NUR 105 WK8 exam Questions and Answers,100% CORRECT

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NUR 105 WK8 exam Questions and Answers 1. Which nursing assessment would cause the RN to collaborate with the health care provider immediately when caring for a client receiving IV infusion of D5... /0.45% sodium chloride with 40mEq of potassium (KCl)? Urninary output of 25mL/hr Rational pg1423 2. A patient has left side weakness and requires one person to assist to ambulate. The RN evaluates the UAP as appropriate assisting this patient when taking which position during ambulation? On the left side of the patient 3. The parent of a 4 year old girl is concerned the child awakens and screams about 20minutes after going to sleep. Which response would be appropriate for the RN to make? Leave a night light on and sit with her speaking softly for 30 minutes after she goes to bed. 4. The US department of health and human services has published physical guidelines for Americans of all age groups and abilities. On which of the following guidelines would the RN base the information to develop a resource for teaching the exercise needed to an older adult? Be as physical active as their abilities allow with guidance from their provider. 5. The RN in the pediatric office is preparing instructions for the single parent of a 4 year old who has been continuously ill for 3 days and is now recovering. What should be considered when providing teaching? The parent may no be clearly comprehending the information that is provided because of fatigue. 6. The RN is planning interventions for a client with the NANDA-I nursing diagnosis of Deficient fluid volume. Which of the following interventions could the RN delegate to the UAP to improve the patients fluid status? Encourage oral fluids as tolerated 7. The order reads: 5% dextrose in 0.45% sodium chloride (D5W/0.45%NS) to infuse at 100mL per hour. The IV tubing drop factor reads; 10gtt At what rate, in drops per minute, will the RN regulate the intravenous solution? Whole numbers= 17 8. Which questions would the RN ask the patient when gathering assessment data related to mobility? Do you have any health problems that interefere with your acitivity? Have there been any recent changes in you daily level of activity? What types of physical activities make you tired? Are there obstacles in your house that make it hard for you to get around? 9. When caring for a client, the RN notes that fluid intake over the last 24 hrs was 1375,mL, muscus membranes and lips are dry and the skin tugor is decreased. Which other assessment data would be obtained? Orthostatic blood pressure. 10. A patient was admitted to the intensive care unit (ICU) 6 days ago as a result of multiple injuries sustained in a car crash. The family is concerned because the patient is demonstrating psychotic behavior. The RN forms a response based on which most likely cause of the behavior? Prolonged REM sleep deprevation 11. The RN is evaluating the student nurse performing passive range of motion for an older adult patient. As the right arm is adducted, the patient reports, “That arm is stiff in the morning.” What feedback would the RN provide to the student nurse? Slowly continue the adduction halting when resistance is met. 12. A patient with a history of restless leg syndrome (RLS) states “I am so tired all the time. It has been increasingly difficult to fall asleep at night because I get a crawling sensation in my legs at night.” Which question would be relevant for the RN to ask? Have you ever had your iron level tested? 13. The RN is providing care to the client with hypernatremia. Which order would cause the RN to collabrote with the health care provider? 1000mL fluid restriction 14. The RN reviews lab results and notes the following: Sodium= 144mEq/L Potassium 5.8mEq/L Chloride 108mEq/L Calcium 9mg/dL Collaborate with healthcare provider for new orders regarding the results 15. What can the RN conclude from the way the patient with the long standing moblitiy problems is using the transfer board? There is evidence of independence in mobility 16. The medication order reads: Ofloxacin (Floxin) 200mg IV to be administered over 30 minutes. The pharmacy label reads: ofloxin 200mg/50mL. At what rate, in mL per hour, will the RN set the infusion control device? 100 17. Which expected outcome is appropriate for an adult patient with a nursing diagnosis label of Risk for deficient fluid volume? 18. The RN is caring for an infant who requires a blood draw for serum electrolytes. The parent tells the RN “I do not want my child to have any more needle sticks.” What is the priority for the RN to take? Do not proceed with the procedure 19. The RN is planning care for a patient whose ABG results are as follows: pH 7.30; PCO2 40; HCO3 19mEq/L; PO2 80. Which nursing diagnosis label applies to the patient? Impaired gas exchange 20. What assessment data would indicate to the RN the patient may have hyponatremia? Lethargy Muscle cramps or twitching Confusion Weakness Anorexia, nausea and vomiting 21. Which benzodiazepine-like drug is most often prescribed for short term sleep disorders? Zolpidem(Ambien) 22. The RN has completed the mobility assessment of a 6 month old infant born three weeks prematurely. Inability to perform which of the following milestones would be cause for concern? Roll from back to front without head lag. 23. Which assessment would lead the RN to suspect obstructive sleep apnea in a client who is schdelued for a sleep study? Daytime fatigue Snoring dsiturbinng to bed partner Headache in the morning 24. The RN is collaborating with a student nurse in the care of a patient with ongoing insomnia. The provider has just prescribed ramelteon (Rozerem). Which statement indicates to the RN that the student nurse understands information about this drug? The medication helps regulate circadian rhythm to promote regular sleep. 25. A patient is prescribed zolpidem tartrate (ambien). Which information should the RN provide to the patient? This drug acts very quickly and lasts for an extended period of time. 26. Anursing intervention reads: Apply trochanter rolls when patient in bed. Which assessment finding indicates the use of the trochanter roll was effective? No external rotation of the hips. 27. Which disorder is classified as a parasomnia? Night terrors 28. Which instruction should the RN provide when teaching the UAP how to monitor intake and output? Include ice cream and Jell-O as well as liquids you drink as oral intake 29. The RN is teaching a parenting class and is preparing a tip sheet for sleep hygiene for children. Which recommendation should be included? Be consistent in the time for bed. 30. The RN is to administer Potassium IV. Prior to administration the RN would be mindful of which of the following implications for administration? IV potassium must be diluted prior to IV admin. 31. A patient tells the RN that she has trouble falling asleep at night, even though she is very tired. A review of symptoms reveals no physical problems and she takes no medication. She has recently quit smoking, is trying to eat healthier foods and has started a moderate intensity excersie program. Her sleep history reveals no changes in bedtime routines, stress level, or environment. Based on this information, the RN applies the nursing diagnosis label Distrubed sleep pattern. What is the most likely related factor for this diagnosis? Nicotine withdrawal 32. The RN is caring for a hospitalized client who has a history of sleepwalking. What is the priority intervention? Instruct the UAP to activate the bed alarm. 33. When obtaining a history on a patient admitted with hypokalemia the RN would specifically ask about the use of which group of drugs? Diuretics 34. The RN reinforces teaching points for an older patient involved with a fitness program. The Patient asks the reason why the physical therapist recommended stretching before and after exercise. The RN explains these actions are aimed at which component of the fitness program? Flexibility 35. The RN is discussing age appropriate activities with the parents of a preschool age child and offers suggestions for ways to promote exercise. What statement by the mother indicates understanding? I will teach my child games ling ring around the rosy. 36. Which class of sleep medications are most likely to linger in the body, causing daytime drowsiness, the risk for rebound insomnia, dependency and tolerance, especially in older adults? Benzodiazepines 37. The RN works with the physical therapist to evaluate the effectiveness of an exercise program for a patient with muscle atrophy in the right lower extremity. Which assessment method provides the most accurate data for evaluation? Use a tape measure to determine increases in the circumference of the extremity 38. Which nursing diagnosis would the RN include when planning care for a patient who experiences chronic hypercalcemia? Urinary retention 39. Which assessment would trigger the RN to assign the NANDA-I nursing diagnosis Risk for infection? History of chronic illness and presence of indwelling IV. 40. The child has been prescribed diphrenhydramine (Benadryl) 20mg orally every 6 hrs as needed for itching. The drug label reads “Diphenhydramine 12.5mg per 5mL” How many mL per dose will the RN administer to the child? 8 41. A patients ABG results read as follows: pH 7.32; PaCO2 51; HCO3 24. How would the RN interpret these values? Respiratory Acidosis 42. The RN is giving discharge instructions to a patient who has recently been diagnosised with obstructive sleep apneia (OSA). Stressing the importance of using the treatment (CPAP) consistently, the RN includes information on which health issues that are associated with untreated OSA? Mood swings Angina Hypertension 43. The RN is caring for a client who takes diazepam for a sleeping disorder and reports, “Sometimes I almost fall asleep while driving home from work.” What is the priority intervention? Discuss the clients medication with the provider 44. Diuertic therapy was prescribed for a patient experiencing hypervolemia. Which outcome indicated the therapy was effective? Pedal edema decreased from 3+ to 2+ after 48hrs. The patients weight returned to baseline weight within 36hrs? 45. Which nursing interventions would be appropriate for the RN to include on a care plan with a NANDA- I nursing diagnosis of Sleep deprivation? Keep room dark and quiet Encourage afternoon napping Support patients bedtime routine 46. Following a procedure,a patient begins to vomit small amounts of gastric contents every 15 minutes. When planning care for this patient, the RN would give priority to monitoring for which acid-base imbalance? Metabolic Alkalosis 47. Which is the most accurate method of evaluating the effectiviness of rehydration for an infant experiencing a fluid volume deficient related to poor sucking? Checking for sunken anterior fontanel 48. The RN is assessing a patient who is experiencing a seizure but is now awake. The patient is weak, confused and has muscle cramping. The RN would review the lab results for which electrolyte imbalance? Hyponatremia 49. What is the priority action the RN should take when assisting with a percutaneous central catheter placement? Verify that informed consent has been signed 50. A central venous access device(CVAD) was inserted in a patient who requires aggressive fluid replacement therapy. What would the RN verify prior to beginning the prescribed therapy? Consent must be obtained Placement confirmed by xray 51. Which teaching point should be included when providing discharge education to a client with hypercalcemia? Encourage fluid in take Encourage fiber Eliminate calcium supplements Avoid calcium based antiacids 52. Which assessment findings are consistent with the development of fluid overload as a systemic complication associated with IV therapy? Hypertension Tachycardia Shortness of breath Edema Possible JVD 53. The student nurse is describing causative factors for hypertonic dehydration. Which of the following stated symptoms would indicate the need for further teaching? Fever 54. Which ABG value for a patient with a head injury requires collaboration with the healthcare provider? PaCO2 of 50 55. A facility has instituted a no lift policy. The UAP asks the RN for help to move the patient up in the bed. What is the appropriate statement for the RN to make to the UAP? [Show More]

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