Exam 5 fundamentals Of Nursing

Question 1

Patients total water volume exists in which compartments?

Answer 1

Intercellular

Question 2

Passively moving water from an area of lower particle concentration to an area of high particles concentration:

Answer 2

Osmosis

Question 3

Pressure that has facilitated the formation of the patients edema?

Answer 3

Hydrostatic

Question 4

In a hypertonic solution which direction will the fluid shift?

Answer 4

From intercellular to extracellular

Question 5

Cation that is the most abundant in the blood?

Answer 5

Sodium

Question 6

Calcium is elevated, the phosphate will be?

Answer 6

Decreased

Question 7

Patient ingested a medication that causes respiratory depression, look for:

Answer 7

Respiratory acidosis

Question 8

A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which ABG values should be observed?

Answer 8

Metabolic alkalosis

Question 9

ECG presents with changes characteristic of hypokalemia. Which assessment finding is expected

Answer 9

Abdominal distention

Question 10

Positive chovostek sign?

Answer 10

Hypocalcemia or hypomagnesemia

Question 11

A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient?

Answer 11

Renal

Question 12

The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. Which action should the nurse take first?

Answer 12

Raise the head of the bed

Question 13

A chemotherapy patient who has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate?

Answer 13

“How many times a day do you urinate?”

Question 14

Hypotonic intravenous solution:

Answer 14

0.45% sodium chloride (1/2 NS)

Question 15

A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting TPN will the nurse add to the care plan?

Answer 15

Replace fluids, electrolytes, and nutrients.

Question 16

Isotonic intravenous therapy

Answer 16

0.9% sodium chloride (NS)

Question 17

A nurse is administering a diuretic to a patient and teaching the patient about foods to increase. Which food choices by the patient will best indicate successful teaching?

Answer 17

Potatoes and fresh fruit

Question 18

Effectiveness of intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement?

Answer 18

Serum sodium concentration returns to normal

Question 19

A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit?

Answer 19

Postural hypotension

Question 20

Longest time you can let RBC’s infuse

Answer 20

4 hours

Question 21

A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions?

Answer 21

Fluid volume overload

Question 22

A nurse is preparing to start a blood transfusion. Which type of tubing will the nurse obtain?

Answer 22

A filter to ensure that clots do not enter the patient

Question 23

The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority

Answer 23

Cardiac

Question 24

Which assessments will alert the nurse that a patient’s IV has infiltrated? (Select all that apply.)

Answer 24

Edema of the extremity near the insertion site
Skin discolored or pale in appearance
Skin cool to the touch

Question 25

A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? (Select all that apply.)

Answer 25

Check for contraindications to the extremity Choose a vein with minimal curvature Avoid areas of flexion

Question 26

A nurse is discontinuing a patient’s peripheral IV access. Which actions should the nurse take? (Select all that apply.)

Answer 26

Stop the infusion before removing the IV catheter Keep the catheter parallel to the skin while removing it Apply pressure to the site for 2 to 3 minutes after removal

Question 27

Patient X is diagnosed with constipation. As a knowledgeable nurse, which nursing intervention is appropriate for maintaining normal bowel function?

Answer 27

Assessing dietary intake

Question 28

A 12-year-old boy was admitted to the hospital two days ago due to hyperthermia. His attending nurse, Dennis, is quite unsure about his plan of care. Which of the following nursing interventions should be included in the care plan for the client?

Answer 28

Room temperature Reduction

Question 29

Which nursing intervention would be appropriate when identifying nursing interventions aimed at promoting and preventing contractures?

Answer 29

Correct body alignment, preventing foot drop, and range-of-motion exercises

Question 30

Which intervention should be included in the home health care nurse’s instructions about measures to prevent constipation?

Answer 30

Instructing the client to fill a 2-L bottle with water every night & drink the next day.

Question 31

A 22-year-old lady is displaying facial grimaces during her treatment in the hospital due to burn trauma. Which nursing intervention should be included for reducing pain due to cellular injury

Answer 31

Administering anti-inflammatory agents as prescribed

Question 32

Lisa, a client with altered urinary function, is under the care of nurse Tine. Which intervention is appropriate to include when developing a plan of care for Lisa who is experiencing urinary dribbling

Answer 32

Having the client perform Kegel exercises

Question 33

Patient is admitted to the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and has shortness of breath and asthma. Which goal is the most important for the client?

Answer 33

Maintenance of adequate oxygenation

Question 34

Maya, who is admitted to a hospital, is scheduled to have her general checkup and physical assessment. Nurse Timothy observed a reddened area over her left hip. Which should the nurse do first

Answer 34

Turn the client to the right side for 2 hours

Question 35

Pierro was noted to be displaying facial grimaces after nurse Kara assessed his complaints of pain rated as 8 on a scale of 1 (no pain) 10 10 (worst pain). Which intervention should the nurse do?

Answer 35

Attempting to rule out complications before administering pain medication

Question 36

A patient with tented skin turgor, dry mucous membranes, and decreased urinary output is under nurse Mark’s care. Which nursing intervention should be included in the care plan of Mark for his patient?

Answer 36

Administering I.V. and oral fluids

Question 37

Khaleesi is admitted to the hospital due to having a lower than normal potassium level in her bloodstream. Her medical history reveals vomiting and diarrhea prior to hospitalization. Which foods should the nurse instruct the client to increase

Answer 37

Orange juice and bananas

Question 38

Mary Jean, a first year nursing student, was rushed to the clinic department due to hyperventilation. Which nursing intervention is the most appropriate for the client who is subsequently developing respiratory alkalosis

Answer 38

Encouraging slow, deep breaths

Question 39

Marie Joy’s lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated

Answer 39

Positive Trousseau's sign

Question 40

Lab tests revealed that [Na+] is 170 mEq/L. Which to expect to assess?

Answer 40

Tented skin turgor and thirst

Question 41

A client with a very dry mouth, skin, and mucous membranes is diagnosed with dehydration. Which intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit?

Answer 41

Assessing urinary intake and output

Question 42

Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium:

Answer 42

Renal disease

Question 43

Patient is diagnosed with hypomagnesemia, which nursing intervention would be appropriate

Answer 43

Instituting seizure precaution

Question 44

Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid

Answer 44

Sodium

Question 45

potassium level of 6.5 mEq/L, what medication would the nurse anticipate

Answer 45

Kayexalate

Question 46

Which clinical manifestation would lead the nurse to suspect that a client is experiencing hypermagnesemia

Answer 46

Hot flushed skin and diaphoresis

Question 47

Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to assess in planning the care for the client

Answer 47

Potassium level

Question 48

(ABG) values: pH of 7.34, partial pressure of arterial oxygen of 80 mm Hg, partial pressure of arterial carbon dioxide of 49 mm Hg, and a bicarbonate level of 24 mEq/L. Which intervention should the nurse implement?

Answer 48

Encouraging the client to cough and deep breathe.

Question 49

A client is diagnosed with metabolic acidosis, which would the nurse expect the health care provider to order

Answer 49

Sodium bicarbonate

Question 50

A nurse is teaching about the energy needed at rest to maintain life sustaining activities for a specific period of time. What is the nurse discussing

Answer 50

Basal metabolic rate (BMR)

Question 51

A nurse is teaching a patient about proteins that must be obtained through the diet and cannot be synthesized in the body. Which term used by the patient indicates teaching is successful?

Answer 51

indispensable amino acids

Question 52

Which statement made by an adult patient demonstrates understanding of healthy nutrition teaching

Answer 52

I will make sure that I eat a balanced diet and exercise

Question 53

The nurse teaches a patient who has had surgery to increase which nutrient to help with tissue repair?

Answer 53

Protein

Question 54

The nurse suspects that the patient receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What action does the nurse need to take first

Answer 54

Turn patient to left lateral decubitus

Question 55

Based on knowledge of peptic ulcer disease (PUD), the nurse anticipates the presence of which bacteria when reviewing the laboratory data for a patient suspected of having PUD?

Answer 55

Helicobacter pylori

Question 56

Knowing that protein is required for tissue growth, maintenance, and repair, the nurse must understand that for optimal tissue healing to occur, the patient must be in

Answer 56

Positive nitrogen balance

Question 57

Some proteins are manufactured in the body, but others are not. Those that must be obtained through diet are known as

Answer 57

indispensable amino acids.

Question 58

In providing diet education for a patient on a low-fat diet, it is important for the nurse to understand that with few exceptions

Answer 58

Saturated fats are found mostly in animal sources

Question 59

Fats are composed of triglycerides and fatty acids

Answer 59

Are made up of three fatty acids

Question 60

The nurse evaluates which laboratory values to assess a patient's potential for wound healing?

Answer 60

Nitrogen balance

Question 61

The nurse is caring for a patient with pneumonia who has severe malnutrition. The nurse recognizes that, because of the nutritional status, the patient is at risk for: (Select all that apply)

Answer 61

Sepsis Pleural effusion Cardiac arrest