NUR 204 EXAM 4 QUESTIONS AND ANSWERS | COMPLETE NURSING EXAM 4
STUDY GUIDE 2026/2027
where should the RN look for the number of drops per mL of fluid the tubing delivers?
a. on the package of tubing
b. in the drug reference book
c. in the charting from the nurse who started the infusion
d. on the roller clamp of the tubing - ANS ✔✔a. on the package of tubing
which is first intervention when RN observes the IV solution is not infusing?
a. inspect the tubing for kinks
b. discontinue the IV
c. lower the height of the IV solution container
d. notify the MD - ANS ✔✔a. inspect the tubing for kinks
how should the nurse plan for a 1200 mL fluid restriction?
a. remove fluid from diet trays and offer them only between meals
b. offer the client soft foods such as sherbert and custard
c. allow 600 mL from 7-3, 400 mL from 3-11, and 20 mL from 11-7
d. tell the pt that fluid placed @ bedside must last until tomorrow - ANS ✔✔c. allow 600 mL from 7-3,
400 mL from 3-11, and 20 mL from 11-7
what action by RN would be appropriate for pt on fluid restriction of 800 mL a day?
a. check pt bedside table for hoarded cups of fluid/juice
b. allow the pt to order her own meals from the kitchen
c. obtain a urinalysis to check for output
d. do not give the pt any fluid after 5:00 pm - ANS ✔✔b. allow the pt to order her own meals from the
kitchen
which intervention should be included in the plan of care for pt with fluid volume excess?
a. restrict the clients sodium in their diet
b. prepare the patient for hemodialysis
c. do not give the patient intravenous fluids
d. monitor blood glucose levels - ANS ✔✔a. restrict the clients sodium in their diet
crackles, SOB, and distended neck veins indicate which complication of IV fluid therapy?
a. impending cardiovascular collapse/ shock
b. pulmonary embolism
c. an allergic reaction to IV fluids
d. fluid volume excess - ANS ✔✔d. fluid volume excess
what is the priority assessment for a pt refusing to eat or drink for several days?
a. increased blood pressure
b. weak, rapid pulse
c. jugular vein distention
d. moist mucous membranes - ANS ✔✔b. weak, rapid pulse
,which statement indicates a need for further teaching regarding treatment of hypokalemia?
a. i will use avocado in my salads
b. i will stop using my salt substitute
c. i will take potassium in the morning after eating breakfast
d. i will be sure to check my heart rate before i take digoxin - ANS ✔✔b. i will stop using my salt
substitute
which of the following signs or symptoms are most representative of a sodium imbalance?
a. muscle weakness
b. hyperreflexia
c. mental confusion
d. irregular pulse - ANS ✔✔c. mental confusion
which adaptation would indicate a K deficiency?
a. dry hair
b. muscle weakness
c. increased BP
d. chest pain - ANS ✔✔b. muscle weakness
a reduction in fluid intake will contribute to:
a. frequent urination
b. decreased urine output
c. incontinence of urine
d. retention of urine - ANS ✔✔b. decreased urine output
the physician should be notified when the pts hourly urinary output falls below what amt?
a. 20 mL
b. 120 mL
c. 30 mL
d. 60 mL - ANS ✔✔c. 30 mL
patients who are taking diuretics must be encouraged to ingest nutrients rich in what?
a. sodium
b. magnesium
c. calcium
d. potassium - ANS ✔✔d. potassium
which if the following signs is indicative of phlebitits at the IV site?
a. warmth
b. cool
c. pallor
d. bleeding - ANS ✔✔a. warmth
pt c/o tingling in her fingers and toes, muscle cramps, and numbness of extremeties. issue?
a. calcium deficit
b. chloride deficit
c. sodium excess
, d. magnesium excess - ANS ✔✔a. calcium deficit
10 min after start of blood transfusion pt c/o CP and chills, T 102. priority action?
a. call the physician
b. stop the transfusion
c. slaw the transfusion down
d. administer prn tylenol for the fever - ANS ✔✔b. stop the transfusion
which pt is at most risk for fluid imbalance?
a. middle aged woman who is vommiting
b. healthy 70 yr old w/ fractured wrist
c. infant w/ diarrhea
d. adolescent mowing the grass in the hot sun - ANS ✔✔c. infant w/ diarrhea
when individuals are in a healthy state their fluid output should be:
a. lower than their fluid intake
b. correlated very little with their fluid intake
c. approx the same as their fluid intake
d. higher than their fluid intake - ANS ✔✔c. approx the same as their fluid intake
admin med at times to maintain a specific amount of the med in the blood at all time:
a. drug half-life
b. peak plasma volume
c. onset of action
d. plateau - ANS ✔✔d. plateau
order for a med that does not have a termination date:
a. STAT
b. PRN
c. standing
d. single - ANS ✔✔c. standing
15 ml of an oral med three times a dat. how much med should pt take at home?
a. 2 tbls
b. 1 tsp
c. 1 tbsp
d. 2 tsp - ANS ✔✔c. 1 tbsp
how should the RN administer a bitter-tasting oral med to a 4 yr old client?
a. tell the child the medication tastes good
b. give the med in orange juice of milk to mask the taste
c. ask the parents how they give meds at home
d. get another nurse to assist by holding the client down - ANS ✔✔c. ask the parents how they give
meds at home
RN finds med patch in the clients bed linens. how can RN avoid new patch from falling off?
a. place a heating pad over the patch for 10 minutes
b. press palm firmly over patch for about 10 seconds
STUDY GUIDE 2026/2027
where should the RN look for the number of drops per mL of fluid the tubing delivers?
a. on the package of tubing
b. in the drug reference book
c. in the charting from the nurse who started the infusion
d. on the roller clamp of the tubing - ANS ✔✔a. on the package of tubing
which is first intervention when RN observes the IV solution is not infusing?
a. inspect the tubing for kinks
b. discontinue the IV
c. lower the height of the IV solution container
d. notify the MD - ANS ✔✔a. inspect the tubing for kinks
how should the nurse plan for a 1200 mL fluid restriction?
a. remove fluid from diet trays and offer them only between meals
b. offer the client soft foods such as sherbert and custard
c. allow 600 mL from 7-3, 400 mL from 3-11, and 20 mL from 11-7
d. tell the pt that fluid placed @ bedside must last until tomorrow - ANS ✔✔c. allow 600 mL from 7-3,
400 mL from 3-11, and 20 mL from 11-7
what action by RN would be appropriate for pt on fluid restriction of 800 mL a day?
a. check pt bedside table for hoarded cups of fluid/juice
b. allow the pt to order her own meals from the kitchen
c. obtain a urinalysis to check for output
d. do not give the pt any fluid after 5:00 pm - ANS ✔✔b. allow the pt to order her own meals from the
kitchen
which intervention should be included in the plan of care for pt with fluid volume excess?
a. restrict the clients sodium in their diet
b. prepare the patient for hemodialysis
c. do not give the patient intravenous fluids
d. monitor blood glucose levels - ANS ✔✔a. restrict the clients sodium in their diet
crackles, SOB, and distended neck veins indicate which complication of IV fluid therapy?
a. impending cardiovascular collapse/ shock
b. pulmonary embolism
c. an allergic reaction to IV fluids
d. fluid volume excess - ANS ✔✔d. fluid volume excess
what is the priority assessment for a pt refusing to eat or drink for several days?
a. increased blood pressure
b. weak, rapid pulse
c. jugular vein distention
d. moist mucous membranes - ANS ✔✔b. weak, rapid pulse
,which statement indicates a need for further teaching regarding treatment of hypokalemia?
a. i will use avocado in my salads
b. i will stop using my salt substitute
c. i will take potassium in the morning after eating breakfast
d. i will be sure to check my heart rate before i take digoxin - ANS ✔✔b. i will stop using my salt
substitute
which of the following signs or symptoms are most representative of a sodium imbalance?
a. muscle weakness
b. hyperreflexia
c. mental confusion
d. irregular pulse - ANS ✔✔c. mental confusion
which adaptation would indicate a K deficiency?
a. dry hair
b. muscle weakness
c. increased BP
d. chest pain - ANS ✔✔b. muscle weakness
a reduction in fluid intake will contribute to:
a. frequent urination
b. decreased urine output
c. incontinence of urine
d. retention of urine - ANS ✔✔b. decreased urine output
the physician should be notified when the pts hourly urinary output falls below what amt?
a. 20 mL
b. 120 mL
c. 30 mL
d. 60 mL - ANS ✔✔c. 30 mL
patients who are taking diuretics must be encouraged to ingest nutrients rich in what?
a. sodium
b. magnesium
c. calcium
d. potassium - ANS ✔✔d. potassium
which if the following signs is indicative of phlebitits at the IV site?
a. warmth
b. cool
c. pallor
d. bleeding - ANS ✔✔a. warmth
pt c/o tingling in her fingers and toes, muscle cramps, and numbness of extremeties. issue?
a. calcium deficit
b. chloride deficit
c. sodium excess
, d. magnesium excess - ANS ✔✔a. calcium deficit
10 min after start of blood transfusion pt c/o CP and chills, T 102. priority action?
a. call the physician
b. stop the transfusion
c. slaw the transfusion down
d. administer prn tylenol for the fever - ANS ✔✔b. stop the transfusion
which pt is at most risk for fluid imbalance?
a. middle aged woman who is vommiting
b. healthy 70 yr old w/ fractured wrist
c. infant w/ diarrhea
d. adolescent mowing the grass in the hot sun - ANS ✔✔c. infant w/ diarrhea
when individuals are in a healthy state their fluid output should be:
a. lower than their fluid intake
b. correlated very little with their fluid intake
c. approx the same as their fluid intake
d. higher than their fluid intake - ANS ✔✔c. approx the same as their fluid intake
admin med at times to maintain a specific amount of the med in the blood at all time:
a. drug half-life
b. peak plasma volume
c. onset of action
d. plateau - ANS ✔✔d. plateau
order for a med that does not have a termination date:
a. STAT
b. PRN
c. standing
d. single - ANS ✔✔c. standing
15 ml of an oral med three times a dat. how much med should pt take at home?
a. 2 tbls
b. 1 tsp
c. 1 tbsp
d. 2 tsp - ANS ✔✔c. 1 tbsp
how should the RN administer a bitter-tasting oral med to a 4 yr old client?
a. tell the child the medication tastes good
b. give the med in orange juice of milk to mask the taste
c. ask the parents how they give meds at home
d. get another nurse to assist by holding the client down - ANS ✔✔c. ask the parents how they give
meds at home
RN finds med patch in the clients bed linens. how can RN avoid new patch from falling off?
a. place a heating pad over the patch for 10 minutes
b. press palm firmly over patch for about 10 seconds
