MS120 CH 13 & 15

Which intervention will the nurse teach the client who has lymphedema in her right arm from a mastectomy?

A -"Exercise your arm and use it during tasks that occur at the level of your chest or higher." -Skeletal muscle contractions facilitate flow in lymph channels. Keeping the arm at chest level or higher prevents stasis of lymph fluid from gravitational forces. The other answer options are not choices that would prevent stasis of lymph fluid.

What information is most important to teach the client going home with a PICC line?

A -"Avoid carrying your grandchild with the arm that has the IV." -A properly placed PICC (in the antecubital fossa or basilic vein) allows the client considerable freedom of movement. Clients can participate in most activities of daily living. Heavy lifting can dislodge the catheter or occlude the lumen. Although it is important to keep the insertion site and tubing dry, the client can shower. The device only needs to be flushed after medications are administered through it or flushed weekly.

Which question will the nurse ask the client who has isotonic dehydration to determine a possible cause?

A -"Do you take diuretics or 'water pills'?" -Misuse or overuse of diuretics is a common cause of isotonic dehydration. The other statements are not indicative of causes of isotonic dehydration.

The client is taking a medication that inhibits aldosterone secretion and release. The nurse assesses for what potential complication?

B - Hyperkalemia -Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client's risk for excessive water loss and increased potassium reabsorption. The client would not be at risk for overhydration or sodium imbalance.

When taking the blood pressure of a very ill client, the nurse observes that the client's hand undergoes flexion contractions. What is the nurse's primary intervention?

B -Deflating the blood pressure cuff and administer oxygen -Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. This effect of hypocalcemia is enhanced in the presence of tissue hypoxia. The flexion contractions occurring during blood pressure measurement are indicative of hypocalcemia and are referred to as a positive Trousseau's sign. The nurse will first treat the hypoxia.

What is the initial action taken after completion of an intermittent medication administration through a Groshong catheter?

B -Flushing the line with saline -The Groshong catheter is not an implanted port. After intermittent use, the catheter is to be flushed with saline. The manufacturer's instructions state that the catheter should not be clamped to maintain the integrity of the catheter valve. If a heparin flush is ordered, it is given after the catheter has been flushed with saline. The access needle is used for implanted ports.

After discontinuing a nontunneled, percutaneous central catheter, it is most important for the nurse to record which information?

B -Length of the catheter -After removal of a catheter, measure the catheter length and compare it with the length documented on insertion. If the entire length has not been removed, the nurse should contact the physician immediately because some of the catheter may still be in the client's vein.

A client is to receive 10 days of antibiotic therapy for urosepsis. The nurse should select which intravenous catheter to place?

B -Midline catheter -Midline catheters are used for therapies lasting from 1 to 4 weeks. Short peripheral catheters can be inserted by the nurse to use for antibiotic therapy, but can only stay in for up to 96 hours. If the length of intravenous therapy is longer than 6 days, a midline catheter should be chosen. Nontunneled central catheters and Hickman catheters are inserted by a physician.

Five days after the start of intraperitoneal therapy, the client is complaining of abdominal pain and "feeling warm." The nurse recognizes that the client is most likely exhibiting symptoms of which condition?

D - Infection -Fever, abdominal pain, abdominal rigidity, and rebound tenderness may be present in the client who has peritonitis related to intraperitoneal therapy. Peritonitis is preventable by using strict aseptic technique in the handling of all equipment and infusion supplies. An allergic reaction would occur earlier in the course of treatment. Bowel obstruction and catheter lumen occlusion can occur, but would present clinically in different ways.

The nurse is caring for a client with a radial arterial catheter. Which assessment is of most concern?

D -Presence of an ulnar pulse -An intra-arterial catheter can cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessing the ulnar pulse could be one way to assess circulation to the arm in which the catheter is located. The nurse would note that there is enough pressure in the fluid container to keep the system flushed, and would also check to see if the catheter tubing needs to be changed. However these are not assessments of most concern. Because of heparin-induced thrombocytopenia, heparin is not used in most institutions for an arterial catheter.

What action should the nurse take to prevent infection in the older adult receiving intravenous therapy?

A -Allowing antiseptic solutions to dry prior to dressing application -The skin of an older adult may be more delicate and compromised. Avoidance of a disruption in skin integrity lessens the chance of an infection occurring with an IV catheter. Allowing antiseptic solutions to dry prior to applying the catheter dressing allows the antiseptic solution to be effective and the dressing to remain securely over the site. Using alcohol pads makes it easier to remove tape and avoid skin tears. The skin should never be shaved before venipuncture because micro-abrasions may occur, which can lead to infection. Excessive friction may damage fragile skin and compromise skin integrity.

The nurse notes that the hand grip of the client with hypokalemia has diminished since the previous assessment 1 hour ago. What is the nurse's priority intervention?

A -Assessing the client's rate, rhythm, and depth of respiration -Progressive skeletal muscle weakness is associated with increasing severity of the hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. The nurse would next call the health care provider for orders for potassium replacement.

The nurse is caring for a client receiving an epidural infusion for pain management. Which action has the highest priority?

A -Assessing the respiratory rate -Complications from an epidural infusion can be caused by the type of medication being infused or can be related to the catheter. When used for pain management, the client needs to be assessed for level of alertness, respiratory status, and itching. Dressings are not routinely changed because the catheter is only used for short periods. Using other pain management therapies and weaning the pain medication are important, but monitoring the respiratory status has the highest priority in the nursing care of this client

To prevent infection when infusing an intermittent "piggyback" line, which intervention is most important for the nurse to implement?

A -Backpriming the secondary container -The backpriming method allows multiple drugs to be infused through the same secondary set. This method allows the primary and secondary sets to remain connected together as an infusion system and allows the nurse to adhere to the Infusion Nurses Society (INS) standards of practice. The client is at an increased risk for infection whenever the catheter is disconnected from the tubing (distractors B and C). Sterile gloves are not necessary for the IV administration of medication.

Which infusion device will the nurse select for the older adult client with the medical diagnosis of "Dehydration"?

A -Cassette pump -An older adult client who has dehydration will require a large fluid volume that is accurately measured by using a cassette pump during the infusion. Volumetric controllers count drops for administered volume and are inherently inaccurate because of variation in drop size. A syringe pump is accurate but not appropriate for a large volume. Elastomeric balloons are used to deliver intermittent medications.

When an IV pump alarms because of pressure, what action will the nurse take first?

A -Checks for kinking of the catheter -Fluid flow through the infusion system requires that the pressure on the external side be greater than the pressure at the catheter tip. Fluid flow can be slowed for many reasons. A common reason, and easy to correct, is a kinked catheter. If this is not the cause of the pressure alarm, the nurse may have to ascertain if a clot has formed inside the catheter lumen or if the pump is no longer functional

The client is admitted with multiple fractures from a motor vehicle crash (MVC). Which of the client's previous or concurrent health problems is most likely to increase his risk for hypophosphatemia?

A -Chronic alcoholic pancreatitis -Chronic alcoholism leads to malnutrition. Malnutrition is a major contributing factor to the development of hypophosphatemia. None of the other conditions contribute to hypophosphatemia.

The nurse is assessing several clients receiving intravenous medications. Which client situation requires immediate intervention?

A -Completion of an intermittent medication into a Groshong catheter -A Groshong catheter is a peripherally inserted catheter that needs to be flushed with saline after intermittent use. Peripheral IV catheters should be discontinued after 4 days. An order to discontinue the peripheral catheter requires intervention, but flushing of the Groshong catheter is more of an immediate intervention to prevent clotting of the catheter. A nonaccessed implanted port site needs to be assessed, but this is not an immediate intervention.

When assessing the client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. What is the most accurate documentation of this finding?

A -Grade 3 phlebitis at IV site -The presence of a red streak and palpable cord indicates grade 3 phlebitis. There is no information in the description to indicate that infection, infiltration, or thrombosis is present.

When changing the administration set on a central venous catheter, it is most important for the nurse to carry out what intervention?

A -Have the client hold his breath during the disconnection and reconnection. -An air embolus is less likely to form if the exit site is lower than the level of the heart and if the pressure in the thoracic cavity is higher when the disconnection occurs. Having the client perform the Valsalva maneuver and maintain it during disconnection and reconnection helps maintain a higher intrathoracic pressure. The slide clamp on the catheter extension should be kept clamped. The client should be placed in the flat position when changing administration sets.

Which client is at greatest risk for the development of hyperkalemia?

A -Man with heart failure using a salt substitute -Many salt substitutes are composed of potassium chloride. Heavy use can contribute to the development of hyperkalemia. The client should be taught to read labels and choose a salt substitute that does not contain potassium. Nonsteroidal anti-inflammatory drugs (NSAIDs) promote the retention of sodium but not potassium.

Which assessment will the nurse use to determine the adequacy of circulation in a client whose blood osmolarity is 250 mOsm/L?

A -Measuring urine output -The blood osmolarity is low. The client could be dehydrated (hypo-osmolar dehydration) or overhydrated, with dilution of blood solute. The most sensitive noninvasive indicator of circulation adequacy is urine output. Measuring abdominal girth, comparing pulses, and monitoring fluid intake would not be accurate assessment techniques for this client.

Which client is at greatest risk for developing hyponatremia?

A -Middle-aged adult client who is NPO and receiving D5W as the mainstay of intravenous therapy -D5W contains no electrolytes. Because the client is not taking any food or fluids by mouth, normal sodium excretion can lead to hyponatremia. The antibiotic, Motrin, and digoxin will not put a client at risk for hyponatremia

Which clinical manifestation or condition indicates that treatment for hypokalemia is effective?

A -The client reports having a bowel movement daily -Hypokalemia depresses all excitable tissues, including gastrointestinal smooth muscle. Clients who have hypokalemia have reduced or absent bowel sounds and are constipated. The other answer options are not applicable to hypokalemia.

The RN assigned a new nurse to a client who was receiving chemotherapy through an intravenous extension set attached to a Huber needle. Which information about disconnecting the Huber needle is most important for the RN to provide to this nurse?

B -"Be aware of a rebound effect when discontinuing the system." -Huber needles are used to access implanted ports placed under the skin. Because the dense septum holds tightly to the needle, there can be a rebound when it is pulled from the septum, often resulting in needle stick injury to the nurse. Topical anesthetic cream can be used when accessing the system. Flushing is carried out when the system is accessed and once monthly. Because the implanted port is not being removed, there is no need for a pressure dressing.

What intervention is most important to teach the client at risk for hypercalcemia?

B -"Be sure to drink adequate amounts of fluids each day." -Dehydration is the most common cause or contributing factor for hypercalcemia. Ingestion of reasonable amounts of dairy products does not increase the risk for hypercalcemia because high normal blood levels of calcium inhibit calcium absorption from the intestinal tract. Not allowing clients at risk for hypercalcemia to have any dairy products at all has not been proven effective for preventing hypercalcemia. Caffeine may decrease calcium levels, but this would not be an appropriate intervention.

Which question will the nurse ask the client to help determine the cause of hypokalemia?

B -"Do you use diuretics or laxatives?" -Misuse or overuse of diuretics, especially high-ceiling (loop) and thiazide diuretics, and laxatives are common causes of hypokalemia in older adults and clients with eating disorders.

Which client statement indicates a correct understanding of prevention and clinical manifestation of dehydration?

B -"I will weigh myself every morning before I eat or drink." -Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or fluid retention. A weight loss of more than 0.5 pound daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.

What action is most important for the nurse to teach the client who is at continued risk for complications from hypocalcemia?

B -"Use an electric shaver rather than a safety razor." -Calcium is a cofactor at every step in the blood-clotting cascade. When hypocalcemia is present, blood takes longer to clot. Clients must be taught to avoid activities that can result in injury to prevent excessive bleeding or bruising.

Which subjective symptom will alert the nurse to the possibility of hypocalcemia?

B -"Usually I wake up several times a night with painful cramps in my legs." -Extracellular calcium is an excitable membrane stabilizer. Irritable skeletal muscles, as manifested by twitches and cramps, are an indication of mild hypocalcemia.

Which client statement indicates the need for more teaching regarding identification of the early manifestations of hypokalemia?

B -"When I am constipated, I drink more fluids." -The intestinal tract is relatively sensitive to decreasing potassium levels. Common manifestations of hypokalemia are decreased peristalsis and constipation.

Which client statement indicates adequate understanding of measures to take to prevent mild dehydration from becoming more severe?

B -"When I feel lightheaded, I will drink a glass of water." -Feeling lightheaded or dizzy is an indication of low blood pressure and poor perfusion. Mild dehydration can cause these problems and increasing fluid intake at the first sign of dehydration may prevent it from becoming worse.

The home care nurse is about to administer intravenous medication to the client and reads in the chart that the PICC line in the client's left arm has been in place for 4 weeks. The IV is patent, with a good blood return. The site is clean and free from manifestations of infiltration, irritation, and infection. What is the nurse's best action?

B -Administers the prescribed medication -A PICC line that is functioning well without inflammation or infection may remain in place for months or even years. Because the line shows no signs of complications, it is permissible to administer the IV antibiotic. The physician does not have to be called to have the IV route changed to an oral route.

Which intervention in a client with dehydration-induced confusion is most likely to relieve the confusion?

B -Applying oxygen by mask or nasal cannula -Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimum. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema.

The nurse observes that the hand grip of the client with hypophosphatemia has diminished in strength since the last assessment 2 hours ago. What is the nurse's primary intervention?

B -Assesses respiratory status immediately -Decreased hand grip strength indicates worsening of the hypophosphatemia and general muscle weakness. Muscle weakness can impair respiratory effort and reduce gas exchange to the point that the client becomes hypoxemic. The other interventions are less important.

Which intervention is most important for the nurse to teach the client who is going home but remains at risk for the development of hyperkalemia?

B -Assessing radial pulse for a full minute twice each day -As potassium levels rise, dysrhythmias can develop. By being vigilant for changes in pulse rate, rhythm, and quality, the client can seek medical attention before hyperkalemia becomes severe. Taking a daily weight will help determine fluid retention, but this is not an accurate indicator of potassium increase or decrease. Fluid intake should be based on body weight. Sodium restriction may not be necessary

A client who is having a tunneled central venous catheter inserted begins to complain of chest pain and difficulty breathing. What action will the nurse take first?

B -Assists with insertion of a chest tube -An insertion-related complication of central venous catheters is a pneumothorax. Signs and symptoms of a pneumothorax include chest pain and dyspnea. The treatment includes removing the catheter, administering oxygen and placement of a chest tube. The pain is caused by the pneumothorax, which must be taken care of with a chest tube insertion. A sterile dressing and placement of the client in a Trendelenburg position are not indicated for the primary problem of a pneumothorax.

Which client will the nurse assess first for the development of hypertonic dehydration?

B -The middle-aged man with diabetic ketoacidosis -Hypertonic dehydration occurs when water loss from the extracellular fluid (ECF) is greater than a proportionate electrolyte loss. The remaining ECF is hypertonic, causing fluid to move from the intracellular space to maintain circulating volume. Thus, the symptoms of hypovolemia are not present. Ketoacidosis contributes to excess water loss through the greatly increased respiratory rate and very little electrolyte is lost. In someone who is hemorrhaging, whole blood with fluid and electrolytes is lost, causing isotonic dehydration. The fluid balance problem with heart failure is overhydration. Malnutrition causes the body fluid to be hypotonic from decreased protein and sodium levels.

As a result of the client's admission to the hospital for excessive nausea, vomiting, and a blood pressure of 80/50 mm Hg, the nurse will choose which peripheral catheter gauge to insert into the hand?

C - 20 gage -The nurse selects the access device most appropriate for the designated purpose. In this case, because a large amount of fluid will be needed as a result of excessive fluid loss, the appropriate needle is the 20-gauge catheter IV because this is the most commonly used size in adults and can be used for all fluids. The 22- and 24-gauge catheters will have a slower rate of flow, which may not be desirable with excessive fluid losses and a low blood pressure. The 18-gauge catheter allows rapid flow of IV fluids. However, it requires a large vein and is more prone to irritation to the vein wall.

Which alteration in psychosocial functioning will alert the nurse to the possibility of hypokalemia?

C - Confusion -Hypokalemia decreases cerebral function and is manifested by lethargy, confusion, inability to perform problem-solving tasks, disorientation, and coma.

The client at risk for continuing hyperkalemia states that she is upset because she cannot eat fruit every day. What is the nurse's best response?

C -"Berries, cherries, apples, and peaches are low in potassium." -Not all fruit is potassium-rich. Fruits that are relatively low in potassium and can be included in the diet include apples, apricots, berries, cherries, grapefruit, peaches, and pineapples. Fruits high in potassium include bananas, kiwi, cantaloupe, oranges, and dried fruit.

Which statement made by the older adult client will alert the nurse to the possibility of fluid and electrolyte imbalances?

C -"I don't drink liquids after 5 PM so I don't have to get up at night." -Restricting fluids without a medical reason can lead to dehydration. Many older clients believe that restricting fluids will prevent incontinence and reduce the number of times that they wake up during the night. The increased osmolarity of the urine in response to reducing fluid intake increases the irritation of the bladder and sphincter, increasing the sensation of needing to urinate. The other statements do not indicate practices that could potentially lead to dehydration.

What action is most important for the nurse to teach the client who is at continued risk for mild hypernatremia?

C -"Read the labels of all packaged foods to determine the sodium content." -Most prepackaged foods have a high sodium content. Teaching the client how to read the labels and calculate the sodium content of food can help him or her adhere to the prescribed sodium restriction and prevent hypernatremia. Daily weights and checking the pulse are methods of identifying manifestations of hypernatremia but do not prevent it. The addition of substances during cooking increases the sodium content of a meal, not the method of cooking.

During an assessment of hydration status, the client tells the nurse that she drank 3 quarts of liquids the day before. What will the nurse ask next?

C -"What kinds of liquids do you usually drink?" -It is just as important to determine the types of fluids ingested as the amount, because fluids vary widely in their osmolarity. In addition, some liquids, such as those that contain alcohol or caffeine, can contribute to fluid and electrolyte imbalances.

Which intervention is most likely to relieve confusion caused by overhydration?

C -Administering diuretic agents as prescribed -Overhydration most frequently leads to poor neuronal function, causing confusion as a result of electrolyte imbalances (usually sodium dilution). Eliminating the fluid excess is the best way to reduce confusion. The other interventions would not relieve the client's confusion.

The client is receiving 100 mL of dextrose 20% in water with 20 units of regular insulin. The client is slightly confused, has a weak hand grasp, and is pale and sweaty. What is the nurse's first intervention?

C -Assessing fingerstick blood glucose -Intravenous fluids containing insulin place the client at risk for hypoglycemia as well as hypokalemia. The client's clinical manifestations could indicate hypoglycemia and/or hypokalemia. Because hypoglycemia can be life-threatening, the nurse should intervene for this first. The nurse's first action will be to assess a fingerstick blood sugar. If the client's blood sugar is low, appropriate intervention must be taken. Stopping the current IV solution but maintaining IV access is critical. Although potassium may be given as a small infusion (100 to 150 mL) of IV fluid, it is not given by IV push.

The nurse observes distended neck veins. What is the priority intervention for this client?

C -Assessing the pulse and blood pressure -Neck veins in the normovolemic person are full in the supine position and flat in the sitting position. Full neck veins in the sitting position are an indicator of overhydration. Checking the pulse and blood pressure can help determine if overhydration is present.

The nurse observes tenting of the skin on the back of the older adult client's hand. What is the nurse's next action?

C -Assessing turgor on the client's forehead -Skin turgor cannot be accurately assessed on an older adult client's hands because of age-related loss of tissue elasticity in this area. Areas that more accurately show skin turgor status on an older client include the skin of the forehead, chest, and abdomen. These should also be assessed, rather than merely examining dependent body areas. Further assessment is needed rather than only documenting, monitoring, and notifying the physician.

Which assessment finding will alert the nurse to a worsening of the client's hyponatremia?

C -Bowel sounds are hyperactive in all abdominal quadrants. -Clinical manifestations of hyponatremia are most evident in excitable tissues and include lethargy, decreased blood pressure, increased gastric motility, and diminished deep tendon reflexes.

The client who has just had an IV started in the right cephalic vein tells the nurse that the wrist and hand below the IV site feel like "pins and needles." What is the nurse's best action?

C -Discontinues the IV and restart it at another sit. -The sensation that the client has described is related to the IV needle touching the nerve or possibly transecting the nerve. This problem can lead to loss of function and the potential for permanent disability in the distal extremity. It is considered an emergency and the IV must be discontinued. Continuing just to monitor the IV site may lead to loss of function. The presence of blood return does not indicate absence of nerve damage. Elevation of the affected extremity does not ensure that the IV catheter has moved away from the nerve.

When assigning a client having intravenous therapy to a licensed practical nurse (LPN), which instruction is most important for the registered nurse (RN) to provide?

C -Hang a designated IV solution if permitted by the institution. -In many states, licensed practical nurses are limited in their scope of practice related to IV therapy. The RN can delegate and supervise selected nursing tasks, such as hanging an IV, to the LPN, as designated by the health care agency. The RN is accountable for comprehensive client care and outcomes of that care. This accountability would include the client's response to intravenous therapy, changing the central venous catheter dressing, and monitoring the client for side effects of the therapy.

What is the priority teaching intervention for the client with chronic hypophosphatemia?

C -How to select foods high in phosphorus and low in calcium -Chronic hypophosphatemia can be managed with nutrition therapy. The client needs to increase her or his ingestion of phosphorus and decrease ingestion of calcium because phosphorus and calcium exist in the blood in a balanced inverse relationship.

The nurse is caring for a client with an intraosseous catheter placed in the leg 20 hours ago. Which assessment is of most concern?

C -Leg cool to touch -Compartment syndrome is a condition in which increased tissue perfusion in a confined anatomic space causes decreased blood flow to the area. A cool extremity can signal the possibility of this syndrome. All the other distractors are important. However, the possible development of a compartment syndrome is one that requires immediate intervention because the client could require amputation of the limb if the nurse does not pick up this perfusion problem.

Which action will the nurse teach a client to reduce the risk for dehydration?

C -Maintaining a daily oral intake approximately equal to daily fluid loss -Although a fixed oral intake of 1500 mL daily is good, the key to prevention of dehydration is to match all fluid losses with the same volume for fluid intake. This is especially true in warm or dry environments or when conditions result in a greater than usual fluid loss through perspiration or ventilation.

What intervention is most important to teach the client about identifying the onset of dehydration?

C -Obtaining and charting accurate weight -Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or fluid retention. Obtaining and charting accurate weight is the most sensitive and cost-effective way of monitoring fluid balance in the home.

Which client does the nurse determine is at highest risk for dehydration?

C -Older adult client receiving blood replacement therapy with 3 units of packed cells -Blood replacement therapy involves intravenous fluid administration, which inherently increases the risk for overhydration. The fact that the fluid consists of packed red blood cells greatly increases the risk because this fluid increases the colloidal oncotic pressure of the blood, causing fluid to move from the interstitial and intracellular spaces into the plasma volume. An older adult may not have sufficient cardiac or renal reserve to manage this extra fluid

Which client is at greatest risk for development of hypocalcemia?

C -Older adult client who has alcoholism and malnutrition -Calcium is absorbed from the gastrointestinal tract under the influence of vitamin D. When a client is malnourished, not only is the dietary intake of calcium usually low, but the client is also vitamin-deficient.

Which protein source will the nurse recommend for a client who needs to restrict dietary potassium intake?

C -Poached eggs -Meat and fish have cells that contain large amounts of potassium. Eggs contain few cells and have one of the lowest potassium contents among high-protein foods. Broccoli is not considered a source of protein.

What dietary meal selection indicates the client understands how to increase dietary potassium intake?

C -Sausage, one slice of whole wheat toast, 1/2 cup of raisins, and a glass of milk -Meat, dairy products, and dried fruit have high concentrations of potassium. Eggs, breads, cereals, sugar, and some fruit (berries, peaches) are low in potassium.

Which assessment data obtained by the home care nurse suggests that an older adult client may be dehydrated?

C -The client states that he feels lightheaded when he gets out of bed or stands up. -Orthostatic or postural hypotension can be caused by or worsened by dehydration. The other statements are not as indicative of the severe degree of dehydration as dizziness on standing.

Which client is at greatest risk for hypokalemia?

C -The client with Cushing's disease -In Cushing's disease, the person has an excess of glucocorticoids, especially cortisol. Cortisol has some action of aldosterone, resulting in an increased reabsorption of sodium and water while enhancing the excretion of potassium. Therefore, any client with cortisol excess, whether from Cushing's disease or from exogenous cortisol, is at high risk for the development of hypokalemia.

What is the most important instruction that the nurse gives to the client who is prescribed oral alendronate?

D -"Do not take this medication with food or any other medication." -Food inhibits the absorption of this medication. This medication has a high potential to interact with other drugs. This medication should not alter the heart rate, cause dependency, or interact with aspirin.

Which assessment finding obtained while taking the history of an older adult client will alert the nurse to the possibility of fluid or electrolyte imbalance?

D -"My rings are tighter this week." -A change in ring size over a relatively short period of time may indicate a change in body fluid amount or distribution rather than a change in body fat. The other statements are not indicators of a fluid or electrolyte imbalance.

A client has been taught the need to restrict sodium. Which food selection indicates appropriate choices?

D -A chicken leg, one slice of whole wheat bread with butter, and 1/2 cup of steamed carrots -The total sodium content of the chicken leg, bread, and carrots is 370 mg. The sodium content of the next lowest sodium-containing meal is 550 mg. The other meal selections are also too high in sodium content for a restricted sodium diet.

Which client would be the best candidate to receive hypodermoclysis for intravenous therapy?

D -Client receiving pain management -Subcutaneous therapy (hypodermoclysis) involves the slow infusion of isotonic fluids into the client's subcutaneous tissue. Most often, it is used in hospices for pain management. It should not be used if the fluid replacement needs exceed 3000 mL/day. To be used, the client must have sufficient areas of intact skin. Hyaluronidase is frequently used to help absorb the fluid during the therapy.

Which IV order would the nurse question?

D -Infuse 0.9% normal saline at keep vein open (KVO) rate -To be complete, IV orders for infusion fluids should specify the rate of infusion. This order does not specify the rate of infusion and is not considered complete.

The nurse is caring for four clients receiving intravenous therapy. Which client should the nurse assess first?

D -Older adult client with normal saline infusing -Older adults are more prone to fluid overload and resulting congestive heart failure. Because this client is receiving continuous IV fluid, he or she is at risk for fluid overload and needs to be assessed. All the other clients would need to be assessed for complications of IV catheters. However, they do not need immediate assessment.

Which clinical manifestation in a client with dehydration indicates the need for oxygen therapy?

D -Pulse rate of 115 beats/min -Severe dehydration can decrease circulating volume and decrease cardiac output, placing vital organs at risk for hypoxia, anoxia, and ischemia. Whenever cardiac output is decreased with dehydration, oxygen therapy is indicated.

In examining a peripheral IV site, the nurse observes a red streak along the length of the vein and the vein feels hard and cordlike. What is the nurse's next action?

D -Removing the catheter -The clinical manifestations described are those associated with phlebitis. Phlebitis is an inflammation of the vein. Its presence in a vein being used for IV therapy may be caused by mechanical forces associated with the IV device or by chemical factors related to the composition and osmolarity of the drug solution. The key manifestation is that the symptoms are directly associated with the vein and the catheter must be removed. Warm compresses can be applied for 20 minutes four times daily after the catheter is removed. The site needs to be monitored after the catheter is removed. The arm is not swollen. Therefore, elevation of the extremity is not a correct option.

Prior to the administration of intravenous fluid, it is most important for the nurse to obtain which information from the health care provider's orders?

D -Specific type of intravenous fluid -An order for infusion therapy must contain the following to be complete: specific type of fluid, rate of administration, and drugs added to the solution. Osmolarity of the solution is not necessary because it is incorporated into the specific type of fluid. It is the nurse's independent decision about the most appropriate vein to cannulate and the catheter size to use.

The client is receiving an intravenous infusion of 60 mEq of potassium chloride in a 1000-mL solution of dextrose 5% in 0.45% saline. The client states that the area around the IV site burns. What intervention will the nurse perform first?

D -Stops the IV fluid containing potassium -Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains the potassium. The nurse could run another solution as assessment continues. Assessing for a blood return may or may not be successful. The solution could be diluted (less potassium) and the rate could be slowed once it is determined that the needle is in the vein.

When assessing a client's peripheral IV site, the nurse notices edema and tenderness above the site. What action will the nurse take first?

D -Stops the infusion of IV fluids -Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of infiltration include edema and tenderness above the site. The nurse should stop the infusion and remove the catheter. Cold compresses and elevation of the extremity can be done after the catheter is discontinued to increase client comfort.

Which client is at greatest risk for developing hypercalcemia?

D -The client with hyperparathyroidism -The parathyroid glands secrete parathyroid hormone. The actions of parathyroid hormone include increasing intestinal absorption of calcium, decreasing renal excretion of calcium, and increasing calcium resorption from the bones. All these actions increase the serum calcium level.

Which client is at greatest risk for dehydration?

D -The older adult client with cognitive impairment -Older adults, because of having less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired, and either cannot obtain fluids independently or cannot make his or her need for fluids known, is at high risk for dehydration.

Which assessment finding for a client with a PICC line requires immediate attention?

D -Upper extremity swelling -Upper extremity swelling could indicate infiltration, and the PICC line will need to be removed. The initial dressing over the PICC site should be changed within 24 hours. However, this does not require immediate attention but the swelling does. The dwell time for PICC lines can be for months or even years. Securement devices are being used more now to secure the catheter in place and prevent complications such as phlebitis and infiltration.

What action will the nurse take when preparing to infuse packed red blood cells through a Groshong catheter?

D -Use a pump to infuse the blood. -The length of the peripherally inserted central catheter (PICC) adds resistance and may prevent the blood from infusing within the 4-hour limitation. Therefore, a pump is needed to ensure adequate flow rates. Infusion of packed red blood cells is considerably slower through a PICC such as the Groshong catheter. Therefore, it would be difficult to infuse the red blood cells within 1 hour. Normal saline solution is used as the priming solution with red blood cell administration. IV tubing containing filters should always be used when administering red blood cells.