Invasive - IV Therapy

A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take if an allergic transfusion reaction is suspected? Select all 1 - Stop the transfusion 2 - Monitor for hypertension 3 - Maintain an IV infusion with 0.9% sodium chloride 4 - Position the client in an upright position with the feet lower than the heart. 5 - Administer diphenhydramine

1 - Stop the transfusion 3 - Maintain an IV infusion with 0.9% sodium chloride 5 - Administer diphenhydramine Rational 2- hypotension 4 - is for fluid overload

A nurse is collecting data from a client who has isotonic fluid-volume deficit. Which of the following findings should the nurse expect? 1 - Weak pulse 2 - Bradycardia 3 - Hypertension 4 - Distended neck veins

1 - Weak pulse Rational 1 - Manifestations of isotonic fluid-volume deficit include a weak pulse, dry mucous membranes, decreased capillary refill, and decreased urine volume. 2 - The nurse should expect a client who has isotonic fluid-volume deficit to have tachycardia. 3 - The nurse should expect a client who has isotonic fluid-volume deficit to have hypotension. 4 - The nurse should expect a client who has isotonic fluid-volume excess to have distended neck veins.

A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant's response to therapy by performing which of the following actions? 1 - Weighing the infant at the same time every day 2 - Taking the infant's vital signs every 2 hr 3 - Measuring the infant's head circumference twice per day 4 - Counting the number of wet diapers every shift

1 - Weighing the infant at the same time every day Rational 1 - Weight is the most sensitive indicator of hydration status for clients of all ages. Weight is the only measurement that reflects both measurable fluid balance changes and incidental fluid loss. 2 - Vital signs are not a reliable indicator of hydration status. 3 - Measuring head circumference gives no useful information regarding the hydration status of an infant. 4 - Counting wet diapers is an inadequate method for accurately determining the hydration status of an infant.

You appropriately elicit a sign of hypocalcemia by: 1 - tapping the face about 1 inch from the ear 2 - palpating a partially stretched tendon 3 - inspecting facial symmetry 4 - Applying pressure on the radial pulse

1 - tapping the face about 1 inch from the ear Rational Tapping the face in front of the ear elicits Chvostek sign, which is a sign of hypocalcemia. (2) Palpating a partially stretched tendon does not elicit a sign of hypocalcemia. (3) Facial symmetry does not give hints to calcium balance. (4) The radial pulse is used to measure heart rate.

Before potassium can be administered to an infant, what must occur

1 void minimum

What is the fluid of choice for dehydration with children over the age of 2 1 - Orange juice 2 - Apple juice 3 - Grape juice 4 - Cranberry juice

2 - Apple juice

A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? 1 - Administer antihypertensive on schedule 2 - Check the client's weight each morning 3 - Notify the provider of a urine output greater than 30 mL/hr 4 - Encourage independent ambulation for times a day

2 - Check the client's weight each morning

A patient recently has gastric surgery and requires total parenteral nutrition (TPN) containing 10% dextrose in water. What type of solution is TPN 1 - Isotonic 2 - Hypertonic 3 - Hypotonic 4 - Vesitonic

2 - Hypertonic

A nurse is caring for a child who has water diarrhea for the past 3 days. Which of the following is an appropriate action for the nurse to take? 1 - Offer chicken broth 2 - Initiate oral rehydration 3 - Start hypertonic IV solution 4 - Keep the child NPO unit the diarrhea subsides

2 - Initiate oral rehydration Rational 1 -Chicken broth has increased sodium and inadequate carbohydrates 3 - Isotonic IV solutions are recommended 4 - Children who experience diarrhea are at risk for dehydration. Keeping them NPO is contraindicated

A nurse is assisting with the administration fo a unit of packed RBCs to a client who has a Hgb of 8 g/dL. Which of the following actions should the nurse plan to take during the first 15 min of the transfusion? 1 - Verify the client has given informed consent for the transfusion 2 - Monitor for an acute hemolytic reaction 3 - Explain the transfusion procedure to the client 4 - Obtain blood culture specimens to send to the lab

2 - Monitor for an acute hemolytic reaction

A patient has severe anemia and is given a blood transfusion. Which symptom should the LPN/LVN report immediately if it occurs during the transfusion? 1 - Euphoria 2 - Pain in the lower back 3 - Temperature of 100° F 4 - Decreased urinary output

2 - Pain in the lower back Rational Hemolysis occurs as the result of a blood transfusion reaction. Signs and symptoms of a reaction include chills, fever, low back pain, flushing, tachycardia, tachypnea, hypotension, vascular collapse, hemoglobinuria, acute jaundice, dark urine, bleeding, acute renal failure, shock, cardiac arrest, and death.

Which would be the most accurate way to assess for dehydration in an elderly patient? 1 - Skin turgor 2 - Urine output 3 - Respirations 4 - Thirst levels

2 - Urine output Rational Inadequate urine outflow is an indication that dehydration is occurring. A decrease in weight would be a secondary finding and would occur later. (1) Skin turgor is not a good indicator of dehydration in older adults. (3) Respirations are not a good indicator of dehydration in older adults. (4) Dehydration in older adults is often not accompanied by thirst.

You respond to a patient complaining of pain, burning, and wetness over the peripheral IV site. On assessment, you find that the IV insertion site is tender and cool to touch. These are signs and symptoms of: 1 - phlebitis 2 - infiltration 3 - infection 4 - venous spasm

2 - infiltration Rational Pain, burning, coolness, and wetness over the IV site are signs of infiltration of IV fluid into the tissue. (1) Phlebitis is inflammation of a vein. (3) Infection will cause the area to be hot to the touch. (4) The first sign of a venous spasm is sharp pain extending up the arm.

The main electrolyte in the intracellular fluid 1 - Sodium 2 -Potassium 3 - Glucose 4 - Hemoglobin

2 -Potassium

A nurse is reinforcing preoperative teaching with a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse make? 1 - "You should make an appointment to donate blood 8 weeks prior to the surgery." 2 - "If you need an autologous transfusion, the blood your bother donates can be used." 3 - "You can donate blood each week if your hemoglobin is stable." 4 - "Any unused blood that is donated can be used for other clients."

3 - "You can donate blood each week if your hemoglobin is stable."

A patient who has congestive heart failure has a fluid excess with a weight gain of 1.5 pounds since yesterday and edematous ankles. Which provider's order has the highest priority? 1 - Maintain accurate intake and output 2 - Monitor skin for signs of breakdown 3 - Administer furosemide 20 mg PO once daily 4 - Obtain daily weight

3 - Administer furosemide 20 mg PO once daily Rational Administering the diuretic medication to help remove excess fluid and correct the imbalance has the highest priority, although all of the choices are important to your care of the patient. (1) Accurate intake and output is important, but it is more important to decrease the fluid load. (2) The skin is at increased risk and should always be monitored for breakdown. (4) Daily weight is important in monitoring fluid overload.

A nurse is inspecting a client's IV catheter insertion site and notes a hematoma. Which of the following actions should the nurse take? Select all 1 - Stop the infusion 2 - Apply alcohol to the insertion site 3 - Apply warm compress to the insertion site 4 - Elevate the client's arm 5 - Obtain a specimen for culture at the insertion site.

3 - Apply warm compress to the insertion site 4 - Elevate the client's arm

With a positive Chvostek's sign, you determine which electrolyte is low 1 - Potassium 2 - Sodium 3 - Calcium 4 - Magnesium

3 - Calcium

With fluid overload, you would hear which type of adventitious sounds 1 - Wheezes 2 - Hyperactive bowel sounds 3 - Crackles 4 - Absent bowel sounds

3 - Crackles

A nurse is preparing to initiate IV therapy for an older adult client. Which of the following actions should the nurse plan to take? 1 - Use a disposable razor to remove excess hair on the extremity 2 - Select the back of the client's hand to insert the IV catheter 3 - Distend the veins by using a blood pressure cuff 4 - Direct the client to raise his arm above his heart.

3 - Distend the veins by using a blood pressure cuff

A nurse is observing a client's IV infusion site. Which of the following findings should the nurse identify as indications of phlebitis? select all 1 - Pallor 2 - Dampness 3 - Erythema 4 - Coolness 5 - Pain

3 - Erythema 5 - Pain

A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? select all 1 - Temperature change from 37°C (98.6°F) pre-transfusion to 37.2°C (99.0°F) 2 - Blood pressure 178/90 mm Hg 3 - Heart rate change from 88/min pre-transfusion to 120/min 4 - Client report of itching 5 - Flushed appearance

3 - Heart rate change from 88/min pre-transfusion to 120/min 5 - Flushed appearance

What blood type is known as the "universal recipient" 1 - Type A 2 - Type B 3 - Type AB 4 - Type O

3 - Type AB

The normal sodium range is 1 - 110-155 mEq/L 2 - 115-125 mEq/L 3 - 125-135 mEq/L 4 - 135-145 mEq/L

4 - 135-145 mEq/L

A donor has AB- blood. Which patient or patients below can receive this type of blood safely? 1 - A patient with O- blood 2 - A patient with A- blood 3 - A patient with B- blood 4 - A patient with AB- blood

4 - A patient with AB- blood

You're educating a group of outpatients about ABO blood typing and compatibility. Which statement is INCORRECT? 1 - A person with B- blood can donate to people with either B- or AB- blood 2 - A person with B- blood can receive blood from donors with O- and B- blood 3 - A person with O- blood can donate to every blood type regardless of the RH factor 4 - A person with AB+ blood can only donate to other people with either AB+ or AB- blood

4 - A person with AB+ blood can only donate to other people with either AB+ or AB- blood

A patient that has a serum potassium level of 5.2 mEq/L would be expected to have which of the following symptoms/complaint? 1 - Muscle weakness 2 - Increased Thirst 3 - Abdomen cramps 4 - Fatigue and nausea

4 - Fatigue and nausea

Leakage of IV fluid from the vein into the tissue is which complication 1 - Phlebitis 2 - Obstruction 3 - Embolis 4 - Infiltration

4 - Infiltration

A nurse is caring for an older adult client who is dehydrated. Which of the following actions should the nurse take? 1 - Initiate fluid restrictions to limit the client's intake 2 - Observe for indications of peripheral edema 3 - Encourage the client to promote oxygenation by ambulating 4 - Monitor for orthostatic hypotension

4 - Monitor for orthostatic hypotension

A newly licensed nurse is assisting a charge nurse with the administration of a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? 1 - Ensure the insertion of an 18-gauge IV catheter in the client 2 - Verifies blood compatibility and expiration date of the blood with another PN 3 - Ensures the administration of dextrose 5% in 0.9% sodium chloride IV with the transfusion 4 - Obtain vitals signs every 15 min throughout the procedure.

4 - Obtain vitals signs every 15 min throughout the procedure.

Name three nursing assessments that would confirm circulatory fluid overload

Adventitious breath sounds, ascites, edema, bounding pulses, increased weight

A 26 year old female is 27 weeks pregnant with her second child. The woman is A-. As the nurse you know that: A. If the patient was A+ she would need to receive RhoGAM. B. The patient will need to receive RhoGAM during this visit to prevent hemolytic disease of the newborn. C. The baby will need to receive RhoGAM after it's born. D. Since the mother is A- the baby can be Rh positive, which could lead to an immune attack on the mother's body.

B. The patient will need to receive RhoGAM during this visit to prevent hemolytic disease of the newborn.

6. A person is O+. Select all the donor blood types this person could receive blood from: A. AB+ B. AB- C. O+ D. O- E. A- F. A+ G. B- H. B+

C. O+ D. O-

Which type of fluid is very harsh on the veins causing a more change of complications? Give one example of fluid

Hypertonic D10, D5 1/2 NS, D5 .9NS, DSLR

Name two medications that could contribute to fluid volume deficit

Lasix and Bumex

With circulatory fluid overload, would your specific gravity be high or low?

Low

What rate would you set the pump with the following order? 1L D5W + 20 mEq of KCL every 6 hours with a drop factor of 15 What would you set it if it was via gravity?

Pump - 167 mL/hour Drop - 42 gtt/min

List two medication for nausea

Zofran, relan, compazine

Bounding pulse are a sign of this fluid imbalance

fluid volume overload

A client who is postoperative is receiving IV fluids and a unit of whole blood. The nurse should observe the client for which of the following as an early sign of circulatory overload? 1 - ​Flushing ​2 - Dyspnea ​3 - Bradycardia ​4 - Vomiting

​2 - Dyspnea Rational 1 - The nurse should recognize flushing as a sign of an allergic reaction to a blood transfusion, not of circulatory overload. 2 - The nurse should monitor the respiratory status of a client who is receiving blood products for reactions to the blood product as well as circulatory overload. Circulatory overload causes dyspnea, cough, rales, tachycardia, and jugular vein distention. 3 - The nurse should recognize that circulatory overload causes tachycardia, not bradycardia. 4 - The nurse should recognize vomiting as a sign of a septic reaction to a blood transfusion, not of circulatory overload.

A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? 1 - A client who has nasogastric suctioning 2 - A client who has chronic constipation 3 - A client who has syndrome of inappropriate antidiuretic hormone 4 - A client who took an overdose of sodium bicarbonate antacids

1 - A client who has nasogastric suctioning Rational 1 - due to excessive gastrointestinal losses

A nurse is observing an older adult client who is receiving packed RBCs. Which of the following findings should the nurse identify as a manifestations of fluid volume excess and report to the charge nurse? Select all 1 - Dyspnea 2 - Edema 3 - Bradycardia 4 - Hypertension 5 - Weakness

1 - Dyspnea 2 - Edema 4 - Hypertension 5 - Weakness

A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should recognize which of the following findings is a manifestation of dehydration select all 1 - Hct 55% 2 - Serum osmolarity 260 mOsm/kg 3 - Serum sodium 150 mEq/L 4 - Urine specific gravity 1.035 5 - Serum creatinine 0.6 mg/dL

1 - Hct 55% 3 - Serum sodium 150 mEq/L 4 - Urine specific gravity 1.035 Rational Hct - 42-52% men & 37-47% women serum osmolarity - 285-295 mOsm/kg Sodium - 136-145 mEq/L Urine specific gravity - 1.005-1.03 Serum creatine - 0.6-1.3 mg/dL

A nurse is collecting data for a client who has fluid volume deficit. Which of the following is an expected findings? 1 - Increased urine specific gravity 2 - Decreased hematocrit 3 - Decreased BUN 4 - Increased urine ketones

1 - Increased urine specific gravity Rational 1 - The client who has an increased urine specific gravity with low urine output is an expected finding of fluid volume deficit. 2 - The client who has an increased, not decreased, hematocrit is an expected finding of fluid volume deficit. 3 - The client who has an increased, not decreased, BUN is an expected finding of fluid volume deficit. 4 - The client who has increased ketones in the urine is an expected finding of diabetic ketoacidosis rather than fluid volume deficit.

What are the potentially serious complications of IV therapy? Select all that apply. 1 - Infiltration 2 - Infection 3 - Catheter embolus 4 - Site irritation resulting from tape

1 - Infiltration 2 - Infection 3 - Catheter embolus Rational Infiltration, infection, and catheter embolus are potentially serious complications of IV therapy. Site irritation is most likely not a serious, but a localized, reaction caused by tape.REF: Page 709, Table 36 2

Diabetic Ketoacidosis can lead to which acid base imbalance? 1 - Metabolic acidosis 2 - Respiratory acidosis 3- Metabolic alkalosis 4 - Respiratory alkalosis

1 - Metabolic acidosis

Blood has the same tonicity as which crystalloid? 1 - Hypertonic 2 - Hypotonic 3 - Isotonic 4 - Vesitonic

3 - Isotonic

When a patient is experiencing fluid volume deficit, it is easier to find appropriate vein for venipuncture true/false

False

Name 2 isotonic fluids

0.9 NS and Lactated Ringers

A nurse is collecting data from a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes. Which of the following findings should the nurse identify as manifestation of fluid volume deficit? select all 1 - Decreased skin turgor 2 - Concentrated urine 3 - Bradycardia 4 - Low-grade fever 5 - Tachypnea

1 - Decreased skin turgor 2 - Concentrated urine 4 - Low-grade fever 5 - Tachypnea

A nurse is assisting in the preparation of a blood transfusion for a client and receives the unit of packed RBCs at 1610. By which of the following times must the transfusion begin? 1 - 1650 2 - 1640 3 - 1700 4 - 1710

2 - 1640 Rational 1- The nurse should initiate the blood transfusion within 30 minutes after obtaining the blood from the blood bank. 2 - The nurse should initiate the blood transfusion within 30 minutes after obtaining the blood from the blood bank. 3 - The nurse should initiate the blood transfusion within 30 minutes after obtaining the blood from the blood bank. 4 - The nurse should initiate the blood transfusion within 30 minutes after obtaining the blood from the blood bank.

A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse anticipate a prescription for fluid restriction? 1 - A client who has a new diagnosis of adrenal insufficiency 2 - A client who has heart failure 3 - A client who is receiving treatment for diabetic ketoacidosis 4 - A client who has abdominal ascites.

2 - A client who has heart failure

Hemoglobin and hematocrit will elevate with this fluid imbalance? 1 - Fluid volume overload 2 - Fluid volume deficit

2 - Fluid volume deficit

What type of fluid is plasma? 1 - Intracellular 2 - Intravascular 3 - Interstitial

2 - Intravascular

If a child is dehydrated what type of cardiac rate will they have? 1 - Bradycardia 2 - Tachycardia 3 - Tachypnea 4 - Bradypnea

2 - Tachycardia

What is the most accurate measurement for fluid gain or loss? 1 - Accurate I & O 2 - Weights 3- Edema measurements 4 - Urine specific gravity

2 - Weights

Which of the following is an Isotonic fluid? 1 - D5 0.9% NS 2 - D5 0.45% NS 3 - 0.9% NS 4 - 0.45% NS

3 - 0.9% NS

A patient is to receive 1,000 mL of 5% dextrose in lactated Ringer's over 8 hours. Using tubing with a drop factor of 15 gtt/mL, the nurse should regulate the fluid to infuse at how many drops per minute? _____________________ gtt/min

31 gtt/min

Your patient is scheduled for surgery and is ordered to be typed and crossmatched. The lab result shows your patient has B- blood. What type of blood can the patient receive during surgery, if needed? A. B- B. B+ C. A- D. A+ E. O+ F. O- G. AB+ H. AB-

A. B- F. O-

True or False: Agglutination can occur when Type A blood is given to a person with Type O blood. A. True B. False

A. True

If your patient is experiencing circulatory fluid overload, will their electrolytes be elevated or decreased?

Decreased (Low)

Hypotonic fluids cause the cell to:

Expand/Swell

True or False: Patients who are Rh positive can only receive Rh positive blood, while patients who are Rh negative can only receive blood from donors who are Rh negative. True False

False

Name two meds for loose stools

Pepto bismol, kaopectate, lomoti

What organ is used to regulate fluids

kidneys

What should the nurse monitor when a patient is receiving a diuretic regularly? Select all 1 - Skin turgor and integrity 2 - Daily weight 3 - Electrolyte status 4 - Mentation

1 - Skin turgor and integrity 2 - Daily weight 3 - Electrolyte status Rational (1) Skin turgor and integrity should be monitored to ensure that the patient does not become dehydrated from excessive dieresis. (2) Weight loss will indicate the degree of effectiveness of the diuretic in decreasing the fluid overload. (3) Electrolyte status must be monitored to catch any electrolyte imbalance caused by the diuretic's effect. (4) Regular doses of diuretic should not affect mentation.

This type of dehydration in children is based on which? 1 - Sodium levels 2 - Potassium levels 3 - Chloride levels 4 - Calcium levels

1 - Sodium levels

Which food should be suggested to be included in the diet of a patient who is taking a potassium wasting diuretic? 1 - Spinach 2- Red meat 3 - Grapefruit 4 - Oranges

1 - Spinach

A post surgical patient consumed a cop of ice chips filled to the 120 mL, 2 oz of broth, and 120 mL of water. In addition, 750 mL of intravenous fluids were infused. The patient voided 650 mL and vomited 100 mL What is the total intake for this patient? ______mL What is the total output for this patient? _______ mL

Intake - 990 Output - 750

The patient has been prescribed a non-potassium-sparing diuretic. Which food(s) should the nurse suggest the patient include in his diet? (select all that apply) Select all that apply. 1 - Eggs 2 - Bananas 3 - Tomatoes 4 - Aged cheese 5 - Baked potato with skin

2 - Bananas 3 - Tomatoes 5 - Baked potato with skin Rational Foods high in potassium should be included in the patient's diet if he is taking a diuretic that does not conserve potassium. Bananas, tomatoes, and baked potatoes with the skin are just three foods that are high in potassium. Eggs and aged cheese are not potassium-rich foods.

Which type of fluid attempts to rehydrate the cell? Give one example of this fluid type

Hypotonic .45 NS & .225 NS

A patient needs 2 units of packed red blood cells. The patient is typed and crossmatched. The patient has A+ blood. As the nurse you know the patient can receive what type of blood? Select all 1 - A- 2 - O- 3 - O+ 4 - A+ 5 - AB- 6 - AB+ 7 - B+

1 - A- 2 - O- 3 - O+ 4 - A+

When completing a physical assessment of a patient you note that the IV site is red, slightly swollen, and painful. What should you do first. 1 - Remove the IV 2 - Notify the physician 3 - Slow down the rate of the irritating IV fluids 4 - irrigate the IV catheter

1 - Remove the IV

When choosing an IV site, name the 3 considerations you as the nurse will consider

- The purpose of the therapy - The purposed duration of the therapy - The condition and locatin of the usable veins

Which patient(s) can be considered at high risk for fluid and electrolyte imbalance select all 1 - A 45-year-old woman with thyroid crisis 2 - A 35-year-old trauma victim on a ventilator 3 - A 60-year-old woman with temperature of 99.6°F (37°C) 4 - A 70-year-old man on anticoagulant therapy 5 - A 30-year-old women complaining of persistent diarrhea

1 - A 45-year-old woman with thyroid crisis 2 - A 35-year-old trauma victim on a ventilator 5 - A 30-year-old women complaining of persistent diarrhea Rational (1, 2, 5) Thyroid crisis, use of a ventilator, and diarrhea can lead to fluid loss affecting electrolyte balance. (3, 4) A low-grade temperature and anticoagulant therapy do not lead to electrolyte imbalances.

The nurse must assess for complications of IV therapy. Signs of common complications include: (Select all that apply.) 1. Swelling and coolness at the site. 2. Redness along the vein. 3. Pale skin at the insertion site. 4. Immobility of the extremity. 5. Erythema and tenderness.

1. Swelling and coolness at the site. 2. Redness along the vein. 3. Pale skin at the insertion site. 5. Erythema and tenderness. Rational Swelling, coolness, or pale skin at the insertion site is a sign of an infiltration of a nonirritating IV fluid. Erythema and tenderness are signs of infiltration of an irritating medication or fluid. Redness along the vein can occur with a very irritating medication. Redness and tenderness could also signal a localized infection. (4) Use of an armboard could decrease the patient's mobility, but armboards are generally not necessary if the IV is properly secured and if the antecubital site is avoided. (6) Vomiting and diarrhea are not usually directly associated with IV fluid therapy or catheter insertion.

A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride 1000 mL to infuse at 100 mL/60. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? _____________________ gtt/min

100 gtt/min

Your patient has chronic anemia and is admitted for a blood transfusion. Which drop factor should be used for the administration? 1 - a burette 2 - Macrodrops (10 gtt/mL) 3 - Microdrops (60 gtt/mL) 4 - Regular drop (20 gtt/mL)

2 - Macrodrops (10 gtt/mL)

Mannitol is given to reduce cerebral edema in patients with a head injury because the osmotic pressure draws water out of the cells. What type of solution is mannitol? 1 - Isotonic 2 - Hypotonic 3 - Hypertonic 4 - Eutonic

3 - Hypertonic Rational Hypertonic solutions have a greater tonicity than blood. They are used to replace electrolytes and, when given as concentrated dextrose solutions, produce a shift in fluid from the intracellular compartment to the extracellular compartment. Isotonic solutions have the same concentration as blood. Hypotonic solutions contain less solute than extravascular fluid. Eutonic does not refer to solutions.REF: Page 699

A nurse is planning care for a child who has severe diarrhea. Which of the following actions is the nurse's priority? 1 - Introduce a regular diet. 2 - Rehydrate. 3 - Maintain fluid therapy. 4 - Assess fluid balance.

4 - Assess fluid balance. Rational 1 - It is important to introduce a regular diet to prevent weight loss, but this is not the first action the nurse should take. 2 - It is important to rehydrate to maintain fluid balance, but this is not the first action the nurse should take. 3 - It is important to maintain fluid therapy to maintain fluid balance, but this is not the first action the nurse should take. 4 - The first action the nurse should take is to assess fluid balance to determine severity of the dehydration.

A nurse manager is reviewing the facility's policies for IV therapy with the members of the team. The nurse manager should remind the team that which of the following techniques helps minimize the risk of catheter embolism? 1 - Performing hand hygiene before and after IV insertion 2 - Rotating IV sites at least every 72 hr 3 - Minimizing tourniquet time 4 - Avoiding reinserting the needle into the IV catheter.

4 - Avoiding reinserting the needle into the IV catheter. Rational 1 - prevent infection 2 - prevent phlebitis 3 - prevent hematoma

A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? select all 1 - Distended neck veins 2 - Hyperthermia 3 - Tachycardia 4 - Syncope 5 - Decreased skin turgor

3 - Tachycardia 4 - Syncope 5 - Decreased skin turgor

In which circumstance would the use of a burette be advised as a safety device? 1. A trauma patient needs several units of packed red blood cells. 2. The patient needs IV fluids, but no infusion pump is available. 3. An infant is at risk for IV fluid volume overload. 4. A confused patient keeps trying to unplug the infusion pump.

3. An infant is at risk for IV fluid volume overload. Rational The burette provides a way to measure the exact amount of IV fluid that could flow into the infant. (1) The burette would not be used in the case of a trauma patient. (2) You could use a burette for a patient who needs IV fluids, but remember that the burette will hold a limited amount of fluid and you will have to refill the burette frequently, so it may cause more work. (4) If a patient unplugs an infusion pump, the pump is likely to continue on a battery. When the battery runs low, an alarm will begin to sound. If the battery depletes, the IV will not infuse. Use of a burette in this case serves no purpose.

A patient returns from physical therapy, and her IV has a very sluggish flow, but it was functioning well before going to physical therapy. What is the priority nursing action? 1. Call the physical therapist and ask if anything happened to the IV during the treatment session. 2. Discontinue the IV and restart the IV at a new site. 3. Assess the IV insertion site and tubing and try repositioning the extremity. 4. Use a heparin flush to clear the line.

3. Assess the IV insertion site and tubing and try repositioning the extremity. Rational Assess the site and try to troubleshoot; repositioning the extremity is one solution. Also, try to aspirate for a small blood clot. (See Table 36-3 for other troubleshooting tips.) (1) PT should have called you if something happened to the patient that created a potential danger. It is unlikely that you will gain any useful information by calling, but you could if you suspect an unusual circumstance. (2) Discontinue and restart, if you have tried to reestablish flow without success. (4) Use of a heparin flush requires a medical order.

The patient is receiving a blood transfusion and develops a fever, shortness of breath, and a diffuse rash within 10 minutes after the start of the transfusion. What is the priority action? 1. Take vital signs and call the primary care provider. 2. Place the patient in a supine position and start oxygen. 3. Stop the blood and change the IV tubing. 4. Slow the blood and check the vital signs.

3. Stop the blood and change the IV tubing. Rational First stop the blood and change the IV tubing so that the patient does not receive the blood that is within the tubing. (1, 2, 3) Taking the vital signs, starting oxygen, and calling the primary care provider are appropriate actions. The high Fowler position is better initially for oxygenation; if the patient's vital signs suggest shock, the supine position is used. Slowing the blood is not an adequate measure if a transfusion reaction is in progress.

A nurse is collecting data from a client who is dehydrated due to fluid volume deficit. Which of the following findings should the nurse expect? 1 - Moist skin 2 - Distended neck vein 3 - Increased urinary output 4 - Thready pulses

4 - Thready pulses

What blood type is known as the "universal donor" 1 - Type A 2 - Type B 3 - Type AB 4 - Type O

4 - Type O

List 3 nursing interventions for circulatory fluid overload

Elevate HOB, Administer oxygen, low sodium diet, administer prescribed medications (diuretics), implement fluid restrictions

What is used for an anesthetic for IV

Emplac cream and saline

Concentrated urine is a sign of this fluid imbalance

Fluid volume deficit

List 3 potential causes for fluid volume deficit

GI loss due to vomiting, diarrhea, NG suctioning, excessive diaphoresis, renal therapy, hemorrhage, NOP status

Which lab is elevated with dehydration that is a landmark assessment

Hematocrit

Name 3 ways to engorge veins prior to cannulation

Tapping, warm packs, below level of heart, clenching fists

A nurse is observing the IV catheter insertion site of a client who is receiving continuous IV therapy. Which of the following manifestations should the nurse identify as an indication that the client has developed phlebitis? 1 - Erythema 2 - Pallor 3 - Coolness 4 - Drainage

1 - Erythema Rational 1 - Erythema (redness), pain, warmth, and swelling indicate phlebitis. 2 - Pallor indicates infiltration. 3 - Coolness indicates infiltration. 4 - If it is purulent, drainage at the insertion site indicates infection. If it is fluid, it could indicate infiltration or extravasation.

Jugular vein distention occurs with fluid volume deficit True/False

False It is will fluid volume overload

A nurse is caring for an 8-month-old infant who is receiving intravenous (IV) fluids via a 24-gauge catheter. Which of the following statements by the client's mother indicates that the nurse should check the site for signs of infiltration? 1 - "My baby's fingers are looking swollen." 2 - "The tape is coming off the IV needle." 3 - "There's blood backing up my baby's IV tubing." 4 - "There's a long red streak up my baby's arm."

1 - "My baby's fingers are looking swollen." Rational 1 - Edema, both distal and proximal to the site, as well as dependent edema, might indicate an infiltrated IV. An infiltrated IV in the hand will likely present as swollen fingers. 2 - This is not a sign of infiltration, but the situation does require the nurse's attention. 3 - This is not a sign of infiltration. Blood can back up in the tubing as a result of increased vascular pressure. 4 - Streaking of the vein is a sign of phlebitis, rather than infiltration.

A nurse is discontinuing an IV infusion. For which of the following reasons is it important to verify and document the integrity and condition of the IV catheter? 1 - A broken-off catheter tip indicates the risk for an embolus. 2 - Catheter erosion indicates that it was left in place too long. 3 - Blood within the catheter could indicate clot formation. 4 - Discoloration of the catheter could be a sign of phlebitis.

1 - A broken-off catheter tip indicates the risk for an embolus. Rational 1 - The tip of the catheter can break off, thus creating an embolus. To limit the movement of the embolus, the nurse should apply a tourniquet high on the extremity where the IV line was located and notify the provider immediately. 2 - This finding is highly unlikely, as IV catheters are made of durable materials that would not disintegrate during the period of time an IV catheter is in place. 3 - It is typical to find blood inside the catheter on removal. If a clot is observed at the tip of the catheter, then clotting has taken place. 4 - Phlebitis, the inflammation of a vein, would not cause discoloration of the catheter.

A nurse is collecting data from a client who has an intravenous (IV) catheter in her left forearm. The nurse should identify that which of the following findings indicates the client has phlebitis? 1 - The client's skin is cool to the touch around the insertion site. 2 - Purulent drainage is noted at the catheter insertion site. 3 - The client has cyanosis of the nail beds and pain along the vein. 4 - The vein is hard and the skin around the insertion site is red.

4 - The vein is hard and the skin around the insertion site is red. Rational 1- Coolness of the skin around the insertion site indicates infiltration or extravasation of the IV site. 2 - Purulent drainage noted at the catheter insertion site indicates a local infection. 3 - Pain along the vein with a weak, rapid pulse and cyanosis of the nail beds indicates a catheter embolus. 4 - An insertion site that is red, swollen, and tender with a vein that is hard and palpable indicates phlebitis.

A nurse initiating peripheral IV therapy should use: 1 - the antecubital site. 2 - sterile technique. 3 - three attempts before asking another nurse to perform the venipuncture. 4 - catheter stabilization device to secure the catheter.

4 - catheter stabilization device to secure the catheter. Rational The catheter stabilization device is used after insertion of a peripheral IV and has a see-through area to view the IV site. The antecubital site is not used extensively as a result of increased risk of damage to the vein and potential muscle or nerve damage. Asepsis must be maintained when performing a venipuncture. If an IV cannot be initiated in two attempts, another nurse should be asked to complete the task.REF: Page 714

To understand what type of fluid a patient needs, the LPN/LVN should understand that the term semipermeable membrane indicates that: 1 - the membrane is only a temporary structure. 2 -only electrically charged particles may pass through the membrane. 3 - the membrane does not allow for the passage of anything but water. 4 - the membrane allows some particles to pass through and prohibits the passage of others.

4 - the membrane allows some particles to pass through and prohibits the passage of others. Rational A semipermeable membrane allows fluid to move between the interstitial and intracellular compartments and between the interstitial and intravascular compartments by osmosis. Semipermeable membranes are permanent structures. Passage through this type of membrane does not require electrically charged particles. More than just water can pass through semipermeable membranes.

What drop factor is used for critical patient sand pediatrics

60 gtt/min

An older adult man is admitted for severe disorientation, confusion, and general weakness. His spouse reports that he is not able to tolerate any food or fluids and has had several episodes of vomiting and diarrhea. Which imbalance is the patient most likely experiencing? 1 - Hypokalemia 2 - Metabolic acidosis 3 - Hyponatremia 4 - Respiratory alkalosis

Correct Answers: 1, 3 ?????? Rational (1) Diarrhea and vomiting cause deficits in potassium. (3) Vomiting may cause a deficit in sodium. (2) Metabolic acidosis is not a result of vomiting and diarrhea. (4) Vomiting and diarrhea do not signify respiratory alkalosis.

What are types of solutions that contain small molecules that flow easily across the cell membranes allowing for the transfer from the bloodstream into the cells and body tissues?

Crystalloids - Name the three types

What is the difference between fluid volume deficit and dehydration

Dehydration is the loss of fluid FVD is loss of fluid and electrolytes

Patients with circulatory fluid overload experience Paroxysmal nocturnal orthopnea True/False

True - difficultly with breathing while laying down

Describe the symptoms of fluid volume deficit in relation to -Urine -Skin -Pulse

Urine - oliguria and concentrated Skin - dry, and poor turgor Pulse - tacky and thready

What rule of thumb should you use when choosing the IV cannula size?

Use the smallest size to get the job done efficiently

A nurse is monitoring a client who is dehydrated. Which of the following laboratory findings should the nurse report to the provider? 1 - BUN 25 mg/dL 2 - Creatinine 0.9 mg/dL 3- Urine specific gravity 1.028 4- Hematocrit 45%

1 - BUN 25 mg/dL Rational 1 -The expected reference range for BUN is 10 to 20 mg/dL. When a client is dehydrated, there is decreased blood flow to the kidneys, which causes a buildup of BUN. 2 - The expected reference range for creatinine is about 0.7 to 1.0 mg/dL. This finding is within that range and does not need to be reported. 3 - The expected reference range for urine specific gravity is 1.005 to 1.030. Although this is at the high end of that range, it is within the expected range and does not need to be reported. The nurse should expect a client who is dehydrated to have a urine specific gravity above the expected reference range. 4 - ​The expected reference range for BUN values is 37% to 47% for females and 42% to 52% for males. This finding is within that range and does not need to be reported. The nurse should expect a client who is dehydrated to have an increased hematocrit.

A nurse is collecting data from an older adult who is postoperative and receiving IV therapy at 125 mL/hr. The nurse should identify that which of the following findings indicates the client is experiencing fluid volume overload? Select all 1 - Bounding radial pulse 2 - Periorbital edema 3 - Swelling at the IV site 4 - Flat neck veins when supine 5 - Crackles in lung bases

1 - Bounding radial pulse 2 - Periorbital edema 5 - Crackles in lung bases Rational 1 - Bounding radial pulse is correct. Pulses that are full and bounding when palpated are an indication of fluid volume overload, as pulse volume is related to circulating fluid volume. 2 - Periorbital edema is correct. Fluid volume overload causes excess fluid to collect in tissues around the eyes (periorbital edema) and in dependent extremities, such as feet, ankles, and legs. 3 - Swelling at the IV site is incorrect. Swelling at the IV site is an indication of IV infiltration, but is not a manifestation of fluid overload. Flat neck veins when supine is incorrect. 4 - Flat neck veins when the client lies in a supine position indicates dehydration rather than excess fluid volume. In fluid volume excess, the nurse should assess for distended neck veins when the client is lying in a supine position. 5 - Crackles in lung bases is correct. The nurse should monitor the client for fluid volume excess by observing the client's breathing patterns and auscultating the lungs. The client develops tachypnea, a moist cough and crackles in the lungs during auscultation.

The nurse is caring for a patient with pitting edema to the lower extremities. Which intervention(s) for pitting edema are the nurse likely to include in the nursing care plan of this patient? (select all that apply) Select all that apply. 1 - Daily weight 2 - High-calorie diet 3 - Intake and output record 4 - Skin care and mouth care 5 - Edema assessment using an edema scale every shift

1 - Daily weight 3 - Intake and output record 5 - Edema assessment using an edema scale every shift Rational Measuring the patient's weight daily, monitoring the intake and output, and assessing the edema using the proper scale every shift are methods that will assist the nurse in properly assessing and monitoring any changes in the patient's edema.

A nurse is reviewing the medical record of a toddler who has moderate dehydration. Which of the following findings should the nurse expect? 1 - Increased respiratory rate 2 - Decreased heart rate 3 - Increased platelet count 4- Decreased hematocrit

1 - Increased respiratory rate Rational 1 - A child who has moderate dehydration will have an increased respiratory rate. Evidence-based practice suggests that an abnormal respiratory pattern is helpful in predicting the extent of dehydration in a child 2 - A child who has moderate dehydration will have an increased heart rate. 3 - Dehydration does not have an impact on platelet counts. Iron deficiency anemia and malignant disorders can cause an increased platelet count. 4 - Dehydration increases hematocrit levels. Anemia and leukemia cause a decrease in hematocrit levels.

Which route of administration results in a drug instantly being available for circulation to all tissues? 1 - Intravenous (IV) 2 - Subcutaneous (SC) 3 - Intradermal (ID) 4- Vaginal application

1 - Intravenous (IV) Rational IV route is the main method of supplying the patient with fluids and medications when the patient is unable to take them orally. The IV route has the advantage of making drugs or fluid instantly available for circulation to all tissues. SC injection does not supply substances as rapidly as the IV route. ID injection does not supply substances as rapidly as the IV route. Vaginal application delivers different types of medications and is not as rapid as the IV route.REF: Page 699

A patient has ingested a large amount of a cathartic containing magnesium. The nurse should observe for which symptom of hypermagnesemia? 1 - Muscle weakness 2 - Hyperactive reflexes 3 - Respirations of 30 breaths/min 4 - Insomnia, twitching, and tremors

1 - Muscle weakness Rational A patient with excessive magnesium level would have muscle weakness, not hyperactive reflexes. Excessive magnesium level would depress the respiratory rate to fewer than 12 breaths/min, not 30. A low magnesium level, rather than a high magnesium level, would cause insomnia, twitching, and tremors.

A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions should the nurse take first? 1 - Stop the transfusion. ​2 - Cover the client with a blanket. ​3 - Notify the provider. ​4 - Assess the skin for a rash.

1 - Stop the transfusion. Rational 1 - The greatest risk to this client is injury from a transfusion reaction; therefore, the priority intervention is to stop the infusion. 2 - ​The nurse should cover the client with a blanket if chilling, but another action is the priority. 3 - ​The nurse should notify the provider, but another action is the priority. 4 - ​The nurse should assess the skin for a rash, but another action is the priority.

A nurse is preparing to administer diphenhydramine to a client who is to receive a blood transfusion. The nurse should explain that the purpose of diphenhydramine is to prevent which of the following manifestations of a transfusion reaction? 1 - Urticaria 2 - Fever 3 - Dyspnea 4 - Low-back pain

1 - Urticaria Rational 1 - Antihistamines such as diphenhydramine are administered prior to blood administration to prevent mild allergic reactions such as itching, flushing, and hives. 2 - Fever is a manifestation of a nonhemolytic transfusion reaction, which is caused by antibodies to the donor's WBCs. Leucocyte-poor blood products can be used for clients who have a history of nonhemolytic transfusion reactions. 3 - Dyspnea, cough, headache, and distended neck veins are manifestations of fluid overload. The nurse should ensure that the rate of the transfusion is based on the client's size and overall condition. 4 - Low-back pain is a clinical manifestation of an acute hemolytic reaction. The nurse should ensure that strict compliance with the agency procedures throughout the blood transfusion process to prevent administration of the wrong unit of blood to the client

A nurse has just inserted a peripheral IV catheter for a continuous infusion. To secure the catheter, the nurse should 1 - leave the connection between the hub and the tubing uncovered. 2 - wrap tape around the circumference of the patient's arm. 3 - tape the IV catheter's hub securely to the patient's skin. 4 - place a piece of paper tape over the insertion site.

1 - leave the connection between the hub and the tubing uncovered. Rational 1- This makes it possible to replace the tubing without removing the dressing. 2 - This can impair circulation, especially if the arm swells. 3 - This can exert pressure on the skin. It is better to place a small gauze pad under the hub of the IV catheter to elevate it and thus avoid direct pressure. 4 - This blocks visibility of the insertion site.

A nurse is assisting to monitor a client who is receiving a blood transfusion. Which of the following should the nurse report to the charge nurse as an indication of an allergic blood transfusion reaction? 1 - ​Generalized urticaria ​2 - Blood pressure 184/92 mm Hg ​3 - Distended jugular veins ​4 - Bilateral flank pain

1 - ​Generalized urticaria Rational 1 - ​The nurse should recognize urticaria as an indicator of an allergic transfusion reaction. Other clinical manifestations include itching and possible signs of anaphylaxis. 2 - ​Hypertension may be an indication of circulatory overload rather than an allergic reaction. 3 - ​Distended jugular veins may be an indication of circulatory overload rather than an allergic reaction. 4 - ​Bilateral flank pain may be an indication of a hemolytic transfusion reaction rather than an allergic reaction.

A nurse is assisting in the care of a client who is to receive a blood transfusion. Prior to the transfusion, which of the following staff members should the nurse select to assist her in checking the blood? 1 - ​Oncology nurse ​2 - Assistive personnel ​3 - Senior nursing student ​4 - Phlebotomist

1 - ​Oncology nurse Rational 1 - The nurse should select the oncology nurse or a provider as a qualified person to double check the blood prior to transfusion. 2 - The nurse should not select the assistive personnel as a qualified person to double check the blood prior to transfusion. Only another nurse or provider is qualified. 3 - The nurse should not select the senior nursing student as a qualified person to double check the blood prior to transfusion. Only another nurse or provider is qualified. 4 - The nurse should not select the phlebotomist as a qualified person to double check the blood prior to transfusion. Only another nurse or provider is qualified.

A nurse is adding a secondary piggyback to the patient's existing IV. To use the gravity system, the nurse should hang: 1. The piggyback bag higher than the maintenance IV bag. 2. The maintenance IV bag at the same height as the piggyback bag. 3. The piggyback bag and the maintenance IV bag using Y tubing. 4. The maintenance IV bag after the piggyback bag is completed.

1. The piggyback bag higher than the maintenance IV bag. Rational If the piggyback bag is higher than the maintenance bag, the fluid from the piggyback will flow in first. As soon as the piggyback is empty, fluid from the maintenance bag will begin. Recall that the fluid level in the piggyback bag must be higher throughout the entire infusion. (2) If the maintenance bag and the piggyback bag are at the same height, the fluid from the maintenance bag can flow up into the piggyback (if there is no backflow valve within the tubing). The bag that has the greater volume will flow first. As the volume of the greater bag depletes, the less the bag will begin to flow. Eventually both would infuse, but the two bags of fluid would be competing for flow. (3) Y-tubing is generally reserved for blood product infusion. It would be an inappropriate waste of a more expensive tubing (which has a special filter). (4) You can manually hang or restart the maintenance IV after the piggyback is completed. In fact, if fluid overload is an issue and you do not have an infusion pump, you may choose to do this; however, this completely eliminates the advantage of having a piggyback setup.

The health care provider has prescribed an isotonic IV solution administration for a patient. The nursing student correctly identifies which solutions as being isotonic? 1 - Sterile distilled water, 5% dextrose in water 2 - 0.9% normal saline, lactated Ringer's solution 3 - 5% dextrose in 0.45% normal saline, Ringer's solution 4 - 10% dextrose in water, 5% dextrose in 0.9% normal saline

2 - 0.9% normal saline, lactated Ringer's solution Rational An isotonic solution is equal in concentration to that of body fluids. D5W is considered isotonic, but sterile distilled water is hypotonic and is never used as an IV solution. Ringer's solution is isotonic, but D5 in ½ normal saline is a hypertonic solution. 10% dextrose is hypertonic.

A nurse is assisting with the care of a client who is receiving a blood transfusion. Which of the following findings should the nurse report to the provider? 1 - Capillary refill of the lower extremities less than 2 seconds 2 - Difficulty breathing 3 - Temperature of 36.8° C (98.3° F) 4 - Platelet count 170,000 mm³

2 - Difficulty breathing Rational 1 - Capillary refill less than 2 seconds indicates that a gross assessment of the circulation to the extremities is adequate. 2 - Dyspnea, cough, pulmonary congestion, headache, tachycardia, and distended neck veins can indicate the client is experiencing fluid overload. The nurse should report this finding to the provider. 3 - Temperature of 36.8° C (98.3° F) is within the expected reference range. 4 - A platelet count of 170,000/mm³ is within the expected reference range.

A nurse is assisting with the care of a client who is hypovolemic due to blood loss following a motor-vehicle crash and needs a blood transfusion immediately. The nurse should anticipate a prescription for which of the following IV solutions while awaiting blood from a type and cross-match? 1 - 0.45% sodium chloride 2 - Lactated Ringer's 3- Dextrose 10% in water 4 - 0.33% sodium chloride

2 - Lactated Ringer's Rational 1 - 0.45% sodium chloride is hypotonic and is not used to treat hypovolemia due to blood loss. 2 - Lactated Ringer's solution is administered to the client who has hypovolemic shock because it contains electrolytes and expands plasma volume. 3 - Dextrose 10% in water is hypertonic and is not used to treat hypovolemia due to blood loss. 4 - 0.33% sodium chloride is hypertonic and is not used to treat hypovolemia due to blood loss.

The nurse caring for a patient with metabolic acidosis would expect the patient to exhibit which symptom? 1 - Flushing 2 - Lethargy 3 - Hyperactivity 4 - Shallow, slow respirations

2 - Lethargy Rational The symptoms of metabolic acidosis include weakness, lethargy, headache, and confusion. If the acidosis is not relieved, these symptoms progress to stupor, unconsciousness, coma, and death. Flushing, hyperactivity, and shallow, slow respirations are not symptoms of metabolic acidosis.

A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction? 1 - Urticaria 2 - Low back pain 3 - Pulmonary congestion 4 - Vomiting

2 - Low back pain Rational 1 - The nurse should monitor for urticaria to identify a mild allergic reaction to a blood transfusion. The nurse can administer an antihistamine. 2 - The nurse should monitor for low back pain, chills, fever, tachycardia, hypotension, and acute jaundice to identify an acute hemolytic reaction to a blood transfusion. 3 - The nurse should monitor for cough, dyspnea, pulmonary congestion, headache, and distended neck veins to identify circulatory overload. 4 - The nurse should monitor for vomiting, diarrhea, high fever, rapid onset of chills, and marked hypotension to identify sepsis.

A nurse initiating a peripheral IV infusion punctures the skin and selected vein and observes blood return in the flashback chamber of the IV catheter. Which of the following actions should the nurse perform next? 1 - Secure the catheter to the skin with a transparent dressing. 2 - Lower the catheter until it is almost flush with the skin. 3 - Advance the catheter about 1/4 inch into the vein. 4 - Remove the stylet slowly from the lumen of the catheter

2 - Lower the catheter until it is almost flush with the skin. Rational 1 - This is one of the final steps in the process. Securing the catheter prior to stabilizing it could, for example, result in dislodgement or injury to the patient. 2 - Lowering the angle and then advancing the catheter slightly facilitates full penetration of the wall of the vein, thus placing the catheter within the vein's lumen and making it easy to advance the catheter off the stylet. 3 - Advancing the catheter at this point in the insertion process might puncture the opposite wall of the vein. 4 - The stylet should remain in place until the catheter is positioned further within the vein.

The new patient is on the floor has been diagnosed with gastroenteritis. What should the most critical level to assess? 1 - Blood glucose 2 - Potassium 3 - Calcium 4 - Sodium

2 - Potassium Gastroenteritis causes nausea and vomiting as well as diarrhea that depletes potassium in the body. (1) Blood glucose may be altered but is not the most immediate danger. (3) Calcium is not quickly depleted by nausea and vomiting. (4) Sodium is not quickly depleted by nausea and vomiting.

A nurse is caring for a 4-year-old child who has dehydration. Which of the following findings should the nurse identify as the priority? 1 - Blood glucose 110 mg/dL 2 - Potassium 2.5 mEq/L 3 - Sodium 142 mEq/L 4 - Urine specific gravity 1.025

2 - Potassium 2.5 mEq/L Rational 1 - The expected reference range for a fasting blood glucose level is 70 to 110 mg/dL. 2 - The expected reference range for a potassium level is 3.4 to 4.7 mEq/L. The nurse should identify this finding as the priority because hypokalemia can lead to cardiac dysrhythmias or cardiac arrest. 3 - The expected reference range for a child's potassium level is 136 to 145 mEq/L. 4 - The expected reference range for urine specific gravity is between 1.015 and 1.025.

A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first? 1 - Obtain vital signs. 2 - Stop the transfusion. 3- Notify the registered nurse. 4 - Administer diphenhydramine.

2 - Stop the transfusion. Rational 1 - The nurse should obtain vital signs of the client who develops signs of a transfusion reaction such as itching and hives in order to monitor the client's condition; however, another action is the priority. 2 - The client who develops itching and hives during a transfusion is at greatest risk for cardiovascular collapse resulting from the allergic reaction to the blood products; therefore, the priority action the nurse should take is to stop the transfusion. 3 - The nurse should notify the registered nurse if the client develops hives and itching so a more in-depth assessment can be made; however, this is not the priority action. 4 -The nurse should administer diphenhydramine as prescribed to minimize the allergic reaction to the blood products; however, another action is the priority.

Following change-of-shift report, a nurse enters the room of a client who is receiving packed RBCs. Which of the following findings should the nurse identify as appropriate for blood product transfusion? 1 - The client is receiving the transfusion through a 24-gauge IV catheter. 2 - The blood is connected to a Y-type infusion set with 0.9% sodium chloride. 3 - The blood has been infusing consistently for 5 hr. 4 - The client is receiving a piggyback antibiotic medication through the closest blood tubing port.

2 - The blood is connected to a Y-type infusion set with 0.9% sodium chloride. Rational 1 - The nurse should recognize that a large-bore IV catheter, such as an 18- or 20-gauge, should be used for blood product administration. A 22-gauge catheter can be used for older adult clients who have frail veins. 2 - The nurse should recognize that 0.9% sodium chloride is the only IV fluid that can be used for blood administration to prime the tube, and to clear the line following administration. Safe blood administration includes using a Y-type infusion tubing which contains a special blood filter. 3 - The nurse should recognize that packed RBCs should be administered over 4 hr or less. Beyond this time, there is increased risk of bacterial growth within the blood bag. 4 - The nurse should recognize that no medications or other solutions can be given at any location in the tubing being used for blood administration.

A nurse is reviewing the medical record of a client who has a fluid volume deficit. The nurse should expect which of the following findings? 1 - BUN 12 mg/dL 2 - Urine output 15 mL/hr 3 - Hct 43% 4 - Urine specific gravity 1.020

2 - Urine output 15 mL/hr Rational 1 - BUN 12 mg/dL is within the expected reference range. A client who has a fluid volume deficit is more likely to have an increased BUN because decreased blood volume leads to decreased blood flow to the kidneys and decreased renal excretion of BUN. 2 - Urine output 15 mL/hr is below the expected reference range. A client who has a fluid volume deficit is likely to have urine output less than 30 mL/hr because decreased blood volume leads to decreased blood flow to the kidneys and decreased urine output. 3 - Hct 43% is within the expected reference range. A client who has a fluid volume deficit is more likely to have an elevated Hct because even though the total blood volume decreases the amount of RBCs remains the same. 4 - Urine specific gravity 1.020 is within the expected reference range. A client who has a fluid volume deficit is more likely to have an increased urine specific gravity because the kidneys reabsorb as much water as possible, thus excreting concentrated urine.

An infusion pump is mandatory when patients receive: 1 - lactated Ringer's. 2 - chemotherapy drugs. 3- proton pump inhibitors (PPIs). 4- normal saline IV fluid.

2 - chemotherapy drugs. Rational Chemotherapy drugs require critical accuracy and an infusion pump is necessary. Infusion pumps are not mandatory with lactated ringer's, PPIs, or normal saline IV fluid.REF: Page 704

A nurse is collecting data about an IV infusion site on an infant's left hand. Which of the following findings should the nurse identify as an indication of an infiltration? 1 - Blood in the IV tubing 2 - Absence of blanching at the insertion site 3 - Edema in the palm of the hand 4 - Warmth around the insertion site

3 - Edema in the palm of the hand Rational 1 - Blood in the IV tubing can indicate disconnection of the catheter from the tubing. 2 - Blanching at the insertion site, not absence of blanching, indicates an infiltration. 3 - Edema, pallor, and coolness around the insertion site indicate an infiltration, that is, a collection of fluid leaking into subcutaneous tissue. 4 - An infiltration causes coolness around the insertion site. Warmth indicates phlebitis.

A patient in early stage renal failure is prescribed an infusion of 0.45% sodium chloride. This type of solution is appropriate because it 1 - pulls fluid from the cells and increases vascular volume. 2 - dilutes extracellular fluid and rehydrates the cells. 3 - replaces extracellular volume and maintains intravascular volume. 4 - draws fluid into blood vessels and reduces interstitial compartments.

2 - dilutes extracellular fluid and rehydrates the cells. Rational 1 - Infusing a hypertonic solution such as 10% dextrose in water pulls fluid from the cells and increases vascular volume; 0.45% sodium chloride is not a hypertonic solution. 2 - Infusing a hypotonic solution such as 0.45% sodium chloride moves fluid into the cells, thus enlarging and rehydrating them. 3 - Infusing an isotonic solution such as 0.9% sodium chloride replaces fluid losses, usually extracellular losses, and maintains or expands the intravascular volume; 0.45% sodium chloride is not an isotonic solution. 4 - Infusing a hypertonic solution such as 3% sodium chloride pulls fluid from the cells and increases vascular volume; 0.45% sodium chloride is not a hypertonic solution.

Blood should be infused with an IV tubing set selected for: 1 - regular drops. 2 - macrodrops. 3 - microdrops. 4 - large drops.

2 - macrodrops. Rational Macrodrops are used for viscous fluids, such as blood. Regular drops are used to administer IV therapy to most adult patients. Microdrops are most often used for infants and children. This is not one of the three major drop sizes.REF: Page 702

A patient requires an intravenous antibiotic for 6 weeks. The appropriate type catheter would be: 1 - Broviac. 2 - midline catheter (ML). 3 - Hickman. 4 - Groshong.

2 - midline catheter (ML). Rational Midline catheter is used in home care for IV therapy of 6 to 8 weeks. Broviac, Hickman, and Groshong are long-term catheters used for more than 6 to 8 weeks.REF: Page 706

After the first few minutes of transfusing packed RBCs, the patient has a temperature of 101.5°F (38.6°C), heart rate 120 beats/min, and blood pressure of 90/50 mm Hg with complaints of back pain. The priority nursing action would be. 1 - flush the line with normal saline 2 - stop the transfusion 3 - notify the provider 4 - administer diphenhydramine (benadryl)

2 - stop the transfusion Rational The transfusion should be immediately stopped to prevent further blood component from infusing. The other answer options are necessary actions, but not top priority.

A nurse identifies an extravasation of a vesicant solution at a client's peripheral IV catheter's insertion site. Identify the sequence in which the nurse should perform the following actions. 1 - Aspirate the solution from the catheter 2 - Stop the infusion 3 - Disconnect the tubing from the catheter 4 - Remove the IV catheter 5 - Attach a syringe to the catheter

2, 3, 5, 1, 4 2 - Stop the infusion 3 - Disconnect the tubing from the catheter 5 - Attach a syringe to the catheter 1 - Aspirate the solution from the catheter 4 - Remove the IV catheter Rational To eliminate any further injury to the client from the vesicant (a medication that injures tissues if it leaks from a vein), the nurse should first stop the infusion. The second step is to disconnect the catheter from the tubing. The third step is to attach a 3- to 5-mL syringe to the catheter. The fourth step is to aspirate any IV solution remaining in the hub and in the catheter. The final step is to remove the IV catheter, and while avoiding exerting pressure on the site, covering it with a dry dressing.

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous infusion of heparin. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse make? 1 - "It usually takes at least 2 to 3 days for heparin to dissolve a clot." 2 - "The time it takes heparin to dissolve clots varies between clients." 3 - "Heparin prevents new clots from forming rather than dissolving established clots." 4 - "The time it takes for heparin to dissolve a clot depends on the size of the clot."

3 - "Heparin prevents new clots from forming rather than dissolving established clots." Rational 1 - Heparin does not dissolve established clots. Thrombolytic medications such as alteplase dissolve established clots. 2 - Heparin does not dissolve established clots. Thrombolytic medications such as alteplase dissolve established clots. 3 - Heparin is an anticoagulant that prevents the formation of new clots by blocking the conversion of prothrombin to thrombin and fibrinogen to fibrin. It does not dissolve established clots. 4 - Heparin does not dissolve established clots. Thrombolytic medications such as alteplase dissolve established clots.

During a change-of-shift report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900 mL of fluid left in it. The nurse makes rounds 30 min later and notes that the IV bag is empty. Which of the following actions should the nurse take? 1 - Elevate the head of the bed to high Fowler's. 2 - Request NPO status for the client. 3 - Check the client's respiratory rate and lung sounds. 4 - Measure the client's temperature.

3 - Check the client's respiratory rate and lung sounds. Rational 1 - Unless the client is showing visible signs of dyspnea, positioning the client upright will not help resolve receiving an excessive amount of IV fluid. 2- There is no rationale for restricting oral fluids completely if the client has received an excess of IV fluids. 3 - The nurse should collect data immediately to identify any indications of fluid-volume excess. To do so, the nurse should listen to the client's lungs for dyspnea and rales. 4 - Receiving 900 mL of fluid in 30 min is unlikely to change the client's temperature. It could help lower a fever, but there is no indication that the client had one.

A nurse finds a patient's IV insertion site red, warm, and slightly edematous. Which of the following actions should the nurse perform first? 1 - Check for a blood return. 2 - Elevate the extremity. 3 - Discontinue the IV line. 4 - Apply warm, moist heat.

3 - Discontinue the IV line. Rational 1 - Even if the line is patent, the patient has still developed a complication. This action will not promote resolution of the problem. 2 -Elevation of the extremity can help promote venous drainage and reduce swelling, but it will not promote resolution of the problem. 3 - The patient has classic signs of phlebitis, an inflammation of the vein. The IV line must be discontinued immediately to reduce the risk of thrombophlebitis and embolism. 4 - Heat application can help relieve the patient's symptoms, but it alone will not promote resolution of the problem.

In planning care for a patient with congestive heart failure, you choose the problem statement: fluid volume excess due to altered cardiac output. The Problem statement would most likely by supported by which sign or symptom? 1 - Temperature of 101.5°F (38.6°C) 2 - Hematocrit 35% 3 - Fine crackles in the lung sounds 4 - Clear, yellow urine

3 - Fine crackles in the lung sounds Rational Fine crackles in the lungs indicate fluid accumulation and are a sign of fluid overload. This finding is consistent with congestive heart failure (CHF). (1) Elevated temperature is not necessarily present in CHF. (2) Low hematocrit is not an indicator of CHF. (4) Urine color is not an indicator of CHF.

A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations? 1 - Urticaria 2 - Muscle pain 3 - Hypotension 4 - Distended neck veins

3 - Hypotension Rational 1 - Urticaria, wheezing, anxiety, and shock are manifestations of an anaphylactic reaction to a blood transfusion. 2 - Muscle pain, fever, chills, headache, anxiety, and flushing are manifestations of a febrile, nonhemolytic transfusion reaction. 3 - Hypotension, tachycardia, tachypnea, low back pain, flushing, chills, and fever are manifestations of an acute hemolytic reaction to a blood transfusion. 4 - Distended neck veins, cough, and dyspnea are manifestations of a transfusion reaction from circulatory overload.

An appropriate diagnosis for a patient on total parenteral nutrition (TPN) is: 1 - Deficient fluid volume related to inability to take fluids by mouth. 2 - Risk for dehydration related to poor fluid intake. 3 - Imbalanced nutrition, less than body requirements, related to inability to take oral foods or fluids. 4 - Ineffective tissue perfusion related to loss of red blood cells/fluid volume.

3 - Imbalanced nutrition, less than body requirements, related to inability to take oral foods or fluids. Rational Nutritional status of patients who are NPO and on IV therapy must be assessed every day because the amount of calories supplied by the IV solution is below the total daily requirement. Supplemental calories can be provided through TPN; therefore the most appropriate nursing diagnosis would be Imbalanced nutrition, less than body requirements, related to inability to take oral foods or fluids. Deficient fluid volume and Risk for dehydration are nursing diagnoses for fluid replacement. Ineffective tissue perfusion is a nursing diagnosis for blood product transfusion.REF: Page 727

A nurse is removing an IV catheter from a patient whose IV infusion has been discontinued. Which of the following actions is appropriate? 1 - Apply firm pressure over the vein. 2 - Leave the roller clamp slightly open. 3 - Pull the catheter straight back from the insertion site. 4 - Lift the hub slightly upward away from the skin.

3 - Pull the catheter straight back from the insertion site. Rational 1 - Firm pressure over the vein can make the procedure unnecessarily painful for the patient. 2 - Moving the roller clamp to the off position is recommended to avoid spilling IV fluid. 3 - With the catheter stabilized and using a slow, steady movement, the nurse should withdraw the catheter straight back and away from the insertion site, making sure to keep the hub parallel to the skin. 4 - Changing the angle of the catheter inside the vein, which would result from elevating the hub, could irritate the vein and put the patient at risk for postinfusion phlebitis.

A nurse is collecting data on a client who is to receive a blood transfusion. Which of the following data is the nurse's priority before the transfusion begins? 1 - ​Skin color ​2 - Fluid intake ​3 - Temperature 4 - ​Hemoglobin level

3 - Temperature Rational 1 - The nurse should collect data on the client's skin color, but this is not the priority action. 2 - The nurse should collect data on the client's fluid intake, but this is not the priority action 3 -The greatest risk to the client is injury from a blood transfusion reaction; therefore, the priority action the nurse should take is to monitor the client's temperature before, during, and after the transfusion. 4 - The nurse should collect data on the client's hemoglobin level before the blood transfusion, but this is not the priority action.

When a patient receives a hypotonic solution intravenously (IV), what happens to the patient's cells? 1 - There is a net loss of water across the cell membrane. 2 - There is no change in the cells because there is no fluid shift. 3 - The cells begin to swell as water enters the intracellular compartment. 4- The cells begin to shrink as water is pulled from the intracellular compartment.

3 - The cells begin to swell as water enters the intracellular compartment Rational A hypotonic solution has a lower osmotic pressure than that of body fluids. During IV administration with a hypotonic solution, cells will swell as water passes from the less concentrated solution across the cell membrane and into the cell. Hypertonic fluid causes cells to shrink. There is a net gain, not loss, of water across the cell membrane. The fluid shift causes the change in the cells.

A nurse is caring for a client who has acute dehydration is receiving IV fluids. Which of the following laboratory values indicates to the nurse that the current treatment regimen is effective? 1 - Sodium 165 mEq/L 2 - Potassium 3.2 mEq/L 3 - Urine specific gravity 1.020 4 - Hematocrit 62%

3 - Urine specific gravity 1.020 Rational 1 - A sodium level of 165 mEq/L is increased and indicates hypernatremia. The expected reference range is 135 to 145 mEq/L. 2 - A potassium level of 3.2 mEq/L is decreased and represents hypokalemia. The expected reference range is 3.5 to 5.0 mEq/L. 3 - In cases of dehydration or fluid volume deficit, the urine specific gravity is elevated. A level of 1.020 is within the expected reference range, which indicates that the current treatment regimen is effective. 4 - In cases of fluid volume deficit or dehydration, the hematocrit will be elevated due to hemoconcentration. The hematocrit should return to an expected level if the therapy (IV fluids) is working. This level is still elevated. Therefore, this level would indicate that treatment is not effective.

A nurse is monitoring a client who is receiving a blood transfusion. For which of the following time spans should the nurse remain in the client's room? 1 - The first hour 2 - The final hour 3 - ​The first 15 min 4 - ​The final 15 min

3 - ​The first 15 min Rational 1 - ​The nurse should remain in the client's room for the first 15 min of the blood transfusion, which is the most critical time for a blood transfusion reaction to occur. 2 - The nurse should remain in the client's room for the first 15 min of the blood transfusion, which is the most critical time for a blood transfusion reaction to occur. 3 - The nurse should remain in the client's room for the first 15 min of the blood transfusion, which is the most critical time for a blood transfusion reaction to occur 4 - The nurse should remain in the client's room for the first 15 min of the blood transfusion, which is the most critical time for a blood transfusion reaction to occur.

A nurse is monitoring a client who has dehydration and is receiving IV fluid replacement. Which of the following findings should the nurse identify as effectiveness of the treatment? 1 - Peripheral pulses +1 2 - Urine specific gravity 1.04 3 -Urine output 200 mL/4 hr 4 - Heart rate 104/min

3 -Urine output 200 mL/4 hr Rational 1 - The nurse should identify peripheral pulses +1, barely palpable, as indicating a fluid volume deficit or impaired circulation. 2 - This value is above the expected reference range. The nurse should recognize a urine specific gravity above 1.025 as indicating possible fluid volume deficit. 3 - This finding indicates a urine output 50 mL/hr. The nurse should identify a urine output of at least 30 mL/hr as indicating adequate circulating fluid volume and kidney function. 4 - The nurse should recognize tachycardia as a finding of fluid volume deficit.

The student nurse reviews the records of a patient with pneumonia and finds that the patient has a blood pH of 7.46. The student is correct in determining that this pH is considered __. 1 - slightly acidic 2 - grossly acidic 3- slightly alkaline 4 - grossly alkaline

3- slightly alkaline Rational Normal blood pH is 7.35 to 7.45, so 7.46 would be considered slightly alkaline; 7.36 and lower would be considered acidic.

At the beginning of the shift, there is 410 mL of fluid in the IV bag. A piggyback medication containing 150 mL is hung at 1200 noon to run over 30 minutes. You hang a new bag of 1000 mL at 100 P.M. to run at 125 mL/hr. At the end of shift there is 250 mL left in the bag. The count for the total amount of fluid infused during your shift ending at 700 P.M. is: 1 - 1260 mL 2 - 1285 mL 3 - 1560 mL 4 - 1310 mL

4 - 1310 mL Rational Intake is 150 mL from the Piggyback medication, 410 mL from the old IV fluid infusion, and 750 mL infused from the bag hung at 1300. 150 + 410 + 750 = 1310 mL.

A nurse is assisting with the admission of a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have? 1 - 3.6 mg/dL 2 - 9 mg/dL 3 - 18.7 mg/dL 4 - 24 mg/dL

4 - 24 mg/dL Rational 1 - 3.6 mg/dL is below the expected reference range, which can indicate liver failure, overhydration, or nephrotic syndrome. 2 - 9 mg/dL is below the expected reference range, which can indicate liver failure, overhydration, or nephrotic syndrome. 3 - 18.7 mg/dL is within the expected reference range. 4 - 24 mg/dL is an expected finding for a client who has dehydration. Clients who have dehydration can have decreased blood flow, which leads to decreased renal excretion of BUN. Other causes of increased BUN levels include gastrointestinal bleeding, heart failure, burns, shock, and myocardial infarction.

A nurse is collecting data about the fluid status of four clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? 1 - A client who has NPO status since midnight for an endoscopy 2 - A client who has heart failure and is receiving diuretic therapy 3 - A client who has end-stage kidney disease who will undergo dialysis 4 - A client who has gastroenteritis and is receiving oral fluids

4 - A client who has gastroenteritis and is receiving oral fluids Rational 1 - Most clients who have an acceptable baseline for fluid status can tolerate having NPO status overnight without risking fluid volume deficit. 2 - A client who has heart failure is likely to have fluid-volume excess that diuretic therapy is treating. 3 - A client who has end-stage kidney disease is likely to have fluid-volume excess that dialysis will treat. 4 - Gastroenteritis causes diarrhea and vomiting, so it can be a significant source of fluid loss. The nurse should identify this client as having a risk for fluid volume deficit.

A nurse who has just initiated an IV infusion explains to the patient that complications are possible and that she will monitor the infusion regularly. The nurse should teach the patient that which of the following findings is an indication of early infiltration? 1 - Moisture 2 - Bruising 3 - Tingling 4 - Coolness

4 - Coolness Rational 1 - A damp or wet dressing or other evidence of moisture typically indicates that the hub is loose or has become detached from the tubing or that the site itself is leaking IV solution. If all connections are secure, moisture could be a late sign of infiltration, not an early sign. 2 -Bruising at the infusion site is likely to be a result of trauma to tiny blood vessels during insertion. Bruising is not uncommon after a venipuncture. 3 - Tingling is generally a sign of nerve irritation or compromise. An infiltration would have to be severe to affect neurological function. 4 - Coolness is a classic sign of infiltration, along with swelling, pallor, and possibly tenderness. Infiltration is a leakage of IV solution out of the intravascular compartment into the surrounding tissue.

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. The client's BUN is 32 mg/dL, creatinine. 1.1 mg/dL, and hematocrit 50%. Which of the following actions should the nurse take? 1 - Collect a urine specimen for culture and sensitivity. 2 - Continue routine care because the results are within the expected reference range. 3 - Decrease the IV fluid infusion rate and limit oral fluid intake. 4 - Evaluate urine output for amount and urine for specific gravity.

4 - Evaluate urine output for amount and urine for specific gravity. Rational 1 - These results do not indicate infection; therefore the nurse does not need to collect a urine specimen for culture and sensitivity. 2 - These results are not all within the expected reference range. 3 - Reducing fluid intake could worsen the client's condition. 4 - These results indicate that the client is dehydrated. Specific gravity and urine output measurements can support the laboratory findings. The higher the specific gravity, the more dehydrated the client.

A nurse has just initiated a new peripheral IV infusion with 5% dextrose in water for continuous infusion. How often should the nurse plan to replace the primary infusion tubing? 1 - Every 24 hours 2 - Every 48 hours 3 - Every 72 hours 4 - Every 96 hours

4 - Every 96 hours Rational 1 - Tubing should be replaced every 24 hours if it is used to administer blood, blood products, or lipid emulsions. 2 - Unless the solution is changed to one that is incompatible with the current infusate or there is some compromise to the tubing, replacing the tubing 48 hours after initiation would be inappropriate. 3 - Unless the infusion system has been compromised in some way, changing the administration set 72 hours after initiating the IV would be inappropriate. 4 - The Centers for Disease Control and Prevention and the Infusion Nurses' Society recommend changing the IV tubing no more than every 96 hours unless the tubing has been contaminated, punctured, or obstructed.

An elderly patient has a rapid pulse, shortness of breath, and distended neck veins. An IV of 0.9 NS at 150 mL/hr is infusing. What should the nurse be concerned about? 1 - Catheter embolus 2 - Speed shock 3 - Septicemia 4 - Fluid overload

4 - Fluid overload Rational Elderly patients who have IV fluid infusing are at risk for potential fluid overload. Rapid pulse, shortness of breath, and distended neck veins are possible signs of fluid overload. Catheter embolus may cause loss of consciousness. Speed shock may result in cardiac arrest. Signs of septicemia are fever, chills, and general malaise.REF: Page 709, Table 36 2

Which of the following is an important nursing action when concerting an IV infusion to a saline lock? 1 - Open the roller clamp of the primary infusion to prime the saline lock. 2 - Apply pressure with a syringe to clear resistance in the IV catheter. 3 - Attach secondary tubing to allow mobility. 4 - Flush the IV catheter to confirm patency.

4 - Flush the IV catheter to confirm patency. Rational 1 - The tubing of a saline lock is primed separately using a syringe. It is not primed from the existing infusion. 2 - If resistance is encountered in an IV line, it should not be flushed. That would place the patient at risk for embolism. 3 - Secondary tubing is used to administer IV medications via piggyback. A saline lock attaches to extension tubing, not to secondary tubing. 4 - It is essential to attach the primed saline lock adapter to the extension tubing and to flush the tubing with normal saline to confirm patency.

An 82-year-old patient is admitted to the unit with a temperature of 100.2° F, urine specific gravity (SG) of 1.032, and dry tongue. The nurse should recognize which to be the most critical aspect of the plan of care? 1 - A diuretic 2 - An antibiotic 3 - An antipyretic 4 - IV solution

4 - IV solution Rational The patient is hypovolemic; she requires IV fluid replacement. The slight elevation in temperature may be related to her dehydration. This is further supported by her urine SG of 1.032; normal urine SG is approximately 1.010 to 1.025. There are no data to support a need for an antibiotic. The patient's body temperature is elevated, but this is not the priority of care. The patient is most likely dehydrated and cannot afford to lose additional fluid volume, so a diuretic would be inappropriate.

The nurse is assessing a patient who was admitted for dehydration. Which assessment finding is an indication that the dehydration is resolving? 1 - Loose skin 2 - Sunken eyes 3 - 1200 mL urine output 4 - Moist mucous membranes

4 - Moist mucous membranes Rational Moist mucous membranes are one sign that the patient's hydration status is resolving. Sunken eyes and loose skin are signs of dehydration. 1200 mL of urine output alone does not indicate hydration status; this would have to be compared to other factors, such as intake.