Foundations Content Review 4

What commonly used intravenous solution is hypotonic? 10% dextrose in water lactated Ringer's 0.45% NaCl 0.9% NaCl

0.45% NaCl

A nurse is preparing to insert an intravenous (IV) catheter into a client's arm. At which angle relative to the client's skin should the catheter be inserted? 10- to 15-degree angle 20- to 25-degree angle 40- to 45-degree angle 30- to 35-degree angle

10- to 15-degree angle

The nurse is monitoring fluid intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the record? Select all that apply. barbecue sandwich cup of ice cream bowl of chili 100 ml from melted ice chips infusion of intravenous solution serving of jello

100 ml from melted ice chips cup of ice cream infusion of intravenous solution serving of jello

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? 1,000 3,000 3,750 500

3,000

The nurse calculates the client's intake and output for the shift (above). Calculate the client's fluid balance, in milliliters, for the 8-hour shift. Record your answer using a whole number.

410

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate? 100 mL/hr 83 mL/hr 103 gtts/hr 13 mL/hr

83 mL/hr

The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance? Select all that apply. Ask provider to order a low-salt diet. Reduce infusing fluid volume as ordered. Administer furosemide as ordered. Increase oral intake to flush excess fluids. Treat the underlying condition that contributes to increased fluid volume.

Ask provider to order a low-salt diet. Reduce infusing fluid volume as ordered. Administer furosemide as ordered. Treat the underlying condition that contributes to increased fluid volume.

A home care nurse is visiting a client with acute kidney injury who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? Use an alcohol-based mouthwash to moisten your mouth. Avoid salty or excessively sweet fluids. Use regular gum and hard candy. Eat crackers and bread.

Avoid salty or excessively sweet fluids.

A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information? Compare the total intake and output of fluids for the 24 hours. Report the exact milliliter of intake to the health care provider's office nurse. Compare the client's intake with the normal range of adult fluid intake. Ensure that the information is included in the verbal end-of-shift report.

Compare the total intake and output of fluids for the 24 hours.

A client has been admitted to the medical-surgical floor for management of a fluid and electrolyte imbalance associated with decreased oral intake and excessive use of laxatives. The nurse analyzes assessment findings to identify those that may be caused by electrolyte imbalances. For each asssessment finding below, click to specify the associated electrolyte imbalance: hypokalemia, hyponatremia, or hypocalcemia. Each finding may support more than 1 disease process. tetany edema confusion muscle weakness seizures

Confusion- hyponatremia Muscle Weakness- hypokalemia, hyponatremia Seizures- hypocalcemia Tetany- hypocalcemia edema- hyponatremia

A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which actions should the nurse perform to avoid further complications and provide relief to the client? Discontinue the IV promptly. Administer oxygen. Elevate the affected arm. Call for help.

Discontinue the IV promptly.

A health care provider writes a prescription to "force fluids." What will be the first action the nurse will take in implementing this prescription? Explain to the client why this is needed. Divide the intake so the largest amount is at night. Decide how much fluid to increase every 8 hours. Tell the client and family to increase oral intake.

Explain to the client why this is needed.

A client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action? Assess the area distal to the IV site for signs and symptoms of deep vein thrombosis. Change from infusion with an electronic pump to infusion by gravity. Flush the IV with 2 mL of 100 U/mL heparin. Flush the IV with 3 mL of normal saline.

Flush the IV with 3 mL of normal saline.

A nurse is providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance? Hyperphosphatemia Hypermagnesemia Hypokalemia Hyponatremia

Hyperphosphatemia

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? colloid hypertonic hypotonic isotonic

Isotonic

A nurse is caring for a client who has recently suffered burns on 30% of his body. Based on his condition, what type of IV solution might be ordered for this client? 5% dextrose in 0.45% NaCl 5% dextrose in 0.9% NaCl 0.9% NaCl (normal saline) Lactated Ringer's

Lactated Ringer's

A nurse must administer an isotonic intravenous solution to a client who has lost fluid. Which fluids are isotonic? Select all that apply. 0.45% NaCl (½-strength saline) 0.9% NaCl (normal saline) Lactated Ringer's solution 5% dextrose in lactated Ringer's solution 0.33% NaCl (1/3-strength normal saline)

Lactated Ringer's solution 0.9% NaCl (normal saline)

A client has the following arterial blood gas results:pH: 7.33PaCO2: 42 mm HgHCO3: 19 mEq/L (19 mmol/L)PaO2: 95 mm HgWhich imbalance would the nurse suspect? Metabolic alkalosis Respiratory alkalosis Respiratory acidosis Metabolic acidosis

Metabolic acidosis

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)? Metabolic alkalosis Metabolic acidosis Respiratory acidosis Respiratory alkalosis

Metabolic alkalosis

The nurse is reviewing the client's arterial blood gas results. The test reveals a pH of 7.52, a PaO2 level of 49 mm Hg (6.52 kPa) and an HCO3 level of 28 mEq/L (28 mmol/L), the nurse suspects the client is most likely experiencing which condition? Metabolic acidosis Metabolic alkalosis Respiratory alkalosis Respiratory acidosis

Metabolic alkalosis

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? Leave water on the bedside table. Ask the client every hour to drink more fluid. Offer small amounts of preferred beverage frequently. Have a loved one tell the client to drink more.

Offer small amounts of preferred beverage frequently.

The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. Rate of the IV solution Type of IV solution Location of the IV catheter access Manufacturer of the IV catheter Client's reaction to the procedure Gauge and length of the IV catheter

Rate of the IV solution Type of IV solution Location of the IV catheter access Client's reaction to the procedure Gauge and length of the IV catheter

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action? Remove the IV. Apply a warm compress. Slow the rate of IV fluids. Elevate the arm.

Remove the IV.

Arterial blood gases (ABGs) have been drawn on the client. The nurse reviews the results. pH is 7.31 PaO2 92 mm Hg (12.24 kPa) PaCO2 50 mm Hg (6.65 kPa) HCO3 28 mEq/L (28 mmol/L) How will the nurse interpret these ABG results? Select all that apply. Complete compensation Metabolic alkalosis Metabolic acidosis Respiratory alkalosis Partial compensation Respiratory acidosis No compensation

Respiratory acidosis Partial compensation

A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse? Check the client's vital signs. Notify the health care provider of the client's response. Stop the transfusion and infuse normal saline using a new administration set. Stop the transfusion and infuse normal saline using the blood tubing.

Stop the transfusion and infuse normal saline using a new administration set.

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action? Call for assistance. Stop the transfusion. Assess oxygen levels. Assess for visible rash.

Stop the transfusion.

The nurse is assessing a client who was hospitalized due to a fall with a brief loss of consciousness. Which sign(s) alerts the nurse that the client is severely dehydrated? Select all that apply. The client has been working outside in warm temperatures. The client reports dizziness when standing up from a chair. The client has dark-colored urine with a noticeable odor. The client reports having increased saliva production. The client reports a loss of 3 lb (1.4 kg) over the past 2 weeks.

The client has dark-colored urine with a noticeable odor. The client reports dizziness when standing up from a chair. The client has been working outside in warm temperatures.

What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution? To provide for effective time management in the administration of the prescribed IV solution To assure effective administration of the prescribed IV solution To demonstrate effective nursing care in the administration of the prescribed IV solution To assure the IV solution is appropriate for this administration

To assure the IV solution is appropriate for this administration

The nurse is preparing to administer fluid replacement to a client. Which action should the nurse take first? Calculate the number of drops per minute. Check for the availability of an IV pump. Regulate the rate of administration. Verify the prescription for type of solution and amount of infusion.

Verify the prescription for type of solution and amount of infusion.

The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland? potassium and chloride potassium and sodium chloride and magnesium calcium and phosphorus

calcium and phosphorus

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? metabolic acidosis muscle weakness cardiac irregularities increased intracranial pressure (ICP)

cardiac irregularities

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status? output measurements daily weights daily BUN and serum creatinine monitoring daily electrolyte monitoring

daily weights

A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply. Determining the amount of IV solution. Administering the IV solution. Prescribing the kind of IV solution. Deciding the location of the IV catheter. Deciding the size of the IV catheter.

deciding the location of the IV catheter Deciding the size of the IV catheter Administering the IV solution

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? muscle twitching distended neck veins nausea and vomiting fingerprinting over sternum

distended neck veins

The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is: fluid volume deficit. atelectasis. fluid volume excess. myocardial infarction.

fluid volume excess.

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of: hypothyroidism. hypocalcemia. hypoglycemia. hypokalemia.

hypokalemia.

During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible? edema circulatory overload hypervolemia hypovolemia

hypovolemia

Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking? nausea, vomiting, and constipation muscle weakness, fatigue, and constipation diminished cognitive ability and hypertension muscle cramping and tetany

muscle cramping and tetany

A client is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. Laboratory results show a serum potassium of 3.2 mEq/l (3.2 mmol/l). For what set of manifestations should the nurse be alert? nausea, vomiting, and constipation muscle weakness, fatigue, and constipation muscle weakness, fatigue, and arrythmias diminished cognitive ability and hypertension

muscle weakness, fatigue, and arrythmias

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding? pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l) pH: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l) pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) pH: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l)

pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)

A client has a health care provider's order for NPO (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose? provide protein supplements treat the client's infection administer blood products replace fluid and electrolytes

replace fluid and electrolytes

A nurse is providing care to a client with an extracellular fluid (ECF) volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding? Select all that apply. poor skin turgor dry mucous membranes slow-filling peripheral veins orthostatic hypotension decreased urine output

slow-filling peripheral veins orthostatic hypotension decreased urine output

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? Start an IV of normal saline as prescribed. Allow nothing by mouth. Give the client a glass of orange juice with added sugar. Encourage fluid intake.

start an IV of normal saline as perscribed

A nurse is inspecting the IV access site of a client receiving intravenous therapy. The nurse suspects that the IV has infiltrated based on which finding at the site? Select all that apply. Coolness Redness Pallor Warmth Swelling

swelling pallor coolness