Ch 13 & 15

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

"I can continue my 20-mile (32-km) running schedule as I have in the past." The statement by the client stating that his or her normal running schedule can continue indicates a need for further education. Excessive physical activity can dislodge the PICC or lead to catheter occlusion and should be avoided.Clients with PICCs should be able to perform normal activities of daily living. PICCs have lower complication rates because the insertion site is in the upper extremity. The dry skin of the arm has fewer types and numbers of microorganisms, leading to lower rates of infection. PICC lines can be used long term (months).

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

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

About how many mL will the nurse record as having been replaced for a client with dehydration initially weighed 142 lb (64.5 kg) and now weighs 156 lb (70.9 kg) after 2 days of rehydration therapy? 3000 6300 9300 7000

6300 kg = 2.2 lb. 1 kg of water = 1 L (1000 mL) of water. 14 lb divided by 2.2 = 6300 g (6300 mL).

Which client will the nurse recognize as having the greatest risk for development of hypocalcemia? A 26 year old with hyperparathyroidism A 70 year old who has alcoholism and malnutrition A 40 year old taking tetracycline for an infection A 35 year old athlete taking NSAIDs for joint pain

A 70 year old who has alcoholism and malnutrition Calcium is absorbed from the gastrointestinal tract under the influence of vitamin D. When a client is malnourished, not only is the dietary intake of calcium usually low, but the client is also vitamin deficient. Hyperparthyroidism would increase serum calcium levels. Neither NSAIDs nor tetracycline increase the risk for hypocalcemia.

A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention? a. The initial site dressing is 3 days old. b. The PICC was inserted 4 weeks ago. c. A securement device is absent. d. Upper extremity swelling is noted.

ANS: D Upper extremity swelling could indicate infiltration, and the PICC will need to be removed. The initial dressing over the PICC site would be changed within 24 hours. This does not require immediate attention, but the swelling does. The dwell time for PICCs can be months or even years. Securement devices are being used more often now to secure the catheter in place and prevent complications such as phlebitis and infiltration. The IV lacking one does not take priority over the client whose arm is swollen.

A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multidose vial of heparin with a concentration of 100 units/mL. Which of the syringes shown below will the nurse use to draw up and administer the heparin?

ANS: D Always use a 10-mL syringe when flushing PICC lines because a smaller syringe creates higher pressure, which could rupture the lumen of the PICC. The PICC line would be accessed with a needleless syringe.

A client is being admitted to the burn unit from another hospital. According to the client's medical record, the client has an intraosseous IV that was started 2 days ago. Which nursing action is most appropriate? Start an epidural IV. Call the previous hospital to verify the date. Anticipate an order to discontinue the intraosseous IV. Immediately discontinue the intraosseous IV.

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

What response does the nurse expect to see in the blood volume and blood osmolarity of a client whose secretion of aldosterone is abnormally low? Decreased blood volume; increased blood osmolarity Increased blood volume; decreased blood osmolarity Decreased blood volume; decreased blood osmolarity Increased blood volume; increased blood osmolarity

Decreased blood volume; decreased blood osmolarity The action of aldosterone, known as the water- and sodium-saving hormone, increases the kidney reabsorption of both water and sodium to maintain blood volume and osmolarity. Clients who have low levels of aldosterone secretion lose large amounts of sodium and water in the urine, which results in low blood volume and low blood osmolarity.

Which assessment finding indicates to the nurse that the older client's therapy for dehydration is successful? Pulse pressure has decreased. Client reports feeling hungry. Hematocrit is 58% (0.58 volume fraction). Hourly urine output is greater than 15 mL.

Hourly urine output is greater than 15 mL. The most sensitive indicator of an adequate fluid volume is increasing urine output. The fact that a client who is dehydrated now has an hourly urine output of more than 15 mL is a positive indicator that the therapy is effective. Decreasing pulse pressure and a hematocrit above normal are indicators of on-going dehydration. Appetite is not a true indicator of hydration status.

Which assessment findings will the nurse consider as possible causes for a client to have a serum potassium level of 6.3 mE/L (mmol/L)? (Select all that apply.) Management of hypertension with an angiotensin converting enzyme inhibitor Presence of chronic kidney disease Vegan diet Excessive use of salt substitute Daily therapy with a potassium-sparing diuretics Past history of hepatitis A

Management of hypertension with an angiotensin converting enzyme inhibitor Presence of chronic kidney disease Excessive use of salt substitute Excessive use of salt substitute Potential causes of hyperkalemia include excessive use of salt substitutes (which contain high levels of potassium), chronic kidney disease (which prevents adequate excretion of potassium), daily use of a potassium-sparing diuretic (reduces potassium excretion), and the use of an angiotensin converting enzyme inhibitor. Neither a vegan diet nor previous illness with hepatitis A is associated with development of hyperkalemia.

Which sign or symptom indicates to the nurse that treatment for a client's hypokalemia is effective? Reports having a bowel movement daily. ECG shows an inverted T wave. Fasting blood glucose level is 106 mg/dL. Two lb weight gain during the past week.

Reports having a bowel movement daily. Hypokalemia depresses all excitable tissues, including gastrointestinal smooth muscle. Clients who have hypokalemia have reduced or absent bowel sounds and are constipated. Gaining 2 lb in a week does not indicate effective management for hypokalemia. An inverted T-wave is associated with worsening hypokalemia. The fasting blood glucose level is not related to recovery from hypokalemia.

Which body areas are best for the nurse to use when assessing skin indications of hydration status for an older client? (Select all that apply.) Tops of the forearms Skin of the shins Skin of the forehead Skin over the abdomen Skin over the sternum Back of the hand

Skin of the forehead Skin over the sternum Assess skin turgor in an older client by pinching the skin over the sternum or on the forehead, rather than on the back of the hand. With aging the skin loses elasticity and tents on hands and arms even when the client is well hydrated and thus, changes in these areas are not reliable indicators of hydration status.Many older clients have dry flaky skin on the shins regardless of hydration status. The skin of the abdomen is looser in older clients and also is not a reliable skin area to check hydration status.

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L) (Select all that apply.) Keeping the client NPO during drug treatment Pushing the drug as a bolus slowly over 5 minutes Using an IV controller to deliver the drug Checking IV access for blood return after the infusion Initiating the IV in a hand vein for rapid access Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution

Using an IV controller to deliver the drug Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution Best practice technique for administering parenteral potassium replacement is to ensure that the concentration is no greater than 1 mEq/10 mL of solution at a rate never to exceed 20 mEq/hr. A pump or controller device must be used to deliver the drug to prevent rapid infusion and complications of hyperkalemia, including cardiac arrest. IV potassium must be infused via a large vein with a high volume of flow, avoiding the hand. Potassium is not to be infused or pushed as a bolus to prevent cardiac. Assessing the IV access for placement and an adequate blood return is performed before administering potassium-containing solutions. It is not necessary or good practice to keep the client NPO during parenteral potassium administration.

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A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first? a. Depth of respirations b. Bowel sounds c. Grip strength d. Electrocardiography

ANS: A A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse would assess the client's respiratory status first to ensure that respirations are sufficient. The respiratory assessment would include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the client's respiratory status.

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) a. Hypokalemia—muscle weakness with respiratory depression b. Hypermagnesemia—bradycardia and hypotension c. Hyponatremia—decreased level of consciousness d. Hypercalcemia—positive Trousseau and Chvostek signs e. Hypomagnesemia—hyperactive deep tendon reflexes f. Hypernatremia—weak peripheral pulses

ANS: A, B, C, E, F Hypokalemia is associated with muscle weakness and respiratory depression. Hypermagnesemia manifests with bradycardia and hypotension. Hyponatremia can present with decreased level of consciousness. Hypomagnesemia can be assessed through hyperactive deep tendon reflexes. Weak peripheral pulses are felt in hypernatremia. Positive Trousseau and Chvostek signs are seen in hypocalcemia.

A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.) a. Unique facility identifier b. Lot number related to the donor c. Name of the client receiving blood d. ABO group and Rh type of the donor e. Blood type of the client receiving blood f. Signature line for 2-person verification

ANS: A, B, D The ISBT universal bar-coding system includes four components: (1) the unique facility identifier, (2) the lot number relating to the donor, (3) the product code, and (4) the ABO group and Rh type of the donor. Positive identification by two qualified health care providers is essential although automated bar coding is acceptable in some care areas. However, a signature line is not required on the blood label.

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (Select all that apply.) a. Increased pulse rate b. Distended neck veins c. Decreased blood pressure d. Warm and pink skin e. Skeletal muscle weakness f. Visual disturbances

ANS: A, B, E, F Signs and symptoms of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, skeletal muscle weakness, and visual disturbances. Decreased blood pressure would be seen in dehydration. Warm and pink skin is a normal finding.

A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss? a. Client taking furosemide. b. Anxious client who has tachypnea. c. Client who is on fluid restrictions. d. Client who is constipated with abdominal pain.

ANS: B Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for insensible fluid loss.

A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the client's chart prior to administering the medication and notes it to have been inserted 4 months ago. The site has no redness, warmth, or swelling and flushes easily. What action does the nurse take? a. Notify the primary health care provider. b. Administer the prescribed medication. c. Discontinue the PICC. d. Switch the medication to the oral route.

ANS: B A PICC that is functioning well without inflammation or infection may remain in place for months. Because the line shows no signs of complications, it is permissible to administer the IV antibiotic. There is no need to call the primary health care provider or to have the IV medication changed to an oral route.

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best? a. Measure intake and output every 4 hours. b. Assess client further for fall risk. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler position.

ANS: B Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. The client with dehydration is at risk for falls because of this confusion, orthostatic hypotension, dysrhythmia, and/or muscle weakness. The nurse's best response is to do a more thorough evaluation of the client's risk for falls. Measuring intake and output may need to occur more frequently than every 4 hours, but does not address a critical need. The nurse would not adjust the IV flow rate without a prescription or standing protocol. For an older adult, this rapid an infusion rate could lead to fluid overload. Sitting the client in a high-Fowler position may or may not be comfortable but still does not address the most important issue which is safety.

A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure? a. Notifies the pharmacy of the IV potassium order. b. Assesses the client's IV site every hour during infusion. c. Sets the IV pump to deliver 30 mEq of potassium an hour. d. Double-checks the IV bag against the order with the precepting nurse.

ANS: C IV potassium should not be infused at a rate exceeding 20mEq/hr under any circumstances. This action shows a need for further knowledge. The other actions are acceptable for this high-alert drug.

A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. What action will the nurse take next? a. Apply cold compresses to the IV site. b. Elevate the extremity on a pillow. c. Flush the catheter with normal saline. d. Stop the infusion of intravenous fluids.

ANS: D Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of infiltration include edema and tenderness above the site. The nurse would stop the infusion and remove the catheter. Cold compresses and elevation of the extremity can be done after the catheter is discontinued to increase client comfort. Alternatively, warm compresses may be prescribed per institutional policy and may help speed circulation to the area.

A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and "feeling warm." For which complication of this therapy will the nurse assess the client? a. Allergic reaction b. Bowel obstruction c. Catheter lumen occlusion d. Infection

ANS: D Fever, abdominal pain, abdominal rigidity, and rebound tenderness may be present in the client who has peritonitis related to intraperitoneal therapy. Peritonitis is preventable by using strict aseptic technique in handling all equipment and infusion supplies. An allergic reaction would show other signs and symptoms. Bowel obstruction and catheter lumen occlusion can occur but would present clinically in different ways

After receiving the change-of-shift report, which client does the nurse assess first? A 67 year old with nausea and vomiting who reports abdominal cramps. A 77 year old with normal saline infusing at 150 mL/hr with an average hourly urine output of 75 mL. A 57 year old receiving IV diuretics whose blood pressure is 88/52 mm Hg. A 45 year old with a nasogastric (NG) tube who has dry oral mucosa and reports feeling very thirsty.

A 57 year old receiving IV diuretics whose blood pressure is 88/52 mm Hg. The nurse must first assess the client receiving IV diuretics whose blood pressure is 88/52 mm Hg. This client with hypotension may have developed hypoperfusion caused by hypovolemia and may require immediate action. All other clients listed have less urgent problems and do not require immediate assessment.

Which client will the nurse consider to be at greatest risk for dehydration?? A 75-year-old woman with chronic back pain A 25-year-old woman taking oral contraceptives A 75-year-old man who has a vitamin deficiency A 25-year-old man who has frequent esophageal reflux

A 75-year-old woman with chronic back pain Women at any age have a higher risk for dehydration because women have more body fat than men, and fat cells contain practically no water. Men have a higher percentage of total body water at any age because they have more muscle mass than women and muscle cells contain a high concentration of water. The risk for dehydration increases with age. As adults age, their total body water volume decreases because both older men and older women loss muscle mass with aging.

A 22-year-old client presents with appendicitis and is preparing for surgery. What gauge catheter will the ED nurse select for this client? 22 14 18 24

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

A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement will the nurse include in this client's teaching? a. "Avoid carrying your grandchild with the arm that has the central catheter." b. "Be sure to place the arm with the central catheter in a sling during the day." c. "Flush the peripherally inserted central catheter line with normal saline daily." d. "You can use the arm with the central catheter for most activities of daily living."

ANS: A A properly placed PICC (in the antecubital fossa or the basilic vein) allows the client considerable freedom of movement. Clients can participate in most activities of daily living; however, heavy lifting can dislodge the catheter or occlude the lumen. Although it is important to keep the insertion site and tubing dry, the client can shower. The device is flushed with heparin

A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia? a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions. b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic. c. A 67 year old who is experiencing pain and is prescribed ibuprofen. d. A 73 year old with tachycardia who is receiving digoxin.

ANS: A Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized when infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic solutions can lead to hyponatremia. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can also lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.

A new nurse is caring for a client receiving drug therapy via a smart pump. What statement by the new nurse demonstrates the need for more instruction on this technology? a. "I don't need to manually calculate IV infusion rates with smart pumps." b. "Responding to IV pump alarms is a high priority for client safety." c. "The hospital can preprogram the pumps for high-alert drug limits." d. "These pumps have a system to prevent fluids from free-flowing into the client."

ANS: A The "smarter" the pump is the more programming needs to occur and errors can happen and systems can fail. Using a programmable pump does not relieve the nurse of his or her responsibility to monitor the infusion site and rates and ensure the client is receiving the fluids or medications as prescribed. The Joint Commission continues to include responding to alarms as a National Patient Safety Goal. Pumps can be preprogrammed so that upper limits exist for high-alert drugs. All electronic infusion devices have some mechanism for preventing free flow of fluids if the cassette or tubing is removed from the pump.

A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention will the nurse suggest to the management team to make the biggest impact on decreasing complications? a. Initiate a dedicated team to insert access devices. b. Require additional education for all nurses. c. Limit the use of peripheral venous access devices. d. Perform quality control testing on skin preparation products.

ANS: A The Centers for Disease Control and Prevention recommends having a dedicated IV team to reduce complications, save money, and improve client satisfaction and outcomes. In-service education would always be helpful, but it would not have the same outcomes as an IV team. Limiting the use of various access devices may not be practical. The quality of skin preparation products is only one aspect of IV insertion that could contribute to infection.

While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 1.5 inch (4-cm) venous cord. How will the nurse document this finding? a. "Grade 3 phlebitis at IV site" b. "Infection at IV site" c. "Thrombosed area at IV site" d. "Infiltration at IV site"

ANS: A The presence of a red streak and palpable cord indicates grade 3 phlebitis. No information in the description indicates that infection, thrombosis, or infiltration is present.

A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are paired with the correct potential imbalance? (Select all that apply.) a. Sodium: 160 mEq/L (mmol/L): Overhydration b. Potassium: 5.4 mEq/L (mmol/L): Dehydration c. Osmolarity: 250 mOsm/L: Overhydration d. Hematocrit: 68%: Dehydration e. BUN: 39 mg/dL: Overhydration f. Magnesium: 0.8 mg/dL: Dehydration

ANS: B, C, D, F In dehydration, hemoconcentration usually results in higher levels of hemoglobin, hematocrit, serum osmolarity, glucose, protein, blood urea nitrogen, and electrolytes. The opposite is true of overhydration. The sodium level is high, indicating dehydration. The potassium level is high, also indicating possible dehydration. The osmolarity is low, indicating overhydration, the hematocrit is high indicating dehydration, the BUN is high indicating dehydration, and the magnesium level is low, indicating possible dehydration and malnutrition from diarrhea-causing diseases.

A nurse prepares to insert a short peripheral venous catheter. What actions will the nurse take to use best practices? (Select all that apply.) a. Choose a distal site on the client's nondominant arm. b. Verify that the prescription is appropriate for peripheral infusion. c. Place the venous catheter near an area of joint flexion. d. Wear a surgical mask during the catheter insertion procedure. e. Perform hand hygiene before inserting the catheter. f. Limit unsuccessful attempts by up to three clinicians to one attempt each.

ANS: A, B, E Best practices for the insertion of a short peripheral venous catheter include hand hygiene prior to the procedure, verification of the prescription for intravenous therapy and its appropriateness for infusion through a short peripheral catheter, and placement of the catheter in a distal site, away from an area of joint flexion and when possible in the client's nondominant arm. Surgical masks are needed for central venous catheter placement but not for short peripheral venous catheter placement. Unsuccessful attempts to insert the catheter should be limited to two per person and no more than four total.

A registered nurse (RN) occasionally delegates client care to licensed practical nurses (LPNs) or technicians. What information does the RN consider when delegating components of IV therapy? (Select all that apply.) a. Each state's Nurse Practice Act will regulate who can perform care related to IVs. b. The nurse would check the facility's Policies and Procedures manual. c. The LPN's level of experience primarily guides the decision. d. Technicians cannot participate in any part of caring for IV infusions. e. The RN remains accountable for all aspects of IV care and delegated actions. f. The Infusion Nurses Society has guidelines and standards of IV therapy competency.

ANS: A, B, E, F The state Nurse Practice Act will have the information the RN needs to determine scope of practice, and in some states, LPNs and technicians are able to perform specific aspects of IV therapy. The nurse would also be familiar with facility policies and procedures regarding delegation of IV therapy. Amount of experience is not a criterion as LPNs and technicians can have their knowledge and skills verified. The nurse remains accountable for all aspects of IV therapy include what has been delegated. The Infusion Nurses Society has published guidelines and standards related to competency for IV therapy

A nurse is caring for a client who has just had a central venous access line inserted. What action will the nurse take next? a. Begin the prescribed infusion via the new access. b. Ensure that an x-ray is completed to confirm placement. c. Check medication calculations with a second RN. d. Make sure that the solution is appropriate for a central line.

ANS: B A central venous access device, once placed, needs an x-ray confirmation of proper placement before it is used. The bedside nurse would be responsible for beginning the infusion once placement has been verified. Any IV solution can be given through a central line.

The nurse is caring for a client who has fluid overload. What action by the nurse takes priority? a. Administer high-ceiling (loop) diuretics. b. Assess the client's lung sounds every 2 hours. c. Place a pressure-relieving overlay on the mattress. d. Weigh the client daily at the same time on the same scale

ANS: B All interventions are appropriate for the client who is overhydrated. However, client safety is the priority. A client with fluid overload can easily go into pulmonary edema, which can be life threatening. The nurse would closely monitor the client's respiratory status

A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, what action will the nurse take to relieve pain? a. Administer topical lidocaine to the site. b. Place warm compresses on the site. c. Administer prescribed oral pain medication. d. Massage the site with scented oils.

ANS: B At the first sign of phlebitis, the catheter will be removed and warm compresses used to relieve pain. The other options are not appropriate for this type of pain.

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? (Select all that apply.) a. Urine output of 25 mL/hr b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) c. Urine specific gravity of 1.02 g/mL d. Serum sodium level of 128 mEq/L (128 mmol/L) e. Blood osmolality of 250 mOsm/kg (250 mmol/kg)

ANS: B, E Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client's risk for excessive water loss (increased urine output), increased potassium reabsorption, decreased blood osmolality, and increased urine specific gravity. The client would not be at risk for sodium imbalance

A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration? a. A 36 year old who is prescribed long-term steroid therapy. b. A 55 year old who recently received intravenous fluids. c. A 76 year old who is cognitively impaired. d. An 83 year old with congestive heart failure.

ANS: C Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration. The client with heart failure has a risk for both fluid imbalances. Long-term steroids and recent IV fluid administration do not increase the risk of dehydration.

A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first? a. Prepare to administer patiromer by mouth. b. Provide a heart-healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment.

ANS: C A client with a critically high serum potassium level and cardiac changes would be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore would be administered with dextrose to prevent hypoglycemia. Patiromer may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first intervention the nurse would implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client's current potassium level.

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching? a. "Have you spouse watch you for irritability and anxiety." b. "Notify the clinic if you notice muscle twitching." c. "Call your primary health care provider for diarrhea." d. "Bake or grill your meat rather than frying it."

ANS: C One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be taught to call the primary health care provider if this is noticed. Irritability and anxiety are common neurologic signs of hypokalemia. Muscle twitching is related to hypernatremia. Cooking methods are not a cause of hyponatremia.

A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 to 22 breaths/min b. Decreased skin turgor on the client's posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic changes when standing

ANS: D The focus of management for clients with dehydration is to increase fluid volumes to normal. When blood volume is normal, orthostatic blood pressure and pulse changes will not occur. This assessment finding shows a therapeutic response to treatment. Increased respirations, decreased skin turgor, and higher urine specific gravity all are indicators of continuing dehydration.

A nurse assesses a client who has a radial artery catheter. Which assessment will the nurse complete first? a. Amount of pressure in fluid container b. Date of catheter tubing change c. Type of dressing over the site d. Skin color and capillary refill

ANS: D An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of color, warmth, sensation, capillary refill time, and distal pulses (if appropriate) are assessments for circulation distal to the catheter site. The nurse would note that there is enough pressure in the fluid container to keep the system flushed, and would check to see whether the catheter tubing needs to be changed. However, these are not assessments of greatest concern. The type of dressing over the site would be noted and most likely prescribed by policy.

A nurse prepares to insert a peripheral venous catheter in an older adult. What action will the nurse take to protect the client's skin during this procedure? a. Lower the extremity below the level of the heart. b. Apply warm compresses to the extremity. c. Tap the skin lightly and avoid slapping. d. Place a washcloth between the skin and tourniquet.

ANS: D To protect the client's skin, the nurse will place a washcloth or the client's gown between the skin and tourniquet. The other interventions are methods to distend the vein but will not protect the client's skin.

What is the nurse's best first action when a client's hand goes into flexion contractures during blood pressure measurement with an external cuff? Deflating the blood pressure cuff and giving the client oxygen Documenting the finding as the only action Initiating the Rapid Response Team Placing the client in the high-Fowler position and increasing the IV flow rate

Deflating the blood pressure cuff and giving the client oxygen Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. This effect of hypocalcemia is enhanced in the presence of tissue hypoxia. The flexion contractions occurring during blood pressure measurement are indicative of hypocalcemia and referred to as a positive Trousseau sign. Initiating the Rapid Response Team is a good second action. Placing the client in high-Fowler position will not help the hypocalcemia.

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload? Checking for presence of dependent edema Assessing blood pressure Measuring intake and output Elevating the head of the bed

Elevating the head of the bed Pulmonary edema with difficulty breathing can develop quickly in clients with fluid overload. Although assessing whether other signs and symptoms of fluid overload is important, the priority is to ensure adequate gas exchange before taking any other action. Raising the head of the bed takes little time and can help improve gas exchange even when pulmonary edema is present.

A male client is seen in the emergency department (ED) with pain, redness, and warmth of the right lower arm. The client was in the ED last week after an accident at work where he received 12 hours of IV fluids. On assessment, the nurse notes the presence of a palpable cord 1 inch (2.5 cm) in length and streak formation. How will the nurse document the assessment? Grade 2 phlebitis Grade 3 phlebitis Grade 1 phlebitis Grade 4 phlebitis

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

Which laboratory value indicates to the nurse that a client's hyponatremia may be related to a fluid volume excess? Serum chloride level is 100 mEq/L (mmol/L) Blood urea nitrogen (BUN) is elevated Arterial blood pH is 7.37 Hematocrit is 29% (0.29 volume fraction)

Hematocrit is 29% (0.29 volume fraction) When hyponatremia is caused by fluid volume excess, other blood/serum values are low as a result of dilution. The hematocrit level is low, which may be related to hyponatremia. The chloride level is normal. Elevated levels are associated with dehydration and reduced kidney function. The arterial pH is normal.

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

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

Which serum electrolyte value indicates to the nurse that the client has hypernatremia? Sodium 132 mEq/L (mmol/L) Potassium 3.5 mEq/L (mmol/L) Sodium 148 mEq/L (mmol/L) Potassium 5.3 mEq/L (mmol/L)

Sodium 148 mEq/L (mmol/L) Normal serum sodium ranges between 136 and 145 mEq/L (mmol/L). Hypernatremia is a serum sodium value greater than 145 mEq/L (mmol/L). In option A, the serum potassium is normal. In options C, the serum potassium value is above normal and indicates hyperkalemia. In option B, the serum sodium value is low, reflecting hyponatremia.

The nurse is revising an agency's recommended central line-associated bloodstream infection (CLABSI) bundle. Which actions decrease the client's risk for this complication? (Select all that apply.) During insertion, draping just the area around the site with a sterile barrier Making certain that observers of the insertion are instructed to look away during the procedure Using chlorhexidine for skin disinfection Thorough hand hygiene before insertion Removing the client's venous access device (VAD) when it is no longer needed

Using chlorhexidine for skin disinfection Thorough hand hygiene before insertion Removing the client's venous access device (VAD) when it is no longer needed As soon as the VAD is deemed unnecessary, it needs to be removed to reduce the risk for infection. Thorough handwashing is a key factor in insertion and maintenance of a central line device. Quick handwashing is not sufficient. Chlorhexidine is recommended for skin disinfection because it has been shown to have the best outcomes in infection prevention.During the insertion, the whole body (head to toe) of the client is draped with a sterile barrier. Draping only the area around the site will increase risk for infection. Looking away will not reduce the risk for infection. Reducing the number of people in the room and having everyone wear a mask will help reduce the risk for infection.

In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach as client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply.) Red meat Cereal Citrus fruit Salt substitutes Eggs Bread

Red meat Citrus fruit Salt substitutes While taking a potassium-sparing diuretic, the client is at risk for developing hyperkalemia and needs to avoid foods and other substances that contain higher concentrations of potassium. These include salt substitutes, meat and fish, and citrus fruit. Foods lowest in potassium include eggs, bread, and cereal grains, as well as most berries.

Which nursing assessment data indicate the need for immediate nursing intervention? Client states, "It really hurt when the nurse put the IV in." Transparent dressing was changed 5 days ago. Tubing for the IV was last changed 72 hours ago. The vein feels hard and cordlike above the insertion site.

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

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

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

A nurse delegates care to an assistive personnel (AP). Which statement will the nurse include when delegating hygiene for a client who has a vascular access device? a. "Provide a bed bath instead of letting the client take a shower." b. "Use sterile technique when changing the dressing." c. "Disconnect the intravenous fluid tubing prior to the client's bath." d. "Use a plastic bag to cover the extremity with the device."

ANS: D The nurse will ask the AP to cover the extremity with the vascular access device with a plastic bag or wrap to keep the dressing and site dry. The client may take a shower or bath with a vascular device. The nurse will disconnect IV fluid tubing prior to the bath and change the dressing using sterile technique if necessary. These options are not appropriate to delegate to the AP

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

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

The nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters will the nurse choose most often? Cephalic vein of the forearm Palmer side of the wrist Back of the hand Subclavian vein

Cephalic vein of the forearm The cephalic vein of the forearm is the insertion site chosen most often. For same-day surgery, the cephalic or basilic vein allows insertion of a larger IV catheter while allowing movement of the arm without impairing intravenous flow.Peripheral venous catheters should never be inserted into the back of the hand in an older adult because the veins are brittle. Peripheral venous catheters are not inserted into the palmar side of the wrist because the median nerve is located close to this area. Catheters are typically inserted into the subclavian vein by the health care provider, not by the nurse.

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

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

Which assessment is most important for the nurse to perform on a client whose serum potassium level is 2.0 mEq/L (mmol/L)? Checking pulse oximetry Measuring blood pressure Listening to bowel sounds in all four quadrants Observing the ECG for flat T-waves

Checking pulse oximetry Although all assessment actions listed are important, the most critical one to perform is assessing respiratory function effectiveness. Skeletal muscle weakness can make respiratory movements ineffective, leading to respiratory failure and death. Although cardiac changes can occur.

Which assessment on an older client with some degree of dehydration will the nurse perform to determine whether the client is safe for independent ambulation? Ensuring that the most recent serum potassium level is above 3.5 mEq/L (mmol/L) Assessing for furrows on the tongue to determine dryness of oral mucous membranes Comparing blood pressure measurements in the lying, sitting, and standing positions Ensuring that the pulse rate obtained radially is within 2 beats/min of that obtained apically

Comparing blood pressure measurements in the lying, sitting, and standing positions When caring for an older adult admitted for dehydration, the nurse determines if the client is safe for independent ambulation by assessing for orthostatic blood pressure changes. Comparisons of blood pressures obtained with the client lying, then sitting, and finally standing can detect postural changes. If the standing blood pressure is significantly lower than that obtained while the client was in the lying or sitting positions, insufficient blood flow to the brain may cause hypotension with light-headedness and dizziness, which increase the risk for falls. Comparing apical to radial pulse rates does not provide information to detect degree of dehydration. Although assessment of oral mucous membranes can detect symptoms of dehydration, it does not provide information for falls risk. Dehydration usually results in an elevated serum potassium level, not a decreased level.

The nurse is checking an IV fluid order and questions accuracy. What nursing action is appropriate? Ask the charge nurse about the order. Start the fluid as ordered. Contact the pharmacy for clarification. Contact the prescribing health care provider.

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

What is the best action for a nurse to take on finding a client's serum chloride level is 101 mEq/L? Urge the client to drink more water. Notify the primary health care provider. Assess the client's deep tendon reflexes. Document the finding as the only action.

Document the finding as the only action. The normal range for serum chloride levels is between 98 and 106 mEq/L. No action beyond confirming documentation is needed.

The nurse is to administer a unit of whole blood to a postoperative client. What will the nurse do to ensure the safety of the blood transfusion? Ensure that another qualified health care professional checks the unit before administering. Check the blood identification numbers with the laboratory technician at the blood bank at the time it is dispensed. Make certain that an IV solution of 0.9% normal saline is infusing into the client before starting the unit. Ask the client to both say and spell his or her full name before starting the blood transfusion.

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

Which assessment finding on a client with hypervolemia indicates to the nurse that the client's condition may be worsening? Nose and ears have a slightly yellow-tinged appearance. Neck veins are now distended in the sitting position. Breath sounds can be heard in the right lower lung lobe. Weight is unchanged from that obtained yesterday.

Neck veins are now distended in the sitting position. Neck veins are normally distended when a client is in the supine position and are flat when a client is sitting or standing. When hypervolemia worsens the neck veins are distended even when the client is upright. Hearing breath sounds in the lower lung lobes is a positive sign, not one that indicates the condition is worsening. An unchanged weight indicates the client's condition is stable, not worsening. The color of the ears and nose is not related to hydration status.

What effect does the nurse expect that an infusion of 200 mL of albumin will have immediately on a client's plasma osmotic and hydrostatic pressures? Decreased osmotic pressure; decreased hydrostatic pressure Decreased osmotic pressure; increased hydrostatic pressure Increased osmotic pressure; increased hydrostatic pressure Increased osmotic pressure; decreased hydrostatic pressure

Increased osmotic pressure; increased hydrostatic pressure The addition of albumin to the plasma would add a colloidal substance that does not move into the interstitial space. Thus, the osmotic pressure would immediately increase. Not only does the additional 200 mL add to the plasma hydrostatic pressure, but also the increased osmotic pressure would draw water from the interstitial space, increasing the plasma volume and ultimately leading to an increased hydrostatic pressure in the plasma volume.

Which action will the nurse perform first for the client who has a serum potassium level of 6.9 mEq/L (mmol/L)? Teaching the client which foods to avoid Administering sodium polystyrene sulfonate orally Collaborating with the registered dietitian nutritionist to provide a potssium-restricted diet Initiating continuous cardiac monitoring

Initiating continuous cardiac monitoring The client has hyperkalemia. The nurse must initiate continuous cardiac monitoring for this client because hyperkalemia can lead to life-threatening bradycardia and other dysrhythmias, including tall, peaked T waves; prolonged PR intervals; flat or absent P waves; wide QRS complexes; and possible ectopic beats. Monitoring allows the nurse to determine whether therapy is effective or if the client's condition is worsening. Administering a potassium-reducing medication, recommending a potassium-restricted diet, and teaching the client about which foods to avoid are appropriate but will not immediately decrease the serum potassium level and do not need to be implemented as quickly as monitoring cardiac rhythm.

Which condition or symptom indicates to the nurse that the client's treatment for hyperkalemia is effective? Chvostek sign is negative. Respiratory rate is 22 breaths/min. Pulse rate is 76 beats/min and regular. Hematocrit is 42%.

Pulse rate is 76 beats/min and regular. Hyperkalemia affects cardiac conduction inducing tall T-waves, widened QRS complexes, absent P waves, prolonged PR intervals, bradycardia, and heart block. A heart rate that is regular and within the client's normal range for rate indicates resolution of the hyperkalemia. The normal respiratory rate does not indicate resolution of the hyperkalemia. Chvostek sign is present with hypocalcemia, not hyperkalemia. The hematocrit is not affected by hyperkalemia or its management.

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

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

The nurse is preparing to insert a peripheral venous catheter. What action will the nurse take? Select the most distal site. Look near the elbow joint first. Palpate for hardness of a vein. Use the client's dominant arm for insertion.

Select the most distal site. The nurse will choose the most distal site and make all subsequent venipunctures proximal to previous sites. The nurse will not palpate for hard or cordlike veins as these are not ideal for cannulation. The nurse will use the client's nondominant arm and avoid areas of joint flexion.

Which client electrocardiography (ECG) change from baseline will alert the nurse to possible development of hypercalcemia? Shortened QT-interval Absent P wave Prominent U wave Inverted T waves

Shortened QT-interval Hypercalcemia affects increases myocardial contractility and slows depolarization. Common ECG changes include wide T-waves and shortened QT-intervals. Bradycardia and heart block may follow.

The nurse is teaching a course about the special needs of older adults receiving IV therapy. What teaching will the nurse include? To avoid rolling the veins, a greater angle of 25 degrees between the skin and the catheter improves success with venipuncture. Placement of the catheter on the back of the client's dominant hand is preferred. When the catheter is inserted into the forearm, excess hair should be shaved before insertion. Skin integrity can be compromised easily by the application of tape or dressings.

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

A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first? a. Assess the client's respiratory rate, rhythm, and depth. b. Measure the client's pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care primary health care provider.

ANS: A In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The client's pulse and blood pressure would be assessed after assessing respiratory status. Next, the nurse would call the health care primary health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client would occur during and after potassium replacement therapy.

A nurse assists with the insertion of a central vascular access device. Which actions will the nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.) a. Include a review for the need of the device each day in the client's plan of care. b. Remind the primary health care provider to perform hand hygiene prior to insertion if he or she forgets. c. Cleanse the preferred site with alcohol and let it dry completely before insertion. d. Ask everyone in the room to wear a surgical mask during the procedure. e. Plan to complete a sterile dressing change on the device every day. f. Minimal client draping and barrier precautions as blood loss are minimal.

ANS: A, B, D The central vascular access device bundle to prevent catheter-related bloodstream infections includes using a checklist during insertion, performing hand hygiene before inserting the catheter and anytime someone touches the catheter, using chlorhexidine to disinfect the skin at the site of insertion, using preferred sites, and reviewing the need for the catheter every day. The practitioner who inserts the device would wear sterile gloves, gown, and mask, and anyone in the room would wear a mask. Maximal barrier precautions are used which requires the client to be draped sterilely from head to toe. The initial dressing on a central vascular access device is changed in 24 hours. Gauze and tape dressings are changed every 48 hours and transparent membrane dressings are changed every 5 to 7 days.

A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which common complications will the nurse assess? (Select all that apply.) a. Phlebitis b. Pneumothorax c. Thrombophlebitis d. Excessive bleeding e. Extravasation f. Pneumothorax g. Infiltration

ANS: A, C Although the complication rate with PICCs is fairly low, the most common complications are phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Excessive bleeding, infiltration, and extravasation are not common complications. Pneumothorax does not occur.

A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? (Select all that apply.) a. Calculate pulse pressure with each blood pressure reading. b. Assess skin turgor using the back of the client's hand. c. Assess for pitting edema in dependent body areas. d. Monitor trends in the client's daily weights. e. Assist the client to change positions frequently. f. Teach client and family how to read food labels for sodium.

ANS: A, C, D, E, F Appropriate interventions for the client who has overhydration include calculating the pulse pressure with each BP reading as this is a sign of cardiovascular involvement, assessing for pitting edema in the client's dependent body areas, monitoring trends in the client's daily weight as fluid retention is not always visible, protecting the client's skin by helping him or her change positions, and teaching the client and family to read food labels some type of sodium restriction may be required at home. The nurse assesses skin turgor on the chest or forehead.

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.) a. Reports of palpitations b. Slow, shallow respirations c. Orthostatic hypotension d. Paralytic ileus e. Skeletal muscle weakness f. Tall, peaked T waves on ECG

ANS: A, E, F Electrolyte imbalances associated with acute renal failure include hyperkalemia. The nurse would assess for electrocardiogram changes, including tall, peaked T waves, reports of palpitations or "skipped beats," diarrhea, and skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of hypokalemia. Respiratory muscles may be affected with lethally high hyperkalemia.

A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? a. Redness at the catheter insertion site b. Report of headache and stiff neck c. Temperature of 100.1° F (37.8° C) d. Pain rating of 8 on a scale of 0-10

ANS: B Complications of epidural therapy include infection, bleeding, leakage of cerebrospinal fluid, occlusion of the catheter lumen, and catheter migration. Headache, neck stiffness, and a temperature higher than 101° F (37.8° C) are signs of meningitis and would be reported to the primary health care provider immediately. The other findings are important but do not require immediate intervention.

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching? a. "I must drink a quart (liter) of water or other liquid each day." b. "I will weigh myself each morning before I eat or drink." c. "I will use a salt substitute when making and eating my meals." d. "I will not drink liquids after 6 p.m. so I won't have to get up at night."

ANS: B One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb (0.2 kg) daily is indicative of excessive fluid loss. One liter of fluid a day is insufficient. A salt substitute is not related to dehydration. Clients may want to limit fluids after dinner so they won't have to get up, but this does not address dehydration if the patient drinks the recommended amount of fluid during the earlier parts of the day

. A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first? a. Encourage oral fluid intake. b. Connect the client to a cardiac monitor. c. Assess urinary output. d. Administer oral calcitonin

ANS: B This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.) a. Hypomagnesemia—kidney failure b. Hyperkalemia—salt substitutes c. Hyponatremia—heart failure d. Hypernatremia—hyperaldosteronism e. Hypocalcemia—diarrhea f. Hypokalemia—loop diuretics

ANS: B, C, D, E, F Salt substitutes contain potassium and are a cause of hyperkalemia. Hyponatremia can be caused by heart failure with fluid overload. Hyperaldosterone is a cause of hypernatremia and diarrhea causes actual calcium deficits. Loop diuretics excrete potassium. Decreased kidney function is a cause of magnesium excess, not deficit.

A nurse teaches a client who is prescribed a central vascular access device and is transferring to a skilled facility for long-term treatment. Which statement will the nurse include in this client's teaching? a. "You will need to wear a sling on your arm while the device is in place." b. "There is no risk of infection because sterile technique will be used during insertion." c. "Ask all providers to vigorously clean the connections prior to accessing the device." d. "You will not be able to take a bath with this vascular access device."

ANS: C The nurse would actively engage the client in the prevention of catheter-related bloodstream infections and taught to remind all providers to perform hand hygiene and vigorously clean connections prior to accessing the device. The other statements are incorrect.

After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that treatment is improving the client's hypokalemia? (Select all that apply.) a. Respiratory rate of 8 breaths/min b. Absent deep tendon reflexes c. Strong productive cough d. Active bowel sounds e. U waves present on the electrocardiogram (ECG)

ANS: C, D A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance. Active bowel sounds also indicate that treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all signs and symptoms of hypokalemia and do not demonstrate that treatment is working.

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital? a. Ask family members to speak quietly to keep the client calm. b. Assess urine color, amount, and specific gravity each day. c. Encourage the client to drink at least 1 L of fluids each shift. d. Dangle the client on the bedside before ambulating.

ANS: D An older adult with moderate dehydration may experience orthostatic hypotension. The client needs to dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the client's urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 L of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency

A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition? a. Assesses the client's Chvostek and Trousseau sign. b. Keeps the client's room quiet and dimly lit. c. Moves the client carefully to avoid fracturing bones. d. Administers bisphosphonates as prescribed.

ANS: D Bisphosphonates are used to treat hypercalcemia. The Chvostek and Trousseau signs are used to assess for hypocalcemia. Keeping the client in a low stimulus environment is important because the excitable nervous system cells are overstimulated. Long-standing hypocalcemia can cause fragile, brittle bones which can be fractured.

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching? a. Slices of smoked ham with potato salad b. Bowl of tomato soup with a grilled cheese sandwich c. Salami and cheese on whole-wheat crackers d. Grilled chicken breast with glazed carrots

ANS: D Clients on restricted sodium diets generally avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham, tomato soup, salami, and crackers are usually high in sodium

A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern? a. The catheter has been in place for 20 hours. b. The client has poor vascular access in the upper extremities. c. The catheter is placed in the proximal tibia. d. The client's left lower extremity is cool to the touch.

ANS: D Compartment syndrome is a condition in which increased tissue pressure in a confined anatomic space causes decreased blood flow to the area. A cool extremity can signal the possibility of this syndrome. All other findings are important; however, the possible development of compartment syndrome requires immediate intervention because the client could require amputation of the limb if the nurse does not correctly assess and respond to this perfusion problem

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

An older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours. The older client admitted for confusion with a heparin lock is the most stable and requires basic monitoring of the IV site for common complications such as phlebitis and local infection, which would be familiar to an LPN/LVN. The client with a diltiazem IV infusion, the client with an IV insulin drip, and the client receiving blood products all are not stable and will require ongoing assessments and adjustments in IV therapy that should be performed by an RN.

The nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What will the nurse do first? Check connections. Check the infusion rate. Assess the insertion site. Discontinue the IV and start another.

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

Which assessments are most important for the nurse to perform to prevent harm on a client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply.) Testing skin turgor Asking about any abdominal pain Assessing cognition Checking deep tendon reflexes Monitoring urine output Checking for the presence of fever

Assessing cognition Monitoring urine output The serum sodium is extremely low, which makes depolarization slower and cell membranes less excitable. It also can cause cerebral edema to form, leading to confusion and seizure activity. When sodium levels become very low, coma and death may occur. Assessing cognition and checking deep tendon reflexes are the most important assessment data to obtain. Monitoring urine output needs to be done but is not the priority action in this situation. Assessing skin turgor, presence of abdominal pain, and fever are not an urgent assessment to prevent immediate harm.

Which assessment is most important for the nurse to perform on a client who is receiving IV magnesium sulfate? Monitoring 24-hour urine output Monitoring the serum calcium levels Assessing the blood pressure hourly Asking the client whether a headache is present

Assessing the blood pressure hourly Assessing hourly blood pressures is critical when caring for a client receiving IV magnesium sulfate because hypotension is a sign/symptom of hypermagnesemia that could occur when too much has infused. Most clients who have fluid and electrolyte problems will be monitored for intake and output; however, changes will not immediately indicate problems with magnesium overdose. Headaches are not associated with hypermagnesemia. Although administration of magnesium sulfate can cause a drop in calcium levels, this occurs over a period of time and would not be the best way to assess magnesium toxicity.

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

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