A patient has dehydration. While planning care, the nurse considers that the majority of the patient’s total water volume exists in with compartment?

The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which process is the nurse describing?

The nurse observes edema in a patient who has venous congestion from right heart failure. Which type of pressure facilitated the formation of the patient’s edema?

The nurse administers an intravenous (IV) hypertonic solution to a patient. In which direction will the fluid shift?

A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the first one? 1. Clean site. 2. Select vein. 3. Apply tourniquet. 4. Release tourniquet. 5. Reapply tourniquet. 6. Advance and secure. 7. Insert vascular access device

The nurse is reviewing laboratory results. Which cation will the nurse observe is the most abundant in the blood?

The nurse receives the patient’s most recent blood work results. Which laboratory value is of greatest concern?

The nurse observes that the patient’s calcium is elevated. When checking the phosphate level, what does the nurse expect to see?

Four patients arrive at the emergency department at the same time. Which patient will the nurse see first?

The patient has an intravenous (IV) line and the nurse needs to remove the gown. In which order will the nurse perform the steps, starting with the first one? 1. Remove the sleeve of the gown from the arm without the IV. 2. Remove the sleeve of the gown from the arm with the IV. 3. Remove the IV solution container from its stand. 4. Pass the IV bag and tubing through the sleeve.

A 2-year-old child is brought into the emergency department after ingesting a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child?

A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe?

Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis?

A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment finding will the nurse expect?

In which patient will the nurse expect to see a positive Chvostek sign?

A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient?

A nurse is caring for a patient with peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel?

The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis?

The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. Which action will the nurse take first?

A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate?

The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare?

The health care provider asks 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 for monitoring both of these patients?

A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan?

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?

A nurse is administering a diuretic to a patient and teaching the patient about foods to increase. Which food choices by the patient will best indicate successful teaching?

The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement?

The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient’s medical record?

A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit?

A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. Which rate will the nurse calculate for the minute flow rate (drops/min)?

A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 50 mL/hr. At what time should the infusion be completed?

A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output. The patient has voided 400 mL of urine. After reporting these values to the health care provider, which order does the nurse anticipate?

A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the nurse is flushing the patient’s peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse’s initial action?

A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)?

The nurse is caring for a group of patients. Which patient will the nurse see first?

A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately?

A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let the blood infuse?

A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, which is the nurse’s next action?

A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions?

A nurse is preparing to start a blood transfusion. Which type of tubing will the nurse obtain?

The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority?

Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?

While the nurse is taking a patient history, the nurse discovers the patient has a type of diabetes that results from a head injury and does not require insulin. Which dietary change should the nurse share with the patient?

A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? (Select all that apply.)

Which assessments will alert the nurse that a patient’s IV has infiltrated? (Select all that apply.)

A nurse is discontinuing a patient’s peripheral IV access. Which actions should the nurse take? (Select all that apply.)

A patient has 250 mL of a jejunostomy feeding with 30 mL of water before and after feeding and 200 mL of urine. Thirty minutes later the patient has 100 mL of diarrhea. At 1300 the patient receives 150 mL of blood and voids another 200 mL. Calculate the patient’s intake. Record your answer as a whole number. _____ mL

A nurse is monitoring patients for fluid and electrolyte and acid-base imbalances. Match the body’s regulators to the function it provides. Antidiuretic hormone

A nurse is monitoring patients for fluid and electrolyte and acid-base imbalances. Match the body’s regulators to the function it provides.... Angiotensin II

A nurse is monitoring patients for fluid and electrolyte and acid-base imbalances. Match the body’s regulators to the function it provides.....Aldosterone

A nurse is monitoring patients for fluid and electrolyte and acid-base imbalances. Match the body’s regulators to the function it provides.......Atrial natriuretic peptide

A nurse is monitoring patients for fluid and electrolyte and acid-base imbalances. Match the body’s regulators to the function it provides.......Bicarbonate

The patient had diarrhea for 5 days and developed an acid-base imbalance. Which statement would indicate that the nurse’s teaching about the acid-base imbalance has been effective?

The patient has type B chronic obstructive pulmonary disease (COPD) exacerbated by an acute upper respiratory infection. Which blood gas values should the nurse expect to see?

The patient has severe hyperthyroidism and will have surgery tomorrow. What assessment is most important for the nurse to assess in order to detect development of the acid-base imbalance for which the patient has highest risk?

The nurse is making a home visit to a child who has a chronic disease. Which finding has the greatest implication for acid-base aspects of this patient’s care?

The nurse has telephone messages from four patients who requested information and assistance. Which one should the nurse refer to a social worker or community agency first?

The patient is hyperventilating from anxiety and abdominal pain. Which assessment findings should the nurse attribute to respiratory alkalosis? (Select all that apply.)

Which statements said by patients indicate that the nurse’s teaching regarding prevention of acid-base imbalances is successful? (Select all that apply.)

The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk for impaired gas exchange?

The nurse is reviewing the patient's arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What might the nurse expect to observe on assessment of this patient?

The nurse would identify which patient condition as a problem of impaired gas exchange secondary to a perfusion problem?

The nurse is assessing a patient's differential white blood cell count. What implications would this test have on evaluating the adequacy of a patient's gas exchange?

The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis?

Which patient finding would the nurse identify as being a risk factor for altered transport of oxygen?

A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk?

Which clinical management prevention concept would the nurse identify as representative of secondary prevention?

The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.)

The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.)

The nurse instructs a patient with type 1 diabetes mellitus to avoid which of the following drugs while taking insulin?

When a diabetic patient asks about maintaining adequate blood glucose levels, which of the following statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74 mg/dL?

The nurse associates which assessment finding in the diabetic patient with decreasing renal function?

What is the nurse’s best response about developing diabetes to the patient whose father has type 1 diabetes mellitus?

The nurse recognizes which patient as having the greatest risk for undiagnosed diabetes mellitus?

A diabetic patient is brought into the emergency department unresponsive. The arterial pH is 7.28. Besides the blood pH, which clinical manifestation is seen in uncontrolled diabetes mellitus and ketoacidosis?

Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.)

To determine whether there is a delay in impulse conduction through the ventricles, the nurse will measure the duration of the patient’s

The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use?

A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of _____ beats/min.

The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, and QRS complex wide and distorted, and QRS duration of 0.18 second. The nurse interprets the patient’s cardiac rhythm as

The nurse notes that a patient’s heart monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm?

A patient has a sinus rhythm and a heart rate of 72 beats/min. The nurse determines that the PR interval is 0.24 seconds. The most appropriate intervention by the nurse would be to

A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/min. Which action should the nurse take next?

After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the drug has been effective?

A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. Teaching for this patient would include information about

Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter?

The nurse knows that discharge teaching about the management of a new permanent pacemaker has been most effective when the patient states

Which intervention by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more teaching about the care of patients with ICDs?

Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg?

A 20-yr-old patient has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54 mm Hg, and the student denies any health problems. What action by the nurse is most appropriate?

When analyzing the rhythm of a patient’s electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n)

A patient has ST segment changes that suggest an acute inferior wall myocardial infarction. Which lead would be best for monitoring the patient?

Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider?

A patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious, apneic, and pulseless. Which action should the nurse take first?

A patient’s heart monitor shows sinus rhythm, rate 64. The PR interval is 0.18 seconds at 1:00 AM, 0.22 seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take next?

A patient develops sinus bradycardia at a rate of 32 beats/min, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which action should the nurse take next?

A 19-yr-old student comes to the student health center at the end of the semester complaining that, “My heart is skipping beats.” An electrocardiogram (ECG) shows occasional unifocal premature ventricular contractions (PVCs). What action should the nurse take next?

The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first?

A patient who is on the telemetry unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first?

A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic, and has no palpable pulses. What action should the nurse take next?

Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?

Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as telemetry technicians on the cardiac care unit?

Which action by a new registered nurse (RN) who is orienting to the telemetry unit indicates a good understanding of the treatment of heart dysrhythmias?

A patient reports dizziness and shortness of breath for several days. During heart monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. The nurse interprets this heart rhythm as

When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular heart rhythm, the nurse counts 30 small blocks from one R wave to the next. The nurse calculates the patient’s heart rate as ____.

When preparing to defibrillate a patient, in which order will the nurse perform the following steps? a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the hands-free, multifunction defibrillator pads on the patient’s chest. e. Check the location of other staff and call out “all clear.”