IV Therapy (Advanced Skills)

the nursing care plan for an older client with dehydration includes interventions for oral health. which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? SELECT ALL THAT APPLY 1. reminding the client to avoid commercial mouthwashes 2. encouraging mouth rinsing with warm saline 3. assess skin turgor by pinking the skin over the back of the hand 4. observing the lips, tongue and mucous membranes 5. providing mouth care every 2 hours while the client is awake 6. seeking a dietary consult to increase fluids on meal trays

1, 2, 4, 5

the charge nurse assigned the care of a client with acute kidney failure and hypernatremia to a new grated RN. which actions can the new graduate RN delegate to the UAP? SATA 1. providing oral care every 3 to 4 hours 2. monitoring for indications of dehydration 3. administering 0.45% saline by IV line 4. record urine output when client voids 5. assessing daily weights for trends 6. help the client change position every 2 hours

1, 4, 6

an experienced LPN/LVN reports to the RN that a clients BP and HR have decreased, and when his face was assessed, one side twitches. what action should the RN take at this time? 1. reassess the clients BP and HR 2. review the clients morning calcium level 3. request a neurologic consult today 4. check the clients pupillary reaction to light

2

the client has fluid volume deficit related to excessive fluid loss. which action related to fluid management should be delegated by the RN to UAP (unlicensed assistive personnel)? 1. administering IV fluids as prescribed by the physician 2. providing straws and offering fluids between meals 3. developing a plan for added fluid intake over 24 hours 4. teaching family members to assist the client with fluid intake

2

which statement by a client with hypovolemia related to dehydration is the best indicator to the nurse of the need for additional teaching? 1. I will drink 2 to 3 L of fluids every day 2. I will drink a glass of water whenever I feel thirsty 3. I will drink coffee and cola drinks throughout the day 4. I will avoid drinking containing alcohol

3

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? (SATA) 1. Tetany 2. Seizures 3. Diarrhea 4. Weakness 5. Dysrhythmias

3, 4, 5

the UAP reports to the nurse that a clients urine output for the past 24 hours has been only 360 mL. what is the nurses priority action at this time? 1. place an 18 gauge IV in the non dominant arm 2. elevate the clients head of bed at least 45 degrees 3. instruct the UAP to provide the client with a pitcher of water 4. contact and notify the health care provider immediately

4

while assessing a patients IV site, the nurse identifies signs and symptoms of infiltration. What is the first action that the nurse implements for this patient? 1. elevate the extremity 2. apply a sterile dressing if weeping from the tissue has occurred 3. remove the IV access 4. stop the IV infusion

4

A nurse is evaluating he effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful? A. Clear breath sounds B. Positive pedal pulses C. Normal potassium level D. Increased urine specific gravity

A

Which findings indicate that a patient may have hypervolemia? (SATA) A. increased, bounding pulse B. jugular venous distention C. presence of crackles D. excessive thirst E. elevated blood pressure F. orthostatic hypotension

A, B, C, E

Patients with which conditions are at greatest risk for defiant fluid volume? (SATA) A. fever of 103ºF (39.4ºC) B. Extensive burns C. thyroid crisis D. water intoxication E. continuous fistula drainage F. diabetes insipidus

A, B, C, E, F

What are the consequences for a patient who does not meet the obligatory urine output? (SATA) A. lethal electrolyte imbalances B. alkalosis C. urine becomes diluted D. toxic buildup of nitrogen E. urine output increases F. acidosis

A, D, F

A client is receiving an IV infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. What nutritional problem prompts the nurse to notify the health care provider? A. Excessive carbohydrate intake B. Lack of protein supplementation C. Insufficient intake of water-soluble vitamins D. Increased concentration of electrolytes in cells

B

A client reports vomiting and diarrhea for 3 days. What clinical finding will MOST accurately indicate that the client has a fluid deficit? A. Presence of dry skin B. Loss of body weight C. Decrease in blood pressure D. Altered general appearance

B

A nurse assess a clients serum electrolyte levels in the laboratory report. What electrolyte in the intracellular fluid should the nurse consider MOST important? A. Sodium B. Calcium C. Chloride D. Potassium

D

A patient shows a positive Trousseau's or Chovestek's sign. The nurse prepares to give the patient which urgent treatment? a. IV calcium b. calcitonin c. IV potassium chloride d. Large doses of oral calcium

a

which illnesses can be treated by an intrathecal infusion? SATA a, cancer of the central nervous system b. reflex sympathetic dystrophy c. irritable bowel syndrome d. multiple sclerosis e. leukemia f. anoxic acquired brain injury

a, b, d, f

a patient with hyponatremia would have which GI findings upon assessment? (SATA) a. hyperactive bowel sounds on auscultation b. hard, dark-brown stools c. hypoactive bowel sounds on auscultation d. frequent watery bowel movements e. abdominal cramping f. nausea

a, d, e, f

the nurse caring for a patient with hypercalcemia anticipates orders for which medications? (SATA) a. magnesium sulfate b. calcitonin c. furosemide d. plicamycin e. calcium gluconate f. aluminum hydroxide

b, c, d

a patient with hypokalemia is likely to have which conditions? (SATA) a. liver failure b. metabolic alkalosis c. cushings syndrome d. hypothyroidism e. paralytic ileus f. kidney failure

b, c, e

plasma is part of which body fluid space compartments? (SATA) a. the intracellular compartment b. the extracellular compartment c. all fluid within the cells d. interstitial fluid e. intravascular fluid f. fluid within joint capsules

b, d, e

a patient with hypocalcemia needs supplemental diet therapy. which foods does the nurse recommend providing both calcium and vitamin D? (SATA) a. tofu b. cheese c. eggs d. broccoli e. milk f. salmon

b, e, f

The intake and output of a client over and 8-hour period. (8 AM to 4 PM) is: 8 AM: IV with D5W infusing and 900mL left in bag 8:30 AM: 150 mL urine voided 9 AM to 3 PM: 200 mL gastric tube formula and 50 mL water at q3h intervals 1 PM: 220 mL voided 3:15 PM: 235 mL voided 4 PM: IV with 550 mL left in bag What is the difference between clients intake and output? (Record your answer using a whole number.)

495 mL

Which changes on a patients electrocardiogram (ECG) reflect hyperkalemia? A. tall peaked T waves B. narrow QRS complex C. Tall P waves D. normal P-R intervals

A

Which factors affect the amount and distribution of body fluids? (SATA) A. race B. age C. gender D. height E. body fat F. weight

B, C, E, F

For what clinical indicator should a nurse assess a client who is have gastric lavage? A. Decreased serum pH B. Increase serum oxygen level C. Increased serum bicarbonate level D. Decreased serum osmotic pressure

C

The nurse is caring for a postoperative surgical patient in the recovery room. What is the MAIN reason for carefully monitoring the patients urine output? A. decreasing urine output indicates poor kidney function B. increasing urine output can indicate too much IV fluid during surgery C. decreasing urine output may mean hemorrhage and risk for shock D. increasing urine output may mean that kidney function is returning to normal

C

An older adult patient is at risk for fluid and electrolyte problem is carefully monitored by the nurse for the first indication of a fluid balance problem. What is this indication? A. fever B. elevated blood pressure C. poor skin turgor D. mental status changes

D

a 65 year old patient has been receiving IV d51/2 NS at 100 mL/hour for the past 3 days, along with IV antibiotic therapy. the patient reports chills and a headache. on assessment the patients temp is elevated. what complication do these assessment findings suggest? a. catheter related infection in the blood b. allergic reaction to the antibiotics c. phlebitis d. fluid volume overload

a

a patient has a low potassium level and the provider has ordered an IV infusion. BEFOR starting an IV potassium infusion , what does the nurse assess? a. IV line patency b. oxygen saturation level c. baseline mental status d. Apical pulse

a

a patient has an intraosseous needles in place. why does the nurse advocate for removal of the device within 24 hours after insertion? a. there is an increased risk for osteomyelitis b. there is an increased risk for arterial insufficiency c. the device hinders patient mobility d. the device is unstable and easily dislodged

a

the nurse is taking care of a trauma patient who was in a motor vehicle accident. the patient has a history of hypertension, which is managed with spironolactone. this patient is at risk for developing which electrolyte imbalance? a. hyperkalemia b. hypernatremia c. hypokalemia d. hypocalcemia

a

when using an intermittent administration set to deliver medications, how often does the infusion nurses society recommend that the set be changed? a. every 24 hours b. every shift c. every morning d. after every dose

a

which is a preventative measure for patients as risk for developing hypocalcemia? a. increase daily dietary calcium and vitamin D b. increase intake of phosphorus c. apply sunblock and what protective clothing whenever outdoors d. administer calcium-containing IV fluids to patients receiving multiple blood transfusions

a

which are typical nursing assessment findings for a patient with hypocalcemia? (SATA) a. positive chvostek's sign b. hypertension c. diarrhea d. prolonged ST interval e. elevated T wave f. positive trousseaus sign

a, c, d, f

which characteristics apply to IV infusion pumps? SATA a. deliver fluids under pressure b. rely on gravity to create fluid flow c. can be pole mounted or ambulatory and portable d. are best for accurate infusion e. count drops to regulate flow f. decrease drug errors through smart technology

a, c, d, f

a patient with congestive heart failure is receiving a loop diuretic. the nurse monitors for which electrolyte imbalances? (SATA) a. hypocalcemia b. hypercalcemia c. hyponatremia d. hypernatremia e. hypokalemia f. hyperkalemia

a, c, e

the nurse is caring for a psychiatric patient who is continuously drinking water. the nurse monitors for which complication related to potential hyponatremia? a. proteinuria/prerenal failure b. change in mental status/increased intracranial pressure c. pitting edema/circulatory failure d. possible ovule blood/ GI bleeding in stool

b

a patient in the hospital as a severely elevated magnesium level. which intervention should the nurse complete FIRST? a. discontinue oral magnesium b. administer furosemide (Lasix) c. discontinue parenteral magnesium d. administer calcium to treat Bradycardia

c

in what position doe the nurse place a patient before starting intraperitoneal therapy? a. semi fowlers b. prone c. supine d. side lying

c

patients with which conditions are at risk for developing hypernatremia? (SATA) a. chronic constipation b. heart failure c. severe diarrhea d. decreased kidney function e. profound diaphoresis f. Cushing's syndrome

c, d, e, f

a young adult patient is in the early stages of being treated for severe burns. which electrolyte imbalance does the nurse expect to assess in this patient? a. hypernatremia b. hypokalemia c. hypercalcemia d. hyperkalemia

d

the nurse is evaluating the lab results of a patient with hyperaldosteronism. what abnormal electrolyte finding does the nurse expect o see? a. hyponatremia b. hyperkalemia c. hypocalcemia d. hypernatremia

d

A patients blood osmolarity is 302 mOsm/L. What manifestation does the nurse expect to see in the patient? A. increased during output B. Thirst C. peripheral edema D. nausea

B

What clinical finding does a nurse anticipate when admitting a client with extracellular fluid volume excess? A. Rapid, thready pulse B. Distended jugular veins C. Elevated hematocrit level D. increased serum sodium level

B

A nurse adds 20 mEq of potassium chloride to the IV solution of a client with diabetic ketoacidosis. What is the PRIMARY purpose for administering this drug? A. Treat hyperpnea B. Prevent flaccid paralysis C. Replace excessive losses D. Treat cardia dysrhythmias

C

A nurse administers and intravenous solution of 0.45% sodium chloride. In what category of fluids does this solution belong? A. Isotonic B. Isomeric C. Hypotonic D. Hypertonic

C

A nurse is caring for a client with ascites. What does the nurse consider to be the cause of the ascites? A. Portal hypotension B. Kidney malfunction C. Diminished plasma protein level D. Decreased production of potassium

C

After a 5-km run on a hot summer day, a diaphoretic patient tells the volunteer nurse that she is very thirsty. What is the nurses BEST action? A. Instruct the patient to sit down B. Apply ice to the patients axilla areas C. Tell the patient to breathe slowly and deeply D. offer the patient bottled water to drink

D

the nurse is preparing to start an infusion of dextrose 10% in water. why would the nurse infuse the solution through a central line? a. osmolarity of the solution could cause phlebitis or thrombosis b. the patient could be at risk for fluid overload c. viscosity of the solution would slow the infusion d. this solution should not be mixed with other drugs or solutions

a

A patients potassium level is high secondary to kidney failure. what laboratory changes does the nurse expect to see? (SATA) a. elevated serum creatinine b. decreased blood pH c. elevated sodium d. low to normal hemaotcrit e. elevated hemoglobin f. decreased blood urea nitrogen

a, b, d

which nursing interventions are implemented when caring for a patient with an implanted port? SATA a. before puncture, palpate the port to locate the septum b. use a large bore needle to access the port c. flush the port before each use d. use a noncoding needle to access the port e. flush the port at least once a month f. check for blood return before giving any drug through a port

a, c, d, f

Which potassium levels are within normal limits? (SATA) a. 2.0 mmol/L b. 3.5 mmol/L c. 4.5 mmol/L d. 5.0 mmol/L e. 6.0 mmol/L

b, c, d

A patient has a PICC placed by an IV therapy nurse at the bedside. Before using the catheter, how is its placement verified? a. the provider who ordered the procedure verifies placement b. the line is aspirated gently and the nurse watches for blood return c. a chest xray is taken, which shows the catheter tip in the lower superior vena cava d. the line is slowly flushed with 10 ml of saline while the nurse notes the ease of flow

c

A patient is talking to the nurse about sodium intake. Which statement by the patient indicates and understanding of high sodium food sources? a. "I have bacon and eggs for breakfast every morning" b. "we never eat seafood because of the salt water" c. "I love chinese food, but I gave it up because of the soy sauce" d. "pickled herring is a fish, and my doctor told me to eat a lot of fish"

c

a patient central venous IV site is covered with a transparent membrane dressing. how often does the nurse change this dressing? a. every 24 hours b. every 48 hours c. every 5 to 7 days d. the dressing does not need changing

c

a patient requires an infusion of packed red blood cells. which factor allows the nurse to infuse the PRBCs through the patients peripherally inserted central catheter PICC? a. length of the PICC allows infusion within 6 hours b. the nurse is unable to obtain an infusion pump c. lumen size of the PICC is 4 Fr or larger d. PRBCs can be warmed before infusion

c

the nurse in caring for several patients at risk for falls because of fluid and electrolyte imbalances. which task related to patient safety and fall prevention does the nurse delegate to the UAP? a. assess for orthostatic hypotension b. orient the patent to the environment c. help the incontinent patient to the toilet every 1-2 hours d. encourage family members or significant other to stay with the patient

c

the nurse instructs the UAP to use precautions with moving and using a lift sheet for which patient with electrolyte imbalance? a. young woman with diabetes and hyperkalemia b. patient with psychiatric illness and hyponatremia c. older woman with hypocalcemia d. child with severe diarrhea and hypomagnesemia

c

the nurse is assessing a patients vascular access for phlebitis. the IV site shows erythema with swelling and pain based on infusion nurse society standards, which grade of phlebitis would the nurse document? a. grade 0 b grade 1 c. grade 2 d. grade 3

c

which patient is the most likely candidate for a tunneled central venous catheter? a. patient with trauma fro a motor vehicle accident b. patient in need of IV antibiotics for several weeks c. patient in need of permanent parenteral nutrition d. patient in need of intermittent chemotherapy

c

the nurse is preparing to start a hypodermoclysis treatment on a patient. what is a preferred insertion site? a. anterior forearm b. anterior tibial area c. lateral aspect of the upper arm d. area under the clavicle

d

How should a nurse prepare and IV piggyback (IVPB) medication for administration to a client reviewing an IV infusion? (SATA) 1. Wear clean gloves to check the IV site 2. Rotate the bag after adding the medication 3. Use 100 mL of fluid to mix the medication. 4. Change the needle before adding the medication. 5. Place the IVPB at a lower level than the existing IV. 6. Use a sterile technique when preparing the medication.

1, 2, 6

An IV solution of 1000 mL 5% dextrose in water is to be infused at 125 mL/hr to correct a clients fluid imbalance. The infusion set delivers 15 drops/mL. To ensure that the solution will infuse over an 8-hour period, at how many drops per minute should the nurse set the rate of flow?

31

A nurse is reviewing the health care providers orders for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which order should the nurse question? A. Oral psyllium (Metamucil) B. Oral potassium supplement C. Parenteral half normal saline D. Parenteral albumin (Albuminar)

D

a patient requires a 2 month course of IV antibiotics to treat a resistant infection. which device is chosen for this therapy? a. short peripheral catheter b. midline catheter c. non tunneled percutaneous central catheter d. peripherally inserted central catheter (PICC)

D

the nurse is flushing a patients short peripheral IV catheter. what solution and volume does the nurse typically use for this procedure? a. 3 mL of Normal saline b. 5 mL of heparin c. 10 mL of normal saline d. 30 mL of bacteriostatic saline

a

the nurse monitors the effectiveness of magnesium sulfate by assessing which factor every hour? a. deep tendon reflexes b. vital signs c. serum laboratory values d. urine output

a

what is the minimum size peripheral IV catheter through which a blood transfusion can be infused? a. 24 gauge b. 22 gauge c. 20 gauge d. 18 gauge

b

a patient with lung cancer is to receive his first chemo treatment. which IV access methods are appropriate for this patient? SATA a. peripheral IV access b. peripherally inserted central catheter c. dialysis catheter d. tunneled central venous catheter e. implanted port f. intraarterial catheter

b, d, e

the nurse is caring for a patient with sever hypocalcemia. what safety measures does the nurse put in place for this patient? (SATA) a. encourage the patient to use a cane when ambulating b. turn on a bed alarm when the patient is in bed c. obtain an order for zolpidem (Ambien) to ensure the patient sleeps at night d. place the patient on a low bed e. ensure the top side rails are up when the patient is in bed f. raise all four side rails

b, d, e

during intraperitoneal therapy a patient reports nausea and vomiting. what does the nurse do next? a. help the patient move from side to side b. flush the catheter with normal saline c. reduce the flow rate and give antiemetics d. obtain an order for an abdominal xray

c

which condition places a patient at risk for hypocalcemia, hyperkalemia, and hypernatremia? a. hypothyroidism b. diabetes mellitus c. chronic kidney disease d. adrenal insufficiency

c

which fluid has the highest corresponding electrolyte content? a. intracellular fluid is highest in potassium b. extracellular fluid is highest in sodium c. extracellular fluid is highest in sodium and chloride d. intracellular fluid is highest in magnesium and sodium

c

which patient is at greatest risk of developing hypocalcemia? a. 30-year-old asian woman with breast cancer b. 45-year-old caucasian man with hypertension and diuretic therapy c. 60-year-old African American woman with a recent ileostomy d. 70-year-old caucasian man on long term lithium therapy

c

the health care provider orders magnesium sulfate (MgSO4) for a patient with sever hypomagnesemia. what is the PREFERRED route of administration for this drug? a. oral b. subQ c. IM d. IV

d

A client's potassium level is 6.7 mEq/L. Which intervention should you delegate to the first-year student nurse whom you are supervising? 1. Administer sodium polystyrene sulfonate (Kayexalate) 15 g orally. 2. Administer spironolactone (Aldactone) 25 mg orally. 3. Assess the electrocardiogram (ECG) strip for tall T waves. 4. Administer potassium 10 mEq orally.

1

An intravenous piggyback (IVPB) of cefazolin (Kefzol) 500 mg in 50 mL of 5% dextrose in water is to be administered over a 20 minute period. The tubing has a drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run?

38 drops per minute

the RN is providing care for a client diagnosed with dehydration and hypovolemic shock. which prescribed intervention from the health care provider should the RN question? 1. BP every 15 minutes 2. place 2 18-gauge IV lines 3. oxygen at 3L via nasal cannula 4. IV 5% dextrose in water to run at 250 ml/hr

4

the RN is reviewing the clients morning laboratory results. which of the results is of most concern? 1. serum potassium level of 5.2 mEq/L 2. Serum sodium level of 134 mEq/L 3. serum calcium level of 10.6 mg/dL 4. serum magnesium level of 0.8 mEq/L

4

There was 200 mL left in a clients IV bag when a nurse started the shift. When there was 50 mL left in this bag the nurse hung a new IV bag containing 1000 mL and discarded the 50 mL from the previous bag. The client received two IVPB's during the shift; each contained 100 mL. At the end of the shift the nurse looks at the IV to document the clients iV fluid intake for the shift. How many mLs of IV fluid did the client receive during the shift. (Pictured: 1000 mL IV bag with 400 mL remaining)

950 mL

A nurse is reviewing a clients serum electrolyte laboratory report. What is a comparison between blood plasma and interstitial fluid? A. They both contain the same kinds of ions. B. Plasma exerts lower osmotic pressure than does interstitial fluid. C. Plasma contains more of each kind of ion than does interstitial fluid D. Sodium is higher in plasma, whereas potassium is higher in interstitial fluid.

A

The emergency department (ED) nurse is caring for a patient who was brought in for significant alcohol intoxication and minor trauma to the wrist. What will serial hematocrits for this patient likely show? A. hemoconcentration B. normal and stable hematocrits C. progressively lower hematocrits D. decreasing osmolality

A

The nurse is working in a long-term care facility where there are numerous patients who are immobile and at risk for dehydration. Which task is BEST to delegate to the unlicensed assistive personnel (UAP)? A. offer patients a choice of fluids every 1 hour B. check patients a the beginning of the shift to see who's thirsty C. give patients extra fluids around medication times D. Evaluate oral intake and urinary output

A

Which patient is at risk for excess insensible water loss? A. Patient with continuous GI suctioning B. patient with slow, depression respirations C. patient receiving oxygen therapy D. patient with hypothermia

A

A clients serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement FIRST? A. Call the laboratory to repeat the test B. Take vital signs and notify the health care provider C. Inform the cardiac arrest team to place them on alert D. Take and electrocardiogram and have lidocaine available

B

A nurse explains to an obese client that the rapid weight loss during the first week after initiating a diet is because of fluid loss. The weight of extracellular body fluid is approximately 20% of the total body weight of an average individual. Which component of the extracellular fluid contributes the GREATEST proportion to this amount? A. Plasma B. Interstitial C. Dense tissue D. Body secretions

B

A nurse in analyzing how a hyperglycemic clients blood glucose can be lowered. The nurse considers that the chemical the buffers the clients excessive acetoacetic acid is: A. Potassium B. Bicarbonate C. Carbon Dioxide D. Sodium Chloride

B

A nurse is caring for a client with ascites who is receiving albumin. What infusion rate and oral fluid intake should the nurse expect to have the GREATEST therapeutic effect? A. Slow IV rate and liberal fluid intake B. Slow IV rate and restricted fluid intake C. Rapid IV rate and withheld fluid intake D. Rapid IV rate and moderate fluid intake

B

A nurse is caring for a client with diarrhea. In which clinical indicator does the nurse anticipate a decrease? A. Pulse rate B. Tissue turgor C. Specific gravity D. Body temperature

B

A nurse is reviewing the laboratory report of a client with a tentative diagnosis of kidney failure. What mechanism does the nurse expect to be maintained when ammonia is excreted by healthy kidneys? A. Osmotic pressure of the blood B. Acid-base balance of the body C. Low bacterial levels in the urine D. Normal red blood cell production

B

The nurse assessing a patient notes a bounding pulse quality, neck vein distention when supine, presence of crackles in the lungs, and increasing peripheral edema. What fluid disorder do these findings reflect? A. fluid volume deficit B. fluid volume excess C. fluid homeostasis D. fluid dehydration

B

The nurse is caring for a patient with hypovolemia secondary to severe diarrhea and vomiting. In evaluating the respiratory system for this patient, what does the nurse expect to find on assessment? A. no changes, because the respiratory system is not involves B. increased respiratory rate, because the body perceives hypovolemia as hypoxia C. Hypoventilation, because the respiratory system is trying to compensate for low pH D. normal respiratory rate, but a decreased oxygen saturation

B

What is the minimum amount of urine output per day needed to excrete toxic waste products? A. 200 to 300 mL B. 400 to 600 mL C. 500 to 1000 mL D. 1000 to 1500 mL

B

What is the term for a difference in concentration of particles that is greater on one side of a permeable membrane than on the other side? A. hydrostatic pressure B. concentration gradient C. passive transport D. active transport

B

A nurse is concerned that a client is at risk for developing hyperkalemia. Which disease does the client have that has caused this concern? A. Crohn B. Cushing C. End-stage renal D. Gastroesophageal reflux

C

The nurse is caring for several older adult patients who are at risk for dehydration. Which task can be delegated to the unlicensed assistive personnel (UAP)? A. withhold fluids if patients have bowel or bladder incontinence B. assess for and report any difficulties that patients are having in swallowing C. stay with patients while they drink fluids and note the exact amount ingested D. divide the Toal amount of fluids needed over a 24-hour period and note in medical record

C

the nurse is reviewing orders for several patients who are at risk for fluid volume overload. for which patient condition does the nurse question an order for diuretics? a. pulmonary edema b. congestive heart failure c. end stage renal disease d. ascites

C

A nurse is assigned to change a central line dressing. The agency policy is to clean the site with Betadine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede Betadine in a dressing change. In addition an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and Betadine. The nurse has a small of the new product. How should the nurse proceed? A. Use the new product sample when changing the dressing. B. Cleanse the site with alcohol first and then with Betadine. C. Cleanse the site with the new product first and then follow the agency's protocol. D. Follow the agency's policy unless it is contraindicated by a health care providers orders.

D

A nurse is caring for a client with albuminuria resulting in edema. What pressure change does the nurse determine as the cause of the edema? A. Decrease in tissue hydrostatic pressure B. Increase in plasma hydrostatic pressure C. Increase in tissue colloid osmotic pressure D. Decrease in plasma colloid oncotic pressure

D

A patient is at risk for fluid volume excess and dependent edema. Which task does the nurse delegate to the UAP? A. massage the legs and heels to stimulate circulation B. evaluate the effectiveness of a pressure-reducing mattress C. assess the coccyx, elbows, and hips daily for signs of redness D. assist the patient to change position every 2 hours

D

The nurse is assessing skin turgor in a 65-year-old patient. What is the correct technique to use with this patient? A. observe the skin for a dry, scaly appearance and compare it to a previous assessment B. Pinch the skin over the back of the hand and observe for tenting; count the number of seconds for the skin to recover position C. observe the mucous membranes and tongue for cracks, fissures, or a pasty coating D. pinch the skin over the sternum and observe for tenting a resumption of skin to its normal position after release

D

a patient has been on prolonged steroid therapy. in assessing the patient for an IV insertion site, what finding does the nurse expect to see? a. ecchymosis and possibly a hematoma b. skin that is thick, tough, dry, and difficult to puncture c. edema or puffiness making visualization of veins difficult d. rash with excoriation from scratching, which limits site selection

a

a patient has hyperkalemia resulting from dehydration. which additional laboratory findings does the nurse anticipate for this patient? a. increase hematocrit and hemoglobin levels b. decreased serum electrolyte levels c. increased urine potassium levels d. decreased serum creatinine

a

a patient is receiving IV therapy via an infusion pump. what is the priority nursing responsibility related to the equipment? a. ensure the IV pump is programmed correctly b. monitor the patients infusion site and rate c. check the equipment at the end of the infusion d. position the container for gravity flow

a

a patient is receiving epidural medication therapy. the nurse assesses for which potential problem specific to this type of therapy? a. meningitis b. loss of bowel function c. allergic reaction d. cardiac dysrhythmias

a

a patient with a recent history of anterior neck injury reports muscle twitching and spasms with tingling in the lips, nose and ears. the nurse suspect these symptoms may be caused by which condition? a. hypocalcemia b. hypokalemia c. hyponatremia d. hypomagnesemia

a

on assessment the patient has respiratory muscle weakness resulting in shallow respirations. which electrolyte abnormality would the nurse suspect? a. hypokalemia b. hyperkalemia c. hypocalcemia d. hypercalcemia

a

the nurse is assessing a patient with a mild increase in sodium level. what early manifestation does the nurse observe in this patient? a. muscle twitching and irregular muscle contractions b. inability of muscles and nerves to respond to a stimulus c. muscle weakness occurring bilaterally with no specific pattern d. reduced or absent bilateral deep tendon reflexes

a

the nurse is assessing a patient with severe hypermagnesemia. which assessment findings are associated with this electrolyte imbalance? a. bradycardia and hypotension b. tachycardia and weak palpable pulse c. hypertension and irritability d. irregular pulse and deep respirations

a

the nurse is giving discharge instructions tl change does the nurse instruct the patio the patient with advanced heart failure who is at continued risk for fluid volume overload. for which physicaent to call the health care provider? a. greater than 3lbs gained in a week or greater than 1 to 2 lbs gain in a 24-hour period b. greater than 5 lbs in a week or greater than 1 to 2 lbs in a 24-hour period c. greater than 15 lbs gained in a month or greater than 5 lbs gained in a week d. greater than 20 lbs gained in a month or greater than 5 lbs gained in a week.

a

the nurse is preparing to deliver IV infusion therapy through an implanted port. what technique does the nurse use to access the port? a. palpate the port, scrub skin, and access with a noncoring (huber) needles b. scrub the port with alcohol and access with a needless device c. scrub the port with butadiene and flush using a 10 mL syringe d. palpate the port, scrub skin, and access with a winged butterfly needle

a

the patient who has undergone which surgical procedure is MOST at risk for hypocalcemia? a. thyroidectomy b. adrenalectomy c. pancreatectomy d. gastectomy

a

the patient with mild fluid volume overload has been instructed by the provider to follow dietary sodium restriction. what would the nurse teach this patient about sodium restriction? a. do not add salt to ordinary table foods b. restrict sodium intake to 2 gm per day c. restrict sodium intake to 4 gm per day d. do not add salt when cooking or eating

a

the provider has ordered therapy for a patient with low sodium and signs of hypervolemia. which diuretic is BEST for this patient? a. conivaptan b. furosemide c. hydrochlorothiazide e. bumetanide

a

when providing care for an older patient receiving IV fluids through a central line at 150 mL/hr the nurse finds the patient has shortness of breath, cough, puffiness around the eyes an crackles. what does the nurse do next? a. place the patient in an upright position, administer oxygen, slow the IV rate, and notify the care provider b. assess for latency of the catheter, change the tubing, and resume IV fluids c. notify the provider, remove the central line, apply pressure, and place the patient in a semi fowlers position d. notify the provider, place the patient in trendelenburg position, and administer urokinase to unclot the catheter

a

which serum value does the nurse expect to see for a patient with hyponatremia? a. sodium less than 136mEq/L b. Chloride less than 95 mEq/L c. sodium less than 145 mEq/L d. chloride less than 103 mEq/L

a

which statement BEST explains how antidiuretic hormone (ADH) affects urine output? a. it increases permeability to water in the tubules, causing a decrease in urine output. b. it increases urine output as a result of water being absorbed by the tubules c. urine output is reduced as the posterior pituitary decreases ADH production d. increased urine output results form increased osmolarity and fluid in the extracellular space.

a

which task would the nurse delegate to a UAP for a patient receiving intraperitoneal therapy? a. place the patient in a high fowlers position for nausea b. assist the patient to move from side to side to distribute the fluid evenly c. assess the patient for side effects of the therapy d. flush the catheter with normal saline when therapy is completed

a

which condition cause a patient to be at risk for hypocalcemia? (SATA) a. crohns disease b. acute pancreatitis c. removal or destruction of parathyroid glands d. immobility e. use of digitalis f. GI wound drainage

a, b, c, d, f

hypodermoclysis can be used for a patient under which types of circumstances? SATA a. if the patient requires palliative care b. for IV fluid replacement that is less than 2000 mL c. when a subcutaneous IV infusion is warranted d. if the patient requires acute care e. when short term fluid volume replacement is warranted f. when a patient requires emergency resuscitation

a, b, c, e

An external long term IV catheter is required for hemodialysis of a hospitalized patient. Which statements are true about this patient's venous access device? SATA a. should not be used for administration of other fluids or medication except in an emergency b. is required for hemodialysis because it has a large lumen c. can often cause a common problem of venous thrombosis d. features a port to access the catheter through e. is a tunneled catheter with large lumen needed for long term hemodialysis f. requires aspiration of the previously instilled heparin before being used

a, b, c, e, f

the nurse is preparing to give a patient IV drug therapy. what information does the nurse need before administering the drug? SATA a. indications, contraindications, and precautions for IV therapy b. appropriate dilution, PH and osmolarity of solution c. rate of infusion and dosage of drugs d. percentage of adverse events for the drug e. compatibility with other IV medications f. parameters to monitor related to immediate drug effects

a, b, c, e, f

the charge nurse is reviewing IV therapy orders. what information must be included in each order? SATA a. specific type of solution b. rate of administration c. specific drug dose to be added to the solution d. method for diluting drugs for the solution e. specific the of administration equipment f. frequency of drug administration

a, b, c, f

a patient with renal failure that results in hypernatremia will require which interventions? (SATA) a. administration of furosemide b. hemodialysis c. IV infusion of 0.9% sodium chloride d. dietary sodium restriction e. administration of potassium supplement f. administration of demeclocycline

a, b, d

which nursing interventions apply to patients with hypercalcemia? (SATA) a. administer IV normal saline b. measure the abdominal girth c. massage calves to encourage blood return to the heart d. monitor for ECG changes e. provide adequate intake of vitamin D f. during treatment, monitor for tetany

a, b, d

the nurse is assessing a patient IV insertion site. what must the nurse loo for during the assessment? SATA a. observe for redness and swelling b. check that the dressing is clean and dry c. ensure that the dressing is adherent to the skin d. observe for yellow discoloration e. observe for hardness or drainage f. check for blood latency and blood return

a, b, d, e

which content must the nurse be sure to teach a patient before central line insertion, specific to prevention of catheter related blood stream infection? SATA a. the type of catheter used b. hand hygiene and aseptic technique for care of the catheter c. how to remove the catheter when it is no longer needed d. activity limitations e. signs and symptoms of complications f. that there is no alternative to the catheter placement or therapy

a, b, d, e

which activities are performed by infusion nurses? SATA a. develop evidence based policies and procedures b. insert and maintain peripheral and central venous catheters c. develop new products for more effective infusion therapy d. consult on product selection and purchasing decisions e. monitor patient outcomes of infusion therapy f. provide education to staff, patients and families

a, b, d, e, f

the nurse is caring for a patient with a central venous catheter. when change the administration set or connectors, what measure will the nurse do to prevent air emboli? SATA a. positions the patient flat so that catheter site is below the heart b. uses the pinch clamp that can be closed during the procedure c. uses sterile technique when handling the equipment d. has an assistant apply pressure at the insertion site e. asks the patient to perform the valsalva maneuver by holding the breath and bearing down f. times the IV set change to the expiratory cycle when the patient is spontaneously breathing

a, b, e, f

which intervention by the staff nurse are essential to prevent an infection in a patient with a central line? SATA a. assess the dressing and insertion site of the central line b. employ aseptic technique when administering medications and changing tubing c. change the catheter every 72 hours and tubing every 24 hours d. monitor the patients temperature for any elevation and give acetaminophen as needed e. use sterile technique when assisting the HCP with insertion of a central line f. use proper hand washing and non sterile gloves before coming in contact with a central line

a, b, e, f

by which mechanisms does parathyroid hormone (PTH) increase serum calcium levels? (SATA) a. releasing free calcium from the bones b. increasing calcium excretion in the urine c. stimulating kidney reabsorption d. causing vitamin D activation e. increasing calcium absorption in the GI tract f. pulling calcium out of the cells

a, c, d, e

which assessment findings are related to mild hypercalcemia? (SATA) a. increased heart rate b. paresthesia c. decreased deep tendon reflexes d. hypoactive bowel sounds e. shortened QT interval f. around muscle weakness

a, c, d, e

the nurse is teaching a patient with hypokalemia about foods high in potassium. which food items does the nurse recommend to this patient? (SATA) a. soybeans b. lettuce c. canteloupe d. potatoes e. peaches f. bananas

a, c, d, f

which patients are at risk for developing hyponatremia? (SATA) a. postoperative patient who has been NPO for 24 hours with no IV fluid infusing b. patient with decreased fluid intake for 3 days c. patient receiving excessive IV fluids with 5% dextrose d. diabetic patient with blood glucose of 250 mg/dL e. patient with overactive adrenal glands f. tennis player in 100ºF (37.7ºC) water who has been drinking water

a, c, d, f

after completing the insertion of a PICC, which entries does the nurse make in the documentation? SATA a. type of dressing applied b. response of the family to IV access c. type of IV access device used d. how long it took to place the IV access e. vein that was used for insertion f. length of catheter, the insertion site, and tip location

a, c, e, f

the patient is ready for discharge. which actions must the nurse follow to remove the patient peripheral catheter? SATA a. hold pressure on the site until hemostasis is achieved b. flush the peripheral catheter with normal saline before removing c. assess the catheter tip to make sure it is intact and completely removed d. rapidly withdraw the catheter from the skin e. remove the peripheral catheter dressing f. document catheter removal and the appearance of the IV site

a, c, e, f

the patients potassium level is 2.5 mEq/L. which clinical findings does the nurse expect to see when assessing this patient? (SATA) a. general skeletal muscle weakness b. moist crackles and tachypnea c. lethargy d. decreased urine output e. weak hand grasps f. weak, thready pulse

a, c, e, f

which are appropriate interventions for a patient who has hypercalcemia? (SATA) a. administer IV normal saline b. administer hydrochlorothiazide (HCTZ) c. ensure adequate hydration d. administer calcium-based antacid for GI upset e. discourage weight bearing activity such as walking f. provide continuous cardiac monitoring

a, c, f

what impacts does sodium have on body function? (SATA) a. maintains electroneutrality b. maintains electrical membrane excitability c. aids in carbohydrate and lipid metabolism d. regulates water balance e. low sodium stimulates secretion of aldosterone f. regulates plasma osmolality

a, d, e, f

which are major causes of hypomagnesemia? (SATA) a. inadequate intake of magnesium b. inadequate intake of sodium c. use of potassium-sparing diuretics d. decreased kidney excretion of magnesium e. prescription of loop diuretics f. cessation of alcohol intake

a, e

The nurse is attaching an administration set to a central venous catheter. Which type of equipment decreases the risk of accidental disconnection or leakage? a. slip lock connecter b. Leur-lock connector c. extension set d. needleless connector

b

a hospitalized patient who is known to be homeless has been diagnosed with severe malnutrition, end-stage renal disease, and anemia. he is transfused with three units of packed red blood cells. which potential electrolyte imbalance does the nurse anticipate could occur in this patient? a. hypernatremia b. hyperkalemia c. hypercalcemia d. hypermagnesemia

b

a patient has a PICC placed and receives IV cisplatin. the drug has infiltrated into the tissue, and redness is observed in the right lower side of the neck. what is the nurses first action? a. apply cold compress to the site of swelling b. stop the infusion and disconnect the IV c. aspirate the drug from the IV access device d. monitor the patient and document

b

a patient requires a non tunneled percutaneous central catheter. what is the nurses role in this procedure? a. insert the catheter using sterile technique b. place the patient in trendelenburg position c. read the chest X-ray to validate placement d. select and prepare the insertion site

b

a patient with low potassium requires an IV potassium infusion. the pharmacy sends a 250-mL IV bag of dextrose in water with 40 mEq of potassium. the label is marked "to infuse over 1 hour" what is the nurses BEST action? a. obtain a pump and administer the solution b. double-check the providers order and call the pharmacy c. hold the infusion because there is an error in labeling d. recalculate the rate so that it is safe for the patient

b

a patines serum potassium value is below 2.8 mEq/L. the patient is also on digoxin. The nurse quickly assesses the patient for which cardiac problem BEFORE notifying the provider? a. cardiac murmur b. cardiac dysrhythmia c. congestive heart failure d. cardiac tamponade

b

an older adult patient needs an oral potassium solution but is refusing it because it has a strong and unpleasant taste. what is the BEST strategy the nurse can use to administer the drug? a, tell the patient that failure to take the drug could result in serious heart problems b. ask the patients preference of juice and mix the drug with a small amount c. mix the solution into food on the patients meal tray and encourage the patient to eat everything d. offer the drug to the patient several times and then document the patients refusal

b

in addition to magnesium levels which other lab values should the nurse be sure to monitor when a patient has hypomagnesemia? a. sodium and potassium b. potassium and calcium c. calcium and sodium d. chloride and sodium

b

intravenous therapy with a hypotonic fluid is ordered for the patient. the nurse would plan to start which solution? a. 0.9% NaCl b. 0.45% NaCl c. 5% dextrose and 0.9% saline d. lactated ringers solution

b

on admission a patient with pulmonary edema weighed 151 lbs; now the patient weight is 149 lbs. assuming the patient was weighed both times with the same clothing on the same scale, and at the same time of day, how many milliliters of fluid does the nurse estimate the patient has lost? a. 500 b. 1000 c. 2000 d. 2500

b

the nurse administering potassium to a patient carefully monitors the infusion because of the risk for which condition? a. pulmonary edema b. cardia dysrhythmia c. postural hypotension d. renal failure

b

the nurse is assessing a patients urine specific gravity. the value is 1.035. how does the nurse interpret this result? a. overhydration b. dehydration c. normal value for an adult d. renal disease

b

the nurse is assessing a short peripheral catheter after removal and it appears that the catheter tip is missing. what does the nurse do next? a. notify the health care provider b. assess the patient for symptoms of emboli c. apply firm pressure to the insertion site d. assess the extremity for coldness, cyanosis, or numbness

b

the nurse is attempting to insert a peripheral IV when the patient reports tingling and a feeling like "pins and needles". what does the nurse do next? a. change to a short winged butterfly needle b. stop immediate, remove the catheter, and choose a new site c. ask the patient to wiggle the fingers to stimulate circulation d. pause the procedure an gently massage the fingers

b

the nurse is caring for a patient who takes potassium and digoxin. for what reason does the nurse monitor both laboratory results? a. digoxin increases potassium loss through the kidneys b. digoxin toxicity can result if hypokalemia is present c. digoxin may cause potassium levels to rise to toxic levels d. hypokalemia causes the cardiac muscle to be less sensitive to digoxin

b

the nurse is caring for a patient with a PICC line. according to recommendations by the infusion nurses society, which technique does the nurse use in maintaining this type of catheter? a. flush the catheter with 10 mL heparinized saline after each dose of IV medication b. use 10 mL of sterile saline to flush before an after medication c. avoid flushing the catheter more than twice in a week d. flush the catheter every 12 hours using a 20 ml syringe

b

the nurse is reviewing the laboratory calcium level results for a patient. which value indicates mild hypocalcemia? a. 5.0 mg/dL b. 8.0 mg/dL c. 10.0 mg/dL d. 12.0 mg/dL

b

the nurse is teaching the patient about hypokalemia. which statement by the patient indicates a correct understanding of the treatment of hypokalemia? a. "my wife does all the cooking. she shops for food high in calcium" b. "when I take the liquid potassium in the evening, I'll eat a snack beforehand" c. "I will avoid bananas, orange juice, and salt substitutes" d. "I hate being stuck with needles all the time to monitor how much sugar I can eat"

b

the patient has an order for 0.45% normal saline 1000 mL to infuse over 15 hours. at what rate in mL/hour would the nurse set the infusion pump? a. 50 ml/hr b. 67 ml/hr c. 75 ml/hr d. 83 ml/hr

b

the patient has sever hypokalemia (2.4 mEq/L). for which intestinal complication does the nurse monitor? a. hypoactive bowel sounds b. paralytic ileus c. nausea d. constipation

b

the patient with a serum magnesium level of 2.9 mEq/L develops bradycardia with a prolonged P-R interval and a widened QRS. what is the nurses BEST FIRST action? a. start an IV with 5% dextrose at 100 mL/hr b. notify the health care provider immediately c. auscultate the patents apical heart rate d. prepare to administer supplemental magnesium by IV

b

the patient with hypokalemia has an IV potassium supplement ordered. which IC potassium supplement can be administered safely? a. KCL 5 mEq in 20 mL NS b. KCl 10 mEq in 100 mL NS c. KCl 15 mEq in 50 mL NS d. KCl 20 mEq in 100 mL NS

b

which clinical condition can result from hypocalcemia? a. stimulated cardiac muscle contraction b. increased intestinal and gastric motility c. decreased peripheral nerve excitability d. increased bone density

b

which component has a high content of potassium and phosphorus? a. extracellular fluid b. intracellular fluid c. extracellular fluid and the intravascular space d. intracellular fluid and lymph fluid

b

which disadvantage accompanies the placement of a large bore peripheral IV catheter? a. increased bloodstream infection b. increased occurrence of phlebitis c. decreased time to need for catheter replacement d. decrease size of vein to accommodate catheter

b

which patient is at greatest risk for chronic hypocalcemia? a. 38-year-old man with chronic kidney disease b. 50-year-old postmenopausal woman c. 62-year-old man with type 2 diabetes d. 78-year-old woman with dehydration

b

a newly admitted patient with congestive heart failure has a potassium level of 5.7 mEq/L. how does the nurse identify contributing factors for the electrolyte imbalance? (SATA) a. assess the patient for hypokalemia b. obtain a list of the patients home medications c. assess the patient for hyperkalemia d. ask about the patients method of taking medications at home e. evaluate the patients appetite f. auscultate for hypoactive bowl sounds

b, c, d

which safety measures does the nurse apply to decrease the risk of catheter related bloodstream infection related to needleless systems? SATA a. clean needleless system connections vigorously every 24 hours b. tape all connections between tubing sets c. clean all needleless connections vigorously for at least 60 seconds before connecting d. use evidence based hand hygiene guidelines from the CDC and OSHA e. use needleless systems only when necessary f. discard needles equipment in a biohazard container

b, c, d

A patient has an elevated potassium level. Which assessment findings are associated with hyperkalemia? (SATA) a. wheezing on exhalation b. numbness in hands and feet and around the mouth c. frequent, watery stools d. irregular heart rate e. circumoral cyanosis f. muscle weakness

b, c, d, f

a patient has a local complication from a peripheral IV access with 0.9% normal saline infusing at 100 mL/hour. what does the nurse assess at the insertion site? SATA a. blood returns in the catheter when nurse draws back on IV access b. a red streak is present proximal to the insertion site c. edema is present proximal to the site d. a scant amount of blood is noted beneath the clear dressing at the site e. the IV fluids are not infusing f. the patient reports. numbness and tingling at the site

b, c, e, f

the electrolyte magnesium is responsible for which functions? (SATA) a. formation of hydrochloric acid b. carbohydrate metabolism c. contraction of skeletal muscle d. regulation of intracellular osmolarity e. vitamin activation f. blood coagulation

b, c, e, f

which foods will the nurse instruct a patient with kidney disease and hyperkalemia to avoid? (SATA) a. canned apricots b. dried beans c. potatoes d. cabbage e. cantaloupe f. canned sausage

b, c, e, f

a patient has a central line inserted in the vena cava. the nurse assess the patient for which potential complications related to the procedure? a. phlebitis b. hemothorax c. air embolism d. cardiac tamponade e. arterial puncture f. bloodstream infection

b, c, f

which statements are correct about intraperitoneal infusions? SATA a. clean technique is used with IP access b. IP can be accomplished by a catheter with an implanted port and large internal lumens c. strict aseptic technique is used with IP access and supplies d. IP is used for patients who are receiving medications for diagnostic tests e. IP can be accomplished by a tunneled catheter with capped ports and large internal lumens f. IP is used for patient who are receiving chemotherapy agents

b, c, f

what are the functions of potassium in the body? (SATA) a. regulates hydration status b. control intracellular osmolarity and volume c. simulates the secretion of antidiuretic hormone (ADH) d. functions as the major cation of intracellular fluid e. regulates glucose use and storage f. helps maintain normal cardiac rhythm

b, d, e, f

the nurse is caring for an older adult patient whose serum sodium level is 150 mEq/L. the nurse assess the patient for which common signs and symptoms associated with with this sodium level? (SATA) a. intact recall of recent events b. increased pulse rate c. rigidity of extremities d. hyperactivity e. muscle weakness f. difficulty palpating peripheral pulses

b, e, f

The nurse must insert a short peripheral IV catheter. In order to decrease the risk of deep vein thrombosis or phlebitis, which area of the arm should be chosen for insertion of the IV catheter? a. wrist b. hand c. forearm d. antecubital area

c

a 65-year-old patient has a potassium laboratory value of 5.0 mEq/L. how does the nurse interpret this value? a. high for the patients age b. low for the patients age c. normal for the patients age d. dependent upon the medical diagnosis

c

a patient with an implanted port is discharged. home to receive long term therapy on an outpatient basis how frequently must the implanted port be flushed between courses of therapy? a. daily b. weekly c. monthly d. when therapy resumes

c

a triple lumen catheter central line is inserted in a patient. what does the nurse do immediately after the procedure? a start IV fluids, but at a slower rate to prevent any fluid overload b. watch and wait for any complications before using the site c. obtain a portable chest xray and hold IV fluids until results are obtained d. assess the patient including vital signs, if the patient is stable start IV fluids

c

the UAP informs the nurse that a patient with hypernatremia who was initially confused and disoriented on admission to the hospital is now trying to pull out the IV access and indwelling urinary catheter. What is the nurses FIRST action? a. place bilateral soft wrists restrains b. inform the provider of the patients change in behavior and obtain an order for restraints c. assess the patient d. offer the patient oral fluids

c

the UAP reports to the nurse that a patient being evaluated for kidney problems has produced a large amount of pale-yellow urine. what does the nurse do NEXT? a. insure the UAP to measure the amount carefully and then discard the urine. b. instruct the UAP to save the urine in a large bottle for a 24-hour urine specimen c. assess the patient for signs of fluid imbalance and check the specific gravity of the urine. d. compare the amount of urine output to the fluid intake for the previous 8 hours

c

the nurse is assessing the patient with a risk for hypocalcemia. what is the correct technique to test for chvostek's sign? a. patient flexes arms against the chest and examiner attempts to pull the arms away from the chest b. place a blood pressure cuff around the upper arm and inflate the cup to greater than the patients systole pressure c. tap the patients face just below and in front of the ear to trigger facial twitching of one side of the mouth, nose and cheek d. lightly tap the patients patellar and achilles tendons with a reflex hammer and measure the movement

c

the nurse is caring for the patient receiving arterial therapy via the carotid artery. what important nursing action is specific to this therapy? a. assess the extremities for sensation and pulses b. monitor respirations for rate and regularity c. perform frequent neurologic assessments d. place antiembolic stockings on the patients lower extremities

c

the patient has an order for one unit of PRBCs (packed red blood cells). which priority action must the nurse complete before starting this infusion? a. place a new IV line designated only for blood product infusion b. ensure that the IV line to be used for infusion is larger than 22 gauge c. check patient identification with another RN using two identifiers d. ensure that the unit of PRBCs has been warmed to body temperature

c

the patient with hyperkalemia is prescribed patiromer. which statement most accurately describes the function of this drug? a. it works in the kidneys to increase excretion of potassium b. the drug prevents the kidneys from absorbing potassium c. it binds with potassium in the GI tract and decreases its absorption d. the drug increases motility in the GI tract, eliminating potassium in diarrhea stools

c

which precaution or intervention does the nurse teach a patient at continued risk for hypernatremia? a. avoid salt substitutions b. avoid aspirin and aspirin containing products c. read labels on canned or packaged foods to determine sodium content d. increase daily intake of caffeine-containing foods and beverages

c

which priority concept is of concern to the nurse when performing infusion therapy? a. acid base imbalance b. tissue integrity c. fluid and electrolyte balance d. perfusion

c

while attempting to remove a PICC line the nurse meets resistance. what technique does the nurse use first to attempt to resolve this problem? a. gently pull on the catheter while the patient holds his or her breath b. place a cold pack on the extremity and give the patient a cold drink c. use simple distraction techniques and deep breathing d. place the patient in trendelenburg position

c

a patient is to be discharged home with n implanted port and needs discharge instructions on prescribed medication administration. which instructions must the nurse give to the patient and family member who will be assisting the patient? SATA a. the device must be flushed every 24 hours b. when the port is not accessed, an occlusive dressing should be applied c. the skin will be punctured over the port when the port is accessed d. when the port is not accessed, no dressing needs to be applied e. the port must be flushed after each use f. check for blood return after medication administration

c, d, e

a patient requires IV therapy via a peripheral line. what factors does the nurse consider when inserting the peripheral IV? SATA a. use either an upper or lower extremity for the insertion site b. for older adults, start with more distal sites such as the hand veins c. for active adults, start with more proximal sites such as the forearm d. choose the patients non dominant arm e. do not use the arm if the patient has a mastectomy on that side f. if the vein is hard and cordlike, use an indirect approach g. avoid placing an IV on the anterior surface of the wrist

c, d, e, g

A patient has a magnesium level of 0.8 mg/dL. Which treatment does the nurse expect to be ordered for this patient? a. IM magnesium sulfate b. increased intake of fruits and vegetables c. oral preparation of magnesium sulfate d. IV magnesium sulfate and discontinuation of diuretic therapy

d

a patient is brought to the emergency department after a serious motor vehicle accident. which factor makes the patient a candidate for intraosseous therapy? a. patient has a history of chronic renal failure b. endotracheal intubation is difficult to accomplish c. patient is an older adult and very thin d. IV access cannot be achieved within a few minutes

d

a patient is ordered to receive peripheral parenteral nutrition. what type of access device is appropriate for this patient? a. peripheral 20 gauge IV needle b. non tunneled percutaneous central catheter c. peripheral 22 gauge IV needle d. peripherally inserted central catheter

d

after assessing the patency of a patients IV catheter, the nurse attempts to flush the catheter and meets resistance. what does the nurse do next? a. get a larger sized syringe and repeat the flush attempt b. use a heparinized solution and repeat the flush attempt c. gently force flush the catheter using the push pause method d. stop the flush attempt and discontinue the IV

d

the home health nurse is adjusting the rate for a hypodermoclysis treatment. what is the usual maximum rate for this therapy? a. 20 mL/hr b. 30 mL/hr c 80 mL/hr d 120 mL/hr

d

the home health nurse is caring for a patient receiving hypodermoclysis therapy. how often are subcutaneous sites rotated? a. every 4 hours b. every 24 hours c. at least every 3 days d. at least once a week

d

the nurse has removed the dressing from a patient central venous catheter site. to monitor the catheter position, what does the nurse do? a. gently push the catheter into the insertion site b. slightly retract the catheter and observe the position c. mark the catheter with a pen to monitor the length d. note the length of the catheter external to the insertion site

d

the nurse is adding a filter to an IV administration setup. where is the best place to add the filter to the IV line? a. as close to the solution container as possible b. immediately below the infusion pump c. at any convenient connect point d. as close as possible to the catheter hub

d

the nurse is caring for a patient with hypernatremia caused by fluid loss. what type of IV solution is best for treating this patient? a. hypotonic 0.225% sodium chloride b. small-volume infusions of hypertonic (2%-3%) saline c. isotonic sodium chloride (NaCl) d. 0.9% sodium chloride

d

the nurse is caring for several patients at risk for fluid and electrolyte imbalances. which patient problem or condition can result in a relative hypernatremia? a. use of a salt substitute b. presence of a feeding tube c. drinking too much water d. long-term NPO status

d

the nurse is caring for several patients with electrolyte imbalances. which intervention is included in the plan of care for patient with hypomagnesemia? a. implementing an oral fluid restriction of 1500 mL/day b. implementing a renal diet c. providing moderate environmental stimulation with music d. placing the patient on seizure precautions

d

the nurse is preparing to administer IV infusion therapy to a patient. when is the choice of using a glass container appropriate? a. when the patient needs a rapid infusion of fluids b. when the patient needs emergency transportation c. when the nurse must accurately read the container d. when the drug is incompatible with a plastic container

d

the nurse is selecting a site for peripheral IV insertion. which patient condition influences the choice of left versus right upper extremity? a. pneumothorax with a chest tube on the right side b. myocardial infarction with pain radiating down the left arm c. right hip fracture with immobilization and traction in place d. regular renal dialysis with a shunt in the left upper forearm

d

the nurse is supervising a student nurse who is preparing an IV bag with IV administration tubing. for which action by the student nurse must the nurse intervene? a. the student touches the drip chamber b. the sterile cap from the distal end of the set is removed c. the distal end is attached to a needless connector d. the student touches the tubing spike

d

under what circumstances does the nurse elect to use on secondary set to administer multiple medications instead of a secondary set to administer each medication? a. when multiple intermittent medications are required b. to eliminate the cost of using multiple secondary sets c. when the nurse is using the back priming method d. when the medications are compatible

d

which instruction does the nurse give to a UAP who has been delegated to check BP on 6 patients being infused with peripheral IV fluids? a. be sure to put the infusion pumps on hold before taking BP b. have the patients sit up at the side of the bed before taking BP c. check BP by placing the cuff at least 12 inches above the IV site d. do the BP checks on the arm that onset have the IV fluids infusing

d

which intervention does the nurse implement for a patient with hypocalcemia? a. encourage activity by the patient as tolerated, including weight lifting b. encourage socialization and active participation in stimulating activities c. keep a tracheotomy tray at the bedside for emergency use d. provide adequate intake of vitamin D and calcium-rich foods

d

which serum laboratory value does the nurse expect to see in a patient with hyperkalemia? a. calcium greater than 8.0 mg/dL b. potassium greater than 3.5 mEq/L c. calcium greater than 11.0 mg/dL d. potassium greater than 5.0 mEq/L

d

which serum laboratory value does the nurse expect to see in the patient with hypokalemia? a. calcium less than 8.0 mg/dL b. potassium less than 5.0 mEq/L c. calcium less than 11.0 mg/dL d. potassium less than 3.5 mEq/L

d

which site is most commonly used for intraosseous therapy? a. distal femur b. proximal humerus c. iliac crest d. proximal tibia

d

what interventions are appropriate for a patient with hypernatremia caused by reduced kidney sodium excretion? (SATA) a. hypotonic solutions b. 0.45% sodium chloride IV infusion c. D5W IV infusion d. administration of bumetanide e. ensure adequate water intake f. diuretics such as furosemide

d, f