PrepU Questions for 117
A physician orders an infusion of 250mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate? a) 40 gtt/min b) 20 gtt/min c) 50 gtt/min d) 30 gtt/min
50 ggt/min
The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible with this client? · O negative _____ · AB negative · A positive · B positive
O negative
A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit? a) 3.5 cm H2O b) 12 cm H2O c) 5 cm H2O d) 9.5 cm H2O
a) 3.5 cm H2O
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? a) cardiac irregularities b) increased intracranial pressure (ICP) c) metabolic acidosis d) muscle weakness
a) cardiac irregularities
Edema happens when there is which fluid volume imbalance a) extracellular fluid volume excess b) extracellular fluid volume deficit c) water excess d) water deficit
a) extracellular fluid volume excess
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? a) placing the tourniquet on the upper arm for 2 minutes b) palpating the veins on the nondominant hand c) asking the client to pump their fist several times d) asking if the client is right or left-handed
a) placing the tourniquet on the upper arm for 2 minutes
A decrease in arterial blood pressure will result in the release of: a) renin b) thrombus c) protein d) insulin
a) renin
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend? a) 1,500 mL/day b) 2,500 mL/day c) 3,500 mL/day d) 1,000 mL/day
b) 2,500 mL/day
A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? a)3,750 b) 3,000 c) 500 d) 1,000
b) 3,000
Within 15 minutes after the start of a blood transfusion, the client complains of chills and headaches. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing? a) allergic reaction b) febrile reaction c) hemolytic reaction d) circulatory overload
b) febrile reaction
The 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)? a) metabolic acidosis b) metabolic alkalosis c) respiratory alkalosis d) respiratory acidosis
b) metabolic alkalosis
A nurse must administer an isotonic intravenous solution to a client who has lost fluid. Which fluids are isotonic? Select all that apply. a) 0.45% NaCl (½-strength saline) b) 0.33% NaCl (1/3-strength normal saline) c) 0.9% NaCl (normal saline) d) 5% dextrose in lactated Ringer's solution e) Lactated Ringer's solution
c) 0.9% NaCl (normal saline) e) Lactated Ringer's solution
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? · 5,000 gtt/min · 42 gtt/min · 83 gtt/min ____ · 167 gtt/min
c) 83 gtt/min
Which is a common anion? a) Ca b) K+ c) Cl d) Mg
c) Cl
The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury that is causing the pressure inside the skull to increase which may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate? a) isotonic b) plasma c) hypertonic d) hypotonic
c) hypertonic
The nurse is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate? a) estimate the amount of fluid that you think was excreted into the undergarment b) you only record urine output in an adult undergarment, you do not record diarrhea output c) weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1bs d) we do not record fluids absorbed into undergarments
c) weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1bs
What is the lab test commonly used in the assessment and treatment of acid-base balance? a) CBC b) UA c) BMP d) ABG's
d) ABG's
The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible with this client? a) AB negative b) A positive c) B positive d) O negative
d) O negative
A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? a) cryoprecipitate b) granulocytes c) albumin d) platelets
d) platelets
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? a) all for the assistance b) assess oxygen levels c) assess for visible rash d) stop the transfusion
d) stop the transfusion
Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as: ·a) hyponatremia b) hyperkalemia c) hypokalemia d) hypernatremia
·a) hyponatremia
How is control over the extracellular concentration of potassium within the human body is exerted? a) aldosterone b) progesterone c) albumin d) testosterone
a) aldosterone
What food would the nurse provide for a client who has hypokalemia? a) bananas b) bread c) cheese d) canned veggies
a) bananas
A registered nurse is overseeing the care of numerous clients in a busy acute medicine unit. Which task would be most safe to delegate to a licensed practical nurse (LPN)? a) changing the dressing on a client's peripheral IV site b) re-accessing a client's implanted port c) removing a client's PICC in anticipation of the client's discharge d) initiating a client's transfusion of packed red blood cells
a) changing the dressing on a client's peripheral IV site
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. a) deciding the location of the IV catheter b) administering the IV solution c) deciding the size of the IV catheter d) determining the amount of IV solution e) prescribing the kind of IV solution
a) deciding the location of the IV catheter b) administering the IV solution c) deciding the size of the IV catherter
A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation? a) discontinue the IV and relocate it to another spot b) call the physician and ask if anti-inflammatory drugs should be administered c) cleanse the site with alcohol and apply transparent polyurethane dressing over the entry site d) cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV
a) discontinue the IV and relocate it to another spot
A nurse who has diagnosed a client as having "fluid volume excess" related to the compromised regulatory mechanism (kidneys) may have been alerted by what symptom? a) distended neck veins b) N/V c) fingerprinting over the sternum d) muscle twitching
a) distended neck veins
a client loses conciousness 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: a) electrolytes b) colloid solution c) nonelectrolytes d) interstitial fluid
a) electrolytes
The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the side rail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate? a) remove the IV catheter and reinsert another in a different location b) verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of the catheter open to the air c) apply a new dressing and observe for signs of infection over the next several hours d) decontaminate the visible portion of the catheter, and then gently reinsert
a) remove the IV catheter and reinsert another in a different location
The primary extracellular electrolytes are: a) sodium, chloride, and bicarbonate b) phosphorous, calcium, and phosphate c) magnesium, sulfate, and carbon d) potassium, phosphate, and sulfate
a) sodium, chloride, and bicarbonate
A client has been diagnosed with a GI bleed and the health care provider has ordered a transfustion. At what rate should the nurse administer the client's packed RBC's? a) as fast as the client can tolerate? b) 1 unit over 2-3 hours, no longer than 4 hours c) 75 mL/hr for the first 15 min, then 2,000 mL/hr d) 200 mL/hr
b) 1 unit over 2-3 hours, no longer than 4 hours
The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? a)I have never given blood before b) I received a blood transfusion in the United Kingdom c) My spouse would also like to donate blood d) My blood type is B positive
b) I received a blood transfusion in the United Kingdom
A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? a) eat crackers and bread b) avoid salty or excessively sweet fluids c) use regular gum and hard candy d) use an alcohol-based mouthwash to moisten your mouth
b) avoid salty or excessively sweet fluids
A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation? a) call the primary care provider to see whether anti-inflammatory drugs should be administered b) discontinue the IV and relocate it to another site c) stop the infusion, cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site d) cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV
b) discontinue the IV and relocate it to another site
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? a) fluid inside cells b) fluid in the tissue space between and around cells c) fluid outside cells d) watery plasma, or serum, the portion of the blood
b) fluid in the tissue space between and around cells
During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect? a) febrile reaction: fever develops during infusion b) hemolytic transfusion reaction: incompatibility of blood product c) bacterial reaction: bacteria present in the blood d) allergic reaction: allergy to transfused blood
b) hemolytic transfusion reaction: incompatibility of blood product
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: a) hypoglycemia b) hypokalemia c) hypothyroidism d) hypocalcemia
b) hypokalemia
Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? a) hypertonic b) isotonic c) colloid d) hypotonic
b) isotonic
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? a) this surgery has a very low chance of hemorrhage, so you will not need blood b) let me refer you to the blood bank so they can provide you with information c) unfortunately, your own blood cannot be reinfused during surgery d) we now have artificial blood products, so giving your own blood is not necessary
b) let me refer you to the blood bank so they can provide you with information
The nurse is preparing to administer a fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice? a) preparing solution for administration b) ordering type of solution, additive, amount of infusion, and duration c)regulating the rate of administration d) performing venipuncture
b) ordering type of solution, additive, amount of infusion, and duration
Which finding best indicates to the nurse that the client has a therapeutic outcome from a blood transfusion? a) the client's blood pressure increases to 90/48 mm Hg b) the client has a steady gait while ambulating to void c) the client's face exhibits a normal skin tone and color d) the client is free of chills, fever, and shortness of breath
b) the client has a steady gait while albulating to void
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: a) cellular hydration b) volume expander c) TPN d) blood transfusion therapy
c) TPN
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? a) decreased blood volume and extracellular overhydration b) increased blood volume and extracellular overhydration c) decreased blood volume and intracellular dehydration d) increased blood volume and intracellular dehydration
c) decreased blood volume and intracellular dehydration
Edema happens when there is which fluid volume imbalance? a) water deficit b) water excess c) extracellular fluid volume excess d) extracellular fluid volume deficit
c) extracellular fluid volume excess
Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert? a) muscle weakness, fatigue, and constipation b) nausea, vomiting, and constipation c) muscle weakness, fatigue, and dysrhythmias d) diminished cognitive ability and hypertension
c) muscle weakness, fatigue, and dysrhythmias
The nurse changing a peripheral venous access site dressing is demonstrating the inappropriate technique by implementing which action? a) not preforming the intervention under sterile conditions b) by applying stabilizing pressure to the catheter c) not wearing gloves when performing the intervention d) by pulling the dressing toward the insertion site
c) not wearing gloves when performing the intervention
Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of: a) a systemic blood infection. b) phlebitis c) an infiltration. d) rapid fluid administration
c) phlebitis
A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. Which action should the nurse perform? a) weigh the client without soiled incontinence pads b) weigh the client before and after meals c) weigh the client's wet linen or dressing d) weigh the volume of IV fluid before instilling
c) weigh the client's wet linen or dressing
A physician has asked the nurse to use micro drip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of micro drip tubing? a) 90 drops/mL b) 120 drops/mL c) 30 drops/mL d) 60 drops/mL
d) 60 drops/mL
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? a) Na b) Cl c) Ph d) K+
d) K+
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? a) a peripheral venous catheter inserted to the antecubital fossa b) a peripheral venous catheter inserted to the cephalic vein c) a midline peripheral catheter d) an implanted central venous access device (CVAD)
d) an implanted central venous access device (CVAD)
A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following is a rich source of potassium? a) processed meat b) bread products c) dairy products d) apricots
d) apricots
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? a) flush with 3-mL normal saline b) flow the rate of infusion by 50% c) attempt to aspirate d) discontinue the IV
d) discontinue the IV
A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? a) void replacing IV solutions every 24 hours b) use half-instilled IV solutions before infusing a new one c) select a primary tubing of about 37 inches (94 cm) long d) ensure that the prescribed solution is clear and transparent
d) ensure that the prescribed solution is clear and transparent
Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking? a) diminished cognitive ability and hypertension b) muscle weakness, fatigue, and constipation c) nausea, vomiting, and constipation d) muscle cramping and tetany
d) muscle cramping and tetany
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in the lungs that were previously clear. What would be the most appropriate intervention in this situation? a) notify the primary care provider immediately because these are signs of speed shock b) check all clamps on the tubing and check the tubing for any kinking c) place the client in the Trendelenburg position to keep the client's airway open d) notify the primary care provider immediately for possible fluid overload
d) notify the primary care provider immediately for possible fluid overload
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? a) infiltration b) air embolism c) sepsis d) phlebitis
d) phlebitis
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? a) elevate the arm b) apply a warm compress c) flow the rate of IV fluids d) remove the IV
d) remove the IV
A woman aged 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires: a) an access route to replace fluids in combination with blood products b) an access route to administer medications intravenously c) intravenous fluids to be administered on an outpatient basis d) replacement of fluids for those lost from vomiting and diarrhea
d) replacement of fluids for those lost from vomiting and diarrhea