NUR 222 (exam 4 practice
Questions with complete
verified solutions(GRADED
A+)
A client with cardiac failure is found to have excess extracellular
fluid of normal tonicity. What life-threatening complication is this
client most likely to suffer: - answer Pulmonary Edema
-The most likely life-threatening complication that can occur in a
client who has excess extracellular fluid of normal tonicity is
pulmonary edema. The excess fluids may filter out of the pulmonary
blood vessels and pool in the pulmonary tissue, causing pulmonary
edema.
-Coma and seizures are likely complications of hypernatremia and
hyponatremia.
-Hypovolemic shock is seen in conditions associated with
extracellular fluid depletion.
Which client being cared for by the nurse is at the highest risk of
developing respiratory acidosis? Client with Hypokalemia,
pulmonary fibrosis, salicylate overdose, or client with COPD: -
answer COPD
-Chronic respiratory acidosis is most commonly caused by COPD.
-Hypokalemia, pulmonary fibrosis, and salicylate overdose do not
predispose a client to respiratory acidosis. Hypokalemia can lead to
cardiac dysrhythmias.
,-Pulmonary fibrosis can result in respiratory arrest, and salicylate
overdose results in central nervous system changes.
Which food item does the nurse include in the diet plan of a patient
with magnesium deficiency? Milk, Broccoli, Brazil nuts, or dark
green leafy vegetables: - answer Dark Green Leafy Vegetables
-Dark-green leafy vegetables are rich in magnesium.
-Milk is rich in phosphate and calcium, not magnesium. -Broccoli is
rich in calcium, not magnesium.
-Brazil nuts are rich in potassium, not magnesium
Which of the following activities can you delegate to nursing
assistive personnel (NAP)?
-Measuring oral intake and urine output
-Preparing intravenous (IV) tubing for routine change
-Reporting an IV container that is low in fluid
-Changing an IV fluid container
-Reporting an electronic infusion device alarm - answer 1. Measure
oral intake and urine output
2. Reporting an IV container that is low in fluid
3. Reporting an electronic infusion device alarm
The nurse is teaching a group of nursing students about the acid-
base regulation process. What should the nurse teach the students
regarding the excretion of carbonic acid from the body?
- The lungs, liver, kidneys or intestines - answer The lungs
,-The lungs are responsible for the excretion of carbonic acid from
the body in the form of exhaled carbon dioxide. Thus, the lungs help
to maintain the acid-base balance of the body.
-The liver is not involved in the excretion of metabolic acids and
carbonic acid, and has no role in acid-base balance of the body.
-Kidneys help in the excretion of all acids except for carbonic acid.
They play an important role in fluid and electrolyte balance.
-The intestine is not involved in the excretion of metabolic acids and
carbonic acid, and has no role in acid-base balance of the body
The nurse is caring for a client diagnosed with chronic heart failure.
The nurse understands that the client is at risk of developing
extracellular fluid volume excess. Which clinical findings would the
nurse observe in this client?
ankle edema, postural hypotension, overnight weight loss,
overnight weight gain, neck veins full (distended) when upright -
answer 1. Ankle edema
2. Overnight weight gain
3. Neck veins full (distended) when upright
-Chronic heart failure can cause extracellular fluid volume excess
due to decreased renal output caused by elevated aldosterone. It
can result in fluid retention manifested as ankle edema and weight
gain.
-The neck veins may feel full on palpation when the client is in
upright position.
-Postural hypotension occurs when there is extracellular fluid
volume deficit and not with excess of extracellular fluid volume.
-Weight loss is observed when there is extracellular fluid volume
deficit and not with excess extracellular fluid volume
, Fluid homeostasis in the body is maintained by fluid intake and
absorption, fluid distribution, and fluid output. How much fluid does
an adult lose through feces: - answer 100 mL
-The fluid loss occurs through the skin, lungs, gastrointestinal tract,
and kidneys.
-Even though the fluid intake would be 3 to 6 liters, only 100 mL of
fluid is lost through feces.
-The rest of the fluid is absorbed by the gastrointestinal system
The health care provider's order is 1000 mL 0.9% NaCl IV over 6
hours. Which rate do you program into the infusion pump: - answer
167 mL/hour
1000 mL divided by 6 hours is 166.7 mL/hr, which rounds to 167
mL/hr (if infusion pump accepts decimals, program it to 166.7
mL/hr)
The nurse is caring for a client who is undergoing intravenous fluid
therapy to correct dehydration. What measures should the nurse
take to prevent complications related to IV lines?
-Order a nursing assistant to regulate intravenous flow.
-Inspect intravenous site and check for client complaints.
-Review the type and amount of intravenous fluid ordered.
-Perform hand hygiene when handling intravenous devices.
-Plan for intravenous therapy at any preferred rate for all clients. -
answer 1. Inspect intravenous site and check for client complaints
2. Review the type and amount of intravenous fluid ordered
3. Perform hand hygiene when handling intravenous devices
Questions with complete
verified solutions(GRADED
A+)
A client with cardiac failure is found to have excess extracellular
fluid of normal tonicity. What life-threatening complication is this
client most likely to suffer: - answer Pulmonary Edema
-The most likely life-threatening complication that can occur in a
client who has excess extracellular fluid of normal tonicity is
pulmonary edema. The excess fluids may filter out of the pulmonary
blood vessels and pool in the pulmonary tissue, causing pulmonary
edema.
-Coma and seizures are likely complications of hypernatremia and
hyponatremia.
-Hypovolemic shock is seen in conditions associated with
extracellular fluid depletion.
Which client being cared for by the nurse is at the highest risk of
developing respiratory acidosis? Client with Hypokalemia,
pulmonary fibrosis, salicylate overdose, or client with COPD: -
answer COPD
-Chronic respiratory acidosis is most commonly caused by COPD.
-Hypokalemia, pulmonary fibrosis, and salicylate overdose do not
predispose a client to respiratory acidosis. Hypokalemia can lead to
cardiac dysrhythmias.
,-Pulmonary fibrosis can result in respiratory arrest, and salicylate
overdose results in central nervous system changes.
Which food item does the nurse include in the diet plan of a patient
with magnesium deficiency? Milk, Broccoli, Brazil nuts, or dark
green leafy vegetables: - answer Dark Green Leafy Vegetables
-Dark-green leafy vegetables are rich in magnesium.
-Milk is rich in phosphate and calcium, not magnesium. -Broccoli is
rich in calcium, not magnesium.
-Brazil nuts are rich in potassium, not magnesium
Which of the following activities can you delegate to nursing
assistive personnel (NAP)?
-Measuring oral intake and urine output
-Preparing intravenous (IV) tubing for routine change
-Reporting an IV container that is low in fluid
-Changing an IV fluid container
-Reporting an electronic infusion device alarm - answer 1. Measure
oral intake and urine output
2. Reporting an IV container that is low in fluid
3. Reporting an electronic infusion device alarm
The nurse is teaching a group of nursing students about the acid-
base regulation process. What should the nurse teach the students
regarding the excretion of carbonic acid from the body?
- The lungs, liver, kidneys or intestines - answer The lungs
,-The lungs are responsible for the excretion of carbonic acid from
the body in the form of exhaled carbon dioxide. Thus, the lungs help
to maintain the acid-base balance of the body.
-The liver is not involved in the excretion of metabolic acids and
carbonic acid, and has no role in acid-base balance of the body.
-Kidneys help in the excretion of all acids except for carbonic acid.
They play an important role in fluid and electrolyte balance.
-The intestine is not involved in the excretion of metabolic acids and
carbonic acid, and has no role in acid-base balance of the body
The nurse is caring for a client diagnosed with chronic heart failure.
The nurse understands that the client is at risk of developing
extracellular fluid volume excess. Which clinical findings would the
nurse observe in this client?
ankle edema, postural hypotension, overnight weight loss,
overnight weight gain, neck veins full (distended) when upright -
answer 1. Ankle edema
2. Overnight weight gain
3. Neck veins full (distended) when upright
-Chronic heart failure can cause extracellular fluid volume excess
due to decreased renal output caused by elevated aldosterone. It
can result in fluid retention manifested as ankle edema and weight
gain.
-The neck veins may feel full on palpation when the client is in
upright position.
-Postural hypotension occurs when there is extracellular fluid
volume deficit and not with excess of extracellular fluid volume.
-Weight loss is observed when there is extracellular fluid volume
deficit and not with excess extracellular fluid volume
, Fluid homeostasis in the body is maintained by fluid intake and
absorption, fluid distribution, and fluid output. How much fluid does
an adult lose through feces: - answer 100 mL
-The fluid loss occurs through the skin, lungs, gastrointestinal tract,
and kidneys.
-Even though the fluid intake would be 3 to 6 liters, only 100 mL of
fluid is lost through feces.
-The rest of the fluid is absorbed by the gastrointestinal system
The health care provider's order is 1000 mL 0.9% NaCl IV over 6
hours. Which rate do you program into the infusion pump: - answer
167 mL/hour
1000 mL divided by 6 hours is 166.7 mL/hr, which rounds to 167
mL/hr (if infusion pump accepts decimals, program it to 166.7
mL/hr)
The nurse is caring for a client who is undergoing intravenous fluid
therapy to correct dehydration. What measures should the nurse
take to prevent complications related to IV lines?
-Order a nursing assistant to regulate intravenous flow.
-Inspect intravenous site and check for client complaints.
-Review the type and amount of intravenous fluid ordered.
-Perform hand hygiene when handling intravenous devices.
-Plan for intravenous therapy at any preferred rate for all clients. -
answer 1. Inspect intravenous site and check for client complaints
2. Review the type and amount of intravenous fluid ordered
3. Perform hand hygiene when handling intravenous devices
