fluid, electrolyte, and acid base
A nurse is preparing to administer 4,200 ml of IV fluids to a pt to infuse over 24 hr. The nurse should set the IV pump to deliver how many ml/hr? (round to the nearest zero)
175 ml/hr 4,200/24=175
A nurse on a pediatric floor is reinforcing teaching with a newly licensed nurse about IV theraphy. Which information should the nurse include.
Performing range of motion exercises on the extremity containing the IV site.
A nurse is collecting data on a client who has been receiving IV therapy for several days and notes that the client's daily weight has increased. The nurse should identify that the client is at increased risk for developing which of the following IV-related complications?
circulatory overload the nurse should assess for other indications circulatory overlaod, including tachycardia,increased bp, edema-cough-and tachypnea. provider should be notified of the pt's increased weight
A client who has an acid-base imbalance. The nurse should include that the stages of the nursing process should be performed in what order? (move the steps into the box on the right, placing them in the order of performance. )
data collection planning implementation evaluation (adopie)
A nurse is participating in a blood drive and is taking a donation who has type O+ blood. The client asks the nurse what type of blood they can receive. Which of the following statements should the nurse make?
you can receive a blood donation with type O- or type O+ clients. O- blood are universal donors anyone can receive their blood
A nurse is collecting data from a client who is exhibiting signs of fluid and electrolyte imbalance. Which of the following reports from the client is an indication that they may have a fluid or electrolyte imbalance?
The client reports that they performed yard work for 8 hr in 35 C (95 F) temperature early that day working outside in high temps for an extended period can cause profuse sweating and lead to a fluid or electrolyte imbalance
A charge nurse is observing a newly licensed nurse who is preparing to administer a blood transfusion to a client. For which of the following actions by the newly licensed nurse should the charge nurse intervene?
The nurse selects 0.45% sodium chloride to use to prime the tubing . 0.9% sodium chloride is the only iv solution that should be used to prime the tubing for blood administration
A nurse is assisting in the care for a client who requires a replacement peripheral IV. the client is dehydrated and requires a smaller gauge the the #20 gauge being replaced. Which of the following gauge catheters should the nurse recommend using?
#22 catheter should be replace for #20gauge IV catheter. as the client is dehydrated, it may be difficult to access the peripheral vein with a larger gauge cath. as the gauge # increases/catheter size decreases
A nurse is calculating a client's I & O for the last 4hr. The client consumed 480ml of water and 240 ml of coffee. The client has also received IV fluids for 4 hr infusion at 100 ml/hr. Which of the following amounts represents the client's intake over the last 4 hr?
1,1120 ml 480+240 +(100 mlx4hr) 720+420=1,120
A nurse is participating in a blood drive and is taking a donation who has type A- blood. The client asks the nurse what type of blood can receive their blood donation. Which of the following responses shoud the nurse make? (select all that apply)
A+ can receive blood from donors who have A- blood type. AB- can receive blood from donors who have A-blood type AB+can receive blood from donors who have A- blood type A-can receive blood from donors who have A-blood type
A nurse is reviewing ABG values for a client who is experiencing metabolic alkalosis. The nurse should identify that this action is part of which of the following steps of the nursing process?
Evaluation reviewing the pts ABG is part of the evaluation stage of the nurse process .
a nurse is caring for a client who's experiencing respiratory alkalosis. Which of the following actions should be the goal of tx for the client?
Increased CO2 level (co2 level is currently below the expected refence range. The goal of tx should be to raise the level of CO2 expected ref range PaCO2 of 35-45 mm hg
A nurse is reviewing the ABG's values of a client and notes the following results: PH 7.49 PaCO2 30 mm hg and HCO3- 35 meq/L The nurse should interpret this ABG reading is an indication of which of the following acid-base imbalances?
Metabolic alkalosis is indicated by a PH value above the expected reference range of 7.35 to 7.45 and HCO3- above (21-28 meq/L) PaCO2 (35 to 45)
A nurse is reviewing a client's latest ABG report. Which of the following values should the nurse identify as the priority to repost to the provider?
PaO2 76 mm hg this value is below the expected reference range of 80 to 100 mm hg and could be an indication the client is decompensating
A nurse has completed collecting data for a client who has acid-base imbalance. which of the following steps of the nursing process should the nurse take next?
Planning after assessing and analyzing data for a client the nurse should move into the planning stage of the nursing process and establish goals and outcomes for the client.
A nurse is caring for a client who is receiving tx for hyponatremia. The nurse should identified which of the followings findings is an indication that the tx has been effective? (select all that apply)
The client states their muscle spasms are absent The client denies being confused
a nurse is caring for a client who has the following ABG values: ph 7.44, PaCO2 37 mm hg and HCO3-24 meq/L. The nurse should identify that these values are an indication of which of the following?
acid-base balance the nurse should identify the ABG are within the expected ranges
A nurse is assisting an RN who is preparing to star an IV for a client who has a high risk of bleeding. Which of the actions should the nurse take?
apply a blood pressure cough set to 30 mm hg instead of using a tourniquet, the nurse should apply a bp cuff set to 30 mm hg prior to starting an IV for this client. This will help protect the pts extremities from bruising and bleeding
A nurse is assisting in the care of a pt who has an acid-base imbalance and is experiencing hypoxia. Which of the following actions should the nurse take first?
elevate the head of the pt's bed abc's next is to elevate the head of the pt's bed
