At the end of shift, you are calculating intake and output on your pat lent who was admited for a non- emergent gall bladder removal. She is alert and oriented and able to recall the amount of ﬂuid she has drank all day. You can calculate the amount of IV ﬂuids administered. Her intake is 2500ml and her output is 1200ml from a catheter bag. You realize she is not excreting enough urine me for water she is taking in. What is the most appropriate next step to determine if she is retaining water?

Put a hat in the toilet to collect proper output.

Assess your patient’s lower extremities and lungs for ﬂuid retention.

Educate her on the importance of writing down all ﬂuids she is drinking.

Document the numbers anyway, there is a probable error with the intake number.

Answer and Explanation

The Correct Answer is B

. Assess your patient’s lower extremities and lungs for ﬂuid retention.

If a patient’s intake is 2500ml and her output is 1200ml from a catheter bag, and you are concerned that she may not be excreting enough urine for the amount of water she is taking in, the most appropriate next step would be to assess her lower extremities and lungs for ﬂuid retention. This can help determine if the patient is retaining water and if further intervention is necessary.

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Correct Answer is A

Explanation

In case of suspected ingestion of a poisonous substance, the priority response of the poison control nurse should be to assess the child's vital signs, especially breathing and heart rate, to determine if the child is experiencing any immediate life-threatening symptoms. This information will help the nurse determine the appropriate course of action, such as whether to instruct the caregiver to perform CPR or to immediately call for emergency medical assistance.

Asking about the substance ingested and the time of ingestion are also important pieces of information to gather, but they should not take priority over assessing the child's vital signs. Inducing vomiting is generally not recommended unless instructed to do so by a medical professional, as it can cause further harm if the substance ingested is corrosive or caustic.

A. Chart the reading at 91%, this is normal for a COPD patient. B. Place a non-rebreather on the patient with high ﬂow oxygen. C. Call the doctor if the patient is declining. D. Sit the patient up and have them breathe deep.

Correct Answer is D

Explanation

Sitting the patient up and encouraging deep breathing can help improve oxygenation and increase the pulse oximetry reading. This is a non-invasive intervention that can be implemented immediately to help improve the patient’s oxygen levels.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The poison control nurse receives a call from the caregiver of a young school age child who may have ingested a poisonous substance. Which is the priority response by the nurse?

Correct Answer is A

Explanation

RH has a history of COPD. The CNA checks his vital signs at the beginning of the shift and tells you that his pulse ox reading is 91%. What should the nurse advise the CAN does next:

Correct Answer is D

Explanation

A nurse on a cardiac care unit oversees the care of diﬀerent client’s cardiac health problems. Which action can be most appropriately delegated to personnel (UAP/CNA) when a patrent is found unresponsive?

The nurse provides care for the client with an asthma crisis experiencing hypoxia. Which lung sound would the nurse expect to auscultate on the physical assessment?

MK is admited with COPD exacerbation. Your nursing care plan reads Impaired Gas Exchange, related to smoking 1 PPD of cigaretes. AED pursed lip breathing shortness of breath. Which is the best expected outcome for this diagnosis.

The nurse is working on a cardiac unit with several patients who have intravenous access lines. The nurse identifies the following are considered central venous catheters: (Select All That Apply)

The Practical Nurse (PN) assessing a client for the nursing diagnosis of Impaired Verbal Communication is aware that the least number of defining characteristics for this diagnosis is:

MA is a 85 year old female who is admited to the hospital with Pneumonia. Education has begun on proper breathing techniques to expand lung volume as much as possible and allow for proper oxygen blood exchange within the alveoli. Which device will help her achieve this as educated by the nurse?

The nurse scaring for a patient who will be needing a blood transfusion. The nurse knows that the universal recipient of blood would be considered blood type: