NURS 230 SI Worksheet Summary Session 1 2021/2022

7. A pt, experiencing multisystem fluid volume deficit, has the symptoms of tachycardia, pale, cool skin, & decreased urine output. The nurse realizes these findings are most likely a direct result of which of the following? a. The body's natural compensatory mechanisms i. RAAS ii. Release of aldosterone (retain sodium iii. ADH (prevent urination b. Pharmacological effects of a diuretic c. Effects of rapidly infused intravenous fluids d. Cardiac failure i. 8. A pt recovering from surgery has an indwelling urinary catheter. The nurse would contact the pt's primary healthcare provider with which of the following 24-hour urine output volumes? a. 600 mL i. 30 mL/hr or less is clincally concerning b. 750 mL c. 1000 mL d. 1200 mL 9. A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will most likely need which of the following precautions implemented? a. Seizure i. Precautions: padded bed sides, don’t hold them down, rails up ii. Other symptoms cerebral edema, headache confusion, lethargy, neuro system involvement b. Infection c. Neutropenic d. High-risk fall 10. It is especially important for the nurse to assess for which of the following in a patient who has just undergone a total parathyroidectomy? a. Weight gain b. Depressed reflexes c. Positive Chvostek's sign d. Confusion and personality changes 11. Select all of the following below which are considered sensible losses a. Urinary Output b. Lungs c. The skin d. GI Tract Output (feces) e. Emesis (Vomiting) 12. The nurse is caring for a client with heart failure. On Assessment, the nurse notes that the client is dyspneic (breathing w/ difficulty) and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present? SELECT ALL THAT APPLY a. Weight gain b. Flat neck and head veins i. FVD, c. An increase in BP d. Decreased central venous pressure i. FVD 13. The nursing student needs to administer potassium chloride IV as prescribed to a client with hypokalemia. The instructor determines that the student is unprepared if the student states that which action is part of the plan for preparation and administration of the potassium? a. Obtaining an IV infusion pump b. Monitoring urine output during the administration c. Preparing the medication for bolus administration i. Low and slow d. Ensuring the med is diluted in the appropriate amount of normal saline 14. The nurse would be most concerned about which lab values obtained from a patient receiving furosemide/lasix (diuretic) therapy? a. BUN 20 b. Sodium 138 c. Creatinine 1.1 d. Potassium 3.2 16. The nurse is planning care for a