NUR 417 Exam 1 Self-Assessment Questions With Complete
Solutions
1. A client with paralytic Ileus is a candidate for TPN.
True or False Correct Answers True
1. Match the assessment to the corresponding complication.
1. Air embolism
2. Sepsis
3. Hyperglycemia
4. Circulatory Overload
5. Hypoglycemia
a. Cold, clammy skin, tremors and slurred speech
b. Polyuria, blurred vision and headache
c. SOB, crackles, hypertension
d. T: 101.5; HR 100; RR 24; WBC 12.4
e. Chest pain and SOB Correct Answers 1. Air embolism: e.
Chest pain and SOB
2. Sepsis: d. T: 101.5; HR 100; RR 24; WBC 12.4
3. Hyperglycemia: b. Polyuria, blurred vision and headache
4. Circulatory Overload: c. SOB, crackles, hypertension
5. Hypoglycemia: a. cold, clammy skin, tremors, and slurred
speech
1. Match the management steps to the corresponding
complication.
1. Management of sepsis
2. Managements of circulatory overload
3. Management of hyperglycemia
,4. Management of hypoglycemia
5. Management of air embolism
a. Increase frequency of CBG testing, increased administration
of insulin, and administration of IV fluids
b. Call MD, administer O2, IV diuretics, and IV vasodilators as
prescribed
c. Administration of dextrose 50% IV push, adjustment of
prescribed insulin
d. Administration of 100% oxygen to maximize the patient's
oxygenation
e. Call MD, discontinue central line, culture the catheter tip and
draw blood cultures Correct Answers 1. Management of sepsis:
e. call MD, discontinue central line, culture the catheter tip and
draw blood cultures
2. Managements of circulatory overload: b. call MD, administer
O2, IV diuretics, and IV vasodilators as prescribed
3. Management of hyperglycemia: a. Increase frequency of CBG
testing, increased administration of insulin, and administration
of IV fluids
4. Management of hypoglycemia: c. administration of dextrose
50% IV push, adjustment of prescribed insulin
5. Management of air embolism: administration of 100% oxygen
to maximize the patient's oxygenation
1. Match the prevention strategy to the corresponding
complication.
1. Prevention of sepsis
2. Prevention of Air embolism
3. Prevention of hyperglycemia
4. Prevention of hypoglycemia
, 5. Prevention of circulatory overload
a. Perform CBG every 6 hours and administer prescribed insulin
b. Hang a 10% dextrose infusion if TPN is not available
c. Change solution every 12 hours, keep refrigerated until 30
minutes before administration and change TPN tubing and
central line dressing every 24-48 hours according to hospital
policy
d. Use Luer lock IV tubing and clear tubing of air
e. Administer on an infusion pump, perform daily weights and
maintain I/O and VS Correct Answers 1. Prevention of sepsis:
c.
2. Prevention of Air embolism: d.
3. Prevention of hyperglycemia: a.
4. Prevention of hypoglycemia: b.
5. Prevention of circulatory overload: e.
1. TPN is what type of solution?
1. Hypotonic
2. Hypertonic
3. Isotonic Correct Answers 2. Hypertonic
A client has a diagnosis of AKI, a PMHX of HTN, CAD, heart
failure, Type2DM, current edema involving the hands and feet,
fine crackles in lung bases bilaterally, and the following labs:
BNP: 182, K+: 5.2, Na+: 132, Troponin: 1.7, Hct: 23,
BUN/Creatinine: BUN 36 mg/dL and Creatinine 4.9 mg/dL,
Glucose: 218, and GFR: 30.
The physician writes the following orders: 500 mL 0.9% NS at
50 mL/hr, Potassium (hyperkalemia) protocol, Cardiac
Solutions
1. A client with paralytic Ileus is a candidate for TPN.
True or False Correct Answers True
1. Match the assessment to the corresponding complication.
1. Air embolism
2. Sepsis
3. Hyperglycemia
4. Circulatory Overload
5. Hypoglycemia
a. Cold, clammy skin, tremors and slurred speech
b. Polyuria, blurred vision and headache
c. SOB, crackles, hypertension
d. T: 101.5; HR 100; RR 24; WBC 12.4
e. Chest pain and SOB Correct Answers 1. Air embolism: e.
Chest pain and SOB
2. Sepsis: d. T: 101.5; HR 100; RR 24; WBC 12.4
3. Hyperglycemia: b. Polyuria, blurred vision and headache
4. Circulatory Overload: c. SOB, crackles, hypertension
5. Hypoglycemia: a. cold, clammy skin, tremors, and slurred
speech
1. Match the management steps to the corresponding
complication.
1. Management of sepsis
2. Managements of circulatory overload
3. Management of hyperglycemia
,4. Management of hypoglycemia
5. Management of air embolism
a. Increase frequency of CBG testing, increased administration
of insulin, and administration of IV fluids
b. Call MD, administer O2, IV diuretics, and IV vasodilators as
prescribed
c. Administration of dextrose 50% IV push, adjustment of
prescribed insulin
d. Administration of 100% oxygen to maximize the patient's
oxygenation
e. Call MD, discontinue central line, culture the catheter tip and
draw blood cultures Correct Answers 1. Management of sepsis:
e. call MD, discontinue central line, culture the catheter tip and
draw blood cultures
2. Managements of circulatory overload: b. call MD, administer
O2, IV diuretics, and IV vasodilators as prescribed
3. Management of hyperglycemia: a. Increase frequency of CBG
testing, increased administration of insulin, and administration
of IV fluids
4. Management of hypoglycemia: c. administration of dextrose
50% IV push, adjustment of prescribed insulin
5. Management of air embolism: administration of 100% oxygen
to maximize the patient's oxygenation
1. Match the prevention strategy to the corresponding
complication.
1. Prevention of sepsis
2. Prevention of Air embolism
3. Prevention of hyperglycemia
4. Prevention of hypoglycemia
, 5. Prevention of circulatory overload
a. Perform CBG every 6 hours and administer prescribed insulin
b. Hang a 10% dextrose infusion if TPN is not available
c. Change solution every 12 hours, keep refrigerated until 30
minutes before administration and change TPN tubing and
central line dressing every 24-48 hours according to hospital
policy
d. Use Luer lock IV tubing and clear tubing of air
e. Administer on an infusion pump, perform daily weights and
maintain I/O and VS Correct Answers 1. Prevention of sepsis:
c.
2. Prevention of Air embolism: d.
3. Prevention of hyperglycemia: a.
4. Prevention of hypoglycemia: b.
5. Prevention of circulatory overload: e.
1. TPN is what type of solution?
1. Hypotonic
2. Hypertonic
3. Isotonic Correct Answers 2. Hypertonic
A client has a diagnosis of AKI, a PMHX of HTN, CAD, heart
failure, Type2DM, current edema involving the hands and feet,
fine crackles in lung bases bilaterally, and the following labs:
BNP: 182, K+: 5.2, Na+: 132, Troponin: 1.7, Hct: 23,
BUN/Creatinine: BUN 36 mg/dL and Creatinine 4.9 mg/dL,
Glucose: 218, and GFR: 30.
The physician writes the following orders: 500 mL 0.9% NS at
50 mL/hr, Potassium (hyperkalemia) protocol, Cardiac
