Exam 4: NUR 204/ NUR204 (NEW 2026/ 2027 Update) Leadership and Management VERSION 1| Questions & Answers| Grade A| 100% Correct (Verified Solutions)- Fortis

1 …..DLDD Exam 4: NUR 204/ NUR204 (NEW 2026/ 2027 Update) Leadership and Management VERSION 1| Questions & Answers| Grade A| 100% Correct (Verified Solutions)- Fortis Q. 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 Answer a. on the package of tubing Q. 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 Answer a. inspect the tubing for kinks 2 Q. 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 Answer c. allow 600 mL from 7-3, 400 mL from 3-11, and 20 mL from 11-7 Q. 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 Answer b. allow the pt to order her own meals from the kitchen 3 Q. 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 Answer a. restrict the clients sodium in their diet Q. 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 Answer d. fluid volume excess 4 Q. 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 Answer b. weak, rapid pulse Q. 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 Answer b. i will stop using my salt substitute 5 Q. 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 Answer c. mental confusion Q. Which adaptation would indicate a K deficiency? a. dry hair b. muscle weakness c. increased BP d. chest pain Answer b. muscle weakness 6 Q. A reduction in fluid intake will contribute to: a. frequent urination b. decreased urine output c. incontinence of urine d. retention of urine Answer b. decreased urine output Q. 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 Answer c. 30 mL 7 Q. Patients who are taking diuretics must be encouraged to ingest nutrients rich in what? a. sodium b. magnesium c. calcium d. potassium Answer d. potassium Q. Which if the following signs is indicative of phlebitits at the IV site? a. warmth b. cool c. pallor d. bleeding Answer a. warmth 8 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? 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 c. infant w/ diarrhea 9 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 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 d. plateau order for a med that does not have a termination date: a. STAT b. PRN c. standing 10 d. single 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 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 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 11 b. press palm firmly over patch for about 10 seconds c. shave the area where the patch is being applies d. run finger around adhesive edges before placing it on skin b. press palm firmly over patch for about 10 seconds RN squeezes sm amt of eye med out of tube when preparing dose. priority action? a. continue to squeeze a line of med from time to discard b. notify pharmacist that new tube id needed c. have 2nd RN witness waste and sign chart d. admin as ordered, bead must be discarded anyway d. admin as ordered, bead must be discarded anyway at which point of preparing med form an ampule does the RN anticipate using a filter needle? a, when administering the med to the client b, filter needles are not used for this preperation c. for drawing up the med and administering the med d. when drawing the medication from the ampule d. when drawing the medication from the ampule 12 poor personal hygiene and difficult with fine motor skills asks if can reuse needles. response? a. all pts are different, I advise using a new one each time b. the ADA revises that syringes are single use only c. only people with good personal hygeine can reuse syringes d. save money and reuse syringes 3 times or needle feels dull a. all pts are different, I advise using a new one each time Rn sees outline of needle bevel visible under skin in intradermal injection. Action? a. insert the needle further into the skin at a deeper angle b. withdraw needle, prepare another injection, and start again c. turn needle bevel down and inject med slowly to form a bleb d. this is an expected finding in intradermal injection d. this is an expected finding in intradermal injection previous injection was given in R ventrogluteal. where will the next 2.5 mL dose go? a. the same site b. the left ventrogluteal c. the rectus femoris d. the deltoid b. the left ventrogluteal 13 while administering an IM injection RN notices blood return in barrel after aspirating. action? a. discard med and start over b. notify the MD immediately c. inject med as planned d. pull needle out 1/4 of an inch and inject the med a. discard med and start over no blood return when aspirating IV lock. action? a. discontinue infiltrated lock, restart another site b. reinsert needle into the lock and aspirate using more pressure c. pull IV catheter out 1/8 of an inch and attempt aspriration d. slowly infuse 1 mL of NS into lock assessing for infiltration d. slowly infuse 1 mL of NS into lock assessing for infiltration pt need IM injection, 1 med is 2 mL cartridge and 2nd is in vial, how to proceed for 3mL? a. call pharmacy for advice on how to admin these meds b. draw both of these meds in a single syringe c. administer each med with seperate injection 14 d. ass some med to cart from vial and give rest in 2nd injection b. draw both of these meds in a single syringe how long after NGT med is administered should the suctioning be off? a. ask the MD b. till the next shift c. 1 1/2-2 hrs d. 30 minutes d. 30 minutes pt is ordered a new med that is outside routine prescribing limits. RN cannot reach MD. action? a. withhold the medication b. give one half of the medication dose prescribed c. give the medication to the client as prescribed d. administer the medication through the oral route a. withhold the medication what are the areas you can inject a subcut injection? -lateral aspects of upper arm 15 -scapular area on back -upper ventrodorsal gluteal area -lateral aspects of the thigh -abdomen (2" away from umbilicus) What gauge needle can you use for a subcut injection? 25-31 G 29-31 G only used for insulin what needle length can you use for a subcut injection? 3/8-5/8 what needle angle do you adminsiter a subcut injection at? 45-90 degree 45 degree used for clients w/ small about of subcut tissue what is the max volume of med that can be injected subcut? 16 1 mL where can you inject intramuscular injections? -deltoid -vastus lateralis -ventrogluteal what size needle gauge can you use for intramuscular injections? 18-25 25 can only be used to administer to deltoid what is the accepted needle length for intramuscular injections? 1- 1 1/2 in at what angle do you administer a intramuscular injection? 90 degree 17 what is the max volume of med that can be injected intramuscularly? -deltoid 1mL -vastus lateralus and ventrogluteal up to 5 mL Where can you inject an intradermal injection? -inner forearm -upper arm -across the scapula What gauge needle can you use for intradermal injections? 25-27 white size needle can you use for intradermal injections? 1/4- 5/8 what angle do you administer an intradermal injection at? 15 degrees 18 what is the max volume of med that can be administered intradermally? 0.1 mL What is homeostasis? balance of fluid and electrolytes in the body what can threaten homeostasis ? illness sodium - 136-145 mEq/L -major extracellular cation -the body uses sodium to control blood pressure and blood volume -need Na for muscles and nerves to work properly What is sodium deficit called? hyponatremia 19 what is sodium excess called? hypernatremia potassium - 3.5-5 mEq/L - one of the most important minerals in the body -helps regulate fluid balance and muscle contractions and nerve signals what is potassium deficit called hypokalemia what is potassium excess called hyperkalemia calcium - 9-10 mg/dL - 99% stored in bones, 1% serum and soft tissue -works w/ phosphorus to form bones and teeth -role in cell membrane permeability 20 -affects cardiac muscle contraction -participates in blood clotting deficit: hypicalcemia excess: hypercalcemia magnesium - 1.8-2.6 mEq/L - helps produce ATP -role in protein synthesis and carb metabolism -helps cardiovascular system function (vasodialation) -regulates muscle contractions chloride - 98-106 mEq/L - maintain blood pressure -maintain the right fluid balance -required for formation of stomach acid deficit: hypochloremia excess: hypochloremia 21 phosphate - 3-4.5 mEq/L -build and repair bones and teeth, ATP production, carb ,metabolism -most of phosphorus contained in phosphate is found in bones a nurse is caring for a critically ill client with a urinary retention catheter. which hourly urine output should first alert the nurse that the primary- healthcare provider should be notified? a. 20 mL b. 30 mL c. 60 mL d. 120 mL b. 30 mL indicates a deficient circulating fluid volume, inadequate renal perfusion, or kidney disease a nurse is caring for a client who has dependent edema. which pressure has caused the excess fluid in the interstitial compartment? a. oncotic pressure 22 b. diffusion pressure c. hydrostatic pressure d. intraventricular pressure c. hydrostatic pressure hydrostatic pressure pressure exerted by a fluid within a compartment such as a blood within the vessels intraventricular pressure pressures do not move fluid from the intravascular compartment to the interstitial component a nurse evaluates a clients fluid balance by monitoring the clients intake and output. which must the nurse understand about the ratio of intake and output? a. intake should be much higher than fluid output b. intake should be slightly more than output c. intake should be lower that the urine output d. intake should be equal to urine output b. intake should be slightly more than output 23 hydrochlorothiazide, a diruretic is prescribed for a client who is retaining fluid. the nurse should encourage the client to ingest nutrients that contain which electrolyte? a. magnesium b. potassium c. calcium d. sodium b. potassium a nurse suspects that an older adult may have a fluid and electrolyte imbalance. which assessment best reflects fluid and electrolyte balance in an older adult? a. serum laboratory values b. intake and output results c. condition of the skin d. presence of tenting a. serum laboratory values lab studies provide objective measurements of indicators of fluid and electrolyte balance which should a nurse do to encourage a client to drink more fluid? 24 a. serve fluid at a tepid temp b. explain the reason for desired intake c. offer the client something to drink every hour d. leave a pitcher of water at clients bedside c. offer the client something to drink every hour frequent smaller volumes are better tolerated than infrequent larger volumes a client has continuos bladder irrigation. which should the nurse do with the irrigant on the I and O sheet when calculating the fluid balance for this client? a. add it to the oral intake column b. deduct it from the total urine output c. subtract it from the intravenous flow sheet as output d. document the intake hourly in the urine column b. deduct it from the total urine output drainage from urinary bladder with consist of both urine and irrigant. amount of irrigant instilled must be detucted from total urinary output a nurse is caring for two clients; one has oliguria and the other has polyuria. which is the priority problem that is a concern for the nurse regarding both of these clients? 25 a. diarrhea b. cachexia c. deficient fluid volume d. impaired skin integrity c. deficient fluid volume oliguria excessively small amount of urine produced by kidneys polyuria excessively large amount of urine from kidneys a primary health-care provider prescribes a cleint's IV fluids to be discontinued, which is an essential nursing intervention when discontinuing the clients intravenous infusion? a. withdraw catheter along the same angle of its insertion b. use an alcohol swab to scrub the insertion site c. flush line with normal saline d. don sterile gloves a. withdraw catheter along the same angle of its insertion 26 minimizes injury a client is admitted to the hospital for a fever of unkown origin. the nursing assessment reveals profuse diaphoresis, dry sticky mucous membranes, weakness, disoriantation and decreasing level of conciousness. which electrolyte imbalance does this data support? a, hyperkalemia b. hypercalcimia c. hypernatriumia d. hypermagnesemia c. hypernatriumia a client exibits an increasing blood pressure and 2 Ib weight gain over 2 days. which additional clinical manifestation can be clustered with this data? a. decrease in heart rate b. increase in skin turgor c. increase in pulse volume d. decrease in pulse pressure c. increase in pulse volume with excess fluid volume the amount of circulating blood volume increases 27 an assessment if which of the following is most important when a nurse is caring for an adult client experiencing vomiting? a. electrolyte values b. bowel function c. body weight d. oral mucosa a. electrolyte values vomiting results in loss of chloride, sodium, and potassium, it can also cause dsrythmias a primary health care provider prescribes IV infusion containing potassium for a client. which is the most important nursing intervention before administering this solution to the client? a. assess the skin turgor b. obtain blood pressure c. measure the depth of edema d. determine the presence of urinary output d. determine the presence of urinary output 28 several clients are taking supplemental calcium daily. the nurse teaches them to maintain their fluid intake at a minimum of 2,500 mL. the nurse explains that this intervention is designed to prevent which compliaction? a. mobilization of calcium from bone b. irritation of the bladder mucosa c. occurence of muscle cramps d. formation of kidney stones d. formation of kidney stones a client receiving an enteral feeding develops diarrhea. which characteristic of the tube feeding formula does the nurse conclude precipitated the diarrhea? a. hypertonic b. hypotonic c. isotonic d. icteric a. hypertonic hypertonic higher concentration of solutes than blood plasma, fluid is pulled from cells causing them to shrink 29 hypotonic lower concentration of solutes than blood plasma, fluid flows into the cells causing them to swell isotonic same concentration of solute as blood plasma, used to restore fluid volume ex. normal saline a nurse identifies that an older adult client may have a problem with excess fluid volume. which charcterisitc of the clients skin support this conclusion? a. dry and scaly b. taut and shiny c. red and irritated d. thin and inelastic b. taut and shiny a nurse is monitoring a client who is receiving IV fluid. which clinical findings indicates that the client has a fluid overload? a. chills, fever and generalized discomfort b. blood in the tubing close to the insertion site 30 c, dyspnea, headache, increased BP d. pallor, swelling, and discomfort at the insertion site c, dyspnea, headache, increased BP the nurse is administering IV fluids to a client. which complication should prompt the nurse to slow the rate of flow of the infusion rather than stop the infusion and remove the catheter? a. infiltration b. extravasation c. inflamed vein d. fluid overload d. fluid overload a nurse is monitoring a client who is receiving fluids intravenously. which of the following at the insertion site indicates that the IV has infliltrated? select all a. redness b. swelling c. firmness d. coolness e. inflammation swelling and coolness 31 how often should intermittent tubing be changed? every 24 hrs how often should continuos tubing be changed? every 72-96 hrs phlebitis -inflammation of vein at insertion site -redness, warmth, burning along vein infiltration -IV needle becomes disloged from vein and fluid flows into intersitial fluid causing swelling -leaking at site, swelling, coolness, pallor, discomfort colloids -contain protein or starch -used to re-establish circulating volumes and onotic presssure 32 - always hypertonic how long does a "unit" of blood need to be finished? 4 hrs fluid volume deficit loss of water and electrolytes fluid volume excess gain of water and electrolytes What are the signs of fluid volume excess? weight gain, pulmonary congestion, edema what are the signs of fluid volume deficit? hypotension, weak and thready pulse, tachycardia 33 fluid volume deficit: third spacing -fluid remains in the body but is not available for use - two phases: loss phase and reabsorption phase hypervolemia -fluid overload -abnormal losses through skin, GI tract, kidney, decreased fluid intake, movement of fluid into 3rd space does BP rise or fall with fluid excess BP will increase signs and symptoms of fluid volume deficit: dry mucous membranes, decreased salvation, low temp, weak HR, orthostatic hypotension, less than 30mL of urine per hour, increased hct and BUN Biotransformation/metabolism -drug is converted to less active from -3 factors that affect it: 34 excretion process where metabolites are removed from the body; mostly by kidneys producing urine Polypharmacy use of more medication than what is clinically warranted: 5 or more drugs including supplements essential parts of a drug order: -name -date and time - name of drug -dosage of drug -frequency of administration -route of admin -signature of person writiting the order medication three checks read the label on the med and compare to MAR: 1. when it is taken from the drawer 35 2. while preparing the med 3. after withdrawing the med/ before returning to drawer or before opening package at bedside what position should pt be in when administering rectal med? left lateral or SIMS how far do you insert a rectal med? 3-4 in eye drops -discard 1st bead of med -instill drops or apply ointment on conjunctival sac -push on nasolacrimal duct for 30 seconds -contacts need to be removed b4 administration otic meds -warm med in hands to prevent dizziness, naseua, pain -press gently on tragus to assist flow of med into ear canal 36 -remain on side for 2-5 min rebound effect over use of med -opposite effect will happen - for nasal meds they become more stuffy than before nurses are legally required to document meds that are adminstered. the nurse is mandated to document which of the following? a. medication b4 administering b. med after administering c. rationale for administering d. prescriber rationale for prescribing it b. med after administering you are caring for a pt who has diabetes complicated by kidney disease. you need to make a detailed asssessment when administering medications because this pt may experience problems w/? a. absorption b. biotranfromation c. distribution 37 d. excretion d. excretion what do you need to do when withdrawing medication from a vial? instill with air of equal volume you want to withdraw if you can grasp 1" of skin what angle should you insert the injection? 45 degrees if you can grasp 2" of skin what angle should you insert the injection? 90 degrees at what angle is heparin always injected at? 90 degrees when administering heparin does the nurse aspirate? no 38 after administering heparin and removing the needle, should the nurse massage the area? no can cause bleeding, bruising, and can hasten drug absorption when the nurse has to mix the regular and NPH insulin, how does the RN proceed? do regular insulin first then NPH because it has a preservative we dont want mixing with regular what is the prefered site for IM injections? a. vastus lateralis b. dorsogluteal c. deltoid d. ventrogluteal e. rectus femoris d. ventrogluteal the nurse accidently gives a pt a med at the wrong time, what is the nurses first priority? a, complete and occurence report 39 b. notify health care provider c. inform charge nurse of error d. assess the pt for adverse side effects d. assess the pt for adverse side effects what factors influence absorption of medication? select all a. total body weight b. body temp c. route of admin d. solubility e. blood flow to the site of administration the mother of a a 2-month old infant calls the nurse. the mother is concerned because her infants has been vomiting and has had several loose stools for 2 days. what instruction should the nurse give the infants mother? a. bring the infant to the clinic for eval b. give the infant at least two oz of apple juice every 1 hr c. measure the infants urine output for 24 hrs d. provide the infant with 50 mL glucose water a. bring the infant to the clinic for eval 40 a senior student nurse delegates the task of intake and output to a new nursing assistant. the student will verify that the nursing assistant understands the task of I & O when the nursing student states: a. i will record the amount of all voided urine b. i will not count liquid stools as output c. i will not record a cafe mocha as intake d. i will notate perspiration and record it as small or large amount a. i will record the amount of all voided urine a patient who is receiving IV fluids develops tenderness, warmth, erythema, and pain at the site, which condition would the nurse suspect? a. sepsis b. phlebitis c. infiltration d. fluid overload b. phlebitis is 0.9 % NaCl hypertonic, isotonic, or hypotonic? isotonic what are the the bodys two compensatory mechanisms for acid-base balance? 41 respiratory and renal systems the nurse observing the pt who is recieiving blood/blood products. in the first 15 minutes the nurse stopes the transfusion for an acute hemolytic reaction, which is characterized by which of the following? a. chills ea c. fever d. itching e. lumbar pain f. vomiting a. chills ea c. fever d. itching e. lumbar pain how can the use of diuretics alter fluid and electrolyte balance? diuretics promote fluid output and they can enhance excretions of sodium and potassium 42 when a pts serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system? a. neurological b. GI c. pulmonary d. hepatic a. neurological the majority of body fluid is located in which areas? a. interstitial b. extracellular c. intravascular d. intracellular d. intracellular of all of the following pts, the nurse recognizes that the individual who is most at risk for a fluid volume deficit is: a. 6 months old learning to drink from a cup b. 42 yr old with severe vomiting c. 90 ur old with frequent headaches d. 12 yr old who is moderately active in 80 degree F weather b. 42 yr old with severe vomiting 43 a pt experiences a loss of intracellular fluid. the nurse anticipates that the IV therapy that will be used to replace this type of loss is: a. 0.33 % NS b. 10% dextrose c. 5% dextrose in lactated ringer d. dextrose 5% in 1/ NS a. 0.33 % NS a pt has experienced an extensive burn and now has bradychardia, muscle weakness, and abdominal cramping, which of the following lab values would be more desirable for the nurse to obtain on the basis of the pts assessment? a. serum potassium b. serum magnesium c. serum sodium d. serum calcium a. serum potassium the nurse will be starting a new IV infusion and need to select the site for insertion. in selection of the site, the nurse should: a. use sites on an extremity away from dialysis graft 44 b. start with the most proximal site c. look for hard, cordlike veins d. use the pts dominant arm a. use sites on an extremity away from dialysis graft pt has IV therapy for the administration of antibiotics and is stating that the "IV site hurts and is swollen". which of the following information assessed on the pt indicates the presence of phelbitis, as opposed to infiltration? a. intensity of the pain b. amount of subcut edema c. skin discoloration of a bruised nature d. warmth of the skin surrounding the IV site d. warmth of the skin surrounding the IV site a pt complains of a headache and nausea and vomiting during blood transfusion which one of the following actions should the nurse take immediately? a. check the vitals b. stop the blood transfusion c. slow down the rate of blood flow d. notify the physician and blood bank personnel b. stop the blood transfusion 45 for a pt with a nursing diagnosis of increased fluid volume/ fluid retention, the nurse is alert to which one of the following signs and symptoms? a. dry mucous membranes b. weak, thready pulse c. hypertension d. flushed skin c. hypertension a pt is currently taking lasix and digoxin. as a result of the medication regimen, the nurse is alert to the presence of: a. cardiac dysrhythmias b. severe diarrhea c. hyperactive reflexes d. peripheral cyanosis a. cardiac dysrhythmias for the pt with a vitamin D deficiency and inadequate calcium intake, the nurse observes for: a. anxiety b. diaphorisis c. chvostek sign 46 d. naseau and vomiting c. chvostek sign single best indicator of fluid status is the nurses assessment of the pts: a. skin turgor b. daily body weight c. intake and output d. serum electrolyte levels b. daily body weight a pt is admitted to the hospital with a diagnosis of adrenal insufficiency. in preparing to complete the admission history, the nurse anticipates that the pt with have experienced increased serum levels of: a, magnesium b. sodium c. chloride d. potassium a, magnesium the nurse anticipates that the pt with insufficient fluid volume deficit with manifest a: 47 a. decreased urine specific gravity b. decreased body weight c. increased BP d. Increased pulse strength b. decreased body weight a pt has severe anemia and will be receiving blood transfusions. the nurse prepares and begins infusion. 10 min after the pt develops tachycardia, chills, and low back pain. after stopping the infusion the nurse should: a. administer an antipyretic b. begin an infusion of epinephrine c. run normal saline through the blood tubing d. obtain and send urine and blood specimens to lab d. obtain and send urine and blood specimens to lab a pt has continuous infusion of 0.9% NS. for this infusion the tubing should be changed every: a. 24 hrs b. 48 hrs c. 72 hrs d. time the bag is changed c. 72 hrs 48 the nurse requires additional instruction if she selects which of the following IV catheter sizes for a pt who will be receiving a blood transfusion? a. 26 gauge b. 22 gauge c. 20 gauge d. 18 gauge a. 26 gauge the nurse anticipates that which of the following diagnostic tests will be done to determine the pts renal function? a. creatine b. calcium level c. hemoglobin d. serum albumin a. creatine the nurse is assessing a pts peripheral edema. an obvious indentation that lasts several seconds is classified as: a. 1+ b. 2+ 49 c. 3+ d. 4+ c. 3+ which of the following is the correct technique for use of an insulin pen? a. clean the open with household soap b. prime the pen with 2 units before use c. cover the needle until next dose d. empty the pen and complete the dosage with a new pen if necessary b. prime the pen with 2 units before use which of the following actions preformed by the new staff nurse and observed by the nurse manager requires additional instruction? a. giving meds 20 min before scheduled time b. applying a topical med cream without gloves c. alternating the sides of the cheeks for buccal meds d. documenting in the MAR that the pt refused meds b. applying a topical med cream without gloves the pt is to receive a med via the buccal route. the nurse plans to implement which of the following actions? 50 a. place the medication inside the cheek b. crush the med before administration c. use sterile technique to administer the med d. offer the patient a glass of orange juice after adminsitration a. place the medication inside the cheek the nurse is working with a pediatric unit. in preparing to give medicaiitons to a peschool-aged child, an appropriate interaction by the nurse is? a. do you want to take your medication now? b. would you like the medication with water or juice c. let me explain about the shot that you will be getting d. if you dont take the medication now you will not get better b. would you like the medication with water or juice a pt has a prescription for a med that is adminsitered via inhaler. to determine if the pt requires a spacer for the inhaler, the nurse will determine the: a. ability of the pt to control the rate of inhalation b. dosage of med required c. schedule of admin d. use of a dry-powder inhaler a. ability of the pt to control the rate of inhalation 51 the student RN reads the order to give a 4 month old pt an intramuscular injection. the appropraite and preferred muscle to select for a child is the: a. deltoid b. dorsogluteal c. ventrogluteal d. vastus lateralis d. vastus lateralis the nurse administers the IM med of iron by the Z-track method. the med was adminsitered by this method to: a. provide faster absorption b. reduce discomfort from the needle c. provide more even absorption of the drug d. prevent the drug from irritating sensitive tissue d. prevent the drug from irritating sensitive tissue an order is written by the prescriber for morphine 40 mg IM q 2h prn for pain. the nurse recognizes that this is significantly more than the usual theraputic dose. the nurse should: a. call the prescriber the clarify the order b. give 4 mg IM as it was probably intended to be written 52 c. refuse to give the med and notify the nurse manager d. adminisiter the med and watch pt carefully a. call the prescriber the clarify the order The nurse assesses that a patient has tachycardia, increased body temperature, and decreased blood pressure. On further assessment, the nurse finds the patient's pulse rate to be weak on palpation. Which complication should the nurse expect to find in this patient based on these findings? Fluid volume deficitTachycardia, which is increased heart rate, is the first indication of a fluid volume deficit. To ensure adequate oxygenation of the tissues, the heart rate accelerates to maintain the normal cardiac output. Fluid volume deficit leads to a weak pulse on palpation, and it also reduces the blood pressure due to a decrease in the circulating volume of the blood. Fluid volume excess increases blood pressure and body temperature and causes a strong bounding pulse. Metabolic acidosis occurs due to loss of bicarbonate ions and an increase in acids produced as byproducts of a metabolic process and causes Kussmaul respirations. Respiratory alkalosis is not associated with the symptoms of increased heart rate, increased body temperature, and decreased blood pressure; it occurs due to hyperventilation and excess exhalation of carbon dioxide. Which type of intravenous solution would the nurse expect the healthcare provider to prescribe for a patient with an isotonic volume deficit? 0.9% normal saline solution D5 0.5 normal saline solution 53 Which statements made by the patient indicate inadequate health literacy? "I take my medication regularly, but I can't tell if my health has changed." "I'm unable to understand the questions asked on the hospital admission forms." "I need you to read this instructions paper to me since I forgot my glasses." Which three A's of the National Action Plan to Improve Health Literacy should the nurse consider when planning patient education? Accurate Accessible Actionable The nursing staff at a healthcare agency strives to meet the goals for nursing set forth by the Institute of Medicine Report. Which goals would the nursing staff attempt to achieve based on the report? Which statement would the nurse make when explaining how to choose a donor for platelet transfusion for a patient with the blood type O who needs platelets The donor should be of blood group O Which electrolyte disturbance would the nurse evaluate when caring for a patient who is suffering from syndrome of inappropriate hormone (SIADH) secretion 54 Hypoatrenemia Which assessment finding would cause the nurse to conclude that the patient has metabolic acidosis after reviewing a patient's arterial blood gas reports? pH 7.25, PaCO2 of 40mmHg, HCO3 of 17 mEq/L Which electrolyte imbalance does the nurse expect initially in a patient with diabetic ketoacidosis? Hyperkalemia Which statement describes the partial pressure of carbon dioxide (PaCO2)? A measure of how well the lungs are excreting CO2. Which needle gauge would the nurse use when providing intravenous therapy for an elderly patient with dehydration? 2