Fashion Everything Study Guide Questions and
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A client has been receiving normal saline intravenously at 75 ml/hr and is NPO. Which of the
following assessment findings indicates a need to contact the health care provider immediately?
A) weight gain of 2 pounds above the preoperative weight
B) an oral temperature of 100.1° F with bibasilar lung crackles
C) gradually decreasing level of consciousness (LOC)
D) serum sodium level of 138 mEg/L (138 mmol/L) - C) gradually decreasing level of
consciousness (LOC)
The nurse obtains all of the following assessment data about a patient with a fluid-volume deficit
caused by a massive burn injury. The patient has IV NSS running at 50 ml/hr. Which of the
following assessment data will be of greatest concern?
a. Oral fluid intake is 100 ml for the last 8 hours with urine output of 320ml
b. The blood pressure change from 110/60 to 80/40 mm Hg
c. Urine output is 30 ml over the last hour with at total of 200 ml
d. There is prolonged skin tenting over the sternum and dry lips - b. The blood pressure
change from 110/60 to 80/40 mm Hg
When evaluating the response to treatment for a client admitted for nausea and vomiting with
fluid imbalance, a prudent nursing action would be to:
,check skin turgor
assess presence of edema
consult the opinion of the charge nurse
obtain further data about the patient - obtain further data about the patient
A patient is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of
hypertension. Symptoms the nurse teaches the patient to report include:
confusion and personality changes
anxiety and muscle twitching
abdominal cramping and diarrhea
fatigue and muscle weakness - fatigue and muscle weakness
A client in a medical surgical unit is taking hydrochlorothiazide, a potassium-wasting diuretic,
for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse
effects such as:
frequent loose stools
facial muscle spasms
sinus bradycardia
,personality changes - sinus bradycardia
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a client as a diuretic.
Which statement by the patient indicates that the teaching about this medication has been
effective?
a. "I will have apple juice instead of orange juice during breakfast"
b. *I will drink an extra amount of water every day to prevent dehydration."
c. "I will sure l have my daily serving of fresh lettuce salad every meal"
d. "I can have cottage cheese with my breakfast as long as it is only the size of one portion." -
a. "I will have apple juice instead of orange juice during breakfast*
When assessing a client with increased extracellular fluid (ECF) osmolality, the nurse prioritizes
assessing for:
capillary refill and skin temperature
skin turgor and tenting
presence of confusion
heart sounds and ECG reading - presence of confusion
While assigned in a medical surgical unit, a newly hired RN recalls that there is a clinical
manifestation that supports the concept that filtration is directly related to hydrostatic pressure.
Which of these clinical manifestations is the RN recalling?
, capillary refill is faster in fingers than in toes
central venous pressure is lowest in the right atrium at 45 degree head elevation
pitting edema is usually detected first in lower extremities while upright
systolic blood pressure is higher than diastolic blood pressure in the left arm - pitting
edema is usually detected first in lower extremities while upright
The home health nurse notes that an elderly client has a low serum albumin level. The nurse will
plan to assess for:
amount of food intake during breakfast
presence of tactile fremitus at the posterior chest
increase in circumference of the lower extremities
color and temperature of the skin - increase in circumference of the lower extremities
A client is receiving a 3% NaCI solution for correction of hyponatremia. Prior to the
administration of the solution, the nurse would like to obtain baseline assessment findings.
Which is the most important for the nurse to obtain?
peripheral pulses
urinary output
Verified Answers, 100% Guarantee
A client has been receiving normal saline intravenously at 75 ml/hr and is NPO. Which of the
following assessment findings indicates a need to contact the health care provider immediately?
A) weight gain of 2 pounds above the preoperative weight
B) an oral temperature of 100.1° F with bibasilar lung crackles
C) gradually decreasing level of consciousness (LOC)
D) serum sodium level of 138 mEg/L (138 mmol/L) - C) gradually decreasing level of
consciousness (LOC)
The nurse obtains all of the following assessment data about a patient with a fluid-volume deficit
caused by a massive burn injury. The patient has IV NSS running at 50 ml/hr. Which of the
following assessment data will be of greatest concern?
a. Oral fluid intake is 100 ml for the last 8 hours with urine output of 320ml
b. The blood pressure change from 110/60 to 80/40 mm Hg
c. Urine output is 30 ml over the last hour with at total of 200 ml
d. There is prolonged skin tenting over the sternum and dry lips - b. The blood pressure
change from 110/60 to 80/40 mm Hg
When evaluating the response to treatment for a client admitted for nausea and vomiting with
fluid imbalance, a prudent nursing action would be to:
,check skin turgor
assess presence of edema
consult the opinion of the charge nurse
obtain further data about the patient - obtain further data about the patient
A patient is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of
hypertension. Symptoms the nurse teaches the patient to report include:
confusion and personality changes
anxiety and muscle twitching
abdominal cramping and diarrhea
fatigue and muscle weakness - fatigue and muscle weakness
A client in a medical surgical unit is taking hydrochlorothiazide, a potassium-wasting diuretic,
for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse
effects such as:
frequent loose stools
facial muscle spasms
sinus bradycardia
,personality changes - sinus bradycardia
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a client as a diuretic.
Which statement by the patient indicates that the teaching about this medication has been
effective?
a. "I will have apple juice instead of orange juice during breakfast"
b. *I will drink an extra amount of water every day to prevent dehydration."
c. "I will sure l have my daily serving of fresh lettuce salad every meal"
d. "I can have cottage cheese with my breakfast as long as it is only the size of one portion." -
a. "I will have apple juice instead of orange juice during breakfast*
When assessing a client with increased extracellular fluid (ECF) osmolality, the nurse prioritizes
assessing for:
capillary refill and skin temperature
skin turgor and tenting
presence of confusion
heart sounds and ECG reading - presence of confusion
While assigned in a medical surgical unit, a newly hired RN recalls that there is a clinical
manifestation that supports the concept that filtration is directly related to hydrostatic pressure.
Which of these clinical manifestations is the RN recalling?
, capillary refill is faster in fingers than in toes
central venous pressure is lowest in the right atrium at 45 degree head elevation
pitting edema is usually detected first in lower extremities while upright
systolic blood pressure is higher than diastolic blood pressure in the left arm - pitting
edema is usually detected first in lower extremities while upright
The home health nurse notes that an elderly client has a low serum albumin level. The nurse will
plan to assess for:
amount of food intake during breakfast
presence of tactile fremitus at the posterior chest
increase in circumference of the lower extremities
color and temperature of the skin - increase in circumference of the lower extremities
A client is receiving a 3% NaCI solution for correction of hyponatremia. Prior to the
administration of the solution, the nurse would like to obtain baseline assessment findings.
Which is the most important for the nurse to obtain?
peripheral pulses
urinary output
