WRITTENSKILLSAPPLICATION s s
QUESTIONSWITHANSWERS s s s
MOBILITY : A nurse in an emergency department is providing discharge teaching to a client s s s s s s s s s s s s s s
who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the
s s s s s s s s s s s s s s s s s s s s s
following instruction should the nurse include - correct answer- Hold the crutches on your
s s s s s s s ss s s s s s s
unaffected side when preparing to sit in a chair
s s s s s s s s s
Nurses came for a client who has a prescription for knee-length anti-embolic stockings which
s s s s s s s s s s s s s
of the following action should the nurse take - correct answer- Measure the clients calf
s s s s s s s s s ss s s s s s
circumference and leg length from heel to knee
s s s s s s s s
A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair.
s s s s s s s s s s s s s s s s s
Which of the following actions by the nurse demonstrates correct transfer technique - correct
s s s s s s s s s s s s s ss
answer- Aligning the nurses knees with the clients knees just before the transfer
s s s s s s s s s s s s s
A nurse is caring for a client who has been hospitalized and is performing active range of motion
s s s s s s s s s s s s s s s s s
exercises. Which of the following body movements should indicate to the nurse that the client
s s s s s s s s s s s s s s s
has full range of motion of the shoulder - correct answer- Flexing the shoulder by raising the
s s s s s s s s s ss s s s s s s s
arm from a side position to a 180° angle
s s s s s s s s s
A nurse is assisting with the ambulation of a client who becomes lightheaded and begins to fall.
s s s s s s s s s s s s s s s s
Which of the following action should the nurse take - correct answer- Extend one leg and allow
s s s s s s s s s s ss s s s s s s
the client to slide down the leg to the floor
s s s s s s s s s s
A nurse is observing an assistive personnel who is using a mechanical lift with a hammock sling
s s s s s s s s s s s s s s s s
to transfer a client from the bed to chair. For which of the following actions by the AP should the
s s s s s s s s s s s s s s s s s s s s
nurse intervene - correct answer- Leaves the bed in the lowest position throughout the
s s s ss s s s s s s s s s s
procedure
s
A nurse stands facing a client to demonstrate active range of motion exercises. Which of the
s s s s s s s s s s s s s s s
following action should the nurse take to demonstrate hyper extension of the hip - correct
s s s s s s s s s s s s s s ss
answer- Move their leg behind their body
s s s s s s s
ENEMAS : A nurse is preparing to administer an oil retention enema to a client who has
s s s s s s s s s s s s s s s s
constipation. The nurse should instruct the client to retain the solution for which of the following
s s s s s s s s s s s s s s s s
durations - correct answer- At least 30 minutes
s s ss s s s s s
,A nurse is preparing to administer a cleansing enema To a client who has a poor sphincter
s s s s s s s s s s s s s s s s
control. Which of the following action should the nurse take - correct answer- Place the client in
s s s s s s s s s s s ss s s s s s
the dorsal recumbent position on a bedpan
s s s s s s s
A nurse is administering an enema medicated with sodium polystyrene sulfonate to an adult
s s s s s s s s s s s s s
client who has hyperkalemia. To which of the following lengths should the nurse insert the
s s s s s s s s s s s s s s s
rectal tube - correct answer- 7.5 cm to 10 cm (3 to 4 in)
s s s ss s s s s s s s s s s
A nurse is preparing an adult client for an enema. The nurse should assist the client to which of
s s s s s s s s s s s s s s s s s s
the following positions - correct answer- Left lateral with the right leg flexed
s s s s ss s s s s s s s s
A client who is postoperative is experiencing abdominal distention and is having difficulty
s s s s s s s s s s s s
expelling flatus. The nurse should expect the provider to prescribe which of the following types
s s s s s s s s s s s s s s s
of enemas - correct answer- Return-flow
s s s ss s s
A nurse is preparing to administer the first of two large volume cleansing enema is prescribed
s s s s s s s s s s s s s s s
for a client in preparation for a diagnostic procedure. Which of the following action should the
s s s s s s s s s s s s s s s s
nurse take - correct answer- Warm the enema solution prior to installation
s s s ss s s s s s s s s
While a nurse is administering a cleansing enema the client reports abdominal cramping.
s s s s s s s s s s s s
Which of the following action should the nurse take - correct answer- Lower the enema fluid
s s s s s s s s s s ss s s s s s
container
s
A nurse is administering a return flow enema to a client. After instilling 100 mL of enema fluid
s s s s s s s s s s s s s s s s s
which of the following action should the nurse take - correct answer- Lower the container to
s s s s s s s s s s ss s s s s s
allow the solution to flow back out
s s s s s s s
ENTERAL TUBE FEEDING: A nurse is caring for a client who has a dysfunctional s s s s s s s s s s s s s
gastrointestinal tract and requires enteral feeding. Which of the following formula should the
s s s s s s s s s s s s s
nurse administer to the client - correct answer- Elemental
s s s s s s ss s s
A nurse is preparing to administer a continuous enteral Tube feeding to a client. The nurse
s s s s s s s s s s s s s s s
should take which of the following actions to invent a complication of the tube feeding - correct
s s s s s s s s s s s s s s s s ss
answer- Limit the time of the formula hang time to eight hours
s s s s s s s s s s s s
A client who lives in a long-term care facility is receiving intermittent enteral Feedings and is
s s s s s s s s s s s s s s s
experiencing social isolation. Which of the following intervention should the nurse
s s s s s s s s s s s
recommend - correct answer- Encourage the client to go to the dining room at meals times to
s s ss s s s s s s s s s s s s s s
talk with other clients
s s s s
A nurse is providing teaching about the risk for aspiration with a client who is receiving
s s s s s s s s s s s s s s s
intermittent bolus nasogastric feedings. Which of the following findings should the nurse
s s s s s s s s s s s s
instruct the client to report - correct answer- persistent coughing
s s s s s s ss s s s
A nurse is caring for a client who has a significant risk of aspiration and requires nutritional
s s s s s s s s s s s s s s s s
support for about two weeks because they are unable to consume adequate nutrition orally.
s s s s s s s s s s s s s s
,sWhich of the following types of feeding tube should the nurse anticipate the provider to
s s s s s s s s s s s s s s
sprescribe - correct answer- Nasointestinal tube s ss s s s
A nurse is caring for a group of clients. The nurse should Identify that which of the following
s s s s s s s s s s s s s s s s s
clients requires an enteral tube feeding - correct answer- A client who has dysphagia
s s s s s s s ss s s s s s s
And a nurse is inserting a nasogastric tube for client asked the client to flex their head towards
s s s s s s s s s s s s s s s s s
their chest after the two passes through the nasal pharynx. This action facilitates proper
s s s s s s s s s s s s s s
insertion of the tube by achieving which of the following - correct answer- Closing off the glottis
s s s s s s s s s s s ss s s s s s
A nurse is administering an enteral tube feeding to a client. Which of the following action should
s s s s s s s s s s s s s s s s
the nurse take to prevent aspiration - correct answer- Place the client Fowlers position
s s s s s s s ss s s s s s s
A nurse is inserting a small bore feeding tube before initiating the feeding the nurse should take
s s s s s s s s s s s s s s s s
which of the following actions to verify placement - correct answer- Obtain an x-ray
s s s s s s s s s ss s s s s
To determine the length of an age so intestinal to to insert a nurse should measure the distance
s s s s s s s s s s s s s s s s s
from the tip of the clients nose to the earlobe in from the earlobe to the - correct answer- Xiphoid
s s s s s s s s s s s s s s s s s ss s s
process +20 to 30 cm more
s s s s s s
INFECTION CONTROL: After completing a procedure that required donning personal s s s s s s s s s
protective equipment consisting of a gown a N 95 respirator face shield and gloves which of the
s s s s s s s s s s s s s s s s s
following should the nurse remove first from removing PPE separately - correct answer-
s s s s s s s s s s s ss s
Gloves
s
Contact Precaution should be implemented for an adult client who has been hospitalized and
s s s s s s s s s s s s s
has which of the following - correct answer- Infectious diarrhea
s s s s s s ss s s s
To decontaminate their hands with an alcohol base gel the nurse should rub their hands
s s s s s s s s s s s s s s
together until all of the gel has evaporated and their hands are dry. Which of the following is the
s s s s s s s s s s s s s s s s s s s
correct rationale for why hand should be rubbed together until dry - correct answer- Dry and
s s s s s s s s s s s s ss s s s
provides a full anti-septic effect
s s s s s
A nurse is caring for a client who has a healthcare associated infection which of the following
s s s s s s s s s s s s s s s s
describes an exogenous HAI - correct answer- A salmonella infection that occurs after eating
s s s s s ss s s s s s s s s
contaminated food from the cafeteria
s s s s s
And after assisting a newly admitted client with removing their shoes an hour where the nurse
s s s s s s s s s s s s s s s
notices what appears to be soil or grime on their hands. Which of the following action should the
s s s s s s s s s s s s s s s s s s
nurse take - correct answer- Wash their hands with soap and water
s s s ss s s s s s s s s
What should the nurse do to maintain standard precautions - correct answer- Disinfectant
s s s s s s s s s ss s s
hands immediately after removing gloves
s s s s s
, A nurse is caring for a client who has mycoplasma pneumonia. The client has been placed on
s s s s s s s s s s s s s s s s
droplet precautions. Which of the following action should the nurse take when caring for the
s s s s s s s s s s s s s s s
client - correct answer- Protect their eyes
s s ss s s s s
Which of the following is an advantage of using alcohol base gel - correct answer- It takes less
s s s s s s s s s s s s ss s s s s
time to use them washing with soap and water
s s s s s s s s s
A nurse is about to irrigate a client open wound besides gloves which of the following personal
s s s s s s s s s s s s s s s s
protective equipment should the nurse wear - correct answer- A face shield
s s s s s s s ss s s s s
Which of the following products can affect the permeability of latex gloves - correct answer-
s s s s s s s s s s s s ss s
Petroleum based hand lotion
s s s s
A nurse is washing their hands with soap and water prior to repositioning a client in bed during
s s s s s s s s s s s s s s s s s
the handwashing procedure it is important to take which of the following actions - correct
s s s s s s s s s s s s s s ss
answer- Wash for at least 20 seconds
s s s s s s s
IV THERAPY: A nurse has just inserted a peripheral IV catheter which of the following action
s s s s s s s s s s s s s s s
should the nurse take to secure the catheter - correct answer- Applying Abbi securement
s s s s s s s s s ss s s s s
device
s
A nurse is removing a client IV catheter. Which of the following action should the nurse take -
s s s s s s s s s s s s s s s s s s
correct answer- Pull the catheter straight back from the insertion site
s s s s s s s s s s s
A nurse is inserting a peripheral IV catheter and observes a blood return in the flash back
s s s s s s s s s s s s s s s s
chamber after puncturing The skin and selected van. Which of the following action should the
s s s s s s s s s s s s s s s
nurse perform next - correct answer- Advance a catheter into the van with the finger hub
s s s s ss s s s s s s s s s s s
A client is to receive 1000 mL bag of 5% dextrose in lactated ringers over eight hours. Using
s s s s s s s s s s s s s s s s s
tubing with a Dropbox of 15 drops per milliliter the nurse should regulate fluid to infuse it how
s s s s s s s s s s s s s s s s s s
many drops per minute round to the nearest whole number - correct answer- 31
s s s s s s s s s s s ss s s
A nurse assesses a client IV insertion site and finds it is red warm and slightly edematous.
s s s s s s s s s s s s s s s s
Which of the following action should the nurse take - correct answer- Discontinue the IV line
s s s s s s s s s s ss s s s s s
A nurse has just initiated an IV infusion and is teaching the client about possible complications.
s s s s s s s s s s s s s s s
The nurse should include that which of the following findings is an indication of early infiltration -
s s s s s s s s s s s s s s s s s s
correct answer- Coolness
s s s
Which of the following action should the nurse take when converting an IV infusion to a saline
s s s s s s s s s s s s s s s s
lock - correct answer- Flush the ivie to confirm patency
s s ss s s s s s s s
A nurse is caring for a client who is an early stage renal failure and has a prescription for the
s s s s s s s s s s s s s s s s s s s
infusion of IV fluids which of the following IV fluids does a nurse anticipate a prescription for and
s s s s s s s s s s s s s s s s s s
why - correct answer- 0.45% sodium chloride because it dilute extracellular fluid and
s s ss s s s s s s s s s s
rehydrates the cells
s s s
QUESTIONSWITHANSWERS s s s
MOBILITY : A nurse in an emergency department is providing discharge teaching to a client s s s s s s s s s s s s s s
who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the
s s s s s s s s s s s s s s s s s s s s s
following instruction should the nurse include - correct answer- Hold the crutches on your
s s s s s s s ss s s s s s s
unaffected side when preparing to sit in a chair
s s s s s s s s s
Nurses came for a client who has a prescription for knee-length anti-embolic stockings which
s s s s s s s s s s s s s
of the following action should the nurse take - correct answer- Measure the clients calf
s s s s s s s s s ss s s s s s
circumference and leg length from heel to knee
s s s s s s s s
A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair.
s s s s s s s s s s s s s s s s s
Which of the following actions by the nurse demonstrates correct transfer technique - correct
s s s s s s s s s s s s s ss
answer- Aligning the nurses knees with the clients knees just before the transfer
s s s s s s s s s s s s s
A nurse is caring for a client who has been hospitalized and is performing active range of motion
s s s s s s s s s s s s s s s s s
exercises. Which of the following body movements should indicate to the nurse that the client
s s s s s s s s s s s s s s s
has full range of motion of the shoulder - correct answer- Flexing the shoulder by raising the
s s s s s s s s s ss s s s s s s s
arm from a side position to a 180° angle
s s s s s s s s s
A nurse is assisting with the ambulation of a client who becomes lightheaded and begins to fall.
s s s s s s s s s s s s s s s s
Which of the following action should the nurse take - correct answer- Extend one leg and allow
s s s s s s s s s s ss s s s s s s
the client to slide down the leg to the floor
s s s s s s s s s s
A nurse is observing an assistive personnel who is using a mechanical lift with a hammock sling
s s s s s s s s s s s s s s s s
to transfer a client from the bed to chair. For which of the following actions by the AP should the
s s s s s s s s s s s s s s s s s s s s
nurse intervene - correct answer- Leaves the bed in the lowest position throughout the
s s s ss s s s s s s s s s s
procedure
s
A nurse stands facing a client to demonstrate active range of motion exercises. Which of the
s s s s s s s s s s s s s s s
following action should the nurse take to demonstrate hyper extension of the hip - correct
s s s s s s s s s s s s s s ss
answer- Move their leg behind their body
s s s s s s s
ENEMAS : A nurse is preparing to administer an oil retention enema to a client who has
s s s s s s s s s s s s s s s s
constipation. The nurse should instruct the client to retain the solution for which of the following
s s s s s s s s s s s s s s s s
durations - correct answer- At least 30 minutes
s s ss s s s s s
,A nurse is preparing to administer a cleansing enema To a client who has a poor sphincter
s s s s s s s s s s s s s s s s
control. Which of the following action should the nurse take - correct answer- Place the client in
s s s s s s s s s s s ss s s s s s
the dorsal recumbent position on a bedpan
s s s s s s s
A nurse is administering an enema medicated with sodium polystyrene sulfonate to an adult
s s s s s s s s s s s s s
client who has hyperkalemia. To which of the following lengths should the nurse insert the
s s s s s s s s s s s s s s s
rectal tube - correct answer- 7.5 cm to 10 cm (3 to 4 in)
s s s ss s s s s s s s s s s
A nurse is preparing an adult client for an enema. The nurse should assist the client to which of
s s s s s s s s s s s s s s s s s s
the following positions - correct answer- Left lateral with the right leg flexed
s s s s ss s s s s s s s s
A client who is postoperative is experiencing abdominal distention and is having difficulty
s s s s s s s s s s s s
expelling flatus. The nurse should expect the provider to prescribe which of the following types
s s s s s s s s s s s s s s s
of enemas - correct answer- Return-flow
s s s ss s s
A nurse is preparing to administer the first of two large volume cleansing enema is prescribed
s s s s s s s s s s s s s s s
for a client in preparation for a diagnostic procedure. Which of the following action should the
s s s s s s s s s s s s s s s s
nurse take - correct answer- Warm the enema solution prior to installation
s s s ss s s s s s s s s
While a nurse is administering a cleansing enema the client reports abdominal cramping.
s s s s s s s s s s s s
Which of the following action should the nurse take - correct answer- Lower the enema fluid
s s s s s s s s s s ss s s s s s
container
s
A nurse is administering a return flow enema to a client. After instilling 100 mL of enema fluid
s s s s s s s s s s s s s s s s s
which of the following action should the nurse take - correct answer- Lower the container to
s s s s s s s s s s ss s s s s s
allow the solution to flow back out
s s s s s s s
ENTERAL TUBE FEEDING: A nurse is caring for a client who has a dysfunctional s s s s s s s s s s s s s
gastrointestinal tract and requires enteral feeding. Which of the following formula should the
s s s s s s s s s s s s s
nurse administer to the client - correct answer- Elemental
s s s s s s ss s s
A nurse is preparing to administer a continuous enteral Tube feeding to a client. The nurse
s s s s s s s s s s s s s s s
should take which of the following actions to invent a complication of the tube feeding - correct
s s s s s s s s s s s s s s s s ss
answer- Limit the time of the formula hang time to eight hours
s s s s s s s s s s s s
A client who lives in a long-term care facility is receiving intermittent enteral Feedings and is
s s s s s s s s s s s s s s s
experiencing social isolation. Which of the following intervention should the nurse
s s s s s s s s s s s
recommend - correct answer- Encourage the client to go to the dining room at meals times to
s s ss s s s s s s s s s s s s s s
talk with other clients
s s s s
A nurse is providing teaching about the risk for aspiration with a client who is receiving
s s s s s s s s s s s s s s s
intermittent bolus nasogastric feedings. Which of the following findings should the nurse
s s s s s s s s s s s s
instruct the client to report - correct answer- persistent coughing
s s s s s s ss s s s
A nurse is caring for a client who has a significant risk of aspiration and requires nutritional
s s s s s s s s s s s s s s s s
support for about two weeks because they are unable to consume adequate nutrition orally.
s s s s s s s s s s s s s s
,sWhich of the following types of feeding tube should the nurse anticipate the provider to
s s s s s s s s s s s s s s
sprescribe - correct answer- Nasointestinal tube s ss s s s
A nurse is caring for a group of clients. The nurse should Identify that which of the following
s s s s s s s s s s s s s s s s s
clients requires an enteral tube feeding - correct answer- A client who has dysphagia
s s s s s s s ss s s s s s s
And a nurse is inserting a nasogastric tube for client asked the client to flex their head towards
s s s s s s s s s s s s s s s s s
their chest after the two passes through the nasal pharynx. This action facilitates proper
s s s s s s s s s s s s s s
insertion of the tube by achieving which of the following - correct answer- Closing off the glottis
s s s s s s s s s s s ss s s s s s
A nurse is administering an enteral tube feeding to a client. Which of the following action should
s s s s s s s s s s s s s s s s
the nurse take to prevent aspiration - correct answer- Place the client Fowlers position
s s s s s s s ss s s s s s s
A nurse is inserting a small bore feeding tube before initiating the feeding the nurse should take
s s s s s s s s s s s s s s s s
which of the following actions to verify placement - correct answer- Obtain an x-ray
s s s s s s s s s ss s s s s
To determine the length of an age so intestinal to to insert a nurse should measure the distance
s s s s s s s s s s s s s s s s s
from the tip of the clients nose to the earlobe in from the earlobe to the - correct answer- Xiphoid
s s s s s s s s s s s s s s s s s ss s s
process +20 to 30 cm more
s s s s s s
INFECTION CONTROL: After completing a procedure that required donning personal s s s s s s s s s
protective equipment consisting of a gown a N 95 respirator face shield and gloves which of the
s s s s s s s s s s s s s s s s s
following should the nurse remove first from removing PPE separately - correct answer-
s s s s s s s s s s s ss s
Gloves
s
Contact Precaution should be implemented for an adult client who has been hospitalized and
s s s s s s s s s s s s s
has which of the following - correct answer- Infectious diarrhea
s s s s s s ss s s s
To decontaminate their hands with an alcohol base gel the nurse should rub their hands
s s s s s s s s s s s s s s
together until all of the gel has evaporated and their hands are dry. Which of the following is the
s s s s s s s s s s s s s s s s s s s
correct rationale for why hand should be rubbed together until dry - correct answer- Dry and
s s s s s s s s s s s s ss s s s
provides a full anti-septic effect
s s s s s
A nurse is caring for a client who has a healthcare associated infection which of the following
s s s s s s s s s s s s s s s s
describes an exogenous HAI - correct answer- A salmonella infection that occurs after eating
s s s s s ss s s s s s s s s
contaminated food from the cafeteria
s s s s s
And after assisting a newly admitted client with removing their shoes an hour where the nurse
s s s s s s s s s s s s s s s
notices what appears to be soil or grime on their hands. Which of the following action should the
s s s s s s s s s s s s s s s s s s
nurse take - correct answer- Wash their hands with soap and water
s s s ss s s s s s s s s
What should the nurse do to maintain standard precautions - correct answer- Disinfectant
s s s s s s s s s ss s s
hands immediately after removing gloves
s s s s s
, A nurse is caring for a client who has mycoplasma pneumonia. The client has been placed on
s s s s s s s s s s s s s s s s
droplet precautions. Which of the following action should the nurse take when caring for the
s s s s s s s s s s s s s s s
client - correct answer- Protect their eyes
s s ss s s s s
Which of the following is an advantage of using alcohol base gel - correct answer- It takes less
s s s s s s s s s s s s ss s s s s
time to use them washing with soap and water
s s s s s s s s s
A nurse is about to irrigate a client open wound besides gloves which of the following personal
s s s s s s s s s s s s s s s s
protective equipment should the nurse wear - correct answer- A face shield
s s s s s s s ss s s s s
Which of the following products can affect the permeability of latex gloves - correct answer-
s s s s s s s s s s s s ss s
Petroleum based hand lotion
s s s s
A nurse is washing their hands with soap and water prior to repositioning a client in bed during
s s s s s s s s s s s s s s s s s
the handwashing procedure it is important to take which of the following actions - correct
s s s s s s s s s s s s s s ss
answer- Wash for at least 20 seconds
s s s s s s s
IV THERAPY: A nurse has just inserted a peripheral IV catheter which of the following action
s s s s s s s s s s s s s s s
should the nurse take to secure the catheter - correct answer- Applying Abbi securement
s s s s s s s s s ss s s s s
device
s
A nurse is removing a client IV catheter. Which of the following action should the nurse take -
s s s s s s s s s s s s s s s s s s
correct answer- Pull the catheter straight back from the insertion site
s s s s s s s s s s s
A nurse is inserting a peripheral IV catheter and observes a blood return in the flash back
s s s s s s s s s s s s s s s s
chamber after puncturing The skin and selected van. Which of the following action should the
s s s s s s s s s s s s s s s
nurse perform next - correct answer- Advance a catheter into the van with the finger hub
s s s s ss s s s s s s s s s s s
A client is to receive 1000 mL bag of 5% dextrose in lactated ringers over eight hours. Using
s s s s s s s s s s s s s s s s s
tubing with a Dropbox of 15 drops per milliliter the nurse should regulate fluid to infuse it how
s s s s s s s s s s s s s s s s s s
many drops per minute round to the nearest whole number - correct answer- 31
s s s s s s s s s s s ss s s
A nurse assesses a client IV insertion site and finds it is red warm and slightly edematous.
s s s s s s s s s s s s s s s s
Which of the following action should the nurse take - correct answer- Discontinue the IV line
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A nurse has just initiated an IV infusion and is teaching the client about possible complications.
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The nurse should include that which of the following findings is an indication of early infiltration -
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correct answer- Coolness
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Which of the following action should the nurse take when converting an IV infusion to a saline
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lock - correct answer- Flush the ivie to confirm patency
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A nurse is caring for a client who is an early stage renal failure and has a prescription for the
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infusion of IV fluids which of the following IV fluids does a nurse anticipate a prescription for and
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why - correct answer- 0.45% sodium chloride because it dilute extracellular fluid and
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rehydrates the cells
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