NUR 104 FINAL EXAM 1 PRACTICE QUESTIONS
AND DETAILED SOLUTIONS
◉ Describe the changes in lab values for urine specific gravity,
hematocrit, BUN with fluid volume deficit.
Answer: they will all increase.
increased hematocrit (54% +)
increased BUN (24+)
increased urine specific gravity (1.030 +)
◉ Identify the primary replacement fluid for dehydration.
Answer: 0.9%NS
◉ Create a list of assessment cues for a patient with isotonic-fluid
volume deficit.
Answer: Vitals - Pulse is thready and weak, tachycardia, orthostatic
hypotension, hyperthermia
Neuro- dizzy, confused, weak, fatigued, lethargic
GI - Thirsty, dry oral mucosa, N/V, anorexia, weight loss.
◉ List the nursing intervention for a patient with alterations in
potassium blood levels
,Answer: Place on an EKG immediately, assess for alterations in heart
rhythm.
◉ Create a set of vital signs for a patient in hypovolemic shock.
Answer: Tachycardia, hypotension, tachypnea, hypothermia,
decreased O2
◉ Identify the changes in blood pressure and pulse rate with
hypovolemic shock.
Answer: BP drops, HR increases
◉ List the assessment cues of shock.
Answer: Tachycardia is the first sign of all shock types.
Then tachypnea/hyperventilation and changes in LOC
◉ Identify the first line medication treatment for anaphylactic shock
Answer: epinephrine
◉ Describe the assessment cues for a patient with sepsis.
Answer: Fever, Chills, tachycardia, tachypnea, altered LOC,
hypotension, dyspnea. Increased WBC
◉ Identify the most common microorganism of sepsis.
, Answer: Staphylococcus aureus (staph)
Escherichia coli (E. coli)
Some types of Streptococcus.
◉ Identify the first assessment change in a patient with altered
cerebral status.
Answer: Change in LOC
◉ Describe the physical cues of intracranial pressure
Answer: Changes in LOC (#1 sign),
Continuous Headache,
Projectile Vomit,
Cushing Triad
Changes in body temp.
◉ Create a list of vital signs exhibiting the Cushing triad.
Answer: Systolic hypertension with wide pulse pressure,
Bradycardia
irregular respirations
◉ List the proper positioning for a patient with intracranial
pressure.
AND DETAILED SOLUTIONS
◉ Describe the changes in lab values for urine specific gravity,
hematocrit, BUN with fluid volume deficit.
Answer: they will all increase.
increased hematocrit (54% +)
increased BUN (24+)
increased urine specific gravity (1.030 +)
◉ Identify the primary replacement fluid for dehydration.
Answer: 0.9%NS
◉ Create a list of assessment cues for a patient with isotonic-fluid
volume deficit.
Answer: Vitals - Pulse is thready and weak, tachycardia, orthostatic
hypotension, hyperthermia
Neuro- dizzy, confused, weak, fatigued, lethargic
GI - Thirsty, dry oral mucosa, N/V, anorexia, weight loss.
◉ List the nursing intervention for a patient with alterations in
potassium blood levels
,Answer: Place on an EKG immediately, assess for alterations in heart
rhythm.
◉ Create a set of vital signs for a patient in hypovolemic shock.
Answer: Tachycardia, hypotension, tachypnea, hypothermia,
decreased O2
◉ Identify the changes in blood pressure and pulse rate with
hypovolemic shock.
Answer: BP drops, HR increases
◉ List the assessment cues of shock.
Answer: Tachycardia is the first sign of all shock types.
Then tachypnea/hyperventilation and changes in LOC
◉ Identify the first line medication treatment for anaphylactic shock
Answer: epinephrine
◉ Describe the assessment cues for a patient with sepsis.
Answer: Fever, Chills, tachycardia, tachypnea, altered LOC,
hypotension, dyspnea. Increased WBC
◉ Identify the most common microorganism of sepsis.
, Answer: Staphylococcus aureus (staph)
Escherichia coli (E. coli)
Some types of Streptococcus.
◉ Identify the first assessment change in a patient with altered
cerebral status.
Answer: Change in LOC
◉ Describe the physical cues of intracranial pressure
Answer: Changes in LOC (#1 sign),
Continuous Headache,
Projectile Vomit,
Cushing Triad
Changes in body temp.
◉ Create a list of vital signs exhibiting the Cushing triad.
Answer: Systolic hypertension with wide pulse pressure,
Bradycardia
irregular respirations
◉ List the proper positioning for a patient with intracranial
pressure.
