ACTUAL EXAM LATEST VERSIONS
COMPLETE 140 QUESTIONS AND
CORRECT DETAILED ANSWERS
Normal Urine Output ...ANSWER...40mL/hr (approximatley 1 Liter a day)
Intake exceeds output ...ANSWER...-weight gain
-electrolyte imbalance
-increased hemodynamic pressures
-decreased lung compliance
Central Venous Pressure (CVP) ...ANSWER...can indicate changes in fluid balance
Normal CVP ...ANSWER...2-6mmHg or 4-12cmH20
-decreased CVP can indicate hypovalemia (fluid therapy)
-increased CVP can indicate hypervalemia (diuretics)
Stuporous, confused , sleepy ...ANSWER...consider sleep apnea or excessive O2
therapy (COPD patient)
Semicomatose ...ANSWER...responds only to painful stimuli
Obtunded ...ANSWER...drowsy state, may have decreased cough or gag reflux (protect
airway)
Coma ...ANSWER...does not respond to painful stimuli
Electrolyte Imbalance Traits ...ANSWER...anger, combative, irritable
Drug Overdose Traits ...ANSWER...Euphoria-intense feelings of emotions (joy)
Panic Traits ...ANSWER...severe hypoxemia, tension pnemothorax, status asthmaticus,
or possibly AAA (abdominal aortic anerysm)
Activites of Daily Living (ADL) Scoring ...ANSWER...Katz Scoring System
0-dependent
6-independent
, Orthopnea ...ANSWER...difficulty breathing except in the upright position (CHF)
Genreal malaise ...ANSWER...run down feeling, nausea, weakness, fatique, headache
(consider electrolyte imbalance)
COPD diet ...ANSWER...high fats, low carbs (carbs causes higher CO2)
Edema ...ANSWER...caused by CHF and renal failure
occurs primarily in arms and ankles
Ascites ...ANSWER...accumulation of fluid in the abdomen generally caused by liver
failure
Clubbing of fingers ...ANSWER...caused by chronic hypoxemia
presence of clubbing suggests pulmonary disease
Venous distension or Jugular venous distension (JVD) ...ANSWER...occurs with CHF
seen during exhalation in patients with obstructive lung disease
Capillary refill ...ANSWER...indication of peripheral circulation
color should return within 3 seconds
Diaphoresis ...ANSWER...heart failure (recommend diuretics, positive inotropic agents)
fever, infection (recommend antibiotics)
anxiety, nervousness (recommend sedatives)
tuberculosis/night sweats (recommend antitubercular drugs)
Cheyne-Stokes Breathing ...ANSWER...gradually increasing then decreasing rate and
depth in a cycle lasting from 30-180 seconds, with periods of apnea lasting up to 60
seconds
Cause: Increased intracranial pressure, brainstem inury, drug overdose
Biot's Breathing ...ANSWER...increased respiratory rate and depth with irregular periods
of apnea. Each breath has the same depth
Cause: CNS problem
Kussmaul's breathing ...ANSWER...increased respiratory rate (usually over 20
breaths/min), increased depth, irregular rhythm, breathing sounds labored
Cause: metabolic acidosis, renal failure, diabetic ketoacidosis
Dry or nonproductive cough may indicate ...ANSWER...a tumor in the lungs
Productive cough may indicate ...ANSWER...an infection or chronic lung disease
COMPLETE 140 QUESTIONS AND
CORRECT DETAILED ANSWERS
Normal Urine Output ...ANSWER...40mL/hr (approximatley 1 Liter a day)
Intake exceeds output ...ANSWER...-weight gain
-electrolyte imbalance
-increased hemodynamic pressures
-decreased lung compliance
Central Venous Pressure (CVP) ...ANSWER...can indicate changes in fluid balance
Normal CVP ...ANSWER...2-6mmHg or 4-12cmH20
-decreased CVP can indicate hypovalemia (fluid therapy)
-increased CVP can indicate hypervalemia (diuretics)
Stuporous, confused , sleepy ...ANSWER...consider sleep apnea or excessive O2
therapy (COPD patient)
Semicomatose ...ANSWER...responds only to painful stimuli
Obtunded ...ANSWER...drowsy state, may have decreased cough or gag reflux (protect
airway)
Coma ...ANSWER...does not respond to painful stimuli
Electrolyte Imbalance Traits ...ANSWER...anger, combative, irritable
Drug Overdose Traits ...ANSWER...Euphoria-intense feelings of emotions (joy)
Panic Traits ...ANSWER...severe hypoxemia, tension pnemothorax, status asthmaticus,
or possibly AAA (abdominal aortic anerysm)
Activites of Daily Living (ADL) Scoring ...ANSWER...Katz Scoring System
0-dependent
6-independent
, Orthopnea ...ANSWER...difficulty breathing except in the upright position (CHF)
Genreal malaise ...ANSWER...run down feeling, nausea, weakness, fatique, headache
(consider electrolyte imbalance)
COPD diet ...ANSWER...high fats, low carbs (carbs causes higher CO2)
Edema ...ANSWER...caused by CHF and renal failure
occurs primarily in arms and ankles
Ascites ...ANSWER...accumulation of fluid in the abdomen generally caused by liver
failure
Clubbing of fingers ...ANSWER...caused by chronic hypoxemia
presence of clubbing suggests pulmonary disease
Venous distension or Jugular venous distension (JVD) ...ANSWER...occurs with CHF
seen during exhalation in patients with obstructive lung disease
Capillary refill ...ANSWER...indication of peripheral circulation
color should return within 3 seconds
Diaphoresis ...ANSWER...heart failure (recommend diuretics, positive inotropic agents)
fever, infection (recommend antibiotics)
anxiety, nervousness (recommend sedatives)
tuberculosis/night sweats (recommend antitubercular drugs)
Cheyne-Stokes Breathing ...ANSWER...gradually increasing then decreasing rate and
depth in a cycle lasting from 30-180 seconds, with periods of apnea lasting up to 60
seconds
Cause: Increased intracranial pressure, brainstem inury, drug overdose
Biot's Breathing ...ANSWER...increased respiratory rate and depth with irregular periods
of apnea. Each breath has the same depth
Cause: CNS problem
Kussmaul's breathing ...ANSWER...increased respiratory rate (usually over 20
breaths/min), increased depth, irregular rhythm, breathing sounds labored
Cause: metabolic acidosis, renal failure, diabetic ketoacidosis
Dry or nonproductive cough may indicate ...ANSWER...a tumor in the lungs
Productive cough may indicate ...ANSWER...an infection or chronic lung disease
