Nursing - 309 Advanced Skills
The nurse identifies the priority problem of potential for injury for a patient with hyponatremia. What is the etiology of this priority patient problem?
Altered mental capabilities
The nurse is caring for a patient with hypernatremia caused by fluid and sodium losses. What type of IV solution is best for treating this patient?
0.45% sodium chloride
What nursing action will limit hypoxia when suctioning a client's airway?
Apply suction only after catheter is inserted.
The nurse is preparing to start a hypodermoclysis treatment on a patient. What is the preferred insertion site?
Area under the clavicle
The nurse is adding a filter to an IV administration setup. Where is the best place to add the filter to the IV line?
As close as possible to the catheter hub.
A nurse is analyzing how a hyperglycemic client's blood glucose can be lowered. The nurse considers that the chemical that buffers the client's excessive acetoacetic acid is:
Bicarbonate.
The nurse is assessing a patient with severe hypermagnesemia. Which assessment findings are associated with this electrolyte imbalance?
Bradycarida and hypotension.
The nurse caring for a patient with hypercalcemia anticipates orders for which medications?
Calcitonin (Calcimar). Furosemide (Lasix). Plicamycin (Mithracin).
A patient's lab results show a decrease in serum phosphorus level. The nurse expects to see a reciprocal increased change in which serum level?
Calcium
The electrolyte magnesium is responsible for which functions?
Carbohydrate metabolism. Contraction of skeletal muscle. Formation of ATP.
The nurse administering potassium to a patient carefully monitors the infusion because of the risk for which condition?
Cardiac dysrhythmia
A patient's serum potassium value is below 2.8 mEq/L. The patient is also on digoxin. The nurse quickly assesses the patient for which cardiac problem before notifying the provider?
Cardiac dysrhythmia.
Which clinical finding in a patient with a recent tracheostomy is the most serious and requires immediate intervention?
Pulsating tracheostomy tube in synchrony with the heartbeat.
After assessing the patency of a patient's IV catheter, the nurse attempts to flush the catheter and meets resistance. What does the nurse do next?
Stop the flush attempt and discontinue the IV.
The nurse is assessing a patient's IV site and identifies signs and symptoms of infiltration. What is the first action that the nurse implements for this patient?
Stops the infusion.
A patient's blood osmolarity is 302 mOsm/L. What manifestation does the nurse expect to see in the patient?
Thirst
When a client suffers a complete pneumothorax, there is danger of a mediastinal shift. If such a shift occurs, what potential effect is a cause for concern?
Decreased filling of the right side of the heart.
The nurse monitors the effectiveness of magnesium sulfate by assessing which factor every hour?
Deep tendon reflexes.
The nurse is assessing a patient's urine specific gravity. The value is 1.035. How does the nurse interpret this result?
Dehydration
Which characteristics apply to IV infusion pumps?
Delivers fluids under pressure. Is pole-mounted or ambulatory and portable. Is best for accurate infusion.
A patient with low potassium must have an IV potassium infusion. The pharmacy sends a 250 mL IV bag of dextrose in water with 40 mEq of potassium. The label is marked "to infuse over 1 hour." What is the nurse's best action?
Double check the provider's order and call the pharmacy.
What interventions are appropriate for a patient with mild hypernatremia caused by excessive fluid loss?
Hypotonic intravenous infusion. Ensure adequate water intake.
What are the consequences for a patient who does not meet the obligatory urine output?
Lethal electrolyte imbalances. Toxic buildup of nitrogen. Acidosis.
A nurse is caring for a client with diarrhea. In which clinical indicator does the nurse anticipate a decrease?
Loss of body weight.
The nurse is attaching an administration set to a central venous catheter. Which type of equipment decreases the risk of accidental disconnection or leakage?
Luer-Lok connector
A patient requires and infusion of packed red blood cells. Which factor allows the nurse to infuse the PRBCs through the patient's PICC?
Lumen size of the PICC is 4 Fr or larger
Which medication order does the nurse clarify before administering the drug to a patient with hypomagnesemia?
Magnesium sulfate 1 g IM every 6 hours for four doses.
The nurse is preparing to start an infusion of 10% dextrose. Why would the nurse infuse the solution through a central line?
Osmolarity of the solution could cause phlebitis or thrombosis.
How should the nurse monitor for the complication of subcutaneous emphysema after the insertion of chest tubes?
Palpate around the tube insertion sites for crepitus.
The nurse is assisting a community group to plan a family sports day. In order to prevent dehydration, what beverage does the nurse suggest be supplied?
bottled water
hypovolemia
circulating blood volume is decreased
A patient with which condition would need priority nursing assessment?
Irritability
The nurse is taking a report on a patient who had a pneumonectomy 4 days ago. Which question is the best to ask during the shift report?
"Does the surgeon want the patient placed on the nonoperative side?"
A patient is talking to the nurse about sodium intake. Which statement by the patient indicates and understanding of high sodium food sources?
"I love Chinese food, but I gave it up because of the soy sauce."
The client has a nasogastric tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate has decreased. What is your best response?
"The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism."
The nurse is teaching the patient about hypokalemia. Which statement by the patient indicates a correct understanding of the treatment of hypokalemia?
"When I take the liquid potassium in the evening, I'll eat a snack beforehand."
1 L of water weighs
1 Kg
On admission, a patient with pulmonary edema weighed 151 lbs; now the patient's weight is 149 lbs. Assuming the patient was weighed both times with the same clothing, same scale, and same time of day, how many milliliters of fluid does the nurse estimate the patient has lost?
1,000
normal magnesium range
1.3 - 2.1
Hyperkalemia intervention
10 units insulin assessing for cardiac complications. Monitor patient for safety.
change propofol (diprovan) tubing every
12 hours
change lipid tubing every
24 hours
normal serum osmolarity in adults
270 to 300 mOsm/L
The nurse is flushing a patient's short peripheral IV catheter. What does the nurse typically use for this procedure?
3 mL of normal saline.
normal phosphorus range
3.0 - 4.5
Which potassium levels are within normal limits?
3.5 mmol/L. 4.5 mmol/L. 5.0 mmol/L.
After a partial gastrectomy is performed, a client is returned from the postanesthesia care unit to the surgical unit with an IV solution infusing and a nasogastric tube in place. The nurse identifies that there is no nasogastric drainage for 30 minutes. There is an order for instillation of the nasogastri tube prn. The nurse should instill.
30 mL of normal saline and continue the suction.
An IV solution of 1000 mL 5% dextrose in water is to be infused at 125 mL/hr to correct a client's fluid imbalance. The infusion set delivers 15 drops/mL. To ensure that the solution will infuse over an 8 hour period, at how many drops per minute should the nurse set the rate of flow?
31 gtt/min
An intravenous piggyback of cefazolin 500 mg in 50 mL of 5% dextrose in water is to be administered over a 20 minute period. The tubing has a drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run?
38 gtt/min.
What is the minimum amount of urine output per day needed to excrete toxic waste products?
400 to 600 mL
Minimum urine amount needed to excrete toxic waste products
400 to 600 mL/day
The intake and output of a client over an 8 hour period is: IV infusing 900 mL left in bag. 150 mL urine voided. 200 mL gastricc tube formula. 50 mL water at q3h intervals. 220 mL voided. 235 mL voided. IV with 550 mL left in bag. What is the difference between the client's intake and output?
495 m/L
Which patient is at greatest risk of developing hypocalcemia?
60 year old African American woman with a recent ileostomy.
The nurse is reviewing the laboratory calcium level results for a patient. Which value indicates mild hypocalcemia?
8.0 mg/dL
The home health nurse is adjusting the rate for a hypodermoclysis treatment. What is the usual maximum rate for this therapy?
80 mL/hr.
A patient has a PICC placed by an IV therapy nurse at the bedside. Before using the catheter, how is its placement verified?
A chest x - ray is taken, which shows the catheter tip in the lower superior vena cava.
A patient has a local complication from a peripheral IV access with 0.9% normal saline infusing at 100 mL/hour. What does the nurse assess at the insertion site?
A red streak is present proximal to the site. Edema is present proximal to the site. The IV fluids are not infusing.
A nurse is reviewing the laboratory report of a client with a tentative diagnosis of kidney failure. What mechanism does the nurse expect to be maintained when ammonia is excreted by healthy kidneys?
Acid base balance of the body
What impacts does phosphorus have in the body?
Activates vitamins and enzymes. Assists in the formation of adenosine triphosphate (ATP). Assists in cell growth and metabolism.
Which are preventive nursing interventions for a patient at risk for developing hypercalcemia?
Administer D5W. Ensure adequate hydration. Discourage weight bearing activity such as walking.
Which nursing interventions apply to patients with hypercalcemia?
Administer IV normal saline (0.9% sodium chloride). Measure the abdominal girth. Monitor for ECG changes.
The nurse is helping the provider insert a central line when the patient develops chest pain and shortness of breath with decreased breath sounds and restlessness. What does the nurse do next?
Administer oxygen, remove the catheter, place an occlusive dressing, and order a STAT chest X-Ray.
A patient with renal failure that results in hypernatremia will require which interventions?
Administration of furosemide (Lasix). Hemodialysis. Dietary sodium restriction.
Which intervention does the nurse include for a patient with moderate hypophosphatemia?
Administration of oral Vitamin D and phosphorus supplements.
Which factors affect the amount and distribution of body fluids?
Age. Gender. Body fat?
A client is diagnosed with a spontaneous pneumothorax. Which physiologic effect of a spontaneous pneumothorax should the nurse include in a teaching plan for the client?
Air will move from the lung into the pleural space.
A patient who is breathing on his own has a fenestrated tracheostomy tube with a cuff. Which precaution must the nurse instruct the student about when caring for this patient?
Always deflate the cuff before capping the tube with the decannulation cap.
A patient has a recent tracheostomy. What necessary equipment does the nurse ensure is kept at the bedside?
Ambu bag, oxygen tubing, suction equipment, tracheostomy tube with obturator
A patient with a tracheostomy is unable to speak. He is not in acute distress, but is gesturing and trying to communicate with the nurse. Which nursing intervention is the best approach to this situation?
Ask questions that can be answered with a "yes" or "no" response.
An older adult patient needs an oral potassium solution, but is refusing it because it has a strong and unpleasant taste. What is the best strategy the nurse uses to administer the drug?
Ask the patient's preference of juice and mix the drug with a small amount.
A patient has a cuffed tracheostomy tube without a pressure relief valve. To prevent tissue damage of the tracheal mucosa, what does the nurse do?
Assess and record cuff pressures each shift using minimal leak technique.
The UAP reports to the nurse that a patient being evaluated for kidney problems has produced a large amount of pale yellow urine. What does the nurse do next?
Assess the patient for signs of fluid imbalance and check the specific gravity of the urine.
The nurse is assessing a short peripheral catheter after removal and it appears that the catheter tip is missing. What does the nurse do next?
Assess the patient for symptoms of emboli.
The UAP informs the nurse that a patient with hypernatremia who was initially confused and disoriented on admission to the hospital is now trying to pull out the IV access and Foley catheter. What is the nurse's first action.
Assess the patient.
A patient is at risk for fluid volume excess and dependent edema. Which task does the nurse delegate to the UAP?
Assist the patient to change position every 2 hours.
A patient's central venous IV site is covered with a transparent membrane dressing. How often does the nurse change this dressing?
At least every 7 days.
The home health nurse is caring for a patient receiving hypodermoclysis therapy. How often are the subcutaneous sites rotated?
At least once a week.
A patient with a tracheostomy tube is currently alert and cooperative but seems to be coughing more frequently and producing more secretions than usual. The nurse determines that there is a need for suctioning. Which nursing intervention does the nurse use to prevent hypoxia for this patient?
Avoid prolonged suction time.
Which nursing interventions are implemented when caring for a patient with an implanted port?
Before puncture, palpate the port to locate the septum.
A patient with a tracheostomy who receives unnecessary suctioning can experience which complications?
Bronchospasm. Mucosal Damage. Bleeding.
A 65 year old patient has been receiving IV fluids at 100mL/hr of D5 1/2% normal saline for the past 3 days, along with IV antibiotic therapy. After receiving the new antibiotic, the patient reports chills and a headache. On assessment, the patient's temperature is elevated. What complication do these assessment findings indicate?
Catheter related infection in the blood.
The nurse is caring for psychiatric patient who is continuously drinking water. The nurse monitors for which complication related to potential hyponatremia?
Change in mental status/increased intracranial pressure.
The patient has an order for a unit of PRBCs. Which priority action must the nurse complete before starting this infusion?
Check patient identification with another RN using two identifiers.
During the first 36 hours after the insertion of chest tubes, when assessing the function of a three chamber, closed - chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What INITIAL action should the nurse take?
Check the tube to ensure that it is not kinked.
A patient with hypocalcemia is in need of supplemental diet therapy. Which foods does the nurse recommend to provide both calcium and vitamin D?
Cheese. Milk.
Which condition places a patient at risk for hypocalcemia, hyperkalemia, and hypernatremia?
Chronic kidney disease.
A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful?
Clear breath sounds
You are caring for four clients who are receiving IV infusions of normal saline. Which client is at highest risk for bloodstream infection?
Client who has a nontunneled central line in the left internal jugular vein.
What is the term for a difference in concentration of particles that is greater on the one side of a permeable membrane than the other side?
Concentration gradient.
The provider has ordered therapy for a patient with low sodium and signs of hypervolemia. Which diuretic is best for this patient?
Conivaptan (Vaprisol)
A nurse is caring for a client with albuminuria resulting in edema. What pressure change does the nurse determine as the cause of edema?
Decrease in plasma colloid oncotic pressure.
Which conditions cause a patient to be at risk for hypocalcemia
Crohn's disease. Acute pancreatitis. Removal or destruction of parathyroid glands. Immobility.
Two hours after a subtotal gastrectomy, the nurse identifies that the drainage from the client's nasogastric tube is a bright red. What should the nurse do FIRST?
Determine that this is an expected finding.
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit?
Diarrhea. Weakness. Dysrhythmias.
The nurse is caring for a patient who takes potassium and digoxin. For what reason does the nurse monitor both laboratory results?
Digoxin toxicity can result if hypokalemia is present.
A nurse is caring for a client with ascites. What does the nurse consider to be the cause of the ascites?
Diminished plasma protein level.
While the nursing student changes a patient's tracheostomy dressing, the nurse observes the student using a pair of scissors to cut a 4 x 4 gauze pad to make a split dressing that will fit around the tracheostomy tube. What is the nurse's best action?
Direct the student in the correct use of materials and explain the rationale.
You are caring for a client with a nasogastric tube. Which task can be delegated to an experienced UAP?
Disconnecting the suction to allow ambulation to the toilet.
A patient in the hospital has a severely elevated magnesium level. Which intervention should the nurse complete first?
Discontinue parenteral magnesium.
What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess?
Distended jugular veins.
Which safety measures does the nurse apply to decrease the risk of catheter related blood stream infection (CR-BSI) related to needleless systems?
Do not tape connections between tubing sets. Use evidence-based hand hygiene guidelines from the CDC and the Occupational Safety and Health Administration (OSHA). Minimize traffic in and out of the patient's room during insertion of the device.
Which foods will the nurse instruct a patient with kidney disease and hyperkalemia to avoid?
Dried beans. Potatoes. Cantaloupe.
A patient has been on prolonged steroid therapy. In assessing the patient for IV insertion. What finding does the nurse expect see?
Ecchymosis and possibly a hematoma
The nurse is reviewing orders for several patients who have risk for fluid volume excess. For which patient condition does the nurse question an order for diuretics?
End- stage renal disease
A nurse is concerned that a client is at risk for developing hyperkalemia. Which disease does the client have that has caused this concern?
End-stage renal
A patient was intubated for acute respiratory failure, and there is an endotracheal tube in place. Which nursing interventions are appropriate?
Ensure that the oxygen is warmed and humidified. Suction the airway, then the mouth, and give oral care. Position the tubing so it does not pull on the airway. Apply suction only when withdrawing the suction catheter.
When using an intermittent administration set to deliver medications, how often does the infusion Nurses Society recommend that the set be changed?
Every 24 hours.
Plasma is part of which components?
Extracellular compartment. Interstitial fluid. Intravascular fluid.
Which fluid has the highest corresponding electrolyte content?
Extracellular fluid is highest in sodium and chloride.
Patients with which conditions are at greatest risk for deficient fluid volume?
Fever of 103 F. Extensive burns. Thyroid crisis. Continuous fistula drainage. Diabetes insipidus.
A patient has a chest tube in place. What does the water in the water seal chamber do when the system is functioning correctly?
Fluctuates with the patient's respirations.
The nurse assessing a patient notes a bounding pulse quality, neck vein distention when supine, presence of crackles in the lungs and increasing peripheral edema. What fluid disorder do these findings reflect?
Fluid volume excess.
The nurse is caring for a patient with a Groshong catheter. According the manufacturer's recommendations, which technique does the nurse use in maintaining this type of catheter?
Flush the catheter with saline.
A nurse is assigned to change a central line dressing. The agency policy is to clean the site with Betadine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede Betadine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and Betadine. The nurse has a sample of the new product. How should the nurse proceed?
Follow the agency's policy unless it is contradicted by a health care provider's order.
The nurse must insert a short peripheral IV catheter. In order to decrease the risk of deep vein thrombosis or phlebitis, which vein does the nurse choose for the infusion site?
Forearm.
The patient's potassium level is 2.5 mEq/L. Which clinical findings does the nurse expect to see when assessing this patient?
General skeletal muscle weakness. Lethargy. Weak hand grasps.
A triple-lumen catheter central line is inserted in a patient. What does the nurse do immediately after the procedure?
Get a portable chest x-ray and hold IV fluids until results are obtained.
The nurse is giving discharge instructions to the patient with advanced heart failure who is at continued risk for fluid volume excess. For which physical change does the nurse instruct the patient to call the health care provider?
Greater than 3 lbs. gained in a week or greater than 1 to 2 lbs. Gained in a 24 hour period.
The nurse is caring for several patients at risk for falls because of fluid and electrolyte imbalances. Which task related to patient safety and fall prevention does the nurse delegate to the UAP?
Help the incontinent patient to toilet every 1 to 2 hours.
The emergency department nurse is caring for a patient who was brought in for significant alcohol intoxication and minor trauma to the wrist. What will serial hematocrits for this patient likely show?
Hemoconcentration
A patient has a central line inserted in the vena cava. The nurse assesses the patient for which potential complications related to the procedure?
Hemothorax. Air embolism.
A client is to have gastric lavage. In which position should the nurse place the client when the nasogastric tube is being inserted?
High-Fowler
The patient is ready for discharge. Which accommodations must the nurse follow to remove the patient's peripheral catheter?
Hold pressure on the site until hemostasis is achieved. Assess the catheter tip to make sure it is intact and completely removed. Slowly withdraw the catheter from the skin. Remove the peripheral catheter dressing. Document catheter removal and appearance of IV site.
A patient with hyponatremia would have which gastrointestinal findings upon assessment?
Hyperactive bowel sounds on auscultation mostly in the left lower quadrant. Bowel movements that are frequent and watery. Abdominal cramping.
What are common causes of hypophosphate-emia?
Hypercalcemia. Uncontrolled diabetes. Use of magnesium based antacids
A hospitalized patient who is known to be homeless has been diagnosed with severe malnutrition, end stage renal disease, and anemia. He is transfused with 3 units of packed red blood cells. Which potential electrolyte imbalance does the nurse anticipate to occur in this patient?
Hyperkalemia
A young adult patient is in the early stages of being treated for severe burns. Which electrolyte imbalance does the nurse expect to assess in this patient?
Hyperkalemia
The nurse is taking care of a trauma patient who was in a motor vehicle accident. The patient has a history of hypertension, which is managed with spironolactone (Aldactone). This patient is at risk for developing which electrolyte imbalance?
Hyperkalemia.
The nurse is evaluating the lab results of a patient with hyperaldosteronism. What abnormal electrolyte finding does the nurse expect to see?
Hypernatremia.
A patient has chronic kidney disease. Which electrolyte imbalance often associated with hypocalcemia and CKD does the nurse monitor for?
Hyperphosphatemia
A patient with a recent history of anterior neck injury reports muscle twitching and spasms with tingling in the lips, nose, and ears. The nurse suspects these symptoms may be caused by which condition?
Hypocalcemia
A patient with congestive heart failure is receiving a loop diuretic. The nurse monitors for which electrolyte imbalances?
Hypocalcemia. Hypokalemia. Hyponatremia.
A nurse administers an intravenous solution of 0.45% sodium chloride. In what category of fluids does this solution belong?
Hypotonic
A patient shows a positive Trousseau's or Chovestek's sign. The nurse prepares to give the patient which urgent treatment?
IV Calcium
A patient is brought to the emergency department after a serious motor vehicle accident. Which factor makes the patient a candidate for intraosseous (IO) therapy?
IV access cannot be achieved within a few minutes.
A patient has a magnesium level of 0.8 mg/dL. Which treatment does the nurse expect to be ordered for this patient?
IV magnesium sulfate and discontinuation of diuretic therapy.
Hypodermoclysis can be used for a patient under which types of circumstances?
If the patient requires palliative care. For IV fluid replacement that is less than 2000 mL. When a subcutaneous IV infusion is warranted. When short term fluid volume replacement is warranted.
Which is a preventive measure for patients at risk for developing hypocalcemia?
Increase daily dietary calcium and vitamin D intake.
A patient with a tracheostomy is being discharged to home. In patient teaching, what does the nurse instruct the patient to do?
Increase the humidity in the home.
A patient has hyperkalemia resulting from dehydration. Which additional laboratory findings does the nurse anticipate for this patient?
Increased hematocrit and hemoglobin levels.
Which clinical condition can result from hypocalcemia?
Increased intestinal and gastric motility
The nurse is caring for an older adult patient whose serum sodium level is 150 mEq/L. The nurse assesses the patient for which common manifestations associated with this sodium level?
Increased pulse rate. Muscle weakness.
The nurse is caring for a patient with hypovolemia secondary to severe diarrhea and vomiting. In evaluating the respiratory system for this patient, what does the nurse expect to find on assessment?
Increased respiratory rate, because the body perceives hypovolemia as hypoxia.
For what clinical indicator should a nurse assess a client who is having a gastric lavage?
Increased serum bicarbonate level.
Which statement best explains how ADH affects urine output?
It increases permeability to water in the tubules causing a decrease in urine output.
The nurse is preparing to give a patient IV drug therapy. What information does the nurse need before administering the drug?
Indications, contraindications, and precautions for IV therapy. Appropriate dilution, pH, and osmolarity of solution. Rate of infusion and dosage of drugs. Compatibility with other IV medications. Specifics of monitoring because of immediate effect.
What are possible complications that can occur with suctioning from an artificial airway?
Infection. Hypoxia. Tissue Trauma. Vagal Stimulation. Bronchospasm.
Which nursing action is important when suctioning the secretions of a client with a tracheostomy?
Initiate suction as the catheter is being withdrawn.
How does the nurse assess for subcutaneous emphysema: a potential complication associated with tracheostomy
Inspecting and palpating for air under the skin.
A nurse explains to an obese client that the rapid weight loss during the first week after initiating a diet is because of fluid loss. The weight of extracellular body fluid is approximately 20% of the total body weight of an average individual. Which component of the extracellular fluid contributes the greatest proportion to this amount?
Interstitial
Which component has a high content of potassium and phosphorus?
Intracellular fluid
What are the functions of potassium in the body?
Intracellular osmolarity and volume. Regulates glucose use and storage. Helps maintain normal cardiac rhythm.
For severe burn victims , ____ can be used when an IV could not be set up
Intraosseous catheter
The health care provider orders magnesium sulfate for a patient with severe hypomagnesemia. What is the preferred route of administration for this drug?
Intravenous
A patient has a low potassium level and the provider has ordered an IV infusion. Before starting an IV potassium infusion, what does the nurse assess?
Intravenous line patency
Which statements are true about electrolyte chloride and its role in the cellular environment of the body?
It maintains plasma acid balance. It provides electroneutrality in relation to sodium. Chloride imbalances occur with alterations in body water volume.
An external long term IV catheter is required for hemodialysis of a hospitalized patient. Which statements are true about this patient's venous access device?
It should not be used for administration of other fluids or medications except in an emergency. Venous thrombosis is a common problem with hemodialysis access. A tunneled catheter with large lumen is required for hemodialysis.
A client loses weight and develops a negative nitrogen balance. What nutritional problem prompts the nurse to notify the health are provider?
Lack of protein supplementation.
What impacts does sodium have on body function?
Maintains electroneutrality. Regulates water balance. Regulates plasma osmolarity.
A patient is receiving epidural medication therapy. The nurse assesses for which potential problem specific to this type of therapy?
Meningitis
An older adult patient at risk for fluid and electrolyte problems is vigilantly monitored by the nurse for the first indication of a fluid balance problem. What is this indication?
Mental status changes.
A patient with hypokalemia is likely to have which conditions?
Metabolic alkalosis. Chronic obstructive pulmonary disease. Paralytic ileus.
A patient is receiving IV therapy via an infusion pump. What is a nursing responsibility related to the therapy and equipment?
Monitor the patient's infusion site and rate.
A patient with an implanted port is discharged home and will receive long term therapy on an outpatient basis. How frequently must the port be flushed between courses of therapy?
Monthly.
The nurse is assessing a patient with a mild increase in sodium level. What early manifestations does the nurse observe in this patient?
Muscle twitching and irregular muscle contractions.
The nurse is caring for several patients at risk for fluid and electrolyte imbalances. Which patient problem or condition can result in a relative hypernatremia.
NPO Status
A 65 year old patient has a potassium laboratory value of 5.0 mEq/L. How does the nurse interpret this value?
Normal for the patient's age
The nurse has removed the dressing form a patient's central venous catheter site. In order to monitor the catheter position, what does the nurse do?
Note the length of the catheter external to the insertion site.
A patient has an elevated potassium level. Which assessment findings are associated with hyperkalemia?
Numbness in hands, feet, and around the mouth. Frequent, explosive diarrhea stools. Irregular heart rate and hypotension.
A chest tube is inserted into a client who was stabbed in the chest and is attached to a closed drainage system. Which is an important nursing intervention when caring for this client?
Observe for fluid fluctuations in the water seal chamber.
The nurse is assessing a patient's IV insertion site. What features must the nurse look for during the assessment?
Observe for redness and swelling. Check that the dressing is clean and dry. Ensure that the dressing is clean and dry. Observe for hardness or drainage.
A newly admitted patient with congestive heart failure has a potassium level of 5.7 mEq/L. How does the nurse identify contributing factors for the electrolyte imbalance?
Obtain a list of the patient's home medications. Assess the patient for hyperkalemia. Ask about the patient's method of taking medications at home.
The nurse is working in a long term care facility where there are numerous patients who are immobile and at risk for dehydration. Which task is best to delegate to the unlicensed assistive personnel?
Offer patients a choice of fluids every 1 to 2 hours.
The nurse instructs the UAP to use precautions with moving and using a lift sheet for which patient with an electrolyte imbalance?
Older woman with hypocalcemia.
How does the nurse define a tracheostomy to the patient?
Opening in the trachea that enables breathing.
The nurse is suctioning the secretions from a patient's endotracheal tube. The patient demonstrates a vagal response by a drop in heart rate to 54/min and a drop in blood pressure to 90/50 mm Hg. After stopping suctioning, what is the nurse's priority action?
Oxygenate with 100% oxygen and monitor the patient.
A patient is ordered to receive peripheral parenteral nutrition (PPN). What type of access device is appropriate for this patient?
PICC
A patient requires a 2 month course of antibiotics to treat a resistant infection. Which device is chosen for this therapy?
PICC
The nurse is preparing to deliver IV infusion therapy through an implanted port. What technique does the nurse use to access the port?
Palpate the port to locate the septum, scrub, and then access with a Huber needle.
A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client?
Palpate the surrounding are for crepitus.
A nurse is reviewing the health care provider's orders for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which order should the nurse question?
Parenteral albumin (Albuminar)
Which patient is the most likely candidate for a tunneled central venous catheter?
Patient in need of permanent parental nutrition
The nurse is caring for the patient receiving arterial therapy via the carotid artery. What important nursing action is specific to this therapy?
Perform frequent neurologic assessments.
A patient is in the hospital for his first chemotherapy treatment for lung cancer. Which IV access methods are appropriate for this patient?
Peripherally inserted central catheter. Tunneled central venous catheter. Implanted port.
The nurse is assessing skin turgor in a 65 year old patient. What is the correct technique to use with this patient?
Pinch the skin over the sternum and observe for tenting and resumption of skin to its normal position after release.
A patient requires a nontunneled percutaneous central catheter. What is the nurse's role in this procedure?
Place the patient in Trendelburg position.
After a tubing change to a patient's central line, the line is later found to be disconnected from the catheter. The patient develops chest pain and restlessness, heart rate of 120bpm, BP drops to 90/40mmHg, and O2 Sats. are 89%. What does the nurse do next?
Place the patient in Trendelenburg position on the left side, clamp the catheter, and notify the provider.
The nurse is caring for several patients with electrolyte imbalances. Which intervention is included in the plan of care for a patient with hypocalcemia?
Placing the patient on seizure precautions.
Which are typical nursing assessment findings for a patient with hypocalcemia?
Positive Chvostek's sign. Diarrhea. Prolonged ST interval. Elevated T Wave
A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider MOST important?
Postassium
Which patients are at risk for developing hyponatremia?
Postoperative patient who has been NPO for 24 hours with no IV fluid infusing. Patient receiving excessive intravenous fluids with 5% dextrose. Diabetic patient with blood glucose of 250 mg/dL Tennis player in 100 F weather who has been drinking water.
Which serum laboratory value does the nurse expect to see in a patient with hyperkalemia?
Potassium greater than 5.0 mEq/L
Which serum laboratory value does the nurse expect to see in the patient with hypokalemia?
Potassium less than 3.5 mEq/L
The nurse is caring for a patient receiving intrathecal pain medication. Which agent is preferred for cleaning the access site?
Povidone Iodine.
Patients with a tracheostomy or endotracheal tube need suctioning. Which nursing interventions apply to proper suctioning technique?
Preoxygenate the patient for at least 30 seconds before suctioning. Instruct the patient that they are going to be suctioned. Quickly insert the suction catheter until resistance is met.
Which manifestations reflect severe hypophosphatemia?
Profound muscle weakness. Irritability. Cardiac muscle damage.
Which assessment findings are related to prolonged hypercalcemia?
Prolonged bradycardia. Shortened QT interval. Impaired blood flow. Profound muscle weakness.
A patient has a temporary tracheostomy following surgery to the neck area to remove a benign tumor. Which nursing intervention is performed to prevent obstruction of the tracheostomy tube?
Provide tracheal suctioning when there are noisy respirations.
Which intervention does the nurse implement for a patient with hypocalcemia?
Provided adequate intake of vitamin D and calcium rich foods.
A patient sustained a serious crush injury to the neck and had a tracheostomy tube placed 3 days ago. As the nurse is performing tracheostomy care, the patient suddenly sneezes very forcefully and the tracheostomy tube falls out onto the bed linens. What does the nurse do?
Quickly and gently replaced the tube with a clean cannula kept at the bedside.
Which precaution or intervention does the nurse teach a patient at continued risk for hypernatremia?
Read labels on canned or packaged foods to determine sodium content.
During intraperitoneal therapy, a patient reports nausea and vomiting. What does the nurse do next?
Reduce the flow rate and give antiemetics.
The nurse is selecting a site for peripheral IV insertion. Which patient condition influences the choice of left versus right upper extremity?
Regular renal dialysis with a shunt in the left upper forearm.
A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department, chest tubes are inserted; one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish?
Remove the air that is present in the intrapleural space.
You are supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause you to intervene?
Removing the inner cannula and cleaning using standard precautions.
A nurse adds 20 mEq of potassium chloride to the IV solution of a client with diabetic ketoacidosis. What is the primary purpose for administering this drug?
Replace excessive losses.
A patient with lung cancer is admitted to the hospital for respiratory distress. Which imbalance does the nurse expect this patient to have?
Respiratory acidosis.
A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" What likely cause of the spontaneous pneumothorax should the nurse's response take into consideration?
Rupture of a subpleural bleb.
To prevent accidental decannulation of a tracheostomy tube, what does the nurse do?
Secure the tube in place using ties or fabric fasteners.
In what position does the nurse place a patient before starting intraperitoneal therapy?
Semi-Fowler's.
Patients with which conditions are at risk for developing hypernatremia?
Severe diarrhea. Poor kidney function. Profound diaphoresis.
A patient returns from the operating room after having a tracheostomy. While assessing the patient, which observations made by the nurse warrant immediate notification of the provider?
Skin is puffy at the neck area with a crackling sensation.
A nurse is caring for a client with ascites who is receiving albumin. What infusion rate and oral fluid intake should the nurse expect to have the greatest therapeutic effect?
Slow IV rate and restricted fluid intake.
Which serum value does the nurse expect to see for a patient with hyponatremia?
Sodium less than 136 mEq/L
The nurse is teaching a patient to recognize foods that are high in sodium. Which food items does the nurse use as examples?
Soup with saltine crackers. Bacon and eggs. Egg roll with soy sauce.
The nurse is teaching a patient with hypokalemia about foods high in potassium. Which food items does the nurse recommend to this patient?
Soybeans. Potatoes. Cantaloupe.
The charge nurse is reviewing IV therapy orders. What information must be included in each order?
Specific type of solution. Rate of administration. Specific drug dose to be added to the solution.
A patient requires IV therapy via a peripheral line. What considerations does the nurse use when inserting the peripheral IV?
Start with more distal sites, such as the hand veins. Choose the patient's nondominant arm. Do not use the arm if the patient had a mastectomy on that side. Avoid placing an IV over the palm side of the wrist.
The nurse is caring for several older adult patients who are at risk for dehydration. Which task can be delegated to the UAP?
Stay with patients while they drink and note the exact amount ingested.
Which statements are correct about intraperitoneal infusion (IP)?
Sterile technique is used with IP access and supplies. IP can be accessed by a catheter with an implanted port and large internal lumens. Strict aseptic technique is used with IP access and supplies. IP is used for patients who are receiving chemotherapy agents.
The nurse is attempting to insert a peripheral IV when the patient reports tingling and a feeling like "pins and needles." What does the nurse do next?
Stop immediately, remove the catheter and choose a new site.
A patient has a peripherally inserted central catheter placed and is ordered to receive IV cisplatin (platinol). The drug has infiltrated into the tissue and redness is observed in the right lower side of the neck. What is the nurse'es first action?
Stop infusion and disconnect the IV line from the administration set.
The provider's prescriptions indicate an increase in the suction to -20 cm for a patient with a chest tube. To implement this, the nurse performs which intervention?
Stops the suction, adds sterile water to level of -20 cm to the water seal chamber, and resumes the wall section.
A patient with a permanent tracheostomy is interested in developing an exercise regimen. Which activity does the nurse advise the patient to avoid?
Swimming.
A client's serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement FIRST?
Take vital signs and notify the health care provider.
Which changes on a patient's electrocardiogram reflect hyperkalemia?
Tall peaked T waves
The nurse is assessing the patient with a risk for hypocalcemia. What is the correct technique to test for Chvostek's sign?
Tap the patient's face just below in front of the ear to trigger facial twitching of one side of the mouth, nose, and cheek.
The nurse is caring for a patient with a chest tube. What is the correct nursing intervention for this patient?
The patient is encouraged to cough and do deep breathing exercises frequently.
The nurse is caring for a patient with a central venous catheter. What measure does the nurse use to prevent air emboli when changing the administration set or connectors?
The patient lies flat so the catheter site is below the heart. Use the pinch clamp that can be closed during the procedure. Ask the patient to perform the Valsalva maneuver by holding the breath and bearing down.
A patient is to be discharged home with an implanted port and needs discharge instructions on prescribed medication administration. Which instructions must the nurse give to the patient and family member who will be assisting the patient?
The skin will be punctured over the port when the port is accessed. When the port is not accessed, no dressing needs to be applied. The port must be flushed after each use.
The nurse is supervising a student nurse who is preparing an IV bag with IV administration tubing. For which action by the student nurse must the charge nurse intervene?
The student touches the tubing spike.
A patient has an IO needle in place. Why does the nurse advocate for removal of the device within 24 hours after insertion?
There is an increased risk for osteomyelitis.
Upon observation of a chest tube setup, the nurse reports to the provider that there is a leak in the chest tube and system. How has the nurse identified this problem?
There was onset of continuous vigorous bubbling water in the water seal chamber.
A nurse is reviewing a client's serum electrolyte laboratory report. What is a comparison between blood plasma and interstitial fluid?
They both contain the same kinds of ions.
The nurse is caring for a patient with a tracheostomy who has recently been transferred from the intensive care unit, but he has had no unusual occurrences related to the tracheostomy or his oxygenation status. What does the routine care for this patient include?
Thorough respiratory assessment at least every 2 hours.
The patient who has undergone which surgical procedure is most at risk for hypocalcemia?
Thyroidectomy
Which complication is the result of constant pressure exerted by a tracheostomy cuff, causing tracheal dilation and erosion of cartilage?
Tracheomalacia
Which factors can cause hyperphophatemia?
Tumor lysis syndrome. Hypoparathyroidism. Decreased renal excretion.
The nurse is caring for a patient with severe hypocalcemia. What safety measures does the nurse put in place for this patient?
Turn on a bed alarm when the patient is in bed. Place the patient on a low bed. Ensure the side rails are up when the patients in bed.
Which items does the nurse include in the documentation after completing the insertion of a PICC?
Type of dressing applied. Type of IV access device used. Location and vein that was used for insertion.
Which nursing interventions are essential to prevent an infection in a patient with a central line?
Use aseptic technique when administering medications and changing tubing. Use sterile technique when inserting a central line. Use proper handwashing and nonsterile gloves before coming into contact with a central line.
A client is admitted to the surgical unit from the postanesthesia care unit with a Salem sump nasogastric tube that is to be attached to wall suction. Which nursing action should the nurse implement when caring for this client?
Use normal saline to irrigate the tube.
The nurse is attempting to remove a PICC line and feels resistance. What technique does the nurse use first to attempt to resolve this problem?
Use simple distraction techniques and deep breathing.
A patient's potassium level is low. What change in the cardiovascular system does the nurse expect to see related to hypokalemia?
Weak, thready pulse.
How should a nurse prepare an IV piggback medication for administration to a client receiving an IV infusion?
Wear clean gloves to check the IV site. Rotate the bag after adding the medication. Use a sterile technique when preparing the medication.
The nurse is preparing to administer IV infusion therapy to a patient. When is the choice of using a glass container appropriate?
When the drug is incompatible with a plastic container.
Under what circumstances does the nurse elect to use only one secondary set rather than a secondary set for each medication?
When the medications are compatible.
Indications for tracheostomy
acute airway obstruction. need for airway protection. laryngeal or facial trauma/burns. involvement in head or neck surgeries
Hormones responsible for fluid balance regulation
aldosterone, antidiuertic hormone, natriuretic peptides.
Ace Inhibitors
disrupt renin-angiotensin II pathway by reducing the amount of ACE produced
intervention for hypokalemia
ensuring adequate oxygenation, patient safety from falls and potassium administration. Monitoring patient.
dehydration
fluid intake or retention is less than what is needed to meet the body's fluid needs, resulting in a fluid volume deficit. (especially a plasma volume deficit)
Hypokalemia manifestations
fluid overload, diuretic therapy, alkalosis, insulin administration, hyperaldosteronism
Hypercalcemia manifestations
hyperthyroidism, hyperparathyroidism kidney failure
assessment findings related to Tracheal Stenosis
increased coughing, inability to expectorate secretions, and difficulty breathing
Which findings indicate that a patient may have hypervolemia?
increased, bounding pulse. Jugular venous distention. Presence of crackles. Elevated blood pressure. Skin pale and cool to touch.
Hyperkalemia manifestations
kidney disease, acidosis, adrenal insufficiency, crush injuries
Veins cannot be used in patients with
mastectomy axillary lymph node dissection lymphedema upper body paralysis dialsis graft fistulas
hypercalcemia interventions
reducing Ca+ levels through drug therapy. Rehydration, cardica monitoring.
Phlebitis intervention
remove short peripheral catheter. Apply warm compress. Document.
IV infiltration intervention
stop infusion and remove short peripheral catheter. Rate infiltration.
Tracheotomy
the surgical incision into the trachea to create an airway.
Tracheostomy
the tracheal stoma that results from a tracheotomy
Angiotensin II causes
vasoconstriction
Isotonic infusate
water does not move into or out of the body's cells
compartment syndrome
when increased tissue perfusion in confined space causes decreased flow to an area.
change blood tubing
within 4 hours