ANSWERS
the bnurse bis bcaring bfor ba bpatient bwith ba bmassive bburn binjury band bpossible
bhypovolemia. bWhich bassessment bdata bwill bbe bof bmost bconcern bto bthe bnurse?
a) boral bfluid bintake bis b100 bl bfor bthe bpast b8 bhrs
b) bblood bpressure b90/40
c) bthere bis ba bprolonged bskin btenting bover bthe bsternum b
d) bUrine boutput bis b30ml/hr b- bcorrect banswer✔✔B
A bpatient bwith bmultiple bdraining bwounds bis badmitted bfor bhypovolemia. bWhich
bassessment bwould bbe bthe bmost baccurate bway bfor bthe bnurse bto bevaluate bfluid
bbalance?
A) bedema bpresence
b) bskin bturgor
c) bdaily bweight b
d) burine boutput b- bcorrect banswer✔✔c) bdaily bweight
A bpatient bwith bnew-onset bconfusion band bhyponatremia bis bbeing badmitted. bWhen
bmaking broom bassignments, bthe bcharge bnurse bshould btake bwhich baction?
a) bassign bthe bpatient bto ba bsemi-private broom
b) bplace bthe bpatient bon btelemetry bto bmonitor bfor bpeaked bT bwaves
c) bassign bthe bpatient bto ba broom bnear bthe bnurses bstation b
d) bplace bthe bpatient bin ba broom bnearest bto bthe bwater bfountain b- bcorrect
banswer✔✔C
IV bpotassium bchloride b(KCl) b60 bmEq bis bprescribed bfor btreatment bof ba bpatient bwith
bsevere bhypokalemia. bWhich baction bshould bthe bnurse btake?
b
a. bAdminister bthe bKCl bas ba brapid bIV bbolus. b
b. bInfuse bthe bKCl bat ba brate bof b10 bmEq/hour. b
c. bOnly bgive bthe bKCl bthrough ba bcentral bvenous bline. b
d. bDiscontinue bcardiac bmonitoring bduring bthe binfusion. b- bcorrect banswer✔✔B
A bpatient breceives b3% bNaCl bsolution bfor bcorrection bof bhyponatremia. bWhich
bassessment bis bMOST bimportant bfor bthe bnurse bto bmonitor bfor bwhile bthe bpatient bis
breceiving bthis binfusion?
, a) blung bsounds
b) burinary boutput
c) bperipheral bedema b
d) bperipheral bpulses b- bcorrect banswer✔✔a) blung bsounds b
Hypertonic bsolutions bcause bwater bretention, bso bthe bpatient bshould bbe bmonitored
bfor bsymptoms bof bfluid bexcess. bCrackles bin bthe blungs bmay bindicate bthe bonset bof
bpulmonary bedema band bare ba bserious bmanifestation bof bfluid bexcess. bPeripheral
bpulses, bperipheral bedema, bor bchanges bin burine boutput bare balso bimportant bto
bmonitor bwhen badministering bhypertonic bsolutions, bbut bthey bdo bnot bindicate bacute
brespiratory bor bcardiac bdecompensation.
The bnurse bis bcaring bfor ba bpatient bwho bhas ba bcalcium blevel bof b12.1 bmg/dL. bWhich
bnursing baction bshould bthe bnurse binclude bon bthe bcare bplan?
a) bmonitor bfor bTrousseaus band bChvosteks bsigns b
b) bmaintain bthe bpatient bon bbed brest b
c) bauscultate blung bsounds bevery b4 bhours
d) bEncourage bfluid bintake bup bto b4000 bml bevery bday b- bcorrect banswer✔✔D
To bdecrease bthe brisk bfor brenal bcalculi, bthe bpatient bshould bhave ba bfluid bintake bof
b3000 bto b4000 bmL bdaily. bAmbulation bhelps bdecrease bthe bloss bof bcalcium bfrom
bbone band bis bencouraged bin bpatients bwith bhypercalcemia. bTrousseau's band
bChvostek's bsigns bare bmonitored bwhen bthere bis ba bpossibility bof bhypocalcemia.
bThere bis bno bindication bthat bthe bpatient bneeds bfrequent bassessment bof blung
bsounds, balthough bthese bwould bbe bassessed bevery bshift.
When bcaring bfor ba bpatient bwith brenal bfailure bon ba blow bphosphate bdiet, bthe bnurse
bwill binform bunlicensed bassistive bpersonnel b(UAP) bto bremove bwhich bfood bfrom bthe
bpatient's bfood btray?
a) bmixed bgreen bsalad
b) bgrape bjuice
c) bfried bchicken b
d) bskim bmilk b- bcorrect banswer✔✔D
Foods bhigh bin bphosphate binclude bmilk band bother bdairy bproducts, bso bthese bare
brestricted bon blow-phosphate bdiets. bGreen, bleafy bvegetables; bhigh-fat bfoods; band
bfruits band bjuices bare bnot bhigh bin bphosphate band bare bnot brestricted.
A bpatient bhas ba bmagnesium blevel bof b1.3 bmg/dL. bWhich bassessment bwould bhelp
bthe bnurse bidentify ba blikely bcause bof bthis bvalue?
a) bmultivitamin/mineral buse
b) bover bthe bcounter blaxative buse
c) bdaily balcohol bintake
d) bdietary bprotein bintake b- bcorrect banswer✔✔C
Hypomagnesemia bis bassociated bwith balcoholism. bProtein bintake bwould bnot bhave ba
bsignificant beffect bon bmagnesium blevel. bOTC blaxatives b(such bas bmilk bof bmagnesia)
band buse bof bmultivitamin/mineral bsupplements btend bto bincrease bmagnesium blevels.