NMNC 3210 EXAM 1 QUESTIONS & ANSWERS
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
Which vital signs would you expect to be increased? - Answers - Increased heart rate,
increased temperature, thready pulses, increased respiration rate
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
If his diarrhea continues, which vital sign would you expect to be decreased? - Answers
- Blood pressure, heart rate, respiratory rate, temperature, peripheral pulse, capillary
refill time
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
Which general signs of fluid volume deficit would you expect to assess? - Answers -
Skin turgor, dry mouth, dry mucous membranes, thirst, concentrated urine, fatigue,
weakness, headache, cool clammy skin, altered mental status, lightheaded/dizzy,
muscle cramps, sunken eyes, decreased urine output.
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
Which specific physical assessments would you perform on an infant? - Answers -
Weight, urine output, fontanelle assessment, skin turgor, dry membranes, assess skin,
tears, behavior, identify fluid loss, temperature, viral signs, lab tests (electrolytes, BUN,
creatinine, hematocrit)
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
How could you obtain a urine sample from an infant with the least trauma? - Answers -
Clean collection by using a urination bag
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
His wet diaper weighs 40 grams more than a dry diaper the same size.
How many milliliters will you record as output? - Answers - About 40 milliliters, g/mL
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
His urine specific gravity is 1.040; what does this indicate? - Answers - The specific
gravity is high, normal SG is 1.005-1.030. indicating that the urine is concentrated,
indicating dehydration in this case.
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
,Would you expect to his serum electrolytes be increased or decreased? - Answers - I
would expect them to be increased due to fluid loss.
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
The provider ordered an anti-diarrheal medication and then try oral rehydration.
Which types of fluids could be offered to an infant? - Answers - Oral water, and
formula or breastmilk
At the clinic, an 87-year-old woman with hypertension and congestive heart failure tells
the nurse, "I must have caught a bug, because I can't seem to keep anything in my
stomach. Sometimes I even throw up my water pill." Her oral temperature is 103
degrees F.
Which specific physical assessments would you perform on an elderly patient? -
Answers - Weight, urine output, central skin turgor, dry membranes, assess skin,
behavior, identify fluid loss, temperature, viral signs, lab tests (electrolytes, BUN,
creatinine, hematocrit)
At the clinic, an 87-year-old woman with hypertension and congestive heart failure tells
the nurse, "I must have caught a bug, because I can't seem to keep anything in my
stomach. Sometimes I even throw up my water pill." Her oral temperature is 103
degrees F.
The provider has ordered a urinalysis and a serum chemistry panel.
Which labs are included in a urinalysis (UA)? - Answers - Color, clarity, odor, pH,
protein, glucose, ketones, blood, bilirubin, urobilirubin, nitrates, RBC, WBC, yeast,
bacteria, crystals
At the clinic, an 87-year-old woman with hypertension and congestive heart failure tells
the nurse, "I must have caught a bug, because I can't seem to keep anything in my
stomach. Sometimes I even throw up my water pill." Her oral temperature is 103
degrees F.
The specific gravity of her urine is below. What does this indicate? - Answers - The
urine is dilute, her electrolytes are probably imbalanced
At the clinic, an 87-year-old woman with hypertension and congestive heart failure tells
the nurse, "I must have caught a bug, because I can't seem to keep anything in my
stomach. Sometimes I even throw up my water pill." Her oral temperature is 103
degrees F.
Which labs are included in a chemistry panel? - Answers - Glucose, electrolytes,
kidney function (BUN, creatinine, eGFR), Liver function tests (ALT, AST, ALP, bilirubin),
proteins, lipids
At the clinic, an 87-year-old woman with hypertension and congestive heart failure tells
the nurse, "I must have caught a bug, because I can't seem to keep anything in my
stomach. Sometimes I even throw up my water pill." Her oral temperature is 103
degrees F.
, The patient's electrolyte results are: Sodium 138 mEq/L, Potassium 3.1 mEq/L,
Magnesium 1.9 mEq/L, and total Calcium 4.8 mEq/L. Which electrolyte would the team
most concerned about for this patient? Why? - Answers - Calcium and potassium, are
extremely low. If calcium is low you can get blood clots and in severe cases you can get
seizures. If potassium is low you can get arrhythmias, your heart will not function at the
potential that it should.
At the clinic, an 87-year-old woman with hypertension and congestive heart failure tells
the nurse, "I must have caught a bug, because I can't seem to keep anything in my
stomach. Sometimes I even throw up my water pill." Her oral temperature is 103
degrees F. The patient's electrolyte results are: Sodium 138 mEq/L, Potassium 3.1
mEq/L, Magnesium 1.9 mEq/L, and total Calcium 4.8 mEq/L.
What are the signs of this imbalance? - Answers - calcium: increased reflexes,
numbness & tingling around mouth, confusion, muscle cramps, trousseaus and
chvostecks sign
Potassium: weak pulse, palpitations, constipation, polyuria, arrhythmias
At the clinic, an 87-year-old woman with hypertension and congestive heart failure tells
the nurse, "I must have caught a bug, because I can't seem to keep anything in my
stomach. Sometimes I even throw up my water pill." Her oral temperature is 103
degrees F. The patient's electrolyte results are: Sodium 138 mEq/L, Potassium 3.1
mEq/L, Magnesium 1.9 mEq/L, and total Calcium 4.8 mEq/L.
The provider orders: Normal saline IV with 20 mEq of KCL at 150 mL/hour
What are the rationales for this fluid type, rate, and additive? - Answers - The fluid is
isotonic, keeps everything balanced. The rate is standard to prevent too much or too
little being given and causing swelling or imbalances. The additive is potassium for
regulation of heart rhythm and correcting the imbalance to prevent any further cardiac
complications.
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
After he drinks 2 ounces, how many milliliters will you record? - Answers - 60 milliliters
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
How would you know if he has improved? - Answers - Vital signs would improve,
turgor would improve, membranes and tears would return to normal, skin would no
longer be cool and clammy, eyes would not be sunken,
At the clinic, an 87-year-old woman with hypertension and congestive heart failure tells
the nurse, "I must have caught a bug, because I can't seem to keep anything in my
stomach. Sometimes I even throw up my water pill." Her oral temperature is 103
degrees F.
How would her medication and temperature contribute to her fluid volume status? -
Answers - Her increased temperature and vomiting indicate fluid volume loss, her
"water pill" may be showing that she is not retaining liquids.
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
Which vital signs would you expect to be increased? - Answers - Increased heart rate,
increased temperature, thready pulses, increased respiration rate
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
If his diarrhea continues, which vital sign would you expect to be decreased? - Answers
- Blood pressure, heart rate, respiratory rate, temperature, peripheral pulse, capillary
refill time
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
Which general signs of fluid volume deficit would you expect to assess? - Answers -
Skin turgor, dry mouth, dry mucous membranes, thirst, concentrated urine, fatigue,
weakness, headache, cool clammy skin, altered mental status, lightheaded/dizzy,
muscle cramps, sunken eyes, decreased urine output.
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
Which specific physical assessments would you perform on an infant? - Answers -
Weight, urine output, fontanelle assessment, skin turgor, dry membranes, assess skin,
tears, behavior, identify fluid loss, temperature, viral signs, lab tests (electrolytes, BUN,
creatinine, hematocrit)
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
How could you obtain a urine sample from an infant with the least trauma? - Answers -
Clean collection by using a urination bag
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
His wet diaper weighs 40 grams more than a dry diaper the same size.
How many milliliters will you record as output? - Answers - About 40 milliliters, g/mL
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
His urine specific gravity is 1.040; what does this indicate? - Answers - The specific
gravity is high, normal SG is 1.005-1.030. indicating that the urine is concentrated,
indicating dehydration in this case.
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
,Would you expect to his serum electrolytes be increased or decreased? - Answers - I
would expect them to be increased due to fluid loss.
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
The provider ordered an anti-diarrheal medication and then try oral rehydration.
Which types of fluids could be offered to an infant? - Answers - Oral water, and
formula or breastmilk
At the clinic, an 87-year-old woman with hypertension and congestive heart failure tells
the nurse, "I must have caught a bug, because I can't seem to keep anything in my
stomach. Sometimes I even throw up my water pill." Her oral temperature is 103
degrees F.
Which specific physical assessments would you perform on an elderly patient? -
Answers - Weight, urine output, central skin turgor, dry membranes, assess skin,
behavior, identify fluid loss, temperature, viral signs, lab tests (electrolytes, BUN,
creatinine, hematocrit)
At the clinic, an 87-year-old woman with hypertension and congestive heart failure tells
the nurse, "I must have caught a bug, because I can't seem to keep anything in my
stomach. Sometimes I even throw up my water pill." Her oral temperature is 103
degrees F.
The provider has ordered a urinalysis and a serum chemistry panel.
Which labs are included in a urinalysis (UA)? - Answers - Color, clarity, odor, pH,
protein, glucose, ketones, blood, bilirubin, urobilirubin, nitrates, RBC, WBC, yeast,
bacteria, crystals
At the clinic, an 87-year-old woman with hypertension and congestive heart failure tells
the nurse, "I must have caught a bug, because I can't seem to keep anything in my
stomach. Sometimes I even throw up my water pill." Her oral temperature is 103
degrees F.
The specific gravity of her urine is below. What does this indicate? - Answers - The
urine is dilute, her electrolytes are probably imbalanced
At the clinic, an 87-year-old woman with hypertension and congestive heart failure tells
the nurse, "I must have caught a bug, because I can't seem to keep anything in my
stomach. Sometimes I even throw up my water pill." Her oral temperature is 103
degrees F.
Which labs are included in a chemistry panel? - Answers - Glucose, electrolytes,
kidney function (BUN, creatinine, eGFR), Liver function tests (ALT, AST, ALP, bilirubin),
proteins, lipids
At the clinic, an 87-year-old woman with hypertension and congestive heart failure tells
the nurse, "I must have caught a bug, because I can't seem to keep anything in my
stomach. Sometimes I even throw up my water pill." Her oral temperature is 103
degrees F.
, The patient's electrolyte results are: Sodium 138 mEq/L, Potassium 3.1 mEq/L,
Magnesium 1.9 mEq/L, and total Calcium 4.8 mEq/L. Which electrolyte would the team
most concerned about for this patient? Why? - Answers - Calcium and potassium, are
extremely low. If calcium is low you can get blood clots and in severe cases you can get
seizures. If potassium is low you can get arrhythmias, your heart will not function at the
potential that it should.
At the clinic, an 87-year-old woman with hypertension and congestive heart failure tells
the nurse, "I must have caught a bug, because I can't seem to keep anything in my
stomach. Sometimes I even throw up my water pill." Her oral temperature is 103
degrees F. The patient's electrolyte results are: Sodium 138 mEq/L, Potassium 3.1
mEq/L, Magnesium 1.9 mEq/L, and total Calcium 4.8 mEq/L.
What are the signs of this imbalance? - Answers - calcium: increased reflexes,
numbness & tingling around mouth, confusion, muscle cramps, trousseaus and
chvostecks sign
Potassium: weak pulse, palpitations, constipation, polyuria, arrhythmias
At the clinic, an 87-year-old woman with hypertension and congestive heart failure tells
the nurse, "I must have caught a bug, because I can't seem to keep anything in my
stomach. Sometimes I even throw up my water pill." Her oral temperature is 103
degrees F. The patient's electrolyte results are: Sodium 138 mEq/L, Potassium 3.1
mEq/L, Magnesium 1.9 mEq/L, and total Calcium 4.8 mEq/L.
The provider orders: Normal saline IV with 20 mEq of KCL at 150 mL/hour
What are the rationales for this fluid type, rate, and additive? - Answers - The fluid is
isotonic, keeps everything balanced. The rate is standard to prevent too much or too
little being given and causing swelling or imbalances. The additive is potassium for
regulation of heart rhythm and correcting the imbalance to prevent any further cardiac
complications.
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
After he drinks 2 ounces, how many milliliters will you record? - Answers - 60 milliliters
You are the nurse caring for a 10-month-old male at a community clinic. The parent
reports that the infant had multiple episodes of diarrhea in the last few days.
How would you know if he has improved? - Answers - Vital signs would improve,
turgor would improve, membranes and tears would return to normal, skin would no
longer be cool and clammy, eyes would not be sunken,
At the clinic, an 87-year-old woman with hypertension and congestive heart failure tells
the nurse, "I must have caught a bug, because I can't seem to keep anything in my
stomach. Sometimes I even throw up my water pill." Her oral temperature is 103
degrees F.
How would her medication and temperature contribute to her fluid volume status? -
Answers - Her increased temperature and vomiting indicate fluid volume loss, her
"water pill" may be showing that she is not retaining liquids.
