Nursing Unit B Practice Questions

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? a) Connective layer b) Subcutaneous layer c) Epidermis d) Dermis

d) Dermis

*Select all answer choices that apply* You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? a) Moisture b) Activity c) Nutrition d) Age e) Admitting diagnosis

a) Moisture b) Activity c) Nutrition Explanation: Six factors are rated using a matrix scoring system: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing? a) 30 drops/mL b) 60 drops/mL c) 90 drops/mL d) 120 drops/mL

b) 60 drops/mL Explanation: Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of drops/mL).

What nursing interventions would be appropriate for a patient diagnosed with deficient fluid volume? (Select all that apply.) a) Hypervolemia management b) Intravenous therapy c) Fluid restriction d) Monitoring edema e) Electrolyte management f) Nutrition management

b) Intravenous therapy e) Electrolyte management f) Nutrition management Explanation: If a patient is at a fluid volume deficit intravenous therapy may be ordered by the primary care provider to replenish fluids and electrolytes, warranting fluid and electrolyte management. Nutrition management may help to increase and maintain electrolyte levels by adding foods high in certain electrolytes to the diet. Hypervolemia refers to fluid volume excess. Fluid restriction would be contraindicated because the patient is already at a deficit. Edema would be monitored in the case of fluid volume excess.

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte? a) Chloride b) Potassium c) Phosphorous d) Sodium

b) Potassium Explanation: Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium.

Which of the following would NOT be considered a behavior demonstrating integrity? a) Providing honest information to patients b) Documenting care accurately and honestly c) Seeking to only remedy errors made by self d) Demonstrating accountability for own actions

c) seeking to only remedy errors made by self Errors should be remedied as soon as noticed, whether the error was made by you or another health care worker. (Taylor 95)

The primary extracellular electrolytes are: a) phosphorous, calcium, and phosphate. b) magnesium, sulfate, and carbon. c) potassium, phosphate, and sulfate. d) sodium, chloride, and bicarbonate.

d) sodium, chloride, and bicarbonate.

Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles. Which is false about potassium? a) Insulin promotes the transfer of potassium from the extracellular fluid into skeletal muscle and liver cells. b) A person loses approximately 30 mEq of potassium. c) Normal serum potassium ranges from 5.5 to 6.0 mEq/L. d) Aldosterone enhances renal excretion of potassium.

c) Normal serum potassium ranges from 5.5 to 6.0 mEq/L. Explanation: Normal serum potassium ranges from 3.5 to 5.0 mEq/L.

Which of the following actions demonstrates social injustice? a) Supporting fairness and nondiscrimination in the delivery of care b) Promoting universal access to health care c) discourages legislation and policies consistent with the advancement of nursing care d) Nurse defends the patient when doctor will not prescribe needed pain medication

c) discourages legislation and policies consistent with the advancement of nursing care Explanation: nurses should encourage this (Taylor 95)

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? a) nausea and vomiting b) muscle twitching c) distended neck veins d) fingerprinting over sternum

c) distended neck veins Explanation: Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

Which of the following would NOT be considered a behavior demonstrating human dignity? a) Providing culturally competent and sensitive care b) Protecting the patient's privacy c)Preserving confidentiality of patients and health care providers d) Designing universal care.

d) Designing universal care -care should be designed with sensitivity to individual patient's needs (Taylor 95)

A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which fluid and electrolyte imbalances? a) fluid volume deficit and acidosis b) fluid volume excess and alkalosis c) fluid volume deficit and alkalosis d) fluid volume excess and acidosis

d) fluid volume excess and acidosis Explanation: Fluid volume excess can be caused by malfunction of the kidneys (i.e., renal failure). The kidneys are also responsible for acid-base balance, and in the presence of renal failure, the kidneys cannot regulate hydrogen ions and bicarbonate ions, so the client develops metabolic acidosis. Taylor p. 1492, 1495