test 1 med surg
_______ solutions cause cell dehydration and help increase fluid in the extracellular space. A. Hypotonic B. Osmosis C. Isotonic D. Hypertonic
D. Hypertonic
A patient has a calcium level of 7.2. What sign below is indicative of this lab value? A. None this is a normal calcium level B. Shortened ST segment C. Hypoactive bowel sounds D. Prolonged QT interval on the EKG
D. Prolonged QT interval on the EKG
Which of the following is not a cause of hypocalcemia? A. Low parathyroid hormone B. Crohn's Disease C. Acute Pancreatitis D. Thiazide Diuretics
D. Thiazide diuretics
Which solution below is NOT a hypertonic solution?A. 5% Dextrose in 0.9% SalineB. 5% SalineC. 5% Dextrose in Lactated Ringer'sD. 0.33% saline (1/3 NS)
D: 0.33% saline (1/3 NS)
A patient is being admitted with dehydration due to nausea and vomiting. Which fluid would you expect the patient to be started on? A. 5% Dextrose in 0.9% Saline B. 0.33% saline C. 0.225% saline D. 0.9% Normal Saline
D: 0.9% Normal Saline
A patient is being admitted with dehydration due to nausea and vomiting. Which fluid would you expect the patient to be started on?A. 5% Dextrose in 0.9% Saline B. 0.33% saline C. 0.225% saline D. 0.9% Normal Saline
D: 0.9% Normal Saline
_______ solutions cause cell dehydration and help increase fluid in the extracellular space.A. Hypotonic B. Osmosis C. Isotonic D. Hypertonic
D: Hypertonic
Which of the following is indicative of an EKG change in a case of hypokalemia? A. Widened QRS complex and prolonged PR interval B. Prolonged ST interval and Widened T-wave C. Tall T-waves and depressed ST segment D. ST depression and inverted T-wave
D: ST depression and inverted T-wave
________ fluids remove water from the extracellular space into the intracellular space.A. Hypotonic B. Hypertonic C. Isotonic D. Colloids
A: Hypotonic
A patient's calcium level is 6.9. Which of the following is a nursing priority? A. Initiate seizure precautions B. Educate patient about foods rich in calcium C. Administer Calcitonin D. Administer Vitamin D supplements as ordered
A: Initiating seizure precautions are priority because this is a critically low calcium level and the patient is at risk for seizures. Next, you would educate the patient about calcium rich foods and administer vitamin D supplements as ordered. Calcitonin is for HYPERcalcemia.
Which patient below would NOT be a candidate for a hypotonic solution? A. Patient with increased intracranial pressure B. Patient with Diabetic Ketoacidosis C. Patient experiencing Hyperosmolar Hyperglycemia D. All of the options are correct
A: Patient with increased intracranial pressure
Which patient below would NOT be a candidate for a hypotonic solution? A. Patient with increased intracranial pressure B. Patient with Diabetic Ketoacidosis C. Patient experiencing Hyperosmolar Hyperglycemia D. All of the options are correct
A: Patient with increased intracranial pressure
A patient with nasogastric suctioning is experiencing diarrhea. The patient is ordered a morning dose of Lasix 20mg IV. Patient's potassium level is 3.0. What is your next nursing intervention? A. Hold the dose of Lasix and notify the doctor for further orders B. Administered the Lasix and notify the doctor for further orders C. Turn off the nasogastric suctioning and administered a laxative D. No intervention is need the potassium level is within normal range
A. Hold the dose of Lasix and notify the doctor for further orders
________ fluids remove water from the extracellular space into the intracellular space. A. Hypotonic B. Hypertonic C. Isotonic D. Colloids
A. Hypotonic
Which of the following is not a symptom of hyperkalemia? A. Positive Chvostek's sign B. Decreased blood pressure C. Muscle twitches/cramps D. Weak and slow heart rate
A. Positive Chvostek's sign is a sign of HypoCalcemia
A patient has a potassium level of 9.0. Which nursing intervention is priority? A. Prepare the patient for dialysis and place the patient on a cardiac monitor B. Administer Spironolactone C. Place patient on a potassium restrictive diet D. Administer a laxative
A. Prepare the patient for dialysis and place the patient on a cardiac monitor
Lithium is known to affect the parathyroid by increasing ______ levels and decreasing _____ levels? A. calcium, phosphate B. phosphate, calcium C. calcium, sodium D. sodium, calcium
A. calcium, phosphate
Which patient is at a potential risk for Digoxin toxicity? A. A patient with Cushing's syndrome taking lasix 20 mg IV twice a day B. A patient with a calcium level of 8.9 C. A patient with a potassium level of 3.8 D. A patient presenting with painful muscle spasms and positive Trousseau's sign
A: A patient with Cushing's syndrome taking lasix 20 mg IV twice a day
A client is prescribed 250 mL of normal saline to infuse over 4 hours via gravity. The facility supplies gravity tubing with a drip factor of 15 drops/mL. At what rate (drops/min) should the nurse set the infusion to deliver? (Record your answer using a whole number.) ________ drops/min
ANS: 16 drops/min
A client is prescribed 1000 mL of normal saline to infuse over 24 hours. At what rate should the nurse set the pump (mL/hr) to deliver this infusion? (Record your answer using a whole number.) ____ mL/hr
ANS: 42 1000 mL 24 hours = 41.6 mL/hr.
A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should 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 should assess the clients respiratory status first to ensure respirations are sufficient. The respiratory assessment should include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the clients respiratory status.
A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia? a. Client with pancreatitis who has continuous nasogastric suctioning b. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor c. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells d. Client with uncontrolled diabetes and a serum pH level of 7.33
ANS: A A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to hypokalemia. The other clients are at risk for potassium excess or hyperkalemia.
3.A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this clients 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 assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess? a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg b. Daily weight increase from 55 kg to 57 kg c. Heart rate decrease from 100 beats/min to 82 beats/min d. Respiratory rate increase from 12 breaths/min to 15 breaths/min
ANS: A ACE inhibitors will disrupt the reninangiotensin II pathway and prevent the kidneys from reabsorbing water and sodium. The kidneys will excrete more water and sodium, decreasing the clients blood pressure.
A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia? a. A 34-year-old on NPO status who is receiving intravenous D5W 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 (Motrin) d. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)
ANS: A Dextrose 5% in water (D5W) contains no electrolytes. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.
10.A nurse responds to an IV pump alarm related to increased pressure. Which action should the nurse take first? a. Check for kinking of the catheter. b. Flush the catheter with a thrombolytic enzyme. c. Get a new infusion pump. d. Remove the IV catheter.
ANS: A Fluid flow through the infusion system requires that pressure on the external side be greater than pressure at the catheter tip. Fluid flow can be slowed for many reasons. A common reason, and one that is easy to correct, is a kinked catheter. If this is not the cause of the pressure alarm, the nurse may have to ascertain whether a clot has formed inside the catheter lumen, or if the pump is no longer functional. Removal of the IV catheter and placement of a new IV catheter should be completed when no other option has resolved the problem.
A nurse is assessing a client with hypokalemia, and notes that the clients handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first? a. Assess the clients respiratory rate, rhythm, and depth. b. Measure the clients pulse and blood pressure. c. Document findings and monitor the client. d. Call the 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 clients pulse and blood pressure should be assessed after assessing respiratory status. Next, the nurse would call the health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client should occur during and after potassium replacement therapy.
A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should 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 IV starts to the most experienced nurses does not allow newer nurses to gain this expertise. The quality of skin preparation products is only one aspect of IV insertion that could contribute to infection.
While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should 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.
1.A registered nurse (RN) delegates client care to an experienced licensed practical nurse (LPN). Which standards should guide the RN when delegating aspects of IV therapy to the LPN? (Select all that apply.) a. State Nurse Practice Act b. The facilitys Policies and Procedures manual c. The LPNs level of education and experience Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 90 d. The Joint Commissions goals and criterion e. Client needs and prescribed orders
ANS: A, B The state Nurse Practice Act will have the information the RN needs, and in some states, LPNs are able to perform specific aspects of IV therapy. However, in a client care situation, it may be difficult and timeconsuming to find it and read what LPNs are permitted to do, so another good solution would be for the nurse to check facility policy and follow it.
A patient is presenting with an orthostatic blood pressure of 80/40 when she stands up, thready and weak pulse of 58, and shallow respirations. In addition, the patient has been having frequent episodes of vomiting and nausea and is taking hydrochlorothiazide. Which of the following findings would explain the patient's condition? A. Potassium level of 7.0 B. Potassium level of 3.5 C. Potassium level of 2.4 D. None of the options are correct
C potassium level of 2.4 = hypokalemia
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
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.
A nurse assists with the insertion of a central vascular access device. Which actions should 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 clients plan of care. b. Remind the provider to perform hand hygiene prior to starting the procedure. 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.
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 should wear sterile gloves, gown and mask, and anyone in the room should wear a mask. A sterile dressing change should be completed per organizational policy, usually every 7 days and as needed.
A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that apply.) a. A 36-year-old who is malnourished b. A 42-year-old with uncontrolled diabetes c. A 50-year-old with hyperparathyroidism d. A 58-year-old with chronic renal failure e. A 76-year-old who is prescribed antacids
ANS: A, B, E Clients at risk for hypophosphatemia include those who are malnourished, those with uncontrolled diabetes mellitus, and those who use aluminum hydroxidebased or magnesium-based antacids. Hyperparathyroidism and chronic renal failure are common causes of hyperphosphatemia.
A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should 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
ANS: A, B, E Manifestations of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, and skeletal muscle weakness.
A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which complications should the nurse assess? (Select all that apply.) a. Phlebitis b. Pneumothorax c. Thrombophlebitis d. Excessive bleeding e. Extravasation
ANS: A, C Although the complication rate with PICCs is fairly low, the most common complications are phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Pneumothorax, excessive bleeding, and extravasation are not common complications.
A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) a. Hypokalemia Flaccid paralysis with respiratory depression b. Hyperphosphatemia Paresthesia with sensations of tingling and numbness c. Hyponatremia Decreased level of consciousness d. Hypercalcemia Positive Trousseaus and Chvosteks signs e. Hypomagnesemia Bradycardia, peripheral vasodilation, and hypotension
ANS: A, C Flaccid paralysis with respiratory depression is associated with hypokalemia. Decreased level of consciousness is associated with hyponatremia. Paresthesia with sensations of tingling and numbness is associated with hypophosphatemia or hypercalcemia. Positive Trousseaus and Chvosteks signs are associated with hypocalcemia or hyperphosphatemia. Bradycardia, peripheral vasodilation, and hypotension are associated with hypermagnesemia.
A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.) a. Electrocardiogram changes b. Slow, shallow respirations c. Orthostatic hypotension d. Paralytic ileus e. Skeletal muscle weakness
ANS: A, D, E Electrolyte imbalances associated with acute renal failure include hyperkalemia and hyperphosphatemia. The nurse should assess for electrocardiogram changes, paralytic ileus caused by decrease bowel mobility, and skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of hypokalemia.
A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should 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 (Calcimar).
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 home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right upper extremity PICC is intact, patent, and has a good blood return. Site clean and free from manifestations of infiltration, irritation, and infection. Sue Franks, RN January 20: Purulent drainage from sacral wound. Wound cleansed and dressing changed. Dr. Smith notified and updated on client status. New orders received for intravenous antibiotics. Sue Franks, RN January 13: Client alert and oriented. Sacral wound dressing changed. Sue Franks, RN January 6: Right upper extremity PICC inserted. No complications. Discharged with home health care. Dr. Smith Based on the information provided, which action should the nurse take? a. Notify the 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 or even years. Because the line shows no signs of complications, it is permissible to administer the IV antibiotic. There is no need to call the physician to have the IV route changed to an oral route.
A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next? a. Begin the prescribed infusion via the new access. b. Ensure an x-ray is completed to confirm placement. c. Check medication calculations with a second RN. d. Make sure 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.
A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next? a. Administer a sublingual nitroglycerin tablet. b. Prepare to assist with chest tube insertion. c. Place a sterile dressing over the IV site. d. Re-position the client into the Trendelenburg position.
ANS: B An insertion-related complication of central venous catheters is a pneumothorax. Signs and symptoms of a pneumothorax include chest pain and dyspnea. Treatment includes removing the catheter, administering oxygen, and placing a chest tube. Pain is caused by the pneumothorax, which must be taken care of with a chest tube insertion. Use of a sterile dressing and placement of the client in a Trendelenburg position are not indicated for the primary problem of a pneumothorax.
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, which action should 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 should be removed and warm compresses used to relieve pain. The other options are not appropriate for this type of pain.
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 to 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 are signsof meningitis and should be reported to the provider immediately. The other findings are important but do not require immediate intervention.
A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first? a. Measure intake and output every 4 hours. b. Apply oxygen by mask or nasal cannula. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowlers position.
ANS: B Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimal. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the client too rapidly with IV fluids can lead to cerebral edema. Measuring intake and output and placing the client in a high-Fowlers position will not address the clients problem.
A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss? a. Client taking furosemide (Lasix) 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 fluid loss.
After teaching a client who is being treated for dehydration, a nurse assesses the clients understanding. Which statement indicates the client correctly understood the teaching? a. I must drink a quart 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 PM so I wont 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 daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.
Tall peaked T-waves, flat P-waves, prolonged PR intervals and widened QRS complexes can present in which of the following conditions? A. Hypocalemia B. Hypercalemia C. Hypokalemia D. Hyperkalemia
D HyperKalemia
A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this clients care plan? (Select all that apply.) a. Encourage oral fluid intake of at least 2 L/day. b. Use a draw sheet to reposition the client in bed. c. Strain all urine output and assess for urinary stones. d. Provide nonslip footwear for the client to use when out of bed. e. Rotate the client from side to side every 2 hours.
ANS: B, D Clients with long-standing hypocalcemia have brittle bones that may fracture easily. Safety needs are a priority. Nursing staff should use a draw sheet when repositioning the client in bed and have the client wear nonslip footwear when out of bed to prevent fractures and falls. The other interventions would not provide safety for this client.
A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.) a. Urine output of 25 mL/hr b. Serum potassium level of 5.4 mEq/L c. Urine specific gravity of 1.02 g/mL d. Serum sodium level of 128 mEq/L e. Blood osmolality of 250 mOsm/L
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 clients 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 cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first? a. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g 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 high serum potassium level and cardiac changes should 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 should be administered with dextrose to prevent hypoglycemia. Kayexalate 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 prescription the nurse should implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the clients current potassium level.
A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients 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 Clients should be actively engaged 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.
A nurse teaches clients at a community center about risks for 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 receiving hypertonic 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.
After teaching a client to increase dietary potassium intake, a nurse assesses the clients understanding. Which dietary meal selection indicates the client correctly understands the teaching? a. Toasted English muffin with butter and blueberry jam, and tea with sugar b. Two scrambled eggs, a slice of white toast, and a half cup of strawberries c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk d. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee
ANS: C Meat, dairy products, and dried fruit have high concentrations of potassium. Eggs, breads, cereals, sugar, and some fruits (berries, peaches) are low in potassium. The menu selection of sausage, toast, raisins, and milk has the greatest number of items with higher potassium content.
A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this clients teaching? a. Weigh yourself every morning and every night. b. Check your radial pulse twice a day. c. Read food labels to determine sodium content. d. Bake or grill the meat rather than frying it.
ANS: C Most prepackaged foods have a high sodium content. Teaching clients how to read labels and calculate the sodium content of food can help them adhere to prescribed sodium restrictions and can prevent hypernatremia. Daily self-weighing and pulse checking are methods of identifying manifestations of hypernatremia, but they do not prevent it. The addition of substances during cooking, not the method of cooking, increases the sodium content of a meal.
A client at risk for developing hyperkalemia states, I love fruit and usually eat it every day, but now I cant because of my high potassium level. How should the nurse respond? a. Potatoes and avocados can be substituted for fruit. b. If you cook the fruit, the amount of potassium will be lower. c. Berries, cherries, apples, and peaches are low in potassium. d. You are correct. Fruit is very high in potassium.
ANS: C Not all fruit is potassium rich. Fruits that are relatively low in potassium and can be included in the diet include apples, apricots, berries, cherries, grapefruit, peaches, and pineapples. Fruits high in potassium include bananas, kiwi, cantaloupe, oranges, and dried fruit. Cooking fruit does not alter its potassium content.
A patient is being discharged home after hospitalization with hypocalcemia. Which statement by the patient indicates she understood the dietary instructions? A. "I will avoid sardines. B. "I'll avoid salt and Vitamin-D supplements." C. "I will tell my husband to only purchase skim milk." D. "I will be sure to eat lots of cheese, tofu and spinach."
D. "I will be sure to eat lots of cheese, tofu and spinach."
After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients 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 treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all manifestations of hypokalemia and do not demonstrate that treatment is working.
A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multi-dose vial of heparin with a concentration of 100 units/mL. Which of the syringes shown below should the nurse use to draw up and administer the heparin? a. b. c. d.
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.
A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first? a. Amount of pressure in fluid container b. Date of catheter tubing change c. Percent of heparin in infusion container d. Presence of an ulnar pulse
ANS: D An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of an ulnar pulse is one way to assess circulation to the arm in which the catheter is located. 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. Because of heparin-induced thrombocytopenia, heparin is not used in most institutions for an arterial catheter.
A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should 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 liter 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 should 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 clients urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 liter 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.
After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the clients understanding. Which food choice for lunch indicates 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 should 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 often high in sodium.
What type of fluid would a patient with severe hyponatremia most likely be started on?A. Hypotonic B. Hypertonic C. Isotonic D. Colloid
B: Hypertonic
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 clients left lower extremity is cool to the touch.
ANS: D Compartment syndrome is a condition in which increased tissue perfusion 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 this perfusion problem.
A patient has a potassium level of 2.0. What would you expect to be ordered for this patient? A. Potassium 30 meq IV push B. Infusion of Potassium intravenously C. An oral supplement of potassium D. Intramuscular injection of Potassium
B: Infusion of Potassium intravenously
When administering a hypertonic solution the nurse should closely watch for?A. Signs of dehydration B. Pulmonary Edema C. Fluid volume deficient D. Increased Lactate level
B: Pulmonary Edema
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 should the nurse assess this 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 occur earlier in the course of treatment. Bowel obstruction and catheter lumen occlusion can occur but would present clinically in different ways.
A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should 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 should 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 is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 breaths/min to 22 breaths/min b. Decreased skin turgor on the clients posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic light-headedness and dizziness
ANS: D The focus of management for clients with dehydration is to increase fluid volumes to normal. When fluid volumes return to normal, clients should perfuse the brain more effectively, therefore improving confusion and decreasing orthostatic light-headedness or dizziness. Increased respiratory rate, decreased skin turgor, and increased specific gravity are all manifestations of dehydration.
12.A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should 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 clients bath. d. Use a plastic bag to cover the extremity with the device.
ANS: D The nurse should ask the UAP 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 with a vascular device. The nurse should 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 UAP.
11.A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the clients 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 clients skin, the nurse should place a washcloth or the clients gown between the skin and tourniquet. The other interventions are methods to distend the vein but will not protect the clients skin.
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 should 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 should have one, but this does not take priority over the client whose arm is swollen.
An EKG shows a shortened QT interval. Which lab value below would be indicative of this change? A. Calcium level of 8.0 B. Calcium level of 12.0 C. Calcium level of 8.7 D Calcium level of 9.2
B. Calcium level of 12.0
Stimulation of the facial nerve via the masseter muscle causes twitching of the nose/lips in hypocalcemia is known as? A. Trousseau's Sign B. Chvostek's Sign C. Homan's Sign D. Goodell's Sign
B. Chvostek's Sign
Which of the following is not a hypertonic fluid? A. 3% Saline B. D5W. C. 10% Dextrose in Water (D10W). D. 5% Dextrose in Lactated Ringer's
B. D5W
A patient has a sodium level of 123 and presents with confusion. The doctor diagnoses the patient with Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH). Which type of hyponatremia is this? A. Hypovolemic B. Euvolemic C. Hypervolemic D. Antivolemic
B. Euvolemic
A patient with Celiac disease is at risk for which of the following? A. Hypokalemia B. Hypocalcemia C. Hypomagnesemia D. Hypercalcemia
B. Hypocalcemia
What type of fluid would a patient with severe hyponatremia most likely be started on? A. Hypotonic B. Hypertonic C. Isotonic D. Colloid
B. Hyponatremia
A patient with a sodium level of 112 is taking Lithium. Which of the following is a nursing priority? A. Hold further doses of Lithium B. Monitor Lithium drug level due to risk of toxicity C. Monitor potassium level due to increased risk of toxicity D. No priority is need. 112 is a normal sodium level
B. Monitor Lithium drug level due to risk of toxicity
When administering a hypertonic solution the nurse should closely watch for? A. Signs of dehydration B. Pulmonary Edema C. Fluid volume deficient D. Increased Lactate level
B. Pulmonary Edema
A patient's potassium level is 3.0. Which foods would you encourage the patient to consume? A. Cheese, collard greens, and fish B. Avocados, strawberries, and potatoes C. Tofu, oatmeal, and peas D. Peanuts, bread, and corn
B: Avocados, strawberries, and potatoes
Which of the following is not a hypertonic fluid?A. 3% Saline B. D5W C. 10% Dextrose in Water (D10W)D. 5% Dextrose in Lactated Ringer's
B: D5W
Which solution below is NOT a hypertonic solution? A. 5% Dextrose in 0.9% Saline B. 5% Saline C. 5% Dextrose in Lactated Ringer's D. 0.33% saline (1/3 NS)
D. 0.33% saline (1/3 NS)
The doctor orders an isotonic fluid for a patient. Which of the following is not an isotonic fluid? A. 0.9% Normal Saline B. Lactated Ringer's C. 0.45% Saline D. 5% Dextrose in 0.225% saline
C. 0.45% saline
A patient has a calcium level of 12.5. Which medication will most likely be ordered for this patient? A. Calcium Chloride B. 10% Calcium Gluconate C. Calcitonin D. Hydrochlorothiazide
C. Calcitonin
A patient's calcium level is 11.2. Which option below could be the cause? A. None, 11.2 is a normal calcium level B. Cushing's Syndrome C. Hydrochlorothiazide D. Hypoparathyroidism
C. Hydrochlorothiazide
When the cell presents with the same concentration on the inside and outside with no shifting of fluids this is called? A. Hypotonic B. Hypertonic C. Isotonic D. Osmosis
C. isotonic
The doctor orders an isotonic fluid for a patient. Which of the following is not an isotonic fluid?A. 0.9% Normal Saline B. Lactated Ringer's C. 0.45% Saline D. 5% Dextrose in 0.225% saline
C: 0.45% Saline
A patient is recovering from parathyroid surgery. Morning labs values are back. Which of the following lab values would correlate as a complication from this type of surgery? A. Calcium 8.7 B. Calcium 12.5 C. Calcium 6.9 D. Calcium 9.2
C: Calcium 6.9 Patients who have had any type of neck surgery, especially parathyroid or thyroidectomy is risk for hypocalcemia.
Which condition below could lead to cell lysis, if not properly monitored? A. Isotonicity B. Hypertonicity C. Hypotonicity D. None of the options are correct
C: Hypotonicity
Which condition below could lead to cell lysis, if not properly monitored?A. Isotonicity B. Hypertonicity C. Hypotonicity D. None of the options are correct
C: Hypotonicity
When the cell presents with the same concentration on the inside and outside with no shifting of fluids this is called?A. HypotonicB. HypertonicC. IsotonicD. Osmosis
C: Isotonic
Which patient is at risk for hyperkalemia? A. Patient with Parathyroid cancer B. Patient with Cushing's Syndrome C. Patient with Addison's Disease D. Patient with breast cancer
C: Patient with Addison's Disease
A patient's lab work shows that they have a high parathyroid hormone level. Which condition is the patient at risk for? A. Hyperkalemia B. Hypocalcemia C. Hypokalemia D. Hypercalcemia
D. Hypercalcemia
Isotonic fluids cause shifting of water from the extracellular space to the intracellular space. True or False
FALSE. HYPOTONIC fluids cause shifting of water from the extracellular space to the intracellular space (not isotonic)
D5W solutions are sometimes considered a hypotonic solution as well as an isotonic solution because after the body metabolizes the dextrose the solution acts as a hypotonic solution. True or False
TRUE. D5W is classified as a ISOTONIC fluid BUT after administration the body metabolizes the dextrose and the fluid left over is a hypotonic solution
A patient with cerebral edema would most likely be order what type of solution? A. 3% Saline B. 0.9% Normal Saline C. Lactated Ringer's D. 0.225% Normal Saline
The answer is A: 3% Saline. A patient with cerebral edema would be ordered a HYPERTONIC solution to decrease brain swelling. The solution would remove water from the brain cells back into the intravascular system to be excreted. 3% Saline is the only hypertonic option.
A patient with cerebral edema would most likely be order what type of solution?A. 3% SalineB. 0.9% Normal SalineC. Lactated Ringer'sD. 0.225% Normal Saline
The answer is A: 3% Saline. A patient with cerebral edema would be ordered a HYPERTONIC solution to decrease brain swelling. The solution would remove water from the brain cells back into the intravascular system to be excreted. 3% Saline is the only hypertonic option.
Isotonic fluids cause shifting of water from the extracellular space to the intracellular space. True or False
The answer is FALSE. HYPOTONIC fluids cause shifting of water from the extracellular space to the intracellular space (not isotonic)
D5W solutions are sometimes considered a hypotonic solution as well as an isotonic solution because after the body metabolizes the dextrose the solution acts as a hypotonic solution.TrueFalse
The answer is TRUE. D5W is classified as a ISOTONIC fluid BUT after adminstration the body metabolizes the dextrose and the fluid left over is a hypotonic solution.
