CORRECT QUESTION AND ANWSERS
AWnurseWisWadministeringW1WLWofW0.9%WsodiumWchlorideWtoWaWclientWwhoWisWpostoperativeWa
ndWhasWfluidWvolumeWdeficit.WWhichWofWtheWfollowingWchangesWshouldWtheWnurseWidentifyWasW
anWindicationWthatWtheWtreatmentWwasWsuccessful?
IncreaseWinWhematocrit
increaseWinWrespiratoryWrateWDecre
aseWinWheartWrate
DecreaseWinWcapillaryWrefillWtimeW-WCorrectWAnswer:
DecreaseWinWheartWrate
FluidWvolumeWdeficitWcausesWtachycardia.WWithWcorrectionWofWtheWimbalance,WtheWheartWrateWs
houldWreturnWtoWtheWexpectedWrange.
IncorrectWAnswers:
IncreaseWinWhematocrit:
FluidWvolumeWdeficitWcausesWanWincreaseWinWhematocritWlevelWdueWtoWdepletionWofWextracellula
rWfluid.WWithWcorrectionWofWtheWimbalance,WtheWhematocritWlevelWshouldWdecrease.
increaseWinWrespiratoryWrate
FluidWvolumeWdeficitWcausesWanWincreaseWinWrespiratoryWrate.WWithWcorrectionWofWtheWimbalan
ce,WtheWrespiratoryWrateWshouldWreturnWtoWtheWexpectedWrange.
DecreaseWinWcapillaryWrefillWtime
FluidWvolumeWdeficitWslowsWcapillaryWrefill.WWithWcorrectionWofWtheWimbalance,WcapillaryWrefil
lWtimeWshouldWreturnWtoWtheWexpectedWrange.
AWnurseWisWcaringWforWaWclientWwhoWisWscheduledWtoWbeWtransferredWtoWaWlong-
termWcareWfacility.WTheWclient'sWfamilyWquestionsWtheWnurseWaboutWtheWreasonsWforWtheWtransfe
r.WWhichWofWtheWfollowing
responsesWmadeWbyWtheWnurseWisWappropriate?
"TheWtransferWofWyourWfamilyWmemberWisWbeingWdoneWbecauseWtheWproviderWknowsWwhat'sWbe
st."W"WouldWyouWlikeWitWifWweWdiscussedWtheWtransferWwithWyourWfamilyWmember?"
"WhyWareWyouWsoWconcernedWaboutWthisWtransfer?"
"IWknowWhowWyouWfeel.WMyWparentWhadWtoWbeWtransferredWtoWaWlong-termWcareWfacility."W-
WCorrectWAnswer:
"WouldWyouWlikeWitWifWweWdiscussedWtheWtransferWwithWyourWfamilyWmember?"
ThisWresponseWfacilitatesWtherapeuticWcommunicationWandWprovidesWgeneralWleadsWwhileWmain
tainingWclientWconfidentiality.
,IncorrectWAnswers:
"TheWtransferWofWyourWfamilyWmemberWisWbeingWdoneWbecauseWtheWproviderWknowsWwhat'sWb
est."WThisWisWaWdefensiveWresponseWwhichWcanWhinderWfurtherWcommunication.
"WhyWareWyouWsoWconcernedWaboutWthisWtransfer?"
AskingWaWwhyWquestionWcanWmakeWtheWrecipientWdefensiveWwhichWcanWhinderWfurtherWcomm
unication.
"IWknowWhowWyouWfeel.WMyWparentWhadWtoWbeWtransferredWtoWaWlong-
termWcareWfacility."WThisWisWaWsympatheticWresponse,WwhichWcanWinterfereWwithWa
WtherapeuticWrelationship.
AWnurseWisWreviewingWtheWlaboratoryWresultsWofWaWfemaleWclientWwhoWhasWhypovolemia.WWhic
hWofWtheWfollowingWlaboratoryWresultWwouldWbeWaWpriorityWforWtheWnurseWreportWtoWtheWprovid
er?
BUNW21Wmg/dLW(10WtoW20Wmg/dL)
CreatinineW1.4Wmg/dLW(0.5WtoW1.1Wmg/dL)
SodiumW132WmEq/LW(136WtoW145WmEq/L)
PotassiumW5.8WmEq/LW(3.5WtoW5WmEq/L)W-WCorrectWAnswer:
PotassiumW5.8WmEq/LW(3.5WtoW5WmEq/L)
WhenWusingWtheWurgentWversusWnonurgentWapproachWtoWclientWcare,WtheWnurseWshouldWdetermi
neWthatWthisWpotassiumWlevelWisWaboveWtheWexpectedWreferenceWrangeWandWshouldWbeWreportedW
toWtheWprovider.WPotassiumWaffectsWtheWcontractilityWofWtheWheartWandWthisWclientWwouldWbeWat
WriskWforWdevelopingWdysrhythmias.
IncorrectWanswers:
BUNW21Wmg/dLW(10WtoW20Wmg/dL)
ThisWBUNWlevelWisWslightlyWaboveWtheWexpectedWreferenceWrangeWandWisWanWexpectedWnon-
urgentWfindingWforWaWclientWwhoWhasWhypovolemia;Wtherefore,WthereWisWanotherWlaboratoryWres
ultWthatWisWaWpriorityWforWtheWnurseWtoWreportWtoWtheWprovider.
CreatinineW1.4Wmg/dLW(0.5WtoW1.1Wmg/dL)
ThisWcreatinineWlevelWisWslightlyWaboveWtheWexpectedWreferenceWrangeWandWisWanWexpectedWno
n-
urgentWfindingWforWaWclientWwhoWhasWhypovolemia;Wtherefore,WthereWisWanotherWlaboratoryWres
ultWthatWisWaWaWpriorityWforWtheWnurseWtoWreportWtoWtheWprovider.
SodiumW132WmEq/LW(136WtoW145WmEq/L)
ThisWsodiumWlevelWisWslightlyWbelowWtheWexpectedWreferenceWrangeWandWisWanWexpectedWnon-
urgentWfindingWforWaWclientWwhoWhasWhypovolemia;Wtherefore,WthereWisWanotherWlaboratoryWres
ultWthatWisWaWpriorityWforWtheWnurseWtoWreportWtoWtheWprovider.
,AWnurseWisWcaringWforWaWclientWwhoWreportsWdifficultyWfallingWasleep.WWhichWofWtheWfollowing
WrecommendationsWshouldWtheWnurseWmake?
"DrinkWaWcupWofWhotWcocoaWbeforeWbedtime."W"M
aintainWaWconsistentWtimeWtoWwakeWupWeachWday."W
"ExerciseW1WhourWbeforeWgoingWtoWbed."
"WatchWaWtelevisionWprogramWinWbedWbeforeWgoingWtoWsleep."W-
WCorrectWAnswer:W"MaintainWaWconsistentWtimeWtoWwakeWupWeachWday."
TheWclientWshouldWmaintainWaWconsistentWtimeWforWwakingWupWandWgoingWtoWsleep.WThisW
helpsWtoWestablishWanWinternalWsenseWofWsleepWandWwakingWonWaWdailyWbasisWandWhelpsWt
oWmaintainWitWoverWtime.WThisWwillWhelpWpromoteWsleepWforWtheWclient.
IncorrectWAnswers:
"DrinkWaWcupWofWhotWcocoaWbeforeWbedtime."
CocoaWcontainsWcaffeine,WwhichWisWaWstimulantWthatWcanWinterfereWwithWsleep.
"ExerciseW1WhourWbeforeWgoingWtoWbed."
ExercisingWwithinW2WhrWofWbedtimeWcanWinterfereWwithWsleep.
"WatchWaWtelevisionWprogramWinWbedWbeforeWgoingWtoWsleep."
TheWclientWshouldWavoidWwatchingWtelevisionWinWbedWbeforeWgoingWtoWsleepWtoWreduceWstimula
tionWinWorderWtoWpromoteWrest.
AWnurseWonWaWmedical-
surgicalWunitWisWcaringWforWaWclientWwhoWhasWaWnewWprescriptionWforWwristWrestraints.WW
hichWofWfollowingWactionsWshouldWtheWnurseWtake?
PadWtheWclient'sWwristWbeforeWapplyingWtheWrestraints.
EvaluateWtheWclient'sWcirculationWeveryW8WhrWafterWapplication.
RemoveWtheWrestraintsWeveryW4WhrWtoWevaluateWtheWclient'sWstatu
s.WSecureWtheWrestraintWtiesWtoWtheWbed'sWsideWrails.W-
WCorrectWAnswer:
PadWtheWclient'sWwristWbeforeWapplyingWtheWrestraints.
TheWuseWofWrestraintsWwithoutWpaddingWcanWabradeWtheWclient'sWskin,WresultingWinWclientWinjur
y.
IncorrectWAnswers:
EvaluateWtheWclient'sWcirculationWeveryW8WhrWafterWapplication.
TheWnurseWshouldWevaluateWtheWclient'sWcirculation,WrangeWofWmotion,WvitalWsigns,WandWoverall
WstatusWeveryW15WminWafterWinitialWapplicationWofWrestraints.
RemoveWtheWrestraintsWeveryW4WhrWtoWevaluateWtheWclient'sWstatus.
, TheWnurseWshouldWremoveWtheWrestraintsWatWleastWeveryW2WhrWtoWrepositionWtheWclientWandWas
sessWneedsWforWhygieneWandWtoileting.
SecureWtheWrestraintWtiesWtoWtheWbed'sWsideWrails.
TheWnurseWshouldWsecureWtheWrestraintWtiesWtoWaWpartWofWtheWbedWframeWthatWmovesWwithWtheW
clientWtoWreduceWtheWriskWofWinjury.
AWclientWwhoWisWnonambulatoryWnotifiesWtheWnurseWthatWtheirWtrashWcanWisWonWfire.WAfterWtheW
nurseWconfirmsWtheWpresenceWofWtheWfire,WwhichWofWtheWfollowingWactionsWshouldWtheWnurseWt
akeWnext?
ActivateWtheWemergencyWfireWalar
m.WExtinguishWtheWfire.
EvacuateWtheWclient.
ConfineWtheWfire.W-WCorrectWAnswer:
EvacuateWtheWclient.
AccordingWtoWtheWRACEWmnemonic,WtheWfirstWactionWinWresponseWtoWaWfireWisWtoWrescueWtheWc
lients,WmovingWthemWtoWaWsafeWarea.
IncorrectWAnswers:
ActivateWtheWemergencyWfireWalarm.
AccordingWtoWtheWRACEWmnemonic,WtheWsecondWactionWinWresponseWtoWaWfireWisWtoWactivate
WtheWalarm.
ExtinguishWtheWfire.
AccordingWtoWtheWRACEWmnemonic,WtheWfourthWactionWinWresponseWtoWaWfireWisWtoWattemptWto
WextinguishWtheWfire.
ConfineWtheWfire.
AccordingWtoWtheWRACEWmnemonic,WtheWthirdWactionWinWresponseWtoWaWfireWisWtoWcontainWthe
WfireWbyWclosingWallWtheWdoorsWandWwindowsWinWtheWarea.WTheWnurseWshouldWalsoWturnWoffWox
ygenWandWelectricalWequipmentWinWtheWareaWofWtheWfire.
AWnurseWisWpreparingWtoWadministerW0.9%WsodiumWchlorideW750WmLWIVWtoWinfuseWoverW7Whr
.WTheWnurseWshouldWsetWtheWinfusionWpumpWtoWdeliverWhowWmanyWmL/hr?W-W107WmL/hr
AWnurseWisWassessingWfourWadultWclients.WWhichWofWtheWfollowingWphysicalWassessmentWtechni
quesWshouldWtheWnurseWuse?
UseWtheWFace,WLegs,WActivity,WCry,WandWConsolabilityW(FLACC)WpainWratingWscaleWforWaWcli
entWwhoWisWexperiencingWpain.