Category 1
The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse’s assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient’s temperature is 100.5°F, and the WBC is 10,500/mm3. Which action should the nurse take first?
Utilize SBAR to notify the primary health care provider.
The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare?
0.45% sodium chloride (1/2 NS)
The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 105 mL of chicken broth. Which totals for intake and output will the nurse document in the patient’s medical record?
Intake 285; output 375
During a blood transfusion, the patient begins to have chills and back pain. What is the nurse’s priority action?
Discontinue the infusion immediately, and notify the prescriber.
In helping maintain fluid and electrolyte balance, this system regulates the amounts of fluid and electrolytes that are excreted and/or reabsorbed; this system bears the label of?
Renal
The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group about the most important thing to do to prevent the spread of infection. Which information did the nurse share with the preschool workers?
Wash their hands between each interaction with children
pH 7.3, PaCO2 36 mm Hg, HCO3– 19 mEq/L
Metabolic acidosis
Which assessment finding should cause a nurse to further assess for extracellular fluid volume excess?
Pitting edema
When reviewing the health history of a patient, the nurse will note that a potential contraindication to potassium supplements exists if the patient has which problem?
Renal disease
A nurse is attempting to minimize the risk of future infection for a post-surgical patient about to be discharged. Which technique will the nurse teach the patient to best achieve this goal?
Medical asepsis handwashing
The nurse administers an intravenous (IV) hypotonic solution to a patient expects the fluid shift to occur in what direction?
From extracellular to intracellular
Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L (135-145), potassium 4.5 mEq/L (3.5-5.0), calcium 4.5 mg/dL (9.0-10.5)?
Tingling of extremities with possible tetany
pH 7.25, PaCO2 48 mm Hg, HCO3– 23 mEq/L
Respiratory acidosis
Which of the following statements is true in regard to the lungs' regulation of acid-base balance?
The lungs correct imbalances by altering the rate and depth of respirations.
A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?
Applying the restraint
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 acid-base imbalance will the nurse expect to observe?
Metabolic alkalosis
A nurse assessing a patient who is receiving a blood transfusion finds that the patient is anxiously fidgeting in bed. The patient is afebrile but dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. Which transfusion complication do you expect?
Fluid volume excess
The nurse is preparing to transfuse a patient with a unit of packed red blood cells (PRBCs). Which patient would be best treated with this transfusion?
A patient with severe anemia
Which finding best indicates learning has occurred?
A nurse presents information about diabetes.
A patient demonstrates how to inject insulin.
A family member listens to a lecture on diabetes.
A primary care provider hands a diabetes pamphlet to the patient.
A patient demonstrates how to inject insulin.
The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan?
Risk for injury
The nurse is assessing a patient and notes crackles in the lung bases and neck vein distention. Which action will the nurse take first?
Raise head of bed
A nurse is caring for a patient diagnosed with cancer who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan?
Replace fluid, electrolytes, and nutrients
When monitoring a patient for signs of hypokalemia, the nurse looks for what early sign?
Muscle weakness
Which statement by a group member indicates understanding of the topic?
Smoking just to control stress is not good for my body.
Our campus is safe; we leave our dorms unlocked all the time.
As long as I have only two drinks, I can still be the designated driver.
I am young, so I can work nights and go to school with 2 hours’ sleep.
Smoking just to control stress is not good for my body.
The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient’s application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient’s plan of care?
Deficient knowledge