NU 211: Exam 3 questions well
answered graded A+ (latest update)
You are the nurse assessing a patient. What are some signs of excess fluid volume
(hypervolemia) - correct answer ✔✔edema/ascites, crackles in the lungs, pale, cool skin,
elevated blood pressure, bounding pulse
What med will help with fluid volume excess? - correct answer ✔✔diuretic (Lasix) med will help
pt urinate out excess fluid--> may cause potassium loss
A patient who is obese is admitted with a diagnosis of congestive heart failure. The nursing
history reveals the patient has diabetes, smokes 2 packs of cigarettes daily, and is noncompliant
with diet, exercise, and medications. The student nurse assigned to the patient states, "Let's
focus on making them compliant, which will solve all the problems. Otherwise, we can't help
them." What is the most appropriate response? - correct answer ✔✔Only compliance will not
fix the issue of taking meds and lifestyle changes.
Start with some baby steps. Start with cutting down to one pack a day. Nurse must understand
that the client must change themselves and take control over their health.
How can we measure fluid status on patient? - correct answer ✔✔Taking a daily weight (usually
in the morning) at the same time every day
What are some signs a patient with deficit fluid volume (hypovolemia) present? - correct answer
✔✔dehydration, dry skin, dry mucous membranes, non-elastic skin turgor, decreased uring
output and hypotension, increased heart rate, rise in temperature, weight loss
What are some fluid volume nursing diagnoses? - correct answer ✔✔-deficient fluid volume
-excess fluid volume
,-risk for deficient fluid volume
-risk for imbalanced fluid volume
Nursing Assessment - correct answer ✔✔systematic and continuous collection and analysis of
information about the client
-vitals
-ABC- airways, breathing, circulation
-pain
-past medical history
-medications
-allergies
-symptoms
urination in older adults - correct answer ✔✔-Kidney function decreases
-Urgency and frequency is common-- nocturnal frequency
-Loss of bladder elasticity--> nocturia, incomplete emptying= stasis and increase risk of UTI's
Factors affecting urinary elimination - correct answer ✔✔-Personal
-Sociocultural
-Environmental
-Nutrition
-Hydration
-Activity level
,-Medications
-Surgery
Pain in lower back and fever with chills. Strong persistant urge to urinate. Urine dipstick is
positive for RBC's. leukocytes and bacteria. - correct answer ✔✔Most likely a UTI that traveled
to the kidneys
The female client states to the nurse, "I'm so distressed. It seems like every time I laugh hard, I
wet myself." The nurse knows that this condition is known as: - correct answer ✔✔Stress
incontinence
Patient cannot make it to the bathroom due to the cords from oxygen tank. What kind of
incontinence would this be? - correct answer ✔✔Functional incontinence
urge incontinence - correct answer ✔✔state in which a person experiences involuntary passage
of urine that occurs soon after a strong sense of urgency to void
The nurse prepares to insert an indwelling urinary catheter. Which statement least explains the
reason for this intervention?
A.Empty your bladder prior to your procedure.
B.Treat your problem of leaking urine.
C.Obtain a sterile urine specimen for culture.
D.Measure the amount of urine left after you emptied your bladder. - correct answer ✔✔B. We
do not put a catheter in because of incontinence
How do nurses manage urinary incontinence with our patients? - correct answer ✔✔Educate:
-preventing skin breakdown
-implement bladder training
, -encourage client to perform kegel exercises
Catheters candidates vs noncandidates - correct answer ✔✔-Catheters need a order. Typically a
standing order by physician
Uses: urinary retention, need exact output to measure, for comfort during hospice sometimes
so we do not have to roll patient too much and to protect the skin integrity of a sore on bottom,
sometimes to prevent bladder distention (full bladder) during surgeries.
Non-uses: incontience, confusion, immobile
overflow incontinence - correct answer ✔✔involuntary loss of urine associated with
overdistention (full bladder) and overflow of the bladder
The nursing process - correct answer ✔✔ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
The coronary arteries receive the most blood flow during - correct answer ✔✔diastole
*Because this is when the heart is relaces and they receive the least blood flow during systole
because this is when the myocardium contracts decreasing the blood flow through the coronary
arteries
answered graded A+ (latest update)
You are the nurse assessing a patient. What are some signs of excess fluid volume
(hypervolemia) - correct answer ✔✔edema/ascites, crackles in the lungs, pale, cool skin,
elevated blood pressure, bounding pulse
What med will help with fluid volume excess? - correct answer ✔✔diuretic (Lasix) med will help
pt urinate out excess fluid--> may cause potassium loss
A patient who is obese is admitted with a diagnosis of congestive heart failure. The nursing
history reveals the patient has diabetes, smokes 2 packs of cigarettes daily, and is noncompliant
with diet, exercise, and medications. The student nurse assigned to the patient states, "Let's
focus on making them compliant, which will solve all the problems. Otherwise, we can't help
them." What is the most appropriate response? - correct answer ✔✔Only compliance will not
fix the issue of taking meds and lifestyle changes.
Start with some baby steps. Start with cutting down to one pack a day. Nurse must understand
that the client must change themselves and take control over their health.
How can we measure fluid status on patient? - correct answer ✔✔Taking a daily weight (usually
in the morning) at the same time every day
What are some signs a patient with deficit fluid volume (hypovolemia) present? - correct answer
✔✔dehydration, dry skin, dry mucous membranes, non-elastic skin turgor, decreased uring
output and hypotension, increased heart rate, rise in temperature, weight loss
What are some fluid volume nursing diagnoses? - correct answer ✔✔-deficient fluid volume
-excess fluid volume
,-risk for deficient fluid volume
-risk for imbalanced fluid volume
Nursing Assessment - correct answer ✔✔systematic and continuous collection and analysis of
information about the client
-vitals
-ABC- airways, breathing, circulation
-pain
-past medical history
-medications
-allergies
-symptoms
urination in older adults - correct answer ✔✔-Kidney function decreases
-Urgency and frequency is common-- nocturnal frequency
-Loss of bladder elasticity--> nocturia, incomplete emptying= stasis and increase risk of UTI's
Factors affecting urinary elimination - correct answer ✔✔-Personal
-Sociocultural
-Environmental
-Nutrition
-Hydration
-Activity level
,-Medications
-Surgery
Pain in lower back and fever with chills. Strong persistant urge to urinate. Urine dipstick is
positive for RBC's. leukocytes and bacteria. - correct answer ✔✔Most likely a UTI that traveled
to the kidneys
The female client states to the nurse, "I'm so distressed. It seems like every time I laugh hard, I
wet myself." The nurse knows that this condition is known as: - correct answer ✔✔Stress
incontinence
Patient cannot make it to the bathroom due to the cords from oxygen tank. What kind of
incontinence would this be? - correct answer ✔✔Functional incontinence
urge incontinence - correct answer ✔✔state in which a person experiences involuntary passage
of urine that occurs soon after a strong sense of urgency to void
The nurse prepares to insert an indwelling urinary catheter. Which statement least explains the
reason for this intervention?
A.Empty your bladder prior to your procedure.
B.Treat your problem of leaking urine.
C.Obtain a sterile urine specimen for culture.
D.Measure the amount of urine left after you emptied your bladder. - correct answer ✔✔B. We
do not put a catheter in because of incontinence
How do nurses manage urinary incontinence with our patients? - correct answer ✔✔Educate:
-preventing skin breakdown
-implement bladder training
, -encourage client to perform kegel exercises
Catheters candidates vs noncandidates - correct answer ✔✔-Catheters need a order. Typically a
standing order by physician
Uses: urinary retention, need exact output to measure, for comfort during hospice sometimes
so we do not have to roll patient too much and to protect the skin integrity of a sore on bottom,
sometimes to prevent bladder distention (full bladder) during surgeries.
Non-uses: incontience, confusion, immobile
overflow incontinence - correct answer ✔✔involuntary loss of urine associated with
overdistention (full bladder) and overflow of the bladder
The nursing process - correct answer ✔✔ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
The coronary arteries receive the most blood flow during - correct answer ✔✔diastole
*Because this is when the heart is relaces and they receive the least blood flow during systole
because this is when the myocardium contracts decreasing the blood flow through the coronary
arteries
