Download Sherpath Final exam with 265 Questions and correct answers updated 2025 and more Exams Nursing in PDF only on Docsity!
Sherpath Final exam with 265
Questions and correct answers
updated 2025
Multichoice exam 1.Which of Mrs. Walters' assessments will Julie, her nurse, need to closely monitor as indicators of changes in her fluid volume status? Select all that apply. Vital signs Pain level Daily weights Bowel sounds Intake and output Vital signs Daily weights Intake and output ,, 2.Julie, Mrs. Walters' nurse, is preparing to tally up Mrs. Walters' fluid intake at the end of the shift. Which substances should be included in the fluid intake tally? Select all that apply. Her intravenous fluids A dish of cherry-flavored gelatin A piece of toast Supplemental enteral feedings
A small piece of chicken Her intravenous fluids A dish of cherry-flavored gelatin Supplemental enteral feedings 3.Julie, Mrs. Walters' nurse, is monitoring Mrs. Walters' fluid output. What will the nurse need to include in the fluid output tally at the end of the shift? Select all that apply. Urine in the Foley catheter collection bag A soft, formed stool Emesis resulting from a vomiting episode A large volume enema Free water flushes for enteral feedings Urine in the Foley catheter collection bag Emesis resulting from a vomiting episode
- Which items are commonly used as measuring tools for urine output? Select all that apply. Urine hat Diaper Urinal Foley catheter Wound dressing Urine hat Diaper Urinal
Assess and document all fluids consumed by the patient using an oral intake log kept at the bedside. Involve the patient, if possible, and plan to space small amounts of fluid intake throughout the day. 7.The nurse notes that at 1 pm a patient on a fluid restriction has consumed 800 mL of the daily allotted 1200 mL. What action should the nurse take in planning the patient's fluid intake for the rest of the day? Hold all fluid intake except for what is needed for administering medications and begin distributing remaining allotment at the evening meal. Fill a water pitcher with 400 mL of water to be budgeted for medications and drinking for the remainder of the day. Involve the patient in planning how to budget the remaining 400 mL over the remainder of the day. Give the patient 200 mL of fluid now and plan on giving the remaining 200 mL with the evening meal. Involve the patient in planning how to budget the remaining 400 mL over the remainder of the day. 8.The nurse is assigned to a patient who requires oral fluid replacement. The nurse writes the nursing intervention, "Provide water and a variety of fluids based on patient preferences." What are the related actions that should be included when carrying out this nursing intervention? Select all that apply. Distribute fluid intake equally throughout the 24-hour day. Encourage intake of caffeinated beverages. Keep a pitcher of fresh water at the bedside at all times. Determine which beverages the patient prefers.
Remove water and beverages during hours of sleep. Keep a pitcher of fresh water at the bedside at all times. Determine which beverages the patient prefers. 9.The nurse has received an order to start IV fluids on a patient. In choosing the IV site, what questions should the nurse consider in making this decision? Select all that apply. What is the condition of the patient's veins? What is the patient's age? For about how long is the patient to receive IV therapy? What is the patient's diagnosis? Will family members be staying in the patient's room? What is the condition of the patient's veins? What is the patient's age? For about how long is the patient to receive IV therapy? What is the patient's diagnosis? ,,
- The nurse is assigned to a patient who is receiving 0.9% Normal Saline IV fluid. The nurse will need to monitor the patient for what IV solution-related complication? Hypovolemia Hypernatremia Cellular dehydration Water intoxication Hypernatremia
The nurse is assigned to a patient who is to have a central venous catheter (CVC) inserted. What are the major uses of this type of IV catheter? Select all that apply. Long-term IV therapies Short-term single IV therapy Short-term intensive therapies Hypertonic solutions IV medications that are nonirritating Long-term IV therapies Short-term intensive therapies Hypertonic solutions Which patients would be possible candidates for blood or blood product administration? Select all that apply. A patient with missing clotting factors A patient with drug-related destruction of red blood cells A patient who is severely dehydrated A patient with abdominal bleeding from trauma A patient who has had recent major surgery A patient with missing clotting factors A patient with drug-related destruction of red blood cells A patient with abdominal bleeding from trauma A patient who has had recent major surgery
Blood has been ordered and the nurse is reviewing who must check and verify the blood. Verification is required by which people? Select all that apply. Personnel in the blood bank Nurse who picks up the blood from the blood bank Two nurses at the patient's bedside before initiating transfusion Shift nurse in charge Primary care provider Personnel in the blood bank Nurse who picks up the blood from the blood bank Two nurses at the patient's bedside before ,, What is the maximum time that a blood product can be infused after leaving the blood bank? 2 hours 4 hours 6 hours 8 hours 4 hours The nurse is monitoring a patient for possible adverse effects while receiving a unit of blood. What common manifestations does the nurse assess the patient for? Select all that apply. Itching Hypotension Dyspnea Fever
Nasogastric tube irrigations Enteral tube feedings Free water gastric tube flushes Intravenous medications ,, The nurse is tallying up a patient's intake and output at the end of the shift. Which patient- related data would require entry of fluid output information on the EHR? Select all that apply. The patient has a nasogastric tube attached to wall suction. The patient is receiving bladder irrigations. The patient has a Foley catheter in place. The patient has a surgical wound drain on his abdomen. The patient had a large volume enema this morning. The patient has a nasogastric tube attached to wall suction. The patient has a Foley catheter in place. The patient has a surgical wound drain on his abdomen. The nurse has received a "force fluids" order for a patient with a fluid volume deficit. Which actions taken by the nurse would be beneficial for meeting the patient's fluid replacement needs? Select all that apply. Ensuring the pitcher of water at the patient bedside is refilled as required Providing coffee and sodas at frequent intervals in addition to water Providing ways to record intake of fluids to meet required levels Tapering off fluid intake so the least amount is ingested before bedtime Reminding the patient to drink throughout the day
Ensuring the pitcher of water at the patient bedside is refilled as required Providing ways to record intake of fluids to meet required levels Tapering off fluid intake so the least amount is ingested before bedtime Reminding the patient to drink throughout the day The nurse is developing a 24-hour fluid budget for a patient with 1000 mL fluid restriction. The fluid budget will need to include which set of factors? Select all that apply. Solid foods consumed Medications IV fluids Between meal fluid sipping Breakfast, lunch, and dinner Medications IV fluids Between meal fluid sipping Breakfast, lunch, and dinner A patient is on a 1000 mL per day fluid restriction. At 3 pm, the patient has consumed 700 mL. What is the best plan for the remainder of the day to maintain that fluid restriction? Allow the patient to consume another 300 mL right away and nothing more by mouth for the rest of the day. Allow 150 mL with dinner and 150 mL for medications and prior to going to sleep. Remove all water and beverages from the room and allow the patient to consume 300 mL before going to sleep.
Monitor the patient for complications of IV therapy. Comply with the 6 rights of safe medication administration. Directly obtain the patient's vital signs. Verify that the fluid is appropriate for the patient. Evaluate the effectiveness of IV therapy. Monitor the patient for complications of IV therapy. Comply with the 6 rights of safe medication administration. The nurse is preparing to administer a blood product. The nurse will prime the IV tubing with what IV solution? 5% dextrose and water 0.45% normal saline 5% dextrose in 0.9% normal saline 0.9% normal saline 0.9% normal saline The nurse is preparing to start a blood transfusion. The nurse is aware that the most common cause of adverse blood transfusion events is what procedural step failure? Incomplete documentation during the verification process Failure to obtain informed consent prior to blood administration Blood exceeds the four-hour time limit after leaving the blood bank Inappropriate identification prior to blood administration Inappropriate identification prior to blood administration
When administering blood to a patient, the nurse knows that the most vigilant monitoring of the patient must take place. When must this monitoring happen? As the transfusion is started and within the first 15 minutes Directly after the unit of blood has infused 1-2 hours after the transfusion has completed Approximately 2 hours after starting a transfusion As the transfusion is started and within the first 15 minutes Match each type of fluid to its description. Intracellular; Extracellular; Interstitial; Intravascular Outside of the cell membrane Between the cells in the tissues Inside of the cell membrane Within the blood vessels Outside of the cell membrane = Extracellular Between the cells in the tissues = Interstitial Inside of the cell membrane = Intracellular Within the blood vessels = Intravascular Match each element to its description.
Body temperature regulation Thick protective cushion for internal organs Transportation of nutrients within the body Elimination of waste products Lubrication for joints Body temperature regulation Transportation of nutrients within the body Elimination of waste products ,, Match the blood component with its description. Plasma; Platelets; Red blood cells (RBCs); White blood cells (WBCs) Cellular component of the immune system Fluid component of blood; acts as transport medium Most numerous; transport oxygen and carbon dioxide Small, irregularly shaped bodies; control bleeding Cellular component of the immune system = White blood cells (WBCs) Fluid component of blood; acts as transport medium = Plasma Most numerous; transport oxygen and carbon dioxide = Red blood cells (RBCs) Small, irregularly shaped bodies; control bleeding = Platelets
A nursing student receives an order for plasma administration and is unsure if this means a whole blood transfusion will be used. The instructor gives which explanation? Plasma can be separated from whole blood; so plasma will be used. Plasma is a small percentage of blood; so whole blood is used. Plasma can be separated out as albumin; so albumin is used. Whole blood does not contain plasma; so plasma is used. Plasma can be separated from whole blood; so plasma will be used. ,, A patient in the emergency department has experienced blood loss and requires a blood transfusion. ABO compatibility testing is conducted. Which description accurately describes which blood types are compatible? Type A- patient can receive blood from a Type O+ donor. Type O+ patient can receive blood from a Type AB+ donor. Type AB+ patient can receive blood from a Type O- donor. Type B- patient can receive blood from a Type B+ donor. Type AB+ patient can receive blood from a Type O- donor. On the maternity ward, the nurse takes a careful admission and health history with what understanding of Rh factors? Select all that apply. Rh antibodies can develop during pregnancy. Rh antibodies can develop during a blood transfusion. Rh antibodies can develop as a normal process of aging.
Application of hydrostatic force enables water and solutes to move through the cell membrane. Water and solutes move between vascular and interstitial compartments. Water moves from an area of lower concentration of solutes to an area of higher concentration. ,, Which statements are important for the nurse to know about the filtration process? Select all that apply. It is the movement of water and solutes together. Water moves from an area of lower solute concentration to an area of higher concentration. Arterial blood pressure affects hydrostatic pressure. Water and solutes move from an area of lower net pressure to an area of higher net pressure. Arterial and venous ends of the capillary beds generally have equal hydrostatic and osmotic pressures. It is the movement of water and solutes together. Arterial blood pressure affects hydrostatic pressure. What controls oncotic pressure in the intravascular space and influences the movement of water across the capillary membrane? The size of the particles in the water The concentration of the particles in the water The size of the red blood cells The shape of the red blood cells The concentration of the particles in the water
How do hydrostatic and oncotic pressures influence the movement of fluid during the filtration process? Hydrostatic and oncotic pressures move water and solutes in the same direction across the capillary wall. Filtration occurs when the oncotic pressure is greater than the hydrostatic pressure. Filtration across the capillary wall occurs when hydrostatic pressure is greater than oncotic pressure. Plasma proteins exert hydrostatic pressure to hold fluid in the intravascular space. Filtration across the capillary wall occurs when hydrostatic pressure is greater than oncotic pressure. ,, Order the steps in the process of the thirst mechanism production. Receptors stimulate release of ADH by posterior pituitary. Person drinks and kidneys reabsorb fluid. Dehydration is detected by osmoreceptors and volume receptors. The thirst center in the hypothalamus is stimulated. The brain produces a conscious awareness of thirst. Plasma volume increases, osmolality decreases. ADH release ends, thirst mechanism subsides. Dehydration is detected by osmoreceptors and volume receptors.
