n n n n n
A nnurse nis nadministering n1 nL nof n0.9% nsodium nchloride nto na nclient nwho nis npostoperative nand
nhas nfluid nvolume ndeficit. nWhich nof nthe nfollowing nchanges nshould nthe nnurse nidentify nas nan
nindication nthat nthe ntreatment nwas nsuccessful?
Increase nin nhematocrit
nincrease nin nrespiratory nrate
Decrease nin nheart nrate
Decrease nin ncapillary nrefill ntime n- nCorrect nAnswer:
Decrease nin nheart nrate
Fluid nvolume ndeficit ncauses ntachycardia. nWith ncorrection nof nthe nimbalance, nthe nheart nrate
nshould nreturn nto nthe nexpected nrange.
Incorrect nAnswers:
Increase nin nhematocrit:
Fluid nvolume ndeficit ncauses nan nincrease nin nhematocrit nlevel ndue nto ndepletion nof nextracellular
nfluid. nWith ncorrection nof nthe nimbalance, nthe nhematocrit nlevel nshould ndecrease.
increase nin nrespiratory nrate
Fluid nvolume ndeficit ncauses nan nincrease nin nrespiratory nrate. nWith ncorrection nof nthe
nimbalance, nthe nrespiratory nrate nshould nreturn nto nthe nexpected nrange.
Decrease nin ncapillary nrefill ntime
Fluid nvolume ndeficit nslows ncapillary nrefill. nWith ncorrection nof nthe nimbalance, ncapillary nrefill
ntime nshould nreturn nto nthe nexpected nrange.
A nnurse nis ncaring nfor na nclient nwho nis nscheduled nto nbe ntransferred nto na nlong-term ncare
nfacility. nThe nclient's nfamily nquestions nthe nnurse nabout nthe nreasons nfor nthe ntransfer. nWhich nof
nthe nfollowing nresponses nmade nby nthe nnurse nis nappropriate?
"The ntransfer nof nyour nfamily nmember nis nbeing ndone nbecause nthe nprovider nknows nwhat's
nbest."
"Would nyou nlike nit nif nwe ndiscussed nthe ntransfer nwith nyour nfamily nmember?"
"Why nare nyou nso nconcerned nabout nthis ntransfer?"
"I nknow nhow nyou nfeel. nMy nparent nhad nto nbe ntransferred nto na nlong-term ncare nfacility." n-
nCorrect nAnswer:
,"Would nyou nlike nit nif nwe ndiscussed nthe ntransfer nwith nyour nfamily nmember?" nThis
nresponse nfacilitates ntherapeutic ncommunication nand nprovides ngeneral nleads nwhile
nmaintaining nclient nconfidentiality.
Incorrect nAnswers:
"The ntransfer nof nyour nfamily nmember nis nbeing ndone nbecause nthe nprovider nknows nwhat's
nbest." nThis nis na ndefensive nresponse nwhich ncan nhinder nfurther ncommunication.
"Why nare nyou nso nconcerned nabout nthis ntransfer?"
Asking na nwhy nquestion ncan nmake nthe nrecipient ndefensive nwhich ncan nhinder nfurther
ncommunication.
"I nknow nhow nyou nfeel. nMy nparent nhad nto nbe ntransferred nto na nlong-term ncare
nfacility." nThis nis na nsympathetic nresponse, nwhich ncan ninterfere nwith na ntherapeutic
nrelationship.
A nnurse nis nreviewing nthe nlaboratory nresults nof na nfemale nclient nwho nhas nhypovolemia. nWhich
nof nthe nfollowing nlaboratory nresult nwould nbe na npriority nfor nthe nnurse nreport nto nthe nprovider?
BUN n21 nmg/dL n(10 nto n20 nmg/dL)
Creatinine n1.4 nmg/dL n(0.5 nto n1.1 nmg/dL)
Sodium n132 nmEq/L n(136 nto n145 nmEq/L)
Potassium n5.8 nmEq/L n(3.5 nto n5 nmEq/L) n- nCorrect nAnswer:
Potassium n5.8 nmEq/L n(3.5 nto n5 nmEq/L)
When nusing nthe nurgent nversus nnonurgent napproach nto nclient ncare, nthe nnurse nshould ndetermine
nthat nthis npotassium nlevel nis nabove nthe nexpected n reference nrange nand nshould nbe nreported nto
nthe nprovider. nPotassium naffects nthe ncontractility nof nthe nheart nand nthis nclient nwould nbe nat nrisk
nfor ndeveloping ndysrhythmias.
Incorrect nanswers:
BUN n21 nmg/dL n(10 nto n20 nmg/dL)
This nBUN nlevel nis nslightly nabove nthe nexpected nreference nrange nand nis nan nexpected nnon-
urgent nfinding nfor na nclient nwho nhas nhypovolemia; ntherefore, nthere nis nanother nlaboratory
nresult nthat nis na npriority nfor nthe nnurse nto nreport nto nthe nprovider.
Creatinine n1.4 nmg/dL n(0.5 nto n1.1 nmg/dL)
This ncreatinine nlevel nis nslightly nabove nthe nexpected nreference nrange nand nis nan nexpected nnon-
urgent nfinding nfor na nclient nwho nhas nhypovolemia; ntherefore, nthere nis nanother nlaboratory
nresult nthat nis na na npriority nfor nthe nnurse nto nreport nto nthe nprovider.
,Sodium n132 nmEq/L n(136 nto n145 nmEq/L)
This nsodium nlevel nis nslightly nbelow nthe nexpected nreference nrange nand nis nan nexpected nnon-
urgent nfinding nfor na nclient nwho nhas nhypovolemia; ntherefore, nthere nis nanother nlaboratory
nresult nthat nis na
priority nfor nthe nnurse nto nreport nto nthe nprovider.
A nnurse nis ncaring nfor na nclient nwho nreports ndifficulty nfalling nasleep. nWhich nof nthe nfollowing
nrecommendations nshould nthe nnurse nmake?
"Drink na ncup nof nhot ncocoa nbefore nbedtime."
"Maintain na nconsistent ntime nto nwake nup neach nday."
"Exercise n1 nhour nbefore ngoing nto nbed."
"Watch na ntelevision nprogram nin nbed nbefore ngoing nto nsleep." n- nCorrect nAnswer:
"Maintain na nconsistent ntime nto nwake nup neach nday."
The nclient nshould nmaintain na nconsistent ntime nfor nwaking nup nand ngoing nto nsleep. nThis nhelps
nto nestablish nan ninternal nsense nof nsleep nand nwaking non na ndaily nbasis nand nhelps nto nmaintain nit
nover ntime. nThis nwill nhelp npromote nsleep nfor nthe nclient.
Incorrect nAnswers:
"Drink na ncup nof nhot ncocoa nbefore nbedtime."
Cocoa ncontains ncaffeine, nwhich nis na nstimulant nthat ncan ninterfere nwith nsleep.
"Exercise n1 nhour nbefore ngoing nto nbed."
Exercising nwithin n2 nhr nof nbedtime ncan ninterfere nwith nsleep.
"Watch na ntelevision nprogram nin nbed nbefore ngoing nto nsleep."
The nclient nshould navoid nwatching ntelevision nin nbed nbefore ngoing nto nsleep nto nreduce
nstimulation nin norder nto npromote nrest.
A nnurse non na nmedical-surgical nunit nis ncaring nfor na nclient nwho nhas na nnew nprescription nfor
nwrist nrestraints. nWhich nof nfollowing nactions nshould nthe nnurse ntake?
Pad nthe nclient's nwrist nbefore napplying nthe nrestraints.
Evaluate nthe nclient's ncirculation nevery n8 nhr nafter napplication.
Remove nthe nrestraints nevery n4 nhr nto nevaluate nthe nclient's nstatus.
Secure nthe nrestraint nties nto nthe nbed's nside nrails. n- nCorrect nAnswer:
Pad nthe nclient's nwrist nbefore napplying nthe nrestraints.
The nuse nof nrestraints nwithout npadding ncan nabrade nthe nclient's nskin, nresulting nin nclient ninjury.
, Incorrect nAnswers:
Evaluate nthe nclient's ncirculation nevery n8 nhr nafter napplication.
The nnurse nshould nevaluate nthe nclient's ncirculation, nrange nof nmotion, nvital nsigns, nand noverall
nstatus nevery n15 nmin nafter ninitial napplication nof nrestraints.
Remove nthe nrestraints nevery n4 nhr nto nevaluate nthe nclient's nstatus.
The nnurse nshould nremove nthe nrestraints nat nleast nevery n2 nhr nto nreposition nthe nclient nand
nassess nneeds nfor nhygiene nand ntoileting.
Secure nthe nrestraint nties nto nthe nbed's nside nrails.
The nnurse nshould nsecure nthe nrestraint nties nto na npart nof nthe nbed nframe nthat nmoves nwith nthe
nclient nto nreduce nthe nrisk nof ninjury.
A nclient nwho nis nnonambulatory nnotifies nthe nnurse nthat ntheir ntrash ncan nis non nfire. nAfter nthe
nnurse nconfirms nthe npresence nof nthe nfire, nwhich nof nthe nfollowing nactions nshould nthe nnurse
ntake nnext?
Activate nthe nemergency nfire nalarm.
Extinguish nthe nfire.
Evacuate nthe nclient.
Confine nthe nfire. n- nCorrect nAnswer:
Evacuate nthe nclient.
According nto nthe nRACE nmnemonic, nthe nfirst naction nin nresponse nto na nfire nis nto nrescue nthe
nclients, nmoving nthem nto na nsafe narea.
Incorrect nAnswers:
Activate nthe nemergency nfire nalarm.
According nto nthe nRACE nmnemonic, nthe nsecond naction nin nresponse nto na nfire nis nto nactivate
nthe nalarm.
Extinguish nthe nfire.
According nto nthe nRACE nmnemonic, nthe nfourth naction nin nresponse nto na nfire nis nto nattempt nto
nextinguish nthe nfire.
Confine nthe nfire.
According nto nthe nRACE nmnemonic, nthe nthird naction nin nresponse nto na nfire nis nto ncontain nthe
nfire nby nclosing nall nthe ndoors nand nwindows nin nthe narea. nThe nnurse nshould nalso nturn noff
noxygen nand nelectrical nequipment nin nthe narea nof nthe nfire.