4335 Midterm Exam Level 3

What is the preferred cleaning solution for CVADs?

-chlorohexidine covered in transparent semipermeable dressing or gauze

The nurse is collecting the urine specimen of a client who has an indwelling catheter. Arrange in order the procedure involved in the collection of urine.

1.Apply a clamp to the drainage tubing distal to the injection port 2.Clean the injection port with an antiseptic 3.Attach a 5-mL sterile syringe into the port 4.Aspirate the quantity of the urine required 5.Inject the urine sample into sterile specimen container 6.Remove the clamp to resume the drainage 7.Dispose of the syringe

A client with an indwelling catheter is prescribed a urinalysis test. Arrange the steps involved in the collection of the urine sample in correct order.

1.Clamp drainage tubing 2.Attach a sterile syringe 3.Aspirate the urine 4.Remove the clamp

While caring for a client with an intravenous cannula, the nurse assesses the site and finds that it red, swollen, and warm with purulent drainage near the insertion site. Which nursing intervention provides client comfort? Slowing the infusion rate temporarily Elevating the extremity slightly above level Applying cold and warm compresses frequently Cleaning the site with alcohol by expressing the drainage

Cleaning the site with alcohol by expressing the drainage

A client receiving 0.9% normal saline (NS) intravenously at keep vein open (KVO) complains of pain at the insertion site. The nurse notes that there is erythema and edema present at the access site. Based on the phlebitis scale, how should the nurse properly document the phlebitis? Grade 1 Grade 2 Grade 3 Grade 4

Grade 2

How do you measure wounds?

LxWxD Use clock method

A client is admitted to the hospital with urinary retention, and an indwelling urinary catheter is prescribed by the primary healthcare provider. What should the nurse do to help prevent the client from developing a urinary tract infection? Assess urine specific gravity. Collect a weekly urine specimen. Maintain the prescribed hydration. Empty the drainage bag once a day.

Maintain the prescribed hydration.

What are concepts that are impacted by poor tissue integrity?

Pain, fluid and electrolyte balance, thermoregulation, elimination, and infection

What is chemical debridement?

Topical enzyme debridement ex: Dakin's solution, sterile maggots, apply solution to gauze and apply to wound

What is a CVAD?

central venous access device -catheters placed in large blood vessels (subclavian vein, jugular vein) -allows vesicant drug administration -can be used for blood products and parenteral nutrition -used for limited peripheral access patients and long term access patients (chemotherapy)

What is infiltration?

complication that causes coolness, trouble flushing and med admin, swelling

What is phlebitis?

complication that causes warmness, redness,tender upon palpation

When do you use low pressure for wound irrigation?

-use on granulation tissue for new epitheliazation

When do you use high pressure for wound irrigation?

-use on necrotic tissue, large amounts of exudate -use a 20 mL syringe with 18 gauge angiocath

A client with a stage IV pressure ulcer is to receive 0.22 g of zinc sulfate by mouth. Each tablet contains 110 mg. How many tablets should the nurse administer? Record your answer using a whole number. _____ tablets

2

How does a pressure injury develop?

tissue is compressed between a bony prominence and an external surface for a long period of time causing tissue damage

A client who has had a transurethral resection of the prostate (TURP) experiences dribbling after the indwelling catheter is removed. Which is an appropriate nursing response? "I know you're worried, but it will go away in a few days." "Increase your fluid intake and urinate at regular intervals." "Limit your fluid intake and urinate when you first feel the urge." "The catheter will have to be reinserted until your bladder regains its tone."

"Increase your fluid intake and urinate at regular intervals."

What is non-cytotoxic solution?

-does not damage or kill fibroblasts -to clean pressure injuries or granulating wounds -example: normal saline, commercial wound cleaners (SafClens)

What is a cytotoxic solution?

-for use on infected wounds -can be used on granulating wounds with Biofilm -example: Dakin's, acetic acid, Sulfamylon 5% (results within 48 hours)

What is a stage 3 pressure injury?

-full thickness tissue loss -subcutaneous fat is visible, but you CANNOT see bone, tendon, or muscle yet -can have undermining and tunneling

What is an unstageable pressure injury?

-full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar -true depth and stage cannot be determined until slough/eschar is removed

Nitrofurantoin 0.1 g is prescribed for a client with a urinary tract infection. Each tablet contains 50 mg. How many tablets will the nurse administer? Record your answer using a whole number. ___

2

The nurse is providing postprocedure care for a client who had a central venous access device (CVAD) inserted. Before the CVAD is used, what procedure is performed to verify placement? Chest x-ray Flushing the line with heparin Withdrawing blood to ensure patency Chest fluoroscopy

Chest x-ray

The nurse is advising an older adult client to apply moisturizer when the skin is moist. Which physical change in the client is associated with this advice? Thinning subcutaneous layer Degeneration of elastic fibers Decreased dermal blood flow Benign proliferation of capillaries

Decreased dermal blood flow

The nurse finds that a client has reduced urinary output. Which condition would the nurse document in the client's medical record? Anuria Dysuria Oliguria Nocturia

Oliguria

What should nurse's assess about skin?

Protect the skin, detect abnormality, describe, teach about risk factors to prevent skin breakdown

A registered nurse is evaluating a new nurse who is preparing to administer intravenous fluids to a client. Which action made by the new nurse indicates the registered nurse needs to intervene? Washing hands with antibacterial soap Using chlorhexidine at the site of insertion Shaving the client's skin at the insertion site Applying skin protectant solutions at the site of insertion

Shaving the client's skin at the insertion site

A client with a known history of opioid addiction is treated for multiple stab wounds to the abdomen. After surgical repair the nurse notes that the client's pain is not relieved by the prescribed morphine injections. The nurse realizes that the failure to achieve pain relief indicates that the client is probably experiencing what phenomenon? Tolerance Habituation Physical addiction Psychological dependence

Tolerance

While reviewing the medical reports in an acute care setting, the nurse finds that the client is at risk for kidney damage and requests the healthcare provider to increase the intravenous fluid rate as a priority nursing intervention. Which finding supports the nurse's conclusion? Pulse pressure is 40 mm Hg Urine output is 25 mL per hr Systolic blood pressure is 120 mm Hg Blood osmolality is 280 milliosmoles per kg

Urine output is 25 mL per hr

A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. The nurse reviews a list of vitamins and expects that which medication may be prescribed because of its major role in wound healing? Vitamin A (retinol) Vitamin K (phytonadione) Vitamin C (ascorbic acid) Vitamin B12 (cyanocobalamin)

Vitamin C (ascorbic acid)

What is DTI?

deep tissue injury -purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying tissue from pressure

Risk factors for skin breakdown

impaired blood flow to skin, fever, sweating, incontinence, cigarette smoking, chronic illness comorbidities, immobility, friction/shear, poor nutrition/hydration, altered level of consciousness, altered sensory perception, prior history of pressure injury

What is an IV bolus?

large volume in short time

What is an IV push?

small volume in short time

Why is it important to manage a moist environment?

supports movement of epithelial cells and facilitates wound closure

The registered nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by the nursing student indicate effective learning? Select all that apply. "I will elevate the head of the client's bed to no more than 30 degrees." "I will ensure that the client is turned and repositioned at least every two hours." "I will advise the client to apply talc directly to the perineum." "I will ensure that the client's fluid intake is 2000 to 3000 mL/day." "I will teach the client to refrain from eating a high-protein and calorie diet."

"I will elevate the head of the client's bed to no more than 30 degrees." "I will ensure that the client is turned and repositioned at least every two hours." "I will ensure that the client's fluid intake is 2000 to 3000 mL/day."

A client is to receive 125 mL of intravenous (IV) fluid every hour. The drop factor of the IV tubing is 10 gtt/mL. How many drops per minute should the nurse administer? Record your answer using a whole number. ___ gtts/min

21

A client has an IV of D5W 250 mL to which 100 mg of morphine is added. The healthcare provider prescribes 14 mg of morphine per hour for end of life palliative treatment of a client . At how many mL per hour should the nurse set the intravenous pump? Record your answer using a whole number. ___mL/hr

35

The healthcare provider prescribes 1 liter of intravenous (IV) fluid to infuse over 4 hours for a client admitted for a urinary tract infection and hyponatremia. The tubing drop factor is 10 drops/mL. At what rate will the nurse infuse the medications? 20 drops/minute 34 drops/minute 42 drops/minute 60 drops/minute

42 drops/minute

During an 8-hour shift a client has a 6-oz (180 mL) cup of tea and 360 mL of water; the client vomits 100 mL, and the intravenous (IV) fluids instilled equal the urinary output. What is this client's fluid balance at the end of this 8-hour period that the nurse must document on the client's intake and output record? 240 mL 340 mL 440 mL 540 mL

440 mL

The intake and output of a client over an 8-hour period (from 0800 to 1600) is as follows: 150 mL urine voided at 0800; 220 mL urine voided at 1200; 235 mL urine voided at 1600; 200 mL gastric tube formula + 50 mL water administered initially and then repeated x 2; IV had 900 mL in the bag at 0800, and 550 mL remains in the bag at 1600. What is the difference between the client's intake and output? Record your answer using a whole number. ___ mL

495

What is the Braden scale?

A Nationally accepted pressure injury risk assessment scale designed to distinguish "at risk" patients so that prevention measures can be targeted

A nurse is preparing to administer an intravenous piggyback medication to a client who is receiving a continuous infusion of intravenous (IV) fluids. What is the priority nursing intervention? Get an additional IV infusion pump for the medication. Check the compatibility of the medication and the continuous IV solution. Disconnect the continuous IV solution while administering the piggyback medication. Flush the client's venous access device to ensure patency

Check the compatibility of the medication and the continuous IV solution.

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? Skin turgor Intake and output results Client's report about fluid intake Blood lab results

Blood lab results

A nurse is caring for a client with acute kidney injury. Which findings should the nurse anticipate when reviewing the laboratory report of the client's blood level of calcium, potassium, and creatinine? Select all that apply. Calcium: 7.6 mg/dL (1.9 mmol/L) Calcium: 10.5 mg/dL (2.6 mmol/L) Potassium 6.0 mEq/L (6.0 mmol/L) Potassium 3.5 mEq/L (3.5 mmol/L) Creatinine: 3.2 mg/dL (194 mcmol/L) Creatinine: 1.1 mg/dL (90 mcmol/L)

Calcium: 7.6 mg/dL (1.9 mmol/L) Potassium 6.0 mEq/L (6.0 mmol/L) Creatinine: 3.2 mg/dL (194 mcmol/L)

A client, receiving a potassium infusion via a peripheral intravenous (IV) site, reports a burning sensation above the IV site. What should the nurse do first? Check the IV access for a blood return Apply warm compresses to the affected extremity Slow the IV infusion until the burning sensation is gone Request an oral supplement from the primary healthcare provider

Check the IV access for a blood return

What are rationale for IV therapy?

-correct or prevent F+E imbalance -nutrition -meds -blood

What are the categories of the Braden scale?

sensory perception, moisture, activity, mobility, nutrition, friction and shear

What is evisceration?

spilling out of abdominal contents

A pain scale of 1 to 10 is used by a nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. What conclusion should the nurse make regarding the client's response to pain medication? Client has a low pain tolerance. Medication is not adequately effective. Medication has sufficiently decreased the pain level. Client needs more education about the use of the pain scale.

Medication is not adequately effective.

What is a stage 4 pressure injury?

-full thickness tissue loss with exposed bone, tendon, or muscle -slough may be present -undermining and tunneling present -can cause osteomyelitis from bone exposure

What is transparent dressing?

-impermeable to bacteria and liquid -permeable to oxygen -adhesive -protective from shear/friction -allow visualization -change every 7 days or prn

What is a Ca2+ alginate dressing?

-natural polymer of seaweed -highly absorbent -for heavy exudate -can be used in tunneling -pad or rope -maintains moist environnent -change every 3-5 days -hemostatic

What is a stage 2 pressure injury?

-partical thickness with loss of dermis presenting as a shallow open injury with red pink wound bed without slough -may looks like a serous filled blister

What is an example of intermittent meds?

-IV piggybacks (antibiotics) -IV push (morphine, digoxin, furosemide)

What is the procedure that should be followed (step-by-step) when administering blood products to patients?

-Perform a physical assessment as a baseline for during and after administration. -Make sure to have correct IV needle, catheter, or cannula. -Hand hygiene -Check for patency. -Check patient identifiers and blood product identification with another nurse. -Adjust infusion rate, as per orders from the doctor and policies, as well as patient''s needs. -Assess for reactions to transfusion. -Have UAP take vitals. -Evaluate for desired effect of blood products. -Monitor for signs of circulatory overload.

What is a implanted infusion port?

-central venous catheter connected to an implanted injection port -port is metal sheath with self-sealing silicone septum -drugs injected through skin into port -low risk of infection -requires regular flushing

What are the three main types of CVADs?

-centrally inserted catheters -peripherally inserted central catheters -implanted ports

What are indication for urinary catheterization?

1. acute urinary retention or bladder obstruction 2. accurate I/Os measurement in critically ill patients 3. periop for selected surgical procedures 4. healing of open sacral wound or perineal wound in incontinent patient 5. prolonged immobilization 6. comfort at end of life care

What are the 6 primary function of skin?

1. protection 2. sensation 3. thermoregulation 4. excretion 5. metabolism 6. body image

What is dehiscence?

bursting open of surgical wound within 2 weeks of surgery

A nurse identifies that a client's IV site is warm, red, and tender. What does the nurse conclude is the most likely cause of this finding? Rapid delivery of the infusion Chemical irritation to the tissues Allergic response to the infusion Catheter infiltration into the tissues

Chemical irritation to the tissues

Which findings in the older client are associated with a urinary tract infection (UTI)? Select all that apply. Fever Urgency Confusion Incontinence Slight rise in temperature

Confusion Incontinence Slight rise in temperature

What are concepts that impact tissue integrity?

perfusion, gas exchange, nutrition, mobility, sensory perception

What is a PICC line?

peripherally inserted central catheter -central venous catheter inserted into a vein in the arm -for long term patient (1week-6 months) -cannot use for blood draw (could contaminate)

How do you maintain a healthy wound environment?

prevent/manage infection, clean wound, remove non-viable tissue, manage exudate, maintain a moist environment, protection

What is a stage 1 pressure injury?

-intact skin with non-blanchable redness of a localized area usually over body prominence -area can be painful, firm, soft, or warmer/coolor compared to adjacent tissue

When should the Braden scale be used?

Within 4 hours of admission and once every shift

What is a hydrogel dressing?

-sheets or gel -use on dry/almost dry wounds/raw wounds -autolysis -non-adhesive -conforms -cools -no trauma removal

What is sharp/surgical debridement?

use surgical instruments such as scalpels, scissors, tweezers, etc, to remove dead tissue, nurse cannot do -use dressing that allows moisture

What is a wound VAC?

vacuum-assisted closure: negative pressure wound therapy, increases healing rate by 40%. removes fluid/drainage from the wound and allows penetration of fresh blood. keeps the wound moist.

What is mechanical debridement?

wound irrigation or whirlpool, covered in a dressing that allows moisture

What is an example of a continuous med infusion?

heparin

How does a floor nurse assess wounds?

location, shape, color, wound edges, peri-wound appearance, exudate, dressing applied

How does a wound nurse assess wounds?

location/etiology, duration, size, shape, color, type/amount of tissue, wound edges, peri-wound appearance, pain, exudate, drains

What is an example of a titrated med?

nitroglycerin, dopamine

What is a centrally inserted catheter?

-inserted into a vein in the neck, chest,or groin with tip resting in the distal end of the superior vena cava -dracon cuff stabilizes catheter and decrease risk of infection

What is a foam dressing?

-insulates -absorbs -cushions -many shapes and sizes -may decrease extra granulation -may self attach with border

What is IV access used for?

-maintain F+E balance -meds -blood or blood products -parenteral nutrition

What is a hydrocolloid dressing?

-occlusive -impearmeable -moisture retentive -autolysis (self debridement) -use for low to moderate exudate -lasts 3-7 days or until edges start to come up

What are some considerations before inserting an IV?

-what is their dominant hand? -avoid edema/bruising -avoid side of mastectomy -avoid side of dialysis shunt arm -avoid lower extremities on adults -start distal and work proximal -avoid joints -avoid interfering with ADLs

A nurse withholds a prescribed opioid medication from a client requesting to be treated for intractable pain because the nurse fears the client will become addicted. In this situation, the nurse is adhering to which ethical principle? Veracity Autonomy Paternalism Beneficence

Paternalism

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. Which data should the nurse use to determine a client's score on this scale? Select all that apply. Age Anorexia Hemiplegia History of diabetes Urinary incontinence

Anorexia Hemiplegia History of diabetes Urinary incontinence

To begin the administration of total parenteral nutrition (TPN), a client has a right subclavian central venous access device inserted. Immediately after insertion of the catheter, what is the priority nursing action? Obtain a chest x-ray to determine placement. Auscultate the lungs to evaluate breath sounds. Draw a blood sample to assess blood glucose level. Assess the right upper extremity for neurologic deficits.

Auscultate the lungs to evaluate breath sounds.

What is the etiology for the development of pressure ulcers in an 80-year-old client? Atrophy of the sweat glands Decreased subcutaneous fat Stiffening of the collagen fibers Degeneration of the elastic fibers

Decreased subcutaneous fat

A client is hospitalized with pressure ulcers. Which task could be delegated to an unlicensed nursing professional (UNP)? Select all that apply. Empty wound drainage containers. Report changes in wound appearance. Apply prescribed dressings and medications. Assess and record data about wound appearance. Choose dressings and therapies for wound treatment.

Empty wound drainage containers. Report changes in wound appearance.

A client with a renal disorder is scheduled for an intravenous pyelogram (IVP). Which interventions should the nurse undertake prior to the procedure? Select all that apply. Ensure that the consent form is signed Assess the client for iodine sensitivity Have the client remove all metal objects Administer an enema or cathartic to the client Instruct the client to lie still during the procedure

Ensure that the consent form is signed Assess the client for iodine sensitivity Administer an enema or cathartic to the client

While assessing the client's skin, a nurse notices a skin condition, the pathophysiology of which involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation. Which condition is associated with this client? Pallor Vitiligo Cyanosis Erythema

Erythema

Why is it important to manage exudate?

Excessive exudate provides an environment that supports bacterial growth, macerates the peri-wound skin, and slows the healing process

After a prostatectomy the client reports that the urinary catheter tubing is pulling too tightly on the leg. The nurse observes that the indwelling catheter tubing is taut and is taped properly to the thigh. Which action should the nurse take? Explain that the traction helps control bleeding. Adjust tension on the catheter to relieve pressure. Untape the catheter and retape it closer to the urinary meatus. Assess the degree of tension on the catheter and contact the primary healthcare provider.

Explain that the traction helps control bleeding.

Which ethical principle is violated when the nurse forgets to give a painkiller to a client as promised? Justice Fidelity Veracity Nonmaleficence

Fidelity

The nurse is preparing to insert an intravenous catheter in a thin, emaciated client who is scheduled to begin intravenous fluid therapy. Which interventions should the nurse follow to provide high-quality care? Select all that apply. Insert an 18 gauge IV catheter Change the intravenous line every 7 days Flush the intravenous line with normal saline Insert the intravenous catheter in the client's femur Stop the insertion procedure when there is a break in technique

Flush the intravenous line with normal saline Stop the insertion procedure when there is a break in technique

A nurse is caring for a client with quadriplegia. Which nursing intervention will decrease the occurrence of pressure ulcers? Avoiding leg massages Frequent repositioning of client Increasing fiber content in food Encouraging weight-bearing exercises

Frequent repositioning of client

A client is receiving total parenteral nutrition (TPN) through a central venous access device. The nurse discovers that the TPN bag is empty and the next bag has not been received yet from the pharmacy. What is the most appropriate action for the nurse to take? Perform a finger stick glucose test and call the primary healthcare provider with the results. Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag. Discontinue the infusion and flush the IV line with saline solution until the next TPN bag is ready. Hang a bag of 5% dextrose at a keep-open rate and notify the nurse manager of the occurrence.

Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag.

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? Incontinence and inability to move independently Periodic diaphoresis and occasional sliding down in bed Reaction to just painful stimuli and receiving tube feedings Adequate nutritional intake and spending extensive time in a wheelchair

Incontinence and inability to move independently

The urinalysis report of a client reveals pH to be 6, turbidity-cloudy, specific gravity of 1.02, and 0.7 mg/dL of proteins. What does the primary healthcare provider infer from the findings? Infection Glomerular disorder Acid-base imbalance Decreased kidney perfusion

Infection

While caring for a client with urinary tract infection, the nurse manager delegated the work of administering oral medications. Which delegatee would be appropriate for this task? Select all that apply. Registered nurse (RN) Patient care associate (PCA) Licensed practical nurse (LPN) Licensed vocational nurse (LVN) Unlicensed assistive personnel (UAP)

Licensed practical nurse (LPN) Licensed vocational nurse (LVN)

A nurse is assisting a primary healthcare provider with insertion of a central venous access catheter. Which equipment will the nurse plan to have in the room to help prepare the skin? Select all that apply. Mask Gown Betadine Checklist Sterile gloves

Mask Gown Checklist Sterile gloves

Which personal protective equipment will the nurse wear when providing central venous access device site care? Double sterile gloves Mask and sterile gloves Hair cap and sterile gloves Mask, gown, and double gloves

Mask and sterile gloves

After a transurethral prostatectomy, a client returns to the postanesthesia care unit with a three-way indwelling catheter with continuous bladder irrigation. Which nursing action is the priority? Observing the suprapubic dressing for drainage Maintaining the client in the semi-Fowler position Monitoring for bright red blood in the drainage bag Encouraging fluids by mouth as soon as the gag reflex returns

Monitoring for bright red blood in the drainage bag

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant enterococci (VRE). After notifying the healthcare provider, which action should the nurse take to decrease the risk of transmission to others? Insert a urinary catheter. Initiate droplet precautions. Move the client to a private room. Use a high-efficiency particulate air (HEPA) respirator during care.

Move the client to a private room.

What are the primary complications associated with IV therapy?

Primary complications are infection, embolism, pneumothorax, catheter migration, catheter occlusion. Embolism can arise from air going into circulation or the catheter breaks. Catheter migration can arise from bad suturing or forceful flushing. Catheter occlusion can happen if the catheter if kinked, it is pressing up against the wall of the vessel, if there is thrombosis, or there is precipitate buildup in the lumen.

A state's Nurse Practice Act (Canada: Provincial/Territorial Registered Nurse Act) does not allow a registered nurse (RN) to suture wounds. The primary healthcare provider offers to teach the RN how to suture and tells the RN that minor wounds may be sutured without supervision. Which action should the nurse take? Refuse to suture wounds Follow the primary healthcare provider's instructions Agree to suture wounds in the primary healthcare provider's presence Report the situation to the state board of nursing (Canada: Provincial/Territorial RN Association)

Refuse to suture wounds

What is autolytic debridement?

Removal of dead tissue via lysis of necrotic tissues by WBC and natural enzymes, covered in a dressing that allows moisture (hydrocolloid)

A client is receiving oxycodone postoperatively for pain. The healthcare provider's prescription indicates that the dose should be administered every 3 hours for eight doses. What should the nurse assess before administering each dose of oxycodone? Respiratory rate and level of consciousness Color, character, and amount of urine output Intravenous site and patency of the intravenous catheter Amount and character of drainage in the portable drainage system

Respiratory rate and level of consciousness

What information should the nurse provide for a client who is discharged from the health care facility with a surgical wound? Select all that apply. Potential drug-drug interactions Skill to care for the surgical wound Safe and effective use of medications List of appropriate community resources Need to report any change in the surgical area

Skill to care for the surgical wound Safe and effective use of medications List of appropriate community resources

What needs to be documented about IV sites?

The date and time the IV was inserted, the name of the vein accessed, the gauge used, the length of catheter used, the number of attempts needed to access IV site, what drug or fluid the patient is receiving and the infusion rate, the patients pain levels and reaction to this procedure all need to be documented, ending with a signature.

A nurse notes that an infant with a diagnosis of failure to thrive who has been receiving tube feedings for 3 days has very dry skin and mucous membranes. The nurse verifies that all feedings have been retained, but the daily urine output is consistently 250 mL, and the infant has lost weight. What does the nurse conclude? This is an expected finding in an infant with failure to thrive. The infant is dehydrated, and the fluid intake needs to be increased. This finding is a reflection of the infant's inability to absorb nutrients. The infant is undernourished, and a higher caloric intake will be required.

The infant is dehydrated, and the fluid intake needs to be increased

Which nursing action is necessary if nerve damage is suspected during an intravenous catheter insertion? The nurse should clean the exit site with alcohol. The nurse should temporarily slow the infusion rate. The nurse should immediately stop the drug infusion and hang isotonic solution. The nurse should immediately stop the insertion if the client reports extreme pain.

The nurse should immediately stop the insertion if the client reports extreme pain.

Which of the following nursing interventions promotes perfusion and healing of the surgical wound for an older adult? The nurse should minimize the use of tape on the skin. The nurse should keep the client adequately hydrated. The nurse should change the dressings as soon as they get wet. The nurse should provide rest for the client throughout the day.

The nurse should keep the client adequately hydrated.

A 7-month-old girl is to be catheterized so a sterile urine specimen may be obtained. One of the infant's parents expresses fear that this procedure may traumatize the baby psychologically. How should the nurse provide reassurance? The fear is justified, and the nurse should obtain a "clean catch" specimen. Parents have a right to refuse the catheterization, and the concerns are realistic. Although the concern is appropriate, the need for a sterile specimen is the priority. The procedure is uncomfortable, but there should not be a damaging long-term effect.

The procedure is uncomfortable, but there should not be a damaging long-term effect.

A 7-year-old child is brought to the emergency department with a puncture wound on the sole. It is determined that the child's history of immunizations is uncertain, and tetanus immune globulin and tetanus vaccine are prescribed and administered. What is the priority reason for using tetanus immune human globulin instead of tetanus antitoxin? It is as effective as the antitoxin. It is safe to give to everyone who needs it. The risk for an anaphylactic reaction is less. Skin tests are not needed with the human globulin

The risk for an anaphylactic reaction is less.

A client comes to the emergency department because of minimal urinary output despite drinking adequate fluid. The client's blood pressure is 190/94 mm Hg. For what additional clinical manifestation associated with this data should the nurse assess the client? Thirst Weight gain Urinary retention Urinary hesitancy

Weight gain