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A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate
way for the nurse to evaluate fluid balance?
a. Skin turgor
b. Daily weight
c. Urine output
d. Edema presence
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important
for the nurse to monitor while the patient is receiving this infusion?
a. Lung sounds
b. Urinary output
c. Peripheral pulses
d. Peripheral edema
Following a thyroidectomy, a patient reports “a tingling feeling around my mouth.” Which assessment
should the nurse complete first?
a. Verify the serum potassium level.
b. Test for presence of Chvostek’s
sign.
c. Observe for blood on the neck dressing.
d. Confirm a prescription for thyroid replacement.
The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in
place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take?
a. Encourage increased incentive spirometer use.
b. Encourage the patient to increase oral fluid intake.
c. Put on sterile gloves and use a sterile catheter to suction.
d. Preoxygenate the patient for 3 minutes before suctioning.
Which action should the nurse take first when a patient develops epistaxis?
a. Pack the affected nare tightly with an epistaxis balloon.
b. Apply squeezing pressure to the nostrils for 10
minutes.
c. Obtain silver nitrate that may be needed for cauterization.
d. Instill a vasoconstrictor medication into the affected nare.
A patient arrives in the emergency department with a possible nasal fracture after being hit by a
baseball. Which finding by the nurse is most important to report to the health care provider?
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, a. Clear nasal drainage
b. Report of nasal pain
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