Next Practice and Application 2 — Questions and Answers
Question 1: A nurse is caring for a patient with heart failure who has gained 3 lbs in 24 hours. Which intervention is the priority?
- Encourage increased fluid intake
- Notify the provider immediately (Correct answer)
- Reweigh the patient in 4 hours
- Restrict sodium intake only
Correct answer: Notify the provider immediately
A weight gain of 2 or more pounds in 24 hours signals fluid retention requiring prompt provider notification.
Question 2: When performing a sterile dressing change, the nurse accidentally touches the sterile field with an ungloved hand. What is the correct action?
- Continue the procedure carefully
- Discard the contaminated supplies and start over (Correct answer)
- Apply antiseptic to the contaminated area
- Document the breach and monitor for infection
Correct answer: Discard the contaminated supplies and start over
Once the sterile field is broken, all contaminated supplies must be discarded and the procedure restarted.
Question 3: A client is prescribed warfarin. Which laboratory value should the nurse monitor to evaluate therapeutic effectiveness?
- aPTT
- Platelet count
- INR (Correct answer)
- Bleeding time
Correct answer: INR
INR (International Normalized Ratio) is the standard measure used to monitor warfarin therapy.
Question 4: A nurse is teaching a newly diagnosed type 2 diabetes patient about foot care. Which instruction is most important?
- Soak feet in hot water daily
- Inspect feet every day for cuts or sores (Correct answer)
- Apply lotion generously between the toes
- Wear open-toed shoes to reduce pressure
Correct answer: Inspect feet every day for cuts or sores
Daily foot inspection allows early detection of wounds that the patient may not feel due to peripheral neuropathy.
Question 5: A nurse receives an order for morphine 4 mg IV. The vial reads morphine 10 mg/mL. How many mL should the nurse administer?
- 0.2 mL
- 0.4 mL (Correct answer)
- 0.8 mL
- 2.5 mL
Correct answer: 0.4 mL
4 mg ÷ 10 mg/mL = 0.4 mL is the correct dose calculation.
Question 6: A postoperative patient reports pain of 8/10 and is due for analgesic medication. Before administering, the nurse should first:
- Reposition the patient for comfort
- Assess respiratory rate and sedation level (Correct answer)
- Apply ice to the surgical site
- Ask the patient to rate pain again in 30 minutes
Correct answer: Assess respiratory rate and sedation level
Opioid analgesics require respiratory and sedation assessment before administration to prevent respiratory depression.
Question 7: Which finding in a patient receiving IV potassium chloride requires the nurse to stop the infusion immediately?
- Serum potassium of 3.8 mEq/L
- Urine output of 35 mL/hour
- Burning at the IV site (Correct answer)
- Heart rate of 78 bpm
Correct answer: Burning at the IV site
Burning at the IV site indicates phlebitis or infiltration, requiring the infusion to be stopped and the site changed.
Next Practice and Application 2
A nurse is caring for a patient with heart failure who has gained 3 lbs in 24 hours.
Which intervention is the priority?