TIA Fundamentals of Nursing 3

Question 1

A client's urine output over 8 hours is 200 mL. The nurse should recognize this as:

Accepted Answer

Oliguria

Answer

Oliguria is defined as urine output less than 400 mL in 24 hours (or less than 30 mL/hour).

Question 2

Which action should a nurse take when a patient's peripheral IV site shows redness, warmth, and swelling?

Accepted Answer

Discontinue the IV and start a new site

Answer

Signs of phlebitis (redness, warmth, swelling) require immediate discontinuation of the IV and insertion at a new site.

Question 3

A nurse must document a medication error. Which entry is most appropriate?

Accepted Answer

'Wrong medication given; incident report filed; physician notified; patient assessed'

Answer

Accurate documentation of a medication error includes the facts, interventions taken, notifications, and patient assessment.

Question 4

Which type of isolation precaution is required for a patient with active pulmonary tuberculosis?

Accepted Answer

Airborne precautions

Answer

Pulmonary TB is transmitted via airborne particles (droplet nuclei <5 microns), requiring airborne precautions and a negative-pressure room.

Question 5

When assessing a patient's pain, which tool is most appropriate for a non-verbal patient?

Accepted Answer

FLACC Behavioral Scale

Answer

The FLACC scale assesses pain through observable behaviors (face, legs, activity, cry, consolability) in non-verbal patients.

TIA - Assessment Technologies Institute Practice Test