ATI Book Quizzes
A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate?
Offer the client sugar-free candy to help combat thirst.
A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?
Remove the IV.
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?
Start an IV of normal saline as prescribed.
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:
total parenteral nutrition.
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?
a newly admitted 88-year-old with a 2-day history of vomiting and loose stools
Potassium is needed for neural, muscle, and:
cardiac function
The student nurse asks, "What is intravascular fluid?" What is the appropriate nursing response?
"Watery plasma, or serum, portion of blood."
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?
50 gtt/min
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?
Acute Confusion related to cerebral edema
A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?
potassium
A nurse is caring for four different pediatric clients, all of whom require insertion of an intravenous (IV) catheter. For which client would it be appropriate to insert the IV into the foot?
Infant
A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?
"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."
A nurse is teaching a client regarding a newly implanted venous access system. Which statement by the nurse is incorrect?
"You won't have to endure any more needlesticks."
What commonly used intravenous solution is hypotonic?
0.45% nacl
A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?
1 unit over 2 to 3 hours, no longer than 4 hours
A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit?
3.5 cm H2O
A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?
60 drops/ml
A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern?
Banana
The nurse is providing care for a client with a peripheral intravenous catheter in situ. What intervention should the nurse implement in the care of this IV?
Change the site every three to four days.
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?
Decreased potassium levels
A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation?
Discontinue the IV and relocate it to another spot.
Edema happens when there is which fluid volume imbalance?
ECF fluid volume excess
The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome?
ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.
A nurse is providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance?
Hyperphosphatemia
A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:
Hypokalemia
A client is hypotensive secondary to hypovolemia resulting from dehydration. Based on the nurse's knowledge about intravenous solutions, the nurse would expect the physician to prescribe which type of solution?
Isotonic
A nurse must administer an isotonic intravenous solution to a client who has lost fluid. Which fluids are isotonic? Select all that apply.
Lactated Ringer's solution 0.9% NaCl (normal saline)
Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert?
Muscle weakness, fatigue, and dysrhythmias
As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action?
Not wearing gloves when performing the intervention
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation?
Notify the primary care provider immediately for possible fluid overloa
The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect?
Phlebitis
What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution?
To assure the IV solution is approprate for this administration
Which statement most accurately describes the process of osmosis?
Water moves from an area of lower solute concentration to an area of higher solute concentration.
Which client would be a candidate for total parenteral nutrition?
a client with colitis and bloody diarrhea
How is control over the extracellular concentration of potassium within the human body is exerted?
aldosterone.
When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication?
apply a warm compress
A client has been admitted with fluid volume deficit. Which assessment data would the nurse anticipate? Select all that apply.
blood pressure 100/48 mmHg heart rate 128/bpm poor skin turgor
A nurse is caring for a client who is on total parenteral nutrition (TPN). Which clients are candidates for TPN? Select all that apply.
clients with major trauma or burns clients with liver and renal failure clients with inflammatory bowel disease
A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?
daily weights
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?
decreased blood volume and intracellular dehydration
After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client?
every 72 hours
When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing:
fluid overload.
A client needs an intravenous fluid that will pull fluids into the vascular space. What type of fluid does the nurse prepare to administer as prescribed?
hypertonic
The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment
intracellular
Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?
isotonic
A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid?
maintenance of cell size
A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing?
metabolic alkalosis
The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice?
ordering type of solution, additive, amount of infusion, and duration
The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths per minute. Which arterial blood gas data does the nurse anticipate finding?
pH: 7.60; PaCO2: 64; HCO3: 42
Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of:
phlebitis
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?
placing the tourniquet on the upper arm for 2 minutes
Which explanations from the student about fluid and electrolyte balance demonstrate that learning has taken place regarding the function of water? Select all that apply.
provides a medium for transporting substances throughout the body facilitates cellular metabolism and proper cellular chemical functioning helps maintain normal body temperature facilitates digestion and promotes elimination
A decrease in arterial blood pressure will result in the release of:
renin
A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area?
sacral area
A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. The nurse looks for a large vein when using a needle with a large gauge. What explains the nurse's action?
to prevent compromising circulation
A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause?
"I've been taking antacids almost every 2 hours over the past several days."
The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client?
Apply pressure to insertion site for at least 3 minutes.
A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?
Avoid salty or excessively sweet fluids.
Which is a common anion?
Chloride
A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?
Ensure that the prescribed solution is clear and transparent.
A nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 5.75 mg/dL (1.8 mEq/L)
Hypokalemia
Many chronic medical problems adversely affect a person's ability to maintain normal fluid, electrolyte, and acid-base homeostasis. What describes complications related to liver disease?
Increased plasma levels of antidiuretic hormone lead to water excess
A client has the following arterial blood gas results:pH: 7.33PaCO2: 42 mm HgHCO3: 19 mEq/L (19 mmol/L)PaO2: 95 mm HgWhich imbalance would the nurse suspect?
Metabolic acidosis
A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)?
Metabolic alkalosis
A nurse is caring for a client who is prescribed a peripheral intravenous (IV) infusion. After reviewing the image, which action is most important for the nurse to take?
Obtain new intravenous tubing and spike the infusion bag without touching the tip of the tubing
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?
Offer small amounts of preferred beverage frequently.
The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present?
The renal system retains more water.
The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action?
Tighten the roller clamp to stop the infusion.
While removing a client's peripherally inserted central catheter (PICC), part of the catheter breaks off. What action is the nurse's priority?
apply tourniquet
What is the lab test commonly used in the assessment and treatment of acid-base balance?
arterial blood gas
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?
calcium and phosphorus
A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?
cardiac irregularities
The nurse is preparing to perform venipuncture. Which items will the nurse plan to gather? Select all that apply
clean gloves tourniquet antiseptic swabs transparent dressing adhesive tape
A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?
distended neck veins
A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:
electrolytes.
The nurse is caring for a client who was found without food or water for 2 days in the desert. What explanation for the need for fluid does the client have? Select all that apply.
facilitates cellular metabolism helps maintain normal body temperature acts as a solvent for electrolytes
Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing?
febrile reaction
During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible?
hypovolemia
The nurse is caring for Mrs. Roberts, an 86-year-old client, who fell at home and was not found for 2 days. Mrs. Roberts is severely dehydrated. The nurse is aware that older adults are at increased risk for fluid imbalance due to:
increase in fat cells.
A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism would the nurse most likely address?
increased hydrostatic pressure
A nurse is assessing a client and suspects an ECF volume excess. Which finding would the nurse identify as being most significant?
weight gain of 0.75 kg in a day