NUR 390 Exam 1 - Modules 1-2
The nurse is caring for a patient who has a massive burn injury and possible
hypovolemia. Which assessment data would be of most concern to the nurse?
1. Urine output is 30 mL/hr.
2. Blood pressure is 90/40 mm Hg.
3. Oral fluid intake is 100 mL for 8 hours.
4. Skin tenting over the sternum is prolonged. - ANS-2. Blood pressure is 90/40 mm Hg.
The blood pressure indicates that the patient may be developing hypovolemic shock
because of intravascular fluid loss from the burn injury. This finding will require
immediate intervention to prevent the complications associated with systemic
hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all
indicate the need for increasing the patient's fluid intake but not as urgently as the
hypotension.
A patient who has a small cell cancer of the lung develops syndrome of inappropriate
antidiuretic hormone (SIADH). The nurse would notify the health care provider about
which assessment finding?
1. Serum hematocrit of 42%
2. Serum sodium of 120 mg/dL
3. Urinary output of 280 mL in 8 hours
4. Reported weight gain of 2.2 pounds (1 kg) - ANS-2. Serum sodium of 120 mg/dL
Hyponatremia is the most important finding to report. SIADH causes water retention and
a decrease in serum sodium level. Hyponatremia can cause confusion and other central
nervous system effects. A critically low value needs to be treated. At least 30 mL/hr of
urine output indicates adequate kidney function. The hematocrit level is normal. Weight
gain is expected with SIADH because of water retention.
A patient with multiple draining wounds is admitted for hypovolemia. Which information
would provide the most accurate way for the nurse to evaluate fluid balance?
1. Skin turgor
2. Daily weight
3. Urine output
,4. Edema presence - ANS-2. Daily weight
Daily weight is the most easily obtained and accurate means of assessing volume
status. Skin turgor varies considerably with age. Considerable excess fluid volume may
be present before fluid moves into the interstitial space and causes edema. Urine
outputs do not take account of fluid intake or of fluid loss through insensible loss,
sweating, or loss from the gastrointestinal tract or wounds.
The home health nurse cares for an alert and oriented older adult patient who has a
history of dehydration. Which instruction would the nurse give this patient?
1. "Drink more fluids in the late evening."
2. "More fluids are needed if you feel thirsty."
3. "Increase the fluids if your mouth feels dry."
4. "If you feel confused, you need more fluids." - ANS-3. "Increase the fluids if your
mouth feels dry."
An alert older patient will be able to self-assess for signs of oral dryness such as thick
oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and
is not an accurate indicator of volume depletion. Many older patients prefer to restrict
fluids slightly in the evening to improve sleep quality. The patient will not be likely to
notice and act appropriately when changes in level of consciousness occur.
A patient who is taking a potassium-depleting diuretic for treatment of hypertension
reports generalized weakness. Which action would the nurse to take?
1. Assess for facial muscle spasms.
2. Ask the patient about loose stools.
3. Recommend the patient avoid drinking orange juice with meals.
4. Suggest that the health care provider order a basic metabolic panel. - ANS-4.
Suggest that the health care provider order a basic metabolic panel.
Generalized weakness is a manifestation of hypokalemia. After the health care provider
orders the metabolic panel, the nurse should check the potassium level. Facial muscle
spasms might occur with hypocalcemia. Orange juice is high in potassium and would be
advisable to drink if the patient is hypokalemic. Loose stools are associated with
hyperkalemia.
,Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient.
Which statement by the patient indicates that the teaching about this medication has
been effective?
1. "I will try to drink at least 8 glasses of water every day."
2. "I will use a salt substitute to decrease my sodium intake."
3. "I will increase my intake of potassium-containing foods."
4. "I will drink apple juice instead of orange juice for breakfast." - ANS-4. "I will drink
apple juice instead of orange juice for breakfast."
Because spironolactone is a potassium-sparing diuretic, teach patients to choose
low-potassium foods (e.g., apple juice) rather than foods that have higher levels of
potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic,
the nurse would not encourage the patient to increase fluid intake. Teach patients to
avoid salt substitutes, which are high in potassium.
A patient with new-onset confusion and hyponatremia is being admitted. Which action
would the charge nurse take when making room assignments?
1. Assign the patient to a semiprivate room.
2. Assign the patient to a room near the nurse's station.
3. Place the patient in a room nearest to the water fountain.
4. Place the patient on telemetry to monitor for peaked T waves. - ANS-2. Assign the
patient to a room near the nurse's station.
The patient would be placed near the nurse's station if confused for the staff to closely
monitor the patient. To help improve serum sodium levels, water intake is restricted.
Therefore, a confused patient would not be placed near a water fountain. Peaked T
waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be
distracting and disruptive for another patient in a semiprivate room.
IV potassium chloride (KCl) 60 mEq is prescribed for a patient with severe hypokalemia.
Which action would the nurse take?
1. Administer the KCl as a rapid IV bolus.
2. Infuse the KCl at a maximum rate of 10 mEq/hr.
3. Discontinue cardiac monitoring during the infusion.
4. Monitor deep tendon reflexes during the infusion. - ANS-2. Infuse the KCl at a
maximum rate of 10 mEq/hr.
, IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can
cause cardiac arrest. Cardiac monitoring would be continued while patient is receiving
potassium because of the risk for dysrhythmias. Deep tendon reflexes are monitored
during magnesium infusions, not potassium infusions.
A patient who had surgery for a perforated gastric ulcer has been receiving nasogastric
suction for 3 days. The patient's serum sodium level is 127 mEq/L (127 mmol/L). Which
prescribed therapy would the nurse question?
1. Infuse 5% dextrose in water intravenously at 125 mL/hr.
2. Administer IV morphine sulfate 4 mg every 2 hours PRN.
3. Give IV metoclopramide 10 mg every 6 hours PRN for nausea.
4. Administer 3% saline intravenously at 50 mL/hr for a total of 200 mL. - ANS-1. Infuse
5% dextrose in water intravenously at 125 mL/hr.
Because the patient's gastric suction has been depleting electrolytes, the IV solution
should include electrolyte replacement. Solutions such as lactated Ringer's solution
would usually be ordered for this patient. The other orders are appropriate for a
postoperative patient with gastric suction.
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to
allow for continued mechanical ventilation. How would the nurse interpret the following
arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25
mEq/L?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis - ANS-4. Respiratory alkalosis
The pH indicates that the patient has alkalosis and the low PaCO2 indicates a
respiratory cause.
A patient who was admitted with diabetic ketoacidosis has rapid, deep respirations.
Which action would the nurse take?
1. Give the prescribed PRN lorazepam (Ativan).
2. Encourage the patient to take deep slow breaths.
3. Start the prescribed PRN oxygen at 2 to 4 L/min.
The nurse is caring for a patient who has a massive burn injury and possible
hypovolemia. Which assessment data would be of most concern to the nurse?
1. Urine output is 30 mL/hr.
2. Blood pressure is 90/40 mm Hg.
3. Oral fluid intake is 100 mL for 8 hours.
4. Skin tenting over the sternum is prolonged. - ANS-2. Blood pressure is 90/40 mm Hg.
The blood pressure indicates that the patient may be developing hypovolemic shock
because of intravascular fluid loss from the burn injury. This finding will require
immediate intervention to prevent the complications associated with systemic
hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all
indicate the need for increasing the patient's fluid intake but not as urgently as the
hypotension.
A patient who has a small cell cancer of the lung develops syndrome of inappropriate
antidiuretic hormone (SIADH). The nurse would notify the health care provider about
which assessment finding?
1. Serum hematocrit of 42%
2. Serum sodium of 120 mg/dL
3. Urinary output of 280 mL in 8 hours
4. Reported weight gain of 2.2 pounds (1 kg) - ANS-2. Serum sodium of 120 mg/dL
Hyponatremia is the most important finding to report. SIADH causes water retention and
a decrease in serum sodium level. Hyponatremia can cause confusion and other central
nervous system effects. A critically low value needs to be treated. At least 30 mL/hr of
urine output indicates adequate kidney function. The hematocrit level is normal. Weight
gain is expected with SIADH because of water retention.
A patient with multiple draining wounds is admitted for hypovolemia. Which information
would provide the most accurate way for the nurse to evaluate fluid balance?
1. Skin turgor
2. Daily weight
3. Urine output
,4. Edema presence - ANS-2. Daily weight
Daily weight is the most easily obtained and accurate means of assessing volume
status. Skin turgor varies considerably with age. Considerable excess fluid volume may
be present before fluid moves into the interstitial space and causes edema. Urine
outputs do not take account of fluid intake or of fluid loss through insensible loss,
sweating, or loss from the gastrointestinal tract or wounds.
The home health nurse cares for an alert and oriented older adult patient who has a
history of dehydration. Which instruction would the nurse give this patient?
1. "Drink more fluids in the late evening."
2. "More fluids are needed if you feel thirsty."
3. "Increase the fluids if your mouth feels dry."
4. "If you feel confused, you need more fluids." - ANS-3. "Increase the fluids if your
mouth feels dry."
An alert older patient will be able to self-assess for signs of oral dryness such as thick
oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and
is not an accurate indicator of volume depletion. Many older patients prefer to restrict
fluids slightly in the evening to improve sleep quality. The patient will not be likely to
notice and act appropriately when changes in level of consciousness occur.
A patient who is taking a potassium-depleting diuretic for treatment of hypertension
reports generalized weakness. Which action would the nurse to take?
1. Assess for facial muscle spasms.
2. Ask the patient about loose stools.
3. Recommend the patient avoid drinking orange juice with meals.
4. Suggest that the health care provider order a basic metabolic panel. - ANS-4.
Suggest that the health care provider order a basic metabolic panel.
Generalized weakness is a manifestation of hypokalemia. After the health care provider
orders the metabolic panel, the nurse should check the potassium level. Facial muscle
spasms might occur with hypocalcemia. Orange juice is high in potassium and would be
advisable to drink if the patient is hypokalemic. Loose stools are associated with
hyperkalemia.
,Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient.
Which statement by the patient indicates that the teaching about this medication has
been effective?
1. "I will try to drink at least 8 glasses of water every day."
2. "I will use a salt substitute to decrease my sodium intake."
3. "I will increase my intake of potassium-containing foods."
4. "I will drink apple juice instead of orange juice for breakfast." - ANS-4. "I will drink
apple juice instead of orange juice for breakfast."
Because spironolactone is a potassium-sparing diuretic, teach patients to choose
low-potassium foods (e.g., apple juice) rather than foods that have higher levels of
potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic,
the nurse would not encourage the patient to increase fluid intake. Teach patients to
avoid salt substitutes, which are high in potassium.
A patient with new-onset confusion and hyponatremia is being admitted. Which action
would the charge nurse take when making room assignments?
1. Assign the patient to a semiprivate room.
2. Assign the patient to a room near the nurse's station.
3. Place the patient in a room nearest to the water fountain.
4. Place the patient on telemetry to monitor for peaked T waves. - ANS-2. Assign the
patient to a room near the nurse's station.
The patient would be placed near the nurse's station if confused for the staff to closely
monitor the patient. To help improve serum sodium levels, water intake is restricted.
Therefore, a confused patient would not be placed near a water fountain. Peaked T
waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be
distracting and disruptive for another patient in a semiprivate room.
IV potassium chloride (KCl) 60 mEq is prescribed for a patient with severe hypokalemia.
Which action would the nurse take?
1. Administer the KCl as a rapid IV bolus.
2. Infuse the KCl at a maximum rate of 10 mEq/hr.
3. Discontinue cardiac monitoring during the infusion.
4. Monitor deep tendon reflexes during the infusion. - ANS-2. Infuse the KCl at a
maximum rate of 10 mEq/hr.
, IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can
cause cardiac arrest. Cardiac monitoring would be continued while patient is receiving
potassium because of the risk for dysrhythmias. Deep tendon reflexes are monitored
during magnesium infusions, not potassium infusions.
A patient who had surgery for a perforated gastric ulcer has been receiving nasogastric
suction for 3 days. The patient's serum sodium level is 127 mEq/L (127 mmol/L). Which
prescribed therapy would the nurse question?
1. Infuse 5% dextrose in water intravenously at 125 mL/hr.
2. Administer IV morphine sulfate 4 mg every 2 hours PRN.
3. Give IV metoclopramide 10 mg every 6 hours PRN for nausea.
4. Administer 3% saline intravenously at 50 mL/hr for a total of 200 mL. - ANS-1. Infuse
5% dextrose in water intravenously at 125 mL/hr.
Because the patient's gastric suction has been depleting electrolytes, the IV solution
should include electrolyte replacement. Solutions such as lactated Ringer's solution
would usually be ordered for this patient. The other orders are appropriate for a
postoperative patient with gastric suction.
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to
allow for continued mechanical ventilation. How would the nurse interpret the following
arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25
mEq/L?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis - ANS-4. Respiratory alkalosis
The pH indicates that the patient has alkalosis and the low PaCO2 indicates a
respiratory cause.
A patient who was admitted with diabetic ketoacidosis has rapid, deep respirations.
Which action would the nurse take?
1. Give the prescribed PRN lorazepam (Ativan).
2. Encourage the patient to take deep slow breaths.
3. Start the prescribed PRN oxygen at 2 to 4 L/min.
