NCLEX Chapter 42

4. Circulatory shock Circulatory shock is a manifestation of sepsis. Cough, crackles, and dyspnea are manifestations of circulatory overload.

How might sepsis manifest? 1. Cough 2. Crackles 3. Dyspnea 4. Circulatory shock

2. Raising the head of the bed Circulatory overload of intravenous solution occurs due to infusion at a too rapid rate or an infusion of too much solution. Circulatory overload causes excessive extracellular volume. Raising the head of the bed will help a patient in this case. Elevating the extremity of the patient reduces extravasations. A warm, moist compress is applied for phlebitis. Starting a new intravenous line in another extremity is considered appropriate when the patient's extremity develops local infection. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking, and look for key words; (2) read each answer thoroughly and see if it completely covers the material the question asks; and (3) narrow the choices by immediately eliminating answers you know are incorrect.

A nurse finds circulatory overload in a patient on intravenous infusion. Which intervention would benefit this patient? 1. Elevating the extremity 2. Raising the head of the bed 3. Applying a warm and moist compress 4. Starting a new intravenous line in another extremity

2. Spinach 3. Dark Chocolate 4. Whole grains

A nurse is treating a patient diagnosed with Hypomagnesemia. What Foods would the nurse suggest they incorporate into their diet at home during discharge? 1. Bananas 2. Spinach 3. Dark Chocolate 4. Whole grains 5. Instant coffee

1. Stop the transfusion immediately. 2. Maintain the blood pressure (BP) at the normal range. 4. Administer diuretics. 5. Insert an indwelling urinary catheter. When a patient develops acute intravascular hemolytic transfusion reaction due to a mismatched transfusion, the transfusion should be stopped immediately to prevent further worsening of the condition. The blood bag and transfusion set should be saved for further investigation. The blood pressure (BP) should be maintained to the normal range to ensure perfusion to vital organs. To maintain urinary flow, the nurse may administer diuretics if prescribed. An indwelling urinary catheter may be inserted for hourly monitoring of urine output. The intravenous (IV) line must be kept open by infusing normal saline through new tubing.

A patient develops acute intravascular hemolytic transfusion reaction following transfusion with incompatible blood. Which treatment strategies should be included in the patient's management? Select all that apply. 1. Stop the transfusion immediately. 2. Maintain the blood pressure (BP) at the normal range. 3. Avoid keeping the intravenous (IV) line connected. 4. Administer diuretics. 5. Insert an indwelling urinary catheter.

1. Epinephrine Blood transfusions may cause anaphylactic reactions. Epinephrine is the drug of choice, because it relieves all of the clinical features of anaphylaxis. Vasopressors do not control the dyspnea and wheezing of anaphylaxis. They are used to control blood pressure. Antihistamines and glucocorticoids may be used as adjuvants to epinephrine, but they are not the primary drugs for anaphylaxis. Study Tip: Recall that patients with severe allergies (such as to bee stings) carry an "epi" pen. It contains epinephrine to help relieve the anaphylactic reaction.

A patient develops an anaphylactic reaction following initiation of a blood transfusion. Which primary drug should the nurse use for the patient? 1. Epinephrine 2. Vasopressor 3. Antihistamine 4. Glucocorticoid

1. Enzyme dysfunction 4. Impaired hemoglobin function 5. Death A pH of 7.25 indicates acidosis in the patient. The normal pH value ranges between 7.35 and 7.45. Any deviation from this range will lead to improper functioning of cellular enzymes because enzymes are active only at a certain pH level. A low pH level also interferes with the normal functions of hemoglobin, including oxygen carrying capacity, and may even result in death. Anemia and pruritis are usually not the direct consequences of acidosis. Anemia may have multifactorial causes. Pruritis is usually a result of allergic reactions.

A patient has a pH value of 7.25. Which possible pathological and physiological changes may occur in this patient? Select all that apply. 1. Enzyme dysfunction 2. Pruritis 3. Anemia 4. Impaired hemoglobin function 5. Death

1. The patient has metabolic acidosis. The patient is at risk of metabolic acidosis due to formation of ketoacids in the blood as a result of excessive alcohol intake. A high anion gap also indicates that the patient has metabolic acidosis. Metabolic alkalosis usually occurs either due to conditions associated with bicarbonate excess or increased excretion of metabolic acids. Respiratory acidosis is seen in conditions associated with alveolar hypoventilation. Respiratory alkalosis occurs as a result of alveolar hyperventilation.

A patient has been brought to the hospital in an unconscious state. On assessment, the nurse learns that the patient has engaged in binge drinking, and the lab reports reveal a high anion gap level. What can the nurse interpret about the patient's metabolic status? 1. The patient has metabolic acidosis. 2. The patient has metabolic alkalosis. 3. The patient has respiratory acidosis. 4. The patient has respiratory alkalosis.

3. Serum K + levels are less than 3.5 mEq/L. Chronic diarrhea and vomiting can cause electrolyte imbalances in the body. Diarrhea and vomiting can result in the loss of electrolytes from the body, resulting in decreased potassium levels. Potassium, magnesium, and calcium levels may increase in the case of increased intake and absorption of these electrolytes. Test-Taking Tip: Notice similarities and differences among the choices. For this question, three of the four choices show increased levels of electrolytes. Because you know that nausea and vomiting cause loss of electrolytes, you have the answer in the choice that indicates a decreased potassium level.

A patient has had chronic diarrhea for 3 months and also suffers from repeated bouts of vomiting. The nurse is reviewing the patient's laboratory report. Which are likely findings in the laboratory report? 1. Serum K + levels are more than 5 mEq/L. 2. Total serum Ca 2+ is greater than 10.5 mg/dL. 3. Serum K + levels are less than 3.5 mEq/L. 4. Serum Mg 2+ levels are greater than 2.5 mEq/L.

4.Bilateral muscle weakness 5. Signs of digoxin toxicity at normal digoxin levels In hypokalemia, the patient experiences bilateral muscle weakness that begins in the quadriceps and ascends to the respiratory muscles. Signs of digoxin toxicity at normal digoxin levels are also seen. Positive Chvostek's sign, hyperactive reflexes, and numbness of the circumoral region are signs of hypocalcemia

A patient has had chronic diarrhea for 3 months. He also is experiencing repeated bouts of vomiting. The laboratory reports indicate hypokalemia. Which signs is the nurse likely to find during examination? Select all that apply. 1. Positive Chvostek's sign 2. Hyperactive reflexes 3. Numbness of circumoral region 4.Bilateral muscle weakness 5. Signs of digoxin toxicity at normal digoxin levels .

1. Measure stool output. 3. Discourage use of high-fiber foods. 4. Encourage easily digestible food. Intestinal cramping, hyperactive bowel sounds on auscultation, and brown stools of more than six episodes per day are suggestive of inflammatory diarrhea. Measuring stool output helps to assess the volume loss through stools. Avoiding intake of high-fiber foods helps reduce the inflammation. The intake of easily digestible food allows the bowels to rest. Antiemetics are not helpful in a patient with inflammatory diarrhea, because the patient is not vomiting. Antidiarrheal agents should be administered as prescribed.

A patient has more than six episodes of diarrhea a day, associated with intestinal cramping, hyperactive bowel sounds on auscultation, and brown stools. Which nursing interventions are appropriate in this situation? Select all that apply. 1. Measure stool output. 2. Administer antiemetics. 3. Discourage use of high-fiber foods. 4. Encourage easily digestible food. 5. Withhold antidiarrheal agents.

3. Fluoxetine Fluoxetine is an antidepressant that leads to hyponatremia. Losartan is an angiotensin II receptor blocker that causes hyperkalemia. Captopril is an angiotensin-converting enzyme inhibitor that also causes hyperkalemia. Furosemide is a diuretic that causes hypokalemia and hypomagnesemia.

A patient on antidepressant therapy has developed hyponatremia. Which drug might have led to this condition? 1. Losartan 2. Captopril 3. Fluoxetine 4. Furosemide

3. Hypernatremia Hypernatremia is a condition in which water shifts out of cells into the extracellular fluid, resulting in dehydration. Therefore, a patient with hypernatremia experiences intense thirst and decreased alertness or level of consciousness. Transient abdominal cramps and diarrhea indicate hyperkalemia. Anorexia and confusion indicate hypercalcemia. Decreased indicate hypercalcemia. Lethargy and bradycardia indicate hypermagnesemia.

A patient reports intense thirst and decreased alertness. The patient's serum sodium level is 170 mEq/L. What condition should the nurse document in the patient's medical chart? 1. Hyperkalemia 2. Hypercalcemia 3. Hypernatremia 4. Hypermagnesemia

2. Calcium Chvostek's sign is associated with the contraction of facial muscles in response to a tap over the facial nerve. It is a test for hypocalcemia, which causes numbness and tingling in the fingers and toes. An electrocardiogram of a patient with hypocalcemia may show prolonged QT due to prolongation of the ST segment. Chvostek's sign is not performed to test potassium, magnesium, or phosphorous levels. Hyponatremia, or a decreased serum sodium level, results in cerebral dysfunction. A potassium imbalance can cause abdominal distention and decreased bowel sounds. A magnesium imbalance can result in insomnia and tachycardia. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

A patient reports numbness and a tingling sensation in the fingers and toes. The nurse observes facial muscle contractions in response to a tap on the facial nerve. The patient's electrocardiogram shows a prolonged ST segment. Which electrolyte imbalance does the nurse suspect? 1. Sodium 2. Calcium 3. Potassium 4. Magnesium

1. Metabolic acidosis The low pH indicates acidosis. The low PaCO 2 is caused by the hyperventilation, either from primary respiratory alkalosis (not compatible with the measured pH) or as a compensation for metabolic acidosis. The low HCO 3 - indicates metabolic acidosis or compensation for respiratory alkalosis (again, not compatible with the measured pH). Thus, metabolic acidosis is the correct interpretation.

A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are -pH: 7.20 -PaCO2: 21 mm Hg -PaO2: 92 mm Hg -HCO 3 -: 8. What do these laboratory values indicate? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

2. Cleaning the skin with alcohol 5. Inserting a new intravenous line in another extremity Redness, inflammation, swelling at the catheter site coupled with purulent indicate an infection. Cleaning the patient's skin with alcohol helps to maintain asepsis. Inserting a new intravenous line in the other extremity helps to reduce the chance of infection. Elevating the patient's extremity helps to reduce infiltration and extravasation. Raising the head of the patient's bed helps to control extracellular volume excess. The application of a pressure dressing over the injection site helps to reduce bleeding.

A patient who is undergoing intravenous therapy develops redness, inflammation, and swelling at the catheter site. After further assessment, the nurse finds purulent drainage from the injection site. Which nursing interventions are useful in this situation? Select all that apply. 1. Elevating the extremity 2. Cleaning the skin with alcohol 3. Raising the head of the patient's bed 4. Applying a pressure dressing over the site 5. Inserting a new intravenous line in another extremity

3. Placing the patient in high Fowler's position A patient who was on intravenous infusion therapy who reports shortness of breath and an increase in in the frequency of urination should be placed in high Fowler's position to promote lung expansion and prevent pulmonary congestion due to fluid overload. The intravenous fluid rate may be slowed but need not be discontinued. The infusion rate should be slowed to 10 gtt/minute. Starting a new intravenous line is applicable when vascular access device (VAD) patency is lost.

A patient who was on intravenous infusion therapy reports shortness of breath and an increase in the frequency of urination. Which nursing interventions would be beneficial? 1. Discontinuing the intravenous infusion 2. Slowing the infusion rate to 25 gtt/minute 3. Placing the patient in high Fowler's position 4. Starting a new intravenous line in another extremity

1. Reduced IV flow rate 2. Elevating the head of the bed 3. Notifying the health care provider Extracellular volume (ECV) excess occurs in a patient with sodium (Na +)-containing isotonic fluid. The assessment finding of circulatory overload of intravenous fluids is ECV excess. A patient with ECV excess is likely to develop crackles in the dependent parts of the lungs, shortness of breath, and edema in the extremities. Appropriate interventions include reducing the intravenous infusion and notifying the health care provider. The nurse should also elevate the head of the patient's bed and administer oxygen and diuretics if ordered. Starting a new intravenous line in another extremity may aggravate the patient's condition. The removal of the catheter and application of a sterile dressing is done in the case of local infection.

A patient with a 3% sodium chloride intravenous line develops shortness of breath and edema in the extremities. Upon auscultation, the nurse hears crackling sounds in the dependent parts of the lungs. Which nursing interventions are beneficial in this condition? Select all that apply. 1. Reduced IV flow rate 2. Elevating the head of the bed 3. Notifying the health care provider 4. Starting a new line in another extremity 5. Removing the line and applying sterile dressing

1. Hyponatremia Commonly used medications can cause alterations in the electrolytes. Administration of drugs such as antidepressants and selective serotonin reuptake inhibitors (SSRI) will decrease sodium levels in the blood; this is known as hyponatremia. Hyperkalemia can be caused by administration of ACE inhibitors. Hypercalcemia can be caused by the administration of calcium carbonate acids. Hypomagnesemia can be caused by drugs such as diuretics.

A patient with a history of depression is on antidepressant therapy. Which electrolyte abnormality is most likely to occur in this patient? 1. Hyponatremia 2. Hyperkalemia 3. Hypercalcemia 4. Hypomagnesemia

1. Arrange to provide red blood cells of group O. The patient requires red blood cells on an emergency basis, and none of the donors of this blood type are available. Therefore, the patient may be managed by transfusion of red cells of blood group O, because this carries minimum risk. Red blood cells of blood group AB should not be given to patients with blood group A, because they cause mismatching. Autologous transfusion takes a few weeks; therefore, it is not suitable on an emergency basis. If the patient did not require blood on an emergency basis, then it would be appropriate to wait until a blood group A donor is found. Test-Taking Tip: Remember that O is the universal d On Or.

A patient with blood type A is in need of packed red cells on an emergency basis, but none of the donors of this type are available. How can the nurse provide better health care to the patient? 1. Arrange to provide red blood cells of group O. 2. Arrange to provide red cells of group AB. 3. Arrange for an autologous blood transfusion. 4.Wait until the donor of blood type A becomes available.

3. Donor should be of blood group O. For platelet transfusion to a patient with blood group O, the donor must be of blood group O only. Any other blood type may cause a mismatch and lead to a transfusion reaction. Rh compatibility should be checked before transfusion, because it can also lead to a transfusion reaction. Donor specifications exist for platelet transfusions; not just any blood group is acceptable. The donor must be screened for all communicable diseases, including human immunodeficiency virus (HIV).

A patient with blood type O needs platelets. What should the nurse consider when choosing a donor for platelet transfusion? 1. Rh compatibility is excluded. 2. Donor can be of any blood group. 3. Donor should be of blood group O. 4. Donor can be exempted from screening for infections.

3. Pulmonary edema The most likely life-threatening complication that can occur in a patient who has excess extracellular fluid of normal tonicity is pulmonary edema. The excess fluids may filter out of the pulmonary blood vessels and pool in the pulmonary tissue, causing pulmonary edema. Coma and seizures are likely complications of hypernatremia and hyponatremia. Hypovolemic shock is seen in conditions associated with extracellular fluid depletion.

A patient with cardiac failure is found to have excess extracellular fluid of normal tonicity. Which life-threatening complication is this patient most likely to suffer? 1. Coma 2. Seizures 3. Pulmonary edema 4. Hypovolemic shock

2. Hypocalcemia 4. Hypomagnesemia A patient with chronic diarrhea who has hypocalcemia and hypomagnesemia may show Chvostek's sign which is contraction of facial muscles when the facial nerve is tapped. Hypokalemia, hyponatremia, and hypophosphatemia manifest in other signs and symptoms. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking, and look for key words; (2) read each answer thoroughly, and see if it completely covers the material the question asks; and (3) narrow the choices by immediately eliminating answers you know are incorrect.

A patient with chronic diarrhea shows Chvostek's sign. What might be the reason behind the patient's condition? Select all that apply. 1. Hypokalemia 2. Hypocalcemia 3. Hyponatremia 4. Hypomagnesemia 5. Hypophosphatemia

3. Position the patient off the inflamed area. 4. Apply moisture barriers to the skin. 5. Provide the bedpan carefully. The nursing interventions should aim at providing comfort to the patient and keeping the patient safe until the dizziness subsides. Positioning the patient off the inflamed area can promote patient comfort. Providing skin care by applying moisture barriers prevents further breakdown. Providing safe access to a bedpan until the dizziness resolves promotes patient safety. Avoiding high-fiber foods and ingestion of easily digestible food is helpful in diarrhea related to inflammation. Test-Taking Tip: Look for patient-centered responses that promote patient comfort and safety.

A patient with chronic infective diarrhea has skin redness on the perianal area due to constant exposure to stool. The patient also has reduced skin turgor and reports dizziness. Which interventions would be helpful to promote patient comfort? Select all that apply. 1. Avoid foods high in fiber. 2. Provide easily digestible food. 3. Position the patient off the inflamed area. 4. Apply moisture barriers to the skin. 5. Provide the bedpan carefully.

3. Offering fluid frequently in large amounts as tolerated Because the patient with vomiting and diarrhea is likely experiencing nausea and lightheadedness, he or she may not be able to tolerate large amounts of fluid; it is more effective to offer this patient small amounts of fluid as tolerated. The other nursing interventions are correct. The nurse should initiate an ordered peripheral IV and administer 1,000 mL 0.9% NaCl with 10 mEq KCl to maintain fluid and electrolyte balance. Providing fluids at the temperature the patient prefers will encourage the patient to consume more than if the temperature is too cold or too warm. Antiemetics will decrease the patient's nausea.

A patient with gastroenteritis is experiencing dehydration due to vomiting and diarrhea. Which nursing intervention requires correction? 1. Initiating ordered peripheral IV and administering 1,000 mL 0.9% NaCl with 10 mEq KCl 2. Providing oral fluids at a temperature the patient prefers 3. Offering fluid frequently in large amounts as tolerated 4. Providing antiemetics as ordere

3. Offering fluid frequently in large amounts as tolerated Because the patient with vomiting and diarrhea is likely experiencing nausea and lightheadedness, he or she may not be able to tolerate large amounts of fluid; it is more effective to offer this patient small amounts of fluid as tolerated. The other nursing interventions are correct. The nurse should initiate an ordered peripheral IV and administer 1,000 mL 0.9% NaCl with 10 mEq KCl to maintain fluid and electrolyte balance. Providing fluids at the temperature the patient prefers will encourage the patient to consume more than if the temperature is too cold or too warm. Antiemetics will decrease the patient's nausea.

A patient with gastroenteritis is experiencing dehydration due to vomiting and diarrhea. Which nursing intervention requires correction? 1. Initiating ordered peripheral IV and administering 1,000 mL 0.9% NaCl with 10 mEq KCl 2. Providing oral fluids at a temperature the patient prefers 3. Offering fluid frequently in large amounts as tolerated 4. Providing antiemetics as ordered

2. Hyperkalemia The most likely complication of diabetic ketoacidosis is hyperkalemia. Acidosis is associated with the shift of potassium from the cells into the extracellular space. Hypokalemia is seen in conditions associated with alkalosis and during treatment of diabetic ketoacidosis with insulin. Hypocalcemia is usually not seen in diabetic ketoacidosis. Hypocalcemia may be found in conditions such as vitamin D deficiency, hypoparathyroidism, and chronic diarrhea. Serum osmolality increases in diabetic ketoacidosis.

A patient with uncontrolled diabetes mellitus has developed diabetic ketoacidosis. Which is the most likely complication that this patient may experience? 1. Hypokalemia 2. Hyperkalemia 3. Hypocalcemia 4. Reduced serum osmolality

3. Hypomagnesemia Prolongation of the QT interval on the electrocardiogram report can be seen in patients with hypomagnesemia. PR prolongation can be seen in patients with hyperkalemia. Prolonged ST segments can be seen in patients with hypercalcemia. A prolonged PR interval is seen in patients with hypermagnesemia.

A patient's electrocardiogram report indicates a prolonged QT interval. Which electrolyte imbalance does the nurse suspect? 1. Hyperkalemia 2. Hypocalcemia 3. Hypomagnesemia 4. Hypermagnesemia

2. Instructing the patient to report symptoms of infection 3. Teaching the safe disposal of intravenous materials exposed to blood The nurse should explain to a patient who is taking anticoagulants about IV therapy and the symptoms of infection or infiltration and instruct the patient to report such symptoms. The nurse should instruct the patient regarding the safe disposal of containers exposed to blood. The nurse should teach the patient how to ambulate and allow the patient to perform activities of daily living. The nurse should teach the patient and caregiver how to change the intravenous tubing when required. Because the patient is on anticoagulant therapy, when the access device is removed, the pressure should be applied for 20 minutes to reduce the risk of bleeding.

A primary health care provider suggested home intravenous (IV) therapy for a patient who is taking anticoagulants. Which nursing actions signify effective understanding regarding intravenous therapy? Select all that apply. 1. Having the patient refrain from performing activities of daily living 2. Instructing the patient to report symptoms of infection 3. Teaching the safe disposal of intravenous materials exposed to blood 4. Advising the patient to report if the intravenous tubing and dressing become soiled 5. Instructing the caregiver to apply pressure for 5 min when the access device is removed

1. Oranges 2. Canned fish with bones 4. Dairy 5. Broccoli

A regular patient burst through the doors of the ED screaming "PHUCKING PHUCK YOU! PHUCK YOU! PHUCK YOU YOU PHUCKING PHUCKERS!!!!!". It takes three gaurds to hold him down and 4mg of IV Lorazepam to sedate him. The nurse suspects this personality change may be due to a sever case of Hypercalcemia. What foods would the nurse suggest a patient to avoid once they return to reality? Select all that apply. 1. Oranges 2. Canned fish with bones 3. Chicken 4. Dairy 5. Broccoli

1. Dark yellow urine 5. Heart rate of 102 bpm In a patient with gastroenteritis, dark yellow urine and an elevated heart rate of 102 bpm indicates deficient fluid volume related to vomiting and diarrhea. Increased salivation and little interest in eating indicate nausea related to gastric irritation. Abdominal cramping indicates diarrhea related to intestinal inflammation.

After assessing a patient with gastroenteritis, the nurse suspects deficient fluid volume related to vomiting and diarrhea. Which symptoms support the nurse's suspicion? Select all that apply. 1. Dark yellow urine 2. Increased salivation 3. Abdominal cramping 4. Little interest in eating 5. Heart rate of 102 bpm

1. Increased salivation 3. Little interest in eating ncreased salivation and little interest in eating in a patient with gastroenteritis are symptoms of nausea related to gastric irritation. Decreased skin turgor indicates impaired skin integrity and deficient fluid volume. A heart rate of 102 bpm and dry oral mucous membranes are symptoms of a deficient fluid volume related to vomiting and diarrhea. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.

After assessing a patient with gastroenteritis, the nurse documents nausea related to gastric irritation. Which symptom supports the nurse's documentation? Select all that apply. 1. Increased salivation 2. Decreased skin turgor 3. Little interest in eating 4. Heart rate of 102 bpm 5. Dry oral mucous membranes

2. Perform hand hygiene and apply clean gloves 1. Clean the site with an antiseptic swab 5. Turn off the electronic infusion device and close the roller clamp 4. Remove the dressing and catheter stabilization device 6. Withdraw the catheter by placing sterile gauze over the puncture site 3. Retain the sterile gauze in place and assess for bleeding

Arrange the steps for discontinuing a peripheral intravenous access in chronological order. 1. Clean the site with an antiseptic swab 2. Perform hand hygiene and apply clean gloves 3. Retain the sterile gauze in place and assess for bleeding 4. Remove the dressing and catheter stabilization device 5. Turn off the electronic infusion device and close the roller clamp 6. Withdraw the catheter by placing sterile gauze over the puncture site

100

Fluid homeostasis in the body is maintained by fluid intake and absorption, fluid distribution, and fluid output. How much fluid does an adult lose through feces? Record your answer using a whole number. __________ mL

500 The fluid loss occurs through the skin, lungs, gastrointestinal tract, and kidneys. Even though fluid intake is likely 3 to 6 liters, only 100 mL of fluid is lost through feces. The rest of the fluid is absorbed by the gastrointestinal system.

Fluid homeostasis in the body is maintained by fluid intake and absorption, fluid distribution, and fluid output. How much fluid does an adult lose through feces? Record your answer using a whole number. __________ mL

2. Crush injuries Crush injuries place a patient at risk for hyperkalemia. Patients with cancer may develop hypercalcemia. Patients with chronic heart failure will be at risk for hypokalemia. Bacterial pneumonia will cause respiratory acidosis.

Which acute condition will place the patient at a high risk for hyperkalemia? 1. Cancer 2. Crush injuries 3. Chronic heart failure 4. Bacterial pneumonia

2. Grade The clinical criteria for grade 2 on the phlebitis scale are pain and erythema at the infusion site. The clinical criterion for grade 1 is erythema at the infusion site. The clinical criteria for grade 3 are pain at the site, erythema, and streak formation or a palpable venous cord. The clinical criteria for grade 4 are pain at the site with erythema and streak formation along with purulent discharge.

Which grade on the phlebitis scale is given to a patient with pain at the infusion site and erythema? 1. Grade 1 2. Grade 2 3. Grade 3 4. Grade 4

2. 167 mL/hr 1000 mL divided by 6 hours is 166.7 mL/hr, which rounds to 167 mL/hr (if the infusion pump accepts decimals, it should be programmed to 166.7 mL/hr).

The health care provider's order is 1000 mL 0.9% NaCl IV over 6 hours. Which rate should the nurse program into the infusion pump? 1. 125 mL/hr 2. 167 mL/hr 3. 200 mL/hr 4. 1000 mL/hr

1. Nausea Avoiding sudden position changes of a patient is done to avoid exacerbating nausea. High-fiber foods should be avoided to reduce the risk of diarrhea. The risk of vomiting can be avoided by offering fluids frequently in small amounts as tolerated. Applying moisture to the skin is an intervention for a patient at risk of impaired skin integrity.

The nurse avoids sudden position changes for a patient with gastroenteritis. Which risk is the nurse avoiding? 1. Nausea 2. Diarrhea 3. Vomiting 4. Impaired skin integrity

2. Assess for intactness of the intravenous (IV) system. The patient has bleeding at the venipuncture site, which could be due to dislodgement of the intravenous (IV) catheter. Therefore, the nurse should check for intactness of the IV system. Because the patient has fresh blood, it does not require culturing. Purulent discharges require cultures. If the catheter is found within the vein, then a pressure dressing must be applied over the site. If the catheter is dislodged, then a new IV line must be set up. Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action.

The nurse finds fresh blood at a venipuncture site in a patient and pooling of fluids under the extremity. Which should be the immediate nursing action? 1. Culture the blood at the venipuncture site. 2. Assess for intactness of the intravenous (IV) system. 3. Start a new line even if the catheter is in place. 4. Apply a pressure dressing if the catheter is dislodged.

4. Local infection A local infection is characterized by redness, heat, and swelling at the catheter-skin entry point, and possible purulent drainage. Fresh blood evident at the venipuncture site and sometimes pooling under the extremity are the assessment findings of bleeding at the venipuncture site. The assessment findings of phlebitis are redness, tenderness, pain, and warmth along the course of the vein. Edematous, blanched skin that is cool to the touch indicates extravasation.

The nurse finds redness, heat, and swelling at the catheter-skin entry point and purulent drainage in a patient on intravenous infusion. Which complication does the nurse suspect? 1. Phlebitis 2. Bleeding 3. Extravasation 4. Local infection

1. Extracellular fluid volume (ECV) excess Sudden weight gain, confusion, edema in dependent areas, and crackles in the lungs indicate extracellular fluid volume (ECV) excess. A decreased level of consciousness, confusion, and lethargy are signs of hypernatremia. Symptoms of both ECV deficit and hypernatremia are associated with clinical dehydration. Postural hypotension, tachycardia, thready pulse, dry mucous membranes, and poor skin turgor are signs of ECV deficit.

The nurse finds that a patient has sudden weight gain, confusion, and edema in the dependent areas. Upon auscultation, the nurse finds crackles in the lungs. What condition does the nurse suspect? 1. Extracellular fluid volume (ECV) excess 2. Hypernatremia 3. Clinical dehydration 4.Extracellular fluid volume (ECV) deficit

3. Tap the tubing to the IV line The nurse should immediately tap the IV tubing if he or she finds bubbles in the tubing and should also check the entire length of tubing to remove all of the bubbles. The nurse should turn the ports upside down if bubbles are found in multiple-port tubing. The nurse should change the IV tubing if it is found to have leaks. The nurse should change the VAD if it becomes dislodged. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.

The nurse identifies air bubbles in the single-port intravenous (IV) tubing of a patient who is on intravenous maintenance therapy. Which action should be performed immediately? 1. Turn the ports upside down 2. Change the Intravenous tubing 3. Tap the tubing to the IV line 4. Change the vascular access device (VAD)

4. A patient with infusion of vasoconstrictors. The INS Standard of Practice provides guidelines for assessment of a peripheral VAD site to determine whether replacement is clinically indicated. During infusions of vesicants or vasoconstrictors, the nurse must monitor the patient every 5 to 10 minutes. The nurse must monitor neonates and children who are on infusion at least every hour. The nurse must assess critically ill patients who are on infusion therapy at least every 1 to 2 hours. The nurse must assess oriented adults who are able to report problems at the VAD site at least every 4 hours. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options .

The nurse is assessing a peripheral vascular access device (VAD) site. Which patient requires monitoring of the site every 5 to 10 minutes? 1. A neonate patient 2. A patient who is critically ill 3. An oriented adult patient 4. A patient with infusion of vasoconstrictors

2 According to the infiltration scale, edema that is 2.54 to 15.2 cm is grade 2. Edema less than 2.54 cm, about an inch, is grade 1. Edema greater than 15.2 cm, or 6 inches, in any direction with mild to moderate pain is grade 3. Edema greater than 15.2 cm with moderate to severe pain is grade 4.

The nurse is assessing the clinical criteria for the infiltration scale. What would the grade be if there is 10.8 cm of edema in the infiltration? 1 2 3 4

3. Peritoneal fluid 4. Synovial fluid 5. Cerebrospinal fluid Transcellular fluids are secreted by epithelial cells. Fluid collection between the two layers of the peritoneum is an example of transcellular fluid. Fluid collection in the synovial space of a joint is secreted by the epithelial cells and is also an example of transcellular fluid. Cerebrospinal fluid is colorless fluid present in the brain and spinal cord. Serum and plasma are constituents of intravascular fluid, which is a part of extracellular fluids. Study Tip: Draw a diagram of the various fluid compartments in the body. Use different colors for different compartments: intracellular, extracellular, interstitial, intravascular, and transcellular. Show which compartments are subdivisions of other compartments. For example, show intravascular fluid as a subdivision of extracellular fluid.

The nurse is caring for a patient who has an accumulation of fluid in the pleural cavity. The nurse understands that this fluid is transcellular fluid secreted by epithelial cells. Which bodily fluids are examples of transcellular fluids? Select all that apply. 1. Serum 2. Plasma 3. Peritoneal fluid 4. Synovial fluid 5. Cerebrospinal fluid

2. Bleeding 3. Phlebitis 4. Infection Bleeding at the venipuncture site is a potential complication of intravenous therapy, which can be noted as oozing or slow seepage of blood at the site. Phlebitis, which is characterized by tenderness, pain, or burning, is an inflammation of the inner layer of a vein. Infection is a potential complication of intravenous therapy if aseptic measures were not taken during the procedure. Pallor is not a potential complication of intravenous therapy and can occur in other conditions such as reduced hemoglobin. Jaundice, characterized by yellowish discoloration of skin, is not a potential complication of intravenous therapy and can occur in other conditions such as hepatitis.

The nurse is caring for a patient who has an intravenous (IV) line for fluid therapy. About which potential complications should the nurse be vigilant while assessing the patient? Select all that apply. 1. Pallor 2. Bleeding 3. Phlebitis 4. Infection 5. Jaundice

2. Insomnia 3. Muscle cramps 5. Hyperactive deep tendon reflexes Because hypomagnesemia occurs due to low serum magnesium level, it increases neuromuscular excitability. The patient may experience insomnia. as well as muscle cramps, twitching, and hyperactive deep tendon reflexes. Lethargy is observed in hypermagnesemia, which causes decreased neuromuscular excitability. Hypoactive deep tendon reflexes are also found in hypermagnesemia. Study Tip: Anxiety leading to an exam is normal. Reduce your stress by studying often, not long. Spend at least 15 minutes every day reviewing the old material. This action alone will greatly reduce anxiety. The more time you devote to reviewing past material, the more confident you will feel about your knowledge of the topics. Start this review process on the first day of the semester. Don't wait until the middle to end of the semester to try to cram information.

The nurse is learning about fluid, electrolyte, and acid-base balance. Which clinical findings would the nurse evaluate in a patient with hypomagnesemia? Select all that apply. 1. Lethargy 2. Insomnia 3. Muscle cramps 4. Hypoactive deep tendon reflexes 5. Hyperactive deep tendon reflexes

4. Inserting the intravenous line at a 10 to 15 degree angle A 78-year-old patient may have a loss of supportive tissue and the veins appear to be superficial. Therefore, the nurse should lower the insertion angle for venipuncture to 10 to 15 degrees after penetrating the needle into the skin. Inserting the intravenous line into the back of the hand may compromise the patient's mobility and result in discomfort. Applying friction while cleaning the injection site may lead to shredding of the skin in older adults. Because older adults have less subcutaneous support tissue, the nurse should avoid placing lines in veins that are superficial.

The nurse is providing intravenous therapy to a 78-year-old patient. Which nursing action is appropriate in this condition? 1. Inserting the intravenous line on the back of the hand 2. Applying friction while cleaning the site 3. Placing the intravenous line in a superficial vein 4. Inserting the intravenous line at a 10 to 15 degree angle

1. "I will avoid selecting fragile dorsal veins." 2. "I will remove my gloves before palpating the vein." 4. "I will avoid the extremity that is affected by the previous stroke." Injecting intravenous fluids into fragile veins can cause hematoma and infiltration; therefore, fragile dorsal veins should be avoided. Removing gloves may help to clearly palpate veins; therefore, gloves should be removed before palpating the vein. Extremities affected by a stroke have compromised circulation and should thus be avoided. Selecting a vein from a tender area may predispose infection. The vein should be punctured at a 10- to 30-degree angle to prevent puncturing the posterior wall of the vein.

The nurse is reinforcing to a nursing student the teachings regarding intravenous administration. Which statements by the nursing student indicate EFFECTIVE understanding? Select all that apply. 1. "I will avoid selecting fragile dorsal veins." 2. "I will remove my gloves before palpating the vein." 3. "I will select a vein from an area that appears tender." 4. "I will avoid the extremity that is affected by the previous stroke." 5. "I will try to puncture the vein by keeping the catheter at a 60- to 90-degree angle."

2. The lungs excrete carbonic acid. The lungs are responsible for the excretion of carbonic acid from the body in the form of exhaled carbon dioxide. Thus, the lungs help to maintain the acid-base balance of the body. The liver is not involved in the excretion of metabolic acids and carbonic acid, and it has no role in the acid-base balance of the body. Kidneys help in the excretion of all acids except for carbonic acid. They play an important role in fluid and electrolyte balance. The intestines are not involved in the excretion of metabolic acids and carbonic acid and have no role in the acid-base balance of the body. Study Tip: To help you recall that the one acid excreted by the lungs is carbonic acid, just remember that the lungs excrete carbon dioxide.

The nurse is teaching a group of nursing students about the acid-base regulation process. What should the nurse teach the students regarding the excretion of carbonic acid from the body? 1. The liver excretes carbonic acid. 2. The lungs excrete carbonic acid. 3. The kidneys excrete carbonic acid. 4. The intestines excrete carbonic acid.

2. "Patients with obstructive lung diseases may have more acid in the blood." 3. "Patients experience deeper respirations when the carbon dioxide level in the blood rises." 5. "Patients with kidney disease have difficulty excreting metabolic acids." Patients with obstructive lung diseases may have more acid in their blood. This can be due to a difficulty in normal excretion of carbonic acid. When the level of carbon dioxide in the blood rises, the chemoreceptors are triggered quickly. The patient hyperventilates in order to excrete the excess carbonic acid. The excretion of metabolic acids occurs in the renal tubules of the kidneys. This is one of the major contributing factors for difficulty in normally excreting metabolic acids. The kidneys excrete all acids except carbonic acid. When the carbon dioxide level in the blood rises, the chemoreceptors trigger hyperventilation to facilitate excretion of excess carbonic acid. The patient also experiences shallow respirations in response to decreased levels of carbon dioxide in the blood to enable the cells to produce more carbon dioxide and make up for the deficit. Study Tip: Get a good night's sleep before an exam. Staying up all night to study before an exam rarely helps anyone. Instead, it usually interferes with the ability to concentrate.

The nurse is teaching a team of student nurses about acid-base balance. Which statements by the nurse are APPROPRIATE? Select all that apply. 1. "The kidneys excrete all acids produced in the patient's body." 2. "Patients with obstructive lung diseases may have more acid in the blood." 3. "Patients experience deeper respirations when the carbon dioxide level in the blood rises." 4. "Patients experience shallow respirations when the carbon dioxide level in the blood rises." 5. "Patients with kidney disease have difficulty excreting metabolic acids."

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The primary health care provider orders the nurse to infuse 500 mL normal saline over 4 hours to a patient with a blood pressure of 100/70 mm Hg. What is the flow rate of infusion? Record your answer in mL per hour. _________ mL/hr

2. Ensuring proper fluid administration Observing intravenous connections and the patency of systems ensures proper fluid administration to the patient. Observing the puncture site detects bleeding. Applying sterile folded gauze helps to prevent bleeding. Discarding the used supplies and performing hand hygiene reduces the risk of infection. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong, and then call on your knowledge, skills, and abilities to choose from the remaining responses.

The primary health care provider tells the nurse to observe the intravenous connections and patency of systems of a patient who is on intravenous fluids. What is the rationale behind this order? 1. Detecting bleeding 2. Ensuring proper fluid administration 3. Maintaining pressure to prevent bleeding 4. Reducing the transmission of microorganisms

1. "Reduce the intravenous (IV) flow." If the nurse suspects circulatory overload in a patient, the immediate nursing intervention is to reduce the IV flow rate and notify the health care provider. The nurse must elevate the extremity when there is any evidence of infiltration near the infusion site; this helps the infiltration to subside. The nurse must disconnect IV tubing and discontinue the IV infusion when there is evidence of infiltration. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

The registered nurse is instructing a nursing student about the interventions that must be performed when there is any evidence of complication due to infusion therapy. Which instruction would the nurse follow for a patient with circulatory overload? 1. "Reduce the intravenous (IV) flow." 2. "Elevate the extremity." 3. "Disconnect the IV tubing." 4. "Discontinue the IV infusion."

2. Refraining from using the smallest-gauge catheter 5 .Refraining from applying traction to the skin below the projected insertion site While caring for older adults who are on IV therapy the nurse must ensure the protection of skin and veins. The nurse uses the smallest-gauge catheter or needle, possibly a 22 to 24 gauge, because veins are fragile and a smaller gauge allows better blood flow to provide better hemodilution of the IV fluids. Veins roll away from the needle because of the loss of subcutaneous tissue; therefore, to stabilize a vein, traction should be applied to the skin below the projected insertion site. The nurse must refrain from using the back of the hand for IV access, because it may compromise the patient's mobility. The nurse must not place an IV line in a vein with a bump, because older adults have less subcutaneous fat. Rigorous friction should be avoided while cleaning the IV site to prevent tearing fragile skin.

The registered nurse is teaching a nursing student about protection of the skin and veins during intravenous (IV) therapy while caring for an older adult. Which actions if by the nursing student indicate the need for FURTHER teaching? Select all that apply. 1. Refraining from using the back of the hand for IV access 2. Refraining from using the smallest-gauge catheter 3. Refraining from using IV lines in the veins with early bumps 4. Refraining from rigorous friction while cleaning the catheter site 5 .Refraining from applying traction to the skin below the projected insertion site

1. Measuring oral intake and urine output 3. Reporting an IV container that is low in fluid 5. Reporting an electronic infusion device alarm The nurse is able to delegate measuring oral intake and urine output, reporting an IV container that is low in fluid, and reporting an electronic infusion device alarm.The registered nurse cannot delegate working with intravenous (IV) tubing or changing an IV infusion to nursing assistive personnel (NAP).

Which activities can the nurse delegate to nursing assistive personnel (NAP)? Select all that apply. 1. Measuring oral intake and urine output 2. Preparing intravenous (IV) tubing for routine change 3. Reporting an IV container that is low in fluid 4. Changing an IV fluid container 5. Reporting an electronic infusion device alarm

4. Hypermagnesemia Hypermagnesemia is an abnormally high magnesium concentration in the blood; this can be caused by end-stage renal disease. Excessive fluid loss can cause hypokalemia. Malignant neoplasms or increased levels of parathyroid hormone can cause hypercalcemia. Chronic diarrhea can cause hypomagnesemia.

What condition may be suspected in a patient with end-stage renal disease? 1. Hypokalemia 2. Hypercalcemia 3. Hypomagnesemia 4. Hypermagnesemia

2. Potatoes 3. Fruits 5. Brazil nuts

What foods would the nurse believe a patient with Hyperkalemia may be eating in excess? Select all that apply. 1. Dairy 2. Potatoes 3. Fruits 4. Red meat 5. Brazil nuts

3. 4.5 to 5.3 mg/dL The normal concentration of ionized calcium in human blood ranges from 4.5 to 5.3 mg/dL. The normal value of phosphate in human blood ranges from 2.7 to 4.5 mg/dL. The normal value of potassium in human blood ranges from 3.5 to 5.0 mEq/L. The normal value of total calcium in human blood ranges from 8.4 to 10.5 mg/dL.

What is the normal concentration of ionized calcium in human blood? 1. 2.7 to 4.5 mg/dL 2. 3.5to 5.0 mEq/L 3. 4.5 to 5.3 mg/dL 4. 8.4 to 10.5 mg/dL

2. 2.7 to 4.5 mg/dL The normal range of values of phosphate in human blood is 2.7 to 4.5 mg/dL. The normal value of potassium is 3.5 to 5.0 mEq/L, the normal value of ionized calcium is 4.5 to 5.3 mg/dL, and the normal value of magnesium is 1.5 to 2.5 mEq/L.

What is the normal range of values of phosphate in human blood? 1. 1.5 to 2.5 mEq/L 2. 2.7 to 4.5 mg/dL 3. 3.5 to 5.0 mEq/L 4. 4.5 to 5.3 mg/

1. Auscultate dependent portions of lungs. Excessive or too-rapid infusion of 0.9% NaCl (normal saline) causes excess extracellular fluid volume (ECF) with pulmonary vessel congestion and potential pulmonary edema, especially in older adults, who cannot adapt as rapidly to increased vascular volume. An overload of intravenous normal saline eventually increases urine volume if kidneys are functioning but may not change urine color. Assessment of muscle strength is appropriate for potassium imbalances, not ECF imbalances. Skin turgor is not a reliable assessment of ECF deficit in older adults. Test-Taking Tip: Consider safety priorities when responding. Pulmonary vessel congestion is more of a hazard than increased urine volume, so auscultation is the best choice.

Which assessment should the nurse perform routinely when an older adult patient is receiving intravenous 0.9% NaCl? 1. Auscultate dependent portions of lungs. 2. Check color of urine. 3. Assess muscle strength. 4. Check skin turgor over sternum or shin.

1. Formation of streak According to the phlebitis scale, the nurse would give a grade of 3 if there is any streak formation or a palpable venous cord. The nurse would give a grade of 2 if there is only erythema. The nurse would grade give a grade of 4 if there is a palpable venous cord greater than 2.54 cm. Erythema at the access site with or without pain is grade 1.

Which clinical criteria of phlebitis should receive a grade of 3? 1. Formation of streak 2. Pain at access site with only erythema 3. Palpable venous cord greater than 2.54 cm 4.Erythema at access site with or without pain

1. Bleeding Bleeding may be a complication of IV therapy; applying pressure at the site can reduce bleeding. Phlebitis may indicate that the infusion should be stopped. The primary health care provider should be notified if symptoms of infection occur. Reduction in the IV flow rate may reduce circulatory overload.

Which complication of intravenous (IV) therapy indicates the need for pressure at the site? 1. Bleeding 2. Phlebitis 3. Infection 4. Fluid overload

3. Hypernatremia Hypernatremia, also known as water deficit, is caused by body fluids becoming too concentrated and results in excessive thirst, known as clinical dehydration; therefore, this condition may be observed in a patient for whom IV therapy was suggested. Hyperkalemia is abnormally high potassium ion concentration in the blood and can cause muscle weakness. Hypercalcemia is abnormally high calcium concentration in the blood and can cause constipation and reduced tendon reflexes. Hypermagnesemia is abnormally high magnesium concentration in the blood and may decrease tendon reflexes.

Which condition can be observed in a patient for whom intravenous (IV) therapy was suggested for excessive thirst? 1. Hyperkalemia 2. Hypercalcemia 3. Hypernatremia 4. Hypermagnesemia

1. Burns 4. Hemorrhage 5. Adrenal insufficiency An extracellular fluid volume (ECV) deficit occurs when there is insufficient isotonic fluid in the extracellular compartment. Burns, hemorrhage, and adrenal insufficiency will lead to an ECV deficit. Cirrhosis and heart failure will lead to an ECV excess.

Which condition may lead to an extracellular fluid volume deficit? Select all that apply. 1. Burns 2. Cirrhosis 3. Heart failure 4. Hemorrhage 5. Adrenal insufficiency

2. Hypocalcemia 3. Hypernatremia 4. Hypomagnesemia Chronic diarrhea may lead to hypernatremia and result in clinical dehydration. It also leads to hypocalcemia and hypomagnesemia because diarrhea decreases electrolyte absorption. Hypokalemia occurs due to an increase in fluid output, not hyperkalemia. Hyperphosphatemia is uncommon during chronic diarrhea. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Which conditions are common in a patient with chronic diarrhea? Select all that apply. 1. Hyperkalemia 2. Hypocalcemia 3. Hypernatremia 4. Hypomagnesemia 5. Hyperphosphatemia

3. Prednisone 4. Furosemide Furosemide and prednisone will cause hypokalemia. Captopril and spironolactone may cause hyperkalemia. Fluoxetine may cause hyponatremia.

Which drugs can cause hypokalemia? Select all that apply. 1. Captopril 2. Fluoxetine 3. Prednisone 4. Furosemide 5. Spironolactone

1. Hyponatremia Hyponatremia can be caused by the use of antidepressants. Hypokalemia, hypocalcemia, and hypomagnesemia can be caused by the use of laxatives. Therefore, in the patients with these conditions laxatives are contraindicated.

Which electrolyte abnormality is least likely to be caused by the use of laxatives? 1. Hyponatremia 2. Hypokalemia 3. Hypocalcemia 4. Hypomagnesemia

1. Calcium (Ca 2+) Calcium influences the excitability of nerve and muscle cells and is necessary for muscle contraction. Potassium maintains the resting membrane potential of skeletal, smooth, and cardiac muscle, allowing for normal muscle function. Electrolyte phosphate is necessary for the production of adenosine triphosphate (ATP), the energy source for cellular metabolism. Electrolyte magnesium influences the function of neuromuscular junctions and is a cofactor for numerous enzymes.

Which electrolyte influences excitability of nerve and muscle cells and is necessary for muscle contraction? 1. Calcium (Ca 2+) 2. Potassium (K +) 3. Phosphate (PO 4) 4. Magnesium (Mg 2+)

4. Magnesium (Mg 2+) Magnesium (Mg 2+) influences the function of the neuromuscular junctions. Potassium (K +) is necessary for normal muscle function. Calcium (Ca 2+) is necessary for muscle contraction. Phosphate (PO 4 3-) is necessary for the production of adenosine triphosphate.

Which electrolyte influences the function of the neuromuscular junctions? 1. Calcium (Ca 2+) 2. Potassium (K +) 3. Phosphate (PO 4 3-) 4. Magnesium (Mg 2+)

1. Antiseptic swab The nurse uses an antiseptic swab prior to inserting a vascular access device (VAD). The nurse should apply friction at the insertion site to penetrate the antiseptic into the layers of the skin. Skin protectant is applied over the area where the tape is applied or dressing is performed to maintain skin integrity. An adhesive remover is used to remove residue from the skin. A sterile gauze pad is placed on the intravenous site after the insertion of the catheter to secure the catheter hub.

Which equipment is used to apply friction prior to inserting a vascular access device (VAD)? 1. Antiseptic swab 2. Sterile gauze pad 3. Adhesive remover 4. Skin protectant solution

2. Hyperkalemia Spironolactone is a potassium-sparing diuretic that may cause hyperkalemia. Hypokalemia and hypomagnesemia may be caused by potassium-wasting diuretics such as furosemide. Hyponatremia is caused by antidepressants such as fluoxetine.

Which fluid electrolyte imbalance may develop in a patient who consumes spironolactone? 1. Hypokalemia 2. Hyperkalemia 3. Hyponatremia 4. Hypomagnesemia

1. Stopping the infusion Redness and pain at an infusion site indicate phlebitis; therefore, the nurse should stop the infusion or start a new line if these symptoms occur in the patient. The extremities are elevated if symptoms of infiltration occur. Applying warmth to the site is an intervention for infiltration. The health care provider can be notified, but the immediate action is to stop the infusion.

Which immediate intervention would be beneficial in a patient who developed redness and pain at the infusion site? 1. Stopping the infusion 2. Elevating the extremity 3. Applying warmth to the site 4. Notifying the health care provider

1. Sodium 2. Calcium 4. Potassium Positively charged ions are called cations. Negatively charged ions are called anions. Sodium (Na +), calcium (Ca +), and potassium (K +) are cations. Chloride (Cl -) and bicarbonate (HCO 3 -) ions are anions.

Which ions are cations? Select all that apply. 1. Sodium 2. Calcium 3. Chloride 4. Potassium 5. Bicarbonate

4. Placing the extremity in a dependent position Placing the extremity in a dependent position promotes venous dilation. Application of warmth to the extremity for several minutes with a warm washcloth increases blood in the vein by causing dilation. Selecting a larger vein for a vascular access device (VAD) prevents interruption of venous flow while allowing adequate blood flow around the catheter. Palpation of the vein by pressing it downward increases the sensitivity for better assessment of vein location.

Which method performed to foster venous distention promotes venous dilation? 1. Applying a cold compress to the extremity 2. Selecting a larger vein for venous access 3. Palpating the vein by pressing downward 4. Placing the extremity in a dependent position

3. Addition of extension tubing When a patient needs more room to maneuver, extension tubing may be added to the intravenous line. Stopcocks should not be used to connect multiple solutions to a single intravenous site due to the increased risk of contamination. Tubing should not be disconnected for moving a patient. A catheter stabilization device is used to prevent accidental dislodgment of a venous access device. Catheter stabilization devices do not allow easy maneuvering of a patient on infusion. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong, and then call on your knowledge, skills, and abilities to choose from the remaining responses.

Which method should the nurse adopt to assist in the easy maneuvering of a patient who is on intravenous infusion? 1. Use of stopcocks 2. Disconnection of the tubing 3. Addition of extension tubing 4. Use of catheter stabilization devices

3. Inserting the volume-control device spike into the container When delivering a small amount of fluid to a pediatric patient who is on IV therapy, inserting the volume-control device spike into the container promotes the slow infusion of the fluid. The drip rate should be monitored every hour to maintain the flow rate. The patient is placed in Fowler's position if symptoms of overhydration occur. The IV container is placed 36 inches above the IV site in adults to regulate the flow rate.

Which nursing action is beneficial to deliver a small amount of fluid to a pediatric patient who is on intravenous (IV) therapy? 1. Monitoring the drip rate every 2 hours 2. Placing the patient in Fowler's position 3. Inserting the volume-control device spike into the container 4. Placing the intravenous container 36 inches above the IV site

4. A patient with chronic obstructive pulmonary disease (COPD) Chronic respiratory acidosis is most commonly caused by chronic obstructive pulmonary disease (COPD). Hypokalemia, pulmonary fibrosis, and salicylate overdose do not predispose a patient to respiratory acidosis. Hypokalemia can lead to cardiac dysrhythmias. Pulmonary fibrosis can result in respiratory arrest, and salicylate overdose results in central nervous system changes. Test-Taking Tip: When using this program, be sure to note if you guess at an answer. This will permit you to identify areas that need further review. Also it will help you to see how correct your guessing can be.

Which patient being cared for by the nurse is at the highest risk of developing respiratory acidosis? 1. A patient with hypokalemia 2. A patient with pulmonary fibrosis 3. A patient with salicylate overdose 4. A patient with chronic obstructive pulmonary disease (COPD)

3. Patient with diarrhea A patient with diarrhea loses fluids and potassium, which can lead to hypokalemia. A patient with cancer develops hypercalcemia because some cancer cells secrete chemicals into the blood that are related to the parathyroid hormone. Oliguria causes decreased potassium output resulting in hyperkalemia. A patient with acute pancreatitis develops hypocalcemia because calcium binds with the undigested fat in the feces and is excreted.

Which patient is most at risk of developing hypokalemia? 1. Patient with cancer 2. Patient with oliguria 3. Patient with diarrhea 4. Patient with acute pancreatitis

2. A 65-year-old recently diagnosed with heart failure Heart failure commonly causes extracellular fluid volume (ECF) excess because diminished cardiac output reduces kidney perfusion and activates the renin-angiotensin-aldosterone system, causing the kidneys to retain Na + and water. Dietary sodium restriction is important with heart failure because Na + holds water in the extracellular fluid, making the ECF excess worse. Study Tip: Remember prefix meanings to remember the differences between intracellular, intravascular, and extracellular. Intra- means within, so intravascular means within (blood) vessels, and intracellular means within the cells. Extra- means outside, so extracellular means outside of the cells.

Which patient would most likely need teaching regarding dietary sodium restriction? 1. An 88-year-old scheduled for surgery for a fractured femur 2. A 65-year-old recently diagnosed with heart failure 3. A 50-year-old recently diagnosed with asthma and diabetes 4. A 20-year-old with vomiting and diarrhea from gastroenteritis

2. Thready pulse 4. Postural hypotension 5. Dry mucous membrane A thready pulse, postural hypotension, and dry mucous membranes are the physical findings of an extracellular fluid volume deficit. Edema in dependent areas and crackles in the lungs are the physical findings of extracellular fluid volume excess.

Which physical findings can be seen in a patient with extracellular fluid volume (ECV) deficit? Select all that apply. 1. Edema 2. Thready pulse 3. Crackles in lungs 4. Postural hypotension 5. Dry mucous membrane

2. Thready pulse 4. Postural hypotension 5. Dry mucous membranes A thready pulse, postural hypotension, and dry mucous membranes are the physical findings of an extracellular fluid volume deficit. Edema in dependent areas and crackles in the lungs are the physical findings of extracellular fluid volume excess.

Which physical findings can be seen in a patient with extracellular fluid volume (ECV) deficit? Select all that apply. 1. Edema 2. Thready pulse 3. Crackles in lungs 4. Postural hypotension 5. Dry mucous membranes

2. Central catheters are long-term devices. Central catheters are long-term devices. The term "central" applies to the location of the catheter tip, not to the insertion site. Peripheral catheters are for short-term use such as for fluid restoration after surgery and short-term administration of antibiotics. Central catheters are mainly useful for administration of large volumes of fluids and for administration of parenteral nutrition. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

Which statement is true regarding vascular access devices (VADs)? 1. The word "central" applies to the insertion site. 2. Central catheters are long-term devices. 3. Peripheral catheters are used for long-term antibiotic administration. 4. Peripheral catheters are more effective for administration of large volumes of fluids.

2. Extravasation Elevating the extremity would benefit a patient with extravasations (tissue damage). Applying warm and moist compresses would benefit a patient with phlebitis. A new intravenous line should be started in another extremity if a patient develops a local infection. Circulatory overload of intravenous solutions occurs when a patient receives fluids too rapidly or receives an excessive amount of fluids. This condition can lead to excessive fluid volume deficit; raising the head of the bed is an appropriate intervention in this case. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

While caring for a patient on intravenous therapy, the nurse elevates the patient's extremity. What is the rationale behind this intervention? 1. Phlebitis 2. Extravasation 3. Local infection 4. Circulatory overload

1. Reducing the IV flow rate 3. Raising the head of the patient's bed A patient on IV therapy may have circulatory overload if the IV solution is infused too rapidly or in an excessive amount. The nurse must reduce the IV flow rate and notify the primary health care provider for further guidance. The nurse must also raise the head of the patient's bed to make the extracellular volume excess subside. If there is any bleeding at the venipuncture site, the nurse must assess whether the IV system is intact. If there is any evidence of local infection or phlebitis near the IV site, the nurse must start a new IV line. If there is any evidence of infiltration near the IV site, the nurse must elevate the patient's extremity. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.

While caring for a patient who is on intravenous (IV) therapy, the nurse notes crackles on auscultation. What are the appropriate nursing interventions? Select all that apply. 1. Reducing the IV flow rate 2. Assessing whether the IV system is intact 3. Raising the head of the patient's bed 4. Starting a new IV line in another extremity 5. Elevating the patient's extremities

3. Deficient fluid volume related to vomiting A supine blood pressure of 90/58 mm Hg and a heart rate of 102 bp in a patient with gastroenteritis indicate deficient fluid volume related to vomiting. The symptoms of impaired skin integrity in a patient with gastroenteritis are intact skin, redness, and decreased skin turgor. Little interest in eating and increased salivation are symptoms of nausea related to gastric irritation. Abdominal cramping and hyperactive bowel sounds are symptoms of diarrhea related to intestinal inflammation.

While caring for a patient with gastroenteritis, the nurse finds a supine blood pressure of 90/58 mm Hg and a heart rate of 102 bpm. What condition does the nurse suspect? 1. Risk for impaired skin integrity 2. Nausea related to gastric irritation 3. Deficient fluid volume related to vomiting 4. Diarrhea related to intestinal inflammation

3. Hypocalcemia Positive Chvostek's sign, Trousseau's sign, and presence of tetany indicate hypocalcemia. Low levels of calcium may affect the excitability of the nerve and muscle cells, causing cramps and abnormal muscle movements. Hypokalemia presents with muscular weakness and cardiac rhythm disturbances. Hyponatremia usually presents with nausea, vomiting, confusion, and seizures. Hypermagnesemia is an abnormally high magnesium concentration in the blood. Chvostek's sign and Trousseau's sign are associated with hypomagnesemia.

While performing a general examination of a patient, the nurse finds that the patient has tetany and is positive for Chvostek's sign and Trousseau's sign. Which electrolyte disturbance is responsible for this clinical presentation? 1. Hypokalemia 2. Hyponatremia 3. Hypocalcemia 4. Hypermagnesemia

4. Stop the transfusion Development of chills, tachycardia, and flushing during a blood transfusion indicate an acute hemolytic reaction. The nurse should stop the transfusion immediately so no more of the incompatible blood reaches the patient. Test-Taking Tip: Remember that the nurse's number 1 priority is the patient's safety! Although the nurse may eventually notify the health care provider and alert the blood bank, stopping the transfusion is the first priority, and thus the best response.

While receiving a blood transfusion, a patient develops chills, tachycardia, and flushing. What is the nurse's priority action? 1. Notify a health care provider. 2. Insert an indwelling catheter. 3. Alert the blood bank. 4. Stop the transfusion

1. Hypotension 2. Cold, clammy skin 4. Dry mucous membranes Hypotension is due to less intake of fluid and sodium volume as compared to the output. Decreased body fluid volume can cause cold clammy skin. The decrease in body fluid due to extracellular fluid volume deficit causes dryness of mucous membranes. Sudden weight gain is observed with extracellular fluid volume excess, due to increased volume of body fluids. Crackles in the dependent portion of the lungs can be observed in cases of extracellular fluid volume excess, due to increased volume of body fluids. Test-Taking Tip: If you are unsure of an answer about extracellular fluid volume deficit, consider its opposite, extracellular fluid volume excess. Extracellular fluid volume excess would cause weight gain, and in the lungs, it would cause crackles. Thus, you can eliminate those choices for this question.

he nurse is caring for a patient who has suffered burns on the chest and back. The nurse suspects that the patient has developed extracellular fluid volume (ECF) deficit. Which clinical findings are likely to be seen in this patient? Select all that apply. 1. Hypotension 2. Cold, clammy skin 3. Sudden weight gain 4. Dry mucous membranes 5. Crackles in dependent portion of lungs

1. A 78-year-old patient with dementia Older patients may become dehydrated because of altered responses to illness related to age. In addition, persons with dementia might not recognize the urge to drink. Patients who are in their 30s, 40s, or 50s with hyperthyroidism, pulmonary embolism, and respiratory infection are not at great risk for dehydration. Study Tip: Stay away from nervous students before the test. Stop reviewing at least 30 minutes before the test. Take a walk, go to the library and read a magazine, listen to music, or do something else that is relaxing. Go to the test room a few minutes before test time so that you are not rushed in settling down in your seat. Tune out what others are saying. Crowd tension is contagious, so stay away from it.

s the nurse is assessing the caseload of patients for the day, which patient would the nurse expect to be at the highest risk of developing dehydration? 1. A 78-year-old patient with dementia 2. A 47-year-old patient with hyperthyroidism 3. A 53-year-old patient with pulmonary embolism 4. A 32-year-old patient with a respiratory infection