Taylor's Fundamentals - Ch. 40
True
True/False: Arterial blood gases are laboratory tests commonly used to determine the adequacy of oxygenation and ventilation, as well as in the assessment and treatment of acid-base imbalance.
C - Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.
Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? A. colloid B. hypotonic C. isotonic D. hypertonic
True
True/False: Surgical hypoparathyroidism, vitamin D deficiency, and malabsorption are also causes of hypocalcemia.
A - Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an extracellular fluid (ECF) volume deficit and hypokalemia. Sodium and chloride levels would be low, not elevated. Changes in magnesium levels typically would not be associated with diarrhea.
A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse likely to find? A. hypokalemia B. hyperphosphatemia C. hyperchloremia D. hypomagnesemia
D - Infants have a far greater volume of total fluid as a percentage of body weight than other children . However, this high percentage of fluid does not give infants a greater reserve against fluid deficit. Instead, it creates a vulnerability to fluid deficit due to the high percentage of fluid required for homeostasis. In addition, kidney immaturity and increased body surface area in relation to body size place infants at greater risk than older children or adults for fluid and electrolyte imbalances.
A nurse is assessing clients across the lifespan for fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances? A. Adolescents B. School-age children C. Toddlers D. Infants
A - The foot is a potential IV insertion site for neonates and infants, but it should not be used once a child can walk.
A nurse is caring for four different pediatric clients, all of whom require insertion of an intravenous (IV) catheter. For which client would it be appropriate to insert the IV into the foot? A. Infant B. Preschool-aged child C. Toddler D. School-aged child
B - Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic.
A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern? A. Milk B. Banana C. Yogurt D. Turkey
B - Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.
A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? A. muscle twitching B. distended neck veins C. nausea and vomiting D. fingerprinting over sternum
True
True/False: Lactated Ringer's intravenous solution contains multiple electrolytes in about the same concentrations as found in plasma.
A - The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate? A. 50 gtt/min B. 30 gtt/min C. 20 gtt/min D. 40 gtt/min
D - The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes. 250 mL × 20 gtt/mL ÷ 60 min = 83 gtt/min
A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min? A. 42 gtt/min B. 5,000 gtt/min C. 167 gtt/min D. 83 gtt/min
B - To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, may increase the client's feeling of thirst. Allowing the client to rinse the mouth frequently may decrease thirst, but this should be done with water, not alcohol-based, mouthwashes, which would have a drying effect.
A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? A. Use regular gum and hard candy. B. Avoid salty or excessively sweet fluids. C. Use an alcohol-based mouthwash to moisten your mouth. D. Eat crackers and bread.
A - In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss.
A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? A. "I should drink 2,500 mL/day of fluid." B. "I should drink 1,500 mL/day of fluid." C. "I need to drink no more than 1,000 mL/day" D. "I should drink more than 3,500 mL/day of fluid."
Hypovolemia
Fluid volume deficit, also known as ____________ , is caused by a loss of both water and solutes in the same proportion from the extracellular fluid space.
Acidosis
Respiratory _____________ is produced by inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 and increased levels of carbonic acid.
D - Transfusions must be completed within 4 hours due to the potential for bacterial growth in a blood product at room temperature.
The nurse is assuming care for a client who is receiving an infusion of packed red blood cells (PRBCs). The PRBCs were hung 4 hours ago, and 100 mL is left to infuse. Which action is most appropriate? A. Continue to infuse the PRBCs until they are completely infused. B. Insert a larger gauge IV catheter and transfer the infusion to the new insertion site. C. Fully open the roller clamp on the infusion set and infuse the remaining PRBCs as rapidly as possible. D. Discontinue the infusion and record the volume left in the blood bag.
Infiltration
The nurse should regularly assess venous access sites to detect common complications of intravenous therapy including _________________, the inadvertent leakage of intravenous solution into the surrounding tissue.
B - Because blood is one possible mode of transmitting prions from animals to humans and humans to humans, the collection of blood is banned from anyone who has lived in the UK for a total of 3 months or longer since 1980, lived anywhere in Europe for a total of 6 months since 1980, or received a blood transfusion in the UK. The other statements do not require nursing intervention.
The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? A. "I have never given blood before." B. "I received a blood transfusion in the United Kingdom." C. "My blood type is B positive." D. "My spouse would also like to donate blood."
False
True/False: Acidosis occurs when there is a lack of H ions or a gain of base (bicarbonate) and the pH exceeds 7.45.
True
True/False: Oxygen and carbon dioxide exchange in the lung's alveoli and capillaries occurs by diffusion.
B - Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, exudate, warmth, induration, and pain. A systemic infection includes manifestations such as chills, fever, tachycardia, and hypotension. An infiltration involves manifestations such as swelling, coolness, and pallor at the catheter insertion site. Rapid fluid administration can result in fluid overload, and manifestations may include an elevated blood pressure, edema in the tissues, and crackles in the lungs.
Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of: A. rapid fluid administration. B. phlebitis. C. an infiltration. D. a systemic blood infection.
Donors
When considering the four main blood types, the nurse is aware that people with type AB blood are often called universal recipients, whereas people with type O blood are often called universal ___________.
B - An infant has considerably more total body fluid and extracellular fluid (ECF) than does an adult. Because ECF is more easily lost from the body than intracellular fluid, infants are more prone to fluid volume deficits. An adolescent at 17 years is considered to have an adultlike body system similar to the 45-and 50-year-old.
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? A. a man age 50 years B. an infant age 4 months C. an adolescent age 17 years D. a woman age 45 years
B - Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium. Signs of potassium defecit, or hypokalemia, include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias.
A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte? A. Calcium B. Potassium C. Chloride D. Phosphorous
C - To treat a client with hypovolemia, the nurse should obtain an IV bag with normal saline (0.9% sodium chloride) as prescribed. Fluid intake by mouth will not provide fluid quickly enough for the desired effect but should be attempted if feasible, in addition to an IV. Orange juice with additional sugar may be given to a person with low blood sugar.
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? A. Encourage fluid intake. B. Give the client a glass of orange juice with added sugar. C. Start an IV of normal saline as prescribed. D. Allow nothing by mouth.
B - To treat a client with hypovolemia, the nurse should obtain an IV bag with normal saline (0.9% sodium chloride) as prescribed. Fluid intake by mouth will not provide fluid quickly enough for the desired effect but should be attempted if feasible, in addition to an IV. Orange juice with additional sugar may be given to a person with low blood sugar.
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? A. Give the client a glass of orange juice with added sugar. B. Start an IV of normal saline as prescribed. C. Allow nothing by mouth. D. Encourage fluid intake.
A - Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume. When a client does not drink, the body begins intracellular dehydration and the client becomes thirsty. There is no extracellular dehydration.
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? A. decreased blood volume and intracellular dehydration B. increased blood volume and extracellular overhydration C. decreased blood volume and extracellular overhydration D. increased blood volume and intracellular dehydration
B - The edema that occurs with heart failure is caused by decreased cardiac output with a back-up of blood resulting from increased hydrostatic pressure. Decreased colloid oncotic pressure is the mechanism responsible for edema of malnutrition, liver failure, and nephrosis. Lymph node blockage is the mechanism responsible for edema associated with a mastectomy or lymphoma. Increased capillary permeability is the mechanism responsible for edema associated with allergies, septic shock and pulmonary edema.
A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address? A. decreased colloid oncotic pressure B. increased hydrostatic pressure C. blockage of the lymph nodes D. increased capillary permeability
A - The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost from vomiting and diarrhea.
A woman aged 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires: A. replacement of fluids for those lost from vomiting and diarrhea. B. an access route to administer medications intravenously. C. an access route to replace fluids in combination with blood products. D. intravenous fluids to be administered on an outpatient basis.
A - When calculating the infusion rate with an electronic device, divide the total volume to be infused (1,000 mL) by the total amount of time in hours (12). This is 83 mL/hr. Other options are incorrect.
The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate? A. 83 mL/hr B. 13 mL/hr C. 100 mL/hr D. 103 gtts/hr
A, C, D, E - The nurse will document all fluid intake and fluid loss. This includes drinking liquids and intravenous fluids. The liquid equivalent of melted ice chips is fluid intake. Foods that are liquid by the time they are swallowed, such as gelatin, ice cream, and thin cooked cereal, are documented as fluid intake. A bowl of chili is a solid food as is a barbecue sandwich. While the amount eaten may be documented in the chart, it is not part of the fluid intake.
The nurse is monitoring fluid intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the record? Select all that apply. A. serving of jello B. barbecue sandwich C. 100 ml from melted ice chips D. infusion of intravenous solution E. cup of ice cream F. bowl of chili
Osmosis
Through the process of ____________, water (solvent) passes from an area of lesser solute concentration and more water to an area of greater solute concentration and less water until equilibrium is established.
D - The nurse knows that the client's electrolytes need to be restored. Rehydration after exercise can only be achieved if the electrolytes lost in sweat, as well as the lost water, are replaced. The client does not need to have nonelectrolytes, colloid solution, or interstitial fluid restored. Nonelectrolytes are chemical compounds that remain bound together when dissolved in a solution. Interstitial fluid is the fluid in the tissue space between and around cells. Colloids are substances that do not dissolve into a true solution and do not pass through a semipermeable membrane.
A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of: A. colloid solution. B. nonelectrolytes. C. interstitial fluid. D. electrolytes.
B - Implanted CVADs are ideal for long-term uses such as chemotherapy. The short-term nature of peripheral IVs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of chemotherapy. Because of the caustic nature of most chemotherapy agents, peripheral IV's are not appropriate.
A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs? A. A peripheral venous catheter inserted to the cephalic vein B. An implanted central venous access device (CVAD) C. A peripheral venous catheter inserted to the antecubital fossa D. A midline peripheral catheter
B - The edema that occurs with heart failure is caused by decreased cardiac output with a back-up of blood resulting from increased hydrostatic pressure. Decreased colloid oncotic pressure is the mechanism responsible for edema of malnutrition, liver failure, and nephrosis. Lymph node blockage is the mechanism responsible for edema associated with a mastectomy or lymphoma. Increased capillary permeability is the mechanism responsible for edema associated with allergies, septic shock and pulmonary edema.
A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address? A. blockage of the lymph nodes B. increased hydrostatic pressure C. decreased colloid oncotic pressure D. increased capillary permeability
A, D - The nurse would prepare the site with a single application of 2% chlorhexidine in 70% isopropyl alcohol, using gentle pressure in a side to side, back and forth motion. For clients with chlorhexidine allergies, the nurse would use povidone-iodine swabs, using an expanding circular motion, allowing one minute contact time and removing the povidone-iodine with an alcohol pad.
A nurse is preparing the site for insertion of a peripheral venous catheter using chlorhexidine. Which actions would be appropriate for the nurse to do? Select all that apply. A. use a back and forth motion B. apply deep pressure C. apply alcohol after the chlorhexidine D. rub in a side to side motion E. rub in a circular motion
D - Life-threatening transfusion reactions generally occur within the first 5 to 15 minutes of the infusion, so the nurse or someone designated by the nurse usually remains with the client during this critical time. Whenever a transfusion reaction is suspected or identified, the nurse's first step is to stop the transfusion, thereby limiting the amount of blood to which the client is exposed. All other options should occur after the transfusion is stopped.
The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action? A. Assess oxygen levels. B. Call for assistance. C. Assess for visible rash. D. Stop the transfusion.
B - he primary extracellular electrolytes are sodium, chloride, and bicarbonate.
The primary extracellular electrolytes are: A. potassium, phosphate, and sulfate. B. sodium, chloride, and bicarbonate. C. phosphorous, calcium, and phosphate. D. magnesium, sulfate, and carbon.
B - Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? A. "Watery plasma, or serum, portion of blood." B. "Fluid in the tissue space between and around cells." C. "Fluid outside cells." D. "Fluid inside cells."
C, D, E - The nurse knows that clients with major trauma or burns, clients with liver and renal failure, and clients with inflammatory bowel disease are likely candidates for TPN. Clients who have not eaten for a day or clients recovering from cataract surgery are not likely candidates for TPN. Clients who have not eaten for 5 days and are not likely to eat during the next week are considered for TPN.
A nurse is caring for a client who is on total parenteral nutrition (TPN). Which clients are candidates for TPN? Select all that apply. A. clients who have not eaten for a day B. clients who are recovering from cataract surgery C. clients with inflammatory bowel disease D. clients with liver and renal failure E. clients with major trauma or burns
D - An IV catheter should not be reinserted. Whether the IV is salvageable depends on how much of the catheter remains in the vein. Because this catheter has been almost completely pulled out of the insertion site, it should be discarded and a new one inserted at a different location. It is not acceptable simply to apply a new dressing and leave the catheter sticking out of the site.
The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the siderail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate? A. Apply a new dressing and observe for signs of infection over the next several hours. B. Decontaminate the visible portion of the catheter, and then gently reinsert. C. Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air. D. Remove the IV catheter and reinsert another in a different location.
D - The nurse is engaged in the scanning of the bar code associated with the selected IV solution. This activity will help assure the solution is the one prescribed and that the expiration date is not expired. This information helps assure the selected solution is appropriate for this IV prescription. Scanning the bar code does not contribute to the affective administration of the solution. While appropriate goals, neither effective time management nor effective nursing care is the priority goal in this particular situation.
What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution? A. To assure the IV solution is appropriate for this administration B. To demonstrate effective nursing care in the administration of the prescribed IV solution C. To provide for effective time management in the administration of the prescribed IV solution D. To assure effective administration of the prescribed IV solution
