Fluid Basics
The nurse is teaching a patient about fluid intake monitoring. Which items should be included when calculating a patient's 24-hour fluid intake? (Select all that apply)
A) Coffee and tea
B) Gelatin
C) Bread and cereal
D) Popsicles
E) IV fluids
A, B, D, E
Rationale: Intake includes fluids and solids that become liquid at body and room temperature, such as gelatin and Popsicles. Intake also includes water, broth, tea, juice, and coffee. IV fluids and continuous/intermittent IVPB and blood components are considered intake. Solids such as bread, cereal, or meats are not considered in fluid intake.
A nurse is teaching an older adult about preventing osteoporosis. Which foods should the nurse recommend as rich sources of calcium? (Select all that apply)
A) Green leafy vegetables
B) White bread
C) Canned sardines with bones
D) Fortified grains
E) Apples
A, C, D
Rationale: Foods rich in calcium include dairy products, green leafy vegetables, soy, nuts, fish (canned sardines and salmon with bones), and fortified grains. These help protect against osteoporosis (a decrease of bone mass density). Screening and treatment are necessary for both older men and women.
A nurse is caring for a patient with stress urinary incontinence related to weakened pelvic musculature. Which intervention should the nurse prioritize?
A) Restrict fluid intake to 500 mL per day
B) Teach pelvic muscle (Kegel) exercises
C) Insert an indwelling urinary catheter
D) Encourage heavy lifting to strengthen muscles
Teach pelvic muscle (Kegel) exercises
Rationale: For stress incontinence related to weakened pelvic musculature, teaching pelvic muscle exercises is a priority intervention. Additional interventions include encouraging weight loss to decrease intra-abdominal pressure, avoiding heavy lifting, avoiding caffeine and bladder irritants, and encouraging adequate hydration.
The health care provider orders 500 mg of amoxicillin to be administered via gastric tube every 8 hours. The bottle is labeled 400 mg/5 mL. How many mL should the nurse administer? (Round to the nearest tenth)
6.3 mL
A nurse enters a patient's room to administer morning medications. The patient states, "I didn't sleep at all last night. I'm so worried about my surgery tomorrow." Which response by the nurse demonstrates therapeutic communication?
A. "Don't worry. Your surgeon is very experienced and performs this surgery all the time."
B. "I can see you're concerned. Tell me more about what's worrying you about the surgery."
C. "You should have asked for a sleeping pill last night. Let me get you something now."
D. "Everyone feels nervous before surgery. You'll feel better once it's over."
Option B is correct because it demonstrates active listening and uses an open-ended statement that encourages the patient to express feelings and concerns. The nurse acknowledges the patient's emotional state ("I can see you're concerned") and invites further communication, which is essential to therapeutic interaction. This response focuses on the patient's needs rather than the nurse's agenda, and it conveys genuine interest and caring—key elements of establishing a therapeutic relationship.
A patient has an indwelling urinary catheter. Which output should the nurse document on the intake and output record?
A) Urine only
B) Urine, wound drainage, and gastric suction
C) Urine and vomitus only
D) All body secretions including saliva
Urine, wound drainage, and gastric suction
Rationale: Fluid output includes urine, diarrhea, vomitus, gastric suction, and drainage from postsurgical wounds or other tubes. When a patient has an indwelling urinary catheter, drainage tube, or suction, document output at the end of each nursing shift or as the patient's condition requires.
Before administering vitamin A supplements, which baseline assessment is most important for the nurse to perform?
A) Blood glucose level
B) Vision assessment including night vision
C) Deep tendon reflexes
D) Bowel sounds
Vision assessment including night vision
Rationale: For vitamin A deficiencies, perform a baseline vision assessment, including night vision. Conduct a thorough examination of the skin and mucous membranes. This baseline is important for comparative findings and because of the adverse effects and signs and symptoms of toxicity associated with overdosage of vitamin A.
A patient has an indwelling urinary catheter. Which nursing action is most important to prevent catheter-associated urinary tract infection (CAUTI)?
A) Change the catheter every 48 hours
B) Perform hand hygiene before and after catheter care
C) Disconnect the drainage system to measure output
D) Keep the drainage bag at the level of the bladder
Perform hand hygiene before and after catheter care
Rationale: CAUTI results in approximately 30% of hospital-acquired infections. Nursing interventions such as maintaining basic infection control procedures, including handwashing, have been proven to reduce the number of UTIs. The drainage system should remain closed, and the drainage bag should be kept below the level of the bladder to prevent backflow.
When calculating medication dosages, what should the nurse do before beginning any calculation?
A) Round all numbers to whole numbers
B) Make a mental estimate of the approximate dosage
C) Convert all measurements to the smallest unit
D) Use a calculator for all steps
Make a mental estimate of the approximate dosage
Rationale: Before beginning any calculation, make a mental estimate of the approximate and reasonable dosage. If your estimate does not closely match the answer you calculate, recheck your math before preparing and administering the medication.
A nurse is documenting care provided to a patient during the shift. Which action by the nurse demonstrates appropriate documentation practice?
A. Charts "Patient appears comfortable and seems to be resting well" at 1400
B. Documents vital signs and patient assessment immediately after completing the physical examination
C. Pre-charts morning medications at 0700 to save time before administering them at 0800
D. Records a verbal order from the physician but plans to have it signed at the end of the shift
Option B is correct because timely, immediate documentation is essential for patient safety and legal protection. The chart should be updated immediately after providing care to ensure accuracy and to reflect exactly what happened to the patient. Delays in documentation can lead to unsafe patient care, and documenting at the time of occurrence ensures the record is current and factual.
A patient gained 2.2 kg overnight. The nurse interprets this weight change as indicating:
A) 500 mL fluid retention
B) 1 L fluid retention
C) 2 L fluid retention
D) Increased caloric intake
1 L fluid retention
Rationale: Each kilogram (2.2 lb) of weight gained or lost overnight is equal to 1 L of fluid retained or lost. These fluid gains or losses indicate changes in the amount of total body fluid, usually extracellular fluid (ECF).
A malnourished patient is unable to consume adequate nutrition despite a high-calorie, high-protein diet. What should the nurse consider next?
A) Restrict fluids to increase appetite
B) Add oral liquid supplements between meals
C) Decrease meal frequency
D) Eliminate snacks
Add oral liquid supplements between meals
Rationale: If the patient is unable to consume enough nutrition with a high-calorie, high-protein diet, consider adding oral liquid supplements. These provide advanced nutrition and calories and include milkshakes, puddings, or commercially available products (e.g., Carnation Instant Breakfast, Ensure, Boost).
After removing an indwelling urinary catheter, what should the nurse monitor?
A) Blood pressure every 4 hours
B) Intake and output for 12 to 24 hours
C) Daily weights
D) Skin turgor
Intake and output for 12 to 24 hours
Rationale: The patient is kept on intake and output recording for 12 to 24 hours after catheter removal to ensure that the bladder is draining adequately.
When converting measurements in medication calculations, which practice helps prevent errors?
A) Always convert to the smallest unit available
B) Convert to the measure stated on the medication label
C) Use decimals whenever possible
D) Convert larger units to smaller units first
Convert to the measure stated on the medication label
Rationale: It is best to convert to the measure stated on the medication label. Conversions that result in decimals are often the source of calculation errors. If possible, avoid conversions that require decimal use. Doing this consistently can prevent confusion.
A nurse is preparing to provide care for multiple patients on a medical-surgical unit. Which action by the nurse demonstrates correct application of Standard Precautions?
A. Wears gloves only when caring for patients with known infectious diseases
B. Performs hand hygiene and uses personal protective equipment (PPE) for every patient contact
C. Shares a stethoscope between patients after wiping the bell with gauze
D. Uses the same blood pressure cuff for all patients to improve efficiency
Option B is correct because Standard Precautions are designed to protect both the nurse and the patient and must be used for every patient contact regardless of the suspected or confirmed presence of an infectious agent. Standard Precautions include hand hygiene and personal protective equipment (PPE), which encompasses gloves, gowns, masks, protective eyewear, shoe coverings, and hair coverings. This approach interrupts the chain of infection at any link, breaking the transmission cycle.
The nurse delegates intake and output measurement to assistive personnel (AP). Which task remains the nurse's responsibility?
A) Measuring urine output
B) Documenting oral fluid intake
C) Measuring IV and feeding tube intake
D) Emptying urinary drainage bags
Measuring IV and feeding tube intake
Rationale: In many institutions, AP document oral intake but not intake through feeding or IV tubes, which are nursing responsibilities. The registered nurse (RN) or licensed practical nurse/licensed vocational nurse (LPN/LVN) and the AP work as a team.
When assisting a patient with eating, which nursing action creates an environment most conducive to eating?
A) Leaving the bedpan visible on the bedside table
B) Performing wound care during mealtime
C) Providing oral hygiene before the meal
D) Scheduling vital signs during meals
Providing oral hygiene before the meal
Rationale: Make sure the environment is conducive to eating. Provide a quiet environment. Offer oral hygiene and hand hygiene. Help the patient to a comfortable position. Clear the bedside table of clutter. Place urinals, bedpans, and emesis basins out of sight. Protect mealtime from unnecessary interruptions by performing nonurgent care before or after mealtime.
A patient with urinary incontinence is at risk for impaired skin integrity. Which intervention should the nurse teach?
A) Apply powder to the perineal area
B) Change incontinence pads frequently
C) Limit fluid intake to reduce incontinence
D) Cleanse skin vigorously after each episode
Change incontinence pads frequently
Rationale: To prevent impaired skin integrity, teach the patient to change pads frequently, inspect skin daily, gently cleanse after each incontinent episode, and apply moisture barrier products as needed.
A unit has 28 patients and 4 nurses. What is the nurse-to-patient ratio in lowest terms?
A) 28:4
B) 7:1
C) 1:7
D) 4:28
1:7
Rationale: The ratio of nurses to patients is 4:28, which reduces to 1:7 in lowest terms. Ratios should always be stated in lowest terms and indicate the relationship between two quantities.
A nursing instructor is teaching students about healthcare-associated infections (HAIs). Which statement by a student indicates understanding of HAI prevention?
A. "HAIs primarily occur due to antibiotic-resistant organisms that cannot be controlled."
B. "Patients develop HAIs because they have lower resistance and increased exposure to pathogens in healthcare settings."
C. "Healthcare workers are not at significant risk for HAIs since they don't have invasive procedures."
D. "HAIs are unavoidable complications of hospitalization and modern medical care."
Option B is correct because patients in all healthcare settings are at risk for acquiring infections due to three key factors: lower resistance to pathogens, increased exposure to pathogens (some of which may be resistant to most antibiotics), and invasive procedures. Understanding these risk factors is essential for implementing appropriate infection prevention and control measures.
The nurse is monitoring a critically ill patient's urinary output. What is the minimum acceptable hourly urine output?
A) 10 mL/h
B) 20 mL/h
C) 30 mL/h
D) 50 mL/h
30 mL/h
Rationale: In critically ill patients, urinary output is typically measured hourly. Urine output should be at least 30 mL/h to indicate adequate kidney perfusion and fluid balance.
A nurse is conducting a nutritional assessment. Which question best assesses the patient's dietary patterns?
A) "What is your blood type?"
B) "What is your normal daily intake of food and liquids?"
C) "Do you exercise regularly?"
D) "What medications do you take?"
"What is your normal daily intake of food and liquids?"
Rationale: The diet history includes assessment of the patient's normal daily intake of food and liquids, food preferences, allergies, cultural background, religious food patterns, and ability to obtain food. This information helps identify actual or potential nutritional needs.
Which environmental factor should the nurse address to promote normal urinary elimination for a hospitalized patient?
A) Encourage use of a bedpan for all elimination
B) Provide privacy by closing doors or curtains
C) Keep the room brightly lit at all times
D) Schedule voiding every 4 hours only
Provide privacy by closing doors or curtains
Rationale: Patients in health care settings may have difficulty urinating in a bedpan or bedside commode. Provide a private environment for urination by closing the door or curtains around the bed. If allowed, ambulate the patient to the bathroom.
A patient receives the following IV fluids during a 24-hour period:
What is the patient's total IV fluid intake in liters?
2.5 L
Rationale: When adding decimals, align the decimal points vertically:
1.5 0.75 + 0.25 ------ 2.50 = 2.5 L
The total IV fluid intake is 2.5 L. When adding decimals, it's essential to line up the decimal points to ensure accurate calculation. This prevents medication errors and ensures proper documentation of intake and output.
Remember: A trailing zero after the decimal point should be dropped (2.50 becomes 2.5) to prevent potential confusion and medication errors. Never use a trailing zero in medication documentation, as it could lead to a tenfold overdose if the decimal point is missed.
A nurse is assessing vital signs for four patients on a medical unit. Which patient situation requires the nurse to consider multiple factors that may be influencing the vital sign readings?
A. A 45-year-old patient with a temperature of 101°F (38.3°C) whose pulse rate is 88 beats per minute
B. A 21-year-old patient with a blood pressure of 110/60 mm Hg measured in a quiet room
C. A 70-year-old patient who just walked from the bathroom and has a pulse rate of 92 beats per minute
D. A patient whose respiratory rate decreased after receiving pain medication
Option A is correct because vital sign readings are interrelated, and this patient's findings are inconsistent with expected patterns. A rise in temperature of 1°F has the potential to cause an increase in pulse rate by 4 beats per minute. With a temperature of 101°F, the nurse would expect the pulse rate to be elevated (approximately 12 beats per minute higher than baseline). A pulse of 88 may indicate the patient is taking medications that affect heart rate, has an underlying cardiac condition, or other factors are influencing the vital signs. This requires further assessment and consideration of multiple influencing factors.