Hesi Fundamentals Practice Test
Which problem does the PN identify as most pertinent in that
situation? - ANS-risk for injury (thrombus formation)
Intake and Output Measurement
Helen continues to receive 0.9% NS at a rate of 100 mL/hour. She is
stronger and has started taking oral food and ...
Which problem does the PN identify as most pertinent in that
situation? - ANS-risk for injury (thrombus formation)
Intake and Output Measurement
Helen continues to receive 0.9% NS at a rate of 100 mL/hour. She is
stronger and has started taking oral food and fluids well. She
receives a regular, no-added-salt diet. Her breakfast includes 1 cup
of scrambled eggs, 1 bowl of oatmeal, a fresh orange, a fruit
smoothie, and a carton of milk.
Which item(s) should be measured as fluid intake? - ANS-carton of
milk and fruit smoothie
(oral intake includes all liquids)
When Helen was first admitted, the healthcare provider did not
include intake and output measurement in the initial prescriptions,
but the PN initiated this activity.
Now that Helen is taking oral fluids well, what action should the PN
implement? - ANS-Continue the ongoing measurement of the clients
fluid intake and output.
Fluid Volume Excess
Helen's intake and output measurements indicate that her intake is
greater than her output. The PN is concerned that she may develop
fluid volume excess.
Which assessment is important for the PN to perform? - ANS-
ausculate the clients breath sounds
The PN also observes that Helen's feet and ankles are swollen. When
the PN presses a finger on the swelling, a 4-mm indentation appears.
How will the PN document this finding? - ANS-2+ pitting edema
present around ankles and feet
Helen has abnormal breath sounds, bilateral pitting edema, and
jugular vein distention.
, Which change in Helen's pulse will the PN anticipate? - ANS-increase
in rate and volume
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