2
NUR 204 Newest Exam 4 with verified detailed solutions
|| || || || || || || ||
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
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d. on the roller clamp of the tubing - ✔✔a. on the package of tubing
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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 - ✔✔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 - ✔✔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
|| || || || || || || ||
,2
d. do not give the pt any fluid after 5:00 pm - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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
|| || || || || || || || || || ||
,2
d. i will be sure to check my heart rate before i take digoxin - ✔✔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 - ✔✔c. mental confusion
|| || || || || ||
which adaptation would indicate a K deficiency?
|| || || || || || ||
a. dry hair
|| || ||
b. muscle weakness
|| ||
c. increased BP
|| || ||
d. chest pain - ✔✔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 - ✔✔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 - ✔✔c. 30 mL
|| || || || || ||
, 2
patients who are taking diuretics must be encouraged to ingest nutrients rich in what?
|| || || || || || || || || || || || || ||
a. sodium
|| ||
b. magnesium
|| ||
c. calcium
|| ||
d. potassium - ✔✔d. potassium
|| || || ||
which if the following signs is indicative of phlebitits at the IV site?
|| || || || || || || || || || || || ||
a. warmth
|| ||
b. cool
|| ||
c. pallor
|| ||
d. bleeding - ✔✔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 - ✔✔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 - ✔✔b. stop the transfusion
|| || || || || || || || || || ||
which pt is at most risk for fluid imbalance?
|| || || || || || || || ||
NUR 204 Newest Exam 4 with verified detailed solutions
|| || || || || || || ||
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 - ✔✔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 - ✔✔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 - ✔✔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
|| || || || || || || ||
,2
d. do not give the pt any fluid after 5:00 pm - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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
|| || || || || || || || || || ||
,2
d. i will be sure to check my heart rate before i take digoxin - ✔✔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 - ✔✔c. mental confusion
|| || || || || ||
which adaptation would indicate a K deficiency?
|| || || || || || ||
a. dry hair
|| || ||
b. muscle weakness
|| ||
c. increased BP
|| || ||
d. chest pain - ✔✔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 - ✔✔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 - ✔✔c. 30 mL
|| || || || || ||
, 2
patients who are taking diuretics must be encouraged to ingest nutrients rich in what?
|| || || || || || || || || || || || || ||
a. sodium
|| ||
b. magnesium
|| ||
c. calcium
|| ||
d. potassium - ✔✔d. potassium
|| || || ||
which if the following signs is indicative of phlebitits at the IV site?
|| || || || || || || || || || || || ||
a. warmth
|| ||
b. cool
|| ||
c. pallor
|| ||
d. bleeding - ✔✔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 - ✔✔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 - ✔✔b. stop the transfusion
|| || || || || || || || || || ||
which pt is at most risk for fluid imbalance?
|| || || || || || || || ||
