240 Test 1: Chapter 13 & 15

Which body system is especially affected by hyponatremia? Select all that apply. One, some, or all responses may be correct. (13) Cerebral Endocrine Respiratory Cardiovascular Neuromuscular

"C.C.N" Cerebral Cardiovascular Neuromuscular

The nurse is teaching a patient about activity recommendations with a peripherally inserted central catheter. Which information needs correcting when the patient repeats the directions? (15) "I must avoid driving." "I must avoid lifting heavy weights." "I can have a shower on your own." "I can jog or run for exercise."

"I can jog or run for exercise." walking or jogging is not recommended because these activities may lead to lumen occlusion (catheter to fall out)

The nurse is teaching proper nutrition to a patient who has been prescribed high-ceiling diuretic therapy. Which patient response indicates a need for further teaching? (13) "I should eat fish several times a week." "Eating meat will help with my potassium needs." "I should have fruits such as oranges and bananas every day." "I should eat more eggs and cereals for potassium."

"I should eat more eggs and cereals for potassium." meats, fish, fruits, and some vegetables are highest in potassium

The student nurse is explaining body responses to alterations of fluid balance. Which statement made by the student requires correction? (13) "Natriuretic peptides (NPs) are secreted by the kidneys to restore tissue perfusion." "The hypothalamus contains osmoreceptors sensitive to changes in blood osmolarity." "Antidiuretic hormone (ADH) is released from the posterior pituitary gland in response to changes in blood osmolarity." "Aldosterone is secreted by the adrenal cortex whenever sodium levels in the extracellular fluid are low."

"Natriuretic peptides (NPs) are secreted by the kidneys to restore tissue perfusion." NPs are hormones secreted by special cells that line the atria of the heart in response to increased blood volume and blood pressure

Which finding is common with hypokalemia? Select all that apply. One, some, or all responses may be correct. (13) Paresthesia Bradycardia Shallow respirations Weak, thready pulse Musculoskeletal weakness

"Sara-Wont-Move" Shallow respirations Weak, thready pulse Musculoskeletal weakness

Which statement made by the nurse about IV peripheral catheters needs correction? (15) "Small-gauge peripheral catheters pose an increased risk for phlebitis." "Dwell time of peripheral catheters does not include a specific time frame." "The preferred site of insertion of a peripheral catheter is in an upper extremity." "The smallest-gauge catheter that suits the prescribed therapy should be chosen."

"Small-gauge peripheral catheters pose an increased risk for phlebitis."

An older adult admitted with dehydration and a history of stress incontinence expresses embarrassment about the need for absorbent undergarments. Which question would the nurse ask this patient related to the present illness? (13) "How is your appetite?" "Have you noticed a change in the tightness of your shoes?" "What is your typical urinary elimination pattern and amount?" "What is your typical amount and type of daily fluid intake?"

"What is your typical amount and type of daily fluid intake?" asking the patient about the amount and types of fluids will provide additional information as to how the patient deals with incontinence through fluid management and possible causes for the dehydration

what things cause HYPOnatremia?

***-heart failure -being NPO -excessive diaphoresis (sweating)

***Catheter Knowledge*** (15)

-Nontunneled percutaneous central venous catheters are preferred in emergency or trauma situations -Implanted ports are used for patients who would require IV therapy for more than a year -Midline catheters are used for therapies lasting from 1 to 4 weeks -Tunneled central venous catheters are used primarily when the need for infusion therapy is frequent and long term

What is a midline catheter used for? (15)

-longer than avg IV -left in up to 4 weeks -if the patient had poor skin integrity or limited peripheral veins

HYPERcalcemia s/s (high calcium)

-muscular weakness -ataxia: lack of muscle coordination -constipation, -abdominal pain/distension -confusion -depression -absent tendon reflexes -arrhythmias

what is grade 4 phlebitis (inflamed vein)? (15)

-pain at the access -site with erythema (red skin) and/or edema -streak formation -palpable venous cord longer than 1 inch -purulent drainage

Non-tunneled percutaneous central venous catheters are used for? (15)

-trauma situations -critical care -surgery -short durations

Which filter pore size (in microns) would the nurse select to remove all particles and bacteria in the infusion system? (15) 0.2 1.2 20 40

0.2

Normal MAGNESIUM level

1.5-2.5

The nurse is preparing to flush a peripherally inserted central catheter (PICC) line to maintain patency (being open). Which size syringe would the nurse use to prevent complications? (15) 1 mL 3 mL 5 mL 10 mL

10 mL smaller syringes exert too much pressure and could rupture the PICC line

A patient with a history of cancer is prescribed an IV infusion of chemotherapeutic agents through a peripherally inserted central catheter (PICC). Which solution would the nurse use to flush the catheter before and after medication administration? (15) 5 mL of heparin 10 mL of heparin 10 mL of sterile saline 20 mL of sterile saline

10 mL of sterile saline

For a patient prescribed furosemide as part of treatment plan for cirrhosis and excess fluid volume, which patient goal would the nurse establish for this patient? (13) Adds salt in diet 10-lb weight loss Potassium level 3.0 mEq/L Intake greater than output

10-lb weight loss a patient would follow a low-salt diet to prevent fluid retention

Normal SODIUM level

135-145

Which IV catheter would the nurse choose to insert a SHORT PERIPHERAL CATHETER into a patient who is scheduled for surgery? (15) 18 gauge 22 gauge 24 gauge 26 gauge

18 gauge

Which gauge size of peripheral IV catheter is preferred for an adult patient undergoing a ROUTINE surgical procedure? (15) 14 gauge 18 gauge 22 gauge 26 gauge

18 gauge this gauge of catheter allows for faster flow rates of fluids and blood administration if necessary

*Flow Rate of Catheters* (15)

18-gauge catheter = 110 mL/min 20-gauge catheter = 65 mL/min 22-gauge catheter = 38 mL/min 26-gauge catheter = 24 mL/min

Which daily dietary sodium limit would the nurse suggest for the patient with chronic fluid overload? (13) 2 to 3 g 4 to 5 g 5 to 6 g 6 to 7 g

2 to 3 g

approximately how many punctures can the septum of an implanted chest port tolerate? (15) 500 750 1000 2000

2000

Which is the smallest gauge of peripheral IV catheter the nurse would use to infuse a blood transfusion without damaging the cells? (15) 16 gauge 18 gauge 20 gauge 22 gauge

22 gauge

The nurse hangs a new bag with new tubing to administer a dose of an IV antibiotic prescribed for a patient with a peripheral saline lock. Based on this information, at which time would the nurse change the tubing? (15) 4 hours 24 hours 72 hours 96 hours

24 hours

The nurse enters the room of a patient who is receiving a blood transfusion. Which finding would require the nurse to intervene? Select all that apply. One, some, or all responses may be correct. (15) Administration set with filter Electronic infusion device use 24-gauge IV catheter Luer-Lok connections on tubing Extension set attached to catheter

24-gauge IV catheter a 24-gauge catheter is is too small to infuse blood products and can damage the red blood cells **THIS IS USED FOR pediatrics BLOOD TRANSFUSIONS

Which osmolarity level is found in a HYPOTONIC solution? (15) 250 mOsm/L 300 mOsm/L 350 mOsm/L 400 mOsm/L

250 mOsm/L

**what is the normal serum level of osmolarity?

270-300 mOsm/L

Normal POTASSIUM level

3.5-5

what is the normal serum of an isotonic infusate?

300 mOsm/L

what is the normal serum of hypertonic IV solutions?

350-400 mOsm/L

Which flow rate is expected through a 22-gauge peripheral catheter? (15) 24 mL/min 38 mL/min 65 mL/min 110 mL/min

38 mL/min

Which potassium level would indicate that therapy for hyperkalemia was effective? (13) 7.6 mEq/L 5.6 mEq/L 4.6 mEq/L 2.6 mEq/L

4.6 mEq/L normal potassium level is 3.5-5.0

Which value falls within the range for the minimal amount of urine that needs to be produced in 24 hours? (13) 150 mL/day 250 mL/day 350 mL/day 450 mL/day

450 mL/day The minimum volume of urine per day needed to excrete toxic waste products is 400 to 600 mL and is called obligatory urine output.

How often would the nurse routinely change the gauze dressing on a patient's midline catheter site? (15) 24 hours 48 hours 36 hours 72 hours

48 hours

Which total urine output for the previous day would place a patient at risk for accumulating waste products? (13) 500 mL 700 mL 900 mL 1100 mL

500 mL

Which fluid volume is the expected insensible water loss for a healthy adult each day? (13) 250 to 500 mL 500 to 1000 mL 1000 to 1250 mL 1250 to 1750 mL

500 to 1000 mL

Which patient is at high risk for hypernatremia? (13) 30-year-old on a low-salt diet 42-year-old receiving hypotonic fluids 54-year-old who is sweating profusely 17-year-old with a serum blood glucose level of 189 mg/dL

54-year-old who is sweating profusely *excessive sweating is a common cause of hypernatremia because you lose water that helps to dilute the sodium in the body

Normal CALCIUM level

8.6-10.5

what are peripherally inserted central catheters "PICC" for? (15)

A PICC line gives access to the large central veins near the heart. It's used to give medications or liquid nutrition. A PICC line can help avoid the pain of frequent needle sticks and reduce the risk of irritation to the smaller veins in the arms

Which solution is hypertonic and can be administered through a peripheral IV catheter? (15) A solution that has an osmolarity of 250 mOsm/L A solution that has an osmolarity of 280 mOsm/L A solution that has an osmolarity of 400 mOsm/L A solution that has an osmolarity of 600 mOsm/L

A solution that has an osmolarity of 400 mOsm/L Hypertonic solutions have an osmolarity greater than 300 mOsm/L. Therefore only the solutions that are 400 or 600 mOsm/L are hypertonic

HYPOkalemia s/s (low potassium)

A-SIC-WALT -Alkalosis -Shallow respiration -Irritability -Confusion and drowsiness -Weakness and fatigue -Arrhythmias- irregular heart rate, tachycardia -Lethargy -Thready pulse decrease intestinal mobility, nausea and vomiting

A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multidose vial of heparin with a concentration of 100 units/mL. Which of the syringes shown below will the nurse use to draw up and administer the heparin? (15)

ANS: D (just rembmer that hahah)

Which action would the nurse take to ensure skin antisepsis before venipuncture in an older adult? (15) Apply chlorhexidine for maximum antiseptic action. Apply vigorous friction when cleaning the skin. Do not let the skin dry after application of the antiseptic. Allow a contact time of 1 minute when using iodophors

Apply chlorhexidine for maximum antiseptic action

Which action would the nurse take when choosing a site for placement of a short peripheral venous catheter in a patient who recently had a mastectomy? (15) Avoid the arm on the operative side. Use a vein in the area of the wrist (never!) Choose a vein that is cordlike. Choose the site on the inner side of the elbow.

Avoid the arm on the operative side

For a patient who presents with hypokalemia (low potassium) secondary to loop diuretic use, which food would the nurse teach the patient to eat? Select all that apply. One, some, or all responses may be correct. (13) Pasta Apples Bananas Cauliflower Blackberries

Bananas *bananas, oranges, and grapes are high in potassium

A patient's morning laboratory results show a serum ionized calcium level of 2.85 mmol/L. Which parameter would the nurse assess based on this result? (13) Respiratory rate Blood clotting Muscle tension Peristalsis

Blood clotting HYPERcalcemia allows blood clots to form more easily, especially in the lower legs and pelvic region

Which fluid is critical to preventing death? (13) Urine Perspiration Blood volume Interstitial fluid

Blood volume

Which site of IV therapy-acquired infections is responsible for increased death rates? (15) Peritoneal Meningeal Joint Bloodstream

Bloodstream

Which finding would the nurse expect during the assessment of a patient with a serum potassium level of 6.8 mEq/L? Select all that apply. One, some, or all responses may be correct. (13) Bradycardia Muscle twitching Extremity numbness Cardiac dysrhythmias Hyperactive bowel sounds

Bradycardia Muscle twitching Extremity numbness Cardiac dysrhythmias Hyperactive bowel sounds (all of them)

HYPERmagnesemia s/s (high magnesium)

Bradycardia (slow HR) Muscle twitching Extremity numbness Cardiac dysrhythmias Hyperactive bowel sounds

When a patient reports disturbed deep sleep because of frequent cramping in the calves, which electrolyte would the nurse review in the patient's health record? (13) Sodium Calcium Potassium Magnesium

Calcium

Which laboratory value obtained from a patient's morning metabolic panel would the nurse report as abnormal? (13) Sodium 138 mEq/L Calcium 10.9 mEq/L Potassium 4.5 mEq/L Magnesium 2.0 mEq/L

Calcium 10.9 mEq/L normal range is 9.0 to 10.5 mEq/L

The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The patient with which electrolyte laboratory value would the nurse manager assign to the licensed practical nurse/licensed vocational nurse (LPN/LVN)? (13) Calcium level of 9.5 mg/dL Sodium level of 120 mEq/L Potassium level of 6.0 mEq/L Magnesium level of 4.1 mEq/L

Calcium level of 9.5 mg/dL Because a calcium level of 9.5 mg/dL is within normal limits, it is appropriate to assign this patient to an LPN

Which drug might be used to manage symptoms of hypocalcemia? (13) Vitamin E Zinc sulfate Calcium with vitamin D Potassium chloride

Calcium with vitamin D calcium supplements are given to restore serum calcium levels. Vitamin D helps to improve calcium absorption

Which body system would the nurse reassess if a patient's laboratory result indicates a serum potassium level of 5.9 mEq/L? (13) Respiratory Genitourinary Cardiovascular Integumentary

Cardiovascular potassium controls conductivity within the heart

Which vein site has an increased risk for nerve damage during venipuncture? Select all that apply. One, some, or all responses may be correct. (15) Radial vein in the forearm Cephalic vein near the wrist Basilic vein in the upper arm Cephalic vein in the upper arm Veins on the palmar side of the wrist

Cephalic vein near the wrist & Veins on the palmar side of the wrist **WRIST**

Which IV insertion site would the nurse choose for an older adult being admitted to a same-day surgery unit? (15) Back of the hand Cephalic vein of the forearm Arm on the side of a radical mastectomy Subclavian vein

Cephalic vein of the forearm

Which finding would the nurse expect to notice during an assessment of a patient admitted with hypocalcemia secondary to chronic kidney disease? (13) Circumoral tingling (numbness around the mouth) Lethargy and seizures Negative Trousseau sign Hypoactive bowel sounds

Circumoral tingling (numbness around the mouth)

HYPOcalcemia s/s (low calcium)

Convulsions Arrhythmias *Tetany (involuntary contraction of muscles, & charley horses in thigh, calf, or foot while sleeping) *Spasms and stridor **+positive Trousseau sign hyperactive bowel sounds

For the patient with "increased " fluid volume secondary to heart failure, which intervention would the nurse include in the patient's plan of care? Select all that apply. One, some, or all responses may be correct. (13) Daily weights Skin pressure relief Fluid restriction Diuretic therapy Low-sodium diet

Daily weights Skin pressure relief Fluid restriction Diuretic therapy Low-sodium diet (all of them)

Which electrolyte imbalance triggers aldosterone secretion to maintain fluid balance within the body? (13) Decreased serum potassium levels Decreased sodium levels in the extracellular fluid (ECF) Increased serum glucose levels Increased calcium levels in the extracellular fluid (ECF)

Decreased sodium levels in the extracellular fluid (ECF)

Which assessment finding would the nurse expect in the skin of an older-adult patient? (13) Decreased turgor Increased elasticity Increased oil production Decreased surface injury

Decreased turgor

After administering IV magnesium sulfate (MgSO4) to a patient with hypomagnesemia, which assessment would the nurse perform to determine the effectiveness of the medication? (13) Urinary output Peripheral pulses Deep tendon reflexes Serum albumin levels

Deep tendon reflexes

Which age-related change affects fluid balance? (13) Diminished knee reflex Diminished thirst reflex Diminished cough reflex Diminished baroreceptor reflex

Diminished thirst reflex

Which type of medication is administered to adjust a patient's fluid balance? (13) Diuretic Anticoagulant Mood stabilizer Opioid analgesic

Diuretic

A patient reports blistering, sloughing, and tissue necrosis from the site after an IV drug infusion. Which drug is likely to have caused this condition? (15) Dopamine Vancomycin Amiodarone Ciprofloxacin

Dopamine dopamine may damage the body's tissues, resulting in tissue integrity impairment, which is manifested by blistering, sloughing, and necrosis

What complication of IV therapy occurs at the local level rather than the systemic level? (15) Ecchymosis (infiltration of blood into the surrounding tissues) Speed shock Catheter embolism Circulatory overload

Ecchymosis (infiltration of blood into the surrounding tissues)

Which term would the nurse use to document the presence of "excess" tissue fluid? (13) Ascites Edema Turgor Filtration

Edema

what is grade 1 phlebitis (inflamed vein)? (15)

Erythema (red colored skin) at access site with or without pain

what diuretic do you NOT give to a patient with hypokalemia? and why? (13)

FUROSEMIDE- because it is a loop diuretic that can cause fluid overload causing low potassium and therefore you do not want your potassium any lower by taking this diuretic

Which site would be avoided for a peripherally inserted central catheter (PICC) in an adult patient? (15) Basilic vein Femoral vein Subclavian vein Internal jugular vein

Femoral vein because there is a higher risk for infection

Which statement describes overhydration? (13) Fluid intake is less than the body's fluid needs Fluid retention is equal to the body's fluid needs Fluid retention is less than the body's fluid needs Fluid intake is greater than the body's fluid needs

Fluid intake is greater than the body's fluid needs

Which statement explains vascular dehydration? (13) Too much fluid loss Too little fluid intake Fluid shift from plasma to interstitial space Fluid shift from interstitial space to plasma

Fluid shift from plasma to interstitial space dehydration without actual loss of total body water, such as when the fluid shifts from plasma to the interstitial space, is called vascular dehydration

Which statement describes isotonic dehydration? (13) Fluids and electrolytes are lost from the body in equal amounts. Electrolytes are lost from the body in greater quantities than fluids. Fluids are lost from the body in greater quantities than electrolytes. Fluids and electrolytes are lost from the body, but only water is replaced.

Fluids and electrolytes are lost from the body in equal amounts

Which action would the nurse include in the plan of care to prevent the lumens of a central venous catheter from occluding? (15) Use smaller syringes. Flush with normal saline. Apply a transparent dressing. Administer infusions slowly.

Flush with normal saline

For which conditions is intraosseous (IO) infusion therapy contraindicated? Select all that apply. One, some, or all responses may be correct. (15) Fracture Osteoporosis Osteoarthritis Adhesive capsulitis Osteogenesis imperfecta

Fracture Osteoporosis Osteogenesis imperfecta Intraosseous infusion is the process of injecting medications, fluids, or blood products directly into the marrow of a bone

A patient who had an IV in place the previous week now has a palpable cord 1 inch in length and streak formation up the arm. Which grade of phlebitis would the nurse assign? (15) Grade 1 Grade 2 Grade 3 Grade 4

Grade 3

Which information would the nurse include in an infection prevention program related to infusion therapy using the HANDS mnemonic? Select all that apply. One, some, or all responses may be correct. (15) Hand hygiene Documentation Skin preparation Not touching site Injection hub cleaning

Hand hygiene Documentation Skin preparation Not touching site Injection hub cleaning (all of them)

Of the diagnoses documented in a patient's health record, which condition would the nurse attribute to the cause of the patient's sodium level of 130 mEq/L? (13) Diarrhea Heart failure Cushing syndrome Fever unknown origin

Heart failure the patient is experiencing hyponatremia as the patient's sodium level is LESS than 136 mEq/L

Which complication is associated with leaving the tourniquet on an older patient's arm for an extended time before a venipuncture? (15) Phlebitis Hematoma Thrombosis Infiltration

Hematoma if a tourniquet is left on for an extended time before the venipuncture, the vein may overfill and burst at the time of puncture causing a hematoma

Which condition would the nurse expect in the laboratory report of a patient with hypervolemia (fluid overload)? (13) Hemostasis (stoping of blood flow) Homeostasis (equal) Hemodilution (decreased blood concentration-watery) Hemoconcentration (increased blood concentration-thick)

Hemodilution fluid overload is characterized by decreased hemoglobin, hematocrit, and serum protein levels because of excessive water in the vascular space

The primary health care provider prescribes IV administration of 100 mL of 20% glucose along with 20 units of insulin. Which condition would the nurse expect the patient to have? (13) Hyperkalemia Hyperglycemia Hypernatremia Hypercalcemia

Hyperkalemia

The nurse is providing care to a patient who is diagnosed with dehydration. Which laboratory finding supports the current diagnosis? (13) Hypokalemia Hypercalcemia Hypernatremia Hypomagnesemia

Hypernatremia

Positive Trousseau and Chvostek signs are consistent with which electrolyte imbalance? (13) Hypokalemia Hyperkalemia Hypocalcemia Hypercalcemia

Hypocalcemia

Which additional electrolyte imbalance would the nurse monitor for in a patient who has hypomagnesemia? (13) Hyperkalemia Hypocalcemia Hypernatremia Hypophosphatemia

Hypocalcemia *Hypocalcemia often occurs with hypomagnesemia. Magnesium is required for the production and release of the parathyroid hormone, so when magnesium is too low, insufficient parathyroid hormone is produced and blood calcium levels are also reduced (hypocalcemia). The hypocalcemia is described as "secondary" because it occurs as a consequence of hypomagnesemia

Which electrolyte imbalance should be anticipated in a patient with hyperphosphatemia (elevated phosphate in the blood)? (13) Hypokalemia Hypocalcemia Hypernatremia Hypermagnesemia

Hypocalcemia phosphorus and calcium have an "inverse" or reciprocal relationship. When one is increased, the other is usually decreased (when one is up the other is down). Therefore a patient with hyperphosphatemia should be monitored for hypocalcemia

Which finding would indicate that a patient is at risk for fluid volume overload? (they have too much fluid in their body "watered down" (13) Hyperkalemia Hypocalcemia Hyponatremia Hyperchloremia

Hyponatremia

Which condition commonly occurs in patients who are on long-term furosemide therapy? (13) Hypocalcemia Hypercalcemia Hyponatremia Hypernatremia

Hyponatremia (low soduim) Furosemide is a high-ceiling or loop diuretic. Prolonged use of this drug to manage fluid overload may cause loss of sodium along with extra water, leading to a decrease in sodium levels, or hyponatremia

Which condition would stimulate renin-angiotensin II to maintain fluid balance within the body? (13) Hypoxia Hypoglycemia Hypercalcemia Water intoxication

Hypoxia

Water loss from the skin (perspiration) lungs (respiration) and stool (feces) is called? (13)

INSENSIBLE water loss because there are no mechanisms to control this loss

Which situation is an indication for placing a NONTUNNELED percutaneous central venous catheter (CVC) in a patient? (15)

Impending surgery Trauma situations Administration of IV fluids

Which central vascular access device (CVAD) is indicated in patients who require IV therapy for more than a year? (15) Implanted port Tunneled central venous catheter Peripherally inserted central catheter Non-tunneled percutaneous central venous catheter

Implanted port

Which central vascular access device (CVAD) can be placed for access to arteries, the epidural space, and the peritoneal cavity? (15) Implanted port Tunneled central venous catheter Peripherally inserted central catheter Nontunneled percutaneous central venous catheter

Implanted port *It can be used for all things!

Which defense mechanism maintains blood flow to the vital organs during isotonic dehydration? (13) Decreased heart rate Decreased peripheral resistance Increased blood vessel constriction Increased pulmonary ventilation rate

Increased blood vessel constriction vasoconstriction is a mechanism that helps increase the blood pressure and maintain blood flow to the vital organs

Which cardiovascular change would the nurse expect to find in a patient with fluid overload? (13) Flat jugular veins Increased heart rate Widened pulse pressure Decreased blood pressure

Increased heart rate

Which patient outcome indicates that a dose of furosemide was effective? (13) Weight gain Increased heart rate Increased urine output Decreased blood pressure (BP)

Increased urine output

Which age-related change increases an older adult patient's risk for dehydration? (13) Increased water loss Increased thirst reflex Increased concentrating capacity Increased glomerular filtration rate

Increased water loss

A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and "feeling warm." For which complication of this therapy will the nurse assess the client? (15) a. Allergic reaction b. Bowel obstruction c. Catheter lumen occlusion d. Infection

Infection

Which complication of peripherally inserted central catheters (PICC) happens RARLY? Phlebitis Infiltration Thrombophlebitis Deep vein thrombosis

Infiltration

Which finding is common in both thrombophlebitis (inflamed vein) and phlebitis? (15) Infiltration Contraction Extravasation Inflammation

Inflammation

A patient has a low serum potassium level and is prescribed a dose of parenteral potassium chloride (KCl). Which administration method would the nurse use? (13) Infuse 10 mEq over a 1-hour period. Administer 5 mEq IM. Push 5 mEq through a central access line. Dilute 200 mEq in 1 L of normal saline, and infuse at 100 mL/hr

Infuse 10 mEq over a 1-hour period

Which route is often used to administer chemotherapeutic agents into a tumor's blood supply? (15) Intraspinal Intraosseous Intra-arterial Intraperitoneal

Intra-arterial

Which function does aldosterone serve? (13) It causes constriction of renal arterioles It promotes the resorption of water and sodium It stimulates the secretion of renin for the kidneys It causes constriction of peripheral blood vessels

It promotes resorption of water and sodium

Which statement regarding the Needlestick Safety and Prevention Act is true? Select all that apply. One, some, or all responses may be correct. (15) It was passed in 2001. It includes the use of needleless-capable devices, such as Luer-activated devices. It requires every employer to maintain a sharps injury log with details of each incident. It constitutes an amendment of the Occupational Safety and Health Administration (OSHA) guidelines. It mandates that staff who perform tasks with devices engineered with safety mechanisms may not be involved in selecting products.

It was passed in 2001 It includes the use of needleless-capable devices, such as Luer-activated devices It requires every employer to maintain a sharps injury log with details of each incident It constitutes an amendment of the Occupational Safety and Health Administration (OSHA) guidelines

Which clinical manifestation would the nurse associate with a patient's admitting diagnoses of heart failure and fluid overload? Select all that apply. One, some, or all responses may be correct. (13) Weight loss Hypotension Clear lung sounds Jugular vein distention Decreased respiratory rate

Jugular vein distention Signs of fluid overload include distended jugular neck veins

A 77-year-old woman who has congestive heart failure (CHF) is brought to the emergency department after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well but that she has been taking her diuretics and other medications. Her laboratory results include a potassium level of 3.0 mEq/L. Which information would the nurse include in the patient's medication teaching? Select all that apply. One, some, or all responses may be correct. (13) Diuretics increase fluid retention. Laxatives can lead to fluid imbalance. It is important to weigh daily at the same time. Diuretics can lead to fluid and electrolyte imbalances. Daily weights are a poor indicator of fluid loss or gain.

Laxatives can lead to fluid imbalance It is important to weigh daily at the same time Diuretics can lead to fluid and electrolyte imbalances

Which condition indicates infiltration? (15) Inflammation of the vein Blood clot inside the vein Leakage of NONVESICANT IV solution into extravascular fluid Leakage of vesicant IV solution into extravascular fluid

Leakage of nonvesicant IV solution into extravascular fluid this occurs because of obstruction of blood flow, causing back flow through the insertion site

Which commercial product is a tunneled central venous catheter (CVC) used for long-term parenteral nutrition? Select all that apply. One, some, or all responses may be correct. (15) PreSep Leonard Hickman Insyte BD Angiocath BD

Leonard Hickman **CVCs were originally named for the physicians who designed them

Which type of anesthetic is typically used to insert a catheter for intraosseous (IO) therapy? (15) Local Topical General None

Local

For which classification of drugs would the nurse instruct a patient to INCREASE intake of dietary potassium? (13) Beta blockers Corticosteroids Alpha antagonists Loop diuretics

Loop diuretics high-ceiling (loop) diuretics are potassium-depleting drugs

Which component would the nurse verify on the blood label before administering a blood transfusion to a patient? Select all that apply. One, some, or all responses may be correct. (15) Dosage Tonicity Lot number Product code ABO group and Rh factor

Lot number Product code ABO group and Rh factor

HYPERkalemia s/s (high potassium)

M.U.R.D.E.R. M - Muscle weakness U - Urine, oliguria, anuria R- Respiratory distress D - Decreased cardiac contractility E - ECG changes R - Reflexes, hyperreflexia, or areflexia (flaccid)

Which site is commonly used for short peripheral catheter placement? Select all that apply. One, some, or all responses may be correct. (15) M-ax C-cant B-owl Median Jugular Cephalic Basilic Vena cava

Median Cephalic Basilic

Which vein would the nurse select for a midline catheter? (15) Cephalic Subclavian Internal jugular Median antecubital

Median antecubital

While the nurse is attempting to remove a midline catheter from a patient, the patient develops venospasms. Which technique would the nurse use to facilitate the removal of the catheter? (15) Medication administration Forceful removal Clipping sutures Breaking the catheter

Medication administration

Which catheter type is likely to cause venospasms if removed forcefully? Select all that apply. One, some, or all responses may be correct. (15) Midline Tunneled Short peripheral Peripherally inserted central Nontunneled percutaneous central

Midline Peripherally inserted central

Which catheter type is usually chosen for IV therapy in older adults? (15) Implanted ports Midline catheters Tunneled catheters Nontunneled percutaneous central catheters

Midline catheters

Which assessment finding is consistent with fluid overload? (13) Heart murmur Decreased pulse rate Decreased respiratory rate Moist crackles in the lungs

Moist crackles in the lungs

Which intervention would the nurse plan for a patient with hypercalcemia? (13) Monitor cardiac rhythm for changes. Limit activities to protect against injury. Assess oxygen saturation levels every 4 hours. Avoid invasive procedures because of increased bleeding risk.

Monitor cardiac rhythm for changes

The nurse enters the room of a patient receiving 0.9% sodium chloride at 100 mL/hr. The nurse assesses the patient is short of breath with jugular vein distention. The nurse determines the patient has received too much fluid. Which action would the nurse take to decrease complications? Select all that apply. One, some, or all responses may be correct. (15) Monitor vital signs. Discontinue the infusion. Notify the health care provider. Place the patient in the Trendelenburg position. Apply a tourniquet to the arm above the IV site.

Monitor vital signs Notify the health care provider

Which regulation requires every health care facility to maintain a sharps injury log with details of each incident? (15) Affordable Care Act Americans with Disabilities Act Patient Self-Determination Act (PSDA) Needlestick Safety and Prevention Act

Needlestick Safety and Prevention Act

A patient receiving IV therapy reports tingling and numbness at the peripheral insertion site. Which complication would the nurse suspect? (15) Ecchymosis Thrombosis Venous spasm Nerve damage

Nerve damage nerve damage is caused by vein puncture at or near the nerve location

Which central catheter insertion procedure requires the patient to be in the Trendelenburg (feet elevated above head) position? (15) Implanted port Tunneled central venous catheter Peripherally inserted central catheter Nontunneled percutaneous central venous catheter

Nontunneled percutaneous central venous catheter being at a trendelenburg position helps to ensure that the catheter exit site is at or below the heart

Which catheter is commonly used in emergency or trauma situations? (15) Implanted ports Midline catheters Tunneled central venous catheters Nontunneled percutaneous central venous catheters

Nontunneled percutaneous central venous catheters

Which condition is a potential complication of intraosseous (IO) infusion therapy (the process of injecting medications, fluids, or blood products directly into the BONE MARROW)? (15) Osteoporosis (brittle bones) Osteogenesis (formation of bone) Osteoarthritis (degeneration of cartilage) Osteomyelitis (inflammation of bone/bone marrow due to infection)

Osteomyelitis (inflammation of bone/bone marrow due to infection

As the nurse assesses the insertion site in the right arm of a short peripheral venous catheter, which finding indicates the presence of phlebitis (inflammation of vein) ? (15) Bruising Swelling Blistering Skin coolness Palpable cord

Palpable cord dilated superficial veins that are caused by an obstruction of the deep venous system

Which ECG finding is consistent with hyperkalemia (high potassium)? (13) Absent T waves Elevated P waves Prolonged PR intervals Shortened QRS complexes

Prolonged PR intervals when hyperkalemia is present, an individual may show: -absent P waves -tall T waves -prolonged PR intervals -widened QRS complexes

For which purpose would a patient with edema receive a hyperosmotic IV solution? (13) Improve diffusion of electrolytes within cells. Reduce diffusion of potassium into the extracellular space. Pull excessive fluid from the interstitial space. Reduce filtration of body fluids.

Pull excessive fluid from the interstitial space osmosis is the movement of water only through a semipermeable membrane down a concentration gradient. By infusing a hyperosmotic solution, interstitial fluid will be pulled into the plasma volume, reducing cerebral edema

Which finding is associated with fluid overload? (13) Tachycardia Hyperthermia Pulmonary crackles Orthostatic hypotension

Pulmonary crackles

Which action would the nurse take when providing care to a patient with hypokalemia? (13) Question the continued administration of prescribed bumetanide. Administer prescribed oral potassium chloride (KCl) before a meal. Establish a peripheral IV, preferably in the hand, for administering IV potassium chloride (KCl). Obtain the prescribed vial of IV potassium chloride (KCl) from the pharmacy, and dilute before administration

Question the continued administration of prescribed bumetanide Bumetanide is a loop diuretic, which contributes to potassium loss and should be questioned

Which group of professionals may initiate infusion therapy in all states of the United States? (15) Registered nurses (RNs) Technicians Licensed practical nurses (LPNs) Licensed vocational nurses (LVNs)

Registered nurses (RNs)

Which condition is the major cause of death in patients with hypokalemia (low potassium)? (13) Stroke Renal failure Cardiac arrest Respiratory insufficiency

Respiratory insufficiency respiratory changes may occur in patients with hypokalemia because of respiratory muscle weakness resulting in shallow respirations

The nurse is preparing to administer packed red blood cells (PRBCs) to a patient with anemia (low red blood cells). Which information would the nurse expect to find on the unit label? Select all that apply. One, some, or all responses may be correct. (15) Rh type ABO group Facility label Product code Donor lot number

Rh type ABO group Facility label Product code Donor lot number (all of them)

The nurse determines the patient has an infection from the short peripheral IV catheter used for treatment. Which action would the nurse take to determine the offending organism? (15) Clean the exit site with alcohol. Remove the peripheral catheter. Send the catheter tip for culture. Apply cold compresses to the site.

Send the catheter tip for culture

The nurse is caring for a patient admitted with dehydration secondary to influenza who is prescribed 0.9% sodium chloride. Which vascular access device would be appropriate for the nurse to insert? (15) Midline catheter Short peripheral catheter Tunneled central catheter Peripherally inserted central catheter

Short peripheral catheter the nurse should insert a short peripheral catheter as the patient is receiving an isotonic solution that will not harm the tissues

Which statement accurately describes hypodermoclysis? Slow infusion of isotonic fluids into the subcutaneous tissues Rapid infusion of isotonic fluids into the subcutaneous tissues Slow infusion of hypotonic fluids into the subcutaneous tissues Rapid infusion of hypotonic fluids into the subcutaneous tissues

Slow infusion of isotonic fluids into the subcutaneous tissues

Which intervention would the nurse expect to be prescribed for a patient with hyponatremia? (13) 2-g sodium diet Administration of furosemide IV administration of 0.45% normal saline Small-volume IV infusions of 3% normal saline

Small-volume IV infusions of 3% normal saline -3% saline is hypertonic and is given in small volumes to replenish serum sodium -0.45% saline is hypotonic and will further dilute serum sodium levels -Furosemide causes sodium loss in the kidneys and would further contribute to hyponatremia -2-g sodium diet restricts sodium intake; the goal of nutritional therapy with hyponatremia is to increase sodium intake

Which electrolyte deficiency results in reduced excitable membrane depolarization and increased cellular swelling? (13) Sodium Calcium Potassium Magnesium

Sodium

Which electrolyte deficiency would the nurse expect to find when reviewing the laboratory data for a patient who presents with seizure activity, decreased deep tendon reflexes, and diarrhea? (13) Sodium Calcium Potassium Magnesium

Sodium

Which electrolyte excess results in cellular irritability and severe cellular dehydration? (13) Sodium Calcium Phosphorus Magnesium

Sodium

Which urine laboratory parameter would help in the diagnosis of a patient with dehydration? (13) pH Glucose Specific gravity Ketones

Specific gravity

Which intervention would the nurse expect the health care provider to prescribe for a patient with "multiple fluid and electrolyte DEFICITS" secondary to a GI virus? (13) Give antihypertensives Initiate fluid restrictions Apply continuous oxygen Administer loop diuretics Start an IV solution of Ringer's lactate

Start an IV solution of Ringer's lactate Ringer's lactate as would help replace some electrolytes

The nurse determines the chemotherapy infusion has leaked into the surrounding tissues and caused extravasation (fluid coming out of a vessle). Which action would the nurse take to prevent further complications? Select all that apply. One, some, or all responses may be correct. (15) Stop the infusion. Take pictures. Disconnect the IV tubing. Aspirate the remaining drug. Leave the IV catheter in place if an antidote is ordered.

Stop the infusion. Take pictures. Disconnect the IV tubing. Aspirate the remaining drug. Leave the IV catheter in place if an antidote is ordered. (all of them)

A 90-year-old patient with hypermagnesemia is seen in the emergency department (ED). To which inpatient unit would the ED nurse expect to admit this patient? (13) Medical-surgical Dialysis/home care Geriatric/rehabilitation Telemetry/cardiac stepdown

Telemetry/cardiac stepdown because hypermagnesemia causes changes in the ECG that may result in cardiac arrest, the patient should be admitted to the telemetry/cardiac stepdown unit

The nurse is admitting a 78-year-old patient with severe diarrhea. Which assessment finding indicates that the patient may be dehydrated? Select all that apply. One, some, or all responses may be correct. (13) Distended neck veins Bounding radial pulses Temperature of 99.4°F (37.4°C) Dizziness when standing Newly reported confusion

Temperature of 99.4°F (37.4°C) Dizziness when standing Newly reported confusion -postural hypotension causing dizziness may occur with dehydration. Because of decreased perfusion to the brain, confusion is common in older adults -low-grade fever is a common result of dehydration. -with dehydration, neck veins are FLAT, not distended; peripheral pulses are WEAK, not bounding

Which statement is accurate regarding fluid balance in older-adult patients? (13) They have less total body water They are prone to hyperkalemia They are prone to hypernatremia They have an increased thirst reflex

They have less total body water

Which condition is a common and serious complication of a peripherally inserted central catheter (PICC)? (15) Phlebitis Infiltration Thrombosis Thrombophlebitis

Thrombophlebitis *thrombophlebitis is the most serious complication of PICC

Which term would the nurse use to document the IV therapy complication of a blood clot inside the vein? (15) Phlebitis Thrombosis Extravasation Thrombophlebitis

Thrombosis

Which term would the nurse use to document the IV therapy complication of a blood clot inside the vein? (15) Phlebitis Thrombosis (blood clot inside the vein) Extravasation Thrombophlebitis (inflammation & a blood clot inside the vein)

Thrombosis

Which history and assessment finding may be associated with hypocalcemia? Select all that apply. One, some, or all responses may be correct. (13) Absent bowel sounds Tingling around the mouth Muscle spasms in the calf at rest Decreased deep tendon reflexes without paresthesia Recent blunt trauma to the throat

Tingling around the mouth Muscle spasms in the calf at rest Recent blunt trauma to the throat

Which device is commonly used to identify superficial veins and assist in the placement of short peripheral catheters? (15) X-ray Ultrasound Fluoroscopy Transilluminator

Transilluminator

HYPOmagnesemia s/s (low magnesium)

Twitching Paresthesias Hyperactive reflexes *Irritability* Confusion Positive Chvostek's or Trousseau's sign Shallow respirations Tetany Seizures Tachycardia *Tall T waves* and depressed ST segment

Which factor would the nurse take into account before selecting an insertion site for a short peripheral venous catheter? Select all that apply. One, some, or all responses may be correct. (15) Type of therapy Length of treatment History of a mastectomy Presence of dialysis fistula Axillary lymph node dissection

Type of therapy History of a mastectomy Presence of dialysis fistula Axillary lymph node dissection

Which parameter would the nurse use to directly evaluate the effectiveness of diuretic therapy? (13) Skin turgor Urinary Output Blood pressure Respiratory rate

Urinary output

Which medication mimics the effect of antidiuretic hormone (ADH) on the body? (13) Insulin Calcium Potassium Vasopressin

Vasopressin (vasopressin is a medication that mimics the effects of ADH on the body to maintain fluid balance within the body)

Which situation increases the risk that a peripherally inserted central catheter (PICC) could become dislodged? (15) Phlebitis Thrombophlebitis Vigorous physical activity Catheter-related bloodstream infections

Vigorous physical activity

When concerned about a patient's GI fluid losses, which parameter would the nurse assess to determine fluid loss? Select all that apply. One, some, or all responses may be correct. (13) Weight Skin turgor Urine output Blood pressure Blood urea nitrogen (BUN)

Weight Skin turgor Urine output Blood pressure Blood urea nitrogen (BUN) (all of them)

Which technique is used to confirm the location of the catheter tip after insertion of a peripherally inserted central catheter (PICC)? (15) X-ray Laser Surgery Infrared

X-ray

A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement will the nurse include in this client's teaching? (15) a. "Avoid carrying your grandchild with the arm that has the central catheter." b. "Be sure to place the arm with the central catheter in a sling during the day." c. "Flush the peripherally inserted central catheter line with normal saline daily." d. "You can use the arm with the central catheter for most activities of daily living."

a. "Avoid carrying your grandchild with the arm that has the central catheter."

While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 1.5 inch (4-cm) venous cord. How will the nurse document this finding? (15) a. "Grade 3 phlebitis at IV site" b. "Infection at IV site" c. "Thrombosed area at IV site" d. "Infiltration at IV site"

a. "Grade 3 phlebitis at IV site"

A new nurse is caring for a client receiving drug therapy via a smart pump. What statement by the new nurse demonstrates the need for more instruction on this technology? (15) a. "I don't need to manually calculate IV infusion rates with smart pumps." b. "Responding to IV pump alarms is a high priority for client safety." c. "The hospital can preprogram the pumps for high-alert drug limits." d. "These pumps have a system to prevent fluids from free-flowing into the client."

a. "I don't need to manually calculate IV infusion rates with smart pumps."

A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia? a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions. b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic. c. A 67 year old who is experiencing pain and is prescribed ibuprofen. d. A 73 year old with tachycardia who is receiving digoxin

a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions

A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first? (13) a. Assess the client's respiratory rate, rhythm, and depth. b. Measure the client's pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care primary health care provider

a. Assess the client's respiratory rate, rhythm, and depth

A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? (Select all that apply.) (13) a. Calculate pulse pressure with each blood pressure reading. b. Assess skin turgor using the back of the client's hand. c. Assess for pitting edema in dependent body areas. d. Monitor trends in the client's daily weights. e. Assist the client to change positions frequently. f. Teach client and family how to read food labels for sodium.

a. Calculate pulse pressure with each blood pressure reading. c. Assess for pitting edema in dependent body areas. d. Monitor trends in the client's daily weights. e. Assist the client to change positions frequently. f. Teach client and family how to read food labels for sodium.

A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first? (13) a. Depth of respirations b. Bowel sounds c. Grip strength d. Electrocardiograph

a. Depth of respirations

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) (13) a. Hypokalemia—muscle weakness with respiratory depression b. Hypermagnesemia—bradycardia and hypotension c. Hyponatremia—decreased level of consciousness d. Hypercalcemia—positive Trousseau and Chvostek signs e. Hypomagnesemia—hyperactive deep tendon reflexes f. Hypernatremia—weak peripheral puls

a. Hypokalemia—muscle weakness with respiratory depression b. Hypermagnesemia—bradycardia and hypotension c. Hyponatremia—decreased level of consciousness e. Hypomagnesemia—hyperactive deep tendon reflexes f. Hypernatremia—weak peripheral puls

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (Select all that apply.) (13) a. Increased pulse rate b. Distended neck veins c. Decreased blood pressure d. Warm and pink skin e. Skeletal muscle weakness f. Visual disturbances

a. Increased pulse rate b. Distended neck veins e. Skeletal muscle weakness f. Visual disturbances

A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention will the nurse suggest to the management team to make the biggest impact on decreasing complications? (15) a. Initiate a dedicated team to insert access devices b. Require additional education for all nurses c. Limit the use of peripheral venous access devices d. Perform quality control testing on skin preparation products

a. Initiate a dedicated team to insert access devices

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.) (13) a. Reports of palpitations b. Slow, shallow respirations c. Orthostatic hypotension d. Paralytic ileus e. Skeletal muscle weakness f. Tall, peaked T waves on ECG

a. Reports of palpitations e. Skeletal muscle weakness f. Tall, peaked T waves on ECG

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching? (13) a. "I must drink a quart (liter) of water or other liquid each day." b. "I will weigh myself each morning before I eat or drink." c. "I will use a salt substitute when making and eating my meals." d. "I will not drink liquids after 6 p.m. so I won't have to get up at night."

b. "I will weigh myself each morning before I eat or drink."

A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the client's chart prior to administering the medication and notes it to have been inserted 4 months ago. The site has no redness, warmth, or swelling and flushes easily. What action does the nurse take? (15) a. Notify the primary health care provider. b. Administer the prescribed medication. c. Discontinue the PICC. d. Switch the medication to the oral route

b. Administer the prescribed medication

A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss? a. Client taking furosemide. b. Anxious client who has tachypnea. c. Client who is on fluid restrictions. d. Client who is constipated with abdominal pain.

b. Anxious client who has tachypnea.

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best? (13) a. Measure intake and output every 4 hours. b. Assess client further for fall risk. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler position

b. Assess client further for fall risk.

The nurse is caring for a client who has fluid overload. What action by the nurse takes priority? (13) a. Administer high-ceiling (loop) diuretics. b. Assess the client's lung sounds every 2 hours. c. Place a pressure-relieving overlay on the mattress. d. Weigh the client daily at the same time on the same scale

b. Assess the client's lung sounds every 2 hours

A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first? (13) a. Encourage oral fluid intake b. Connect the client to a cardiac monitor c. Assess urinary output d. Administer oral calcitonin

b. Connect the client to a cardiac monitor

A nurse is caring for a client who has just had a central venous access line inserted. What action will the nurse take next? (15) a. Begin the prescribed infusion via the new access. b. Ensure that an x-ray is completed to confirm placement. c. Check medication calculations with a second RN. d. Make sure that the solution is appropriate for a central line

b. Ensure that an x-ray is completed to confirm placement

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.) (13) a. Hypomagnesemia—kidney failure b. Hyperkalemia—salt substitutes c. Hyponatremia—heart failure d. Hypernatremia hyperaldosteronism e. Hypocalcemia—diarrhea f. Hypokalemia—loop diuretics

b. Hyperkalemia—salt substitutes c. Hyponatremia—heart failure d. Hypernatremia hyperaldosteronism e. Hypocalcemia—diarrhea f. Hypokalemia—loop diuretics

A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, what action will the nurse take to relieve pain? (15) a. Administer topical lidocaine to the site. b. Place warm compresses on the site. c. Administer prescribed oral pain medication. d. Massage the site with scented oils

b. Place warm compresses on the site

A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are paired with the correct potential imbalance? (Select all that apply.) (13) a. Sodium: 160 mEq/L (mmol/L): Overhydration b. Potassium: 5.4 mEq/L (mmol/L): Dehydration c. Osmolarity: 250 mOsm/L: Overhydration d. Hematocrit: 68%: Dehydration e. BUN: 39 mg/dL: Overhydration f. Magnesium: 0.8 mg/dL: Dehydration

b. Potassium: 5.4 mEq/L (mmol/L): Dehydration c. Osmolarity: 250 mOsm/L: Overhydration d. Hematocrit: 68%: Dehydration f. Magnesium: 0.8 mg/dL: Dehydration

A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? (15) a. Redness at the catheter insertion site b. Report of headache and stiff neck c. Temperature of 100.1° F (37.8° C) d. Pain rating of 8 on a scale of 0-10

b. Report of headache and stiff neck

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? (Select all that apply.) (13) a. Urine output of 25 mL/hr b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) c. Urine specific gravity of 1.02 g/mL d. Serum sodium level of 128 mEq/L (128 mmol/L) e. Blood osmolality of 250 mOsm/kg (250 mmol/kg)

b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) e. Blood osmolality of 250 mOsm/kg (250 mmol/kg)

20, 40, & 80 microns are used to? (15)

blood administration and are used to remove degenerating platelets, white blood cells, and fibrin strands

What is thrombosis? (15)

blood clot in a vein

what color is a 22g catheter? (15)

blue

A nurse teaches a client who is prescribed a central vascular access device and is transferring to a skilled facility for long-term treatment. Which statement will the nurse include in this client's teaching? (15) a. "You will need to wear a sling on your arm while the device is in place." b. "There is no risk of infection because sterile technique will be used during insertion." c. "Ask all providers to vigorously clean the connections prior to accessing the device." d. "You will not be able to take a bath with this vascular access device."

c. "Ask all providers to vigorously clean the connections prior to accessing the device."

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching? (13) a. "Have you spouse watch you for irritability and anxiety." b. "Notify the clinic if you notice muscle twitching." c. "Call your primary health care provider for diarrhea." d. "Bake or grill your meat rather than frying it."

c. "Call your primary health care provider for diarrhea."

A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration? (13) a. A 36 year old who is prescribed long-term steroid therapy. b. A 55 year old who recently received intravenous fluids. c. A 76 year old who is cognitively impaired. d. An 83 year old with congestive heart failure

c. A 76 year old who is cognitively impaired

A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first? (13) a. Prepare to administer patiromer by mouth. b. Provide a heart-healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment.

c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push

A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure? (13) a. Notifies the pharmacy of the IV potassium order. b. Assesses the client's IV site every hour during infusion. c. Sets the IV pump to deliver 30 mEq of potassium an hour. d. Double-checks the IV bag against the order with the precepting nurse.

c. Sets the IV pump to deliver 30 mEq of potassium an hour

After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that treatment is improving the client's hypokalemia? (Select all that apply.) (13) a. Respiratory rate of 8 breaths/min b. Absent deep tendon reflexes c. Strong productive cough d. Active bowel sounds e. U waves present on the electrocardiogram (ECG)

c. Strong productive cough d. Active bowel sounds

A nurse delegates care to an assistive personnel (AP). Which statement will the nurse include when delegating hygiene for a client who has a vascular access device? (15) a. "Provide a bed bath instead of letting the client take a shower." b. "Use sterile technique when changing the dressing." c. "Disconnect the intravenous fluid tubing prior to the client's bath." d. "Use a plastic bag to cover the extremity with the device."

d. "Use a plastic bag to cover the extremity with the device."

A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition? (13) a. Assesses the client's Chvostek and Trousseau sign. b. Keeps the client's room quiet and dimly lit. c. Moves the client carefully to avoid fracturing bones. d. Administers bisphosphonates as prescribed.

d. Administers bisphosphonates as prescribed bisphosphonates are used to treat hypercalcemia

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital? (13) a. Ask family members to speak quietly to keep the client calm. b. Assess urine color, amount, and specific gravity each day. c. Encourage the client to drink at least 1 L of fluids each shift. d. Dangle the client on the bedside before ambulating.

d. Dangle the client on the bedside before ambulating

A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan? (13) a. Increased respiratory rate from 12 to 22 breaths/min b. Decreased skin turgor on the client's posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic changes when standing

d. Decreased orthostatic changes when standing

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching? (13) a. Slices of smoked ham with potato salad b. Bowl of tomato soup with a grilled cheese sandwich c. Salami and cheese on whole-wheat crackers d. Grilled chicken breast with glazed carrots

d. Grilled chicken breast with glazed carrots

A nurse prepares to insert a peripheral venous catheter in an older adult. What action will the nurse take to protect the client's skin during this procedure? (15) a. Lower the extremity below the level of the heart. b. Apply warm compresses to the extremity. c. Tap the skin lightly and avoid slapping. d. Place a washcloth between the skin and tourniquet.

d. Place a washcloth between the skin and tourniquet

A nurse assesses a client who has a radial artery catheter. Which assessment will the nurse complete first? (15) a. Amount of pressure in fluid container b. Date of catheter tubing change c. Type of dressing over the site d. Skin color and capillary refill

d. Skin color and capillary refill

A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. What action will the nurse take NEXT? (15) a. Apply cold compresses to the IV site. b. Elevate the extremity on a pillow. c. Flush the catheter with normal saline. d. Stop the infusion of intravenous fluids.

d. Stop the infusion of intravenous fluids

A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern? (15) a. The catheter has been in place for 20 hours. b. The client has poor vascular access in the upper extremities. c. The catheter is placed in the proximal tibia. d. The client's left lower extremity is cool to the touch.

d. The client's left lower extremity is cool to the touch.

A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention? (15) a. The initial site dressing is 3 days old. b. The PICC was inserted 4 weeks ago. c. A securement device is absent. d. Upper extremity swelling is noted.

d. Upper extremity swelling is noted

1.2 microns is used to? (15)

filter lipid-containing parenteral nutrition

what color is a 18g catheter? (15)

green

A 22g catheter is typically used for? (15)

is for patient's who won't need an IV long (routine IV)

what is grade 2 phlebitis (inflamed vein)? (15)

only pain at the access site with erythema and/or edema

what color is a 14g catheter? (15)

orange

A 26g catheter is typically used for? (15)

pediatrics & neonatal premies

what color is a 26g catheter? (15)

purple

Tunneled catheters are used for patients who? (15)

require weeks or months of infusion therapy or months of parenteral nutrition (TPN)

Which statement is accurate about the special needs of older adults receiving IV therapy? (15) Placement of the catheter on the back of the patient's dominant hand is preferred. Skin integrity can be compromised easily by the application of tape or dressings. Use an angle greater than 25 degrees between the skin and the catheter for the venipuncture. Excess hair should be shaved before the catheter is inserted into the forearm.

skin integrity can be compromised easily by the application of tape or dressings old people have fragile skin

what common signs and symptoms do you find with infiltration? (15)

swelling & coolness around the catheter insertion site

Hyponatremia causes the kidneys to do what? (13) increase blood pressure and maintain perfusion and fluid balance

to secrete renin to increase blood pressure and maintain perfusion and fluid balance

a 14g catheter is typically used for? (15)

trauma/surgical patients that need rapid fluid resuscitation -blood transfusion

A patient's temperature has risen 2°C from normal. Calculate the amount of body fluid the patient has lost. Record your answer using a whole number. _________ mL (13)

when a patient's temperature is above normal (98.6°F [37°C]), the body will lose 500 mL FOR EVERY DEGREE Celsius the temperature has RISEN! Therefore a patient with a temperature 2°C over normal would have lost 1000 mL of body fluid

HYPERnatremia s/s (high sodium)?

you are FRIED *Diarrhea *Cushing Syndrome *Fever of unknown origin Restless Increased BP Edema Decreased urinary output

Which effect causes edema in a patient's dependent areas? (13) Large intercellular spaces Filtration of fluid in the cells Changes in normal hydrostatic pressure Equilibrium in solute concentration on each side of the cell

Changes in normal hydrostatic pressure

A patient is brought in an unconscious state to the emergency department. The primary health care provider suspects dehydration. Which parameter in the laboratory results would indicate internal hemorrhage as a reason for dehydration? (13) Increased osmolarity Absence of hemoconcentration Elevated levels of blood components Decreased hemoglobin level

Absence of hemoconcentration Hemoconcentration is not present when dehydration is caused by hemorrhage because loss of all blood and plasma products occurs together

Which age-related change to the endocrine system affects fluid balance in the body? (13) Adrenal atrophy Insulin resistance Increased secretion of aldosterone Decreased secretion of antidiuretic hormone

Adrenal atrophy an age-related change to the endocrine gland is adrenal atrophy, which causes poor regulation of sodium and potassium, placing the patient at risk for fluid imbalance

Which hormone regulates fluid and electrolyte balance by preventing water and sodium loss? (13) Antidiuretic Thyrotropin Aldosterone Natriuretic peptide (NP)

Aldosterone

what diuretic DO you give to a patient with hypokalemia? (13)

Amiloride

Which type of medication may affect the assessment of a patient's fluid balance? (13) Anticoagulant once daily Cardiac glycoside once daily Antibiotic every 6 hours Angiotensin-converting enzyme (ACE) inhibitor twice daily

Angiotensin-converting enzyme (ACE) inhibitor twice daily medications used to manage hypertension such as ACE inhibitors disrupt the renin-angiotensin II pathway, resulting in greater excretion of water and sodium in the urine

Which assessment parameter is useful for identifying magnesium toxicity during IV magnesium administration? (13) Measuring urine output Monitoring serum calcium levels Checking deep tendon reflexes (DTRs) Asking the patient about mood changes

Checking deep tendon reflexes (DTRs) Hypermagnesemia causes depressed or absent DTRs

Which serum electrolyte result would be of concern to the nurse? (13) Chloride: 88 mEq/L Sodium: 143 mEq/L Potassium: 4.8 mEq/L Magnesium: 2.0 mEq/L

Chloride: 88 mEq/L the normal chloride range is 98 to 106 mEq/L

For which electrolyte imbalance will the nurse monitor while providing care to a patient who is receiving diuretic therapy? (13) Hypokalemia Hypercalcemia Hypernatremia Hypophosphatemia

Hypokalemia (LOW POTASSIUM)

A patient with pitting edema of the right foot and ankle are prescribed diuretic therapy. Which intervention would the nurse include in the plan of care? Select all that apply. One, some, or all responses may be correct. (13) Monitoring respiratory rate Monitoring urine output Assessing sodium and potassium values Checking urine for specific gravity Monitoring ECG patterns

Monitoring urine output Assessing sodium and potassium values Monitoring ECG patterns

HYPOnatermia s/s (low sodium)

Nausea Muscle cramps Changes is mental status: lethargy & coma ***Muscular twitching ***Seizures ***Decreased tendon reflexes ***Diarrhea

Which route of fluid loss is unmeasurable? (13) Urine Feces Emesis Perspiration

Perspiration (sweat)

When analysis of a patient's telemetry strip reveals a widened QRS complex with peaked T waves, which laboratory value would the nurse review before notifying the health care provider? (13) Sodium Calcium Potassium Magnesium

Potassium **too much potassium, can cause cardiovascular changes, including peaked T waves and widened QRS complexes

A patient with hypocalcemia secondary to chronic kidney disease may notice what?

tingling of the nose, lips, and ears as this precedes tetany

signs and symptoms of hyponatreimia (low sodium)

hyponatremia can cause: -mental status changes -lethargy -coma -seizure activity

Risk factor for tachypnea? (13)

increased insensible water loss