CH. 11-13 MedSurg AQ

The nurse is teaching a hospitalized patient who is being discharged about how to care for a peripherally inserted central catheter (PICC) line. Which patient statement indicates a need for further education? 1. "I can continue my 20-mile running schedule as I have for the past 10 years." 2. "I can still go about my normal activities of daily living." 3. "I have less chance of getting an infection because the line is not in my hand." 4. "The PICC line can stay in for months."

1. "I can continue my 20-mile running schedule as I have for the past 10 years." Excessive physical activity can dislodge the PICC and should be avoided. Patients 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).

A patient has a serum magnesium level of 1.2 mEq/L. Which instruction by the nurse is appropriate? 1. "Notify me if you have diarrhea." 2. "I will be giving you an intramuscular injection of magnesium sulfate." 3. "Your urine may become darker and more concentrated in appearance." 4. "I will be administering a phosphorus supplement in addition to the magnesium supplement."

1. "Notify me if you have diarrhea." A serum magnesium level of 1.2 mEq/L represents mild hypomagnesemia (normal is 1.3-2.1 mEq/L) for which oral magnesium supplements are administered. Oral magnesium may lead to diarrhea; diarrhea contributes to magnesium loss. With severe hypomagnesemia, the IV route (instead of IM) is used because the IM route causes tissue damage and pain. Any medications containing phosphorus are contraindicated because they would contribute to associated hypocalcemia. Magnesium therapy does not affect the urine.

A patient with severe hypokalemia is prescribed parenteral administration of potassium. How does the nurse administer potassium to the patient? 1. 1 mEq of potassium to 10 mL intravenous solution 2. 10 mEq of potassium to 10 mL intravenous solution 3. 1 mEq of potassium to 10 mL solution intramuscularly 4. 10 mEq of potassium to 10 mL solution intramuscularly

1. 1 mEq of potassium to 10 mL intravenous solution Potassium is given intravenously for severe hypokalemia, but only mixed in a solution. It is available in many concentrations. The risk of solute overload causing congested states with peripheral and pulmonary edema is directly proportional to the electrolyte concentrations of such solutions. Therefore 1 mEq of potassium to 10 mL of solution is the preferred dilution to prevent the risk associated with hyperkalemia. A concentration of 10 mEq of potassium to 10 mL of solution is too high and can cause tissue irritation. Potassium is a severe tissue irritant; it may cause necrosis and loss of function of the tissue, and so is never given as an intramuscular or subcutaneous injection.

When administering 20 mEq potassium chloride intravenously (IV), which is the priority intervention? 1. Administer at a rate of 10 mEq/hr. 2. Monitor respiratory rate and depth. 3. Monitor for pain or burning at the IV infusion site. 4. Place the patient on a heart monitor during administration.

1. Administer at a rate of 10 mEq/hr. The maximum recommended infusion rate is 5 to 10 mEq/hr to avoid potentially lethal cardiac dysrhythmias. Monitoring for pain at the IV infusion site, assessing respiratory rate and depth, and placing the patient on a heart monitor are all appropriate options, but because a rapid rate of administration could have lethal effects, it has the greatest priority.

The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The patient with which electrolyte laboratory value is assigned to the LPN/LVN? 1. Calcium level of 9.5 mg/dL 2. Sodium level of 120 mEq/L 3. Potassium level of 6.0 mEq/L 4. Magnesium level of 4.1 mEq/L

1. Calcium level of 9.5 mg/dL Because a calcium level of 9.5 mg/dL is within normal limits, it is appropriate to assign this patient to an LPN/LVN. A magnesium level of 4.1 mEq/L, potassium level of 6.0 mEq/L, and a sodium level of 120 mEq/L are abnormalities in electrolytes that can cause serious complications and will require assessments and/or interventions by the RN.

Hyponatremia most affects the cells of which body systems? Select all that apply. 1. Cerebral 2. Endocrine 3. Respiratory 4. Cardiovascular 5. Neuromuscular

1. Cerebral 4. Cardiovascular 5. Neuromuscular The cells of the cerebral, cardiovascular, and neuromuscular systems are most affected by hyponatremia. The cells of the endocrine and respiratory systems are not as affected.

Which nursing interventions are consistent with safe administration of intravenous (IV) potassium to a patient with hypokalemia? Select all that apply. 1. Evaluate the heart rate and regularity. 2. Establish and evaluate the patency of a large vein. 3. Obtain an IV controller device (pump). 4. Plan to assess the respiratory rate and oxygen saturation every hour. 5. Prepare to administer potassium IV push to reduce the risk of infiltration. 6. Encourage the patient to ambulate independently to relieve muscle cramps

1. Evaluate the heart rate and regularity. 2. Establish and evaluate the patency of a large vein. 3. Obtain an IV controller device (pump). 4. Plan to assess the respiratory rate and oxygen saturation every hour. Pulse irregularities (rapid to slow and irregular) may occur with changes in serum potassium levels and should be evaluated. To safely administer IV potassium, the nurse would ensure that the patient has IV access in a large vein if possible, obtain an IV pump to regulate the infusion rate at no greater than 10 mEq of potassium per hour, and evaluate the patient's respiratory status hourly during and immediately following infusion (as respiratory insufficiency is the major cause of death). Potassium should never be given IV push, as it will result in cardiac arrest. Patients with hypokalemia have skeletal muscle weakness, so fall precautions should be implemented, and the patient should have assistance with ambulation.

The primary health care provider prescribes intravenous administration of 100 mL of 20% glucose along with 20 units of insulin in a patient who is receiving furosemide therapy. What is the probable diagnosis of the patient? 1. Hyperkalemia 2. Hyperglycemia 3. Hypernatremia 4. Hypercalcemia

1. Hyperkalemia Hyperkalemia is a condition where serum potassium levels are high. Potassium movement into the cells is enhanced by insulin. Intravenous administration of 100 mL 10% to 20% glucose with 10 to 20 units of regular insulin helps decrease serum potassium levels. Insulin increases the activity of sodium-potassium pumps, which decreases serum potassium levels temporarily by moving potassium from the extracellular fluid to the cells. This therapy is prescribed as an add-on therapy along with diuretics in a hyperkalemic patient. Conditions such as hyperglycemia, hypernatremia, and hypercalcemia cannot be managed with this insulin and glucose therapy.

A patient is admitted to the hospital with a heart rate of 166 beats/min, increased thirst, restlessness, and agitation. Which electrolyte imbalance does the nurse suspect? 1. Hypernatremia 2. Hypercalcemia 3. Hypomagnesemia 4. Hyperphosphatemia

1. Hypernatremia These symptoms are indicative of hypernatremia. Clinical manifestations of hypomagnesemia are seen in the neuromuscular, central nervous, and intestinal systems. Hypercalcemia manifests with an altered level of consciousness that can range from confusion and lethargy to coma, and severe hypercalcemia depresses electrical conduction, slowing heart rate. Hyperphosphatemia causes few direct problems with body function (although hypocalcemia is usually also present).

A patient has a low serum potassium level and is ordered a dose of parenteral potassium chloride (KCl). How does a nurse safely administer KCl to the patient? 1. Infuses 10 mEq over a 1-hour period 2. Administers 5 mEq intramuscularly (IM) 3. Pushes 5 mEq through a central access line 4. Dilutes 200 mEq in 1 liter of normal saline and infuses at 100 mL/hr

1. Infuses 10 mEq over a 1-hour period A dose of KCl 10 mEq given over 1 hour is appropriate for this patient. A dose of KCl 200 mEq in 1 liter of normal saline infused at 100 mL/hr is too concentrated and can cause injury. Potassium is a severe tissue irritant and is never given by the intramuscular or subcutaneous route. Because rapid infusion of potassium can cause cardiac arrest, potassium is not administered through central lines.

A morbidly obese patient has chosen gastric bypass surgery to promote weight loss. The nurse plans to teach the patient about the need to perform monitoring to detect what disturbance consistent with rapid weight loss associated with this procedure? 1. Ketosis 2. Hypoxemia 3. Urinary retention 4. Insufficient ventilation

1. Ketosis Starvation, fasting, or following a strict calorie-reduced diet with rapid weight loss contributes to ketone formation and metabolic acidosis. Weight loss should decrease the work of breathing and improve hypoxemia, if present, as well as hypoventilation. Urinary retention does not occur in acid-base imbalance.

Which fruit will the nurse remove from the dietary tray of a patient with high potassium levels? 1. Kiwi 2. Berries 3. Apricots 4. Grapefruit

1. Kiwi Kiwis are high in potassium, so the nurse will remove this food from the tray. However, berries, apricots, and grapefruits are low in potassium, so this patient does not need to avoid them.

A patient has been having acute diarrhea for more than 24 hours from a viral infection. Which acid-base imbalance is most likely to manifest? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Metabolic acidosis Diarrhea results in excessive elimination of bicarbonate, creating an imbalance between hydrogen ions and bicarbonate, leading to metabolic acidosis. Diarrhea would not cause a respiratory acid-base imbalance. Metabolic alkalosis is incorrect because the patient is losing base rather than experiencing higher concentrations of base seen with alkaline conditions.

Deep and rapid breaths consistent with Kussmaul respirations are found in patients with which type of acid-base imbalance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Metabolic acidosis In metabolic acidosis, the rate and depth of breathing increase as the hydrogen ion levels rise. The breathing pattern becomes deep and rapid and not under voluntary control. This type of breathing is known as Kussmaul respiration, which is not present in respiratory alkalosis, respiratory acidosis, or metabolic alkalosis.

The nurse obtains lab results for a 50-year-old patient with the following results: pH 7.24; bicarbonate 20; PaO 2 82; PaCO 2 35. These findings are consistent with which acid-base imbalance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Metabolic acidosis In metabolic acidosis, there is a decrease in pH (normal is 7.35-7.45), a decrease in bicarbonate (normal is 21-28), a normal PaO 2 (normal is 80-100), and a normal or decreased PaCO 2 (normal is 35-45). The arterial blood gas results of pH 7.24; bicarbonate 20; PaO 2 82; PaCO 2 35 reflect metabolic acidosis. In metabolic alkalosis, there is an increase in pH, increase bicarbonate, normal PaO 2, and normal PaCO 2. In respiratory alkalosis, there is an increase in pH, a normal bicarbonate, a normal PaO 2, and a decrease in PaCO 2 In respiratory acidosis, there is an in decrease in pH, normal bicarbonate, normal PaO 2, and increased PaCO 2.

The nurse is attending to a patient receiving IV vancomycin. What actions does the nurse take for this patient during IV therapy? Select all that apply. 1. Monitor the IV site continuously for manifestations of infiltration. 2. Insert the IV at a new location if redness occurs at the current site. 3. Continue administration until the prescribed dose is administered. 4. Discontinue the IV if swelling, cooling, or redness occurs. 5. Notify the infusion team of any adverse reactions

1. Monitor the IV site continuously for manifestations of infiltration. 4. Discontinue the IV if swelling, cooling, or redness occurs. 5. Notify the infusion team of any adverse reactions The nurse should monitor the IV site continuously for manifestations of infiltration, discontinue the IV if swelling, cooling, or redness occurs at the site of administration, and notify the infusion team of any adverse reactions. The nurse should not insert the IV at a new location if redness occurs at the current site or continue administration until the prescribed dose is administered. The health care provider should be notified of the reaction. Based on the health care provider's order, the IV may be continued using a central line.

A patient with a central vascular access device (CVAD) reports unusual pain during an infusion. Which assessment would be done for this patient? 1. Obtain a repeat chest x-ray. 2. Assess for redness, hardness, or swelling. 3. Palpate the area over the dressing lightly. 4. Assess for signs of phlebitis and thrombosis.

1. Obtain a repeat chest x-ray. A repeat x-ray should be obtained prior to subsequent catheter use if the patient reports unusual pain. Correct placement of the catheter tip must be confirmed before re-initiating infusion through the catheter. All infusion systems should be assessed by lightly palpating the area over the dressing and checking for redness, hardness, or swelling at the site. When a midline catheter or a peripherally inserted central catheter (PICC) is used, the nurse should observe the extremity and chest area for phlebitis and thrombosis. These assessment activities are done in all patients with CVADs, but do not specifically address a patient with a complaint of pain after CVAD use.

A diabetic patient shows symptoms of diabetic ketoacidosis. What mechanism causes acidosis in this patient? 1. Overproduction of hydrogen ions 2. Underelimination of hydrogen ions 3. Overelimination of bicarbonate ions 4. Underproduction of bicarbonate ions

1. Overproduction of hydrogen ions In diabetic ketoacidosis, there is an excessive breakdown of fatty acids. This produces strong acids (ketoacids) with the release of large amounts of hydrogen ions. Underelimination of hydrogen ions occurs when hydrogen ions are produced at normal rates, but their elimination is reduced. This is seen in patients with lung and kidney problems. Bicarbonate ion is made in the kidney or in the pancreas. In patients with impaired kidney or pancreatic function, there is underproduction of bicarbonate ions leading to acidosis. Overelimination of bicarbonate ions occurs when there is an excessive loss of bicarbonate ions. This occurs in diarrhea.

What is a possible initial complication of a patient receiving an intravenous infusion of a drug with a pH of 3 and an osmolarity of 500 mOsm/L through a short peripheral catheter? 1. Phlebitis 2. Infiltration 3. Ecchymosis 4. Thrombosis

1. Phlebitis For a short peripheral catheter, the pH of the intravenous infusion should be between 5 and 9 and the osmolarity should be between 270 to 300 mOsm/L. Infusions of a low pH and high osmolarity may cause chemical injury, which leads to vein irritation and phlebitis. Infiltration is the leakage of non-vesicants into surrounding tissues. Ecchymosis is caused by infiltration of blood into the surrounding tissues. Thrombosis is the formation of a blood clot caused by vein inflammation, not irritation.

The health care provider writes orders for a patient who is admitted with a serum potassium (K) level of 6.9 mEq/L. What does the nurse implement first? 1. Place the patient on a cardiac monitor. 2. Administer sodium polystyrene sulfonate orally. 3. Ensure that a potassium-restricted diet is ordered. 4. Teach the patient about foods that are high in potassium

1. Place the patient on a cardiac monitor. Because hyperkalemia can lead to life-threatening bradycardia, the initial action should be to place the patient on a cardiac monitor. Administering a potassium-reducing medication, recommending a potassium-restricted diet, and teaching the patient 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.

The nurse has just received a report on a patient being admitted from the emergency department (ED). Which items from the report would contribute to the development of metabolic acidosis? Select all that apply. 1. Reported heavy alcohol consumption 2. Chronic cirrhosis of the liver with liver failure 3. Fractured wrist from an altercation at a local bar 4. Seizure in the ambulance en route to the hospital 5. Blood pressure of 148/92 mm Hg upon admission to the ED

1. Reported heavy alcohol consumption 2. Chronic cirrhosis of the liver with liver failure 4. Seizure in the ambulance en route to the hospital Ingestion of a large amount of alcohol causes acidosis. Liver disease can impair production of bicarbonate, contributing to acidosis. Lactic acidosis occurs with seizure activity. Mild hypertension and a fractured wrist will not affect acid-base balance.

Which electrolyte deficiency results in decreased depolarization in the excitable cells and increased cellular swelling? 1. Sodium 2. Calcium 3. Potassium 4. Magnesium

1. Sodium Hyponatremia occurs when sodium levels are low; this condition causes decreased depolarization in excitable cells and increased cellular swelling. Low serum calcium levels lead to muscle cramping and cardiac arrhythmias. A potassium deficiency causes cardiac dysrhythmias. A decrease in the level of magnesium may cause increased nerve impulse transmission.

Which nursing intervention is the most appropriate when meeting resistance during the flushing of a peripheral catheter? 1. Stop flushing the catheter. 2. Assess the IV line for kinks. 3. Assess the catheter for blood return. 4. Reposition the extremity where the catheter is.

1. Stop flushing the catheter. When meeting resistance while flushing a catheter, the procedure should be stopped immediately. Continuing to apply pressure while flushing a catheter with resistance can result in a ruptured catheter or forcing a blood clot into the circulation. Assessing the IV line for kinks, assessing for blood return, and repositioning the extremity the catheter where the catheter is will not alter the patency of the catheter.

Which statement made by a student nurse regarding the guidelines published by the Occupational Safety and Health Administration (OSHA) on needleless connection devices indicates a need for further education? 1. "The guidelines necessitate the use of devices developed with safety mechanisms." 2. "The goal of the guidelines is to limit the transmission and spread of airborne pathogens." 3. "This regulation requires each employer to maintain a log regarding sharps injury along with the incident details." 4. "The Occupational Exposure to Bloodborne Pathogens, Final Rule has been revised as per the Needlestick Safety and Prevention Act."

2. "The goal of the guidelines is to limit the transmission and spread of airborne pathogens." The OSHA guidelines have the goal of limiting the spread of bloodborne, not airborne, pathogens. The Occupational Exposure to Bloodborne Pathogens, Final Rule necessitates the use of devices developed with safety mechanisms. It also requires each employer to maintain a log regarding sharps injury along with the incident details. The Occupational Exposure to Bloodborne Pathogens, Final Rule was revised in 2001 as per the Needlestick Safety and Prevention Act.

A hypertensive patient was brought to the emergency department with a heart rate of 115 beats per minute and an abnormal electrocardiogram showing a shortened QT interval. The laboratory findings of the patient show a serum calcium level of 11 mg/dL. What nursing interventions would help stabilize the patient? Select all that apply. 1. Administering thiazide diuretics 2. Administering high ceiling or loop diuretics 3. Administering 0.9% normal saline intravenously 4. Administering nonsteroidal, anti-inflammatory agents 5. Administering lactated Ringer's solution intravenously

2. Administering high ceiling or loop diuretics 3. Administering 0.9% normal saline intravenously Hypercalcemia clinically manifests as serum calcium levels above 10.5 mg/dL. This condition can be managed by using loop diuretics such as furosemide, which promote the excretion of calcium. One cause of hypercalcemia is dehydration, which can be well managed by administering 0.9% normal saline intravenously. Thiazide diuretics do not promote the excretion of calcium and thus are not suitable treatments for hypercalcemia. Lactated Ringer's solution contains calcium; administering this solution does not help decrease the serum calcium levels. Administering nonsteroidal, anti-inflammatory agents prevents hypercalcemia by calcium resorption from the bone; however, it does not treat hypercalcemia.

Which veins may lead to nerve damage if used for intravenous therapy? Select all that apply. 1. Radial vein in the forearm 2. Cephalic vein near the wrist 3. Basilic vein in the upper arm 4. Cephalic vein in the upper arm 5. Veins on the palmar side of the wrist

2. Cephalic vein near the wrist 5. Veins on the palmar side of the wrist The cephalic vein near the wrist and veins near the palmar side of the wrist should not be used for infusion therapy to prevent nerve damage. Radial veins in the forearms, basilic veins in the upper arms, and cephalic veins in the upper arms can be used for infusion therapy. These veins are not associated with nerve damage.

Which is the least preferred site for peripherally inserted central catheters (PICC)? 1. Basilic vein 2. Femoral vein 3. Subclavian vein 4. Internal jugular vein

2. Femoral vein Because there is a higher risk for infection, the femoral vein is the least preferred site for a PICC line insertion. The basilic vein is preferred because it offers the largest diameter of the blood vessels. The subclavian vein is also preferred because it is easy to access using bony landmarks, followed by an internal jugular vein. The basilic, subclavian, and internal jugular veins have a lower risk for infection than the femoral vein.

A patient who recently experienced an anterior neck injury reports frequent and painful muscle spasms in the calf during sleep. Which condition does the nurse suspect in the patient? 1. Hypokalemia 2. Hypocalcemia 3. Hyponatremia 4. Hypophosphatemia

2. Hypocalcemia Patients with a history of anterior neck injury are at a high risk for hypocalcemia. Frequent painful muscle spasms in the calf or foot during rest or sleep (charley horses) indicate hypocalcemia. Hypokalemia, hyponatremia, and hypophosphatemia do not cause painful calf muscle spasms.

A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Her laboratory results include a potassium level of 3.0 mEq/L. What does the nurse include in the patient's medication teaching? Select all that apply. 1. Diuretics increase fluid retention. 2. Laxatives can lead to fluid imbalance. 3. It is important to weigh daily at the same time. 4. Diuretics can lead to fluid and electrolyte imbalances. 5. Daily weights are a poor indicator of fluid loss or gain

2. Laxatives can lead to fluid imbalance. 3. It is important to weigh daily at the same time. 4. Diuretics can lead to fluid and electrolyte imbalances. Diuretics decrease fluid retention and increase loss of fluids, thus can lead to fluid and electrolyte imbalances. Laxatives can also lead to fluid imbalance. Daily weight recording is a good indicator of fluid retention. Patients should be taught to weigh themselves at the same time, in the same clothing, and on the same scale.

The nurse is assessing a patient with hyponatremia. Which finding requires immediate action? 1. Heightened acuity 2. Muscular weakness 3. Urine output of 35 mL/hr 4. Diminished bowel sounds

2. Muscular weakness Muscle weakness in patients with hyponatremia requires immediate action. If muscle weakness is present, immediately check respiratory effectiveness because ventilation is dependent on adequate strength of the respiratory muscles. Excessive bowel sounds, not diminished bowel sounds, are expected in the patient with hyponatremia, as well as mild confusion, not heightened acuity. A urine output of 35 mL/hr is normal (minimally) and does not require immediate action.

A patient is admitted with hypokalemia and skeletal muscle weakness. Which assessment does the nurse perform first? 1. Pulse 2. Respirations 3. Temperature 4. Blood pressure

2. Respirations Respiratory changes are likely because of weakness of the muscles needed for breathing. Skeletal muscle weakness results in shallow respirations. Thus respiratory status should be assessed first in any patient who might have hypokalemia. Blood pressure and pulse will be altered in this patient, but they are not the priority assessment. Temperature is not a priority assessment for the patient with hypokalemia.

What history and assessment findings may be associated with hypocalcemia in a 22-year-old man? Select all that apply. 1. Absent bowel sounds 2. Tingling around the mouth 3. Awakening at night with muscle spasms in the calf 4. Decreased deep tendon reflexes without paresthesia 5. Recent blunt trauma to the throat during a football game

2. Tingling around the mouth 3. Awakening at night with muscle spasms in the calf 5. Recent blunt trauma to the throat during a football game A history of anterior neck injury may be associated with hypocalcemia. Symptoms of hypocalcemia include "charley horses" in the calf during rest or sleep, and tingling in the lips. Hypocalcemia does not affect bowel sounds. Decreased deep tendon reflexes without paresthesia is a neuromuscular change in hypercalcemia.

The nurse is performing discharge dietary teaching for a patient with hyperkalemia. Which statement does the nurse include in the teaching? 1. "You may use salt substitutes." 2. "You don't need to restrict dairy products." 3. "You may eat apples, strawberries, and peaches." 4. "You may eat avocados, broccoli, and cantaloupe."

3. "You may eat apples, strawberries, and peaches." The patient with hyperkalemia should be instructed to consume foods low in potassium such as apples, strawberries, and peaches. The patient should avoid foods high in potassium, which include avocados, broccoli, cantaloupe, and dairy products. Salt substitutes contain potassium.

A patient receiving insulin and glucose infusion therapy for hyperkalemia now has a serum potassium level of 3.6 mEq/L. What is the nurse's first action? 1. Stop the infusion immediately. 2. Continue the infusion at the prescribed rate. 3. Assess the patient's heart rate, rhythm, and respiratory status. 4. Slow the infusion and increase the frequency of vital sign assessment

3. Assess the patient's heart rate, rhythm, and respiratory status. The serum potassium is now at the low end of normal range (3.5-5.0 mEq/L). The nurse must first assess the patient's response to the infusion and subsequent change in serum potassium (notably a change in respiratory effectiveness and quality and regularity of the heart rate). Once assessment data are obtained, the nurse should contact the provider and the infusion may be stopped, but it does not have to occur immediately.

Laboratory results for a patient with a large draining abdominal wound show a serum sodium decrease from 138 mEq/L to 131 mEq/L. What is the nurse's first action? 1. Establish intravenous (IV) access. 2. Assess for orthostatic hypotension. 3. Assess the patient's respiratory status. 4. Notify the provider of laboratory results.

3. Assess the patient's respiratory status. Hyponatremia may present with neuromuscular changes including muscle weakness of the legs, arms, and respiratory muscles. The nurse should assess the respiratory effectiveness of a patient with hyponatremia as a priority. Obtaining assessment data is important when calling the provider in addition to reporting the laboratory result. Establishing IV access and assessing for orthostatic hypotension are important but are lower-priority interventions.

The nurse is caring for a patient with a peripherally inserted central catheter (PICC). What could cause this catheter to become dislodged? 1. Phlebitis 2. Thrombophlebitis 3. Excessive physical activity 4. Catheter-related bloodstream infections

3. Excessive physical activity Patients with PICCs should be instructed to avoid excessive physical activity because it may result in the dislodgement of the catheter and the development of lumen occlusion. Phlebitis, thrombophlebitis, and catheter-related bloodstream infections do not cause dislodgement of the catheter, but they are possible complications during infusion therapy.

Positive Trousseau's and Chvostek's signs are consistent with which electrolyte imbalance? 1. Hypokalemia 2. Hyperkalemia 3. Hypocalcemia 4. Hypercalcemia

3. Hypocalcemia Trousseau's sign (palmar flexion) and Chvostek's sign (facial twitching) are consistent with acute hypocalcemia. These manifestations are caused by overstimulation of the nerves and muscles. Trousseau's and Chvostek's signs are not used to assess for potassium imbalances.

An electrocardiogram (ECG) is ordered for a patient who was placed on intravenous (IV) fluids containing potassium. Which ECG finding is consistent with hyperkalemia? 1. Absent T waves 2. Elevated P waves 3. Prolonged PR intervals 4. Shortened QRS complexes

3. Prolonged PR intervals When hyperkalemia is present, an individual may show absent P waves, tall T waves, prolonged PR intervals, and widened QRS complexes.

Which are common symptoms of hypokalemia? Select all that apply. 1. Paresthesia 2. Bradycardia 3. Shallow respirations 4. Weak, thready pulse 5. Musculoskeletal weakness

3. Shallow respirations 4. Weak, thready pulse 5. Musculoskeletal weakness Common symptoms of hypokalemia include shallow respirations; weak, thready pulse; and musculoskeletal weakness. Paresthesia and bradycardia are symptoms of hyperkalemia.

The nurse is teaching proper nutrition to a patient who has been prescribed high-ceiling diuretic therapy. Which patient response indicates a need for further teaching? 1. "I should eat fish a few times a week." 2. "Eating meat will help with my potassium needs." 3. "I should have fruits such as oranges, kiwi, and bananas every day." 4. "I should eat more eggs and cereals to maintain a high potassium intake."

4. "I should eat more eggs and cereals to maintain a high potassium intake." Breads, eggs, and cereal grains contain the least amount of natural potassium. Meats, fish, fruits, and some vegetables are highest in potassium. Diuretics that increase the kidney excretion of potassium can cause hypokalemia. The patient should be encouraged to eat foods high in potassium when taking high-ceiling diuretic agents to help compensate for potassium loss.

Which type of intravenous therapy-acquired infection is most responsible for increased death rates? 1. Peritoneal 2. Meningeal 3. Joint 4. Catheter-related bloodstream

4. Catheter-related bloodstream The Institute for Health Care Development identified catheter-related bloodstream infections (CR-BSI) as a severe hospital-acquired infection responsible for about 28,000 deaths per year. Hand hygiene of hospital staff and selection of the appropriate infusion site can reduce the risk of CR-BSI to a greater extent. Peritonitis is the inflammation and infection of the peritoneum, usually acquired in the hospital by peritoneal administration of medications. Meningitis is the inflammation of the meninges and can be caused in the hospital by the intraspinal administration of medications. Joint infection can be caused when medications are administered into a joint cavity.

After successful resuscitation of cardiopulmonary arrest, the nurse views these arterial blood gases: pH 7.28; CO 2 52; HCO 3 - 16. What is the interpretation of these values? 1. Fully compensated respiratory acidosis 2. Partially compensated metabolic acidosis 3. Partially compensated respiratory acidosis 4. Combined respiratory and metabolic acidosis

4. Combined respiratory and metabolic acidosis With a pH of 7.28 (acidosis), there is evidence of a respiratory component (CO 2 > 45) and a metabolic component (HCO 3 - < 21). This is therefore combined respiratory and metabolic acidosis, which would likely follow a cardiopulmonary arrest (CO 2 retention, lactic acidosis). Compensation in respiratory acidosis is demonstrated by an elevated HCO 3 -. In metabolic acidosis, there is very little, if any, change in CO 2. Full compensation would be demonstrated by a normal pH.

A patient with Crohn's disease reports numbness, tingling, and painful muscle contractions. After assessing the deep tendon reflexes of the patient, which intervention does the nurse perform next? 1. Intravenous administration of sodium 2. Intravenous administration of bicarbonate 3. Intravenous administration of phosphorus 4. Intravenous administration of magnesium sulfate

4. Intravenous administration of magnesium sulfate Patients with Crohn's disease are at a high risk for magnesium imbalance, mainly hypomagnesemia. A decrease in the levels of magnesium may cause increased nerve impulse transmission causing hyperactive deep tendon reflexes, numbness, tingling, and painful muscle contractions. This condition can be well treated by administering magnesium sulfate intravenously. Intravenous administration of sodium, bicarbonate, or phosphorous is not a suitable intervention.

Which laboratory value requires a priority response by the nurse to notify the primary health care provider? 1. Sodium 133 mEq/L 2. Calcium 9.0 mg/dL 3. Potassium 5.0 mEq/L 4. Magnesium 4.2 mEq/L

4. Magnesium 4.2 mEq/L A magnesium level of 4.2 is markedly elevated (normal 1.3-2.1 mEq/L). Manifestations are not usually apparent until levels exceed 4 mEq/L. Patients with severe hypermagnesemia are in danger of cardiac arrest, so a level of 4.2 mEq/L requires prompt attention. A sodium level of 133 mEq/L is slightly low, but does not require immediate notification of the health care provider. A potassium level of 5.0 mEq/L is normal. A calcium level of 9.0 mg/dL is normal.

A patient with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide? 1. Instruction on the proper use of drugs 2. Education about potassium-rich foods 3. Assessment of muscle tone and strength 4. Measurement of the patient's urine output

4. Measurement of the patient's urine output A home health aide may measure the patient's intake and output, which then would be reported to the RN. Assessment, education, and instruction are higher-level nursing actions that should be done by the RN.

Which written order does the nurse clarify with the provider when caring for a patient with a serum sodium level of 149 mEq/L? 1. Weigh the patient daily. 2. Monitor intake and output. 3. Institute seizure precautions. 4. Place the patient on nothing by mouth (NPO) status.

4. Place the patient on nothing by mouth (NPO) status. Ensuring adequate water intake is an important nutritional therapy in the treatment of hypernatremia; the nurse should ask for clarification of the NPO order. The other orders are appropriate in the management of patients with hypernatremia.

What is the major cause of death in patients diagnosed with hypokalemia? 1. Stroke 2. Renal failure 3. Cardiac arrest 4. Respiratory insufficiency

4. Respiratory insufficiency Respiratory changes may occur in patients with hypokalemia because of respiratory muscle weakness resulting in shallow respirations. The respiratory status of a patient with hypokalemia should be assessed at least every 2 hours because respiratory insufficiency is the major cause of death for these patients. A stroke is not a risk factor for hypokalemia. Hypokalemia does not cause renal failure; rather, hyperkalemia is caused by renal failure. Dysrhythmias may occur due to hypokalemia but are not the major cause of death in patients with hypokalemia.

A patient is brought to the emergency department with symptoms of diarrhea, chest discomfort, and paresthesia. The patient has a heart rate of 60 beats per minute. The electrocardiogram (ECG) of the patient shows missed P waves, tall T waves, prolonged PR intervals, and wide QRS complexes. Which laboratory finding would be consistent with the patient's condition? 1. Serum sodium levels below 135 mEq/L 2. Serum sodium levels above 145 mEq/L 3. Serum potassium levels below 3.5 mEq/L 4. Serum potassium levels above 5.0 mEq/L

4. Serum potassium levels above 5.0 mEq/L Laboratory data confirms hyperkalemia if serum potassium levels are above 5.0 mEq/L. Hyperkalemia clinically manifests with cardiovascular changes such as bradycardia, hypotension, and ECG changes that include missed P waves, tall T waves, prolonged PR intervals, and wide QRS complexes. A neuromuscular change associated with hyperkalemia is numbness around the mouth, or paresthesia. Intestinal changes include frequent and watery bowel movements. Abnormalities in sodium levels are not associated with hyperkalemia. Hypokalemia is associated with serum potassium levels below 3.5 mEq/L, which do not show any such ECG changes.

When caring for a patient with hyponatremia, which intervention does the nurse implement? 1. 2-gram sodium diet 2. Administration of furosemide 3. Intravenous administration of 0.45% normal saline 4. Small-volume intravenous infusions of 3% normal saline

4. Small-volume intravenous infusions of 3% normal saline 3% saline is hypertonic and is given in small volumes to replenish serum sodium. 0.45% saline is hypotonic and will further dilute serum sodium levels. Furosemide causes sodium loss in the kidneys and would further contribute to hyponatremia. A 2-gram sodium diet restricts sodium intake; the goal of nutritional therapy with hyponatremia is to increase sodium intake.

Which arterial blood gas laboratory values would be seen in metabolic alkalosis? 1. pH 7.49, HCO 3 - 32 2. pH 7.28, CO 2 54 3. pH 7.53, CO 2 28 4. pH 7.31, HCO 3 - 18

1. pH 7.49, HCO 3 - 32 In metabolic alkalosis, pH is greater than 7.45 and HCO 3 - is greater than 28. pH 7.28 and CO 2 54 = respiratory acidosis (pH < 7.35, CO 2 >45). pH 7.53 and CO 2 28 = respiratory alkalosis (pH > 7.45, CO 2 < 35). pH 7.31 and HCO 3 - 18 = metabolic acidosis (pH < 7.35, HCO 3 - < 21).

Which electrolyte imbalance does the nurse anticipate in association with a serum magnesium reading of 1.1 mEq/L? 1. Calcium 7.8 mg/dL 2. Sodium 149 mEq/L 3. Potassium 5.7 mEq/L 4. Phosphorus 2.6 mg/dL

1. Calcium 7.8 mg/dL Hypocalcemia often occurs with hypomagnesemia. A calcium level of 7.8 mg/dL is low. A sodium level of 149 mEq/L is slightly elevated, but not related to the low magnesium level. A phosphorus level of 2.6 mg/dL is slightly low, but not related to hypomagnesemia. A potassium level of 5.7 is elevated, but not related to low magnesium levels.

Which statements made by the student nurse shows effective learning about securing an intravenous (IV) catheter? Select all that apply. 1. "I will use strips of clean tape." 2. "I will use the tape from tape roll." 3. "I will use the tape from the IV starter kit." 4. "I will use the tape from my uniform pocket." 5. "I will use the tape that I placed on the patient's bedrail."

1. "I will use strips of clean tape." 3. "I will use the tape from the IV starter kit." Using a clean piece of tape will reduce the risk of infection. Using the tape from the IV starter kit also reduces the risk for infection. Rolls of tape are used for all patients, so using the tape from the tape roll increases the risk for infection. Since the uniform is not sterile, the tape in a uniform pocket is contaminated, which may lead to infection. Because the patient's bedrail is not sterile, using the tape that is placed on it also increase the chance of infection.

What is one of the causes of respiratory alkalosis? 1. Anxiety 2. Antacid use 3. Kidney failure 4. Diuretic therapy

1. Anxiety Hyperventilation is one cause of respiratory alkalosis, which can result from fear and anxiety. Kidney failure and diuretic therapy are not causes of respiratory alkalosis. The use of antacids can result in metabolic alkalosis.

The nurse is teaching a student nurse about caring for a patient receiving infusion therapy. Which statement made by the student nurse shows ineffective learning? 1. "I will infuse the fluids at a faster rate to complete the infusion." 2. "I will assess the dressing covering for cleanliness and dryness." 3. "I will make sure all the containers have the correct labels for the patient's name and type of fluid." 4. "I will check the connections of the administration set to make sure that they are secure."

1. "I will infuse the fluids at a faster rate to complete the infusion." To reduce the risk of complications, the prescribed fluids should be administered at the appropriately prescribed rate. Infusing the fluids at a faster rate than prescribed may lead to complications. A clean and dry dressing will reduce the risk of infection. The student nurse should make sure all the container labels are correctly marked. The connections of the administration set should be secured to prevent fluid leakage; they should not be taped to prevent contamination.

Confidence: Just a guess Stats Issue with this question? 8. Which statements made by the student nurse shows effective learning about the care of older adults who are receiving intravenous (IV) therapy? Select all that apply. 1. "I will stay away from hard, cordlike veins." 2. "I will shave the skin before the vein puncture." 3. "I will cleanse the skin by using excessive friction." 4. "I will use skin protectant solution between the skin and dressing." 5. "I will use betadine as an antiseptic for patients who are allergic to iodine."

1. "I will stay away from hard, cordlike veins." 4. "I will use skin protectant solution between the skin and dressing." Hard, cordlike veins should be evaded because they roll easily, are hard to cannulate, and the blood flow may be slow. A skin protectant solution puts a protective barrier between the skin and dressing, which improves the adherence of the dressing to the skin. Shaving causes microabrasions that can lead to infection, but hair should be clipped in case of excessive hair. Cleansing the skin with excessive friction may damage fragile skin and cause impaired tissue integrity. Betadine should not be used in patients who are allergic to iodine because it can cause allergic reactions.

When treating a patient for hyponatremia, which type of drug must be altered to decrease sodium loss? 1. Diuretics 2. Biphosphates 3. Corticosteroids 4. Beta-adrenergic agonists

1. Diuretics When treating a patient with hyponatremia, if the patient is already taking diuretics, his or her dosage must be adjusted because diuretics increase sodium loss. Biphosphates are used to prevent hypercalcemia. Corticosteroids can cause hypernatremia. Beta-adrenergic agonists can cause hypokalemia.

The nurse is caring for a patient with an oxygen saturation of 88% and use of accessory muscles for breathing. The nurse provides oxygen and anticipates which of these health care provider orders? 1. Intubation and mechanical ventilation 2. Computed tomography (CT) of the chest, STAT 3. Administration of intravenous sodium bicarbonate 4. Administration of concentrated potassium chloride solution

1. Intubation and mechanical ventilation Support with mechanical ventilation may be needed for patients who cannot keep their oxygen saturation at 90% or who have respiratory muscle fatigue. Signs of hypoxemia and work of breathing are present, requiring correction with intubation and mechanical ventilation. Sodium bicarbonate is used to treat metabolic acidosis; this patient displays hypoxemia. Although the underlying reason for this patient's hypoxemia may eventually require a diagnostic study such as a CT scan of the chest, the priority is to restore oxygenation. There is no clinical evidence of hypokalemia, so administration of potassium chloride is not indicated.

Which statements regarding the Needlestick Safety and Prevention Act are true? Select all that apply. 1. It was passed in 2001. 2. It includes the use of needleless-capable devices, such as Luer-activated devices. 3. It requires every employer to maintain a sharps injury log with details of each incident. 4. It constitutes an amendment of the Occupational Safety and Health Administration guidelines. 5. It mandates that staff who perform tasks with devices engineered with safety mechanisms be indirectly involved in selecting products

1. It was passed in 2001. 2. It includes the use of needleless-capable devices, such as Luer-activated devices. 3. It requires every employer to maintain a sharps injury log with details of each incident. 4. It constitutes an amendment of the Occupational Safety and Health Administration guidelines. The Needlestick Safety and Prevention Act, passed in 2001, requires each employer to maintain a sharps injury log with details of every incident and includes the use of needless-capable devices, such as Luer-activated devices. It constitutes an amendment of the Occupational Safety and Health Administration (OSHA) guidelines titled Occupational Exposure to Bloodborne Pathogens, Final Rule. The Needlestick Safety and Prevention Act mandates that staff who perform tasks with devices engineered with safety mechanisms be directly, not indirectly, involved in selecting products.

Which veins are most appropriate for common peripheral catheter placement? Select all that apply. 1. Median 2. Jugular 3. Cephalic 4. Basilic 5. Vena cava

1. Median 3. Cephalic 4. Basilic The veins that are most appropriate for common peripheral catheter placement include the median, cephalic, and basilic vein. The jugular vein and vena cava are not typically used for peripheral catheter placement.

While the nurse is attempting to remove a midline catheter from a patient, the patient develops venospasms. Which technique does the nurse use to facilitate the removal of the catheter in this patient? 1. Medication administration 2. Forceful removal 3. Clipping of sutures 4. Breaking the catheter

1. Medication administration Veins can develop venospasms when rapid or forceful catheter removal techniques are used. Use of medications to relax the vein wall may be required if the catheter cannot be removed. Imaging studies can confirm whether the cause of removal failure is a thrombosis instead of venospasm. Extreme traction or forceful removal of a catheter could cause the catheter to break and embolize to the heart or pulmonary circulation. Clipping of sutures is used for the removal of non-tunneled percutaneous central catheters. Breaking the catheter is never an option.

While assessing a patient with metabolic acidosis, the nurse suspects that the patient has lactic acidosis. The nurse makes the conclusion based on which finding? 1. Symptoms of hypoxia 2. Low blood glucose levels 3. History of excessive oral antacid use 4. Inability of kidney tubules to secrete hydrogen ions into the urine

1. Symptoms of hypoxia Lactic acidosis occurs when the body has too little oxygen to meet metabolic oxygen demands, such as during heavy exercise, seizure activity, fever, and reduced oxygen intake. Insufficient blood glucose causes the breakdown of fatty acids and accumulation of ketones, resulting in ketoacidosis. Oral antacids contain sodium bicarbonate or calcium carbonate. Therefore excess intake of oral antacids increases the risk of metabolic alkalosis. If the patient's kidney tubules cannot secrete hydrogen ions into the urine, it causes the under-elimination of hydrogen ions, leading to metabolic acidosis but not lactic acidosis.

The trauma nurse is caring for a patient who sustained thoracic trauma with multiple rib fractures and flail chest. Which intervention may be considered to promote gas exchange and prevent respiratory acidosis in this patient? 1. Ventilatory assistance 2. Placement of a nasogastric tube 3. 100% oxygen via rebreather mask 4. Continuous intravenous (IV) bicarbonate infusion

1. Ventilatory assistance Flail chest/thoracic trauma restrict respiratory expansion, leading to respiratory acidosis. Ventilatory support may be needed. Supplemental oxygen will likely be needed, but improving ventilation best promotes gas exchange. IV bicarbonate is not utilized with respiratory acidosis. A nasogastric tube is not indicated.

The nurse is caring for a patient with hypoxemia and metabolic acidosis. Which task can be delegated to the nursing assistant who is helping with the patient's care? 1. Assess the patient's respiratory pattern. 2. Apply the pulse oximeter for continuous readings. 3. Increase the intravenous normal saline to 120 mL/hr. 4. Titrate O 2 to maintain an O 2 saturation of 95% to 100%.

2. Apply the pulse oximeter for continuous readings. Placing a peripheral pulse oximeter is a standardized nursing skill that is within the scope of practice for unlicensed personnel. Assessment and intravenous therapy are skills performed by the professional nurse. Titration of O 2 requires assessment and intervention beyond the scope of practice of an unlicensed individual.

The laboratory reports of a patient show the patient has metabolic alkalosis. What conditions may result in metabolic alkalosis? Select all that apply. 1. Starvation 2. Blood transfusion 3. Prolonged vomiting 4. Prolonged diarrhea 5. Nasogastric suctioning 6. Total parenteral nutrition

2. Blood transfusion 3. Prolonged vomiting 5. Nasogastric suctioning 6. Total parenteral nutrition Prolonged vomiting and nasogastric suctioning can lead to acid deficits causing metabolic alkalosis. Blood transfusion and total parenteral nutrition increase the base components by parenteral base administration. Therefore they also cause metabolic alkalosis. Prolonged diarrhea can cause overelimination of bicarbonate ions resulting in metabolic acidosis. Starvation leads to excessive oxidation of fatty acids leading to overproduction of hydrogen ions and metabolic acidosis.

When caring for a patient with kidney failure who has metabolic acidosis, which symptom does the nurse expect as evidence of the body's compensatory effort? 1. Pallor and diaphoresis 2. Rapid and deep respirations 3. Bradycardia and bounding pulse 4. Hypotension and weak, thready pulse

2. Rapid and deep respirations Kussmaul respirations (rapid, deep respirations) represent the body's attempt to compensate for metabolic acidosis. The skin is warm, dry, and flushed in metabolic acidosis. Cardiovascular symptoms may occur, but they are manifestations of acidosis, not evidence of compensation.

What complication should the nurse suspect in a patient who had a central venous catheter insertion a month ago and now reports swelling, tenderness, and redness at the insertion site? 1. Phlebitis 2. Thrombosis 3. Ecchymosis 4. Thrombophlebitis

2. Thrombosis The presence of a blood clot inside the vein is known as a thrombus [1] [2]. Swelling, tenderness, and redness at the insertion site are the signs and symptoms of thrombosis. Thrombosis may be caused by damage to the endothelial lining, traumatic venipuncture, multiple venipuncture attempts, the use of catheters too large for the vein, hypercoagulable states, or venous stasis. Swelling, tenderness, and redness at the injection site are not associated with phlebitis. Though swelling and tenderness are also the signs and symptoms of ecchymosis, it would also be accompanied by pain and bruises. In thrombophlebitis, signs and symptoms of both phlebitis and thrombosis are seen.

What could be the reason that a patient with a peripherally inserted central catheter (PICC) would have pain and numbness at the insertion site? 1. Phlebitis 2. Venous spasm 3. Nerve damage 4. Thrombophlebitis

2. Venous spasm Pain and numbness are the signs of venous spasm [1] [2], which is a complication of infusion therapy. Though pain is a sign of phlebitis, numbness is not associated with it. Pain is a sensation that is absent when there is nerve damage. Pain is a sign of thrombophlebitis but numbness is not observed with thrombophlebitis.

The nurse is inserting a peripheral intravenous (IV) catheter. Which patient statement is of greatest concern during this procedure? 1. "I hate having IVs started." 2. "It hurts when you are inserting the line." 3. "My hand tingles when you poke me." 4. "My IV lines never last very long."

3. "My hand tingles when you poke me." The patient's statement about a tingling feeling indicates possible nerve puncture. To avoid further nerve damage, the nurse should stop immediately, remove the IV catheter, and choose a new site. The other statements indicate a need for patient teaching, but are not indicators of immediate complications of catheter insertion—pain at the insertion site is common, and IV sites that "never last very long" should be addressed with teaching about the importance of proper protection of the site.

Which hormone regulates fluid and electrolyte balance by preventing water and sodium loss? 1. Antidiuretic 2. Thyrotropin 3. Aldosterone 4. Natriuretic peptide (NP)

3. Aldosterone Aldosterone stimulates the nephrons to reabsorb sodium and water into the blood, preventing sodium and water loss. NP hormone levels are altered in response to increased blood volume and blood pressure. Antidiuretic hormone acts on the collecting ducts of the kidney to normalize the blood osmolarity. Thyrotropin is a thyroid-stimulating hormone that is released in response to low levels of the thyroid hormone.

A patient is admitted with severe diabetic ketoacidosis. Arterial blood gas results reveal a pH of 7.21. What is this patient's acidosis most likely in response to? 1. Anaerobic metabolism 2. Excessive intake of insulin 3. Excessive breakdown of fatty acids 4.Excessive intake of alcoholic beverages

3. Excessive breakdown of fatty acids Metabolic acidosis can result from the overproduction of hydrogen ions, underelimination of hydrogen ions, or insufficient bicarbonate ions. Excessive breakdown of fatty acids that occurs with diabetic ketoacidosis or starvation results in overproduction of hydrogen ions and metabolic acidosis. Anaerobic metabolism produces lactic acid as a cause of metabolic acidosis. Excessive intake of alcoholic beverages will also cause metabolic acidosis because of the high concentration of hydrogen ions in alcohol. Excessive intake of insulin will not result in diabetic ketoacidosis.

When flushing a patient's central line with normal saline, the nurse feels resistance. Which action does the nurse take first? 1. Decrease the pressure being used to flush the line. 2. Obtain a 10-mL syringe and reattempt flushing the line. 3. Stop flushing and try to aspirate blood from the line. 4. Use "push-pull" pressure applied to the syringe while flushing the line

3. 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. 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 patient's circulation.

The nurse is planning care for a patient with hypocalcemia. Which nursing action is appropriate to delegate to unlicensed assistive personnel (UAP)? 1. Evaluating the patient's laboratory results 2. Implementing seizure precautions for the patient 3. Transferring the patient from the bed to a stretcher using a lift sheet 4. Collaborating with the dietitian to provide calcium-rich foods for the patient

3. Transferring the patient from the bed to a stretcher using a lift sheet Transferring patients is a nursing skill that is included in UAP education and scope of practice. Collaborating with the dietitian, evaluating the patient's laboratory results, and implementing seizure precautions all require broader education and scope of practice and should be done by licensed nursing personnel.

A paraplegic patient is prescribed intravenous antibiotics for 6 weeks via a central venous catheter. Which complication might the patient develop? 1. Catheter rupture 2. Catheter migration 3. Catheter occlusion 4. Catheter dislodgement

4. Catheter dislodgement Paraplegic patients may use the upper extremities excessively for daily activities. Excessive activity may cause catheter dislodgment [1] [2]. Forceful flushing of the catheter against the resistance may cause catheter rupture. Catheter migration may be caused by changes in intrathoracic pressure caused by coughing, sneezing, and heavy lifting. Catheter occlusion may occur because of fibrin formation.

A patient receiving intravenous therapy reports tingling and numbness at the insertion site. What could be the possible complication? 1. Ecchymosis 2. Thrombosis 3. Venous spasm 4. Nerve damage

4. Nerve damage Tingling and numbness at the insertion site are the signs of nerve damage. Nerve damage is due to vein puncture at or near the nerve location. Ecchymosis is the infiltration of blood into the surrounding tissues. It may cause swelling, bruising, pain, or tenderness. Thrombosis is characterized by swollen extremities and engorged veins of the ipsilateral chest. Venous spasms are sudden vein contractions caused by vein irritation or injury. This condition causes cramping or pain at the insertion site.

Which patient is most likely to exhibit the following ABG results: pH 7.30; PaCO 2 49; HCO 3 - 26; PaO 2 76? 1. Patient with kidney failure 2. Patient with hyperkalemia 3. Patient with anxiety disorder 4. Patient taking hydromorphone

4. Patient taking hydromorphone Hydromorphone, a narcotic analgesic, can cause respiratory depression, hypoventilation, and respiratory acidosis, as this blood gas reading demonstrates. Kidney failure causes metabolic acidosis. Anxiety will cause hyperventilation and subsequent respiratory alkalosis. Although hyperkalemia can be caused by acidosis, it is not a cause of acidosis.

A severely dehydrated patient 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? 1. RN who is certified in the administration of oral and infused chemotherapy medications 2. RN with 2 years of experience in the ED who is skilled at insertion of short peripheral catheters 3. RN with 10 years of experience on a medical-surgical unit who has cared for many patients requiring IV infusions 4. RN with certified registered nurse infusion (CRNI) certification who is assigned to the ED for the day

4. RN with certified registered nurse infusion (CRNI) certification who is assigned to the ED for the day The nurse with CRNI certification is most likely to be able to quickly insert a midline catheter for a patient 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.

Which interventions should a nurse include when removing a central venous catheter in order to prevent a venous air embolism? Arrange the sequence in order. 1. Positioning the patient in Trendelenburg position 2. Ensuring that the intrathoracic pressure is higher than atmospheric pressure 3. Asking the patient to hold the breath or perform the Valsalva maneuver 4. Clamping the catheter during the procedure 5. Measuring the length of the catheter in comparison with length documented on insertion

To prevent venous air embolism when removing any central venous catheter, the patient should be in a flat supine or Trendelenburg position. To ensure the intrathoracic pressure is higher than atmospheric pressure, the patient should hold his or her breath or perform the Valsalva maneuver during catheter removal. The catheter should be clamped during the procedure. The length of the catheter should be measured in comparison with length documented on insertion.

Which electrolyte imbalance should be anticipated and monitored in a patient with hyperphosphatemia? 1. Hypokalemia 2. Hypocalcemia 3. Hypernatremia 4. Hypermagnesemia

2. Hypocalcemia Phosphorus and calcium have an inverse or reciprocal relationship. When one is increased, the other is usually decreased. Therefore a patient with hyperphosphatemia should be monitored for hypocalcemia. Hyperphosphatemia does not cause hypernatremia, hypokalemia, or hypermagnesemia.

After a patient's intravenous (IV) infusion is discontinued, the nurse assesses the patient and observes swollen extremities, engorged peripheral veins of the ipsilateral chest, and tenderness and redness at the site of infusion. Which nursing intervention is appropriate for this patient? 1. Applying a cold compress 2. Applying less pressure while removing the IV catheter 3. Encouraging the patient to drink warm liquids 4. Inserting a new catheter in the opposite extremity

1. Applying a cold compress Swollen extremities, engorged peripheral veins of the ipsilateral chest, and tenderness and redness at the site of infusion indicate thrombosis. The nurse applies a cold compress in order to decrease the blood flow and stabilize the clot. Application of less pressure while removing the IV catheter is appropriate for patients with ecchymosis. Encouraging the patient to drink warm liquids is appropriate in cases of venous vasospasm. Inserting a new catheter on the opposite side is useful if the patient has infiltration.

The nurse is caring for a group of patients with acidosis. The nurse recognizes that Kussmaul respirations are consistent with which situation? 1. Aspirin overdose 2. Use of hydrochlorothiazide 3. Administration of sodium bicarbonate 4. Patient receiving mechanical ventilation

1. Aspirin overdose If acidosis is metabolic in origin, the rate and depth of breathing increase as the hydrogen ion level rises; this is known as Kussmaul respiration. Metabolic acidosis is caused by alcoholic beverages, methyl alcohol, and acetylsalicylic acid (aspirin). Mechanical ventilation is used to correct hypoxemia and hypercapnia (elevated Paco 2). Hydrochlorothiazide causes metabolic alkalosis. Sodium bicarbonate is used in the treatment of metabolic acidosis; administration of this buffer may cause metabolic alkalosis.

The nurse who is starting the shift finds a patient with an IV that is leaking all over the bed linens. What does the nurse do initially? 1. Assess the insertion site. 2. Check connections. 3. Check the infusion rate. 4. Discontinue the IV and start another.

1. Assess the insertion site. Assessing the insertion site to check for patency is the priority. IV assessments typically begin at the insertion site and move "up" the line; that is, 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 preparing to administer an IV solution to a patient who underwent a recent mastectomy. What must the nurse remember when choosing a site for placement of a short peripheral venous catheter? 1. Avoid the arm on the side of the mastectomy. 2. Use the vein in the area of the wrist. 3. Choose a site in a vein that is cordlike. 4. Choose the site on the inner side of the elbow

1. Avoid the arm on the side of the mastectomy. The nurse should avoid the arm on the side of the mastectomy when choosing a site for placement of a short peripheral venous catheter. Similarly, the arm on the side of a lymph node dissection, arteriovenous shunt or fistula, or paralysis is not considered for placement of a short peripheral venous catheter, because they alter the normal pattern of blood flow through the arm. Generally, a site should be chosen in the upper extremity for adults, but not the wrist because of the possibility of puncturing the median nerve. A vein that is hard or cordlike is not suitable for placement of the catheter. The site on the inner side of the elbow or in the area of a joint flexion is generally avoided because it causes immobilization of the arm.

The nurse is preparing to administer an IV solution to a patient who underwent a recent mastectomy. What must the nurse remember when choosing a site for placement of a short peripheral venous catheter? 1. Avoid the arm on the side of the mastectomy. 2. Use the vein in the area of the wrist. 3. Choose a site in a vein that is cordlike. 4. Choose the site on the inner side of the elbow.

1. Avoid the arm on the side of the mastectomy. The nurse should avoid the arm on the side of the mastectomy when choosing a site for placement of a short peripheral venous catheter. Similarly, the arm on the side of a lymph node dissection, arteriovenous shunt or fistula, or paralysis is not considered for placement of a short peripheral venous catheter, because they alter the normal pattern of blood flow through the arm. Generally, a site should be chosen in the upper extremity for adults, but not the wrist because of the possibility of puncturing the median nerve. A vein that is hard or cordlike is not suitable for placement of the catheter. The site on the inner side of the elbow or in the area of a joint flexion is generally avoided because it causes immobilization of the arm.

A patient in acute respiratory distress from an asthma attack becomes more confused. Respirations remain rapid but are more shallow. The most recent blood gas results are pH 7.29, PaO 2 62 mm Hg, PaCO 2 56 mm Hg, HCO 3 -25 mEq/L. What is the nurse's priority intervention? 1. Call the Rapid Response Team. 2. Place the patient in a semi-Fowler's position. 3. Increase the oxygen delivery system to 100% Fio 2. 4. Evaluate the patient's need for sedation to assist with breathing.

1. Call the Rapid Response Team. Inadequate gas exchange from the airway narrowing associated with asthma and shallow respirations reduce oxygen and carbon dioxide exchange (ventilation). The patient is showing signs of respiratory acidosis and ineffective breathing. The Rapid Response Team should be called to assess the patient for possible protective airway measures to improve ventilation and oxygenation. Although oxygen is the first priority, 100% Fio 2 is not correct because the oxygen should be started lower. Sedation is not appropriate for this patient. The patient would be placed in high-Fowler's position.

A patient has been poisoned by botulinum toxins. What assessment findings suggest the patient has acidosis? Select all that apply. 1. Confusion 2. Hypertension 3. Hyperreflexia 4. Warm, flushed, dry skin 5. Pounding peripheral pulse

1. Confusion 4. Warm, flushed, dry skin If the patient is confused and has a warm, flushed, and dry skin, it may indicate the patient has acidosis. Acidosis decreases the ability of excitable tissues in the blood vessels to respond adequately. So, there is vasodilation leading to hypotension rather than hypertension. Decrease in the ability of the excitable tissues in the muscles to respond adequately to stimulus and the hyperkalemia associated with acidosis reduce the muscle tone. This leads to hyporeflexia rather than hyperreflexia. Mild acidosis may increase the heart rate, but as the acidosis worsens and there is hyperkalemia, the heart rate decreases making the peripheral pulse hard to find. Therefore the peripheral pulse is thready rather than pounding.

How does the body compensate for a low pH? 1. Increases respiratory rate 2. Decreases respiratory rate 3. Retention of carbon dioxide 4. Decreases release of bicarbonate

1. Increases respiratory rate When the body has an acid-base imbalance, it finds ways to compensate. Low pH indicates acidosis, which the body can combat with an increased respiratory rate to blow off carbon dioxide. Decreased respirations would result in worsening acidosis. The kidneys may also respond by releasing bicarbonate, not decreasing its release. The body is already retaining carbon dioxide, so continuing to retain it would not affect low pH.

Which nursing intervention takes priority for a patient admitted with severe metabolic acidosis? 1. Initiate cardiac monitoring. 2. Perform medication reconciliation. 3. Obtain a diet history for the past 3 days. 4. Assess the patient's strength in the extremities

1. Initiate cardiac monitoring. The nurse follows the ABCs and initiates cardiac monitoring to observe for signs of hyperkalemia or cardiac arrest. Medication reconciliation should be performed as soon as possible; however, this patient is at risk for cardiac and neurologic complications of acidosis. Starvation may precipitate ketosis/acidosis, but this is not the priority. Assessing the patient's strength in the extremities is an intervention important to do due to the neurologic complications of acidosis, but it is not the priority over initiating cardiac monitoring.

The nurse has instructed unlicensed assistive personnel (UAP) to check the blood pressure of a patient who has a peripherally inserted central catheter (PICC) on the left arm. The UAP applied a blood pressure cuff on the left arm. Which complication may occur? 1. Phlebitis 2. Infiltration 3. Hematoma 4. Extravasation

1. Phlebitis When the arm with a peripherally inserted central catheter (PICC) is used to measure blood pressure, the compression from the blood pressure cuff may increase vein irritation and lead to phlebitis. Infiltration is seen if blood pressure is measured from the same arm in which intravenous fluids are infusing through a short peripheral catheter. Increased venous pressure due to the compression of a blood pressure cuff will not result in clotting. Therefore, the patient would not develop a hematoma. Increased venous pressure due to the compression of a blood pressure cuff may not cause extravasation.

The nurse is administering a drug to a patient through an implanted port. Before giving the medication, what does the nurse do to ensure safety? 1. Administer 5 mL of a heparinized solution. 2. Check for blood return. 3. Flush the port with 10 mL of normal saline. 4. Palpate the port for stability.

2. Check for blood return. Before a drug is given through an implanted port, it is critical that the nurse check for blood return. 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 patient's safety.

The nurse checking an IV fluid order questions its accuracy. What does the nurse do first? 1. Asks the charge nurse about the order 2. Contacts the health care provider who ordered it 3. Contacts the pharmacy for clarification 4. Starts the fluid as ordered, with plans to check it later

2. Contacts the health care provider who ordered it The nurse is responsible for accuracy and has the duty to verify the order with the health care provider who ordered it. Although the nurse can consult the charge nurse, this is not the definitive action that the nurse should take. Contacting the pharmacy is not the definitive action that the nurse should take. Giving (or starting) the fluid when the order is questionable is not appropriate.

During an intravenous drug infusion, the patient reports lightheadedness. On further examination, the nurse finds that the patient has a flushed face and an irregular pulse. The nurse should perform which intervention? 1. Slow the infusion rate 2. Discontinue the drug infusion 3. Administer diuretics as prescribed 4. Help the patient to an upright position

2. Discontinue the drug infusion Signs and symptoms such as lightheadedness, flushed face, and irregular pulse after an intravenous infusion [1] [2] are caused by speed shock. Speed shock results from rapid infusion of drugs or bolus infusion, which causes the drug to reach toxic levels quickly. Therefore, the nurse discontinues the drug infusion for this patient. Slowing the infusion rate is beneficial for patients who have circulatory overload. Administering diuretics as prescribed will help reduce edema in patients with circulatory overload. Raising the patient to an upright position is beneficial to alleviate symptoms of shortness of breath or edema in case of circulatory overload.

A nurse is assessing a patient with metabolic and respiratory acidosis. What manifestations does the nurse anticipate finding in the patient? Select all that apply. 1 . Hypertension 2. Flaccid paralysis 3. Cold and moist skin 4. Kussmaul respirations 5. Delayed electrical conduction

2. Flaccid paralysis 4. Kussmaul respirations 5. Delayed electrical conduction An increase in carbon dioxide and hydrogen ion levels causes respiratory acidosis, and reduced elimination of hydrogen ions causes metabolic acidosis. Acidosis causes neuromuscular manifestations such as flaccid paralysis, which is associated with muscle tenderness and severe hypokalemia. Acidosis causes Kussmaul respirations, which is associated with respiratory compensation. Acidosis slows down the electrical conduction by prolonging the atrioventricular node delay. Acidosis causes a decrease in blood pressure, or hypotension, not hypertension. The integumentary manifestations of acidosis include warm, flushed, and dry skin.

A patient is admitted from the emergency department for intravenous (IV) fluids to treat dehydration caused by several days of vomiting and diarrhea. The patient's admission venous blood work reveals a pH of 7.27 and bicarbonate of 26 mEq/L; potassium and chloride levels are within normal ranges. The provider has ordered adding bicarbonate to the IV fluids. Which action by the nurse is correct? 1. Suggest adding potassium chloride to the IV fluids. 2. Hold the bicarbonate and report the laboratory values to the provider. 3. Request an order for renal function tests before giving the bicarbonate. 4. Administer the bicarbonate as ordered to treat this patient's metabolic acidosis

2. Hold the bicarbonate and report the laboratory values to the provider. Bicarbonate is not given for metabolic acidosis unless the patient's bicarbonate levels are low. This patient's levels are within normal limits. Normal renal function is necessary if potassium is added to IV fluids. The patient has normal potassium and chloride levels, so potassium is not needed at this time.

When assessing the laboratory results of a patient who has hypomagnesemia, for which additional electrolyte imbalance should the nurse monitor? 1. Hyperkalemia 2. Hypocalcemia 3. Hypernatremia 4. Hypophosphatemia

2. Hypocalcemia Hypocalcemia often occurs with hypomagnesemia, so the nurse would monitor for signs and symptoms of low calcium levels. Hypomagnesemia may increase potassium secretion in certain circumstances, leading the health care provider to be aware that replacement of magnesium is crucial before attempting to replace potassium if the patient is deficient in both. Hypernatremia and hypophosphatemia are not related to hypomagnesemia.

A patient admitted with diabetic ketoacidosis was treated for metabolic acidosis with intravenous (IV) fluids and insulin. Which electrolyte imbalance does the nurse monitor for as the acid-base imbalance resolves? 1. Hyponatremia 2. Hypokalemia 3. Hyperkalemia 4. Hypernatremia

2. Hypokalemia In acidosis, extracellular hydrogen ions move into the cell and potassium moves out, causing hyperkalemia. In diabetic ketoacidosis, by treating the elevated serum glucose with insulin and IV fluids, the acid-base imbalance resolves. As the acidosis resolves, the hydrogen ions move out of the cell, and potassium moves back into the cell, causing hypokalemia in the plasma. Sodium levels are not affected by diabetic ketoacidosis.

The nurse observes that a patient with intravenous (IV) fluids infusing via a peripheral catheter has developed skin tightening, tenderness, coolness of the skin, and fluid leaking from the insertion site. Which complication does the nurse suspect in this patient? 1. Phlebitis 2. Infiltration 3. Ecchymosis 4. Thrombosis

2. Infiltration Skin tightening, tenderness, coolness of the skin, and fluid leaking from the insertion site indicate that the patient has developed an infiltration [1] [2]. Phlebitis is characterized by redness and inflammation of the vein. Ecchymosis is characterized by swelling, bruising, pain, or tenderness. Thrombosis is characterized by a swollen extremity and engorged peripheral veins of the ipsilateral chest and extremities.

The nurse is caring for a patient with metabolic alkalosis. What manifestations of metabolic alkalosis is the nurse likely to assess? Select all that apply. 1. Decrease in heart rate 2. Numbness around the mouth 3. Increase in handgrip strength 4. Presence of Kussmaul respiration 5. Hyperactivity of deep tendon reflexes

2. Numbness around the mouth 5. Hyperactivity of deep tendon reflexes Hypercalcemia occurs with alkalosis, which can cause hyperactivity of deep tendon reflexes. Alkalosis overexcites the nervous system leading to tingling or numbness around the mouth. Overstimulation of the nerves may cause contraction of skeletal muscles, but the contractions are weaker because of hypokalemia. Therefore there is a decrease in handgrip strength. Alkalosis increases myocardial irritability and increases the heart rate. Kussmaul respiration (deep and rapid involuntary breathing) is seen in metabolic acidosis with respiratory compensation.

When caring for a group of patients at risk for respiratory acidosis, the nurse identifies which person as at highest risk? 1. An athlete in training 2. Patient who smokes cigarettes 3. Person with uncontrolled diabetes 4. Pregnant woman with hyperemesis gravidarum

2. Patient who smokes cigarettes Cigarette smoking worsens gas exchange, leading to disorders that contribute to hypoventilation and respiratory acidosis. An athlete in training should be healthy with optimal lung function, not respiratory acidosis. Hyperemesis gravidarum is characterized by nausea and vomiting, and vomiting causes metabolic alkalosis. Uncontrolled diabetes may result in diabetic ketoacidosis, which causes metabolic acidosis.

Which principles from the catheter-related bloodstream infection prevention bundle (CRBSI) are important to remember when assisting with the placement of a central line? Select all that apply. 1. Disinfect the site with alcohol. 2. Perform hand hygiene before touching the line. 3. Use a checklist during the insertion of the central line. 4. Drape the patient head to toe with a sterile barrier prior to line insertion. 5. Everyone in the room during the insertion procedure should wear a mask.

2. Perform hand hygiene before touching the line. 3. Use a checklist during the insertion of the central line. 4. Drape the patient head to toe with a sterile barrier prior to line insertion. 5. Everyone in the room during the insertion procedure should wear a mask. CRBSI principles of care for insertion of a central line include performing hand hygiene before touching the line; using a checklist during the insertion of the central line; draping the patient head to toe with a sterile barrier prior to the line insertion; and having all personnel, including the patient, wear a mask during the placement of the central line. The site should be disinfected with chlorhexidine, not alcohol.

A student nurse was instructed by the primary health care provider to obtain a blood sample from a patient who is receiving peripheral infusion therapy. The student nurse draws blood from the venipuncture site, proximal to the catheter. What could be the result of this action? 1. The catheter may become damaged. 2. The blood test results may be altered. 3. The patient may develop a vein irritation. 4. The patient may develop vein inflammation.

2. The blood test results may be altered. If blood is drawn from the venipuncture site proximal to the catheter, the test results may become altered due the infusing fluid. Venipuncture at or near the insertion site of a midline catheter may damage the catheter and cause vein inflammation. Vein irritation is seen if blood pressure is measured on the arm where the catheter is inserted.

A patient with diabetes mellitus is brought to the emergency department after vomiting for several days. The patient has rapid, deep respirations and a urine dipstick reveals ketonuria. Which process does the nurse suspect is occurring with this patient? 1. Kidney compensation for metabolic acidosis 2. Kidney compensation for metabolic alkalosis 3. Respiratory compensation for metabolic acidosis 4. Respiratory compensation for metabolic alkalosis

3. Respiratory compensation for metabolic acidosis Patients with diabetes mellitus can develop metabolic acidosis. Respiratory compensation occurs through the lungs as the rate and depth of respirations increase in order to reduce hydrogen ion levels. Kidney compensation is not occurring.

The nurse suspects that a patient has developed metabolic acidosis because of an overproduction of hydrogen ions. The nurse makes the conclusion based on what assessment findings? Select all that apply. 1. The patient has hyperaldosteronism. 2. The patient has diabetic ketoacidosis. 3. The patient has salicylate intoxication. 4. The patient is on nasogastric suctioning. 5. The patient has been fasting for 30 days

2. The patient has diabetic ketoacidosis. 3. The patient has salicylate intoxication. 5. The patient has been fasting for 30 days Metabolic acidosis is a condition that occurs when the body produces excess quantities of acid. When the patient is fasting, the body fat breaks down and causes excess oxidation of fatty acids, resulting in metabolic acidosis. Diabetic ketoacidosis is a metabolic disorder that causes severe acidosis because of the accumulation and ionization of ketones. Salicylate intoxication causes a high anion gap, resulting in metabolic acidosis. High serum aldosterone decreases the levels of acid components and causes metabolic alkalosis, not acidosis. Nasogastric suctioning increases serum bicarbonate levels and causes metabolic alkalosis, not acidosis.

The nurse assessing a patient's peripheral IV site obtains and documents information about it. Which assessment data indicate the need for immediate nursing intervention? 1. Patient states, "It really hurt when the nurse put the IV in." 2. The vein feels hard and cordlike above the insertion site. 3. Transparent dressing was changed 5 days ago. 4. Tubing for the IV was last changed 72 hours ago.

2. The vein feels hard and cordlike above the insertion site. A hard, cordlike vein suggests phlebitis at the IV site. 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 72-96 hours.

How will the nurse document the intravenous (IV) therapy complication of a blood clot inside the vein? 1. Phlebitis 2. Thrombosis 3. Extravasation 4. Thrombophlebitis

2. Thrombosis A thrombosis is a blood clot inside the vein, a potential complication of IV therapy. Phlebitis is inflammation of the vein. Extravasation is the leakage of the IV fluid into extravascular tissue. Thrombophlebitis is inflammation and a blood clot in the vein.

Which arterial blood gas reading does the nurse anticipate in a patient diagnosed with chronic obstructive pulmonary disease (COPD)? 1. pH 7.33, PaO 2 65 mm Hg, PaCO 2 41 mm Hg, HCO 3 - 19 mEq/L 2. pH 7.36, PaO 2 63 mm Hg, PaCO 2 52 mm Hg, HCO 3 - 32 mEq/L 3. pH 7.48, PaO 2 82 mm Hg, PaCO 2 32 mm Hg, HCO 3 - 25 mEq/L 4. pH 7.36, PaO 2 72 mm Hg, PaCO 2 30 mm Hg, HCO 3 - 18 mEq/L

2. pH 7.36, PaO 2 63 mm Hg, PaCO 2 52 mm Hg, HCO 3 - 32 mEq/L The kidneys will compensate to correct for changes in blood pH that occur when the respiratory system is unhealthy (i.e., COPD) or overwhelmed by increasing the absorption of bicarbonate and excreting hydrogen ions. The reading of pH 7.36, PaO 2 63 mm Hg, PaCO 2 52 mm Hg, HCO 3 - 32 mEq/L reflects this state of compensated respiratory acidosis. A reading of pH 7.33, PaO 2 65 mm Hg, PaCO 2 41 mm Hg, HCO 3 - 19 mEq/L reflects an uncompensated metabolic acidosis. A reading of pH 7.48, PaO 2 82 mm Hg, PaCO 2 32 mm Hg, HCO 3 -25 mEq/L reflects an uncompensated respiratory alkalosis. A reading of pH 7.36, PaO 2 72 mm Hg, PaCO 2 30 mm Hg, HCO 3 - 18 mEq/L reflects a compensated metabolic acidosis state.

The registered nurse is teaching a student nurse about flushing the intravenous catheter to maintain patency of the lumens. Which statement made by the student nurse shows ineffective learning? 1. "I will stop the flushing procedure if I feel any resistance." 2. "I will remove the catheter if I observe signs of redness at the insertion site." 3. "I will stop the flushing procedure if the catheter lumen yields a blood return." 4. "I will apply slow and gentle pressure to the syringe plunger to flush the catheter."

3. "I will stop the flushing procedure if the catheter lumen yields a blood return." A brisk blood return from the catheter is a positive sign that indicates that the operator has entered the vein without any dislocation. Therefore, the nurse should not stop the flushing procedure. The catheter should be removed if redness is seen at the insertion site. If there is any resistance while flushing a catheter, the nurse should immediately stop the procedure. If the procedure is continued, the catheter may rupture or a blood clot may move into the circulation. Slow and gentle pressure should be applied to the syringe plunger to flush the catheter to prevent complications.

Which conditions place a patient at risk for developing metabolic alkalosis? Select all that apply. 1. Fever 2. Diarrhea 3. Blood transfusion 4. Hypovolemic shock 5. Nasogastric suctioning 6. Total parenteral nutrition

3. Blood transfusion 5. Nasogastric suctioning 6. Total parenteral nutrition Conditions placing a patient at risk for metabolic alkalosis result from an overproduction or underelimination of base. Blood transfusion, administration of total parenteral nutrition, and nasogastric suctioning increase a patient's risk for metabolic alkalosis. Hypovolemic shock will result in respiratory alkalosis. Diarrhea and fever will cause metabolic acidosis.

Which action does the nurse take to ensure aseptic skin preparation prior to insertion of an intravenous (IV) therapy device? 1. Shave hair in the area to be punctured. 2. Perform hand hygiene after palpating the insertion site. 3. Clean the skin with 70% alcohol. 4. Puncture the skin immediately following application of povidone-iodine

3. Clean the skin with 70% alcohol. The nurse should prepare clean skin with 70% alcohol or chlorhexidine before peripheral venous catheter insertion. Hair should only be clipped, not shaved, in the site to be punctured. Hand hygiene should be performed before palpating the insertion site. The nurse must wait for 2 minutes to allow the application of povidone-iodine to dry, in order for the agent to be effective.

A patient with a central venous catheter reports back pain between the shoulder blades. What should be the immediate nursing intervention in this situation? 1. Changing the entire infusion administration system 2. Obtaining a chest X-ray to assess the catheter tip location 3. Discontinuing all infusions and flushing the central venous line 4. Informing the primary health care provider of the assessment findings

3. Discontinuing all infusions and flushing the central venous line Back pain between the shoulder blades is a sign of catheter migration [1] [2]. The nurse should immediately stop the infusion and flush the catheter. Repositioning the catheter tip is a better intervention than changing the entire infusion system in this situation. A chest X-ray is always needed to assess the catheter tip; this action can be performed when the symptoms have subsided. The nurse should inform the primary health care provider after discontinuing the infusion.

A new nurse is caring for a postoperative patient with the following arterial blood gas (ABG) result: pH 7.30; PaCO 2 60 mm Hg; PaO 2 80 mm Hg; bicarbonate 24 mEq/L; and O 2 saturation 96%. Which of these actions by the new graduate is indicated? 1. Administer oxygen by nasal cannula. 2. Inform the charge nurse that no changes in therapy are needed. 3. Encourage the patient to use the incentive spirometer and cough. 4. Request a prescription for sodium bicarbonate from the health care provider

3. Encourage the patient to use the incentive spirometer and cough. Postoperative respiratory acidosis is caused by CO 2 retention and impaired chest expansion secondary to anesthesia. The nurse takes steps to promote CO 2 elimination, including maintaining a patent airway and expanding the lungs through respiratory interventions such as use of an incentive spirometer and purposeful coughing. Post anesthesia, the patient will need interventions related to promoting CO 2 elimination, or the patient may progress to a state of somnolence and unresponsiveness. Supplemental oxygen is not indicated because PaO 2 and oxygen saturation are within the normal range. Sodium bicarbonate is not indicated because the bicarbonate level is in the normal range.

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

3. Grade 3 Grade 3 indicates pain at the access site with erythema and/or edema and streak formation with a palpable cord. Grade 1 indicates only erythema with or without pain; the patient has additional symptoms. Grade 2 indicates only pain at the access site with erythema and/or edema; the patient 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, and purulent drainage. No purulent drainage is present in this patient, and the palpable cord is 1 inch in length.

The nurse is caring for a patient who has taken a large quantity of furosemide to promote weight loss. The nurse anticipates the finding of which acid-base imbalance? 1. pH of 7.31 2. PaO 2 of 78 mm Hg 3. HCO 3 - of 34 mEq/L 4. PaCO 2 of 56 mm Hg

3. HCO 3 - of 34 mEq/L Diuretics (non-potassium-sparing), evidenced by a finding of HCO 3 - of 34 mEq/L, cause metabolic alkalosis. A PaO 2 of 78 mm Hg demonstrates mild hypoxemia consistent with respiratory disorders, not with diuretic use. CO 2 retention results from hypoventilation, which is not consistent with diuretic use. A pH of 7.31 is acidotic; diuretics promote metabolic alkalosis.

What is one of the causes of acidosis? 1. Colitis 2. Heart failure 3. Kidney failure 4. Excessive body fluids

3. Kidney Failure Causes of acidosis include kidney failure, pancreatitis, liver failure, and dehydration. Excessive body fluids, heart failure, and colitis are causes of alkalosis.

A patient is recovering from an acute episode of chronic obstructive pulmonary disease (COPD). Which nursing action is the greatest priority in the plan of care? 1. Raise the head of the bed 60 degrees. 2. Assess orientation status every 4 hours. 3. Monitor the respiratory rate and effort hourly. 4. Administer oxygen at 4 L/min per nasal cannula.

3. Monitor the respiratory rate and effort hourly. It is most important to monitor respiratory status in the patient with respiratory acidosis. Use caution in giving oxygen to patients who have COPD. Raising the head of the bed will improve respiratory expansion, but 60 degrees is excessive. Assessing the patient's orientation status is not as great a priority as respiratory status.

When evaluating the laboratory results of a patient with diabetic ketoacidosis, which lab value indicates the body has fully compensated from this acid-base imbalance? 1. Normal serum glucose 2. Normal serum potassium 3. Normal pH on arterial blood gases 4. Normal bicarbonate on arterial blood gases

3. Normal pH on arterial blood gases Arterial blood gas pH returns to normal when the body's compensatory efforts are fully effective. Glucose, potassium, and bicarbonate are affected by diabetic acidosis, but their return to normal is not an indicator of acid-base balance.

Which acid-base imbalance does the nurse anticipate the patient with morbid obesity may develop? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3. Respiratory acidosis Respiratory acidosis is related to CO 2 retention secondary to respiratory depression, inadequate chest expansion, airway obstruction, or reduced alveolar-capillary diffusion. Respiratory acidosis is common in morbidly obese patients who experience inadequate chest expansion owing to their size and work of breathing. Metabolic acidosis is related to overproduction of hydrogen ions, underelimination of hydrogen ions, underproduction of bicarbonate ions, and overelimination of bicarbonate ions. Metabolic alkalosis is related to loss of bicarbonate or buffers (i.e., vomiting or nasogastric suction). Respiratory alkalosis usually is caused by excessive loss of CO 2 through hyperventilation secondary to fever, central nervous system lesions, and salicylates.

The nurse is teaching safety measures to an unlicensed assistive person (UAP) who is caring for a patient with a peripherally inserted central catheter in the right hand. Which statement made by the UAP shows ineffective learning? 1. "I will obtain blood from the left hand." 2. "I will measure blood pressure from the left hand." 3. "I will inform the nurse if bleeding is noticed at the catheter site." 4. "I will clean the insertion area on the right hand carefully when giving the patient a bath."

4. "I will clean the insertion area on the right hand carefully when giving the patient a bath." The extremity that has an intravenous line should be covered with a plastic bag or wrap when giving a bath to keep the dressing dry and free from contamination. Blood should not be drawn from the extremity with the catheter to reduce complications such as vein irritation and inflammation. Taking blood pressures from the extremity with the catheter may increase the venous pressure and may lead to complications. If bleeding is observed at the insertion site, the nurse should be immediately informed so that he or she can change the dressing to prevent infection.

A patient admitted to the emergency department is having an acute episode of asthmatic bronchitis. The nurse notes the pH on the most recent arterial blood gas is 7.31. What is the most likely explanation for this finding? 1. Acidosis in response to the presence of excessive ketoacids 2. Alkalosis in response to the excessive loss of hydrogen ions 3. Alkalosis in response to the excessive retention of bicarbonate 4. Acidosis in response to the excessive retention of carbon dioxide

4. Acidosis in response to the excessive retention of carbon dioxide Patients who have asthmatic bronchitis and resulting impaired respiratory function retain carbon dioxide, which leads to acidosis. This patient is not retaining bicarbonate. An increase of hydrogen ions would occur with acidosis. Excessive ketoacids are associated with metabolic acidosis, not respiratory acidosis occurring in this patient.

Which assessment finding requires priority nursing intervention in a patient with metabolic or respiratory acidosis? 1. Dry skin 2. Rapid respiratory rate 3. Lethargy and confusion 4. Bradycardia with widened QRS complex

4. Bradycardia with widened QRS complex Cardiovascular manifestations that require priority nursing interventions are related to delayed electrical conduction; specifically bradycardia that may progress to heart block, tall T waves, widened QRS complex, and prolonged PR interval. Other changes like lethargy, confusion, rapid respiratory rate, and dry skin are important to address but may not require priority interventions.

What should the nurse document after inserting a venous catheter? 1. Patient's birth date 2. Name of the patient 3. Diagnosis of the patient 4. Date and time of the insertion

4. Date and time of the insertion Because intravenous (IV) therapy is risk prone, the nurse should document the date and time of the insertion after insertion. This will let other nurses know when the IV site needs to be rotated. The patient's birth date, name, and diagnosis are more important to note when infusing fluids and medication.

When caring for a patient with metabolic acidosis, what must the nurse keep in mind regarding acid-base chemistry? 1. Acids bind free hydrogen ions in solution. 2. Acetic acid (CH 3COOH) is a strong acid. 3. Normally, blood is slightly acidic in nature. 4.Fluids with lower pH have higher acidity

4. Fluids with lower pH have higher acidity. Fluids with lower pH have a higher level of free hydrogen ions and therefore have higher acidity. Acids release hydrogen ions rather than bind with them when dissolved in water. Strong acids readily dissociate in water and release all of their hydrogen ions. Acetic acid (CH 3COOH) is a weak acid. When dissolved in water, it releases only one of its four hydrogen molecules. Normally, blood has a pH of between 7.35 and 7.45, so it is slightly alkaline.

The nurse instructs an older adult patient to increase intake of dietary potassium when the patient is prescribed which classification of drugs? 1. Beta blockers 2. Corticosteroids 3. Alpha antagonists 4. High-ceiling (loop) diuretics

4. High-ceiling (loop) diuretics High-ceiling (loop) diuretics are potassium-depleting drugs. The patient should increase intake of dietary potassium to compensate for this depletion. Alpha antagonists, beta blockers, and corticosteroids are not potassium-depleting drugs.

Which electrolyte abnormality does the nurse anticipate when reviewing laboratory data for a patient admitted with metabolic acidosis? 1. Hyponatremia 2. Hypernatremia 3. Hypokalemia 4. Hyperkalemia

4. Hyperkalemia Serum potassium (hyperkalemia) occurs during metabolic acidosis as the body attempts to maintain pH by moving potassium ions from the cell in exchange with hydrogen ions moving into the cell. Hypokalemia may occur as the cause of the metabolic acidosis is corrected. Sodium concentrations (hypernatremia and hyponatremia) are not affected in the buffering process of acid-base balance.

Which organs play major roles in maintaining pH balance in the body? 1. Lungs and liver 2. Kidneys and brain 3. Liver and pancreas 4. Lungs and kidneys

4. Lungs and kidneys Blood pH represents a delicate balance between hydrogen ions (acid) and bicarbonate anions (base), which is largely controlled by the lungs and kidneys. The lungs adjust the blood pH by releasing or retaining hydrogen ions (acid), and the kidneys adjust the blood pH by releasing or retaining bicarbonate anions (base). The liver plays a role in metabolism, immunity, and clotting. The pancreas releases insulin for glucose metabolism and enzymes for digestion. The brain plays a secondary role in maintaining pH balance by sensing the need for alterations in acid or base levels and sends appropriate signals to the kidneys and lungs.

To decrease the risk of acid-base imbalance, what goal must the patient with diabetes mellitus strive for? 1. Drinking 3 L of fluid per day. 2. Eating regularly, every 4 to 8 hours. 3. Checking blood glucose levels once daily. 4. Maintaining blood glucose level within normal limits

4. Maintaining blood glucose level within normal limits Maintaining blood glucose levels within normal limits is the best way to decrease the risk of acid-base imbalance. Blood glucose levels must be checked not once but several times a day. Drinking 3 L of fluid per day is not necessary to maintain acid-base balance. Eating regularly is a way to achieve acid-base balance but is not the goal itself.

The nurse is preparing to administer a blood transfusion to a patient. Which vein is selected for a midline catheter? 1. Cephalic 2. Subclavian 3. Internal jugular 4. Median antecubital

4. Median antecubital The median antecubital vein is the preferred site for the administration of a midline catheter because it does not require vein transillumination for visualization. The basilic vein, which is the second choice for midline catheter administration, requires ultrasound visualization. The cephalic, subclavian, and internal jugular veins are not used for midline catheter placement. The cephalic vein is the site of placement for short peripheral catheters. The subclavian and internal jugular veins are used for placement of nontunneled percutaneous central venous catheters.

Which regulation or act requires every health care facility to maintain a sharps injury log with details of each incident? 1. Affordable Care Act 2. Americans with Disabilities Act 3. Patient Self-Determination Act (PSDA) 4. Needlestick Safety and Prevention Act

4. Needlestick Safety and Prevention Act The Needlestick Safety and Prevention Act requires each employer to maintain a sharps injury log with details of every incident. The Affordable Care Act helps patients use their insurance benefits to cover high-cost treatment. The Americans with Disabilities Act requires every employer to offer reasonable assistance to a disabled employee to allow him or her to perform the job. The PSDA requires patients to determine the medical care they want provided (or not provided) if they become incapacitated.

After a motor vehicle crash, the nurse is consoling a patient in the emergency department who is hysterical and hyperventilating after being notified of the death of a family member. What acid-base imbalance is this patient likely to develop? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

4. Respiratory alkalosis Hyperventilation leads to excessive loss of CO 2 and respiratory alkalosis. The patient will not develop respiratory acidosis, which is caused by hypoventilation, nor will the patient develop metabolic alkalosis or acidosis.

A 70-year-old patient 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 patient has crackles throughout all lung fields. Which action does the nurse take first? 1. Assess the midline IV insertion site. 2. Have the patient cough and deep-breathe. 3. Notify the health care provider about the crackles. 4. Slow the rate of the IV infusion.

4. Slow the rate of the IV infusion. The presence of crackles throughout the lungs is a sign of possible fluid overload [1] [2]. The nurse should slow the rate of infusion and further assess for indicators of volume overload and/or respiratory distress. Assessing the site, having the patient cough and deep-breathe, and notifying the provider may be appropriate, but are not the initial actions for this patient.