PNR 408 TEST #1 | UPDATED Questions with 100% Verified
Answers
Question: When monitoring a client with prolonged vomiting for fluid volume deficit, what does the nurse
recognize about fluid shifts that occur as a result of vomiting?
Answer:
A Prolonged vomiting can lead to a 2nd space shift
Question: A.Fluid moves from the cells into the interstitial space and the blood vessels. B.Fluid moves from
the vascular system, causing cellular swelling and rupture. C.An overload of extracellular fluid occurs with a
significant increase in intracellular fluid volume. D.Excretion of large amounts of interstitial fluid occurs with
depletion of extracellular fluids.
Answer:
Question: A client is taking hydrochlorothiazide for treatment of hypertension. What symptoms should the
nurse teach the client to report? A.Anxiety and muscle twitching B.Abdominal cramping and diarrhea
C.Fatigue and muscle weakness D.Confusion and personality changes
Answer:
C - HYPOKALEMIA A - hypocalcemia B - hypERkalemia D - hypomagnesemia
Question: A client who has required prolonged mechanical ventilation has the following arterial blood gas
results: pH 7.48, PO2 85 mm Hg, PCO2 32 mm Hg, and HCO3- 25 mmol/L. How would the nurse interpret
these results? A.Metabolic acidosis B.Metabolic alkalosis C.Respiratory acidosis D.Respiratory alkalosis
Answer:
D pH is HIGH = alkaline PCO2 is altered = RESP When PCO2 is low, pH will be higher (alkaline), and when
PCO2 is high, pH will be low (acidic)
Question: The physician has written an order for a client to receive 0.9% NaCl @ 125mL/hr.
Answer:
Drop factor! You can find this on the package for IV tubing.
Question: -What other information is needed to run the rate manually? -Where can this information be found?
-What is the gtts/min?
, Answer:
125ml/60min = 2.08 2.08ml/minx10gtts/ml = 21gtts/min
Question: You are administering Cefoxitin 250 mg IV in 50 mL NS over 20 minutes. At what rate per hour
will you program the secondary IV line to infuse?
Answer:
50ml/20min = 150ml/hr
Question: A patient with acute blood loss requires a transfusion with packed red blood cells. Which task is
appropriate for the nurse to delegate to nursing assistive personnel (NAP)? A.Monitor the patient for shortness
of breath and back pain. B.Confirm the IV solution is 0.9% saline. C.Obtain and record the vital signs before
the transfusion is initiated. D.Double-check the patient identity, and verify the blood product.
Answer:
C The RN may delegate tasks such as taking vital signs to NAP. Assessments (e.g., monitoring for signs of a
blood transfusion reaction [shortness of breath and back pain]) are within the scope of practice of the RN and
may not be delegated to UAP. The RN must also assume responsibility for ensuring the correct IV fluid is used
with blood products. A licensed nurse must complete verification of the patient's identity and the blood product
data.
Question: Characteristics of a deep partial-thickness burn include all of the following except: a.Weeping
surface b.Absence of edema c.Broken epidermis d.Mottled, red base
Answer:
B Partial-thickness burns often have blisters that fill with edematous fluids
Question: A patient is burned in a house fire. The burns cover the face and the left forearm. What percentage of
burn does the patient have?
Answer:
C - 4.5%+4.5% = 9%
Question: A.10% B.25% C.9% D.18%
Answer:
Question: When monitoring initial fluid replacement for the patient with 40% TBSA deep partial-thickness and
full-thickness burns, which of the following findings is of most concern to the nurse? A.Urine output of 35
mL/hr B.Serum K+ of 4.5 mmol/L C.Decreased bowel sounds D.Blood pressure of 86/72 mm Hg
Answer:
D
, Question: During the emergent phase of burn injury, the nurse assesses for the presence of hypovolemia. In
burn patients, hypovolemia occurs primarily as a result of: A.Blood loss from injured tissue. B.Third spacing of
fluid into fluid-filled vesicles. C.Evaporation of fluid from denuded body surfaces. D.Capillary permeability
with fluid shift to the interstitium.
Answer:
D Hypovolemic shock is caused by a massive shift of fluids out of the blood vessels as a result of increased
capillary permeability. Water, sodium, and plasma proteins move into interstitial spaces and other surrounding
tissue.
Question: The nurse is admitting a client who has abdominal pain, nausea, and vomiting. A bowel obstruction
is suspected. The nurse assesses this client for which of the following anticipated primary acid-base imbalances
if the obstruction is high in the intestine?
Answer:
B Because gastric secretions are rich in hydrochloric acid, the client who is vomiting will lose a significant
amount of gastric acid and be at an increased risk for metabolic alkalosis.
Question: a)Metabolic acidosis b)Metabolic alkalosis c)Respiratory acidosis d)Respiratory alkalosis
Answer:
Question: Which of the following serum potassium results best supports the rationale for administering a stat
dose of potassium chloride 20 mmol in 250 mL of NSS over 2 hours?
Answer:
A Normal K range = 3.5-5.0
Question: a)3.1 mmol/L b)3.9 mmol/L c)4.6 mmol/L d)5.3 mmol/L
Answer:
Question: The nurse receives a health care provider's prescription to change a client's IV from D5½NS with 40
mmol KCl/L to D5NS with 20 mmol KCl/L. Which of the following serum laboratory values, documented on
this same client, best supports the rationale for this IV order change? a)Sodium 136 mmol/L, potassium 4.5
mmol/L b)Sodium 145 mmol/L, potassium 4.8 mmol/L c)Sodium 135 mmol/L, potassium 3.6 mmol/L
d)Sodium 144 mmol/L, potassium 3.7 mmol/L
Answer:
A We know that provider has upped the sodium concentration since the new order has a change from 0.45NS to
0.9NS, so we would expect the Na level to be on the lower end of 135-145, so either A or C. The we know that
the potassium level is likely getting close to the upper limit as the KCl conc was decreased from 40 to
20mmol/L, which means we can eliminate C as a K level of 3.6 would not be a reason to DECREASE the
potassium infusion.
Answers
Question: When monitoring a client with prolonged vomiting for fluid volume deficit, what does the nurse
recognize about fluid shifts that occur as a result of vomiting?
Answer:
A Prolonged vomiting can lead to a 2nd space shift
Question: A.Fluid moves from the cells into the interstitial space and the blood vessels. B.Fluid moves from
the vascular system, causing cellular swelling and rupture. C.An overload of extracellular fluid occurs with a
significant increase in intracellular fluid volume. D.Excretion of large amounts of interstitial fluid occurs with
depletion of extracellular fluids.
Answer:
Question: A client is taking hydrochlorothiazide for treatment of hypertension. What symptoms should the
nurse teach the client to report? A.Anxiety and muscle twitching B.Abdominal cramping and diarrhea
C.Fatigue and muscle weakness D.Confusion and personality changes
Answer:
C - HYPOKALEMIA A - hypocalcemia B - hypERkalemia D - hypomagnesemia
Question: A client who has required prolonged mechanical ventilation has the following arterial blood gas
results: pH 7.48, PO2 85 mm Hg, PCO2 32 mm Hg, and HCO3- 25 mmol/L. How would the nurse interpret
these results? A.Metabolic acidosis B.Metabolic alkalosis C.Respiratory acidosis D.Respiratory alkalosis
Answer:
D pH is HIGH = alkaline PCO2 is altered = RESP When PCO2 is low, pH will be higher (alkaline), and when
PCO2 is high, pH will be low (acidic)
Question: The physician has written an order for a client to receive 0.9% NaCl @ 125mL/hr.
Answer:
Drop factor! You can find this on the package for IV tubing.
Question: -What other information is needed to run the rate manually? -Where can this information be found?
-What is the gtts/min?
, Answer:
125ml/60min = 2.08 2.08ml/minx10gtts/ml = 21gtts/min
Question: You are administering Cefoxitin 250 mg IV in 50 mL NS over 20 minutes. At what rate per hour
will you program the secondary IV line to infuse?
Answer:
50ml/20min = 150ml/hr
Question: A patient with acute blood loss requires a transfusion with packed red blood cells. Which task is
appropriate for the nurse to delegate to nursing assistive personnel (NAP)? A.Monitor the patient for shortness
of breath and back pain. B.Confirm the IV solution is 0.9% saline. C.Obtain and record the vital signs before
the transfusion is initiated. D.Double-check the patient identity, and verify the blood product.
Answer:
C The RN may delegate tasks such as taking vital signs to NAP. Assessments (e.g., monitoring for signs of a
blood transfusion reaction [shortness of breath and back pain]) are within the scope of practice of the RN and
may not be delegated to UAP. The RN must also assume responsibility for ensuring the correct IV fluid is used
with blood products. A licensed nurse must complete verification of the patient's identity and the blood product
data.
Question: Characteristics of a deep partial-thickness burn include all of the following except: a.Weeping
surface b.Absence of edema c.Broken epidermis d.Mottled, red base
Answer:
B Partial-thickness burns often have blisters that fill with edematous fluids
Question: A patient is burned in a house fire. The burns cover the face and the left forearm. What percentage of
burn does the patient have?
Answer:
C - 4.5%+4.5% = 9%
Question: A.10% B.25% C.9% D.18%
Answer:
Question: When monitoring initial fluid replacement for the patient with 40% TBSA deep partial-thickness and
full-thickness burns, which of the following findings is of most concern to the nurse? A.Urine output of 35
mL/hr B.Serum K+ of 4.5 mmol/L C.Decreased bowel sounds D.Blood pressure of 86/72 mm Hg
Answer:
D
, Question: During the emergent phase of burn injury, the nurse assesses for the presence of hypovolemia. In
burn patients, hypovolemia occurs primarily as a result of: A.Blood loss from injured tissue. B.Third spacing of
fluid into fluid-filled vesicles. C.Evaporation of fluid from denuded body surfaces. D.Capillary permeability
with fluid shift to the interstitium.
Answer:
D Hypovolemic shock is caused by a massive shift of fluids out of the blood vessels as a result of increased
capillary permeability. Water, sodium, and plasma proteins move into interstitial spaces and other surrounding
tissue.
Question: The nurse is admitting a client who has abdominal pain, nausea, and vomiting. A bowel obstruction
is suspected. The nurse assesses this client for which of the following anticipated primary acid-base imbalances
if the obstruction is high in the intestine?
Answer:
B Because gastric secretions are rich in hydrochloric acid, the client who is vomiting will lose a significant
amount of gastric acid and be at an increased risk for metabolic alkalosis.
Question: a)Metabolic acidosis b)Metabolic alkalosis c)Respiratory acidosis d)Respiratory alkalosis
Answer:
Question: Which of the following serum potassium results best supports the rationale for administering a stat
dose of potassium chloride 20 mmol in 250 mL of NSS over 2 hours?
Answer:
A Normal K range = 3.5-5.0
Question: a)3.1 mmol/L b)3.9 mmol/L c)4.6 mmol/L d)5.3 mmol/L
Answer:
Question: The nurse receives a health care provider's prescription to change a client's IV from D5½NS with 40
mmol KCl/L to D5NS with 20 mmol KCl/L. Which of the following serum laboratory values, documented on
this same client, best supports the rationale for this IV order change? a)Sodium 136 mmol/L, potassium 4.5
mmol/L b)Sodium 145 mmol/L, potassium 4.8 mmol/L c)Sodium 135 mmol/L, potassium 3.6 mmol/L
d)Sodium 144 mmol/L, potassium 3.7 mmol/L
Answer:
A We know that provider has upped the sodium concentration since the new order has a change from 0.45NS to
0.9NS, so we would expect the Na level to be on the lower end of 135-145, so either A or C. The we know that
the potassium level is likely getting close to the upper limit as the KCl conc was decreased from 40 to
20mmol/L, which means we can eliminate C as a K level of 3.6 would not be a reason to DECREASE the
potassium infusion.
