
vomiting results in
Fluid movement from the cells into the interstitial spaces and the blood vessels
Excretion of large amounts of interstitial fluid with depletion of extracellular fluids
,An overload of extracellular fluid with a significant increase in intracellular fluid volume
Fluid movement from the vascular system into the cells, causing cellular swelling and rupture -
CORRECT ANSWER-Excretion of large amounts of interstitial fluid with depletion of extracellular
fluids
A client with Crohn's disease has concentrated urine; decreased urinary output; dry skin with
decreased turgor; hypotension; and weak, thready pulses. The nurse should do which of the
following first?
Encourage the cline to drink at lease 1000ml/day
Provide parenteral rehydration therapy prescribed by the physician
Turn and reposition every 2 hours
Monitor vital signs every shift - CORRECT ANSWER-Provide parenteral rehydration therapy
prescribed by the physician
* in severe fluid volume deficit
A client has been admitted to the unit for treatment of dehydration. During the initial meeting
of the client and nurse, which nursing action is most appropriate?
Establish the outcomes of hospitalization for the client
Evaluate the clients response to treatment thus far
Tell the client that the provider will explain what to expect in the hospital
Determine preliminary client needs upon discharge - CORRECT ANSWER-Establish the outcomes
of hospitalization for the client
Evaluate the clients response to treatment thus far - last part of ADPIE
Tell the client that the provider will explain what to expect in the hospital- will never happen
Determine preliminary client needs upon discharge- shouldn't be worried about discharge yet
The nurse is caring for a client with multiple myeloma who is receiving intravenous hydration at
100 mL/hr. Which finding indicates a positive response to the treatment plan?
Creatinine of 1.0mg/dL
, Weight increase of 1 kilogram
White blood cell count of 6000/mm3
Respirations of 18 breath per/min - CORRECT ANSWER-Creatinine of 1.0mg/dL
Weight increase of 1 kilogram- pt. would not have that much of an increase in weight (should
only have a ¼ increase kg)
White blood cell count of 6000/mm3- nothing to do with hydration (focus on what the question
is asking)
Respirations of 18 breath per/min- not a way to test fluid
The nurse is assessing a client with heart failure who is receiving home health care monitoring
using electronic devices including scales, blood pressure monitoring. The nurse reviews the data
obtained within the last 3 days. The nurse calls the client to follow up. The nurse should ask the
client which of the following first: ***photo showing increase weight of 5lbs in three days**
How are you feeling today
Are you having shortness of breath
Did you calibrate the scales before using them
How much fluid did you drink during the last 24 hours - CORRECT ANSWER-How are you feeling
today
Are you having shortness of breath- HF patient (1st sign) can't sleep lying down @ night
Did you calibrate the scales before using them
How much fluid did you drink during the last 24 hours
Lasix (furosemide) 40 mg intravenous push (IVP) is prescribed. Lasix 10 mg/mL is available. The
nurse should administer _______mL - CORRECT ANSWER-40/10=
4mL
Cramps when potassium is decreased- furosemide is a loop diuretic (excretes potassium)
A nurse on a medical-surgical unit is caring for a group of clients. For which of the following
clients should the nurse anticipate a prescription for fluid restriction?
(detailed & elaborated)
QUESTIONS AND VERIFIED
CORRECT ANSWERS
GRADED A+ LATEST 100%
GUARANTEED PASS
The nurse is assessing a client with viral meningitis. Which of the following findings would the
nurse expect to observe? Select all that apply.
Nausea
Vomiting
Piloerection
Bradycardia
Photophobia- - CORRECT ANSWER-Nausea
Vomiting
Piloerection- goose bumps
Bradycardia- usually will see increase in HR (tachy)
Photophobia- headache will make bright light hurt (increase seizures, brain swelling, increased
ICP)
In a patient with prolonged vomiting, the nurse monitors for fluid volume deficit because
vomiting results in
Fluid movement from the cells into the interstitial spaces and the blood vessels
Excretion of large amounts of interstitial fluid with depletion of extracellular fluids
,An overload of extracellular fluid with a significant increase in intracellular fluid volume
Fluid movement from the vascular system into the cells, causing cellular swelling and rupture -
CORRECT ANSWER-Excretion of large amounts of interstitial fluid with depletion of extracellular
fluids
A client with Crohn's disease has concentrated urine; decreased urinary output; dry skin with
decreased turgor; hypotension; and weak, thready pulses. The nurse should do which of the
following first?
Encourage the cline to drink at lease 1000ml/day
Provide parenteral rehydration therapy prescribed by the physician
Turn and reposition every 2 hours
Monitor vital signs every shift - CORRECT ANSWER-Provide parenteral rehydration therapy
prescribed by the physician
* in severe fluid volume deficit
A client has been admitted to the unit for treatment of dehydration. During the initial meeting
of the client and nurse, which nursing action is most appropriate?
Establish the outcomes of hospitalization for the client
Evaluate the clients response to treatment thus far
Tell the client that the provider will explain what to expect in the hospital
Determine preliminary client needs upon discharge - CORRECT ANSWER-Establish the outcomes
of hospitalization for the client
Evaluate the clients response to treatment thus far - last part of ADPIE
Tell the client that the provider will explain what to expect in the hospital- will never happen
Determine preliminary client needs upon discharge- shouldn't be worried about discharge yet
The nurse is caring for a client with multiple myeloma who is receiving intravenous hydration at
100 mL/hr. Which finding indicates a positive response to the treatment plan?
Creatinine of 1.0mg/dL
, Weight increase of 1 kilogram
White blood cell count of 6000/mm3
Respirations of 18 breath per/min - CORRECT ANSWER-Creatinine of 1.0mg/dL
Weight increase of 1 kilogram- pt. would not have that much of an increase in weight (should
only have a ¼ increase kg)
White blood cell count of 6000/mm3- nothing to do with hydration (focus on what the question
is asking)
Respirations of 18 breath per/min- not a way to test fluid
The nurse is assessing a client with heart failure who is receiving home health care monitoring
using electronic devices including scales, blood pressure monitoring. The nurse reviews the data
obtained within the last 3 days. The nurse calls the client to follow up. The nurse should ask the
client which of the following first: ***photo showing increase weight of 5lbs in three days**
How are you feeling today
Are you having shortness of breath
Did you calibrate the scales before using them
How much fluid did you drink during the last 24 hours - CORRECT ANSWER-How are you feeling
today
Are you having shortness of breath- HF patient (1st sign) can't sleep lying down @ night
Did you calibrate the scales before using them
How much fluid did you drink during the last 24 hours
Lasix (furosemide) 40 mg intravenous push (IVP) is prescribed. Lasix 10 mg/mL is available. The
nurse should administer _______mL - CORRECT ANSWER-40/10=
4mL
Cramps when potassium is decreased- furosemide is a loop diuretic (excretes potassium)
A nurse on a medical-surgical unit is caring for a group of clients. For which of the following
clients should the nurse anticipate a prescription for fluid restriction?
