NSG 1520 Chapter #40 PrepU

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?

"Fluid in the tissue space between and around cells."

The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention?

"I received a blood transfusion in the United Kingdom."

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?

"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response?

"Let me refer you to the blood bank so they can provide you with information."

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?

1 unit over 2 to 3 hours, no longer than 4 hours

The physician writes an order for intravenous fluids to infuse at 150 mL per hour. If the drop factor of the tubing is 10, at how many drops per minute should the fluid infuse? Record your answer using a whole number.

25

The nurse is calculating the infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtt [drops]/1mL. What is the infusion rate?

42 gtt/min

A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?

60 drops/mL

A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min?

83 gtt/min

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate?

83 mL/hr

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?

An implanted central venous access device (CVAD)

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level?

Cardiac dysrhythmias

The nurse is providing care for a client with a peripheral intravenous catheter in situ. What intervention should the nurse implement in the care of this IV?

Change the site every three to four days.

A registered nurse is overseeing the care of numerous clients on a busy acute medicine unit. Which task would be most safe to delegate to a licensed practical nurse (LPN)?

Changing the dressing on a client's peripheral IV site

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

Decreased potassium levels

The nurse is working with a colleague and observes the colleague changing the bag of a client's IV solution as pictured above. What is the nurse's most appropriate response?

Encourage the colleague to hang the bag on the IV pole before spiking it.

A nurse is caring for four different pediatric clients, all of whom require insertion of an intravenous (IV) catheter. For which client would it be appropriate to insert the IV into the foot?

Infant

Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert?

Muscle weakness, fatigue, and dysrhythmias

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation?

Notify the primary care provider immediately for possible fluid overload.

The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client?

O negative

The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect?

Phlebitis

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?

Potassium

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

Remove the IV.

A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area?

Sacral area

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action?

Stop the transfusion.

The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean?

The client has anti-A antibodies.

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use:

a winged infusion needle.

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?

an infant age 4 months

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

cardiac irregularities

Which is a common anion?

chloride

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

distended neck veins

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:

hypokalemia

The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice?

ordering type of solution, additive, amount of infusion, and duration

A client with renal disease requires IV fluids. It is important for the nurse to:

place the fluids on an electronic device.

A decrease in arterial blood pressure will result in the release of

renin.

The primary extracellular electrolytes are:

sodium, chloride, and bicarbonate.

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:

total parenteral nutrition.

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess

A client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells?

plasma

A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving?

A hypotonic solution

A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply.

Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution.

A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation?

Discontinue the IV and relocate it to another spot.

A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What is the nurse's most appropriate action?

Discontinue the IV.

The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client?

O negative

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?

Offer small amounts of preferred beverage frequently.

Which client(s) would be an appropriate candidate for total parenteral nutrition (TPN)? Select all that apply.

client who has full-thickness (third-degree) burns over 40% of the body client who had gastric surgery and is unable to eat for a few weeks client with anorexia nervosa

A nurse is caring for a client who is on total parenteral nutrition (TPN). Which clients are candidates for TPN? Select all that apply.

clients with major trauma or burns clients with liver and renal failure clients with inflammatory bowel disease

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?

decreased blood volume and intracellular dehydration

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:

electrolytes.

When capping a primary line for intermittent use, a nurse notices local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. Which complication has most likely occurred?

thrombus

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)?

Metabolic alkalosis

A nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 4.5 mg/dL (2.6 mEq/L) Based on these levels, the nurse would identify which imbalance?

hypokalemia