Fundamentals Unit 2

A nurse is participating in a blood drive and is taking a donation from a client who has type O+ blood. The client asks the nurse what type of flood they can receive. Which of the following statements should the nurse make?

"You can receive a blood donation from donors with type O- or type O+ blood. Rationale: Clients who have type O+ bloodcan only receive blood from donors who have type O- blood or type O+ blood. Clients who have type O- are universal donors, meaning that anyone can receive their blood, regardless of blood type

A nurse is caring for a patient who requires a replacement peripheral IV. The client is dehydrated and requires a smaller gauge catheter than the 20-gauge being replaced. Which of the following gauge catheters should the nurse plan to use?

#22-gauge Rationale: The nurse should use a 22-gauge catheter as a replacement for the current 20-gauge IV catheter. As the client is dehydrated, it may be difficult to access a peripheral vein with a larger gauge catheter. As the gauge # increases, the actual catheter size decreases.

A nurse is reviewing prescriptions for a client who needs intravenous fluid replacement therapy due to vomiting and diarrhea. Which of the following fluid prescriptions should the nurse expect to initiate?

0.9% sodium chloride solution Rationale: A 0.9% sodium chloride solution is isotonic and is used for hydration needs such as from vomiting, diarrhea, hemorrhage, and shock. This is the most appropriate solution for the provider to prescribe for this client

A nurse is receiving report on four clients. The nurse should identify that which of the following clients might be experiencing hypomagnesemia?

A client who has vomited four times during the last 8 hr

A nurse is participating in a blood drive and is taking a donation from a client who has type A- blood. The client asked the nurse what blood types can receive their blood donation. which of the following responses should the nurse make? (Select all that apply.)

A+, AB-, AB+, A- Rationale: A+ can receive A- blood AB- can receive A- blood AB+ can receive A- blood A- can receive A- blood

A nurse caring for a client who is experiencing hypovolemia. Which of the following findings should the nurse identify as the priority to report to the provider?

Decrease in level of consciousness Rationale: When using the urgent vs non-urgent priority framework, the nurse determines that the priority finding is a decrease in the client's level of consciousness. This is an indication that hypovolemia has progressed to a critical level and requires immediate intervention

A nurse is reviewing the latest arterial blood gas (ABG) values for a client who is experiencing metabolic alkalosis. The nurse should identify that this action is part of which of the following steps of the nursing process?

Evaluation Rationale: Reviewing the client's ABG values is part of the evaluation stage of the evaluation stage of the nursing process. During the evaluation stage, the nurse should determine if the actions taken in the implementation stage were successful in meeting the goals in the client's plan of care

A nurse has completed assessing and analyzing data for a client who has an acid-base imbalance. Which of the following steps of the nursing process should the nurse take next?

Planning Rationale: After assessing and analyzing data for a client who has an acid-base imbalance, the nurse should move into the planning stage of the nursing process and establish goals and outcomes for the client

A nurse is assessing a client who is exhibiting signs of a fluid and electrolyte imbalance. Which of the following findings should the nurse identify as a potential cause for the client's fluid and electrolyte imbalance?

The client reports that they performed yard work for 8 hrs in 35 C (95F) temperature earlier that day Rationale: The nurse should identify that working outside in high temperatures for an extended period can cause profuse sweating and lead to a fluid and electrolyte imbalance.

A nurse is caring for a client who is receiving treatment for hyponatremia. The nurse should identify that which of the following findings is an indication that the treatment has been effective? (Select all that apply.)

The client states their muscle spasms are absent The client denies being confused Rationale: The absence of muscle spasms indicates that the treatment for hyponatremia has been effective. The client reporting that they are not confused is an indication of adequate sodium levels. Therefore, this is an indication that the treatment has been effective