Fluids & Electrolytes
The nurse plans care for a hospitalized patient. Which data necessitate the inclusion of interventions to address a fluid volume deficit?
A. Urine output of 30 mL/hour
B. Heart rate of 110 bmp
C. Weight gain of 10 pounds in 3 days
D. Plus-3 edema in bilateral lower extremities
B. Heart rate of 110 bmp
Solutions that contain the same amount of electrolytes as the plasma are considered:
A. Hypotonic
B. Isotonic
C. Hypertonic
D. Diffused
B. Isotonic
The nurse provides care to a male patient admitted with a respiratory disorder. Which laboratory finding is most concerning?
A. Blood pH 7.32 (normal range: 7.35-7.45)
B. Oxygen saturation 96%
C. PaO2 80 mm Hg (normal range: 75-100 mm Hg)
D. Hemoglobin level 12 mg/dL (normal range: 13.2-16.6 mg/dL)
A. Blood pH 7.32 (normal range: 7.35-7.45)
The amount of blood ejected by the heart every minute (stroke volume x heart rate) is known as:
A. Preload
B. Afterload
C. Cardiac output
D. Contractility
C. Cardiac output
The patient enters the outpatient clinic and states to the triage nurse, “I think I have the flu. I'm so tired, I have no appetite, and everything hurts.” The triage nurse assesses the patient and finds a butterfly rash over the bridge of the nose and on the cheeks. Then nurse correlates this data with the clinical manifestations of which disorder?
A. Gout
B. Lyme disease
C. Fibromyalgia
D. Systemic lupus erythematosus
D. Systemic lupus erythematosus
A patient is found to have a sodium of 119 (normal range: 135-145). Which statement by the nurse indicates the need for further teaching?
A. "Since the patient's sodium is so low, I will replace sodium via several rapid intravenous infusions of hypertonic saline"
B. " I need to go get seizure pads to put on this patient's bed rails"
C. "I should administer the morning dose of Lasix because the patient has 3+ pitting edema in the lower extremities"
D. "I should make sure the kitchen knows to restrict fluids on this patient's meal trays"
A. "Since the patient's sodium is so low, I will replace sodium via several rapid intravenous infusions of hypertonic saline"
A trauma patient comes into the emergency department with rapid blood loss. The provider asks the nurse to insert two large-bore peripheral IV sites. Which gauge IV does the nurse select to insert?
A. 18
B. 20
C. 22
D. 24
A. 18
The nurse is obtaining a pain history. The patient reports pain in the right ear. Which response by the nurse is the most appropriate?
A. “Is the pain minor?”
B. “Do you have anything else that hurts?”
C. “I will note that in the record. Is there anything else I should know?”
D. “Tell me more about the pain and what you do for it when it hurts.”
D. “Tell me more about the pain and what you do for it when it hurts.”
Which type of shock is characterized by blood/fluid in the wrong place causing relative hypovolemia and inadequate venous return (e.g., sepsis, anaphylaxis, neurogenic shock)?
A. Hypovolemia
B. Cardiogenic
C. Obstructive
D. Distributive
D. Distributive
A nurse is caring for a patient who is newly diagnosed with rheumatoid arthritis (RA). The patient asks the nurse what the difference is between RA and osteoarthritis (OA). Which response by the nurse is most appropriate?
A. “The onset of OA is gradual, whereas the onset of RA may be rapid.”
B. “With OA, multiple joints are symmetrically affected; RA affects one joint at a time.”
C. “The affected joints in RA feel cold to the touch, whereas the joints affected by OA are warm or hot to the touch.”
D. “The pain and stiffness with RA is with activity; OA pain and stiffness is predominant on arising.”
A. “The onset of OA is gradual, whereas the onset of RA may be rapid.”
Which of the following EKG changes would the nurse expect to find in a hyperkalemic patient?
A. T wave inversion
B. ST depression
C. Peaked T waves
D. Prominent U wave
C. Peaked T waves
The nurse is providing care to a patient admitted for a traumatic brain injury who has developed respiratory acidosis. Which action by the nurse is the priority?
A. Monitoring peripheral vascular status
B. Reassuring the patient to decrease anxiety
C. Assessing respiratory rate and depth closely
D. Administering sodium bicarbonate as ordered
C. Assessing respiratory rate and depth closely
The nurse provides care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) who requires supplemental oxygen. Which is the correct flow rate range by nasal cannula (NC) when providing care for this patient?
A. 1-2 L/min
B. 2-3 L/min
C. 3-4 L/min
D. 4-5 L/min
A. 1-2 L/min
The nurse admits a patient in neurogenic shock. Which finding supports this finding?
A. Bradycardia
B. Increased central venous pressure
C. Increased cardiac output
D. Hyperventilation
A. Bradycardia
The nurse correlates an increased risk of osteoarthritis in which patient?
A. A 40-year-old obese female who works as an administrative assistant
B. A 45-year-old obese male who is a construction worker
C. A 55-year-old obese female with works as a machine operator
D. A 60-year-old obese male who works as an accountant
C. A 55-year-old obese female with works as a machine operator
The nurse provides care to an older adult patient who is receiving intravenous (IV) fluids at 150 mL/hour. Which finding is most concerning?
A. Flattened neck veins
B. Elevated blood pressure
C. Bradycardia
D. Skin tenting
B. Elevated blood pressure
The nurse is administering a hypotonic solution to a patient in DKA. What is happening at a cellular level during this administration?
A. Cell size remains unchanged
B. Cells swell or increase in size
C. Cells shrink or decrease in size
D. Cells begin to sickle
B. Cells swell or increase in size
The nurse instructs a patient on the use of incentive spirometry. Which patient statement requires additional instruction?
A. "I will use the device 5 to 10 times per day."
B. "I will exhale completely before I begin this breathing exercise."
C. "I will take in a slow, deep breath, like inhaling through a straw."
D. "I will sit up in bed as this allows my lungs to expand during the exercise."
A. "I will use the device 5 to 10 times per day."
The nurse is preparing an educational session on sepsis. Which does the nurse include as a major risk factor for the development of this health problem?
A. Immunosuppression
B. Decreased antibiotic use
C. Fungal infections
D. Leukocytosis on the complete blood count (CBC)
A. Immunosuppression
Raynaud's phenomenon may be a clinical manifestation of which disorder?
A. Systemic lupus erythematosus
B. Scleroderma
C. Gout
D. Fibromyalgia
B. Scleroderma
The nurse is caring for a patient admitted with hypertension and chronic renal failure who receives hemodialysis three times per week. The nurse is assessing the patient's diet and notes the use of salt substitutes. When teaching the patient to avoid salt substitutes, which rationale supports this teaching point?
A. They can potentiate hyperkalemia.
B. They may cause the patient to retain fluid.
C. They may interfere with the hemodialysis.
D. They may interact with the patient's antihypertensive medications.
A. They can potentiate hyperkalemia.
A patient is admitted for evaluation of a bowel obstruction and has a nasogastric tube placed at low intermittent suction. The physician orders arterial blood gases, and the following results are reported:
pH: 7.37
PaCO2: 33 mm Hg
PaO2: 94 mm Hg
HCO3: 19 mm Hg
SaO2: 98%
What is the nurse’s interpretation of these results?
A. Fully compensated metabolic acidosis
B. Uncompensated metabolic acidosis
C. Uncompensated respiratory alkalosis
D. Partially compensated respiratory alkalosis
A. Fully compensated metabolic acidosis
The nurse must intervene if heat application is prescribed to treat pain in the patient with which disorder?
A. Menstrual cramps
B. Acute appendicitis
C. Herniated nucleus pulposus
D. Nausea and vomiting
B. Acute appendicitis
In the patient diagnosed with multiple organ dysfunction syndrome (MODS). Which finding indicates impaired tissue perfusion?
A. Decreased urine output
B. Change in the character of stool
C. Elevated temperature
D. Change in pupil reactions
A. Decreased urine output
Which connective tissue disorder responds to cognitive-behavioral therapy (CBT)?
A. Systemic lupus erythematosus
B. Gout
C. Fibromyalgia
D. Rheumatoid arthritis
C. Fibromyalgia