NURS 3119 D446
ADULT HEALTH II
OBJECTIVE ASSESSMENT
2025
Normal range for BUN -Correct Answer= 10-20 mg/dL
What is hematocrit? -Correct Answer= percent of blood volume that is RBCs
Partial pressure of oxygen range (PAO2) -Correct Answer= 80-100
What type of IV solution would be used for someone with cerebral edema or
severe hyponatremia? -Correct Answer= Hypertonic solution
How do you know an ABG issue is partially compensated? -Correct Answer=
When all 3 factors are abnormal (pH, HCO3, CO2)
How do you know when an ABG issue is uncompensated? -Correct Answer=
When pH and one other factor are abnormal and the other factor is normal
How do you know when an ABG issue is fully compensated? -Correct
Answer= when the pH is normal and both the other parameters are abnormal
What are the normal parameters for pH, CO2 and HCO3? -Correct Answer=
pH- 7.35-7.45
CO2- 35-45
HCO3- 22-26
How do you know what the original problem was for a fully compensated
problem? -Correct Answer= Look at the pH!
If the pH is 7.35-7.4 it was an acidic problem
If the pH is 7.41-7.45 it was an alkalotic problem
Respiratory alkalosis can lead to the same symptoms as what type of
electrolyte imbalance? -Correct Answer= Hypocalcemia symptoms- tingling
of the face, chvosteks sign etc.
What electrolyte imbalance is the rarest imbalance? -Correct Answer=
metabolic alkalosis
Why is metabolic alkalosis hard to compensate for? -Correct Answer=
Because the RR needs to slow down in order to compensate for it and you
don't want it to slow down too much otherwise you could die
,Acidodic patients tend to be more whereas alkalotic patients
tend to be more -Correct Answer= Acidodic patients= more
lethargic
Alkalotic patients= more excitable
What is Chvostek's sign? -Correct Answer= It is a sign of hypocalcemia. You
tap on the facial nerve (on the cheek in front of the ear) and the persons face
will twitch when you do that.
What is Trousseau's sign? -Correct Answer= It is another sign of
hypocalcemia. BP cuf f inflated and causes a carpal spasm.
What are 2 important assessments to perform when looking for signs of
hyponatremia? -Correct Answer= LOC and UO
Normal calcium lab values? -Correct Answer= 9.0-10.5
Normal Magnesium values? -Correct Answer= 1.3-2.1 mEq/L
Normal potassium levels? -Correct Answer= 3.5-5.0 mEq/L
Normal Sodium levels? -Correct Answer= 135-145 mEq/L
What does aldosterone do? -Correct Answer= tells body to hold onto sodium
and water follows
What are expected lab values for fluid volume deficit? -Correct Answer=
increased hematocrit, serum osmolality, BUN and sodium
What are expected lab values for fluid volume excess? -Correct Answer=
decreased hematocrit, serum osmolality, BUN and sodium
What is sodium in charge of? -Correct Answer= controls water distribution,
nerve impulses and muscle contraction
What is potassium in charge of? -Correct Answer= skeletal and cardiac
muscle contraction
What is calcium in charge of? -Correct Answer= nerve impulse transmission,
regulates muscles contractions, bone and teeth density
What is magnesium in charge of? -Correct Answer= muscle contractions,
influences use of potassium, calcium and protein
Low Mg= low albumin
What are other drugs you would expect to be given with potassium? -Correct
Answer= magnesium and spironolactone (potassium sparing diuretic)
How to tell if someone is experiencing a anterior or posterior nose bleed
,-Correct Answer= have them open their mouth and see if there is blood in
their mouth or throat (this would be indicative of a posterior bleed)
What is the biggest concern with nasal packing> -Correct Answer= Airway
obstruction
S/S: decreased O2 saturation
-Correct Answer= retention
sodium (hyponatremia)
What is the most accurate way for a nurse to evaluate fluid balance for
someone with hypovolemia? -Correct Answer= Daily weight
Rationale: daily weight is the most easily obtained and accurate means of
assessing volume status
A nurse is caring for an alert and oriented older adult patient who struggles
with dehydration. Which instructions should the nurse give to her patient
related to fluid intake? -Correct Answer= Drink fluids if your mouth feels dry
Rationale: the ability to notice thirst decreases with old age, therefore, for
A&O patients, teach them how to notice signs of thirst
If a patient is taking a potassium wasting diuretic for hypertension and they
report generalized weakness, what should the nurses next action be? Why?
-Correct Answer= Suggest a HCP order a basal metabolic panel because
weakness is a sign of hypokalemia and the patient is on a diuretic that gets
rid of potassium
If someone is taking spironolactone should they increase their potassium rich
foods intake or decrease their overall potassium intake? -Correct Answer=
They should choose lower potassium foods over high potassium foods
Ex: apple juice over orange juice
Peaked T waves are a sign of what type of electrolyte imbalance? -Correct
Answer= hyperkalemia
Where would be the ideal room assignment for a patient who is admitted
with new-onset confusion and hyponatremia? -Correct Answer= Room near
the nurses station to be closely monitored
A patient is prescribed potassium chloride by IV for severe hypokalemia.
What is the maximum rate that the nurse can infuse potassium? why?
-Correct Answer= maximum rate of 10mEq/hr because potassium by IV is
painful and rapid infusion could cause cardiac arrest
What is the most important thing to be monitored for a patient who is
, receiving KCl by IV? why? -Correct Answer= Cardiac monitoring because of
the risk of dysrhythmias
A patient has been receiving nasogastric suction for 3 days and has a serum
sodium level of 127 mEq/. What would the nurse expect to be prescribed for
this patient? -Correct Answer= Lactated Ringers to replace lost electrolytes
How should the nurse interpret the following ABG results?
pH: 7.49
PaCO2: 32 mm Hg
HCO3: 25 mEq/L -Correct Answer= Respiratory alkalosis
How should the nurse interpret the following ABG results?
pH: 7.32
PaCO2: 52 mm Hg
HCO3: 23 mEq/L -Correct Answer= Respiratory acidosis
How should the nurse interpret the following ABG results?
pH: 7.51
PaCO2: 38 mm Hg
HCO3: 29 mEq/L -Correct Answer= Metabolic alkalosis
How should the nurse interpret the following ABG results?
pH: 7.29
PaCO2: 40
HCO3: 18 -Correct Answer= Metabolic acidosis
A patient presents to the ER with DKA and deep, rapid respirations. What
would be the ideal nursing actions for this patient? -Correct Answer=
Administer prescribed fluids and insulin
Rationale:The deep rapid respirations indicate metabolic acidosis and the
best way to correct the acidosis is to Administer prescribed saline bolus to
prevent hypovolemia and then administer insulin to allow glucose to reenter
cells
What is an expected clinical finding for someone with a low serum protein
level. ( < 6.4 g/dL) -Correct Answer= Edema
Normal range for total protein is 6.4-8.3
A patient is receiving a hypertonic solution to correct hyponatremia. Which
assessment is most important for the nurse to monitor during this infusion?
why? -Correct Answer= Lung sounds because hypertonic solutions cause
water retention so the patient should be monitored for signs of fluid excess
and when thinking of ABCs this would be the most important out of all things
that should be monitored.
- UO, peripheral pulses and peripheral edema should also be monitored
For someone who has hypokalemia, what medication is most concerning with
ADULT HEALTH II
OBJECTIVE ASSESSMENT
2025
Normal range for BUN -Correct Answer= 10-20 mg/dL
What is hematocrit? -Correct Answer= percent of blood volume that is RBCs
Partial pressure of oxygen range (PAO2) -Correct Answer= 80-100
What type of IV solution would be used for someone with cerebral edema or
severe hyponatremia? -Correct Answer= Hypertonic solution
How do you know an ABG issue is partially compensated? -Correct Answer=
When all 3 factors are abnormal (pH, HCO3, CO2)
How do you know when an ABG issue is uncompensated? -Correct Answer=
When pH and one other factor are abnormal and the other factor is normal
How do you know when an ABG issue is fully compensated? -Correct
Answer= when the pH is normal and both the other parameters are abnormal
What are the normal parameters for pH, CO2 and HCO3? -Correct Answer=
pH- 7.35-7.45
CO2- 35-45
HCO3- 22-26
How do you know what the original problem was for a fully compensated
problem? -Correct Answer= Look at the pH!
If the pH is 7.35-7.4 it was an acidic problem
If the pH is 7.41-7.45 it was an alkalotic problem
Respiratory alkalosis can lead to the same symptoms as what type of
electrolyte imbalance? -Correct Answer= Hypocalcemia symptoms- tingling
of the face, chvosteks sign etc.
What electrolyte imbalance is the rarest imbalance? -Correct Answer=
metabolic alkalosis
Why is metabolic alkalosis hard to compensate for? -Correct Answer=
Because the RR needs to slow down in order to compensate for it and you
don't want it to slow down too much otherwise you could die
,Acidodic patients tend to be more whereas alkalotic patients
tend to be more -Correct Answer= Acidodic patients= more
lethargic
Alkalotic patients= more excitable
What is Chvostek's sign? -Correct Answer= It is a sign of hypocalcemia. You
tap on the facial nerve (on the cheek in front of the ear) and the persons face
will twitch when you do that.
What is Trousseau's sign? -Correct Answer= It is another sign of
hypocalcemia. BP cuf f inflated and causes a carpal spasm.
What are 2 important assessments to perform when looking for signs of
hyponatremia? -Correct Answer= LOC and UO
Normal calcium lab values? -Correct Answer= 9.0-10.5
Normal Magnesium values? -Correct Answer= 1.3-2.1 mEq/L
Normal potassium levels? -Correct Answer= 3.5-5.0 mEq/L
Normal Sodium levels? -Correct Answer= 135-145 mEq/L
What does aldosterone do? -Correct Answer= tells body to hold onto sodium
and water follows
What are expected lab values for fluid volume deficit? -Correct Answer=
increased hematocrit, serum osmolality, BUN and sodium
What are expected lab values for fluid volume excess? -Correct Answer=
decreased hematocrit, serum osmolality, BUN and sodium
What is sodium in charge of? -Correct Answer= controls water distribution,
nerve impulses and muscle contraction
What is potassium in charge of? -Correct Answer= skeletal and cardiac
muscle contraction
What is calcium in charge of? -Correct Answer= nerve impulse transmission,
regulates muscles contractions, bone and teeth density
What is magnesium in charge of? -Correct Answer= muscle contractions,
influences use of potassium, calcium and protein
Low Mg= low albumin
What are other drugs you would expect to be given with potassium? -Correct
Answer= magnesium and spironolactone (potassium sparing diuretic)
How to tell if someone is experiencing a anterior or posterior nose bleed
,-Correct Answer= have them open their mouth and see if there is blood in
their mouth or throat (this would be indicative of a posterior bleed)
What is the biggest concern with nasal packing> -Correct Answer= Airway
obstruction
S/S: decreased O2 saturation
-Correct Answer= retention
sodium (hyponatremia)
What is the most accurate way for a nurse to evaluate fluid balance for
someone with hypovolemia? -Correct Answer= Daily weight
Rationale: daily weight is the most easily obtained and accurate means of
assessing volume status
A nurse is caring for an alert and oriented older adult patient who struggles
with dehydration. Which instructions should the nurse give to her patient
related to fluid intake? -Correct Answer= Drink fluids if your mouth feels dry
Rationale: the ability to notice thirst decreases with old age, therefore, for
A&O patients, teach them how to notice signs of thirst
If a patient is taking a potassium wasting diuretic for hypertension and they
report generalized weakness, what should the nurses next action be? Why?
-Correct Answer= Suggest a HCP order a basal metabolic panel because
weakness is a sign of hypokalemia and the patient is on a diuretic that gets
rid of potassium
If someone is taking spironolactone should they increase their potassium rich
foods intake or decrease their overall potassium intake? -Correct Answer=
They should choose lower potassium foods over high potassium foods
Ex: apple juice over orange juice
Peaked T waves are a sign of what type of electrolyte imbalance? -Correct
Answer= hyperkalemia
Where would be the ideal room assignment for a patient who is admitted
with new-onset confusion and hyponatremia? -Correct Answer= Room near
the nurses station to be closely monitored
A patient is prescribed potassium chloride by IV for severe hypokalemia.
What is the maximum rate that the nurse can infuse potassium? why?
-Correct Answer= maximum rate of 10mEq/hr because potassium by IV is
painful and rapid infusion could cause cardiac arrest
What is the most important thing to be monitored for a patient who is
, receiving KCl by IV? why? -Correct Answer= Cardiac monitoring because of
the risk of dysrhythmias
A patient has been receiving nasogastric suction for 3 days and has a serum
sodium level of 127 mEq/. What would the nurse expect to be prescribed for
this patient? -Correct Answer= Lactated Ringers to replace lost electrolytes
How should the nurse interpret the following ABG results?
pH: 7.49
PaCO2: 32 mm Hg
HCO3: 25 mEq/L -Correct Answer= Respiratory alkalosis
How should the nurse interpret the following ABG results?
pH: 7.32
PaCO2: 52 mm Hg
HCO3: 23 mEq/L -Correct Answer= Respiratory acidosis
How should the nurse interpret the following ABG results?
pH: 7.51
PaCO2: 38 mm Hg
HCO3: 29 mEq/L -Correct Answer= Metabolic alkalosis
How should the nurse interpret the following ABG results?
pH: 7.29
PaCO2: 40
HCO3: 18 -Correct Answer= Metabolic acidosis
A patient presents to the ER with DKA and deep, rapid respirations. What
would be the ideal nursing actions for this patient? -Correct Answer=
Administer prescribed fluids and insulin
Rationale:The deep rapid respirations indicate metabolic acidosis and the
best way to correct the acidosis is to Administer prescribed saline bolus to
prevent hypovolemia and then administer insulin to allow glucose to reenter
cells
What is an expected clinical finding for someone with a low serum protein
level. ( < 6.4 g/dL) -Correct Answer= Edema
Normal range for total protein is 6.4-8.3
A patient is receiving a hypertonic solution to correct hyponatremia. Which
assessment is most important for the nurse to monitor during this infusion?
why? -Correct Answer= Lung sounds because hypertonic solutions cause
water retention so the patient should be monitored for signs of fluid excess
and when thinking of ABCs this would be the most important out of all things
that should be monitored.
- UO, peripheral pulses and peripheral edema should also be monitored
For someone who has hypokalemia, what medication is most concerning with
