Fundi's 2 Ch. 40 Prep U
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? A. hypotonic, followed by isotonic B. isotonic C. hypertonic D. hypotonic
C. hypertonic
The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding? A. pH: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l) B. pH: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l) C. pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) D. pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l)
C. pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)
Which is a common anion? A. magnesium B. potassium C. calcium D. chloride
D. chloride
The nurse is calculating the infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtt [drops]/1mL. What is the infusion rate? A. 42 gtt/min B. 25 gtt/min C. 20 gtt/min D. 125 gtt/min
A. 42 gtt/min
The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client? A. Apply pressure to insertion site for at least 3 minutes. B. Instruct client to remain flat for 30 minutes. C. Apply petroleum-based ointment and sterile occlusive dressing. D. Ask client to perform Valsalva maneuver.
A. Apply pressure to insertion site for at least 3 minutes.
The student nurse asks the instructor how buffer systems work in the body to maintain the pH of the blood. The instructor explains the buffer systems to the students. Which buffer systems will be discussed by the instructor? Select all that apply. A. Carbonic acid-sodium bicarbonate buffer system B. Protein buffer system C. Respiratory buffer system D. Potassium buffer system E. Phosphate buffer system
A. Carbonic acid-sodium bicarbonate buffer system B. Protein buffer system E. Phosphate buffer system
A nurse monitoring an IV infusion notes the signs and symptoms of a thrombus. Which nursing interventions would the nurse perform? Select all that apply. A. Restart the IV at another site. B. Stop the infusion immediately. C. Apply warm compresses as ordered by the primary care provider. D. Rub or massage the affected area. E. Place client on left side in Trendelenburg position. F. Monitor vital signs and pulse oximetry.
A. Restart the IV at another site. B. Stop the infusion immediately. C. Apply warm compresses as ordered by the primary care provider.
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 both anti-A and anti-B antibodies. C. The client is a universal donor. D. The client has anti-B antibodies.
A. The client has anti-A antibodies.
A nurse is caring for a client who is on total parenteral nutrition (TPN). Which clients are candidates for TPN? Select all that apply. A. clients with major trauma or burns B. clients with liver and renal failure C. clients who have not eaten for a day D. clients who are recovering from cataract surgery E. clients with inflammatory bowel disease
A. clients with major trauma or burns B. clients with liver and renal failure E. clients with inflammatory bowel disease
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 2,500 mL/day of fluid." C. "I should drink more than 3,500 mL/day of fluid." D. "I should drink 1,500 mL/day of fluid."
B. "I should drink 2,500 mL/day of fluid."
A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells? A. 75 mL/hr for the first 15 minutes, then 200 mL/hr B. 1 unit over 2 to 3 hours, no longer than 4 hours C. 200 mL/hr D. As fast as the client can tolerate
B. 1 unit over 2 to 3 hours, no longer than 4 hours
A nurse is preparing to insert an intravenous (IV) catheter into a client's arm. At which angle relative to the client's skin should the catheter be inserted? A. 40- to 45-degree angle B. 10- to 15-degree angle C. 30- to 35-degree angle D. 20- to 25-degree angle
B. 10- to 15-degree angle
The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr A. 160 gtt/min B. 100 gtt/min C. 60 gtt/min D. 600 gtt/min
B. 100 gtt/min
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 cephalic vein B. An implanted central venous access device (CVAD) C. A peripheral venous catheter inserted to the antecubital fossa D. A midline peripheral catheter
B. An implanted central venous access device (CVAD)
A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse? A. Stop the transfusion and infuse normal saline using the blood tubing. B. Stop the transfusion and infuse normal saline using a new administration set. C. Check the client's vital signs. D. Notify the health care provider of the client's response.
B. Stop the transfusion and infuse normal saline using a new administration set.
The process of filtration begins at the: A. collecting ducts. B. glomerulus. C. Loop of Henle. D. Bowman's capsule.
B. glomerulus.
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. high magnesium. B. low calcium. C. low potassium. D. high sodium.
B. low calcium.
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
B. placing the tourniquet on the upper arm for 2 minutes
The primary extracellular electrolytes are: A. magnesium, sulfate, and carbon. B. sodium, chloride, and bicarbonate. C. potassium, phosphate, and sulfate. D. phosphorous, calcium, and phosphate.
B. sodium, chloride, and bicarbonate.
Which age group is at risk for fluid and electrolyte imbalances resulting from fad dieting? A. Middle-age adults B. Older adults C. Adolescents D. Young adults
C. Adolescents
What is the lab test commonly used in the assessment and treatment of acid-base balance? A. Basic metabolic panel B. Urinalysis C. Arterial blood gas D. Complete blood count
C. Arterial blood gas
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. Respiratory acidosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory alkalosis
C. Metabolic alkalosis
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? A. a 47-year-old who had a colon resection yesterday and is reporting pain B. a 60-year-old who is 3 days post-myocardial infarction and has been stable. C. a newly admitted 88-year-old with a 2-day history of vomiting and loose stools D. a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today
C. a newly admitted 88-year-old with a 2-day history of vomiting and loose stools
The student nurse asks, "What is intravascular 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, portion of blood."
D. "Watery plasma, or serum, portion of blood."
What commonly used intravenous solution is hypotonic? A. 10% dextrose in water B. lactated Ringer's C. 0.9% NaCl D. 0.45% NaCl
D. 0.45% NaCl
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. 4+ B. 3+ C. 2+ D. 1+
D. 1+
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend? A. 3,500 mL/day B. 1,500 mL/day C. 1,000 mL/day D. 2,500 mL/day
D. 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. 1,000 B. 3,750 C. 500 D. 3,000
D. 3,000
A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing? A. 120 drops/mL B. 90 drops/mL C. 30 drops/mL D. 60 drops/mL
D. 60 drops/mL
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? A. 167 gtt/min B. 5,000 gtt/min C. 42 gtt/min D. 83 gtt/min
D. 83 gtt/min
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. 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 C. Stop the infusion, cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site. D. Discontinue the IV and relocate it to another site.
D. Discontinue the IV and relocate it to another site.
A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving? A. A hypotonic solution B. Packed red blood cells C. An isotonic solution D. A hypertonic solution
A. A hypotonic solution
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. nausea and vomiting B. distended neck veins C. muscle twitching D. fingerprinting over sternum
B. distended neck veins
The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client? A. A positive B. AB negative C. O negative D. B positive
C. O negative
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 intermittent infusion device. B. an 18-gauge needle. C. a central venous access. D. a winged infusion needle.
D. a winged infusion needle.
Edema happens when there is which fluid volume imbalance? A. water excess B. extracellular fluid volume excess C. water deficit D. extracellular fluid volume deficit
D. extracellular fluid volume deficit
A client with chronic anemia is admitted for the administration of blood. What would the nurse expect the physician to order? A. D5W 1000 mL B. Whole blood C. White blood cells D. Platelets E. Packed cells
E. Packed cells
The nursing instructor is explaining how the respiratory system is involved in hydrogen ion regulation to maintain normal pH. Place the steps in order once the CO2 in the blood has increased, resulting in increased respirations to eliminate CO2. Decreased respirations Carbon dioxide retention pH becomes more alkaline H2CO3 level in the blood decreases Carbonic acid formed Blood level of CO2 decreases
H2CO3 level in the blood decreases pH becomes more alkaline Blood level of CO2 decreases Decreased respirations Carbon dioxide retention Carbonic acid formed
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. Avoid salty or excessively sweet fluids. B. Eat crackers and bread. C. Use an alcohol-based mouthwash to moisten your mouth. D. Use regular gum and hard candy.
A. Avoid salty or excessively sweet fluids.
A client with type AB blood has experienced a precipitous drop in hemoglobin levels due to a gastrointestinal bleed and now requires a blood transfusion. Which blood types may this client safely receive? Select all that apply. A. B B. O C. AB D. A
A. B B. O C. AB D. A
A nurse is performing a venipuncture on an older client. The client has visible veins that appear to roll. What nursing technique is most appropriate? A. Select a large-gauge needle. B. Consider venipuncture in the foot where veins are less visible. C. Avoid use of a tourniquet. D. Use the client's nondominant hand to hold the vein in place.
C. Avoid use of a tourniquet.
A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? A. Avoid replacing IV solutions every 24 hours. B. Select a primary tubing of about 37 inches (94 cm) long. C. Ensure that the prescribed solution the expected color and consistency. D. Use half-instilled IV solutions before infusing a new one.
C. Ensure that the prescribed solution the expected color and consistency.
Which finding best indicates to the nurse that the client has a therapeutic outcome from a recent blood transfusion? A. Blood pressure increases to 90/48 mm Hg B. Steady gait while ambulating C. No signs of chills, fever, or shortness of breath D. Slight flushing of the face
C. No signs of chills, fever, or shortness of breath
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. Chloride B. Phosphorous C. Potassium D. Calcium
C. Potassium
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. Slow the rate of IV fluids. C. Remove the IV. D. Apply a warm compress.
C. Remove the IV.
Which client would be a candidate for total parenteral nutrition? A. a client receiving intravenous antibiotics B. a postoperative appendectomy client C. a client with colitis and bloody diarrhea D. a client with diabetic ketoacidosis
C. a client with colitis and bloody diarrhea
Which statement most accurately describes the process of osmosis? A. Plasma proteins facilitate the reabsorption of fluids into the capillaries. B. Water shifts from high-solute areas to areas of lower solute concentration. C. Solutes pass through semipermeable membranes to areas of lower concentration. D. Water moves from an area of lower solute concentration to an area of higher solute concentration.
D. Water moves from an area of lower solute concentration to an area of higher solute concentration.
The nursing instructor is quizzing a group of students about fluid and electrolyte balance. Which statements made by the students indicate an understanding of the efforts of the organs to maintain fluid and electrolyte balance? Select all that apply. A. "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst." B. "The kidneys react to hypovolemia by stimulating fluid retention." C. "The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." D. "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." E. The adrenal glands regulate blood volume by secreting aldosterone."
A. "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst." C. "The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." D. "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." E. The adrenal glands regulate blood volume by secreting aldosterone."
A nurse explains the homeostatic mechanisms involved in fluid homeostasis to a student nurse. Which statements accurately describe this process? Select all that apply. A. The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. B. The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acid-base balance. C. The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the body's needs. D. The thyroid gland secretes aldosterone, a mineralocorticoid hormone that helps the body conserve sodium, helps save chloride and water, and causes potassium to be excreted. E. Thyroxine, released by the adrenal glands, increases blood flow in the body, leading to increased renal circulation and resulting in increased glomerular filtration and urinary output. F. The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus.
A. The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. B. The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acid-base balance. C. The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the body's needs. F. The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus.
The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action? A. Tighten the roller clamp to stop the infusion. B. Tap the tubing below the air bubbles. C. Milk the air in the direction of the drip chamber. D. Twist the tubing around a pencil.
A. Tighten the roller clamp to stop the infusion.
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. hemolytic transfusion reaction: incompatibility of blood product B. bacterial reaction: bacteria present in the blood C. febrile reaction: fever develops during infusion D. allergic reaction: allergy to transfused blood
A. hemolytic transfusion reaction: incompatibility of blood product
The nurse is caring for Mrs. Roberts, an 86-year-old client, who fell at home and was not found for 2 days. Mrs. Roberts is severely dehydrated. The nurse is aware that older adults are at increased risk for fluid imbalance due to: A. increase in fat cells. B. smaller stomach capacity. C. decreased skin area. D. increase in muscle mass.
A. increase in fat cells.
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. "Unfortunately, your own blood cannot be reinfused during surgery." B. "Let me refer you to the blood bank so they can provide you with information." C. "This surgery has a very low chance of hemorrhage, so you will not need blood." 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."
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate? A. 30 gtt/min B. 50 gtt/min C. 40 gtt/min D. 20 gtt/min
B. 50 gtt/min
While removing a client's peripherally inserted central catheter (PICC), part of the catheter breaks off. What action is the nurse's priority? A. Have the client perform the Valsalva maneuver. B. Apply a tourniquet to the client's upper arm. C. Apply pressure to the site with sterile gauze until hemostasis is achieved. D. Measure the catheter and compare it with the length listed in the chart.
B. Apply a tourniquet to the client's upper arm.
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. Prescribing the kind of IV solution. B. Deciding the size of the IV catheter. C. Determining the amount of IV solution. D. Administering the IV solution. E. Deciding the location of the IV catheter.
B. Deciding the size of the IV catheter. D. Administering the IV solution. E. Deciding the location of the IV catheter.
The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. A. Manufacturer of the IV catheter B. Gauge and length of the IV catheter C. Type of IV solution D. Rate of the IV solution E. Client's reaction to the procedure F. Location of the IV catheter access
B. Gauge and length of the IV catheter C. Type of IV solution D. Rate of the IV solution E. Client's reaction to the procedure F. Location of the IV catheter access
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? A. Allow nothing by mouth. B. Start an IV of normal saline as prescribed. C. Give the client a glass of orange juice with added sugar. D. Encourage fluid intake.
B. Start an IV of normal saline as prescribed.
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. Infuse saline at a rapid rate. B. Stop the transfusion immediately. C. Prepare to give an antihistamine. D. Administer oxygen.
B. Stop the transfusion immediately.
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. output measurements B. daily weights C. daily electrolyte monitoring D. daily BUN and serum creatinine monitoring
B. daily weights
A nurse is providing care to a client with an extracellular fluid (ECF) volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding? Select all that apply. A. poor skin turgor B. decreased urine output C. orthostatic hypotension D. slow-filling peripheral veins E. dry mucous membranes
B. decreased urine output C. orthostatic hypotension D. slow-filling peripheral veins
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. hypokalemia. C. hypoglycemia. D. hypothyroidism.
B. hypokalemia.
The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). On rounds, the nurse notes that the client's IV site and arm are swollen and cool to the touch. Based on these assessment findings, what will the nurse do next? A. Place a warm compress over the swollen site. B. Decrease the rate of the intravenous fluids. C. Remove the peripheral intravenous catheter. D. Elevate the swollen extremity on a pillow.
C. Remove the peripheral intravenous catheter.
A student has joined the marching band at high school. The band begins practicing outside during hot summer weather. Which health promotion information will the school nurse teach the students? A. With heat, endurance decreases as time increases on the field. B. The exercise will have minimal effect on fluid and electrolytes. C. The student should drink large amounts of water on practice days. D. The hot weather will help the student prepare for the marching season.
C. The student should drink large amounts of water on practice days.
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? A. an adolescent age 17 years B. a man age 50 years C. an infant age 4 months D. a woman age 45 years
C. an infant age 4 months
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. potassium and sodium B. potassium and chloride C. calcium and phosphorus D. chloride and magnesium
C. calcium and phosphorus
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
The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers as well as showing signs of tetany. Which imbalance does the nurse suspect? A. hypokalemia B. hypermagnesemia C. hypocalcemia D. hypophosphatemia
C. hypocalcemia
A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by: A. preventing excretion of acids into the urine. B. decreasing the excretion of H+ ion into the urine. C. increasing ventilation through the lungs. D. increasing the excretion of HCO3− into the urine.
C. increasing ventilation through the lungs.
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. "If the undergarment is soiled, document this fact but do not estimate its contents." B. "You only record urine output in an adult undergarment; you do not record diarrhea output." C. "We do not record fluids absorbed into undergarments." D. "Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."
D. "Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."
A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client? A. Sealed IV dressing B. Occlusive dressing C. Transparent semipermeable membrane dressing D. Gauze dressing
D. Gauze dressing
Which statement accurately describes appropriate nursing interventions in unexpected situations when removing a peripherally inserted central catheter (PICC)? A. If resistance is encountered when removing a PICC, apply sufficient force to the catheter to pull it out. B. If resistance is encountered when removing a PICC line, stop removal, tape it down, and do not attempt to remove again. C. If a portion of the catheter breaks when removing it, tape the catheter down and notify the health care provider. D. If a portion of the catheter breaks when removing it, apply a tourniquet to the upper arm and notify the health care provider.
D. If a portion of the catheter breaks when removing it, apply a tourniquet to the upper arm and notify the health care provider.
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. Metabolic acidosis B. Respiratory alkalosis C. Respiratory acidosis D. Metabolic alkalosis
D. Metabolic alkalosis
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 constipation B. Nausea, vomiting, and constipation C. Diminished cognitive ability and hypertension D. Muscle weakness, fatigue, and dysrhythmias
D. Muscle weakness, fatigue, and dysrhythmias
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? A. Ask the client every hour to drink more fluid. B. Leave water on the bedside table. C. Have a loved one tell the client to drink more. D. Offer small amounts of preferred beverage frequently.
D. Offer small amounts of preferred beverage frequently.
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. Assess oxygen levels. B. Call for assistance. C. Assess for visible rash. D. Stop the transfusion.
D. Stop the transfusion.
A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client? A. isotonic solution B. colloid solution C. hypotonic solution D. hypertonic solution
D. hypertonic solution
A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address? A. increased capillary permeability B. decreased colloid oncotic pressure C. blockage of the lymph nodes D. increased hydrostatic pressure
D. increased hydrostatic pressure
The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment? A. interstitial B. extracellular C. intravascular D. intracellular
D. intracellular
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. nausea, vomiting, and constipation C. muscle weakness, fatigue, and constipation D. muscle cramping and tetany
D. muscle cramping and tetany
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. rapid fluid administration. C. An infiltration. D. phlebitis.
D. phlebitis.
A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? A. albumin B. cryoprecipitate C. granulocytes D. platelets
D. platelets
The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client? A. diaphoresis B. increased cardiac output C. excessive use of laxatives D. renal failure
D. renal failure