Course Pt: Quiz #5

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

2,500 mL/day

A client's intake and output is being measured and recorded each shift. The client has had the following intake: 3 oz apple juice, 4 oz tea, 5 oz pureed chicken, 2 oz mashed potatoes, 4 oz orange gelatin, and 2 oz vanilla ice cream. Calculate the amount, in milliliters, the nurse documents as fluid on the intake sheet. Record your answer using a whole number.

390

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

An implanted central venous access device (CVAD)

The nurse is preparing to insert an intravenous catheter into an adult client. Place the following steps in the correct order. Use all options.

Apply a tourniquet 3 to 4 in (7.5 to 10 cm) above the site. Cleanse the site with chlorhexidine. Place nondominant hand 1 to 2 in (2.5 to 5 cm) below the site and pull the skin taut. Insert the needle gently. Release the tourniquet. Stabilize the catheter or needle.

The nurse is providing care to a client who has a serum potassium level of 5.2 mEq/L (5.2 mmol/L). Which findings would the nurse expect to assess? Select all that apply.

Cardiac arrythmia, Muscle weakness

The hospital recently adopted a self-administration medication system. Which is an important consideration for safe self-administration of medications?

Does the client have cognitive and functional ability to self-administer medication?

An older adult client with hypokalemia is being discharged to the home of a caregiver. Which information should the nurse include in the family teaching?

Include more bananas in the diet.

A client is experiencing withdrawal from alcohol and admitted to the behavioral health unit. The client begins to have muscle weakness, tremors, hyperactive deep tendon reflexes, and a change in mental status. What should the nurse prepare to replace in this client?

Magnesium

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?

Metabolic alkalosis

The nurse has provided a client with oral medications in a small plastic cup. What is the best nursing action to ensure the rights of safe medication administration are implemented?

Wait with the client until the medications are taken.

Cross-matching of blood is ordered for a client before major surgery. What does this process do?

determines compatibility between blood specimens

The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing?

hypertonic

A nurse is preparing to administer intravenous fluids, including accessing a vein. What is the most potentially harmful risk posed for the client when accessing the vein?

infection

Which body fluid is the fluid within the cells, constituting about 70% of the total body water?

intracellular fluid (ICF)

A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible?

phlebitis

A nurse is assessing a client and suspects an ECF volume excess. Which finding would the nurse identify as being most significant?

weight gain of 0.75 kg in a day

The nurse is assuming care for a client who is receiving an infusion of packed red blood cells (PRBCs). The PRBCs were hung 4 hours ago, and 100 mL is left to infuse. Which action is most appropriate?

Discontinue the infusion and record the volume left in the blood bag.

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. Which action should the nurse take?

Stop the transfusion and notify the health care provider.

A client has a health care provider's order for NPO (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose?

replace fluid and electrolytes

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?

platelets