chapter 38 fluid and electrolytes

The nurse is providing IV push meperidine (Demerol) through a free-flowing IV line and notes a hazy appearance in the tubing. It is necessary to:

Stop the infusion.

The nurse may administer which of the following IV solutions via a peripheral vein?Select all that apply.

10% dextrose 5% dextrose in 0.45% sodium chloride

The nurse is caring for the client who has allergies to corn and shellfish. Which of the following should the nurse NOT use with the client? Select all that apply.

10% povidone-iodine 10% to 50% Dextrose

The nurse assumes responsibility for a blood transfusion that was initiated 2.5 hours ago. The client is tolerating the procedure well, and there is roughly 50% of the blood remaining. The best action by the nurse is to:

Increase the transfusion rate.

The nurse who is caring for a client with an infusion of D5 1/2NS 1,000 mL with 20 mEq KCL at 100 mL/hr notes that there is slight swelling at the insertion site and no blood return when aspirating at the injection port closest to the IV site. Which of the following problems does the nurse suspect?

Infiltration

The nurse who is working on a medical-surgical floor recognizes that vesicant precautions should be taken with which of the following? Select all that apply.

Potassium chloride Promethazine (Phenergan) Vancomycin (Vancocin)

Place the following steps for hanging a new IV bag in the proper order (1-6). (Enter the number of each step in the proper sequence without spaces; do not use commas).

1. hang the bag on the iv pole 2.remove the piercing pain 3. remove the iv bag from the pole 4.insert the piercing pin into the tubing port 5. assess the iv site 6. stop the infusion

The health-care provider orders that a client who is dehydrated receive lactated ringer's solution (LR). Which statement made by the nurse indicates an understanding of safety items to consider?

"I should confirm what other medications the client is on."

Under the supervision of the RN, theLPN/LVN discusses the IV push route of administration to the client. Which statements by the LPN/LVN are accurate? Select all that apply.

"This method means the drug will take effect instantaneously." We can administer this through the injection port you already have." We'll flush your device with saline before administering using this method."

The nurse needs to infuse a dose of 250 mL gentamicin over 120 minutes. What drip rate should the nurse use, in mL/hr? Record your answer as a whole number

2

Before preparing the equipment to administer peripheral venipuncture, the nurse should wash his or her hands for seconds.

20 seconds

nurse caring for several clients in the emergency department. The nurse will plan to monitor the rate of infusion and assess the condition of an IV site every hour for which of the following clients? Select all that

A 4-year-old child A 72-year-old man A 42-year-old man who is prone to circulatory fluid overload

Which of the following clients would likely receive packed red blood cells?Select all that apply.

A client with acute blood loss A client with symptomatic anemia

A nurse knows that a client who needs an IV to provide simple water replacement because of lack of fluid intake should be given which of the following?

A hypotonic solution

the nurse is caring for a client who reports that the IV site is sore. The nurse notes swelling and tenderness at the site, as well as a red streak up the arm. The nurse's care should include which of the following? Select all that apply.

Discontinuing the IV. Elevating the arm on pillows. Applying warm packs to the area.

The nurse is providing care to a client who is receiving a blood transfusion and who becomes acutely short of breath and anxious within a few minutes of the nurse's initiating the transfusion. Which of the following actions will be included in the nurse's care? Select all that apply.

Frequent checks of the vital signs Stopping the blood transfusion and notifying the physician Sending tubing and unused blood to the blood bank Obtaining a urine sample for analysis

The nurse is providing care for a client who is receiving a blood transfusion. Pre-transfusion vital signs were blood pressure (BP), 144/78 mm Hg; temperature (T), 98.4°F; pulse (P), 86; respirations (R), 14. Now, approximately an hour after the transfusion was initiated, the client's vital signs are BP, 168/92 mm Hg; P, 98; R, 20. Next, the nurse should:

Listen to the client's breath sounds.

The nurse is caring for a client with an IV. The client begins to have redness and swelling at the IV site. The client also complains of burning and tenderness at the IV site. Which does the nurse suspect?

Phlebitis

The nurse is providing care for a client who has a central line and a suspected air embolism. The best action by the nurse is to:

Place the client on her left side in Trendelenburg position.

When continuous IV infusion of a drug is desired, a nurse understands that which of the following is true? Select all that apply.

The health-care provider must order the dosage of medication to be administered. The volume of solution may vary from 250 to 1,000 mL. The nurse must monitor the IV solution carefully to maintain the desired rate of IV infusion.

The nurse asks a nursing student to help initiate a transfusion. Which of the following are parts of this process? Select all that apply.

The student has two RNs double check the order for a transfusion. The student is using Y-tubing for the transfusion. The student verifies the client's name, birth date, and blood identification tags. The student assesses the client's vital sign right before the infusion begins.

A nurse could correctly provide which of the following viaIV therapy as part of a maintenance fluid?

Water

When there is a risk for hemorrhage, fluctuation of vital signs, or shock, such as when a client is scheduled for surgery, the nurse should use a -bore needle when administering an IV.

larger

A nurse knows that if a client needs IV fluid replacement because of low blood volume, he or she should be given a solution.

hypertonic solution

A nurse knows that there is a risk for cerebral edema, increased intracranial pressure, rupture of brain cells, and death if there is an infusion of an excessive volume of a(n) solution.

hypotonic solution