Acute - Module 5

While reviewing a client's laboratory results, a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions should the nurse take? A) Prepare the client for hemodialysis. B) Initiate diuretic therapy. C) Administer phosphate. D) Implement seizure precautions.

Answer: D. A) Hemodialysis is administered to treat hypercalcemia, not hypocalcemia. B) Diuretic therapy can further decrease the client's calcium level. C) Administering phosphate can further decrease the client's calcium level. D) The client is at risk for seizures due to low excitation threshold as a result of a decreased calcium level. The nurse should initiate seizure precautions to prevent injury.

A nurse is providing teaching for a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates an understanding of the teaching? A) "I will wait until my pain is at least six out of ten before I use the PCA." B) "I should conserve energy by limiting my physical activity." C) "I will limit my daily fluid intake to two to three glasses." D) "I will use the incentive spirometer every hour."

Answer: D. A) The nurse should encourage the client to use the PCA when she feels acute pain to prevent the pain from worsening. B) The nurse should encourage the client to ambulate and change positions frequently to prevent postoperative complications. C) Dehydration can cause metabolic acidosis. The nurse should encourage the client to take in approximately 2,200 mL of fluid daily. This includes fluid intake of six to eight glasses containing 240 mL each, plus liquids obtained from eating solid foods. Limiting her fluid intake to two to three 8 oz glasses would not meet the client's total daily intake needs. D) Respiratory depression and limited chest expansion are both causes of respiratory acidosis. Therefore, using an incentive spirometer will promote adequate chest expansion.

A nurse is teaching nutritional strategies to a client who has a low serum calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching? A) "I need to avoid foods with vitamin D because I am allergic to milk." B) "I will eat more cheese because I can't drink milk." C) "I will stop taking my calcium supplements if they irritate my stomach." D) "I will add broccoli and kale to my diet."

Answer: D. A) Vitamin D is necessary for calcium absorption and is unlikely to trigger an allergic reaction in a client who has a dairy allergy. B) Cheese is a dairy product. If the client is allergic to milk, she also will be allergic to cheese. C) The nurse should recommend that the client prevent gastric upset by taking the calcium supplements with food. D) The nurse should recommend that the client consume broccoli and kale, which are good sources of calcium, as alternatives to dairy products.

The nurse is caring for a client with long standing emphysema and respiratory acidosis. For which of these compensatory mechanisms will the nurse assess? A) Decreased rate of breathing. B) Increased loss of bicarbonate through the kidney. C) Decreased depth of breathing. D) Decreased loss of bicarbonate through the kidney.

Answer: D. The compensatory mechanism the nurse anticipates is present in the client with long standing emphysema and respiratory acidosis is conservation of bicarbonate. A partially compensated respiratory acidosis will typically result.Increased loss of bicarbonate through the kidney, decreased rate, and depth of breathing will promote acidosis.

A client with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide? A) Assessment of muscle tone and strength. B) Education about potassium-rich foods. C) Instruction on the proper use of drugs. D) Measurement of the client's weight

Answer: D. The intervention that can be delegated to the home health aide is to measure the client's weight. Measuring the client's intake and output and reporting it to the RN helps determines if the plan of care has been effective.Assessment, education, and instruction are higher-level nursing actions within the scope of practice of the professional nurse.

A nurse is providing teaching for a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching? A) "If my stockings feel tight, I'll just roll them down for a while." B) "I'll put on my elastic stockings at the first sign of swelling." C) "When I sit down to watch television, I'll be sure to put my feet up." D) "It's okay to cross my legs as long as it's for less than an hour."

Answer; C. A) The client should not roll the stockings down because the rolled part can become a constricting band around the leg which can impede circulation. B) The client should don graduated compression stockings upon awakening and remove them at bedtime. Wearing the stockings throughout the day prevents swelling of the extremities and improves circulation. C) Venous insufficiency makes it difficult for blood flow to return to the heart. Elevating her feet will increase the return. The client should elevate her feet for at least 20 min several times per day. D) The client should not cross her legs. Doing so can further impair circulation of the lower extremities.

The nurse is documenting peripheral venous catheter insertion for a client. What does the nurse include in the note? (Select all that apply). A) Client's name and hospital number. B) Client's response to the insertion. C) Date and time inserted. D) Type and size of device. E) Type of dressing applied. F) Vein used for insertion.

Answer: B, C, D, E, F. The client's ability to adapt to interventions, such as IV insertion, should be noted when the intervention is performed. The date and time of the insertion are important data. IV sites need to be routinely monitored and changed at prescribed intervals per facility policy. It is important to note the device used (often the brand name is given), as well as all specifics such as needle or cannula length, gauge, and material (Teflon). It is necessary to describe the dressing applied, and the vein used should be noted.The client's name and hospital number should be on the medical record, but the nurse makes certain that the information is recorded in the correct medical record.

The nurse is caring for a client receiving lactated Ringer's solution IV for rehydration. Which assessments will the nurse monitor during intravenous therapy? (Select all that apply). A) Blood serum glucose. B) Blood pressure. C) Pulse rate and quality. D) Urinary output. E) Urine specific gravity

Answer: B, C, D, E. The two most important areas to monitor during rehydration are pulse rate and quality and urine output. In addition, decreasing specific gravity of urine is also an indication of rehydration. Blood pressure is another important vital sign to monitor during rehydration.Blood glucose changes do not have a direct relation to a client's hydration status; lactated ringers are free from glucose.

A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurse include in the teaching as containing the lowest amount of magnesium? A) 1 cup bran cereal. B) 1 large hard-boiled egg. C) 1/2 cup almonds. D) 1 cup cooked spinach.

Answer: B. A) One cup of bran cereal contains 112 mg of magnesium. Therefore, the nurse should include a different food as containing the lowest amount of magnesium. B) One large hard-boiled egg contains 5 mg of magnesium. Therefore, the nurse should recommend this food as containing the lowest amount of magnesium. C) One-half cup of almonds contains 193 mg of magnesium. Therefore, the nurse should include a different food as containing the lowest amount of magnesium. D) One cup of cooked spinach contains 157 mg of magnesium. Therefore, the nurse should include a different food as containing the lowest amount of magnesium.

Which of the following symptoms would the nurse anticipate in a patient with right-sided heart failure? (Select all that apply.) A) Pulmonary congestion. B) Shortness of breath. C) Neck vein distension. D) Lower Extremity Edema. E) A third heart sound.

C, D

_____: Increased plasma volume; or fluid excess.

Hypervolemia

_____: Describes fluids with osmolarities of less than 270 mOsm/L. Hypo-osmolar fluids have a lower osmotic pressure than isosmotic fluids, and water tends to be pulled from the hypo-osmotic fluid space into the isosmotic fluid space until an osmotic balance occurs.

Hypo-osmotic (hypotonic)

_____: A total serum calcium level below 9.0 mg/dL or 2.25 mmol/L.

Hypocalcemia

_____: The slow infusion of isotonic fluids into subcutaneous tissue.

Hypodermoclysis (clysis)

_____: A decreased serum potassium level; a common electrolyte imbalance.

Hypokalemia

_____: A low serum magnesium level, usually lower than 1.8 mEq/L or 0.74 mmol/L.

Hypomagnesemia

_____: A serum sodium level below 136 mEq/L (mmol/L).

Hyponatremia

_____: A state in which gas exchange at the alveolar-capillary membrane is inadequate so that too little oxygen reaches the blood and carbon dioxide is retained.

Hypoventilation

A patient is admitted to a telemetry unit with a new diagnosis of atrial fibrillation (AF). The patient states, "I feel fine, this rhythm won't hurt me." Which nursing response is appropriate? A) "AF can cause clots to form from the irregular blood flow in the heart." B) "It's important to monitor the AF for 24 hours." C) "AF leads the death of the heart muscle." D) "AF can cause cardiac output to increase."

A

A patient who smokes asks the nurse, "Smoking just hurts my lungs, not my heart, right?" Which nursing response is appropriate? A) "Smoking is a major risk factor for coronary artery disease and peripheral vascular disease." B) "You are correct, smoking only hurts the lungs." C) "The primary impact of smoking is only on the heart." D) "What concerns you most about smoking?"

A

_____: A substance that releases hydrogen ions when dissolved in water. The strength of an acid is measured by how easily it releases hydrogen ions in solution.

Acid

_____: An acid-base imbalance in which blood pH is below normal.

Acidosis

_____: An unintended harmful reaction to an administered drug.

Adverse Drug Event (ADE)

_____: An acid-base imbalance in which blood pH is above normal.

Alkalosis

_____: Infusion therapy pump generally used with a home care patient to allow a return to his or her usual activities while receiving infusion therapy.

Ambulatory pump

_____: Lacking adequate oxygen.

Anaerobic

_____: Ion that has a negative charge.

Anion

A nurse is reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis? A) pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L. B) pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 24 mEq/L C) pH 7.51, PaO2 94 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L D) pH 7.36, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 26 mEq/L

Answer: A. A) A pH below 7.35 is an indication of acidosis. HCO3- below 22 mEq/L is an indication of metabolic acidosis. B) A pH above 7.45 is an indication of alkalosis. C) A pH above 7.45 is an indication of alkalosis. D) This pH value is within the expected reference range.

A nurse is reviewing the laboratory report of a client who has fluid volume excess. Which of the following laboratory values should the nurse expect? A) Hematocrit 34%. B) BUN 25 mg/dL. C) Urine specific gravity 1.050. D) Hemoglobin 20 g/dL.

Answer: A. A) The nurse should identify that a client who has fluid volume excess can have a hematocrit level that is below the expected reference range of 37 to 47% for females or 42 to 52% for males. Fluid volume excess can cause hemodilution and a decreased hematocrit level. B) The nurse should identify that a client who has dehydration can have a BUN that is above the expected reference range of 10 to 20 mg/dL. Fluid volume excess can cause a decrease in BUN. C) The nurse should identify that a client who has dehydration can have a urine specific gravity that is above the expected reference range of 1.010 to 1.025. Fluid volume excess can cause a decrease in urine specific gravity. D) The nurse should identify that a client who has dehydration can have a hemoglobin level that is above the expected reference range of 12 to 16 g/dL for females or 14 to 18 g/dL for males. Fluid volume excess can cause hemodilution and a decreased hemoglobin level.

Which of these findings causes the critical care nurse to notify the primary care provider (PCP) for evaluation for intubation? A) Increasing somnolence. B) Pallor. C) Deep respirations. D) Bounding pulse.

Answer: A. The critical nurse notifies the primary health care provider for somnolence consistent with worsening respiratory acidosis. Other client findings related to worsening respiratory acidosis caused by CO2 retention include: headache, fatigue, lethargy, and decreased respirations which may require intubation and mechanical ventilation.Pallor is a sign of hypoxemia, lack of oxygen to the tissues. As pallor may occur with anemia, this finding alone does not represent a need for intubation. Deep respirations and bounding pulse are not consistent with respiratory acidosis.

The nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters does the nurse choose most often? A) Back of the hand for an older adult. B) Cephalic vein of the forearm. C) Lower arm on the side of a radical mastectomy. D) Subclavian vein.

Answer: B. The cephalic vein of the forearm is the insertion site chosen most often. For same-day surgery, the cephalic or basilic vein allows insertion of a larger IV catheter while allowing movement of the arm without impairing intravenous flow.Peripheral venous catheters should never be inserted into the back of the hand in an older adult because the veins are brittle. Peripheral venous catheters should never be inserted into the lower arm on the same side as a radical mastectomy because they interfere with limited circulation. Catheters are typically inserted into the subclavian vein by the health care provider, not by the nurse

A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving regular insulin by continuous IV infusion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider? A) Urine output of 30 mL/hr. B) Blood glucose of 180 mg/dL C) Serum potassium 3.0 mEq/L D) BUN 18 mg/dL

Answer: C. A) Urine output of 30 mL/hr is within the expected reference range. The nurse does not need to report this finding to the provider. B) A blood glucose level of 200 mg/dL or less is an indication that the client's diabetic ketoacidosis is resolving and is within the expect reference range for a casual glucose level. Therefore, the nurse does not need to report this finding to the provider. C) This serum potassium level is below the expected reference range. Hypokalemia is a serious complication that can occur when a client who has diabetic ketoacidosis is receiving insulin to treat the condition. The nurse should report this finding to the provider. D) A BUN of 18 mg/dL is within the expected reference range. A BUN of 30 mg/dL or greater can occur due to dehydration for a client who has diabetic ketoacidosis.

The nurse is assessing a client with a sodium level of 118 mEq/L (118 mmol/L). Which activity takes priority? A) Monitoring urine output. B) Encouraging sodium rich fluids and foods throughout the day. C) Instructing the client not to ambulate without assistance. D) Assessing deep tendon reflexes.

Answer: C. Safety is the priority in this instance. Instructing the client not to ambulate without assistance is the priority for a client with a sodium level of 118 mEq/L (118 mmol/L). This sodium level denotes severe hyponatremia which makes depolarization slower and cell membranes less excitable. This is manifested as general muscle weakness which is worse in the legs and arms. Additionally, this client may have developed confusion from cerebral edema.Monitoring urine output needs to be done but is not the priority action in this situation. Generally, fluid is restricted, rather than sodium rich foods offered, to minimize the hyponatremia. While the nurse may assess muscle strength and deep tendon reflex responses, safety is the priority.

A client is brought to the emergency department for increasing weakness and muscle twitching. The laboratory results include a potassium level of 7.0 mEq/L (7.0 mmol/L). Which assessments does the nurse make? (Select all that apply). A) History of liver disease. B) Use of salt substituet. C) Use of an ACE inhibitor. D) Potassium-sparing diuretics. E) Prescription for insulin

Answer; B, C, D. When caring for an ED client with an elevated potassium level, the nurse needs to assess the client for any use of salt substitutes, any use of ACE inhibitors or potassium-sparing diuretics, as well as kidney disease.History of liver disease does not increase the client's potassium level. Insulin, which moves potassium into the cell, can be used as a treatment for hyperkalemia, in addition to diabetes. Taking insulin would lower the potassium level.

"The nurse is caring for four clients with a history of hypertension. Which client would require intervention? A) 40-year-old with chronic kidney disease, BP 138/80. B) 58-year-old on diuretics, BP 160/80 C) 28-year-old with LDL-C 140 mg/dL, BP 114/84 D) 30-year-old with pre-eclampsia, BP 120/68"

B

_____: A substance that binds (reduces) free hydrogen ions in solution. Strong bases bind hydrogen ions easily; weak bases bind less readily.

Base

_____: Health care-acquired bloodstream infection caused by the presence of any type of intravenous catheter.

Catheter-related bloodstream infection (CRBSI)

_____: An nationally recognized set of evidence-based interventions to prevent CR-BSIs.

Catheter-related bloodstream infection (CRBSI) prevention bundle

_____: Ion that has a positive charge.

Cation

_____: IV therapy in which a vascular access device (VAD) is placed in a central blood vessel, such as the superior vena cava.

Central IV therapy

_____: Health care-acquired bloodstream infection caused by the presence of a central intravenous line.

Central line-associated bloodstream infection (CLABSI)

_____: The primary cause of hyponatremia in the neurosurgical population; characterized by hyponatremia, decreased serum osmolality, and decreased blood volume. It is thought to result from the extrarenal influence of atrial natriuretic factor.

Cerebral salt wasting (CSW)

_____: A condition in which increased tissue pressure in a confined anatomic space causes decreased blood flow to the area, leading to hypoxia and pain.

Compartment syndrome

_____: The means of producing compensation. Also called adaptive mechanism.

Compensatory mechanism

What is the most common symptom when a patient is diagnosed with hypertension? A) Headache. B) Slurred speech. C) Fainting and dizziness. D) Hypertension is often asymptomatic.

D

_____: Fluid intake less than what is needed to meet the body's fluid needs.

Dehydration

_____: The amount of pressure/force against the arterial walls during the relaxation phase of the heart.

Diastolic blood pressure

_____: The spontaneous, free movement of particles (solute) across a permeable membrane down a concentration gradient; that is, from an area of higher concentration to an area of lower concentration.

Diffusion

_____: A condition in which the hydrostatic pressure is not the same in the two fluid spaces on either side of a permeable membrane.

Disequilibrium

_____: Tissue swelling as a result of the accumulation of excessive fluid in the interstitial spaces.

Edema

_____: A substance in body fluids that carries an electrical charge. Also called an ion.

Electrolyte

_____: Term for the space between the dura mater and vertebrae; it consists of fat, connective tissue, and blood vessels.

Epidural

_____: The portion of total body water (about one third) that is in the space outside the cells. This space also includes interstitial fluid, blood, lymph, bone, and connective tissue water, and the transcellular fluids.

Extracellular fluid (ECF)

_____: Escape of fluids or drugs into the subcutaneous tissue; a complication of intravenous infusion.

Extravasation

_____: Diffusion across a cell membrane that requires the assistance of a transport system or membrane-altering system

Facilitated diffusion (facilitated transport)

_____: The movement of fluid from the space with higher hydrostatic pressure through the membrane into the space with lower hydrostatic pressure.

Filter

_____: The movement of fluid through a cell or blood vessel membrane because of hydrostatic pressure differences on both sides of the membrane.

Filtration

_____: An excess of body fluid. Also called overhydration.

Fluid overload

_____: Elevated plasma levels of hemoglobin, hematocrit, serum osmolarity, glucose, protein, blood urea nitrogen, and electrolytes that occur when only the water is lost and other substances remain.

Hemoconcentration

_____: Excessive water in the vascular space.

Hemodilution

_____: A drug that has an increased risk for causing patient harm if given in error.

High-alert drug

_____: A safeguard or control mechanism within the human body that prevents dangerous changes.

Homeostatic mechanism

_____: The force of the weight of water molecules pressing against the confining walls of a space.

Hydrostatic pressure

_____: A total serum calcium level above 10.5 mg/dL or 2.75 mmol/L, which can cause fatigue, anorexia, nausea and vomiting, constipation, polyuria, and serious damage to the urinary system.

Hypercalcemia

_____: Increased arterial carbon dioxide levels.

Hypercapnia

_____: An elevated level of potassium in the blood.

Hyperkalemia

_____: A serum magnesium level above 2.1 mEq/L.

Hypermagnesemia

_____: An excessive amount of sodium in the blood.

Hypernatremia

_____: Describes fluids with osmolarities (solute concentrations) greater than 300 mOsm/L; hyperosmotic fluids have a greater osmotic pressure than do isosmotic fluids and tend to pull water from the isosmotic fluid space into the hyperosmotic fluid space until an osmotic balance occurs. Also called hypertonic.

Hyperosmotic (Hypertonic)

_____: A serum phosphorus level above 4.5 mg/dL.

Hyperphosphatemia

_____: A state of increased rate and depth of breathing.

Hyperventilation

_____: Abnormally decreased volume of circulating fluid in the body; fluid deficit.

Hypovolemia

_____: Decreased blood oxygen levels; hypoxia.

Hypoxemia (hypoxemic)

_____: The surgical creation of an opening into the ileum, usually by bringing the end of the terminal ileum through the abdominal wall and forming a stoma, or ostomy

Ileostomy

_____: Not porous

Impermeable

_____: A device used for long-term or frequent infusion therapy; consists of a portal body, a dense septum over a reservoir, and a catheter that is surgically implanted on the upper chest or upper extremity.

Implanted port

_____: The leakage of IV solution into the tissues around the vein.

Infiltration

_____: A solution that is infused into the body.

Infusate

_____: The delivery of parenteral medications and fluids through a variety of catheter types and locations using multiple techniques and procedures, such as intravenous and intra-arterial therapy to deliver solutions into the vascular system.

Infusion therapy

_____: Water loss from the skin, lungs, and stool that cannot be controlled.

Insensible water loss

_____: A portion of the extracellular fluid that is between cells, sometimes called the third space.

Interstitial fluid

_____: The use of catheters placed into arteries to obtain repeated arterial blood samples, to monitor various hemodynamic pressures continuously, and to infuse chemotherapy agents or fibrinolytics.

Intra-arterial infusion therapy

_____: The portion of total body water (about two thirds) that is found inside the cells.

Intracellular fluid (ICF)

_____: Infusion therapy that is delivered to the vascular network in the long bones.

Intraosseous (IO) therapy

_____: The administration of antineoplastic agents into the peritoneal cavity.

Intraperitoneal (IP) infusion therapy)

_____: Referring to the spine

Intrathecal

_____: A substance found in body fluids that carries an electrical charge. Also called electrolyte.

Ion

_____: An overresponse to stimuli.

Irritability

_____: Having the same osmotic pressures. Also called normotonic.

Isosmotic (isotonic)

_____: A type of breathing that occurs when excess acids caused by the absence of insulin increase hydrogen ion and carbon dioxide levels in the blood. This state triggers an increase in the rate and depth of respiration in an attempt to excrete more carbon dioxide and acid.

Kussmaul respiration

_____: An individual who has a low reading level ability.

Literacy challenged

_____: A mineral that forms a cation when dissolved in water.

Magnesium (Mg2+)

_____: A type of catheter that is 6 to 8 inches long and inserted through the veins of the antecubital fossa; used in therapies lasting from 1 to 4 weeks.

Midline catheters

_____: A group of degenerative myopathies characterized by weakness and atrophy of muscle without nervous system involvement. At least nine types have been clinically identified and can be broadly categorized as slowly progressive or rapidly progressive.

Muscular dystrophy (MD)

_____: A type of catheter, usually 15 to 20 cm long and with dual or triple lumens, that is inserted through the subclavian vein in the upper chest or through the jugular veins in the neck using sterile technique.

Nontunneled percutaneous central venous catheters (CVCs)

_____: The minimum amount of urine per day needed to dissolve and excrete toxic waste products.

Obligatory urinary output

_____: A federal agency that protects workers from injury or illness at their place of employment.

Occupational Safety and Heath Administration (OSHA)

_____: A decrease in blood pressure (20 mm Hg systolic and/or 10 mm Hg diastolic) that occurs during the first few seconds to minutes after changing from a sitting or lying position to a standing position.

Orthostatic (postural) hypotension

_____: The number of milliosmoles in a kilogram of solution.

Osmolality

_____: The number of milliosmoles in a liter of solution.

Osmolarity

_____: The movement of a solvent across a semipermeable membrane (a membrane that allows the solvent but not the solute to pass through) from a lesser to a greater concentration.

Osmosis

_____: Absence of peristalsis.

Paralytic ileus

_____: Abnormal or unusual nerve sensations of touch, such as tingling and burning.

Paresthesia

_____: IV therapy in which a vascular access device (VAD) is placed in a peripheral vein, usually in the arm.

Peripheral IV therapy

_____: A long catheter inserted through a vein of the antecubital fossa (inner aspect of the bend of the arm) or the middle of the upper arm.

Peripherally inserted central catheter (PICC)

_____: The quality of being porous.

Permeable

_____: Inflammation of a vein, which can predispose patients to thrombosis.

Phlebitis

_____: Openings or spaces.

Pores

_____: A hormone that is produced in the juxtaglomerular complex of the kidney and that helps regulate blood flow, glomerular filtration rate, and blood pressure. Renin is secreted when sensing cells (macula densa) in the distal convoluted tubule sense changes in blood volume and pressure

Renin

_____: A short conduit that is attached to the primary administration set at a Y-injection site and is used to deliver intermittent medications.

Secondary administration set (piggyback set)

_____: A catheter that consists of a plastic cannula built around a sharp stylet for venipuncture, which extends slightly beyond the cannula and is advanced into the vein.

Short peripheral catheters

_____: An infusion pump with dosage calculation software.

Smart pumps

_____: A mineral that is the major cation in the extracellular fluid and maintains extracellular fluid (ECF) osmolarity.

Sodium (Na+)

_____: A particle dissolved or suspended in the water portion (solvent) of body fluids; a solution consists of a solute and a solvent.

Solute

_____: The water portion of fluids.

Solvent

_____: Term for the space between the arachnoid mater and pia mater of the spinal cord. Also called subarachnoid.

Subarachnoid (subarachnoid space)

_____: Infusion therapy that is delivered under the skin when patients cannot tolerate oral medications, when intramuscular injections are too painful, or when vascular access is not available.

Subcutaneous infusion therapy

_____: Pump for infusion therapy that uses a battery-powered piston to push the plunger continuously at a selected mL/hr rate; limited to small-volume continuous or intermittent infusions.

Syringe pump

_____: The amount of pressure/force generated by the left ventricle to distribute blood into the aorta with each contraction of the heart.

Systolic blood pressure

_____: Continuous contractions of muscle groups; hyperexcitability of nerves and muscles.

Tetany

_____: The formation of a blood clot (thrombus) within a blood vessel.

Thrombosis

_____: Any of the fluids in special body spaces, including cerebrospinal fluid, synovial fluid, peritoneal fluid, and pleural fluid.

Transcellular fluid

_____: A type of catheter used for long-term infusion therapy in which a portion of the catheter lies in a subcutaneous tunnel, separating the points where the catheter enters the vein from where it exits the skin.

Tunneled central venous catheters

_____: A catheter; a plastic tube placed in a blood vessel to deliver fluids and medications.

Vascular access device (VAD)

_____: Drugs that cause severe tissue damage if they escape into the subcutaneous tissue; also referred to as vesicants.

Vesicant medications

_____: Chemicals or drugs that cause tissue damage on direct contact or extravasation.

Vesicants

For which clients is it most important for the nurse to check frequently for dehydration? (Select all that apply.) A) 24-year-old athlete who is NPO for 4 hours awaiting an appendectomy B) 42-year-old client who has diabetes insipidus C) 56-year-old client recently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) D) 68-year-old client with poorly controlled type 2 diabetes mellitus E) 72-year-old client taking 80 mg of furosemide orally every day F) 74-year-old undergoing a bowel preparation with multiple enemas before colon surgery

"ANS: B, D, E, F. The 24-year-old athlete is highly unlikely to become dehydrated from being NPO for 4 hours. The client with SIADH retains water and is at greater risk for fluid overload rather than dehydration. The client with diabetes insipidus is at great risk for dehydration because the kidneys do not respond to ADH or to high blood osmolarity. Urine output is huge and the adult can dehydrate quickly. Any adult with type 2 diabetes mellitus that is poorly controlled is at high risk for dehydration because the body's response to high blood glucose levels is to pull fluid from the interstitial and intracellular spaces and increase urine output.

The health care provider prescribes 1 L 5%D/0.45%NS to be infused over 8 hours. The nurse sets the rate at ___mL/hr of IV solution.

ANS: 125. 1000 mL______ = 125 mL/hr 8 hr

When evaluating the hydration status of a new 84-year-old nursing home client, the nurse observes tenting of the skin on the back of the client's hand. What is the nurse's best action? A) Assess the skin turgor on the client's forehead. B) Ask the client when he or she last had anything to drink. C) Examine the client's dependent body areas, especially the ankles. D) Document this observation in the client's record as the only action.

ANS: A. Skin turgor and hydration status cannot be accurately assessed on an older adult's hands because of age-related loss of elastic tissue in this area. Areas that more accurately show turgor and hydration status on an older adult are the skin of the forehead and the chest.

Which blood laboratory values does the nurse need to evaluate to determine whether the client's acidosis has a respiratory origin or a metabolic origin? (Select all that apply.) A) Calcium B) HCO3− C) Lactic acid (lactate) D) PaCO2 E) PaO2 F).pH G) Potassium

ANS: B, D, E. In acidosis, the pH is low, and the potassium and lactic acid levels are elevated regardless of the origin or cause of the acidosis, making C, F, and G incorrect. The calcium level is not affected by acidosis, making response A incorrect. In metabolic acidosis, the PaO2 and the PaCO2 remain normal (or the PaCO2 slightly low) and the HCO3− is usually low as a cause of metabolic acidosis. In respiratory acidosis the PaO2 is low and the PaCO2 is high because the problem causing the acidosis is poor gas exchange with carbon dioxide retention. The HCO3− level is normal in acute respiratory acidosis and high in chronic respiratory acidosis.

Which food items selected by a client who must restrict potassium because of a continuing risk for hyperkalemia indicates to the nurse that more teaching is needed? A) Strawberries, Cheerios, eggs B) Cantaloupe, broccoli, sweet potatoes C) Apple pie, black coffee with sugar, carrot sticks D) Whole wheat toast with butter, canned pineapple chunks

ANS: B. As indicated in 11-6, the fruits and vegetable selected by the client are all rich sources of potassium and must be avoided. Cereals, grains, bread, eggs, berries, apples, pineapples, carrots, and black coffee are low in potassium

A client asks why the provider has recommended that he breathe into a paper bag for several minutes when his anxiety disorder causes him to hyperventilate. What is the nurse's best response? A) "Even your exhaled breath still has some oxygen in it and rebreathing this air ensures that you won't pass out from lack of oxygen." B) "When you breathe fast you can lose too much carbon dioxide and rebreathing this air keeps you from becoming dizzy and falling." C) "Rapid breathing can lead to dehydration from excessive fluid loss and rebreathing this air helps you retain fluid in the form of vapor moisture." D) "Breathing into the bag for several minutes helps you become distracted from whatever is making you anxious and allows you to calm down."

ANS: B. Rapid respirations allow carbon dioxide to be "blown off" and lead to respiratory alkalosis. Rebreathing air from the bag, which contains carbon dioxide, helps prevent the loss of carbon dioxide and alkalosis. The technique has nothing to do with oxygen or moisture retention. Breathing into a bag is highly unlikely to reduce anxiety, which is not its purpose.

What immediate response does the nurse expect as a result of infusing 1 liter of an isotonic intravenous solution into a client over a 3-hour time period if urine output remains at 100 mL per hour? A) Extracellular fluid (ECF) osmolarity increases; body weight increases. B) Extracellular fluid (ECF) osmolarity decreases; body weight decreases. C) Extracellular fluid (ECF) osmolarity is unchanged; body weight increases. D) Extracellular fluid (ECF) osmolarity is unchanged; body weight decreases.

ANS: C. Isotonic solutions have the same tonicity as plasma and other extracellular fluids. Therefore, the intravenous fluid would not change the ECF osmolarity. When 1000 mL are infused within 3 hours and the client only urinates 300 mL, the extra fluid would increase the client's weight. Remember that 1 liter of fluid is equal to 2.2 lb.

How are blood hydrogen ion levels and blood carbon dioxide levels related? A) These two blood values are negatively related to the extent that as carbon dioxide levels rise, the concentration of hydrogen ions decreases. B) Carbon dioxide is attached to and becomes part of hydrogen ions in the blood so that the loss of one always leads to the loss of the other. C) There is no relationship between blood hydrogen ion level and carbon dioxide making the concentration of each substance independent of the other. D) Blood hydrogen ion levels and blood carbon dioxide levels are directly related so that when the level of one increases the level of the other increases to the same degree.

ANS: D. Blood hydrogen ion levels and carbon dioxide levels are directly related to one another, so that an increase in one causes an equal increase in the other, making response C incorrect. This is a positive relationship, not a negative one, making response A incorrect. There is no direct attachment of hydrogen ions to carbon dioxide. When they combine, they form carbonic acid and no longer exist as separate substances. Thus response B is incorrect.

A client receiving gentamycin intravenously reports that the peripheral IV insertion site has become painful and reddened. What action will the nurse take first? A) Report the client's problem to the health care provider. B) Document findings and actions in the electronic health record. C) Change the IV insertion site to a new location. D) Stop the infusion of the drug immediately.

ANS: D. The nurse needs to remove the IV first because it is infiltrated. Then documentation, notifying the primary health care provider, and starting a new IV can occur.

A client is receiving 250 mL of a 3% sodium chloride solution intravenously for severe hyponatremia. Which signs and symptoms indicate to the nurse that this therapy is effective? A) The client reports hand swelling. B) Bowel sounds are present in all four abdominal quadrants. C) Serum potassium level has decreased from 4.4 mEq/L (mmol/L) to 4.2 mEq/L (mmol/L). D) Blood pressure has increased from 100/50 mm Hg to 112/70 mm Hg.

ANS: D. Where sodium goes, water follows. Clients with severe hyponatremia are most often hypovolemic and hypotensive because fluid does not stay in the plasma volume when sodium levels are low. The plasma volume leaks into the interstitial space, which leads to edema formation. Having the blood pressure increase is the best nonlaboratory indicator that the treatment is effective.

A client with hypokalemia has a prescription for parenteral potassium chloride (KCl). Which of these interventions does the nurse use to safely administer KCl? (Select all that apply) A) Use a potassium infusion prepared by a registered pharmacist. B) Assess for burning or redness during infusion. C) Infuse at a rate of no more than 10 mEq per hour. D) Administer only through a central venous catheter. E) Administer by IV push only during cardiac arrest.

Answer: A, B, C. Interventions to safely administer KCl to a client with hypokalemia include: using a pharmacy prepared potassium infusion, checking the client for any burning or redness during infusion, and infusing the IV at not more than 10 mEq per hour. The Joint Commission's National Client Safety Goals mandates that concentrated potassium be diluted and added to IV solutions only in the pharmacy by a registered pharmacist and that vials of concentrated potassium not be available in client care areas. IV potassium solutions irritate veins and cause phlebitis. Assess the IV site hourly, and ask the client whether he or she feels burning or pain at the site. The presence of pain or burning at the insertion site may require a new intravenous to be started. A dose of KCl 5-10 mEq/hour, no more than 20 mEq/hr is recommended.Potassium may be administered by peripheral or central vein. There is no circumstance where potassium is given by IV push.

The nurse is starting a peripheral IV catheter on a recently admitted client. What actions does the nurse perform before insertion of the line? A) Apply povidone-iodine to clean skin, dry for 2 minutes. B) Clean the skin around the site. C) Prepare the skin with 70% alcohol or chlorhexidine. D) Shave the hair around the area of insertion. E) Wear clean gloves and touch the site only with fingertips after applying antiseptics.

Answer: A, B, C. Povidone-iodine (Betadine) is applied to the selected insertion site before insertion. The solution is allowed to dry, which takes about 2 minutes. The insertion site should be cleansed before the antiseptic skin preparations are completed. After soap and water cleansing, prepping with 70% alcohol or chlorhexidine is done.Clipping, rather than shaving, hair around the selected IV site is done. Shaving is abrasive and makes the skin more vulnerable to infection (i.e., microbial invasion). The insertion site should not be palpated again after it has been prepped; this mistake is frequently made with IV starts.

A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure (CHF). What nursing actions are indicated at this time? (Select all that apply). A) Place the client on bed rest. B) Evaluate the electrolyte levels. C) Administer the ordered diuretic. D) Assess for orthostatic hypotension. E) INitiate cardiac monitoring

Answer: A, B, D, E. Nursing actions indicated at this time include: placing the client on bedrest and assisting the client out of bed, evaluating electrolyte levels, assessing for orthostatic hypotension, and applying a cardiac monitor. Safety is required to prevent falls due to weakness from a likely fluid volume deficit and electrolyte imbalance. The nurse should review the laboratory and diagnostic results to detect likely loss of sodium, potassium, and magnesium secondary to diarrhea and diuretic us. Fluid volume deficit is likely with diarrhea and diuretic use and leads to fluid and electrolyte imbalances, especially hypokalemia. Assessing for orthostatic changes will confirm presence of volume deficit. Monitoring for inverted T wave or presence of U wave on the ECG as well as dysrhythmias is indicated when hypokalemia is anticipated.Diuretics increase loss of fluids and electrolytes. The nurse would question this order in the presence of assessment data indicating fluid loss from the diuretics and diarrhea.

A client is admitted to the hospital with dehydration secondary to influenza and vomiting. The provider orders an intravenous (IV) potassium replacement for potassium level of 2.7 mEq/L (2.7 mmol/L). Which of these best practice techniques does the nurse include when administering this medication? (Select all that apply). A) Ensuring that the concentration is no greater than 1?9?mEq/10?9?mL of solution. B) Use a vein in the hand for better flow. C) Use an IV pump to deliver the medication. D) Check IV access for blood return after the infusion. E) Push the medication over 5 minutes

Answer: A, C. Best practice technique for administering IV potassium replacement is to ensure that the concentration is no greater than 1 mEq/10 mL of solution. A pump or controller device must be used to deliver the medication to prevent rapid infusion and complications of hyperkalemia, including cardiac arrest.Potassium must be infused via a large vein with a high volume of flow, avoiding the hand. The maximum recommended infusion rate of potassium is 5 to 10 mEq/hr. This rate is never to exceed 20 mEq/hr. Potassium would never be administered via IV push. Assess the IV access for placement and an adequate blood return before administering potassium-containing solutions.

A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports this finding? A) Potassium 6.1 mEq/L. B) Magnesium 1.8 mEq/L. C) Sodium 152 mEq/L. D) Chloride 102 mEq/L

Answer: A. A) Hyperkalemia, defined as a potassium level above 5.0 mEq/L, can cause a prolonged PR interval, a wide QRS complex, flat or absent P waves, and tall, peaked T waves. B) This magnesium level is within the expected reference range. It would not result in a prolonged PR interval and widened QRS complex. C) Although this sodium level is outside the expected reference range, it would not cause a prolonged PR interval and widened QRS complex. However, it can cause cerebral dysfunction. D) This chloride level is within the expected reference range. It would not result in a prolonged PR interval and widened QRS complex.

A nurse is assessing a client who has dehydration. Which of the following assessments is the priority? A) Mental status. B) Skin turgor. C) Weight. D) Urine output.

Answer: A. A) The greatest risk to this client is injury from a fall due to a decline in the client's mental status. Therefore, assessing the client's mental status is the nurse's priority B) The nurse should assess skin turgor to monitor the client's hydration status. Poor skin turgor is a manifestation of dehydration. However, another assessment is the nurse's priority. C) The nurse should weigh the client because weight loss is a manifestation of dehydration. A decreased weight is the best indication of the client's fluid status. However, another assessment is the nurse's priority. D) The nurse should assess urine output to monitor the client's hydration status. Decrease urine output is a manifestation of dehydration. However, another assessment is the nurse's priority.

A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does the nurse teach the new graduate nurse to use for this client? A) Midline catheter. B) Tunneled percutaneous central catheter. C) Peripherally inserted central catheter. D) Short peripheral catheter.

Answer: A. For a client with fragile veins (which occur with long-term corticosteroid use) and the need for a catheter for 5 days, the midline catheter is the best choice.Tunneled central catheters usually are used for clients who require IV access for longer periods. Peripherally inserted central catheters usually are used for clients who require IV access for longer periods. A short peripheral catheter is likely to infiltrate before 5 days in a client with fragile veins, requiring reinsertion.

The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse? A) Client behavior that changes from anxious to lethargic. B) Deep furrows on the surface of the tongue. C) Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched. D) Urine output of 950 mL for the past 24 hours

Answer: A. Immediate intervention by the nurse is required when a client's behavior changes from anxious to lethargic. This change in mental status suggests poor cerebral blood flow and fluid shifts within the brain cells. Immediate intervention is needed to prevent further cerebral dysfunction.Deep furrows on the surface of the tongue, poor skin turgor, and low urine output are all caused by the fluid volume deficit, but do not indicate complications of dehydration that are immediately life-threatening.

A client admitted to the intensive care unit is expected to remain for 3 weeks. The nurse has orders to start an IV. Which vascular access device is best for this client? A) Midline catheter. B) Peripherally inserted central catheter (PICC). C) Short peripheral catheter. D) Tunneled central catheter.

Answer: A. Midline catheters are the best device for this client. These catheters are used for therapies lasting from 1 to 4 weeks.PICCs are typically used when IV therapy is expected to last for months. Short peripheral catheters are allowed to dwell (stay in) for 72 to 96 hours, but they then require removal and insertion at another venous site. Tunneled central catheters must be inserted by a health care provider. Nurses are typically not qualified to start tunneled central catheters.

A client is being admitted to the burn unit from another hospital. The client has an intraosseous IV that was started 2 days ago, according to the client's medical record. What does the admitting nurse do first? A) Anticipate an order to discontinue the intraosseous IV and start an epidural IV. B) Call the previous hospital to verify the date. C) Immediately discontinue the intraosseous IV. D) Nothing; this is a long-term treatment.

Answer: A. The admitting nurse would first anticipate an order to discontinue the intraosseous IV and start an epidural IV. The intraosseous route should be used only during the immediate period of resuscitation and should not be used for longer than 24 hours. Alternative IV routes, such as epidural access, should then be considered for pain management.The nurse should know what to do in this client's situation without contacting the previous hospital. Other client data, such as the date and time that the burn occurred, should validate the date and time of insertion of the IV. Discontinuing the IV is not the priority in this situation—the client is in a precarious fluid balance situation. One IV access should not be stopped until another is established. This type of IV is not used for long-term therapy; an action must be taken.

The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the LPN/LVN? A) Calcium level of 9.5 mg/dL (2.4 mmol/L). B) Magnesium level of 4.1 mEq/L (2.1 mmol/L). C) Potassium level of 6.0 mEq/L (6.0 mmol/L). D) Sodium level of 120 mEq/L (120 mmol/L)

Answer: A. The client with a calcium level of 9.5 mg/dL (2.4 mmol/L), a normal value, would be assigned to the LPN/LVN.A magnesium level of 4.1 mEq/L (2.1 mmol/L) (normal is 1.8-2.6 mEq/L [0.74-1.07 mmol/L]) and potassium level of 6.0 mEq/L (6.0 mmol/L) pose risk for dysrhythmia, and a sodium level of 120 mEq/L (120 mmol/L) may cause serious cerebral dysfunction requiring assessments and/or interventions by the RN.

The nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What does the nurse do initially? A) Assess the insertion site. B) Check connections. C) Check the infusion rate. D) Discontinue the IV and start another.

Answer: A. The initial response by the nurse is to assess the insertion site. The purpose of this action is to check for patency, which is the priority. IV assessments typically begin at the insertion site and move "up" the line from the insertion site to the tubing, to the tubing's connection to the bag.Checking the IV connection is important, but is not the priority in this situation. Checking the infusion rate is not the priority. Discontinuing the IV to start another may be required, but it may be possible to "save" the IV, and the problem may be positional or involve a loose connection.

The nurse is caring for a client who takes furosemide (Lasix) and digoxin (Lanoxin). The client's potassium (K+) level is 2.5 mEq/L (2.5 mmol/L). Which additional assessment will the nurse make? A) Heart rate. B) Blood pressure (BP). C) Increases in edema. D) Sodium level.

Answer: A. The nurse must assess the heart rate for bradycardia related to digoxin and irritability or irregularity related to hypokalemia. Hypokalemia increases the sensitivity of cardiac muscle to digoxin and may result in digoxin toxicity, even when the digoxin level is within the therapeutic range. The nurse also assesses for GI symptoms such as diarrhea, and other symptoms of toxicity to digoxin.The BP may decrease with low potassium level but monitoring the pulse is essential. The diuretic would reduce edema, therefore assessing the heart rate is the priority. High serum sodium levels would not be expected in this scenario unless fluid volume deficit is present.

When caring for a client with a burn injury and eschar banding the chest, the nurse plans to observe the client for which of these acid base disturbances? A) Respiratory acidosis. B) Respiratory alkalosis. C) Metabolic acidosis. D) Metabolic alkalosis.

Answer: A. The nurse plans to observe the client with a burn injury and eschar banding the chest for respiratory acidosis related to decreased chest excursion. Circumferential eschar will result in hypoventilation, accumulation of carbon dioxide and resulting respiratory acidosis.Respiratory alkalosis is caused by hyperventilation, increased rate or depth of breathing, causing carbon dioxide to be eliminated in excess. Metabolic acid base disturbances are usually caused by renal issues.

The nurse is caring for a group of clients. Which client will the nurse carefully observe for signs and symptoms of hyperkalemia? A) The client who has metabolic acidosis B) The client receiving total parenteral nutrition. C) The client who has profuse vomiting. D) The client taking a thiazide diuretic.

Answer: A. The nurse would carefully observe for signs of metabolic acidosis in a client with hyperkalemia. Hyperkalemia occurs as the body attempts to buffer the acidosis by moving hydrogen ions into the cells. An equal number of potassium ions move from the cells into the blood to maintain intracellular electroneutrality, resulting in hyperkalemia.The client receiving TPN is at risk for metabolic alkalosis due to an increase in base components. Metabolic alkalosis is associated with hypochloremia rather than hyperkalemia. The client with profuse vomiting or taking a diuretic is also at risk for metabolic alkalosis and hypokalemia.

The rapid response team (RRT) is called to the bedside of a client with heart rate of 38 beats per minute and a potassium level of 7.0 mEq/L (7.0 mmol/L). For which medication will the nurse anticipate a prescription? A) Insulin. B) Atropine. C) Sodium polystyrene sulfonate (Kayexalate). D) Potassium phosphate.

Answer: A. The rapid response team (RRT) is called to the bedside of a client with heart rate of 38 beats per minute and a potassium level of 7.0 mEq/L (7.0 mmol/L). For which medication will the nurse anticipate a prescription?

The nurse is teaching a hospitalized client who is being discharged about how to care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education? A) "I can continue my 20-mile (32-km) running schedule as I have for the past 10 years." B) "I can still go about my normal activities of daily living." C) "I have less chance of getting an infection because the line is not in my hand." D) "The PICC line can stay in for months."

Answer: A. The statement by the client stating that his or her normal running schedule can continue indicates a need for further education. Excessive physical activity can dislodge the PICC and should be avoided.Clients with PICCs should be able to perform normal activities of daily living. PICCs have low complication rates because the insertion site is in the upper extremity. The dry skin of the arm has fewer types and numbers of microorganisms, leading to lower rates of infection. PICC lines can be used long term (months).

The nurse is caring for a client with sepsis and impending septic shock. Which of these interventions will help prevent lactic acidosis? A) Ensure adequate oxygenation. B) Restrict carbohydrates. C) Supplement potassium. D) Monitor hemoglobin.

Answer: A. When caring for a client with sepsis and impending shock the nurse will ensure adequate oxygenation to help prevent lactic acidosis. Cellular metabolism under anaerobic (no oxygen) conditions forms lactic acid. Shock states are due to a lack of cellular perfusion and delivery of oxygen to the tissues. Providing adequate oxygenation and perfusion will help to reverse the need for the body to make ATP without oxygen which causes lactic acid to accumulate.Carbohydrate metabolism forms carbon dioxide (CO2) and carbohydrate restriction will not prevent lactic acidosis, a form of metabolic acidosis. Supplementing potassium may worsen hyperkalemia, as this is an expected finding during episodes of metabolic acidosis. While hemoglobin is a weak buffer, monitoring the value will not prevent an acid-base disturbance.

A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care? (Select all that apply). A) Assess the client for pitting edema. B) Encourage the client to rise slowly when standing up. C) Weigh the client every 8 hr. D) Administer IV fluids to the client evenly over 24 hr. E) Provide the client with a salt substitute.

Answer: B, C, D. A) This action is appropriate for a client who has fluid volume overload. B) This action can prevent injury from falls caused by orthostatic hypotension. C) Weighing the client every 8 hr will provide information regarding fluid balance. D) A client who has excessive fluid loss is typically prescribed IV replacement fluids. Administering IV fluids rapidly over a short period of time places the client at risk for fluid volume overload. E) There is no reason to limit the client's sodium intake. A client who has hypernatremia might require dietary sodium restriction. However, this client might require electrolyte replacement, depending on the cause of fluid loss.

The nurse is caring for a client with acute respiratory failure and PaCO2 level of 88 mm Hg For which of these signs and symptoms will the nurse assess? (Select all that apply). A) Hyperactivity. B) Headache. C) Shallow breathing. D) pH 7.49. E) Fatigue.

Answer: B, C, E. When caring for a client with acute respiratory failure and respiratory acidosis, the nurse would assess for lethargy, flushing, headache, shallow breathing, and fatigue. Clients experiencing acidosis have problems associated with the decreased function of excitable membranes.Generally, the client with respiratory acidosis will be lethargic rather than hyperactive and have a pH <7.35, which is a characteristic of acidosis.

The nurse is teaching a client who is taking a potassium-sparing diuretic about precautions while taking this medication. Which of these does the nurse teach the client to avoid or use cautiously? (Select all that apply). A) Apples. B) Bananas. C) ACE inhibitors. D) Grapes. E) Salt substituet.

Answer: B, C, E. While taking a potassium-sparing diuretic, the nurse teaches the client to avoid bananas, ACE inhibitors, and salt substitutes. Other foods high in potassium include cantaloupe, kiwi, oranges, avocados, broccoli, dried beans, lima beans, mushrooms, potatoes, seaweed, soybeans, and spinach. Salt substitutes contain potassium and may predispose the client to hyperkalemia.Apples and grapes are considered lower potassium-containing foods.

The nurse is revising an agency's recommended central line catheter-related bloodstream infection prevention (CR-BSI) bundle. Which actions decrease the client's risk for this complication? (Select all that apply). A) During insertion, draping the area around the site with a sterile barrier. B) Immediately removing the client's venous access device (VAD) when it is no longer needed. C) Making certain that observers of the insertion are instructed to look away during the procedure. D) Thorough hand hygiene (i.e., no quick scrub) before insertion. E) Using chlorhexidine for skin disinfection

Answer: B, D, E. As soon as the VAD is deemed unnecessary, it needs to be removed to reduce the risk for infection. Thorough handwashing is a key factor in insertion and maintenance of a central line device. Quick handwashing is not sufficient. Chlorhexidine is recommended for skin disinfection because it has been shown to have the best outcomes in infection prevention.During the insertion, the whole body (head to toe) of the client is draped with a sterile barrier. Draping only the area around the site will increase risk for infection. Looking away will not reduce the risk for infection. Reducing the number of people in the room and having everyone wear a mask will help reduce the risk for infection.

The nurse assessing a client's peripheral IV site obtains and documents information about it. Which assessment data indicate the need for immediate nursing intervention? A) Client states, "It really hurt when the nurse put the IV in." B) The vein feels hard and cordlike above the insertion site. C) Transparent dressing was changed 5 days ago. D) Tubing for the IV was last changed 72 hours ago.

Answer: B. A hard, cordlike vein suggests phlebitis at the IV site and indicates an immediate need for nursing intervention. The IV should be discontinued and restarted at another site.It is common for IVs to cause pain during insertion. An intact transparent dressing requires changing only every 7 days. Tubing for peripheral IVs should be changed every 72 to 96 hours.

A nurse is assessing aclient who is using PCA following a thoracotomy. The client is short of breath, appears restless, and has a respiratory rate of 28/min. The client's ABG results are pH 7.52, PaO2 89 mm Hg, PaCO228 mm Hg, and HCO3- 24 mEq/L. Which of the following actions should the nurse take? A) Instruct the client to cough forcefully. B) Provide calming interventions. C) Assist the client with ambulation. D) Discontinue the PCA.

Answer: B. A) Coughing forcefully will not treat the underlying cause of the ABG results. B) The client's respiratory rate is above the expected range. Calming the client should decrease the respiratory rate, which will cause the client's carbon dioxide levels to increase to expected levels of 35 to 45 mm Hg and lower the pH to expected levels of 7.35 to 7.45. The nurse should instruct the client to breathe slowly. C) Ambulation can exacerbate the client's respiratory distress and is not appropriate at this time. D) Discontinuing the PCA will not treat the underlying cause of the ABG results and could exacerbate the client's respiratory distress.

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect? A) Peripheral edema. B) Confusion. C) Facial flushing. D) Hyperreflexia.

Answer: B. A) Peripheral edema is not a manifestation of respiratory acidosis. B) A client who has respiratory acidosis will experience confusion from a lack of cerebral perfusion. If acidosis is not reversed, the client's level of consciousness will decrease and coma may occur. C) Facial flushing and warmth are manifestations of metabolic acidosis. Pale, cyanotic, dry skin is a manifestation of respiratory acidosis as ineffective breathing causes a lack of perfusion to the tissues. D) Hyporeflexia, not hyperreflexia, is a manifestation of respiratory acidosis. As acidosis increases, hyperkalemia can occur, causing muscle weakness, flaccid paralysis, and hyporeflexia.

A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? A) Drowsiness. B) Decreased blood pressure. C) Hyperactive deep-tendon reflexes. D) Increased bowel sounds.

Answer: C. A) Insomnia is an expected finding for a client who has hypomagnesemia. B) Increased blood pressure is an expected finding for a client who has hypomagnesemia. C) Hyperactive deep-tendon reflexes is an expected finding for a client who has hypomagnesemia. Other expected findings include muscle cramps, numbness, and tingling. D) Decreased bowel sounds are an expected finding for a client who has hypomagnesemia.

A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary edema. Which of the following actions should th enurse take first? A) Assist with intubation. B) Initiate high-flow oxygen therapy. C) Provide cardiac monitoring. D) Administer a rapid-acting diuretic.

Answer: B. A) The nurse should be prepared to assist the provider with intubation and mechanical ventilation if less invasive measures are ineffective; however, there is another action the nurse should take first. B) When using the airway, breathing, circulation approach to client care, the nurse should first administer high-flow oxygen therapy by face mask at 5 to 6 L/min to keep the client's oxygen saturation above 90%. C) The nurse should provide cardiac monitoring because premature ventricular contractions and dysrhythmias are manifestations of pulmonary edema; however, there is another action the nurse should take first. D) The nurse should administer a rapid-acting diuretic IV bolus to the client to relieve pulmonary congestion; however, there is another action the nurse should take first.

A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect? A) Increased blood pressure. B) Decreased muscle strength. C) Increased heart rate. D) Decreased gastric motility.

Answer: B. A) The nurse should expect the client to experience hypotension. B) The nurse should expect the client to experience muscle weakness, fatigue, paresthesia, and nausea. C) The nurse should expect the client to experience bradycardia. D) The nurse should expect the client to experience increased gastric motility, including abdominal cramps and diarrhea.

A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first? A) Monitor for paresthesia. B) Withhold the medication. C) Administer a hypertonic solution. D) Repeat the potassium level.

Answer: B. A) The nurse should monitor the client for paresthesia because numbness and tingling are indications of hyperkalemia, but another action is the priority. B) The greatest risk to the client is bradycardia, hypotension, and life-threatening cardiac complications due to hyperkalemia, defined as a potassium level above 5.0 mEq/L. Therefore, the nurse's priority action is to withhold the oral potassium and notify the provider. C) A potassium level of 5.5 mEq/L indicates the client has hyperkalemia. This places the client at risk for bradycardia, hypotension, and life-threatening cardiac complications. The nurse should administer a hypertonic solution to correct the hyperkalemia, but another action is the priority. D) A potassium level of 5.5 mEq/L indicates the client has hyperkalemia. This places the client at risk for bradycardia, hypotension, and life-threatening cardiac complications. The nurse should repeat the potassium level to evaluate for effective treatment, but another action is the priority.

A nurse is caring for a client who requires nasogastric suctioning. Which of the following sets of laboratory results indicates that the client has metabolic alkalosis? A) pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 26 mEq/L. B) pH 7.51, PaO2 94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L. C) pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L. D) pH 7.31, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 23 mEq/L

Answer: B. A) With metabolic alkalosis, the pH is above 7.45 and HCO3- is elevated, not within the expected reference range. The PaCO2 is either elevated or within the expected reference range.. B) An elevated pH and HCO3- with a PaCO2 either elevated or within the expected reference range indicates metabolic alkalosis. C) With respiratory alkalosis and metabolic alkalosis, the pH is elevated above 7.45. D) With respiratory alkalosis and metabolic alkalosis, the pH is elevated above 7.45.

A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened and begun 20 hours ago. What action does the nurse take? A) Change the set immediately. B) Change the set in about 4 hours. C) Change the set in the next 12 to 24 hours. D) Nothing; the set is for long-term use.

Answer: B. Because both ends of the set are being manipulated with each dose, standards of practice dictate that the set should be changed every 24 hours, so the set should be changed in about 4 hours.It is not necessary to change out the set immediately, but it must be changed before the next 12 to 24 hours.

A client is admitted to the cardiothoracic surgical intensive care unit after cardiac bypass surgery. The client is still sedated on a ventilator and has an arterial catheter in the right wrist. What assessment does the nurse make to determine patency of the client's arterial line? A) Blood pressure. B) Capillary refill and pulse. C) Neurologic function. D) Questioning the client about the pain level at the site.

Answer: B. Capillary refill and pulse should be assessed to ensure that the arterial line is not occluding the artery.Blood pressure and neurologic function are not pertinent to the client's arterial line. Although the client's comfort level is important with an arterial line, it is not a determinant of patency of the line.

The nurse checking an IV fluid order questions its accuracy. What does the nurse do first? A) Asks the charge nurse about the order. B) Contacts the health care provider who ordered it. C) Contacts the pharmacy for clarification. D) Starts the fluid as ordered, with plans to check it later

Answer: B. First, the nurse contacts the health care provider who ordered it. The nurse is legally and professionally responsible for accuracy and has the duty to verify the order with the health care provider who ordered it.The nurse can consult the charge nurse, but this is not the definitive action that the nurse should take. Contacting the pharmacy is not the best action that the nurse should take. Giving (or starting) the fluid when the order is questionable is not appropriate and could possibly harm the client.

Which statement is true about the special needs of older adults receiving IV therapy? A) Placement of the catheter on the back of the client's dominant hand is preferred. B) Skin integrity can be compromised easily by the application of tape or dressings. C) To avoid rolling the veins, a greater angle of 25 degrees between the skin and the catheter will improve success with venipuncture. D) When the catheter is inserted into the forearm, excess hair should be shaved before insertion.

Answer: B. Skin in older adults tends to be thin. Tape or dressings used with IV therapy can compromise skin integrity.Placement on the back of the dominant hand is contraindicated because hand movement can increase the risk of catheter dislodgement. An angle smaller than 25 degrees is required for venipuncture success in older adults. This technique is less likely to puncture through the older adult client's vein. Clipping, and not shaving, the hair around the insertion site typically is necessary only for younger men.

The nurse is caring for a client who has developed postoperative respiratory acidosis. Which of these interventions will the nurse use to help correct this problem? A) Medicate for pain. B) Encourage use of incentive spirometer. C) Perform fingerstick blood glucose. D) Encourage protein intake.

Answer: B. The intervention that will best help the client with postoperative respiratory acidosis is to encourage the client to use the incentive spirometer. Respiratory acidosis is caused by hypoventilation. Improving ventilation through lung expansion, suctioning, or upright positioning will help to resolve this.While pain medication may make use of the incentive spirometer easier, narcotic analgesics may suppress respirations and worsen acidosis. There is no indication the client has an unstable blood glucose level. Protein intake facilitates wound healing, not resolution of acidosis.

The nurse at a long-term care facility is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. Which of these should be included in the education session? A) "Be careful not to overload them with too many oral fluids." B) "Offer fluids that they prefer frequently and on a regular schedule." C) "Restrict their fluids if they are incontinent." D ) "Wake them every 2 hours during the night with a drink."

Answer: B. The long-term care nurse teaches the UAPs to frequently offer older adults fluids that they prefer and on a regular basis. Because of the decreased thirst mechanism, older adults can become dehydrated and must be offered oral fluids every 2 hours. The likelihood of their accepting the fluid increases if it is one they prefer.Risk of overhydration, especially with oral fluids, is minimal. Fluids would never be restricted even if the client is incontinent. Restricting fluids to incontinent clients is a common mistake made by UAP in long-term care environments. It is not necessary to disturb older adults during their sleep to offer fluids. However, they should be offered a drink during waking hours at frequent intervals (e.g., every 2 hours).

The nursing assistant reports that the client with metabolic acidosis due to kidney failure is breathing rapidly and deeply. The nurse explains this to the nursing assistant in which of these manners? A) "The client is acting out and we should pay him no mind". B) "Rapid breathing is a way to compensate for acidosis caused by his condition". C) "Normally a client with this disorder will breathe slowly, I will go assess him". D) "Deep breathing is a symptom of diabetes, I will check his blood glucose".

Answer: B. The nurse explains that kussmaul or rapid and deep breathing helps the body compensate for metabolic acidosis by blowing off the CO2 or respiratory acid through the lungs. This will also increase the body's pH level.The client would not be judged for acting out without a clear understanding of the underlying client's cause. Slow respirations are not consistent with metabolic acidosis, however, may cause respiratory acidosis. Deep breathing (Kussmaul breathing) is a compensatory mechanism for metabolic acidosis ocurring with DKA or kidney disease.

A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first? A) Draws blood for laboratory tests. B) Elevates the head of the bed. C) Places the extremities in a dependent position. D) Puts the client in a side-lying position.

Answer: B. The nurse first needs to elevate the client's head of bed when caring for a client with fluid overload. Remember to follow the ABC's and perform interventions that promote lung expansion and oxygenation to relieve symptoms of fluid overload.Drawing blood for laboratory tests may be indicated, but would not be performed first. Placing the extremities in a dependent position increases peripheral edema, and positioning the client in a side-lying position increases the work of breathing.

The nurse is infusing 3% saline for a client with syndrome of inappropriate secretion (SIADH). Which of these complications does the nurse report to the primary care provider? A) Peripheral edema. B) Crackles 1/2 way up the lung fields. C) Serum osmolarity of 294 mOsm/kg (294 mmol/kg). D) Urine output of 1300 mL over 24 hours

Answer: B. The nurse needs to report to the PCP crackles heard ½ way up the lung fields when assessed on a client with SIADH receiving an infusion of 3% saline. When a hyperosmotic IV solution such as 3% saline is infused, the interstitial fluid is pulled into the circulation in an attempt to dilute the blood. As a result, the plasma volume expands. The nurse needs to evaluate the client for fluid volume excess and symptoms of heart failure including crackles.Peripheral edema may occur with SIADH. A serum osmolarity of 294 mOsm/kg (294 mmol/kg) is normal. A urine output of 1300 mL over 24 hours is considered normal.

A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess? A) Deep-tendon reflexes. B) Cardiac rhythm. C) Peripheral sensation D) Bowel sounds.

Answer: B. The nurse should assess the client's deep-tendon reflexes because this total serum calcium level is below the expected reference range and hypocalcemia can cause neuromuscular changes. However, there is another assessment the nurse should make first. When using the airway, breathing, circulation approach to client care, the nurse should first assess the client's cardiac rhythm because this total serum calcium level is below the expected reference range. Hypocalcemia can cause ECG changes, bradycardia, or tachycardia. The nurse should assess the client's peripheral sensation to check for paresthesias because this total serum calcium level is below the expected reference range and hypocalcemia can cause neuromuscular changes. However, there is another assessment the nurse should make first. The nurse should assess the client's bowel sounds to check for hypermotility because this total serum calcium level is below the expected reference range and hypocalcemia can cause increased peristalsis. However, there is another assessment the nurse should make first.

A nurse is providing dietary teaching to a client who has heart failure and is receiving furosemide. Which of the folowing foods should the nurse recommend as containing the greatest amount of potassium? A) 1/2 cup cooked tofu. B) 1 slice whole grain bread. C) 1 cup plain yogurt. D) 1/2 cup chopped celery.

Answer: C. A) One-half cup of cooked tofu contains 164 g of potassium. Therefore, there is another food the nurse should recommend as containing the greatest amount of potassium. B) One slice of whole grain bread contains 60 g of potassium. Therefore, there is another food the nurse should recommend as containing the greatest amount of potassium. C) One cup of plain yogurt contains 380 g of potassium. Therefore, the nurse should recommend this food as containing the greatest amount of potassium. D) One-half cup chopped celery contains 132 g of potassium. Therefore, there is another food the nurse should recommend as containing the greatest amount of potassium.

The nurse and nursing student are caring for a client with a new diagnosis of diabetes whose blood glucose is 974 mg/dL (54.1 mmol/L). Which of these statements indicates the student understands the relationship between blood glucose and acid base balance? A) "The excess glucose in the blood causes the client to hypoventilate and retain carbon dioxide resulting in respiratory acidosis" B) "The hyperglycemia is caused by inability of glucose to enter the cell causing a starvation state and break down of fats" C) "The client has a hyperosmolar condition causing polyuria and polyphagia, but the acid base balance is normal" D) "The client is retaining carbon dioxide which led to respiratory acidosis and somnolence"

Answer: B. The nursing student understands the relationship between blood glucose and acid base balance when the student states that hyperglycemia is caused by inability of glucose to enter the cell causing a starvation state and break down of fats. Glucose cannot enter the cell to provide energy without the presence of insulin. The body begins to break down fat for energy which produces ketones and causes ketoacidosis.The client with ketoacidosis will hyperventilate, breathing more rapidly and deeply to rid the body of respiratory acids such as CO2. This process buffers the acidosis. A hyperosmolar state does occur, however the acid base balance is still affected. CO2 is retained when the client's inability to ventilate or remove CO2 effectively occurs. Hypercarbia, CO2 retention, is generally caused by problems affecting the pulmonary system.

The nurse is administering a drug to a client through an implanted port. Before giving the medication, what does the nurse do to ensure safety? A) Administer 5 mL of a heparinized solution. B) Check for blood return. C) Flush the port with 10 mL of normal saline. D) Palpate the port for stability.

Answer: B. To ensure safety, before a drug is given through an implanted port, the nurse must first check for blood return. If no blood return is observed, the drug should be held until patency is reestablished.If no blood return is observed, the drug should be held until patency is reestablished. Ports are flushed with heparin or saline after, rather than before, use. The port is palpated for stability, but this action alone does not ensure the client's safety.

The nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion? A) Asks the client to both say and spell his or her full name before starting the blood transfusion. B) Ensures that another qualified health care professional checks the unit before administering. C) Checks the blood identification numbers with the laboratory technician at the blood bank at the time it is dispensed. D) Makes certain that an IV solution of 0.9% normal saline is infusing into the client before starting the unit

Answer: B. To ensure safety, blood must be checked by two qualified health care professionals, usually two registered nurses.Administering an incorrectly matched unit of blood creates great consequences for the client and is considered to be a sentinel event. It requires a great amount of follow-up and often changing of policies to improve safety. The Joint Commission requires that the client provide two identifiers, but they are the name and date of birth or some other identifying data, depending on the facility; saying and spelling the name is only one identifier. Although a check is provided at the blood bank, this is not the one that is done before administration to the client. Clients do need to have normal saline running with blood, but this is not considered to be part of the safety check before administration of blood and blood products.

An older adult is admitted to the medical surgical unit with dehydration. The nurse performs which of these assessments to determine whether the client is safe for independent ambulation? A) Assesses for dry oral mucous membranes. B) Checks for orthostatic blood pressure changes. C) Notes pulse rate is 72 beats/min and bounding. D) Evaluates that the serum potassium level is 4.0 mEq/L (4.0 mmol/L)

Answer: B. When caring an older adult admitted for dehydration, the nurse determines if the client is safe for independent ambulation by assessing for orthostatic blood pressure. Blood pressure measured with the client lying, then sitting, and finally standing is done to detect orthostatic or postural changes. During low blood volume states, especially when standing, insufficient blood flow to the brain may cause hypotension and tachycardia upon arising. This may cause light-headedness and dizziness, which increases the risk for falls, especially in older adults.Assessment of oral mucous membranes and the pulse rate can detect symptoms of dehydration, but these are not the best ways to assess for a fall risk. Checking serum potassium does ensure safety for ambulation nor assess for fall risk.

A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs." Which of the following actions should the nurse take first? A) Palpate the client's peripheral pulses. B) Review the client's daily laboratory results. C) Auscultate the client's lungs. D) Monitor the client's bowel sounds.

Answer: C. A) An adverse effect of many diuretics, including furosemide, is hypokalemia. The nurse should palpate the client's peripheral pulses to assess for cardiovascular changes, such as a thready and weak pulse. However, there is another action the nurse should take first. B) An adverse effect of many diuretics, including furosemide, is hypokalemia. The nurse should review the client's daily laboratory results, especially his potassium level. However, there is another action the nurse should take first. C) An adverse effect of many diuretics, including furosemide, is hypokalemia. When using the airway, breathing, circulation approach to client care, the nurse should first auscultate the client's lungs to assess for respiratory changes due to weakness of the respiratory muscles. D) An adverse effect of many diuretics, including furosemide, is hypokalemia. The nurse should monitor the client's bowel sounds for increased or decreased peristalsis due to hypokalemia. However, there is another action the nurse should take first.

A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medicaitons should the nurse prepare to administer? A) Bumetanide 8 mg/day. B) 100 mL of dextrose 10% in water with 10 units of insulin. C) 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr. D) Sodium polystyrene sulfonate 30 g/day.

Answer: C. A) High-ceiling loop diuretics such as bumetanide are given to treat hyperkalemia, not hypokalemia. B) Dextrose 10% in water with 10 units of insulin is an IV solution given to treat hyperkalemia, not hypokalemia. C) This IV solution will provide adequate fluid and potassium replacement to offset the losses from vomiting. The typical amount of potassium chloride to administer IV is 5 to 10 mEq/hr and not to exceed 20 mEq/hr. The dilution should be 1 mEq to 10 mL of 0.9% sodium chloride. D) Sodium polystyrene sulfonate is an electrolyte cation exchange medication that is given to treat hyperkalemia, not hypokalemia.

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory aklalosis? A) PaO2. B) Bicarbonate. C) PaCO2. D) Sodium.

Answer: C. A) The nurse should anticipate that a client who has respiratory alkalosis will have a PaO2 level within the expected reference range. B) The nurse should anticipate that a client who has respiratory alkalosis will have a bicarbonate level within the expected reference range. The bicarbonate level is increased in metabolic alkalosis. C) The nurse should anticipate that a client who has respiratory alkalosis will have a decreased PaCO2 level due to hyperventilation. D) The nurse should anticipate that a client who has respiratory alkalosis will have a sodium level within the expected reference range.

A nurse is caring for a client wh ohas dehydration and is receiving IV fluids. When assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload? A) Decreased respiratory rate. B) Hypoactive bowel sounds. C) Bounding peripheral pulses. D) Increased urine specific gravity.

Answer: C. A) The nurse should recognize that an increased respiratory rate is a manifestation of fluid volume overload. . B) The nurse should recognize that increased gastrointestinal motility is a manifestation of fluid volume overload. C) The nurse should recognize that increased vascular volume results in full, bounding peripheral pulses. D) The nurse should recognize that an increased urine specific gravity indicates a greater concentration of urine, which occurs with dehydration, not fluid volume overload.

A nurse is assessing a client who has a phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect? A) Hepatic failure. B) Abdominal pain. C) Slow peripheral pulses. D) Increase in cardiac output.

Answer: C. A) This phosphorus level is below the expected reference range. The nurse should assess a client who has hypophosphatemia for manifestations of kidney failure, not hepatic failure. B) This phosphorus level is below the expected reference range. Hypophosphatemia causes weakness of skeletal muscles and rhabdomyolysis, which is acute muscle breakdown. It does not cause abdominal pain. C) This phosphorus level is below the expected reference range. The nurse should expect the client to have slow peripheral pulses. The nurse might also find that the client's pulses are difficult to find and easy to block. D) This phosphorus level is below the expected reference range. The nurse should expect a decrease in cardiac output.

A 22-year-old client is seen in the emergency department (ED) with acute right lower quadrant abdominal pain, nausea, and rebound tenderness. It appears that surgery is imminent. What gauge catheter does the ED nurse choose when starting this client's intravenous solution? A) 24. B) 22. C) 18. D) 14

Answer: C. An 18-gauge catheter is the size of choice for clients who will undergo surgery. If they need to receive fluids rapidly, or if they need to receive more viscous fluids (such as blood or blood products), a lumen of this size would accommodate those needs.Neither a 24-gauge nor a 22-gauge catheter is an appropriate size (too small) for clients who will undergo surgery. If it becomes necessary to administer fluids to the client rapidly, another IV would be needed with a larger needle—18, for example. Administering through the smallest gauge necessary is usually best practice, unless the client may be going into hypovolemic status (shock). A 14-gauge catheter is an extremely large-gauge needle that is very damaging to the vein.

The nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical? A) Monitoring 24-hour urine output B) Asking the client about feeling depressed. C) Assessing the blood pressure hourly. D) Monitoring the serum calcium levels

Answer: C. Assessing hourly blood pressures is critical when caring for a client receiving IV magnesium sulfate. Hypotension is a sign/symptom of hypermagnesemia during magnesium infusion.Most clients who have fluid and electrolyte problems will be monitored for intake and output, and will not immediately indicate problems with magnesium overdose. Low magnesium levels can cause psychological depression, but assessing this parameter as the levels are restored would not safely assess a safe dose or an overdose. Although administration of magnesium sulfate can cause a drop in calcium levels, this occurs over a period of time and would not be the best way to assess magnesium toxicity.

A client is seen in the emergency department (ED) with pain, redness, and warmth of the right lower arm. The client was in the ED last week after an accident at work. On the day of the injury, the client was in the ED for 12 hours receiving IV fluids. On close examination, the nurse notes the presence of a palpable cord 1 inch (2.5 cm) in length and streak formation. How does the nurse classify this client's phlebitis? A) Grade 1. B) Grade 2. C) Grade 3. D) Grade 4.

Answer: C. Grade 3 indicates pain at the access site with erythema and/or edema and streak formation with a 1' palpable cord.Grade 1 indicates only erythema with or without pain; the client has additional symptoms. Grade 2 indicates only pain at the access site with erythema and/or edema; the client has additional symptoms. Grade 4 indicates pain at the access site with erythema and/or edema, streak formation, a palpable venous cord longer than 1 inch (2.5 cm), and purulent drainage. No purulent drainage is present in this client, and the palpable cord is 1 inch (2.5 cm) in length.

The step down unit receives a new admission who has uncontrolled diabetes, polyuria, and a blood pressure of 86/46 mm Hg. Which staff member is assigned to care for her? A) LPN/LVN who has floated from the hospital's long-term care unit B) LPN/LVN who frequently administers medications to multiple clients C) RN who has floated from the intensive care unit D) RN who usually works as a diabetes educator

Answer: C. The RN who has floated from the intensive care unit needs to care for this clinically unstable woman with uncontrolled diabetes. The clinical manifestations suggest that the client is experiencing hypovolemia and possible hypovolemic shock from osmotic diuresis. The RN from the intensive care unit will have extensive experience caring for clients with hypovolemia, hyperglycemia, and fluid volume deficit/shock.The LPN/LVN who has floated from the long-term care unit or who frequently administers medications to multiple clients will not be as familiar with care for critically ill clients, or qualified to care for this clinically unstable client. Although the resource on diabetes is helpful, the RN who works as a diabetes educator will not be as familiar with care for acutely or critically ill clients.

The nurse is inserting a peripheral intravenous (IV) catheter. Which client statement is of greatest concern during this procedure? A) "I hate having IVs started." B) "It hurts when you are inserting the line." C) "My hand tingles when you poke me." D) "My IV lines never last very long."

Answer: C. The client's statement about a tingling feeling indicates possible nerve puncture and is of greatest concern to the nurse. To avoid further nerve damage, the nurse should stop immediately, remove the IV catheter, and choose a new site.Statements such as, "I hate having IVs started," "It hurts when you are inserting the line," and "My IVs never last very long," are addressed with teaching about the importance of proper protection of the site.

The nurse is caring for a group of clients with electrolytes and blood chemistry abnormalities. Which client will the nurse see first? A) The client with a random glucose reading of 123 mg/dL (6.8 mmol/L) B) The client who has a magnesium level of 2.1 mEq/L (1.0 mmol/L). C) The client whose potassium is 6.2 mEq/L (6.2 mmol/L). D) The client with a sodium level of 143 mEq/L (143 mmol/L)

Answer: C. The first client the nurse sees with electrolyte and blood chemistry abnormalities is the client whose potassium is 6.2 mEq/L (6.2 mmol/L). A potassium value of 6.2 mEq/L (6.2 mmol/L) is elevated and the client has potential for cardiac dysrhythmias.A random or casual glucose, taken at any time of day, is elevated if ≥200mg/dL (>11.1mmol/L); a random value of 123 mg/dL (6.9 mmol/L) does not require intervention. The other clients with a magnesium value of 2.1 mEq/L (1.0 mmol/L) and a sodium value of 143 mEq/L (143 mmol/L) demonstrate normal laboratory values and do not require intervention.

The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which client is most appropriate to assign to the LPN/LVN? A) A 44-year-old with congestive heart failure (CHF) who has gained 3 pounds (1.4 kg) since the previous day. B) A 58-year-old with chronic renal failure (CRF) who has a serum potassium level of 6 mEq/L (6.0 mmol/L). C) A 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/kg (300 mmol/kg). D) An 80-year-old with 3+ peripheral edema and crackles throughout the posterior chest

Answer: C. The most appropriate client for the nurse to assign to the LPV/LVN is the 76-year-old adult with poor skin turgor and a serum osmolarity of 300 mOsm/kg (300 mmol/kg). Although the 76-year-old client has poor skin turgor, the serum osmolarity indicates normal fluid balance. This client is the most stable of the four clients described.The 44-year-old with CHF who has gained 3 pounds (1.4 kg) since the previous day requires additional assessments and interventions which should be performed by an RN. The data about the 58-year-old client with CRF and a serum potassium level of 6 mEq/L (6.0 mmol/L) has a risk for dysrhythmia and instability. Assessments and interventions performed by an RN are also needed on this client. The data about the 80-year-old client with edema and congested lungs indicate that the client is not stable, requiring ongoing assessments and interventions by an RN.

Which client is most appropriate for the nurse manager of the medical-surgical unit to assign to the LPN/LVN? A) A client admitted with dehydration who has a heart rate of 126 beats/min. B) A client just admitted with hyperkalemia who takes a potassium-sparing diuretic at home. C) A client admitted yesterday with heart failure with dependent pedal edema. D) A client who has just been admitted with severe nausea, vomiting, and diarrhea

Answer: C. The most appropriate client to assign to the LPN/LVN is the 64-year-old client admitted yesterday with heart failure and dependent pedal edema. This client is the most stable of all the four clients.Dehydration, tachycardia, potassium overload, and GI signs and symptoms in a client indicate that he or she is unstable. Care must be given by the RN who can carry out assessments, prescriptions, and participate interdisciplinary collaboration as needed.

A client who used to work as a nurse asks, "Why is the hospital using a 'fancy new IV' without a needle? That seems expensive." How does the nurse respond? A) "OSHA, a government agency, requires us to use this new type of IV." B) "These systems are designed to save time, not money." C) "They minimize health care workers' exposure to contaminated needles." D) "They minimize clients' exposure to contaminated needles."

Answer: C. The nurse informs the client that needleless IVs were designed to protect health care personnel from exposure to contaminated needles.The Occupational Safety and Health Administration (OSHA) requires the use of devices with engineered safety mechanisms only. It does not mandate that they be needleless. Saving time and money is not the purpose of the needleless IV, and it was not designed to protect clients from exposure to contaminated needles.

After receiving change-of-shift report, which client does the RN assess first? A) A client with nausea and vomiting who complains of abdominal cramps B) A client with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst. C) A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg. D) A client with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL.

Answer: C. The nurse must first assess the client receiving IV diuretics whose blood pressure is 88/52 mm Hg. This client with hypotension may have developed hypoperfusion caused by hypovolemia. Immediate interventions are needed.The client with nausea and vomiting, the client with an NG tube complaining of thirst, and the client receiving normal saline with an hourly urine output of 75 mL/hr have problems which are not urgent at this time.

The primary care provider writes prescriptions for a client who is admitted with a serum potassium level of 6.9 mEq/L (6.9 mmol/L). What does the nurse implement first? A) Administer sodium polystyrene sulfonate (Kayexalate) orally. B) Ensure that a potassium-restricted diet is ordered. C) Place the client on a cardiac monitor. D) Teach the client about foods that are high in potassium.

Answer: C. The nurse must first place this client on a monitor. Because hyperkalemia can lead to life-threatening bradycardia, placing the client on a cardiac monitor permits early intervention in the event of dysrhythmias.Administering a potassium-reducing medication, recommending a potassium-restricted diet, and teaching the client about diet are appropriate but will not immediately decrease the serum potassium level and do not need to be implemented as quickly as monitoring cardiac rhythm.

Furosemide (Lasix) has been ordered for a client with heart failure, shortness of breath, and 3+ pitting edema of the lower extremities. Which assessment finding indicates to the nurse that the medication has been effective? A) The clients potassium level is 5.1 mEq/L (5.1 mmol/L). B) The client's heart rate is 101 beats per minute. C) The client is free from adventitious breath sounds. D) The client has experienced a weight gain of 1 pound (0.5 kg).

Answer: C. The nurse recognizes that Furosemide is effective when the client is free from adventitious breath sounds such as crackles. Other positive outcomes to the diuretic include normal heart rate, weight loss with resolution of edema, and increased urine output.A potassium value of 5.1 mEq/L or (5.1 mmol/L) is normal. Changes in potassium levels such as hypokalemia are side effects of furosemide, not therapeutic effects. Although a fall in the client's BP may occur with the decrease in body fluid, this is not the priority. Tachycardia may occur during episodes of fluid volume excess or deficit and does not directly indicate the medication has been effective. Weight loss, rather than weight gain, is often the effect of Furosemide, caused by the diuresis.

When flushing a client's central line with normal saline, the nurse feels resistance. Which action does the nurse take first? A) Decrease the pressure being used to flush the line. B) Obtain a 10-mL syringe and reattempt flushing the line. C) Stop flushing and try to aspirate blood from the line. D) Use "push-pull" pressure applied to the syringe while flushing the line.

Answer: C. The nurse's first step is to stop flushing and try to aspirate blood from the line. If resistance is felt when flushing any IV line, the nurse should stop and further assess the line. Aspiration of blood would indicate that the central line is intact and is not obstructed by thrombus.Decreasing the pressure to flush the line is not appropriate. Continuing or reattempting to flush the line, or using a push-pull action on the syringe, might result in thrombus or injection of particulate matter into the client's circulation.

The nurse is discussing safety when administering bumetanide with a nursing student. The nurse recognizes that the student understands side effects of this medication when the student makes which statement? A) "The client's PT and INR may be prolonged while taking this medication." B) "The client may develop hypoglycemia during treatment." C) "Inverted T waves and a U wave may appear on the ECG." D) "I need to tell the client to avoid salt substitutes."

Answer: C. The nursing student understands the side effects of Bumex when commenting that inverted T waves and a U wave may appear on the EKG. Hypokalemia may cause depressed ST segments, flat or inverted T waves or the presence of a U wave on the ECG as well as dysrhythmias. High-ceiling (loop) diuretics, such as furosemide (Lasix, furosemide), promote loss of water, sodium, and potassium.PT and INR are typically prolonged with therapy with warfarin (Coumadin) or individuals with liver disease. Hypoglycemia may occur with oral hypoglycemic medications or insulin. Salt substitutes are typically avoided when the client has hyperkalemia or is taking an ACE inhibitor because many substitutes contain potassium chloride.

Which client does the charge nurse on a medical-surgical unit assign to the LPN/LVN? A) Cardiac client who has a diltiazem (Cardizem) IV infusion being titrated to maintain a heart rate between 60 and 80 beats/min B) Diabetic client admitted for hyperglycemia who is on an IV insulin drip and needs frequent glucose checks. C) Older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours D) Postoperative client receiving blood products after excessive blood loss during surgery

Answer: C. The older client admitted for confusion with a heparin lock is the most stable and requires basic monitoring of the IV site for common complications such as phlebitis and local infection, which would be familiar to an LPN/LVN.The cardiac client with a diltiazem (Cardizem) IV infusion, the diabetic client on an IV insulin drip, and the postoperative client receiving blood products all are not stable and will require ongoing assessments and adjustments in IV therapy that should be performed by an RN.

A client is to receive an IV solution of 5% dextrose and 0.45% normal saline at 125 mL/hr. Which system provides the safest method for the nurse to accurately administer this solution? A) Controller. B) Glass container. C) Infusion pump. D) Syringe pump.

Answer: C. The safest method is to administer the solution with an infusion pump. Infusion pumps are used for drugs or fluids under pressure. They accurately measure the volume of fluid being infused.A controller is a stationary, pole-mounted electronic device that uses a sensor to monitor fluid flow and detect when flow has been interrupted. Because controllers rely completely on gravity to create fluid flow and do not create pressure, they do not ensure infusion but only control the drip rate. A glass container is necessary to use only with IV solutions that may cling to the plastic bag. This IV solution does not cling to plastic bags. A syringe pump does not hold sufficient volume to be practical in this situation.

When caring for a client who has the following blood gas results, which of these interventions does the nurse plan to use to correct the acid base disturbance? pH 7.47—pCO2 37 mm hg- HCO3 30 mEq/L (30 mmol/L)—pO2 88mm hg A) Endotracheal suctioning. B) Applying oxygen. C) Administering anantiemetic. D) Administering sodium bicarbonate.

Answer: C. When caring for a client who has the following blood gas results, which of these interventions does the nurse plan to use to correct the acid base disturbance? pH 7.47—pCO2 37 mm hg- HCO3 30 mEq/L (30 mmol/L)—pO2 88mm hg

A nurse is evaluating a client wh ois receiving IV fluids to treat isotonic dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective? A) BUN 26 mg/dL. B) Urine specific gravity 1.035. C) Hct 56%. D) Serum sodium 138 mEq/L

Answer: D. A) A BUN of 26 mg/dL is above the expected reference range. An elevated BUN is an indication that the client is still dehydrated. B) A urine specific gravity of 1.035 is above the expected reference range. An elevated urine specific gravity is an indication that the client is still dehydrated. C) This Hct is above the expected reference range. An elevated Hct is an indication of that the client is still dehydrated. D) Isotonic dehydration includes loss of water and electrolytes due to a decrease in oral intake of water and salt. A serum sodium level of 138 mEq/L is within the expected reference range and indicates that the fluid therapy has been effective.

A nurse is caring for a client who has a sodium level of 155 mEq/L. Which of the following IV fluids should the nurse anticipate the provider to prescribe? A) 3% sodium chloride. B) Dextrose 5% in 0.9% sodium chloride. C) Dextrose 5% in lactated Ringer's. D) 0.45% sodium chloride.

Answer: D. A) A sodium level of 155 mEq/L is an indication of hypernatremia. The 3% sodium chloride is a hypertonic solution. The nurse should anticipate a prescription for a hypotonic solution. B) A sodium level of 155 mEq/L is an indication of hypernatremia. Dextrose 5% in 0.9% sodium chloride is a hypertonic solution. The nurse should anticipate a prescription for a hypotonic solution. C) A sodium level of 155 mEq/L is an indication of hypernatremia. Lactated Ringer's solution contains sodium and other electrolytes and is not indicated for hypernatremia. D) A sodium level of 155 mEq/L is an indication of hypernatremia. The nurse should anticipate a prescription for a hypotonic solution. The 0.45% sodium chloride is a hypotonic solution used to provide free water and treat cellular dehydration, which promotes waste elimination by the kidneys.

A nurse is planning care for a client who has a serum potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings? A) Rapid, deep respirations. B) Strong, bounding pulse. C) Hyperactive deep-tendon reflexes. D) Orthostatic hypotension.

Answer: D. A) The nurse should plan to monitor the client for respiratory distress. Weakening of the respiratory muscles and shallow respirations are manifestations of hypokalemia. B) The nurse should plan to monitor the client for a weak and thready pulse. A weak, thready pulse is a manifestation of hypokalemia. C) The nurse should plan to monitor the client for hyporeflexia. Manifestations of hypokalemia include weak hand grip strength and weak deep-tendon reflexes. D) The nurse should plan to monitor the client for orthostatic hypotension, which places him at risk for falls. Orthostatic hypotension is a manifestation of hypokalemia.

A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mm Hg, PaCO2 56 mm Hg, and HCO3- 26 mEq/L. The nurse should interpret these laboratory results as which of the following imbalances? A) Respiratory alkalosis. B) Metabolic acidosis. C) Metabolic alkalosis. D) Respiratory acidosis.

Answer: D. A) The pH is elevated above 7.45 in both respiratory and metabolic alkalosis. B) With metabolic acidosis, the pH is less than 7.35 but the PaCO2 is either within or below the expected reference range, and the HCO3- is decreased. C) The pH is elevated above 7.5 in both respiratory and metabolic alkalosis. D) Status asthmaticus causes inadequate gas exchange, resulting in a low pH and PaO2, an elevated PaCO2, and an HCO3- within the expected reference range. These laboratory values indicate respiratory acidosis.

A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following laboratory values should the nurse report to the provider? A) Potassium 4.8 mEq/L. B) Calcium 9.1 mg/dL. C) Magnesium 2.0 mEq/L. D) Sodium 128 mEq/L

Answer: D. A) This finding is within the expected reference range. However, the nurse should continue to monitor for hypokalemia while the client is taking hydrochlorothiazide. B) This finding is within the expected reference range. However, the nurse should continue to monitor for hypercalcemia while the client is taking hydrochlorothiazide. C) This finding is within the expected reference range. However, the nurse should continue to monitor for hypomagnesemia while the client is taking hydrochlorothiazide. D) This level is below the expected reference range and is the likely cause of the client's altered mental status. The nurse should report this finding to the provider and monitor the client for weakened respiratory effort.

The RN is caring for a client who is severely dehydrated. Which nursing action can be delegated to the unlicensed assistive personnel (UAP)? A) Consulting with a health care provider about a client's laboratory results. B) Infusing 500 mL of normal saline over 60 minutes. C) Monitoring IV fluid to maintain the drip rate at 75 mL/hr. D) Providing oral care every 1 to 2 hours.

Answer: D. Appropriate intervention by an UAP to a client who is severely dehydrated is to provide oral care every 1 to 2 hours. Frequent oral care is important for a client with fluid volume deficit.Consulting with a primary care provider about a client's laboratory results, infusing 500 mL of normal saline, and monitoring IV fluids are complex actions and would be performed by licensed personnel.

A client with hypermagnesemia is seen in the emergency department (ED). Which of these interventions is most appropriate? A)Monitor for hyperactive reflexes. B) prepare for endotracheal intubation. C) Institute teaching on avoiding magnesium rich foods. D) Place the client on a cardiac monitor

Answer: D. Hypermagnesemia causes changes in cardiac rhythm and may result in cardiac arrest, therefore instituting cardiac monitoring is most appropriate.Reflexes are typically reduced in the presence of hypermagnesemia. There is no indication that the client has signs and symptoms of respiratory distress at this time, however the nurse would monitor the client for respiratory weakness and respiratory failure. The nurse will institute teaching after the emergency passes and the cause of the magnesium excess is determined.

The nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed assistive personnel (UAP)? A) Assessing oral mucosa for dryness. B) Choosing appropriate oral fluids. C) Monitoring skin turgor for tenting. D) Offering fluids to drink every hour.

Answer: D. Offering oral fluids every hour is within the scope of practice for a UAP.Assessments of oral mucosa, selection of appropriate fluids, and assessment of skin turgor would be done by licensed nursing staff, who have the needed education and scope of practice to implement these more complex actions.

The nurse is preparing a client a diagnosis of congestive heart failure (CHF) for discharge. Which statement by the client indicates a correct understanding of self-management of CHF? A) "I can gain 2 pounds (1 kg) of water a day without risk." B) "I should call my provider if I gain more than 1 pound (0.5 kg) a week." C) "Weighing myself daily can determine if my caloric intake is adequate." D) "Weighing myself daily can reveal increased fluid retention."

Answer: D. The client with CHF should weigh himself daily to observe for increasing fluid retention, which may not be visible. Rapid weight gain is the best indicator of fluid retention and overload. Each pound (0.5 kg) of weight gained (after the first half-pound [0.2 kg]) equates to 500 mL of retained water. The client must be weighed at the same time every day (before breakfast), and on the same scale.The client would call the primary care provider if more than 1 or 2 pounds (0.5 or 1 kg) are gained in a 24-hour period or if more than 3 pounds (1.4 kg) are gained in 1 week. Daily weights are not an indication of effective dieting for purposes of weight loss or gain. They will show fluid retention after an especially high sodium intake (in a client with fluid retention problems), but caloric intake is related to food intake rather than fluid retention problems.

The nurse is caring for a group of clients on a medical surgical unit. Which newly written prescription will the nurse administer first? A) Intravenous normal saline to a client with a serum sodium of 132 mEq/L (132 mmol/L) B) Oral calcium supplements to a client with severe osteoporosis C) Oral phosphorus supplements to a client with acute hypophosphatemia D) Oral potassium chloride to a client whose serum potassium is 3 mEq/L (3 mmol/L)

Answer: D. The nurse must first administer oral potassium supplements to the client with hypokalemia. Even minor changes in serum potassium levels can cause life-threatening dysrhythmias.The electrolyte disturbances (sodium level of 132 and low phosphorus level) and the need for calcium in the other clients are not immediately life-threatening.

A severely dehydrated client requires a rapid infusion of normal saline and needs a midline IV placed. Which staff member does the emergency department (ED) charge nurse assign to complete this task? A) RN who is certified in the administration of oral and infused chemotherapy medications B) RN with 2 years of experience in the ED who is skilled at insertion of short peripheral catheters. C) RN with 10 years of experience on a medical-surgical unit who has cared for many clients requiring IV infusions. D) RN with certified registered nurse infusion (CRNI) certification who is assigned to the ED for the day.

Answer: D. The nurse with CRNI certification is most likely to be able to quickly insert a midline catheter for a client who is dehydrated.The chemotherapy nurse and the ED nurse have the appropriate scope of practice, but will not be as skilled in inserting a midline IV catheter. The medical-surgical nurse may be skilled at inserting short peripheral catheters, but will not be skilled in inserting midline IV catheters.

A 70-year-old client with severe dehydration is ordered an infusion of an isotonic solution at 250 mL/hr through a midline IV catheter. After 2 hours, the nurse notes that the client has crackles throughout all lung fields. Which action does the nurse take first? A) Assess the midline IV insertion site. B) Have the client cough and deep-breathe. C) Notify the health care provider about the crackles. D) Slow the rate of the IV infusion.

Answer: D. The presence of crackles throughout the lungs is a sign of possible fluid overload. The nurse should slow the rate of infusion and further assess for indicators of volume overload and/or respiratory distress.The presence of crackles throughout the lungs is a sign of possible fluid overload. The nurse should slow the rate of infusion and further assess for indicators of volume overload and/or respiratory distress. Assessing the site and having the client cough and deep-breathe are not appropriate. Crackles do not disappear with coughing. Notifying the provider may be appropriate, but is not the initial actions for this client.

The nurse is assessing fluid balance in the client with heart failure. Which of these strategies will the nurse employ? A) Ask the client how much fluid was consumed yesterday. B) Place an indwelling catheter to measure urine output. C) Auscultate the lungs for adventitious sounds. D) Weigh the client daily, at the same time.

Answer: D. When assessing fluid balance on a client with heart failure the nurse must weigh the client at the same time every day. Changes in daily weights are the best indicators of fluid losses or gains. A weight change of 1 pound (0.5 kg) corresponds to a fluid volume change of about 500 mL therefore the weight must be compared to intake and output.The nurse must weigh the client rather than rely on client estimate or memory. An indwelling catheter poses a risk for catheter associated urinary tract infection, and is reserved for specific reasons. Auscultating for adventitious lung sounds or crackles will demonstrate fluid overload, but may not immediately show up.

The nurse is caring for an older adult with hypernatremia. Which of these interventions does the nurse perform first? A) Restrict the client's intake of sodium. B) Administer a diuretic. C) Monitor the serum osmolarity. D) Encourage fluid intake

Answer: D. When caring for an older adult with hypernatremia, the nurse first encourages the client to take more fluid. Encouraging fluids in the older adult is important to prevent dehydration with resulting concentrated sodium levels.Hypernatremia and fluid loss typically occur in tandem in the older adult. Restricting sodium does not replace fluids needed by many elderly clients. A diuretic will worsen the fluid volume deficit the client is experiencing. Monitoring the osmolarity will detect an abnormality, but not resolve the problem.

The nurse is caring for a client who is receiving a loop diuretic for treatment of heart failure. Which of these actions will be included in the plan of care? (Select all that apply). A) Assess daily weights. B) Encourage consumption o f citrus fruits. C) Weigh the client weekly. D) Monitor serum potassium . E) Discourage intake of spinach. F) MOnitor for bradycardia

Answer; A, B, D. Actions for the nurse to include when caring for a client taking a loop diuretic for heart failure include: assessing daily weights, encouraging consumption of citrus fruits, and monitoring the client's serum potassium. High-ceiling (loop) diuretics remove excess fluid and are potassium-depleting drugs. Consuming citrus fruit, green leafy vegetables, cantaloupe, tomato, and other food with potassium is indicated while receiving this type of diuretic to compensate for urinary loss of potassium.The client must be weighed at the same time each day, using the same scale and wearing approximately the same amount of clothes. Green leafy vegetables such as spinach contain potassium and are encouraged. The diuretic itself has no effect on the heart rate, however potassium depletion caused by the diuretic may cause cardiac irritability with a weak and thready pulse.