NUR 390 EXAM 1
Normal Hbg levels ANS: Male: 14-18 g/dL
Female: 12-16 g/dL
normal potassium labs ANS: 3.5-5.0 mEq/L
normal WBC labs ANS: 5000-10,000/mm3
normal sodium labs ANS: 135-145 mEq/L
Normal platelet count ANS: 150,000-400.000
Normal neutrophil count ANS: 55%-70%
normal calcium values ANS: 9.0-10.5 mg/dL
normal Hct ANS: Male: 42%-52%
Female: 37%-47%
normal pH value ANS: 7.35-7.45 (7.4)
normal chloride values ANS: 98-106 mEq/L
normal fasting glucose values ANS: 74-106 mg/dL
,normal magnesium values ANS: 1.3-2.1 mEq/L
normal ALT values ANS: 4-36 U/L
normal AST values ANS: 0-35 U/L
normal creatinine value ANS: Male: 0.6-1.2 mg/dL
Female: 0.5-1.1 mg/dL
normal bilirubin values (total) ANS: 0.3-1.0 mg/dL
normal bicarb value ANS: 22-26
normal CO2 value ANS: 35-45
how do you calculate urine output for a patient? ANS: 0.5ml/kg/hr
The nurse is caring for a patient with deficient fluid volume caused by a massive burn injury.
Which of the following assessment data will be of greatest concern to the nurse?
a. The blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL over the last hour.
c. Oral fluid intake is 100 mL for the last 8 hours.
d. There is prolonged skin tenting over the sternum. ANS: ANS: A
The blood pressure indicates that the patient may be developing hypovolemic shock as a result
of fluid loss. This will require immediate intervention to prevent the complications associated
,with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all
indicate the need for increasing the patient's fluid intake but not as urgently as the
hypotension.
The nurse is caring for a patient recently admitted with small cell carcinoma of the lung and
the syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following
assessments should the nurse carefully monitor?
a. Increased total urinary output
b. Elevation of serum hematocrit
c. Decreased serum sodium level
d. Rapid and unexpected weight loss ANS: ANS: C
SIADH causes water retention and hyponatremia—a decrease in serum sodium level. Weight
loss, increased urine output, and elevated serum hematocrit may be associated with excessive
loss of water, but not with SIADH and water retention.
The nurse is evaluating the fluid balance for a patient admitted for hypovolemia associated
with multiple draining wounds. Which of the following assessments is the most accurate to
evaluate volume status in this patient?
a. Skin turgor
b. Daily weight
c. Presence of edema
d. Hourly urine output ANS: ANS: B
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor
varies considerably with age. Considerable excess fluid volume may be present before fluid moves into
the interstitial space and causes edema. Hourly urine outputs do not take account of fluid intake or of
fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds
, The nurse is caring for an alert and oriented older-adult patient with a history of dehydration.
Which of the following information should the home health nurse teach the patient as to when
to increase fluid intake?
a. In the late evening hours
b. If the oral mucosa feels dry
c. When the patient feels thirsty
d. As soon as changes in level of consciousness (LOC) occuR ANS: ANS: B
An alert, elderly patient will be able to self-assess for signs of oral dryness such as thick oral secretions
or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of
volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep
quality. The patient will not be likely to notice and act appropriately when changes in LOC occur.
The nurse is caring for a patient who is taking a potassium-wasting diuretic for treatment of
hypertension. Which of the following assessment data would the nurse include in the teaching
plan?
a. Personality changes
b. Frequent loose stools
c. Facial muscle spasms
d. Lower extremity weakness ANS: ANS: D
Lower extremity weakness progressing to flaccidity is a manifestation of hypokalemia. Facial
muscle spasms might occur with hypocalcemia. Loose stools are associated with
hyperkalemia. Personality changes are not associated with electrolyte disturbances, although
changes in mental status are common manifestations with sodium excess or deficit.
The nurse is teaching a patient about spironolactone as a diuretic. Which statement by the
patient indicates that the teaching about this medication has been effective?
a. "I will try to drink at least eight glasses of water every day."
Normal Hbg levels ANS: Male: 14-18 g/dL
Female: 12-16 g/dL
normal potassium labs ANS: 3.5-5.0 mEq/L
normal WBC labs ANS: 5000-10,000/mm3
normal sodium labs ANS: 135-145 mEq/L
Normal platelet count ANS: 150,000-400.000
Normal neutrophil count ANS: 55%-70%
normal calcium values ANS: 9.0-10.5 mg/dL
normal Hct ANS: Male: 42%-52%
Female: 37%-47%
normal pH value ANS: 7.35-7.45 (7.4)
normal chloride values ANS: 98-106 mEq/L
normal fasting glucose values ANS: 74-106 mg/dL
,normal magnesium values ANS: 1.3-2.1 mEq/L
normal ALT values ANS: 4-36 U/L
normal AST values ANS: 0-35 U/L
normal creatinine value ANS: Male: 0.6-1.2 mg/dL
Female: 0.5-1.1 mg/dL
normal bilirubin values (total) ANS: 0.3-1.0 mg/dL
normal bicarb value ANS: 22-26
normal CO2 value ANS: 35-45
how do you calculate urine output for a patient? ANS: 0.5ml/kg/hr
The nurse is caring for a patient with deficient fluid volume caused by a massive burn injury.
Which of the following assessment data will be of greatest concern to the nurse?
a. The blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL over the last hour.
c. Oral fluid intake is 100 mL for the last 8 hours.
d. There is prolonged skin tenting over the sternum. ANS: ANS: A
The blood pressure indicates that the patient may be developing hypovolemic shock as a result
of fluid loss. This will require immediate intervention to prevent the complications associated
,with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all
indicate the need for increasing the patient's fluid intake but not as urgently as the
hypotension.
The nurse is caring for a patient recently admitted with small cell carcinoma of the lung and
the syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following
assessments should the nurse carefully monitor?
a. Increased total urinary output
b. Elevation of serum hematocrit
c. Decreased serum sodium level
d. Rapid and unexpected weight loss ANS: ANS: C
SIADH causes water retention and hyponatremia—a decrease in serum sodium level. Weight
loss, increased urine output, and elevated serum hematocrit may be associated with excessive
loss of water, but not with SIADH and water retention.
The nurse is evaluating the fluid balance for a patient admitted for hypovolemia associated
with multiple draining wounds. Which of the following assessments is the most accurate to
evaluate volume status in this patient?
a. Skin turgor
b. Daily weight
c. Presence of edema
d. Hourly urine output ANS: ANS: B
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor
varies considerably with age. Considerable excess fluid volume may be present before fluid moves into
the interstitial space and causes edema. Hourly urine outputs do not take account of fluid intake or of
fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds
, The nurse is caring for an alert and oriented older-adult patient with a history of dehydration.
Which of the following information should the home health nurse teach the patient as to when
to increase fluid intake?
a. In the late evening hours
b. If the oral mucosa feels dry
c. When the patient feels thirsty
d. As soon as changes in level of consciousness (LOC) occuR ANS: ANS: B
An alert, elderly patient will be able to self-assess for signs of oral dryness such as thick oral secretions
or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of
volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep
quality. The patient will not be likely to notice and act appropriately when changes in LOC occur.
The nurse is caring for a patient who is taking a potassium-wasting diuretic for treatment of
hypertension. Which of the following assessment data would the nurse include in the teaching
plan?
a. Personality changes
b. Frequent loose stools
c. Facial muscle spasms
d. Lower extremity weakness ANS: ANS: D
Lower extremity weakness progressing to flaccidity is a manifestation of hypokalemia. Facial
muscle spasms might occur with hypocalcemia. Loose stools are associated with
hyperkalemia. Personality changes are not associated with electrolyte disturbances, although
changes in mental status are common manifestations with sodium excess or deficit.
The nurse is teaching a patient about spironolactone as a diuretic. Which statement by the
patient indicates that the teaching about this medication has been effective?
a. "I will try to drink at least eight glasses of water every day."
