Fundamentals/Med-Surg Chapter 41
A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?
"I should drink 2,500 mL/day of fluid"
Which IV solutions would the nurse expect to be ordered for a client who has hypovolemia? Select all that apply. -10% dextrose in water (D10W) -0.45% NaCl (½-strength normal saline) -0.9% NaCl (normal saline) -Lactated Ringer's solution -5% dextrose in 0.9% NaCl -5% dextrose in water (D5W)
-0.9% NaCl (normal saline) -Lactated Ringer's solution -5% dextrose in 0.9% NaCl
The nurse is monitoring intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the I&O record? Select all that apply. -100 mL from melted ice chips -serving of jello -bowl of chili -infusion of intravenous solution -barbecue sandwich -cup of ice cream
-100 mL from melted ice chips -serving of jello -infusion of intravenous solution -cup of ice cream
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 healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?
3,000
A health care provider 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
Which of the following pH findings would indicate the presence of acidosis?
7.3
The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate?
83 mL/hr
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
A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?
An implanted central venous access device (CVAD)
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?
An infant age 4 months
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 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
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 the expected color and consistency
Which of the following accounts for about 30% of the total body water?
Extracellular fluid
T/F: Acidosis occurs when there is a lack of H ions or a gain of base (bicarbonate) and the pH exceeds 7.45
False
A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse likely to find?
Hypokalemia
The Which of the following electrolyte imbalances occurs when the sodium in the extracellular fluid is below 135 mEq/L?
Hyponatremia
Cells that are surrounded by this type of fluid in the intravascular space will swell and possibly burst
Hypotonic solution
Because metabolism continually produces acids, maintenance of pH within these incredibly narrow limits depends on two processes: buffering and compensation. Which statement describes a function of buffering?
It helps to prevent large changes in pH by absorbing or releasing H+ ions
A client is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. Laboratory results show a serum potassium of 3.2 mEq/l (3.2 mmol/l). For what set of manifestations should the nurse be alert?
Muscle weakness, fatigue, and arrhythmias
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
The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). On rounds, the nurse notes that the client's IV site and arm are swollen and cool to the touch. Based on these assessment findings, what will the nurse do next?
Remove the peripheral intravenous catheter
A client's blood pressure has dropped from 146/92 mmHg to 107/68 mmHg over the course of several minutes. Increased levels of which of the following will be released into the client's bloodstream?
Renin
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?
Restart infusion in another vein and apply a warm compress
The primary extracellular electrolytes include which of the following?
Sodium, chloride, and bicarbonate
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?
Start an IV of normal saline as prescribed
During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first?
Stop the transfusion immediately
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:
Total parenteral nutrition
T/F: Arterial blood gases are laboratory tests commonly used to determine the adequacy of oxygenation and ventilation, as well as in the assessment and treatment of acid-base imbalances
True
T/F: Lactated Ringer's intravenous solution contains multiple electrolytes in about the same concentrations as found in plasma
True
T/F: Major electrolytes found inside cells include potassium, phosphorus, and magnesium
True
T/F: Surgical hypoparathyroidism, vitamin D deficiency, and malabsorption are also causes of hypocalcemia.
True
Which of the following blood types is considered the universal donor?
Type O
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
The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding?
pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)
The nurse is providing care to a client who has a serum potassium level of 5.2 mEq/L (5.2 mmol/L). Which findings would the nurse expect to assess? Select all that apply. -Nausea and vomiting -Cardiac arrythmia -Muscle weakness -Polyuria -Polydipsia
-Cardiac arrythmia -Muscle weakness
Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply. -Hypervolemia management -Fluid restriction -Intravenous therapy -Electrolyte management -Monitoring edema -Nutrition management
-Intravenous therapy -Electrolyte management -Nutrition management
A nurse is preparing the site for insertion of a peripheral venous catheter using chlorhexidine. Which actions would be appropriate for the nurse to do? Select all that apply. -apply deep pressure -rub in a side to side motion -rub in a circular motion -use a back and forth motion -apply alcohol after the chlorhexidine
-Rub in a side to side motion -Use a back and forth motion
The nurse is assessing an adult client who has presented to the emergency department with general weakness. The nurse reviews the client's health record to find there is no history of underlying health conditions. The nurse will begin preparing for the insertion of a peripheral intravenous line if which assessment finding(s) are present? Select all that apply. -The client has experienced 24 hours of diarrhea. -The client reports using laxative substances daily. -The client has been vomiting for several days. -The client is only willing to drink juices. -The client has a serum potassium level of 2.0 mEq/l (2.0 mmol/l). -The client has severe iron-deficiency anemia.
-The client reports using laxative substances only -The client has been vomiting for several days -The client has a serum potassium level of 2.0 mEq/l (2.0mmol/l) -The client has severe iron-deficiency anemia
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
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?
Decreased potassium levels
A nurse is inspecting the IV site of a client and notices that the site is swollen, red, warm to the touch, and painful. Which action by the nurse is appropriate?
Discontinue the IV and relocate it to another spot
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
A client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells?
Plasma
A client has been diagnosed with excessive levels of aldosterone. The nurse's assessment will include what value?
Potassium level