Hesi Fundamentals Practice Test

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 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? - ANSausculate 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 The PN monitors the infusion of fluids via a peripheral line. The prescription states, "3% Normal Saline (NS) to infuse at 100 ml/hour." The client's most recent serum sodium level is 135 mEq/L. What action should the PN take? - ANS-Consult with a healthcare provider about the prescription Which lab test will the PN monitor to determine if this may be a factor contributing to Helen's problem? - ANS-serum protein Which problem often occurs in the elderly and may have contributed to the fluid volume deficit Helen is experiencing? - ANS-decreased hepatic blood flow The PN then explains that Helen's weight loss represents approximately how many liters of fluid loss? - ANS-three. The PN explains to Helen's daughter that Helen has lost approximately how many pounds? (Enter numerical value only. If rounding is required, round to the whole number.) - ANS-7= 65 kg 2x2 = 143. 150 lbs.-143= 7lbs What action should the PN implement? - ANS-document the presence of inelastic skin turgor Since Helen has a fluid volume deficit, the PN anticipates a decrease in which vital sign when Helen moves from a lying to a standing position? - ANS-Blood pressure After recording the first blood pressure measurement, what action will the PN take? - ANS-count the clients radial pulse Vital Signs: Orthostatic Changes The PN plans to observe Helen for orthostatic vital sign changes. Which action will the PN take first? - ANS-Position the client in Supine position For ongoing evaluation of Helen's fluid volume status, it is most important to obtain which data? - ANS-body weigh