NUR235 Exam: Questions With Stepwise Solutions
What should nurses monitor when a patient is receiving a diuretic regularly
SATA Right Ans - Skin turgor and integrity
Daily weight
Electrolyte status
Which patient can be considered a high-risk for fluid and electrolyte
imbalance select all that apply Right Ans - A 45-year-old woman with
thyroid crisis
a35-year-old trauma victim on a ventilator
a 30-year-old woman complaining of persistent diarrhea
An older adult man is admitted for Severe disorientation confusion in general
weakness his spouse reports that he is not able to tolerate any food or fluids
and has had several episodes of vomiting and diarrhea which imbalances is
the patient most likely experiencing select all that apply Right Ans -
Hypokalemia and hyponatremia
In planning care for a patient with congestive heart failure you choose the
problem statement fluid volume overload due to altered cardiac output the
problem statement would most likely be supported by which sign or symptom
Right Ans - Fine crackles in lung sounds
A patient who has congestive heart failure has fluid access with a weight gain
of 1.5 pounds since yesterday and a dermatitis ankles which healthcare
providers order has the highest priority Right Ans - Administer furosemide
20 mg PO once daily
A new patient on the floor has been diagnosed with gastroenteritis what
would be the most critical level to assess Right Ans - Potassium
You appropriately elicit a sign of hypocalcemia by Right Ans - Tap in the
face about 1 inch from the ear
At the beginning of shift there is 400 mL of fluid in the IV bag a piggyback
medication contain 100 mL is hung at 12 noon to run over 30 minutes you
hang a new bag of 1000 ML's at 1 PM to run at 125 ML's per hour at the end of
, the shift there's 250 mL left in the bag the count for the total amount of fluid
infused during your shift ended at 7 PM is Right Ans - 1310ml
Which would be the most accurate way to assess for dehydration in an older
adult Right Ans - Urine output
You respond to a patient complaining of pain swelling and wetness over the
peripheral IV site on assessment you find the IV insertion site is tender and
cold to touch these are signs and symptoms of Right Ans - Infiltration
Why is fluid balance essential Right Ans - The life processes of every sale
takes place within fluid
Who or at the greatest risk for fluid in balance Right Ans - Infants in older
adults
Function of water in the body Right Ans - (1) transports nutrients, wastes,
hormones, and cells
(2) facilitate cellular metabolism
(3) as a solvent for electrolytes
(4) to regulate body temperature
(5) aid in digestion and elimination
(6) as a tissue lubricant
How is fluid volume managed Right Ans - My hormones and thirst
Fluids and solutes move within the body by Right Ans - Diffusion, filtration,
osmosis and active transport
What is tonicity? Right Ans - the ability of a surrounding solution to cause a
cell to gain or lose water
How is water diffused Right Ans - By osmosis
How does diffusion move water Right Ans - From the interstital spaces i to
the cells
What is the most accurate way to measure fluid gain or loss Right Ans -
Checking weight
What should nurses monitor when a patient is receiving a diuretic regularly
SATA Right Ans - Skin turgor and integrity
Daily weight
Electrolyte status
Which patient can be considered a high-risk for fluid and electrolyte
imbalance select all that apply Right Ans - A 45-year-old woman with
thyroid crisis
a35-year-old trauma victim on a ventilator
a 30-year-old woman complaining of persistent diarrhea
An older adult man is admitted for Severe disorientation confusion in general
weakness his spouse reports that he is not able to tolerate any food or fluids
and has had several episodes of vomiting and diarrhea which imbalances is
the patient most likely experiencing select all that apply Right Ans -
Hypokalemia and hyponatremia
In planning care for a patient with congestive heart failure you choose the
problem statement fluid volume overload due to altered cardiac output the
problem statement would most likely be supported by which sign or symptom
Right Ans - Fine crackles in lung sounds
A patient who has congestive heart failure has fluid access with a weight gain
of 1.5 pounds since yesterday and a dermatitis ankles which healthcare
providers order has the highest priority Right Ans - Administer furosemide
20 mg PO once daily
A new patient on the floor has been diagnosed with gastroenteritis what
would be the most critical level to assess Right Ans - Potassium
You appropriately elicit a sign of hypocalcemia by Right Ans - Tap in the
face about 1 inch from the ear
At the beginning of shift there is 400 mL of fluid in the IV bag a piggyback
medication contain 100 mL is hung at 12 noon to run over 30 minutes you
hang a new bag of 1000 ML's at 1 PM to run at 125 ML's per hour at the end of
, the shift there's 250 mL left in the bag the count for the total amount of fluid
infused during your shift ended at 7 PM is Right Ans - 1310ml
Which would be the most accurate way to assess for dehydration in an older
adult Right Ans - Urine output
You respond to a patient complaining of pain swelling and wetness over the
peripheral IV site on assessment you find the IV insertion site is tender and
cold to touch these are signs and symptoms of Right Ans - Infiltration
Why is fluid balance essential Right Ans - The life processes of every sale
takes place within fluid
Who or at the greatest risk for fluid in balance Right Ans - Infants in older
adults
Function of water in the body Right Ans - (1) transports nutrients, wastes,
hormones, and cells
(2) facilitate cellular metabolism
(3) as a solvent for electrolytes
(4) to regulate body temperature
(5) aid in digestion and elimination
(6) as a tissue lubricant
How is fluid volume managed Right Ans - My hormones and thirst
Fluids and solutes move within the body by Right Ans - Diffusion, filtration,
osmosis and active transport
What is tonicity? Right Ans - the ability of a surrounding solution to cause a
cell to gain or lose water
How is water diffused Right Ans - By osmosis
How does diffusion move water Right Ans - From the interstital spaces i to
the cells
What is the most accurate way to measure fluid gain or loss Right Ans -
Checking weight
