Ch. 40 PrepU
a
A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status? a. daily weights b. daily BUN and serum creatinine monitoring c. output measurements d. daily electrolyte monitoring
a
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 chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV. d. Cleanse the site with alcohol and apply transparent polyurethane dressing over the entry site.
a
A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area? a. Sacral area b. Face c. Hands d. Abdomen
a
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. 5 cm H2O c. 9.5 cm H2O d. 12 cm H2O
b
A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? a. Select a primary tubing of about 37 inches (94 cm) long. b. Ensure that the prescribed solution is clear and transparent. c. Use half-instilled IV solutions before infusing a new one. d. Avoid replacing IV solutions every 24 hours.
a
During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first? a. Stop the transfusion immediately. b. Infuse saline at a rapid rate. c. Prepare to give an antihistamine. d. Administer oxygen.
a
Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert? a. Muscle weakness, fatigue, and dysrhythmias b. Nausea, vomiting, and constipation c. Diminished cognitive ability and hypertension d. Muscle weakness, fatigue, and constipation
b
The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client? a. B positive b. O negative c. A positive d. AB negative
b
The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present? a. The client has a decreased sensation of thirst. b. The renal system retains more water. c. Urine becomes more diluted. d. The frequency of voiding increases.
a
The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean? a. The client has anti-A antibodies. b. The client has anti-B antibodies. c. The client has both anti-A and anti-B antibodies. d. The client is a universal donor.
c
The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client? a. excessive use of laxatives b. diaphoresis c. renal failure d. increased cardiac output
c
The primary extracellular electrolytes are: a. potassium, phosphate, and sulfate. b. magnesium, sulfate, and carbon. c. sodium, chloride, and bicarbonate. d. phosphorous, calcium, and phosphate.
a
The process of filtration begins at the: a. glomerulus. b. Loop of Henle. c. Bowman's capsule. d. collecting ducts.
c
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? a. "Fluid inside cells." b. "Fluid outside cells." c. "Fluid in the tissue space between and around cells." d. "Watery plasma, or serum, portion of blood."
a
What commonly used intravenous solution is hypotonic? a. 0.45% NaCl b. 0.9% NaCl c. lactated Ringer's d. 5% dextrose in 0.45% NaCl
c
Which is a common anion? a. magnesium b. potassium c. chloride d. calcium
a
Which statement most accurately describes the process of osmosis? a. Water moves from an area of lower solute concentration to an area of higher solute concentration. b. Solutes pass through semipermeable membranes to areas of lower concentration. c. Water shifts from high-solute areas to areas of lower solute concentration. d. Plasma proteins facilitate the reabsorption of fluids into the capillaries.
a
A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? a. platelets b. granulocytes c. albumin d. cryoprecipitate
b
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? a. asking the client to pump their fist several times b. placing the tourniquet on the upper arm for 2 minutes c. asking if the client is right or left handed d. palpating the veins on the nondominant hand
a
The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade? a. 1+ b. 2+ c. 3+ d. 4+
b
When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? a. Elevate the client's head. b. Apply a warm compress. c. Position the client on the left side. d. Apply antiseptic and a dressing.
d
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. hypocalcemia. b. hypothyroidism. c. hypoglycemia. d. hypokalemia.
c
A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)? a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis
d
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? a. Allow nothing by mouth. b. Give the client a glass of orange juice with added sugar. c. Encourage fluid intake. d. Start an IV of normal saline as prescribed.
b
A client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action? a. Assess the area distal to the IV site for signs and symptoms of deep vein thrombosis. b. Flush the IV with 3 mL of normal saline. c. Change from infusion with an electronic pump to infusion by gravity. d. Flush the IV with 2 mL of 100 U/mL heparin.
c
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? a. Increased sodium levels b. Increased potassium levels c. Decreased potassium levels d. Decreased oxygen levels
d
A client with dehydration will have an increase in: a. albumin b. potassium c. glucose d. aldosterone
a
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. muscle weakness c. increased intracranial pressure (ICP) d. metabolic acidosis
b
A nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 5.75 mg/dL (1.8 mEq/L)Based on these levels, the nurse would identify which imbalance? a. Hyponatremia b. Hypokalemia c. Hypercalcemia d. Hypermagnesemia
b
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation? a. Notify the primary care provider immediately because these are signs of speed shock. b. Notify the primary care provider immediately for possible fluid overload. c. Check all clamps on the tubing and check tubing for any kinking. d. Place the client in the Trendelenburg position to keep the client's airway open.
b
A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? a. muscle twitching b. distended neck veins c. fingerprinting over sternum d. nausea and vomiting
b
A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate? a. "Infiltration is the inflammation of the vein, while phlebitis is a localized irritation." b. "Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein." c. "Infiltration is a localized blood clot, and phlebitis occurs when an IV is improperly placed." d. "Infiltration occurs when an IV is improperly placed, and phlebitis indicates circulatory overload."
c
A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? a. "I need to drink no more than 1,000 mL/day" b. "I should drink 1,500 mL/day of fluid." c. "I should drink 2,500 mL/day of fluid." d. "I should drink more than 3,500 mL/day of fluid."
a
A registered nurse is overseeing the care of numerous clients on a busy acute medicine unit. Which task would be most safe to delegate to a licensed practical nurse (LPN)? a. Changing the dressing on a client's peripheral IV site b. Initiating a client's transfusion of packed red blood cells c. Deaccessing a client's implanted port d. Removing a client's PICC in anticipation of the client's discharge
b
A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing? a. Respiratory alkalosis b. Metabolic alkalosis c. Respiratory acidosis d. Metabolic acidosis
b
An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use: a. an 18-gauge needle. b. a winged infusion needle. c. an intermittent infusion device. d. a central venous access.
c
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. allergic reaction: allergy to transfused blood b. febrile reaction: fever develops during infusion c. hemolytic transfusion reaction: incompatibility of blood product d. bacterial reaction: bacteria present in the blood
b
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. Sepsis b. Phlebitis c. Infiltration d. Air embolism
a
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland? a. calcium and phosphorus b. potassium and sodium c. chloride and magnesium d. potassium and chloride
a
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 siderail. 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. Decontaminate the visible portion of the catheter, and then gently reinsert. c. Apply a new dressing and observe for signs of infection over the next several hours. d. Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air.
a
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. phlebitis. b. an infiltration. c. a systemic blood infection. d. rapid fluid administration.
c
What is the lab test commonly used in the assessment and treatment of acid-base balance? a. Complete blood count b. Basic metabolic panel c. Arterial blood gas d. Urinalysis
b
When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's: a. low potassium. b. low calcium. c. high sodium. d. high magnesium.
a
While removing a client's peripherally inserted central catheter (PICC), part of the catheter breaks off. What action is the nurse's priority? a. Apply a tourniquet to the client's upper arm. b. Apply pressure to the site with sterile gauze until hemostasis is achieved. c. Have the client perform the Valsalva maneuver. d. Measure the catheter and compare it with the length listed in the chart.