1. The nurse is caring for a client with hypovolemic shock. The family
member asks why the fluids are being warmed. What is the
Best response by the nurse?
“to prevent complications from hypothermia”
2. The nurse is caring for a newly admitted client diagnosed with acute
kidney injury. The nurse understands that the acute kidney injury is
Most likely related to a history of which condition?
Sepsis
3. The nurse is caring for a client being monitored by arterial pressure
monitoring. The nurse notes a systolic pressure of 164 mmHg. What
action should the nurse take first ?
Assess the client.
4. The nurse is caring for a client with an arteriovenous (AV) fistula.
Upon assessment, the nurse is unable to auscultate a bruit. What
action should the nurse take first?
Notify the provider
5. The nurse is assessing jugular venous pressure. In what order
should the nurse proceed with the steps in the process? [place the
steps in the correct order beginning with the first step
3.place head of bed between 30-45 degrees.
2. Have client turn head slightly to the left.
6. Shine a pen light across the neck, assess for jugular venous
distension at end of exhalation.
5.observe the highest point of pulsation in the internal jugular vein at
end exhalation.
4. Measure the vertical distance between the pulsation and the angle
of louis.
1. Add 5 cm to the measurement
Category | NR & NUR Exams |
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