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1. A nurse on the respiratory unit is interpreting ABGs for several patients. The patient with which problem will the
nurse suspect may have developed respiratory alkalosis?
c. Chronic respiratory illness
d. Sedative overdose
2. A nurse is caring for a group of patients. The patient with which problem would the nurse identify is at high risk for
fluid volume excess?
a. Renal failure
d. NPO for surgery
3. A nurse is caring for a patient who has developed hypernatremia. For which intravenous solution would the nurse
anticipate a prescription?
a. 5% dextrose in 0.9% NaCl
b. 0.9% NaCl (normal saline)
c. 0.45% NaCl (½-strength normal saline)
d. 5% dextrose in lactated Ringer’ s solution
4. A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as
the most reliable indicator of a patient’ s fluid balance status?
a. Recording intake and output
b. Testing skin turgor
c. Reviewing the complete blood count
d. Measuring weight daily
5. A nurse is caring for a patient in the intensive care unit. How will the nurse interpret the patient’ s arterial blood gas
values: pH, 7.30; PaCO2
, 36 mm Hg; HCO3
–, 14 mEq/L?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
6. A patient with dehydration has been encouraged to increase fluid intake. Which measure would be most effective for
the nurse to implement?
a. Explaining the mechanisms of fluid transport in cellular compartments
b. Keeping the patient’ s preferred fluids readily available for the patient
c. Emphasizing the long-term benefit of increasing fluids
d. Planning to offer most daily fluids in the evening
7. A nurse is flushing a patient’ s peripheral venous access device. The nurse finds that the access site is leaking fluid
during flushing. What action will the nurse take next?
a. Removing the IV from the site and start at another location
b. Immediately notifying the primary care provider
c. Outlining the affected area in ink and monitoring for changes
d. A spirating the catheter and attempting to flush again
8. A nurse is monitoring a patient who is receiving an IV infusion of normal saline at 250 mL /hr. The patient is
apprehensive and presents with a pounding headache, rapid pulse, chills, and dyspnea. What would be the nurse’ s
priority intervention related to these symptoms?
a. Discontinuing the infusion immediately, monitoring vital signs, and reporting findings to the primary care provider
b. Slowing the rate of infusion, notifying the primary care provider immediately, and monitoring vital signs
c. Pinching off the catheter or securing the system to prevent entry of air, placing the patient in the Trendelenburg
position, and calling for assistance
d. Discontinuing the infusion immediately, applying warm compresses to the site, and restarting the IV at another site
9. A nurse carefully assesses the acid–base balance of a patient whose bicarbonate (HCO3
–) level is decreased on the
ABG results. This typically occurs in patients with damage to which organ?
c. Adrenal glands
10. A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate
for this patient?
a. Encouraging foods and fluids with higher sodium content
b. Administering oral potassium supplements as prescribed
c. Cautioning the patient about eating foods high in potassium content
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d. Discussing calcium-losing aspects of nicotine and alcohol use
11. A nurse has begun administering an intravenous antibiotic via the patient’s peripheral venous access. Immediately, the
nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and
cool to the touch. What would be the nurse’s next action related to these findings?
a. Repositioning the extremity and raise the height of the IV pole
b. Applying pressure to the dressing on the IV
c. Pulling the catheter out slightly and reinserting it
d. Putting on gloves; removing the catheter
12. When caring for a patient receiving hemodialysis through an arteriovenous fistula, which action is essential for the
nurse to take?
a. Avoiding IM injections
b. Not assessing the radial pulse on the same side as the access
c. Performing BP and venipuncture on the opposite extremity
d. Using the distended portion of the fistula for IV medications
13. A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient
displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse’s priority actions related to
a. Slowing or stopping the infusion; monitoring vital signs, notifying the health care provider, and placing the patient in
an upright position with their feet dependent
b. Stopping the transfusion immediately and keeping the vein open with normal saline, notifying the health care
provider immediately, and administering antihistamine parenterally as needed
c. Stopping the transfusion immediately and keeping the vein open with normal saline, notifying the health care
provider, and treating symptoms with acetaminophen
d. Stopping the infusion immediately, obtaining a culture of the patient’s blood, monitoring vital signs, notifying the
health care provider, and administering antibiotics immediately
14. A nurse is performing physical assessments for patients with fluid imbalance. Which findings indicate a fluid volume
excess? Select all that apply.
a. Pinched and drawn facial expression
b. Deep, rapid respirations
c. Moist crackles heard upon auscultation
e. Distended neck veins
f. Sluggish skin turgor
|FOLLOWING OF INSTRUCTIONS
|NEATNESS AND OTHERS
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