SAUNDERS COMPREHENSIVE REVIEW, NCLEX-RN,
7TH EDITION CHAPTER 6-9 EXAM WITH COMPLETE
SOLUTIONS 100% VERIFIED!!
General tasks that can be delegated to UAP - ANSWER *noninvasive
interventions:
-skin care
-range of motion exercises
-ambulation
-grooming
-hygiene measures
General tasks that can be delegated to LPN or LVN - ANSWER *all tasks a UAP
can perform
*dressing changes
*suctioning
*urinary catheterization
*medication administration (oral, subq, IM, and selected piggyback meds)
*review of teaching initially taught by RN
A wound that is pulsating bright red blood indicates what type of puncture -
ANSWER arterial puncture
Triage: emergent - ANSWER *tagged red/priority 1
*assigned to clients with life threatening conditions needing immediate attention
*continuous evaluation
*high probability for survival once stabilized
Conditions that are considered emergent - ANSWER *trauma victims
*chest pain
*severe respiratory distress
*cardiac arrest
*limb amputation
*acute neurological deficits
*chemical splashes to the eye
Triage: urgent - ANSWER *tagged yellow/ priority 2
*assigned to clients who require treatment and whose injuries have
complications that are not life-threatening, provided that they are treated within
30 minutes to 2 hours
*continuous evaluation every 30-60 minutes after initial treatment
,Conditions considered urgent - ANSWER *open fracture with a distal pulse
*large wounds
Triage: non-urgent - ANSWER *tagged green/ priority 3
*assigned to clients with local injuries, no immediate complications, and who can
wait at least 2 hours for treatment
*evaluate every 1-2 hours after after initial treatment
Non-urgent conditions - ANSWER *closed fracture
*minor lacerations
*sprains
*strains
*contusions
Anasarca - ANSWER *(generalized edema) excessive accumulation of fluid in the
interstitial space throughout the body
*occurs as a result of conditions such as cardiac, renal, or liver failure
Sources of fluid intake - ANSWER *ingested water = 1200-1500 ml
*ingested food = 800-1100 ml
*metabolic oxidation = 300 ml
Total daily intake = 2300-2900 ml
Sources of fluid output - ANSWER kidneys = 1500 ml
Insensible loss (skin) = 600-800 ml
Insensible loss (lungs) = 400-600 ml
GI tract = 100 ml
Total daily output = 2600-3000 ml
Function of aldosterone - ANSWER
Function of antiduretic hormone - ANSWER
Isotonic dehydration - ANSWER water and dissolved electrolytes are lost in equal
proportions
Causes of isotonic dehydration - ANSWER *inadequate intake of fluids and
solutes
*fluid shifts between compartments
*excessive losses of isotonic body fluids
Hypertonic dehydration - ANSWER water loss exceeds electrolyte loss
Causes of hypertonic dehydration - ANSWER *conditions that increase fluid loss
-excessive perspiration
, -hyperventilation
-ketoacidosis
-prolonged fever
-diarrhea
-early-stage kidney disease
-diabetes insipidus
Hypotonic dehydration - ANSWER electrolyte loss exceeds water loss
Causes of hypotonic dehydration - ANSWER *chronic illness
*excessive fluid replacement (hypotonic)
*kidney disease
*chronic malnutrition
Fluid Volume Deficit: Cardiovascular assessment findings - ANSWER * thready,
increased pulse rate
* decreased BP and orthostatic hypotension
* flat neck and hand veins in dependent positions
* diminished peripheral pulses
* decreased central venous pressure
* dysrhythmias
Fluid Volume Deficit: Respiratory assessment findings - ANSWER * increased
rate and depth of respirations
* dyspnea
Fluid Volume Deficit: Neuromuscular assessment findings - ANSWER * decreased
central nervous system activity, from lethargy to coma
* fever, depending on the amount of fluid loss
* skeletal muscle weakness
Fluid Volume Deficit: Renal assessment findings - ANSWER * decreased urine
output
Fluid Volume Deficit: Integumentary assessment findings - ANSWER * Dry skin
* poor turgor, tenting
* dry mouth
Fluid volume deficit: GI assessment findings - ANSWER * decreased motility and
diminished bowel sounds
*constipation
* thirst
* decreased body weight
Fluid volume deficit: laboratory findings - ANSWER *increased serum osmolality
*increased hematocrit
7TH EDITION CHAPTER 6-9 EXAM WITH COMPLETE
SOLUTIONS 100% VERIFIED!!
General tasks that can be delegated to UAP - ANSWER *noninvasive
interventions:
-skin care
-range of motion exercises
-ambulation
-grooming
-hygiene measures
General tasks that can be delegated to LPN or LVN - ANSWER *all tasks a UAP
can perform
*dressing changes
*suctioning
*urinary catheterization
*medication administration (oral, subq, IM, and selected piggyback meds)
*review of teaching initially taught by RN
A wound that is pulsating bright red blood indicates what type of puncture -
ANSWER arterial puncture
Triage: emergent - ANSWER *tagged red/priority 1
*assigned to clients with life threatening conditions needing immediate attention
*continuous evaluation
*high probability for survival once stabilized
Conditions that are considered emergent - ANSWER *trauma victims
*chest pain
*severe respiratory distress
*cardiac arrest
*limb amputation
*acute neurological deficits
*chemical splashes to the eye
Triage: urgent - ANSWER *tagged yellow/ priority 2
*assigned to clients who require treatment and whose injuries have
complications that are not life-threatening, provided that they are treated within
30 minutes to 2 hours
*continuous evaluation every 30-60 minutes after initial treatment
,Conditions considered urgent - ANSWER *open fracture with a distal pulse
*large wounds
Triage: non-urgent - ANSWER *tagged green/ priority 3
*assigned to clients with local injuries, no immediate complications, and who can
wait at least 2 hours for treatment
*evaluate every 1-2 hours after after initial treatment
Non-urgent conditions - ANSWER *closed fracture
*minor lacerations
*sprains
*strains
*contusions
Anasarca - ANSWER *(generalized edema) excessive accumulation of fluid in the
interstitial space throughout the body
*occurs as a result of conditions such as cardiac, renal, or liver failure
Sources of fluid intake - ANSWER *ingested water = 1200-1500 ml
*ingested food = 800-1100 ml
*metabolic oxidation = 300 ml
Total daily intake = 2300-2900 ml
Sources of fluid output - ANSWER kidneys = 1500 ml
Insensible loss (skin) = 600-800 ml
Insensible loss (lungs) = 400-600 ml
GI tract = 100 ml
Total daily output = 2600-3000 ml
Function of aldosterone - ANSWER
Function of antiduretic hormone - ANSWER
Isotonic dehydration - ANSWER water and dissolved electrolytes are lost in equal
proportions
Causes of isotonic dehydration - ANSWER *inadequate intake of fluids and
solutes
*fluid shifts between compartments
*excessive losses of isotonic body fluids
Hypertonic dehydration - ANSWER water loss exceeds electrolyte loss
Causes of hypertonic dehydration - ANSWER *conditions that increase fluid loss
-excessive perspiration
, -hyperventilation
-ketoacidosis
-prolonged fever
-diarrhea
-early-stage kidney disease
-diabetes insipidus
Hypotonic dehydration - ANSWER electrolyte loss exceeds water loss
Causes of hypotonic dehydration - ANSWER *chronic illness
*excessive fluid replacement (hypotonic)
*kidney disease
*chronic malnutrition
Fluid Volume Deficit: Cardiovascular assessment findings - ANSWER * thready,
increased pulse rate
* decreased BP and orthostatic hypotension
* flat neck and hand veins in dependent positions
* diminished peripheral pulses
* decreased central venous pressure
* dysrhythmias
Fluid Volume Deficit: Respiratory assessment findings - ANSWER * increased
rate and depth of respirations
* dyspnea
Fluid Volume Deficit: Neuromuscular assessment findings - ANSWER * decreased
central nervous system activity, from lethargy to coma
* fever, depending on the amount of fluid loss
* skeletal muscle weakness
Fluid Volume Deficit: Renal assessment findings - ANSWER * decreased urine
output
Fluid Volume Deficit: Integumentary assessment findings - ANSWER * Dry skin
* poor turgor, tenting
* dry mouth
Fluid volume deficit: GI assessment findings - ANSWER * decreased motility and
diminished bowel sounds
*constipation
* thirst
* decreased body weight
Fluid volume deficit: laboratory findings - ANSWER *increased serum osmolality
*increased hematocrit
