NURS 265 (SURGERY) WEEK 4 EAQ QUESTIONS AND
ANSWERS ELABORATIONS!!
The nurse is completing an assessment of a patient with heart failure who is being
treated for accidental overuse of diuretics. For which potential respiratory issue
should the nurse monitor the patient?
Answers :Rationale
Patients with deficient fluid volume experience decreased tissue perfusion and
hypoxia resulting in an increased respiratory rate. Pulmonary congestion, shortness
of breath, and moist crackles on inspiration are all characteristic of a fluid volume
excess, not deficit.
p. 277
The nurse is caring for a patient with hyponatremia associated with heart failure
and liver cirrhosis. What drug does the nurse anticipate administering to treat this
patient?
Answers :Rationale
Tolvaptan is used to treat hyponatremia associated with heart failure and liver
cirrhosis. It acts by blocking the activity of antidiuretic hormone. Amiloride is a
potassium-sparing diuretic that is not effective in treating hyponatremia.
Kayexalate is an ion-exchange resin used to treat hyperkalemia. Pamidronate is
used to treat hypercalcemia.
pp. 278-279
Which term is used to describe the fact that extracellular fluid and intracellular
fluid have the same osmolality?
Answers :Rationale
Extracellular fluid and intracellular fluid have the same osmolality; this
characteristic is termed isotonic, meaning that there is no net movement of fluids.
Hypotonic refers to fluids with a lower osmolality, which results in water moving
,into the cell when the cell is surrounded by a hypotonic fluid. Hypertonic refers to
fluids with a higher osmolality, which results in water moving out of the cells when
they are surrounded by a hypertonic solution. Oncotic pressure refers to the
pressure of plasma colloids in a solution.
p. 273
The emergency room nurse is caring for a patient with a severe fluid volume deficit
who presented after several days of diarrhea secondary to C. difficile infection.
Which intravenous (IV) fluid does the nurse anticipate will be used to rapidly
replace the fluid volume?
Answers :Rationale
An isotonic fluid such as 0.9% sodium chloride is used to rapidly replace fluid
volume. The solutions 0.45% sodium chloride, 5% dextrose in 0.25% saline, and
5% dextrose in 0.9% saline are all hypertonic solutions that are not used to rapidly
increase fluid volume.Test-Taking Tip: Make certain that the answer you select is
reasonable and obtainable under ordinary circumstances and that the action can be
carried out in the given situation.
p. 276
A patient is diagnosed with Cushing syndrome. What manifestation does the nurse
anticipate while assessing this patient?
Answers :Rationale
Excess extracellular volume may result from fluid retention during Cushing
syndrome. This shift of fluid into the interstitial spaces leads to blockage of air
spaces (pulmonary edema) resulting in dyspnea, crackles, and peripheral edema.
Dry mouth, weight loss, and restlessness are the common manifestations resulting
from extracellular fluid depletion.Test-Taking Tip: Identifying content and what is
being asked about that content is critical to your choosing the correct response. Be
alert for words in the stem of the item that are the same or similar in nature to those
in one or two of the options.
p. 273
,The nurse is preparing to cleanse the skin around a central venous access device.
Which solution would the nurse select as the most effective means of killing
harmful bacteria?
Answers :Rationale
Chlorhexidine-based solutions such as chlorhexidine gluconate have been shown to
be more effective at killing bacteria than povidone-alcohol or isopropyl alcohol
solutions. Therefore chlorhexidine-based solutions should be used to cleanse
around the central venous access device. A sterile saline solution does not have any
antiseptic properties.
p. 296
The nurse assesses the present of Trousseau's sign in a patient that had an
inadvertent removal of the parathyroids during a thyroidectomy. What electrolyte
disturbance should the nurse check the laboratory studies for?
Answers :Rationale
Trousseau's sign refers to carpal spasms induced by inflating a blood pressure cuff
on the arm. Hypocalcemia can be identified by Trousseau's sign. Hypercalcemia,
hypermagnesemia, and hyperphosphatemia cannot be identified by Trousseau's
sign.
p. 284
The nurse is preparing to document output for a patient at the end of the shift. The
patient has had 500 mL of urine output, vomited 100 mL of clear liquid, and 25 mL
of wound drainage was removed via a wound vacuum device. What does the nurse
record as the total output for this shift? Record your answer as a whole number. mL
Answers :625
Rationale
, The calculation of output includes excessive perspiration, urinary output, vomit,
diarrhea, and wound drainage. Totaling 500 mL of urine, 100 mL of vomit, and 25
mL of wound drainage results in 625 mL for the shift.
p. 277
The nurse is caring for a patient who is febrile with a body temperature of 103 oF.
What clinical manifestation does the nurse anticipate when assessing this patient?
Answers :Rationale
A patient with an elevated body temperature of 103 oF may have a loss of body
fluids leading to decreased blood volume and resulting in postural or orthostatic
hypotension. Muscle spasm, a bounding pulse, and jugular vein distention are
manifestations that occur due to an increase in the body fluid volume.
p. 276
The intravenous (IV) prescription reads "D5.45 normal saline (NS) with 40 mEq
KCl/L at 125 mL/hour." The nurse needs to add KCl to the IV because no
premixed solutions are available. The unit's medication supply has a stock of KCl 5
mEq/mL in multidose vials. The nurse would need to draw up milliliters to add to
the IV solution? Record your answer using a whole number.
Answers :8 mL
Rationale
The end concentration of the KCl is listed on the vial as follows: "5 mEq/mL."
Using ratio and proportion, multiply 5 by x and multiply 40 × 1 to yield 5x = 40.
Divide 40 by 5 to yield 8 mL.
p. 282
The nurse is caring for a group of patients. Which patient is at greatest risk for
increased extracellular fluid accumulation?
Answers :A patient with renal impairment
ANSWERS ELABORATIONS!!
The nurse is completing an assessment of a patient with heart failure who is being
treated for accidental overuse of diuretics. For which potential respiratory issue
should the nurse monitor the patient?
Answers :Rationale
Patients with deficient fluid volume experience decreased tissue perfusion and
hypoxia resulting in an increased respiratory rate. Pulmonary congestion, shortness
of breath, and moist crackles on inspiration are all characteristic of a fluid volume
excess, not deficit.
p. 277
The nurse is caring for a patient with hyponatremia associated with heart failure
and liver cirrhosis. What drug does the nurse anticipate administering to treat this
patient?
Answers :Rationale
Tolvaptan is used to treat hyponatremia associated with heart failure and liver
cirrhosis. It acts by blocking the activity of antidiuretic hormone. Amiloride is a
potassium-sparing diuretic that is not effective in treating hyponatremia.
Kayexalate is an ion-exchange resin used to treat hyperkalemia. Pamidronate is
used to treat hypercalcemia.
pp. 278-279
Which term is used to describe the fact that extracellular fluid and intracellular
fluid have the same osmolality?
Answers :Rationale
Extracellular fluid and intracellular fluid have the same osmolality; this
characteristic is termed isotonic, meaning that there is no net movement of fluids.
Hypotonic refers to fluids with a lower osmolality, which results in water moving
,into the cell when the cell is surrounded by a hypotonic fluid. Hypertonic refers to
fluids with a higher osmolality, which results in water moving out of the cells when
they are surrounded by a hypertonic solution. Oncotic pressure refers to the
pressure of plasma colloids in a solution.
p. 273
The emergency room nurse is caring for a patient with a severe fluid volume deficit
who presented after several days of diarrhea secondary to C. difficile infection.
Which intravenous (IV) fluid does the nurse anticipate will be used to rapidly
replace the fluid volume?
Answers :Rationale
An isotonic fluid such as 0.9% sodium chloride is used to rapidly replace fluid
volume. The solutions 0.45% sodium chloride, 5% dextrose in 0.25% saline, and
5% dextrose in 0.9% saline are all hypertonic solutions that are not used to rapidly
increase fluid volume.Test-Taking Tip: Make certain that the answer you select is
reasonable and obtainable under ordinary circumstances and that the action can be
carried out in the given situation.
p. 276
A patient is diagnosed with Cushing syndrome. What manifestation does the nurse
anticipate while assessing this patient?
Answers :Rationale
Excess extracellular volume may result from fluid retention during Cushing
syndrome. This shift of fluid into the interstitial spaces leads to blockage of air
spaces (pulmonary edema) resulting in dyspnea, crackles, and peripheral edema.
Dry mouth, weight loss, and restlessness are the common manifestations resulting
from extracellular fluid depletion.Test-Taking Tip: Identifying content and what is
being asked about that content is critical to your choosing the correct response. Be
alert for words in the stem of the item that are the same or similar in nature to those
in one or two of the options.
p. 273
,The nurse is preparing to cleanse the skin around a central venous access device.
Which solution would the nurse select as the most effective means of killing
harmful bacteria?
Answers :Rationale
Chlorhexidine-based solutions such as chlorhexidine gluconate have been shown to
be more effective at killing bacteria than povidone-alcohol or isopropyl alcohol
solutions. Therefore chlorhexidine-based solutions should be used to cleanse
around the central venous access device. A sterile saline solution does not have any
antiseptic properties.
p. 296
The nurse assesses the present of Trousseau's sign in a patient that had an
inadvertent removal of the parathyroids during a thyroidectomy. What electrolyte
disturbance should the nurse check the laboratory studies for?
Answers :Rationale
Trousseau's sign refers to carpal spasms induced by inflating a blood pressure cuff
on the arm. Hypocalcemia can be identified by Trousseau's sign. Hypercalcemia,
hypermagnesemia, and hyperphosphatemia cannot be identified by Trousseau's
sign.
p. 284
The nurse is preparing to document output for a patient at the end of the shift. The
patient has had 500 mL of urine output, vomited 100 mL of clear liquid, and 25 mL
of wound drainage was removed via a wound vacuum device. What does the nurse
record as the total output for this shift? Record your answer as a whole number. mL
Answers :625
Rationale
, The calculation of output includes excessive perspiration, urinary output, vomit,
diarrhea, and wound drainage. Totaling 500 mL of urine, 100 mL of vomit, and 25
mL of wound drainage results in 625 mL for the shift.
p. 277
The nurse is caring for a patient who is febrile with a body temperature of 103 oF.
What clinical manifestation does the nurse anticipate when assessing this patient?
Answers :Rationale
A patient with an elevated body temperature of 103 oF may have a loss of body
fluids leading to decreased blood volume and resulting in postural or orthostatic
hypotension. Muscle spasm, a bounding pulse, and jugular vein distention are
manifestations that occur due to an increase in the body fluid volume.
p. 276
The intravenous (IV) prescription reads "D5.45 normal saline (NS) with 40 mEq
KCl/L at 125 mL/hour." The nurse needs to add KCl to the IV because no
premixed solutions are available. The unit's medication supply has a stock of KCl 5
mEq/mL in multidose vials. The nurse would need to draw up milliliters to add to
the IV solution? Record your answer using a whole number.
Answers :8 mL
Rationale
The end concentration of the KCl is listed on the vial as follows: "5 mEq/mL."
Using ratio and proportion, multiply 5 by x and multiply 40 × 1 to yield 5x = 40.
Divide 40 by 5 to yield 8 mL.
p. 282
The nurse is caring for a group of patients. Which patient is at greatest risk for
increased extracellular fluid accumulation?
Answers :A patient with renal impairment
