Fundamentals of Nursing Flashcards

The nurse notes a patient's urine output has been 200 mL over the past 8 hours. This finding is best described as:

Answer: Oliguria

Oliguria is defined as urine output less than 400 mL/day (or 0.5 mL/kg/hr). 200 mL over 8 hours equals 25 mL/hr, which is significantly below the normal minimum of 30 mL/hr, indicating oliguria.

When performing nasopharyngeal suctioning, the nurse should apply suction:

Answer: Only while withdrawing the catheter

Suction should only be applied while withdrawing the catheter to minimize mucosal trauma and hypoxia. Applying suction during insertion causes unnecessary tissue damage and depletes oxygen.

Which electrolyte imbalance is most commonly associated with muscle cramps, tetany, and positive Chvostek's sign?

Answer: Hypocalcemia

Hypocalcemia causes neuromuscular excitability, resulting in muscle cramps, tetany, and positive Chvostek's sign (facial muscle twitching when tapping the facial nerve). Hypercalcemia causes muscle weakness and lethargy.

A nurse is assessing a patient and finds the following: BP 90/60, HR 120, RR 24, diaphoresis, and confusion. What condition should the nurse suspect?

Answer: Hypovolemic shock

Hypovolemic shock presents with hypotension, tachycardia, tachypnea, diaphoresis, and altered mental status due to inadequate circulating blood volume. These are classic early-to-late signs of volume depletion.

The nurse is preparing to give a subcutaneous injection of insulin. At what angle should the needle be inserted?

Answer: 45–90 degrees depending on body fat

Subcutaneous injections are given at 45–90 degrees. The angle depends on the patient's body fat: 90 degrees for patients with adequate subcutaneous tissue, 45 degrees for thin patients to avoid injecting into muscle.

A nurse is caring for a patient receiving total parenteral nutrition (TPN). Which complication should the nurse monitor for most closely?

Answer: Hyperglycemia

Hyperglycemia is the most common complication of TPN because of the high dextrose concentration. Blood glucose should be monitored every 4–6 hours, and insulin may be required to maintain glucose within target range.