NURS 404 EXAM 1 QUESTIONS WITH VERIFIED
ANSWERS
A pt is admitted to the ED with hypovolemia. Which IV solution should the RN anticipate
administering? - Answers - Lactated Ringers (LR)
Why use a 10mL syringe to flush a PICC line? - Answers - 1, 3, and 5mL syringes will
exert too much pressure
The RN notes a grating heart sound when auscultating the apical pulse of a patient with
pericarditis. What should the RN do with this assessment data? - Answers - Note the
findings in the patients medical record (normal for pericarditis)
A client with an increasing number of PVCs is scheduled for 24 hr Holter monitoring.
The nurse instructs the client to - Answers - Keep an accurate record of activity during
the day
The RN receives in report that the patient with a pacemaker has experienced loss of
capture. Which situation is consistent with this? - Answers - Pacemaker spikes are
noted, but no P waves or QRS complex follows
A nurse on a cardiac unit is caring for a patient who is on telemetry. The nurse
recognizes the patient's HR is 44/min and notifies the healthcare provider. The nurse
should anticipate which of the following management strategies will be used by this
patient? - Answers - Pacemaker insertion
Influenza vaccination - Answers - 22-25 gauge IM injection
D5W - Answers - -isotonic in bag, hypotonic when infused with
TACO - Answers - -more serious
-elevated BNP
-can be seen during or directly after transfusion
-pulmonary edema
-treat with diuretics
TRALI - Answers - -NO DIURETICS
-within 6 hours of transfusion
Rate to give platelets - Answers - 15-30 minutes
BNP - Answers - -made in the ventricles
-<100 pg/mL
, -used for diagnosing heart failure
Blood Transfusions - Answers - -120mL/hr for 1st 15 minutes and can increase to 15-
250 mL/hr after
-must be done within 4 hours
A new RN is caring for a client receiving drug therapy via a smart pump. What
statement by the new nurse demonstrates the need for more instruction on this
technology? - Answers - "I don't need to manually calculate IV infusion rates with smart
pumps."
PICC Lines - Answers - -3-8 inches long
-in upper arm
-hydration and drug therapy for 6-14 days
-DO NOT USE VESICANT DRUGS or to draw blood
Which electrolytes are affected by low magnesium levels? - Answers - -calcium
-potassium
Which condition or manifestation in the client with a serum sodium level of 149 indicates
to the nurse that this electrolyte imbalance may be caused by excessive fluid loss? -
Answers - Hematocrit is 52%
A client is receiving an intravenous infusion of 100 KCl in 1000 mL of normal saline.
How many mEq of potassium per hour does the nurse calculate the client will receive if
the IV is infused at 150 mL/hour? - Answers - 15 mEq
Which assessment data is the most relevant for the nurse to obtain from a client who
has a serum potassium level of 2.9? - Answers - Determine what drugs are taken daily
A client is receving gentamycin intravenously reports that the peripheral IV insertion site
has become painful and reddened. What is the priority nursing action? - Answers - Stop
the infusion of the drug
An older adult client receiving an infusion of 5% dextrose in 0.9% normal saline at
150mL/hour has developed shortness of breathe with a decrease in O2 saturation to
86%. What is the priority nursing intervention? - Answers - Place the client on O2
The nurse is teaching a class regarding reduction of risk factors for cardiovascular
disease. Which teaching statement will the nurse include? - Answers - -if you tend to get
angry easily, then your risk for heart disease is higher
-do not eat more calories on a daily basis that you are able to burn
-secondhand smoke creates a significant risk to others
-exercise moderately at least 2 days per week for a total of 150 minutes
ANSWERS
A pt is admitted to the ED with hypovolemia. Which IV solution should the RN anticipate
administering? - Answers - Lactated Ringers (LR)
Why use a 10mL syringe to flush a PICC line? - Answers - 1, 3, and 5mL syringes will
exert too much pressure
The RN notes a grating heart sound when auscultating the apical pulse of a patient with
pericarditis. What should the RN do with this assessment data? - Answers - Note the
findings in the patients medical record (normal for pericarditis)
A client with an increasing number of PVCs is scheduled for 24 hr Holter monitoring.
The nurse instructs the client to - Answers - Keep an accurate record of activity during
the day
The RN receives in report that the patient with a pacemaker has experienced loss of
capture. Which situation is consistent with this? - Answers - Pacemaker spikes are
noted, but no P waves or QRS complex follows
A nurse on a cardiac unit is caring for a patient who is on telemetry. The nurse
recognizes the patient's HR is 44/min and notifies the healthcare provider. The nurse
should anticipate which of the following management strategies will be used by this
patient? - Answers - Pacemaker insertion
Influenza vaccination - Answers - 22-25 gauge IM injection
D5W - Answers - -isotonic in bag, hypotonic when infused with
TACO - Answers - -more serious
-elevated BNP
-can be seen during or directly after transfusion
-pulmonary edema
-treat with diuretics
TRALI - Answers - -NO DIURETICS
-within 6 hours of transfusion
Rate to give platelets - Answers - 15-30 minutes
BNP - Answers - -made in the ventricles
-<100 pg/mL
, -used for diagnosing heart failure
Blood Transfusions - Answers - -120mL/hr for 1st 15 minutes and can increase to 15-
250 mL/hr after
-must be done within 4 hours
A new RN is caring for a client receiving drug therapy via a smart pump. What
statement by the new nurse demonstrates the need for more instruction on this
technology? - Answers - "I don't need to manually calculate IV infusion rates with smart
pumps."
PICC Lines - Answers - -3-8 inches long
-in upper arm
-hydration and drug therapy for 6-14 days
-DO NOT USE VESICANT DRUGS or to draw blood
Which electrolytes are affected by low magnesium levels? - Answers - -calcium
-potassium
Which condition or manifestation in the client with a serum sodium level of 149 indicates
to the nurse that this electrolyte imbalance may be caused by excessive fluid loss? -
Answers - Hematocrit is 52%
A client is receiving an intravenous infusion of 100 KCl in 1000 mL of normal saline.
How many mEq of potassium per hour does the nurse calculate the client will receive if
the IV is infused at 150 mL/hour? - Answers - 15 mEq
Which assessment data is the most relevant for the nurse to obtain from a client who
has a serum potassium level of 2.9? - Answers - Determine what drugs are taken daily
A client is receving gentamycin intravenously reports that the peripheral IV insertion site
has become painful and reddened. What is the priority nursing action? - Answers - Stop
the infusion of the drug
An older adult client receiving an infusion of 5% dextrose in 0.9% normal saline at
150mL/hour has developed shortness of breathe with a decrease in O2 saturation to
86%. What is the priority nursing intervention? - Answers - Place the client on O2
The nurse is teaching a class regarding reduction of risk factors for cardiovascular
disease. Which teaching statement will the nurse include? - Answers - -if you tend to get
angry easily, then your risk for heart disease is higher
-do not eat more calories on a daily basis that you are able to burn
-secondhand smoke creates a significant risk to others
-exercise moderately at least 2 days per week for a total of 150 minutes
