1. A nurse is assessing an older adult client who is receiving IV therapy. The nurse should
recognize that which of the following findings indicates fluid volume excess? Select all
that apply.
a. Bounding Pulse
b. Pitting edema
c. Swelling at the IV site
d. Urine-specific gravity greater than 1,030- Normal 1.002 and 1.030
e. Crackles upon auscultation.
2. The nurse is assessing the patient at risk for fluid volume excess. Which findings indicate
that the patient has fluid volume excess? Select all that apply.
a. Increased, bounding pulse
b. Jugular venous distention
c. Diminished peripheral pulses
d. presence of crackles
e. Excessive thirst
f. Elevated blood pressure
g. Orthostatic Hypertension
h. Skin pale and cool to touch
3. The nurse is assessing a client a who has fluid overload. Which of the following finding
should the nurse expect? Select all that apply.
A. Increased heart rate
B. Increased blood pressure
C. Increased respiratory rate
D. Increased hematocrit
E. Increased temperature
4. A nurse is conducting a health assessment. How will the information collected from the
patient be used?
A. As a basis for the nursing process
B. To illustrate nursing competence
C. To facilitate nurse-patient caring
D. As one componence of medical care
5. An adolescent comes to a community health clinic with complaints of vaginal itching and
discharge. She believes it is from having sex with her boyfriend. Which of the following
responses should the nurse use during the health history to elicit information?
A. “Tell me about sexual activity with your boyfriend”
B. Why did you ever have sex with someone you don’t know”
C. “you are old enough to know to use condom”
D. “ I don’t understand how could you be so careless”
6. The nurse receives the patient’s most recent blood work results. Which laboratory value
is of greatest concern?
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, A. Sodium of 145 mEq/L---Normal 135-145
B. Calcium of 15.5 mg/dl---Normal 8.6-10.3
C. Potassium of 3.5 mEq/L----Normal 3.5-5.0
D. Chloride of 100 mEq/L----Normal 98-107
7. The health care provider ask the nurse to monitor the fluid volume status of a heart
failure patient and a patient at risk for clinical dehydration. Which is the most effective
nursing intervention both of these patient’s?
C. Weigh the patient every morning before breakfast
8. A patient presents to the emergency department with reports of vomiting and diarrhea
for the past 48 hours. The health care provider orders isotonic intravenous IV therapy.
Which IV will the nurse prepare?
C. 0.9 % sodium chloride (NS)
9. A nurse in a large metropolitan city enjoys working in a health clinic that primarily serves
Hispanic patients. What does this statement imply about the nurse?
B. The nurse respects and values providing culturally competent care
10. Four patients arrive at the emergency department at the same time. Which patient will
the nurse see first?
A. An infant with a temperature of 102.2 F and diarrhea for 3 days.
11. All of the following patients have a body temperature of 38C (100F). about which patient
would a nurse be most concerned?
D.A month old infant
12. The health care provider has ordered a hypotonic intravenous solution to be
administered. Which IV bag will the nurse prepare?
A. 0.45% sodium chloride (1/2 NS)
13. A nurse is admitting a client who is dehydrated. Which of the following BUN levels should
the nurse expect the client to have upon admission?
Patient would require a 0.9% NS IV fluids
14. A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney
disease. When he arrives for his first dialysis treatment, he tells the nurse “I decided to come
today, but I am not sure If I will need to come back again this week. I am feeling much better
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https://www.coursehero.com/file/61271652/260-Exam-1docx/
recognize that which of the following findings indicates fluid volume excess? Select all
that apply.
a. Bounding Pulse
b. Pitting edema
c. Swelling at the IV site
d. Urine-specific gravity greater than 1,030- Normal 1.002 and 1.030
e. Crackles upon auscultation.
2. The nurse is assessing the patient at risk for fluid volume excess. Which findings indicate
that the patient has fluid volume excess? Select all that apply.
a. Increased, bounding pulse
b. Jugular venous distention
c. Diminished peripheral pulses
d. presence of crackles
e. Excessive thirst
f. Elevated blood pressure
g. Orthostatic Hypertension
h. Skin pale and cool to touch
3. The nurse is assessing a client a who has fluid overload. Which of the following finding
should the nurse expect? Select all that apply.
A. Increased heart rate
B. Increased blood pressure
C. Increased respiratory rate
D. Increased hematocrit
E. Increased temperature
4. A nurse is conducting a health assessment. How will the information collected from the
patient be used?
A. As a basis for the nursing process
B. To illustrate nursing competence
C. To facilitate nurse-patient caring
D. As one componence of medical care
5. An adolescent comes to a community health clinic with complaints of vaginal itching and
discharge. She believes it is from having sex with her boyfriend. Which of the following
responses should the nurse use during the health history to elicit information?
A. “Tell me about sexual activity with your boyfriend”
B. Why did you ever have sex with someone you don’t know”
C. “you are old enough to know to use condom”
D. “ I don’t understand how could you be so careless”
6. The nurse receives the patient’s most recent blood work results. Which laboratory value
is of greatest concern?
This study source was downloaded by 100000869269453 from CourseHero.com on 07-12-2023 01:48:01 GMT -05:00
https://www.coursehero.com/file/61271652/260-Exam-1docx/
, A. Sodium of 145 mEq/L---Normal 135-145
B. Calcium of 15.5 mg/dl---Normal 8.6-10.3
C. Potassium of 3.5 mEq/L----Normal 3.5-5.0
D. Chloride of 100 mEq/L----Normal 98-107
7. The health care provider ask the nurse to monitor the fluid volume status of a heart
failure patient and a patient at risk for clinical dehydration. Which is the most effective
nursing intervention both of these patient’s?
C. Weigh the patient every morning before breakfast
8. A patient presents to the emergency department with reports of vomiting and diarrhea
for the past 48 hours. The health care provider orders isotonic intravenous IV therapy.
Which IV will the nurse prepare?
C. 0.9 % sodium chloride (NS)
9. A nurse in a large metropolitan city enjoys working in a health clinic that primarily serves
Hispanic patients. What does this statement imply about the nurse?
B. The nurse respects and values providing culturally competent care
10. Four patients arrive at the emergency department at the same time. Which patient will
the nurse see first?
A. An infant with a temperature of 102.2 F and diarrhea for 3 days.
11. All of the following patients have a body temperature of 38C (100F). about which patient
would a nurse be most concerned?
D.A month old infant
12. The health care provider has ordered a hypotonic intravenous solution to be
administered. Which IV bag will the nurse prepare?
A. 0.45% sodium chloride (1/2 NS)
13. A nurse is admitting a client who is dehydrated. Which of the following BUN levels should
the nurse expect the client to have upon admission?
Patient would require a 0.9% NS IV fluids
14. A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney
disease. When he arrives for his first dialysis treatment, he tells the nurse “I decided to come
today, but I am not sure If I will need to come back again this week. I am feeling much better
This study source was downloaded by 100000869269453 from CourseHero.com on 07-12-2023 01:48:01 GMT -05:00
https://www.coursehero.com/file/61271652/260-Exam-1docx/
