NUR 2356 MULTIDIMENSIONAL
CARE I EXAM 2
Which data reflect the priority assessments that a nurse would
monitor when concerned that a patient may be developing a fluid
volume imbalance? - ANSWERS-The patient's pulse and blood
pressure
The patient's weight changes over the past day
The patient's intake and output balance over the past 48 hours
Which substances would a nurse need to include in the fluid intake
tally? - ANSWERS-Nasogastric (NG) tube irrigations
Enteral tube feedings
Free water gastric tube flushes
Intravenous medications
Which patient-related data would require entry of fluid output
information on the electronic health record (EHR)? - ANSWERS-The
patient has a nasogastric (NG) tube attached to wall suction.
The patient has an indwelling urinary catheter in place.
The patient has a surgical wound drain on his abdomen.
Which factors would be included by the nurse when developing a 24-
hour fluid budget for a patient with a 1000 mL fluid restriction? -
ANSWERS-Medications
,Intravenous (IV) fluids
Between-meal fluid sipping
Breakfast, lunch, and dinner
Which plan would a nurse suggest for the remainder of the 24-hour
period for a patient on a 1000 mL per day fluid restriction who has
consumed 700 mL as of 3:00 p.m.? - ANSWERS-Allow 150 mL with
dinner and 150 mL for medications and prior to going to sleep.
The nurse suspects that a patient receiving an intravenous (IV)
infusion of D5 0.45% NS is developing intracellular dehydration and
circulatory overload. For which reason would this IV solution cause
this complication? - ANSWERS-It is a hypertonic solution.
Which intravenous (IV) site in infants is most commonly used? -
ANSWERS-The vein in the middle of the scalp
Which actions related to intravenous (IV) fluid administration are the
responsibility of the registered nurse? - ANSWERS-Verify that the
fluid is appropriate for the patient.
Evaluate the effectiveness of IV therapy.
Monitor the patient for complications of IV therapy.
Comply with the 6 rights of safe medication administration.
Which complications would a nurse need to monitor for when caring
for a patient receiving a hypertonic intravenous (IV) fluid? -
ANSWERS-Cellular dehydration
, Circulatory overload
Air embolism
Which intravenous (IV) solution would a nurse use to prime the IV
tubing when preparing to administer a blood product? - ANSWERS-
0.9% normal saline
Which procedural step failure would a nurse recognize as the most
common cause of adverse blood transfusion events? - ANSWERS-
Inappropriate identification prior to blood administration
During which time period would the nurse ensure extra vigilance
when administering a blood product? - ANSWERS-As the transfusion
is started and within the first 15 minutes
Which signs or symptoms of an adverse reaction would a nurse
monitor for in a patient who is receiving a unit of blood? -
ANSWERS-Itching
Hypotension
Dyspnea
Fever
Which actions are taken when a patient refuses a medication?
A- notify the health care provider
B- contact a family member
CARE I EXAM 2
Which data reflect the priority assessments that a nurse would
monitor when concerned that a patient may be developing a fluid
volume imbalance? - ANSWERS-The patient's pulse and blood
pressure
The patient's weight changes over the past day
The patient's intake and output balance over the past 48 hours
Which substances would a nurse need to include in the fluid intake
tally? - ANSWERS-Nasogastric (NG) tube irrigations
Enteral tube feedings
Free water gastric tube flushes
Intravenous medications
Which patient-related data would require entry of fluid output
information on the electronic health record (EHR)? - ANSWERS-The
patient has a nasogastric (NG) tube attached to wall suction.
The patient has an indwelling urinary catheter in place.
The patient has a surgical wound drain on his abdomen.
Which factors would be included by the nurse when developing a 24-
hour fluid budget for a patient with a 1000 mL fluid restriction? -
ANSWERS-Medications
,Intravenous (IV) fluids
Between-meal fluid sipping
Breakfast, lunch, and dinner
Which plan would a nurse suggest for the remainder of the 24-hour
period for a patient on a 1000 mL per day fluid restriction who has
consumed 700 mL as of 3:00 p.m.? - ANSWERS-Allow 150 mL with
dinner and 150 mL for medications and prior to going to sleep.
The nurse suspects that a patient receiving an intravenous (IV)
infusion of D5 0.45% NS is developing intracellular dehydration and
circulatory overload. For which reason would this IV solution cause
this complication? - ANSWERS-It is a hypertonic solution.
Which intravenous (IV) site in infants is most commonly used? -
ANSWERS-The vein in the middle of the scalp
Which actions related to intravenous (IV) fluid administration are the
responsibility of the registered nurse? - ANSWERS-Verify that the
fluid is appropriate for the patient.
Evaluate the effectiveness of IV therapy.
Monitor the patient for complications of IV therapy.
Comply with the 6 rights of safe medication administration.
Which complications would a nurse need to monitor for when caring
for a patient receiving a hypertonic intravenous (IV) fluid? -
ANSWERS-Cellular dehydration
, Circulatory overload
Air embolism
Which intravenous (IV) solution would a nurse use to prime the IV
tubing when preparing to administer a blood product? - ANSWERS-
0.9% normal saline
Which procedural step failure would a nurse recognize as the most
common cause of adverse blood transfusion events? - ANSWERS-
Inappropriate identification prior to blood administration
During which time period would the nurse ensure extra vigilance
when administering a blood product? - ANSWERS-As the transfusion
is started and within the first 15 minutes
Which signs or symptoms of an adverse reaction would a nurse
monitor for in a patient who is receiving a unit of blood? -
ANSWERS-Itching
Hypotension
Dyspnea
Fever
Which actions are taken when a patient refuses a medication?
A- notify the health care provider
B- contact a family member
