NURS 172 Exam 3 Questions With
Complete Solutions
A 22-year-old male is admitted to the emergency department
with a stab wound to the abdomen. The patient's vital signs are
blood pressure 82/56 mm Hg, pulse 132 beats/minute,
respirations 28 breaths/minute, and temperature 97.9° F (36.6°
C). Which fluid, if ordered by the health care provider, should
the nurse question?
A. 0.9% saline
B. 0.45% saline
C. Packed red blood cells
D. Lactated Ringer's solution Correct Answers B. 0.45% saline
IV administration of 0.45% saline is hypotonic and is used for
maintenance fluid replacement and dilutes the extracellular
fluid. Intravenous solutions used for volume expansion for
hypovolemic shock include lactated Ringer's solution and 0.9%
saline. If hypovolemia is due to blood loss, blood may be
administered.
A 28-year-old male patient is admitted with diabetic
ketoacidosis. The nurse realizes that this patient will have a need
for which of the following electrolytes?
A. sodium
B. potassium
C. calcium
D. magnesium Correct Answers D. magnesium
,One risk factor for hypomagnesaemia is an endocrine disorder,
including diabetic ketoacidosis.
A 35-year-old female patient comes into the clinic postoperative
parathyroidectomy. Which of the following should the nurse
instruct this patient?
A. Drink one glass of red wine per day.
B. Avoid the sun.
C. Milk and milk-based products will ensure an adequate
calcium intake.
D. Red meat is the protein source of choice. Correct Answers
C. Milk and milk-based products will ensure an adequate
calcium intake.
This patient is at risk for developing hypocalcemia. This risk can
be avoided if instructed to ingest milk and milk-based products.
A 46-year-old woman with a subclavian triple-lumen catheter is
transferred from a critical care unit after an extended stay for
respiratory failure. Which action is important for the nurse to
take?
A. Change the injection cap after the administration of IV
medications.
B. Use a 5-mL syringe to flush the catheter between medications
and after use.
C. During removal of the catheter, have the patient perform the
Valsalva maneuver.
,D. If resistance is met when flushing, use the push-pause
technique to dislodge the clot. Correct Answers C. During
removal of the catheter, have the patient perform the Valsalva
maneuver.
The nurse should withdraw the catheter while the patient
performs the Valsalva maneuver to prevent an air embolism.
Injection caps should be changed at regular intervals but not
routinely after medications. Flushing should be performed with
at least a 10-mL syringe to avoid excess pressure on the catheter.
If resistance is encountered during flushing, force should not be
applied. The push-pause method is preferred for flushing
catheters but not used if resistance is encountered during
flushing.
A 50-year-old woman with hypertension has a serum potassium
level that has acutely risen to 6.2 mEq/L. Which type of order, if
written by the health care provider, should be questioned by the
nurse?
A. Limit foods high in potassium
B. Spironolactone (Aldactone) daily
C. Calcium gluconate IV piggy back
D. Administer intravenous insulin and glucose Correct Answers
B. Spironolactone (Aldactone) daily
Spironolactone (Aldactone) is a potassium-sparing diuretic that
inhibits the exchange of sodium for potassium in the distal renal
tubule and helps to prevent potassium loss. Spironolactone is
contraindicated in a patient with hyperkalemia (serum potassium
>5.0 mEq/L). Collaborative management for patients with
, hyperkalemia may include limiting foods high in potassium, IV
insulin and glucose, administration of calcium gluconate,
potassium-wasting diuretics (e.g., furosemide [Lasix]),
hemodialysis, sodium polystyrene sulfonate (Kayexalate), and
IV fluid administration.
A client is admitted with diabetic ketoacidosis who, with
treatment, has a normal blood glucose, pH, and serum
osmolality. During assessment, the client complains of weakness
in the legs. Which of the following is a priority nursing
intervention?
A. Request a physical therapy consult from the physician
B. Ensure the client is safe from falls and check the most recent
potassium level
C. Allow uninterrupted rest periods throughout the day
D. Encourage the client to increase intake of dairy products and
green leafy vegetables. Correct Answers B. Ensure the client is
safe from falls and check the most recent potassium level.
In the treatment of diabetic ketoacidosis, the blood sugar is
lowered, the pH is corrected, and potassium moves back into the
cells, resulting in low serum potassium. Client safety and the
correction of low potassium levels are a priority. The weakness
in the legs is a clinical manifestation of the hypokalemia. Dairy
products and green, leafy vegetables are a source of calcium.
A client is receiving an intravenous magnesium infusion to
correct a serum level of 1.4 mEq/L. Which of the following
assessments would alert the nurse to immediately stop the
infusion?
Complete Solutions
A 22-year-old male is admitted to the emergency department
with a stab wound to the abdomen. The patient's vital signs are
blood pressure 82/56 mm Hg, pulse 132 beats/minute,
respirations 28 breaths/minute, and temperature 97.9° F (36.6°
C). Which fluid, if ordered by the health care provider, should
the nurse question?
A. 0.9% saline
B. 0.45% saline
C. Packed red blood cells
D. Lactated Ringer's solution Correct Answers B. 0.45% saline
IV administration of 0.45% saline is hypotonic and is used for
maintenance fluid replacement and dilutes the extracellular
fluid. Intravenous solutions used for volume expansion for
hypovolemic shock include lactated Ringer's solution and 0.9%
saline. If hypovolemia is due to blood loss, blood may be
administered.
A 28-year-old male patient is admitted with diabetic
ketoacidosis. The nurse realizes that this patient will have a need
for which of the following electrolytes?
A. sodium
B. potassium
C. calcium
D. magnesium Correct Answers D. magnesium
,One risk factor for hypomagnesaemia is an endocrine disorder,
including diabetic ketoacidosis.
A 35-year-old female patient comes into the clinic postoperative
parathyroidectomy. Which of the following should the nurse
instruct this patient?
A. Drink one glass of red wine per day.
B. Avoid the sun.
C. Milk and milk-based products will ensure an adequate
calcium intake.
D. Red meat is the protein source of choice. Correct Answers
C. Milk and milk-based products will ensure an adequate
calcium intake.
This patient is at risk for developing hypocalcemia. This risk can
be avoided if instructed to ingest milk and milk-based products.
A 46-year-old woman with a subclavian triple-lumen catheter is
transferred from a critical care unit after an extended stay for
respiratory failure. Which action is important for the nurse to
take?
A. Change the injection cap after the administration of IV
medications.
B. Use a 5-mL syringe to flush the catheter between medications
and after use.
C. During removal of the catheter, have the patient perform the
Valsalva maneuver.
,D. If resistance is met when flushing, use the push-pause
technique to dislodge the clot. Correct Answers C. During
removal of the catheter, have the patient perform the Valsalva
maneuver.
The nurse should withdraw the catheter while the patient
performs the Valsalva maneuver to prevent an air embolism.
Injection caps should be changed at regular intervals but not
routinely after medications. Flushing should be performed with
at least a 10-mL syringe to avoid excess pressure on the catheter.
If resistance is encountered during flushing, force should not be
applied. The push-pause method is preferred for flushing
catheters but not used if resistance is encountered during
flushing.
A 50-year-old woman with hypertension has a serum potassium
level that has acutely risen to 6.2 mEq/L. Which type of order, if
written by the health care provider, should be questioned by the
nurse?
A. Limit foods high in potassium
B. Spironolactone (Aldactone) daily
C. Calcium gluconate IV piggy back
D. Administer intravenous insulin and glucose Correct Answers
B. Spironolactone (Aldactone) daily
Spironolactone (Aldactone) is a potassium-sparing diuretic that
inhibits the exchange of sodium for potassium in the distal renal
tubule and helps to prevent potassium loss. Spironolactone is
contraindicated in a patient with hyperkalemia (serum potassium
>5.0 mEq/L). Collaborative management for patients with
, hyperkalemia may include limiting foods high in potassium, IV
insulin and glucose, administration of calcium gluconate,
potassium-wasting diuretics (e.g., furosemide [Lasix]),
hemodialysis, sodium polystyrene sulfonate (Kayexalate), and
IV fluid administration.
A client is admitted with diabetic ketoacidosis who, with
treatment, has a normal blood glucose, pH, and serum
osmolality. During assessment, the client complains of weakness
in the legs. Which of the following is a priority nursing
intervention?
A. Request a physical therapy consult from the physician
B. Ensure the client is safe from falls and check the most recent
potassium level
C. Allow uninterrupted rest periods throughout the day
D. Encourage the client to increase intake of dairy products and
green leafy vegetables. Correct Answers B. Ensure the client is
safe from falls and check the most recent potassium level.
In the treatment of diabetic ketoacidosis, the blood sugar is
lowered, the pH is corrected, and potassium moves back into the
cells, resulting in low serum potassium. Client safety and the
correction of low potassium levels are a priority. The weakness
in the legs is a clinical manifestation of the hypokalemia. Dairy
products and green, leafy vegetables are a source of calcium.
A client is receiving an intravenous magnesium infusion to
correct a serum level of 1.4 mEq/L. Which of the following
assessments would alert the nurse to immediately stop the
infusion?
