Nursing 2 test 1 pharm/parental/fluid/E+/acid base

A school-aged child is admitted to the hospital with a vaso-occlusive sickle cell crisis. Which measure in the child's care plan should be given priority?

Maintaining fluids through an intravenous line

A nurse is assessing a client who has dehydration. Which of the following assessments is the priority?

Mental status (or a fall from worsened dehydration)

Which electrolyte is a major cation in body fluid?

Potassium

Ondansetron (Zofran) iv push guideline

4mg given over 2-5 minutes. Monitor for irregular pulse

Calcium value normal range

9-11 mg/dL or 4.5-5.5 mEq/L

Hypovolemia

increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1.030

A nurse is providing teaching to a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates an understanding of the teaching?

"I will use the incentive spirometer every hour."

[4-year-old child with diagnosis of hemophilia A admitted for the management of hemorrhage following joint and large muscle injury following a fall. The child exhibits intractable signs of bleeding and fluid volume deficit, including hypotension and diffuse ecchymosis and purpura, despite the administration of clotting factor replacement at 0500. At 0700, the child's international normalized ratio (INR) was 2.5. The health care provider placed the following prescription at 0855: Prothrombin complex concentrate 25 units/kg.] The nurse is caring for a child with hemophilia A with the note above. The child's parent is present at the bedside and asks, "Why will this new medication be given?" How should the nurse respond?

"It produces clotting in spite of the factor deficit caused by an immune response."

A nurse is providing teaching to the parents of a child diagnosed with sickle cell anemia. The discussion is focused on precipitating factors for sickle ceil crisis. Which statement by the parents requires the nurse to reinforce the teaching?

"Our family is taking a fun hiking trip up in the mountains next week."

A couple is expecting a child. The fetus undergoes genetic testing and the couple discover the fetus has sickle cell disease. The couple ask the nurse how most commonly happens. Which statement is accurate for the nurse to provide?

"Sickle cell disease is passed to a fetus when both parents have the gene."

A parent calls the pediatric clinic and tells the nurse "I think my child is having a sickle cell crisis. Should I bring the child to the office?" What is the nurse's best response?

"Tell me about the symptoms your child is experiencing"

A client is returning home after having a bone marrow aspiration and biopsy. Which statement indicates that teaching by the nurse has been effective?

"The area might ache for 1 to 2 days."

A nurse is conducting a class to a group of parents on sickle cell anemia. Which statement by a parent indicates teaching has been effective?

"The sickle shape of red blood cells decreases oxygen to tissues."

The nurse is caring for a child with aplastic anemia. The nurse is reviewing the child's blood work and notes the granulocyte count is about 500, platelet count is over 20,000, and the reticulocyte count is over 1%. The parents ask if these values have any significance. Which response by the nurse is appropriate?

"These values will help us monitor the disease." This response answers the parent's questions. In the nonsevere form, the granulocyte count remains about 500, the platelets are over 20,000, and the reticulocyte count is over 1%. The other responses do not address what the parents are asking and would block therapeutic communication.

A nurse is providing teaching to a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?

"When I sit down to watch TV, I'll be sure to put my feet up." Elevating the feet will increase venous return.

A nurse working in hematology reviews the characteristics of stem cells and their role in disease. Which statements does the nurse understand is true regarding stem cells? Select all that apply.

- There is a continuous supply throughout the life cycle. - Lymphoid stem cells produce lymphocytes. - Myeloid stem cells produce erythrocytes. - They have the ability to self-replicate.

ECF (extracellular fluid)

- fluid found outside the cells of the body, constitutes approximately about one third of total body fluid, - transporter of oxygen, nutrients, and waste products - includes: intravascular fluid, interstitial fluid, transcellular fluid

The nurse is caring for a child with aplastic anemia, Which nursing intervention(s) will assist in improving the child's red blood cell production? Select all that apply.

-Assess medications for side effects of bone marrow suppression. -Assist with documentation needed to obtain a stem cell donor. -Administer a corticosteroid to the child as prescribed. -Instruct on administration of subcutaneous erythropoietin as prescribed.

Lactated Ringer's Solution

-Isotonic -Similar in composition to plasma except contains no magnesium -Expands ECF—treat burns and GI losses -Contraindicated with hyperkalemia and lactic acidosis -No free water or calories

Dextrose solutions

-Primarily used to provide hydration and parenteral calories -May also be used to help correct the low blood sugar, monitor blood sugar -May also be used to carry medications

Central Access Devices

-Sites: subclavian, jugular, or femoral veins -Tunneled central venous catheters: surgically placed with proximal end of catheter, exits on chest -Implantable infusion ports: for long-term therapy in central vein for IV fluids, medications, TPN, and chemotherapy; accessed with 90-degree Huber needle

A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering?

0.45% NaCl

A nurse is caring for a client who has a sodium level of 155 mEq/L. Which of the following IV fluids should the nurse anticipate the provider to prescribe?

0.45% sodium chloride since 155mEq?L is an indication of hypernatremia. Prescription for a hypotonic solution.

A nurse is providing dietary teaching to a client who has heart failure and is receiving furosemide. Which of the following foods should the nurse recommend as containing the greatest amount of potassium?

1 cup of plain yogurt contains 380 g of potassium

Magnesium value normal range

1.5-2.5 mEq/L

A client has chronic hyponatremia, which requires weekly laboratory monitoring to prevent the client lapsing into convulsions or a coma. What is the level of serum sodium at which a client can experience these side effects?

114 mEq/L

Sodium value normal range (major cation of extracellular fluid)

135-145 mEq/L

The nurse is caring for a client in the intensive care unit (ICU) following a near-drowning event in saltwater. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen and dry tongue, flushed skin, and peripheral edema. The nurse anticipates that the client's serum sodium value would be

155 mEq/L

Phosphorus

2.5-4.5

Potassium Value normal range( intercellular cation)

3.5-5.0 mEq/L

A client with a history of congestive heart failure has an order to receive 1 unit of packed red blood cells (RBCS). If the nurse hangs the blood at 12:00 pm, by what time must the infusion be completed?

4:00 pm

implanted port (port-a-cath)

A device used for long-term or frequent infusion therapy (greater than 1 year); consists of a portal body, a dense septum over a reservoir, and a catheter that is surgically implanted on the upper chest or upper extremity. They need to be flushed after each use and at least once a month between courses of therapy.

The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance?

A 52-year-old with diarrhea

Dehydration

A serious reduction in the body's water content

isotonic solution

A solution in which the concentration of solutes is essentially equal to that of the cell which resides in the solution

hypertonic solution

A solution in which the concentration of solutes is greater than that of the cell that resides in the solution

hypotonic solution

A solution in which the concentration of solutes is less than that of the cell that resides in the solution

A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL. daily. What patient teaching would the nurse provide for this patient? Select all that apply. a. "Try to drink at least six to eight glasses of water each day." b.Try to limit your fluid intake to 1 quart of water daily." C. "Limit sugar, salt, and alcohol in your diet." d. "Report side effects of medications you are taking, especially diarrhea." e. "Temporarily increase foods containing caffeine for their diuretic effect." f. "Weigh yourself daily and report any changes in your weight."

A, c, d, f. In general, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.

A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Administer IV fluids to the client evenly over 24hours Encourage the client to rise slowly when standing up Weigh the client every 8hours

Which of the following is the most common cause of symptomatic hypomagnesemia in the United States?

Alcoholism - Alcoholism is currently the most common cause of symptomatic hypomagnesemia in the United States. Any disruption in small bowel function, as in intestinal resection or inflammatory bowel disease, can lead to hypomagnesemia.

adding potassium Cl(KCl)

Always get an order, can burn veins and damage heart so never give IV push; check kidney function and urine output; hypokalemia forms quickly

A child is hospitalized with complications related to hemophilia. The health care provider has discussed the child's plan of care with the parents, but they continue to ask questions. What action will the nurse take?

Answer the parents' questions as completely as possible.

A nurse is administering 500 mL. of saline solution to a patient over 10 hours. The administration set delivers 60 gtts/min. Determine the infusion rate to administer via gravity infusion.

Answer: 50 gtts/min Rationale: When administering 500mL of solution over 10 hours, and the set delivers 60 gtts/mL, the nurse would use the following formula: gtt/min = (500x60)/600 500 x 60 = 30,000/600 = 50 gtts/min

A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect?

Decreased muscle strength

The physician performs a bone marrow biopsy from the posterior iliac crest on a client with pancytopenia. What intervention should the nurse perform after the procedure?

Apply pressure over the site for 5-7 minutes

A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs." Which of the following actions should the nurse take first?

Auscultate the client's lungs to assess for respiratory changes due to weakness of the respiratory muscles

A nurse is caring for a client who has dehydration and is receiving IV fluids. When assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload?

Bounding peripheral pulses due to increased vascular volume

A nurse is assessing a client who has a calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess?

Cardiac rhythm

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect?

Confusion due to lack of cerebral perfusion.

The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise?

Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.

Osmosis

Diffusion of water through a selectively permeable membrane

Famotidine (Pepcid) iv push guideline

Dilute 20mg to 5-10 ml with 0.9% sodium chloride

Morphine Sulfate iv push guideline

Dilute in 4-5 ml 0.9% sodium chloride or sterile water. Causes respiratory depression. Keep patient supine; orthostatic hypotension and fainting may occur

A nurse is administering a blood transfusion to a child diagnosed with a hematologic disorder. Fifteen minutes into the transfusion, the child reports severe headache, nausea, and low back pain. There is no evidence of urticaria and vital signs are unchanged from the baseline. What action should the nurse take next?

Discontinue the transfusion.

A client receiving a blood transfusion reports shortness of breath, appears anxious, and has a pulse of 125 beats/minute. What is the best action for the nurse to take after stopping the transfusion and awaiting further instruction from the health care provider?

Ensure there is an oxygen delivery device at the bedside.

A client wants to donate blood before his or her abdominal surgery next week. What should be the nurse's first action?

Explain the time frame needed for autologous donation.

The nurse cares for a client with a coagulation factor deficiency who is actively bleeding. Which blood component replacement does the nurse anticipate administering?

FFP

The process by which solutes move from an area of higher concentration to one of lower concentration is called

Filtration

Methylpredisolone (Solu-Medrol) iv push guideline

For higher doses, administer by IVPB. Administer over several minutes, rapid administration of high doses may cause hypotension cardiac arrhythmia and sudden death

A nurse is providing care for a child diagnosed with beta-thalassemia who is receiving a blood transfusion. The child reports being bored and asks to go to the playroom. What is the best action for the nurse to take?

Have a child-life specialist find an appropriate activity to occupy the child during the transfusion.

A child is diagnosed with sickle cell anemia. Which test will the nurse expect the primary health care provider to prescribe for this client?

Hemoglobin level

A client is scheduled for surgery to remove an abdominal mass. The nurse knows that which reason hemodilution would be contraindicated as a method to provide blood to the client during the surgery?

History of renal disease

A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect?

Hyperactive deep-tendon reflexes, as well as muscle cramps, numbness, and tingling.

A nurse is teaching nutritional strategies to a client who has a low calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching?

I will add broccoli and kale to my diet

While reviewing a client's laboratory results, a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions should the nurse take?

Implement seizure precautions

A 3-year-old child is hospitalized with a diagnosis of sickle cell anemia and is experiencing a pain crisis. Using the FACES scale, the nurse assesses the child's pain to be a 10 on a scale of 1 to 10. The child is receiving intravenous fluids and oxygen at 2 L/min via nasal cannula. The parent is at the bedside holding the child's hand and has a concerned look. What is the nurse's priority in caring for the child?

Implement strategies to address the child's pain.

A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary edema. Which of the following actions should the nurse take first?

Initiate high-flow oxygen therapy by face mask at 5 to 6 L/min

The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which?

Insensible fluid loss

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Light-headedness or paresthesia

Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate?

Limit sodium and water intake.

Furosemide (Lasix) iv push guideline

Monitor BP, electrolytes, CO2, and BUN. Risk of proximity increases with higher doses, rapid injection, decreased renal function, or concurrent use with other otoxic drugs

Diffusion

Movement of molecules from an area of higher concentration to an area of lower concentration.

A 64-year-old client is brought in to the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client?

No, sodium intake should be restricted.

A home care nurse is teaching a parent how to administer a clotting factor infusion to their child. How can the nurse best evaluate the effectiveness of the teaching?

Observe the parent set up and administer the infusion.

A nurse is preparing a discharge plan for a child diagnosed with Fanconi anemia who has associated congenital defects. What aspect of the plan should the nurse include to address the child's development of orthopedic function?

Occupational therapy

A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurse include in the teaching as containing the lowest amount of magnesium?

One large hard-boiled egg contains 5 mg of magnesium

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis?

PaCO2, decreased due to hyperventilation

A client is diagnosed with extreme thrombocytosis. The nurse knows this condition is a result of which elevated blood cell count?

Platelets

A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports this finding?

Potassium 6.1 mg/L Hyperkalemia can cause a prolonged PR interval; a wide QRS complex; flat or absent P waves; and tall, peaked T waves.

A nurse is assessing a client who is using PCA following a thoracotomy. The client is short of breath, appears restless, and has a respiratory rate o 28/min. The client's ABG results are pH 7.52, PaO2 89 mm Hg, PaCO2 28 mm Hg, and HOg- 24 mEq/L. Which of the following actions should the nurse take?

Provide calming interventions

A nurse is providing teaching on the medication regimen for beta-thalassemia to an adolescent. What is the best way for the nurse to determine if the teaching was successful?

Request that the adolescent teach the information to the nurse.

A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mm Hg, PaCO2 56 mm Hg, and HCO3- 26 mEq/L. The nurse should interpret these laboratory values as which of the following imbalances?

Respiratory acidosis Status asthmaticus causes inadequate gas exchange, resulting in a low pH and PaO2, an elevated PaCO2, and an HCO3- within the expected reference range. These laboratory values indicate respiratory acidosis.

A nurse cares for several mothers and babies in the postpartum unit. Which mother does the nurse recognize as being most at risk for a febrile nonhemolytic reaction?

Rh-negative mother; Rh-positive child

A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving regular insulin by continuous IV infusion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider?

Serum potassium 3.0 mEq/L This serum potassium level is outside the expected reference range. The nurse should report this finding to the provider.

A nurse is assessing a client who has a phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect?

Slow peripheral pulses due to phosphorus levels being below the expected reference range

Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality?

Sodium - Sodium is the primary determinant of ECF osmolality. Sodium plays a major role in controlling water distribution throughout the body because it does not easily cross the intracellular wall membrane and because of its abundance and high concentration in the body. Potassium, calcium, and magnesium are not primary determinants of ECF osmolality.

A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following laboratory values should the nurse report to the provider?

Sodium 128 mEq/L. ( Likely to cause mental status because range is low)

A nurse is evaluating a client who is receiving IV fluids to treat dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective?

Sodium 142 mEq/L A sodium level of 142 mEg/L is within the expected reference range of 136 to 145 mEq/L and indicates that the fluid therapy has been effective.

saline solution

Sodium chloride and sterile water for dehydrated patient

Which type of lymphocyte is responsible for cellular immunity?

T lymphocyte

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?

The client had a liver transplant 2 years ago.

Treatment of FVE involves dietary restriction of sodium. Which of. the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)?

Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad

A nurse is providing preoperative care to a child with sickle cell disease. What treatment should the nurse expect to implement prior to surgery?

Transfusion of packed red blood cells (PRBCs)

The cardinal feature of metabolic acidosis is a decrease in the serum bicarbonate level.

True

Hypervolemia

abnormal increase in the volume of blood plasma in the body

A nurse is preparing to administer oral potassium to a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first?

Withhold the medication The greatest risk to the client is bradycardia, hypotension, and life-threatening cardiac complications due to hyperkalemia, defined as a potassium level above 5.0 mEq/L. Therefore, the nurse's priority action is to withhold the oral potassium and notify the provider.

A nurse is flushing a patient's peripaeral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation? a. Remove the IV from the site and start at another location. b. Immediately notify the primary care provider. c. Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes. d. Aspirate the catheter and attempt to flush again.

a. If the peripheral venous access site leaks fluid when flushed the nurse should remove it from site, evaluate the need for continued access, and if clinical need is present, restart in another location. The primary care provider does not need to be notified first. The nurse should use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes or aspirate and attempt to flush again if the IV does not flush easily.

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? a. Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. b. Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. c. Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. d. Discontinue the infusion immediately, apply warm compresses to the site, and restart the IV at another site.

a. The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? a. Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. b. Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider stat, administer antihistamine parenterally as needed. c. Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider, and treat symptoms. d. Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the health care provider, administer antibiotics stat.

a. The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.

When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document? a. 1 b. 2 c. 3 d. 4

b. Grade 2 phlebitis presents with pain at access site with erythema and/or edema. Grade 1 presents as erythema at access site with or without pain. Grade 3 presents as grade 2 with a streak formation and palpable venous cord. Grade 4 presents as grade 3 with a palpable venous cord >1 in and with purulent drainage.

A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? a. Explaining the mechanisms involved in transporting fluids to and from intracellular compartments. b. Keeping fluids readily available for the patient. c. Emphasizing the long-term outcome of increasing fluids when the patient returns home. d. Planning to offer most daily fluids in the evening.

b. Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day.

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? a. Encourage foods and fluids with high sodium content. b. Administer oral K supplements as ordered. c. Caution the patient about eating foods high in potassium content. d. Discuss calcium-losing aspects of nicotine and alcohol use.

b. Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia, and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.

A nurse carefully assesses the acid-base balance of a patient whose carbonic acid (H,COg) level is decreased. This is most likely a patient with damage to the: a. Kidneys b. Lungs c. Adrenal glands d. Blood vessels

b. The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are the primary controller of the body's bicarbonate supply. The adrenal glands secrete catecholamines and steroid hormones. The blood vessels act only as a transport system.

A nurse is providing client teaching about the body's plasma pH and the client asks the nurse what is the major chemical regulator of plasma pH. What is the best response by the nurse?

bicarbonate-carbonic acid buffer system

A nurse is performing a physical assessment of a patient who is experiencing fluid volume loss. Upon examination of the patients legs the nurse documents: "Pitting edema; 6-mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented?

c. 3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection. 1+ is a slight indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal. 2+ is a 4-mm pit that lasts longer than 1+ with fairly normal contour. 4+ is a deep pit (8mm) that remains for a prolonged time after pressing with frank swelling. .

Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3-, 14 mEg/L? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

c. A low pH indicates acidosis. This, coupled with a low bicarbonate, indicates metabolic acidosis. The pH and bicarbonate would be elevated with metabolic alkalosis. Decreased PaCO, in conjunction with a low pH indicates respiratory acidosis; increased PaCO, in conjunction with an elevated pH indicates respiratory alkalosis.

A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess? a. A pinched and drawn facial expression b. Deep, rapid respirations. c. Moist crackles heard upon auscultation d. Tachycardia

c. Moist crackles may indicate fluid volume excess. A person with a severe fluid volume deficit may have a pinched and drawn facial expression. Deep, rapid respirations may be a compensatory mechanism for metabolic acidosis or a primary disorder causing respiratory alkalosis. Tachycardia is usually the earliest sign of the decreased vascular volume associated with fluid volume deficit.

The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition?

confusion

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. a. 5% dextrose in 0.9% NaCl b. 0.9% NaCI (normal saline) c. Lactated Ringer's solution d. 0.33% NaCI (½-strength normal saline) e. 0.45% NaCI (½-strength normal saline) f. 5% dextrose in Lactated Ringer's solation

d, e. 0.33% NaCI (⅓-strength normal saline), and o.45% NaCI (½-strength normal saline) are used to treat hypernatremia. 5% dextrose in 0.9% NaCl is used to treat SIADH and can temporarily be used to treat hypovolemia if plasma expander is not available. 0.9% NaCl (normal saline) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. 5% dextrose in Lactated Ringer's solution replaces electrolytes and shifts fluid from the intracellular compartment into the intravascular space, expanding vascular volume.

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? a. Recording intake and output. b. Testing skin turgor. c. Reviewing the complete blood count. d. Measuring the weight daily.

d. Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete b count does not necessarily reflect fluid balance.

A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? a. Reposition the extremity and raise the height of the IV pole. b. Apply pressure to the dressing on the IV. c. Pull the catheter out slightly and reinsert it. d. Put on gloves; remove the catheter

d. This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes and secure gauze with tape over the insertion site without applying pressure. The nurse should assess the area distal to the venous access device for capillary refill, sensation and motor function and restart the IV in a new location. Finally the nurse should estimate the volume of fluid that escaped into the tissue based on the rate of infusion and length of time since last assessment, notify the primary health care provider and use an appropriate method for clinical management of the infiltrate site, based on infused solution and facility guidelines (INS, 2016b), and record site assessment and interventions, as well as site for new venous access.

The nurse expects which assessment finding when caring for a client with a decreased hemoglobin level?

decreased oxygen level

metabolic acidosis

decreased pH in blood and body tissues Lowered HR, BP, deep rapid RR as a result of an upset in metabolism such as DM-insulin, poison, sepsis

Peripheral Access Device

for short term use in peripheral veins in the hand or forearm

A nurse is reviewing the laboratory report of a client who has fluid volume excess. Which of the following laboratory values should the nurse expect?

hematocrit 34%. ( Fluid volume excess can cause he mode delusion and a decreased hematocrit level, Normal 37-47% Females & 42-52% Males)

metabolic alkalosis

high pH, high HCO3 Underlying causes: bulimia, too much antacids Primary excess of bicarbonate in EFC

Fluid volume excess (hypervolemia)

hypervolemia: water intoxication d/t excessive Na intake

An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?

hypokalemia

Clients diagnosed with hypervolemia should avoid sweet or dry food because it

increases the client's desire to consume fluid.

thrombophlebitis

inflammation of a vein associated with a clot formation

phelbitis

inflammation of the walls of a vein

A client in acute renal failure has been prescribed 2 units of packed red blood cells (PRBCs). The nurse explains to the client that the blood transfusion is most likely needed for which reason?

lack of erythropoietin

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

lactated ringers solution

Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following?

liver

fluid volume deficit

loss of both water and electrolytes from the extracellular fluid; also called hypovolemia

respiratory acidosis

low pH, high CO2 Drug OD Airway obstruction Pulmonary edema

Which term refers to a form of white blood cell involved in immune response?

lymphocyte

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance?

metabolic acidosis

Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets?

myeloid stem cell

The body responds to infection by increasing the production of white blood cells (WBCs). The nurse should evaluate the differential count for what type of WBCs, which are the first WBCs to respond to an inflammatory event?

neutrophils

A nurse is planning care for a client who has a potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings?

orthostatic hypotension The nurse should plan to monitor the client for orthostatic hypotension, which places them at risk for falls. Orthostatic hypotension is a manifestation of hypokalemia.

A nurse is reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis?

pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3 30 mEq/L A pH below 7.35 is an indication of acidosis. An COg- below 22 mEq/L is an indication of metabolic acidosis.

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?

pH 7.48

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?

pH 7.48 - Metabolic alkalosis is a clinical disturbance characterized by a high pH and high plasma bicarbonate concentration. The HCO value is below normal. The PaCO value and the oxygen saturation level are within a normal range.

Which set of arterial blood gas (ABG) results requires further investigation?

pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L

A nurse is caring for a client who requires nasogastric suctioning. Which of the following sets of laboratory results indicates that the client has metabolic alkalosis?

pH 7.51, PaO2 94mmHg, PaCO2 36mmHg, HCO3- 31mEq/L An elevated pH and HOg- with a PaCO, that is either elevated or within the expected reference range indicates metabolic alkalosis.

The calcium concentration in the blood is regulated by which mechanism?

parathyroid hormone (PTH)

The client is planned to have a splenectomy. The nurse should prepare which medication to administer to this client?

pneumococcal vaccine

The nurse is administering meperidine as ordered for pain management for a 10-year-old boy in sickle cell crisis. The nurse would be alert for:

seizures