NUR 211 STUDY GUIDE TEST
QUESTIONS WITH CORRECT
ANSWERS
Which assessment do you use as a clinical marker of vascular volume in a patient at
high risk of ECV deficit?
a. dryness of mucous membranes
b. presence or absence of edema
c. fullness of neck veins when supine
d. fullness of neck veins when upright - Answer-c. fullness of neck veins when supine
Your patient is hyperventilating from acute pain and hypoxia. Interventions to manage
his pain and oxygenation will decrease his risk of which acid-base imbalance?
a. metabolic acidosis
b. metabolic alkalosis
c. respiratory acidosis
d. respiratory alkalosis - Answer-d. respiratory alkalosis
What is the correct order for discontinuing IV access?
1. Perform hand hygiene and apply gloves
2. Explain procedure to patient
3. Remove IV site dressing and tape
4. Use two identifiers to ensure correct pt
5. Stop the infusion and clamp the tubing
6. Carefully check the health care provider's order
7. Clean the site, withdraw the catheter, and apply pressure
a. 6,4,2,1,5,3,7
b. 4,6,2,1,5,3,7
c. 6,4,2,5,3,1,7
d. 6,2,4,1,3,7,5 - Answer-Carefully check the health care provider's order
Use two patient Identifiers to ensure correct pt
Explain procedure to pt
preform hand hygiene and apply gloves
Stop the infusion and clam the tubing
Remove IV site dressing and tape
Clean the site, withdraw the catheter, and apply pressure
a. 6,4,2,1,5,3,7
An IV fluid is infusing more slowly than ordered. The infusion pump is set correctly.
Which factors could cause this slowing? (select all that apply)
,a. infiltration at vascular access device (VAD) site
b. patient lying on tubing
c. roller clamp wide open
d. tubing kinked in bedrails
e. circulatory overload - Answer-a. infiltration at vascular access device (VAD) site
b. patient lying on tubing
d. tubing kinked in bedrails
Your patient has severe hypercalcemia. What are your priority nursing interventions
(select all that supply)
a. fall prevention interventions
b. teaching regarding sodium
c. encouraging increased fluid intake
d. monitoring for constipation
e. explaining how to take daily weights - Answer-a. fall prevention
c. encouraging increased fluid intake
d. monitoring for constipation
Your patient has hypokalemia with stable cardiac function. What are your priority
nursing interventions (select all that apply)
a. fall prevention interventions
b. teaching regarding sodium
c. encouraging increased fluid intake
d. monitoring for constipation
e. explaining how to take daily weights - Answer-a. fall prevention
d. monitoring for constipation
Sodium Normal Range - Answer-136-145mEq/L
Chloride Normal Range - Answer-95-102mEq/L
Potassium Normal Range - Answer-3.5-5.0mEq/L
Phosphate Normal Range - Answer-3.0-4.5mEq/L
Calcium Normal Range - Answer-9.0-10.5mEq/L
Magnesium Normal Range - Answer-1.3-2.1mEq/L
Bicarbonate Normal Range - Answer-22.-26mEq/L
BUN Normal Range - Answer-8-22mg/dL
Creatinine Normal Range - Answer-0.6-1.2mg/dL
Glucose Normal Range - Answer-70-110mg/dL
, Hemoglobin Normal Range - Answer-m: 135-180g/L
f: 120-160g/L
Hematocrit Normal Range - Answer-m: 45-52%
f: 37-48%
Platelet Normal Range - Answer-150,000-350,000
WBC Normal Range - Answer-4,500-10,500 mm3
Thirst control mechanism - Answer-Hypothalamus
ADH - Answer-functions: decreases urine output, decreases sweat, increases BP
ADH released & inhibited - Answer-released= dehydration
inhibited= overhydration
RAA system - Answer-Angiotensinogen
Renin
Angiotensin 1
Angiotensin 2
ADH & Aldosterone
Angiotensin - Answer-made by liver
Renin - Answer-produced by the kidneys
Angiotensin 2 - Answer-causes arteries to constrict reducing BP, decreasing GFR-
absorbing H2O, increases thirst
ADH - Answer-made by the hypothalamus, released from posterior pituitary
Aldosterone - Answer-reabsorption of Na+ and H2O
produced by adrenal gland on top of the kidney
Hyperkalemia Symptoms - Answer-muscle weakness
cardiac dysrhythmias
decreased urine output
diarrhea
abdominal cramps
paresthesia (mouth, hands, fingers)
hypotension
hyperactive bowel sounds
HR below 60
QUESTIONS WITH CORRECT
ANSWERS
Which assessment do you use as a clinical marker of vascular volume in a patient at
high risk of ECV deficit?
a. dryness of mucous membranes
b. presence or absence of edema
c. fullness of neck veins when supine
d. fullness of neck veins when upright - Answer-c. fullness of neck veins when supine
Your patient is hyperventilating from acute pain and hypoxia. Interventions to manage
his pain and oxygenation will decrease his risk of which acid-base imbalance?
a. metabolic acidosis
b. metabolic alkalosis
c. respiratory acidosis
d. respiratory alkalosis - Answer-d. respiratory alkalosis
What is the correct order for discontinuing IV access?
1. Perform hand hygiene and apply gloves
2. Explain procedure to patient
3. Remove IV site dressing and tape
4. Use two identifiers to ensure correct pt
5. Stop the infusion and clamp the tubing
6. Carefully check the health care provider's order
7. Clean the site, withdraw the catheter, and apply pressure
a. 6,4,2,1,5,3,7
b. 4,6,2,1,5,3,7
c. 6,4,2,5,3,1,7
d. 6,2,4,1,3,7,5 - Answer-Carefully check the health care provider's order
Use two patient Identifiers to ensure correct pt
Explain procedure to pt
preform hand hygiene and apply gloves
Stop the infusion and clam the tubing
Remove IV site dressing and tape
Clean the site, withdraw the catheter, and apply pressure
a. 6,4,2,1,5,3,7
An IV fluid is infusing more slowly than ordered. The infusion pump is set correctly.
Which factors could cause this slowing? (select all that apply)
,a. infiltration at vascular access device (VAD) site
b. patient lying on tubing
c. roller clamp wide open
d. tubing kinked in bedrails
e. circulatory overload - Answer-a. infiltration at vascular access device (VAD) site
b. patient lying on tubing
d. tubing kinked in bedrails
Your patient has severe hypercalcemia. What are your priority nursing interventions
(select all that supply)
a. fall prevention interventions
b. teaching regarding sodium
c. encouraging increased fluid intake
d. monitoring for constipation
e. explaining how to take daily weights - Answer-a. fall prevention
c. encouraging increased fluid intake
d. monitoring for constipation
Your patient has hypokalemia with stable cardiac function. What are your priority
nursing interventions (select all that apply)
a. fall prevention interventions
b. teaching regarding sodium
c. encouraging increased fluid intake
d. monitoring for constipation
e. explaining how to take daily weights - Answer-a. fall prevention
d. monitoring for constipation
Sodium Normal Range - Answer-136-145mEq/L
Chloride Normal Range - Answer-95-102mEq/L
Potassium Normal Range - Answer-3.5-5.0mEq/L
Phosphate Normal Range - Answer-3.0-4.5mEq/L
Calcium Normal Range - Answer-9.0-10.5mEq/L
Magnesium Normal Range - Answer-1.3-2.1mEq/L
Bicarbonate Normal Range - Answer-22.-26mEq/L
BUN Normal Range - Answer-8-22mg/dL
Creatinine Normal Range - Answer-0.6-1.2mg/dL
Glucose Normal Range - Answer-70-110mg/dL
, Hemoglobin Normal Range - Answer-m: 135-180g/L
f: 120-160g/L
Hematocrit Normal Range - Answer-m: 45-52%
f: 37-48%
Platelet Normal Range - Answer-150,000-350,000
WBC Normal Range - Answer-4,500-10,500 mm3
Thirst control mechanism - Answer-Hypothalamus
ADH - Answer-functions: decreases urine output, decreases sweat, increases BP
ADH released & inhibited - Answer-released= dehydration
inhibited= overhydration
RAA system - Answer-Angiotensinogen
Renin
Angiotensin 1
Angiotensin 2
ADH & Aldosterone
Angiotensin - Answer-made by liver
Renin - Answer-produced by the kidneys
Angiotensin 2 - Answer-causes arteries to constrict reducing BP, decreasing GFR-
absorbing H2O, increases thirst
ADH - Answer-made by the hypothalamus, released from posterior pituitary
Aldosterone - Answer-reabsorption of Na+ and H2O
produced by adrenal gland on top of the kidney
Hyperkalemia Symptoms - Answer-muscle weakness
cardiac dysrhythmias
decreased urine output
diarrhea
abdominal cramps
paresthesia (mouth, hands, fingers)
hypotension
hyperactive bowel sounds
HR below 60
