Learning Unit 1 | PrepU | Chapter 16: Caring for Clients with Fluid, Electrolyte, and Acid-Base Imbalances

The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching? "I can use laxatives and enemas but only once a week." "A good breakfast for me will include milk and a couple of bananas." "I will be sure to buy frozen vegetables when I grocery shop." "I will take a potassium supplement daily as prescribed."

"I can use laxatives and enemas but only once a week."

The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction? "I will not salt my food; instead I'll use salt substitute." "Bananas have a lot of potassium in them; I'll stop buying them." "I'll drink cranberry juice with my breakfast instead of coffee." "I need to check to see whether my cola beverage has potassium in it."

"I will not salt my food; instead I'll use salt substitute."

A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering? Lactated Ringer solution 0.45% NaCl 0.9% NaCl 5% NaCl

0.45% NaCl

Which solution is hypotonic? Lactated Ringer solution 0.45% NaCl 0.9% NaCl 5% NaCl

0.45% NaCl

Which is considered an isotonic solution? 0.9% normal saline Dextran in normal saline 0.45% normal saline 3% NaCl

0.9% normal saline

The nurse is caring for a client who has experienced an isotonic fluid deficit caused by vomiting and expects the healthcare provider to order which intravenous fluid? 0.9% saline 3% saline 10% dextrose 5% dextrose in 0.45% saline

0.9% saline

The weight of a client with congestive heart failure is monitored daily and entered into the medical record. In a 24-hour period, the client's weight increased by 2 lb. How much fluid is this client retaining? 1 L 500 ml 1500 ml 1250 ml

1 L

At which serum sodium concentration might convulsions or coma occur? 130 mEq/L (130 mmol/L) 145 mEq/L (145 mmol/L) 140 mEq/L (140 mmol/L) 142 mEq/L (142 mmol/L)

130 mEq/L (130 mmol/L)

A client is prescribed 1 liter of 5% dextrose and 0.9% normal saline to be infused over 12 hours. The fluid will be infused by gravity, using tubing with a drop factor of 12 gtts/ml. How many drops per minute will the nurse set the solution to infuse? (Calculate to the nearest whole number.)

17 gtts/min

A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be? <136 mOsm/kg 275-300 mOsm/kg >408 mOsm/kg 350-544 mOsm/kg

275-300 mOsm/kg

A nurse is preparing a dose of furosemide for an older adult with heart failure. The health care provider orders furosemide 1 mg/kg to be given intravenously. The client weighs 50 kg. The concentration of the drug is 40 mg/4mL (10 mg/mL). How many milliliters would the nurse administer? Record your answer using a whole number.

5 mL

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?

50 gtt/min

A nurse is preparing to use microdrip tubing. What is the standard volume that this device delivers?

60 gtt/mL

Which of the following clients would be a candidate for total parenteral nutrition? A client with diabetic ketoacidosis A postoperative appendectomy client A client with colitis and bloody diarrhea A client receiving intravenous antibiotics

A client with colitis and bloody diarrhea

Hypomagnesemia is a common yet often overlooked imbalance in acutely and critically ill patients. Which of the following patients is most likely at the highest risk of experiencing low serum magnesium levels? An obese male patient who has a history of atherosclerosis and a previous non-ST wave elevation myocardial infarction A patient who is temporarily receiving total parenteral nutrition (TPN) as a result of complications from gastric bypass surgery A female patient who has liver cirrhosis and who is experiencing withdrawal from heavy alcohol use A teenage patient who is currently being treated for non-Hodgkin's lymphoma (NHL)

A female patient who has liver cirrhosis and who is experiencing withdrawal from heavy alcohol use

A client with excess fluid volume and hyponatremia is in a comatose state. What are the nursing considerations concerning fluid replacement? Restrict fluids and salt for 24 hours. Correct the sodium deficit rapidly with salt. Administer small volumes of a hypertonic solution. Monitor the serum sodium for changes hourly.

Administer small volumes of a hypertonic solution.

The nurse is preparing to administer a unit of platelets to an adult client. When administering this blood product, which of the following actions should the nurse perform? Administer the platelets as rapidly as the client can tolerate. Establish IV access as soon as the platelets arrive from the blood bank. Ensure that the client has a patent central venous catheter. Aspirate 10 to 15 mL of blood from the client's IV immediately following the transfusion.

Administer the platelets as rapidly as the client can tolerate.

A client suffers from infectious diarrhea. Based on her loss of fluid, her protein level is below normal. What blood product will the physician order to restore intravascular volume? Whole blood Packed red cells Platelets Albumin

Albumin

Which is the most common cause of symptomatic hypomagnesemia? Intravenous drug use Alcoholism Sedentary lifestyle Burns

Alcoholism

An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction? Ensure that blood components are never infused at a rate greater than 125 mL/h. Administer prophylactic antihistamines prior to all blood transfusions. Establish baseline vital signs for all clients receiving transfusions. Be vigilant in identifying the client and the blood component.

Be vigilant in identifying the client and the blood component.

A client reports tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the client's laboratory work has returned? Potassium Phosphorus Calcium Iron

Calcium

When you complete the initial postoperative assessment for a client aged 55 years, you note that his IV is on time and infusing at 33 gtts/min (administration set - 10 gtts/ml). You check the order, which reads: "IV of 1000 cc D5S to infuse over 8 hours." What actions would you take? Continue infusing the IV at 33 gtts/min; check for pulmonary congestion. Change the rate to 21 gtts/min and observe for fluid overload. Reduce the rate to 150 ml/hr and observe for increased urine output. Check the IV site and ask the client who adjusted the flow rate last; clarify with that person.

Change the rate to 21 gtts/min and observe for fluid overload.

A client with aplastic anemia is going to receive a blood transfusion. In addition to taking vital signs and verifying that the unit of blood cells is matched to the client, what other assessments/actions would you take? Assess pain at the transfusion site and transfuse the packed blood cells over 5 hours to prevent fluid overload. Check the client regarding chills, low back pain, dyspnea, and skin itching during the transfusion. Ask the client about headaches; maintain bed rest during the transfusion, and reduce intake of fluids. Rapidly transfuse the blood for the first 15 minutes to detect transfusion reactions and allergic responses.

Check the client regarding chills, low back pain, dyspnea, and skin itching during the transfusion.

The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply. Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms. Administer IV bicarbonate. Suction the client's airway.

Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms.

The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition? Confusion Headache Nausea Hallucinations

Confusion

The nurse is caring for a client with a serum potassium concentration of 6.0 mEq/L (6.0 mmol/L) and a fluid volume excess. The client is ordered to receive oral sodium polystyrene sulfonate and furosemide. What other order should the nurse anticipate giving? Discontinue the intravenous lactated Ringer solution. Increase the rate of the intravenous lactated Ringer solution. Change the lactated Ringer solution to 3% saline. Change the lactated Ringer solution to 2.5% dextrose.

Discontinue the intravenous lactated Ringer solution.

A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? Extracellular fluid volume deficit Altered blood urea nitrogen (BUN) value Metabolic alkalosis Respiratory acidosis

Extracellular fluid volume deficit

During the most recent check of a client receiving IV daunorubicin, the nurse notes that the IV has infiltrated and stops the infusion. What is the priority concern with this infiltration? Extravasation of associated tissue Discomfort to the client Blanching at the site Hypersensitivity reaction to the medication

Extravasation of associated tissue

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? Myasthenia gravis Type 1 diabetes mellitus Extreme anxiety Opioid overdose

Extreme anxiety

A patient with a diagnosis of colon cancer has undergone a bowel resection with the creation of an ileostomy. The patient's ileostomy output has been unexpectedly high in the 2 days since surgery, and the patient's most recent blood work indicates a K+ level of 2.7 mEq/L. This potassium level should prompt the nurse to assess for which of the following physical manifestations? Confusion and decreased level of consciousness Shortness of breath, rales, and peripheral edema Dysphagia, tetany, and emotional lability Fatigue, cramps, and weakness

Fatigue, cramps, and weakness

The nurse is preparing to perform a skin assessment for an older adult client. What principle should guide the assessment of this client's skin turgor? Overhydration is common among older adults, causing inelastic skin with tenting. Dehydration in older adults can cause the skin to appear spongy. For older adults, skin turgor is best tested over the forehead or the sternum. Skin turgor cannot be assessed in patients over the age of 70.

For older adults, skin turgor is best tested over the forehead or the sternum.

The nurse has received a health care provider's order to initiate intravenous therapy and will check the client's medical record for what prior client condition that would impact placement of the client's intravenous site? History of a myocardial infarction History of repeated urinary tract infections History of a mastectomy for breast cancer History of a hysterectomy for uterine cancer

History of a mastectomy for breast cancer

The nurse is called to a client's room by a family member who voices concern about the client's status. On assessment, the nurse finds the client tachypneic, lethargic, weak, and exhibiting a diminished cognitive ability. The nurse also identifies 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this client's signs and symptoms? Hypocalcemia Hyponatremia Hyperchloremia Hypophosphatemia

Hyperchloremia

A patient is being treated with loop diuretics; gastric suctioning has been initiated. The nurse understands the patient is at risk for developing which of the following electrolyte imbalances? Hypokalemia Hyponatremia Hypocalcemia Hypomagnesemia

Hypokalemia

The nurse is assessing the client for the presence of a Chvostek sign. What electrolyte imbalance would a positive Chvostek sign indicate? Select all that apply. Hypermagnesemia Hyponatremia Hypocalcemia Hyperkalemia Hypomagnesemia Hypercalcemia

Hypomagnesemia Hypocalcemia

The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of which imbalance? Metabolic alkalosis Hypermagnesemia Hypercalcemia Hypovolemia

Hypovolemia

A client is being treated for idiopathic thrombocytopenia purpura. Which blood component will the nurse expect to be prescribed to the client? Platelets Factor IX Plasma albumin Immunoglobulin

Immunoglobulin

The nurse is evaluating a newly admitted client's laboratory results, which include several values that are outside of reference ranges. Which of the following alterations would cause the release of antidiuretic hormone (ADH)? Increased serum sodium Decreased serum potassium Decreased hemoglobin Increased platelets

Increased serum sodium

A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level? No effect Increases arterial pH Decreases arterial pH Provides long-term pH regulation

Increases arterial pH

You are doing an admission assessment on an elderly patient newly admitted for end-stage liver disease. You must assess the patient's skin turgor. What should you remember when evaluating skin turgor? Overhydration causes the skin to tent. Dehydration causes the skin to appear edematous and spongy. Inelastic skin turgor is a normal part of aging. Normal skin turgor is moist and boggy.

Inelastic skin turgor is a normal part of aging.

A nurse assessing the IV site of a patient observes swelling and pallor around the site and notes a significant decrease in the flow rate. The patient complains of coldness around the infusion site. What IV complication does this describe? Infiltration Thrombus Sepsis Speed shock

Infiltration

While making an initial shift assessment the nurse notes that the patient's peripheral IV site appears edematous around the insertion site. How should the existence of this complication be documented by the nurse? Air emboli Phlebitis Infiltration Fluid overload

Infiltration

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg? Administer an ordered decongestant. Instruct the client to breathe into a paper bag. Offer the client fluids frequently. Administer ordered supplemental oxygen.

Instruct the client to breathe into a paper bag.

The nurse is preparing to administer the solution in the attached image to a client. Which of the following types of solution is the nurse going to administer? Isotonic Hypertonic Hypotonic Tonic-clonic

Isotonic

Which of the following solutions is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? Hypertonic Colloid Isotonic Hypotonic

Isotonic

A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider? The nurse should use new tubing when attaching additional IV solutions As one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 10 mL of fluid remains in the original container. It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order. Generally, the nurse should change the administration sets of simple IV solutions every 24 hours.

It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order.

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? Headache or blurry vision Abdominal pain or diarrhea Hallucinations or tinnitus Light-headedness or paresthesia

Light-headedness or paresthesia

The nurse is caring for a client who is receiving total parenteral nutrition therapy (TPN) and should know that what else is usually infused regularly with the TPN? Antibiotics Lipid emulsion Dextrose in 5% water 0.9% saline

Lipid emulsion

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder? Respiratory alkalosis Respiratory acidosis Metabolic alkalosis Metabolic acidosis

Metabolic acidosis

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis

Metabolic acidosis

The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Metabolic acidosis

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis

Metabolic alkalosis

A client with type O blood and a history of anemia is scheduled for a blood transfusion. To avoid a transfusion reaction, this client must receive which blood type? O AB All blood types would work for this client. B

O

Which is the preferred route of administration for potassium? Subcutaneous Intramuscular Oral IV (intravenous) push

Oral

A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately? CO2 Sodium Chloride Potassium

Potassium

Which electrolyte is a major cation in body fluid? Chloride Bicarbonate Potassium Phosphate

Potassium

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? Prepare to assist with ventilation. Monitor the client's heart rhythm. Prepare for gastric lavage. Obtain a urine specimen for drug screening.

Prepare to assist with ventilation.

A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance? Presence of Trousseau sign Slurred speech Negative Chvostek sign Muscle weakness

Presence of Trousseau sign

The nurse is teaching a group of student nurses about the function of calcitonin. The student nurse is correct in sharing which of the following? Select all that apply. Reduces bone resorption Increases urinary excretion of calcium Increases deposition of calcium in bones Decreases deposition of phosphorous in bones Decreases urinary excretion of phosphate

Reduces bone resorption Increases urinary excretion of calcium Increases deposition of calcium in bones

A nurse is assigned to care for a client who is bleeding severely following an accident and has been ordered transfusion of blood components. Which of the following should the nurse do to reduce the risk of septic reactions? Avoid infusing blood components within four hours of refrigeration. Keep the frozen blood components at room temperature for a longer duration. Immerse the refrigerated blood components in warm water before use. Refrigerate red blood cells and thawed fresh frozen plasma until use.

Refrigerate red blood cells and thawed fresh frozen plasma until use.

The nurse is caring for a healthy adult client who developed a gastrointestinal virus in the last 24 hours that has caused vomiting and diarrhea and now has a diagnosis of dehydration. The nurse should know that a health care provider's order to initiate intravenous therapy is given primarily for which reason(s)? Select all that apply. Replace electrolytes. Administer medications. Administer water-soluble vitamins. Replace blood or blood products. Replace fluids.

Replace electrolytes. Replace fluids.

Assessing a client at 4:00 PM, a nurse notes that 800 ml of normal saline solution has been infusing since it was hung at 4:00PM yesterday. What would be the nurse's next action? Replace the IV solution. Leave the IV solution until it completes. Write an incident report. Discontinue the IV site.

Replace the IV solution.

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 24 mm Hg. Which condition does the ABG reflect? Respiratory acidosis Metabolic alkalosis Respiratory alkalosis Metabolic acidosis

Respiratory acidosis

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory acidosis

A patient in the ICU starts complaining of being "short of breath." An arterial blood gas (ABG) is drawn. The ABG has the following values: pH = 7.21, PaCO2 = 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? Respiratory acidosis Metabolic alkalosis Respiratory alkalosis Metabolic acidosis

Respiratory acidosis

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory alkalosis

A patient with a history of poorly controlled type 1 diabetes has begun displaying the characteristic signs and symptoms of diabetic nephropathy. The patient's nurse recognizes that the patient is at risk of disruptions to fluid balance. What role do the kidneys play in the maintenance of normal fluid balance? Secreting or withholding antidiuretic hormone in response to extracellular fluid volume Selectively retaining needed substances and excreting waste products Synthesizing and releasing angiotensin in cases of fluid volume deficit Maintaining the correct concentration of H+ ions in the blood

Selectively retaining needed substances and excreting waste products

Which of the following arterial blood gas results would be consistent with metabolic alkalosis? Serum bicarbonate of 28 mEq/L PaCO2 less than 35 mm Hg Serum bicarbonate of 21 mEq/L pH 7.26

Serum bicarbonate of 28 mEq/L

Fresh-frozen plasma (FFP) has been prescribed for a hospital client. Prior to administration of this blood product, the nurse should prioritize which client education? Infection risks associated with FFP administration Physiologic functions of plasma Signs and symptoms of a transfusion reaction Strategies for managing transfusion-associated anxiety

Signs and symptoms of a transfusion reaction

A client receiving IV fluid therapy suddenly becomes anxious and exhibits an elevated blood pressure, a bounding pulse, and shortness of breath. Which nursing action(s) would be most appropriate to assist this client? Select all that apply. Slow the IV rate. Contact the physician. Lower the client's head. Provide oxygen to the client. Restart the IV.

Slow the IV rate. Contact the physician. Provide oxygen to the client.

A client is receiving a blood transfusion and reports a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? Slow the infusion rate and monitor the client closely. Discontinue the transfusion and begin resuscitation. Pause the transfusion and administer a 250 mL bolus of normal saline. Discontinue the transfusion and administer a beta-blocker, as prescribed

Slow the infusion rate and monitor the client closely.

A client is receiving a blood transfusion and reports a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? Slow the infusion rate and monitor the client closely. Discontinue the transfusion and begin resuscitation. Pause the transfusion and administer a 250 mL bolus of normal saline. Discontinue the transfusion and administer a beta-blocker, as prescribed.

Slow the infusion rate and monitor the client closely.

A client receiving intravenous therapy is experiencing circulatory overload. Which of the following nursing actions is correct? Select all that apply. Slow the infusion rate. Discontinue any oxygen. Elevate the client's head. Apply warm compresses at the site. Contact the physician

Slow the infusion rate. Elevate the client's head. Contact the physician.

A client receiving intravenous therapy is experiencing circulatory overload. Which of the following nursing actions is correct? Select all that apply. Slow the infusion rate. Discontinue any oxygen. Elevate the client's head. Apply warm compresses at the site. Contact the physician.

Slow the infusion rate. Elevate the client's head. Contact the physician.

Which medication does the nurse anticipate administering to antagonize the effects of potassium on the heart for a patient in severe metabolic acidosis? Sodium bicarbonate Magnesium sulfate Furosemide Calcium gluconate

Sodium bicarbonate

A client is receiving chemotherapy through a central venous catheter into her right subclavian vein. The nurse observes that she is dyspneic and cyanotic; her blood pressure has dropped to 86/48 mm Hg and she has a weak, rapid pulse and temperature of 40C. The client reports pain in her chest and shoulder. What complication would the nurse suspect? Circulatory overload due to infusion of fluid so close to the heart. Air embolism. Systemic infection. Infiltration at the site of insertion.

Systemic infection.

A client seeks medical attention for an acute onset of severe thirst, polyuria, muscle weakness, nausea, and bone pain. Which health history information will the nurse report to the health care provider? Ingests alcohol occasionally Takes high doses of vitamin D Follows a high-fiber eating plan Works as a customer service representative

Takes high doses of vitamin D

The nurse is observing a UAP provide basic comfort measures to a client who has recently returned from surgery. The client's IV is currently being infused by gravity because the electronic infusion device is not yet available. The UAP will correct the UAP's actions if which is noted by the nurse? The UAP elevates the client's arm where the intravenous site is located on two pillows. The UAP ensures that the client's call light is within arm's reach. The UAP explains how to operate the TV and how to call for the nurse. The UAP makes sure that all IV tubing is straight and not under the client.

The UAP elevates the client's arm where the intravenous site is located on two pillows.

A physician orders IV solution for a 92-year-old client to treat dehydration. The order was written to administer the fluid at a slower rate than what the nurse expected. Why would the physician designate the slower infusion rate for this client? The client may have cardiac or renal disorders. Older adults may have poor skin turgor. Veins of older adults tend to be rigid. Older adults often find infusions painful.

The client may have cardiac or renal disorders.

The nurse is caring for an older adult client who is receiving intravenous therapy (IV). Which assessment data would indicate that the client is experiencing a complication of IV therapy? The client's respiratory rate has increased from 16/minute to 18/minute. The client complains of a stomachache. The client's jugular veins are distended. The client complains of aching joints.

The client's jugular veins are distended.

A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction? Antibodies to donor leukocytes remained in the blood. The donor blood was incompatible with that of the client. The client had a sensitivity reaction to a plasma protein in the blood. The blood was infused too quickly and overwhelmed the client's circulatory system.

The donor blood was incompatible with that of the client.

The nurse is preparing to administer a unit of blood to a client and should know that which is the FIRST action of the nurse prior to the administration? The nurse will obtain the client's vital signs. The nurse will connect the unit of blood to Y-administration set tubing. The nurse will check that the numbers of the client's wrist band and the unit of blood match and that this information is confirmed by another nurse. The nurse will explain to the client the symptoms associated with a transfusion reaction.

The nurse will check that the numbers of the client's wrist band and the unit of blood match and that this information is confirmed by another nurse.

Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)? Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad Three ounces of sliced ham, beets, and a salad A frozen, packaged low-fat dinner with a side salad Tomato juice, low-fat cottage cheese, and three slices of bacon

Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad

A client receiving intravenous therapy shows signs of swelling at the infusion site and says it is uncomfortable. The infusion is also slowing. Which of the following complications would the nurse most likely prepare to assist in managing? Infection Pulmonary embolus Thrombus formation Circulatory overload

Thrombus formation

A client is prescribed to receive an intravenous infusion of 5% dextrose and 0.45% normal saline to be infused over 12 hours. Which action will the nurse take to prepare the client for this infusion? Select all that apply. Validate the client's identity. Explain the purpose of the infusion. Review how long the infusion will take. Discuss the location of the insertion needle. Measure vital signs before starting the infusion.

Validate the client's identity. Explain the purpose of the infusion. Review how long the infusion will take. Discuss the location of the insertion needle.

A client requires a blood transfusion, and the nurse is preparing the blood transfusion equipment. Which item will the nurse need? Y-administration tubing 22-gauge catheter primary tubing pressure infusion sleeve

Y-administration tubing

A client has hypertonic solution running via gravity at 100 mL/hour to decrease postoperative edema. Before transporting the client, the nurse sets the IV pole at the proper height to overcome the pressure within the client's veins. What is that height? at least 18 to 24 inches above infusion site no more than 18 to 24 inches above infusion site no more than 6 to 12 inches above infusion site at least 24 to 30 inches above infusion site

at least 18 to 24 inches above infusion site

A nurse caring for a patient with metabolic alkalosis knows to assess for the primary, compensatory mechanism of: a. Increased serum HCO3. b. Increased PaCO2. c. Decreased serum HCO3. d. Decreased PaCO2.

b. Increased PaCO2.

A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. sodium 137 mEq/L (137 mmol/L)potassium 4.6 mEq/L (4.6 mmol/L)chloride 94 mEq/L (94 mmol/L)calcium 12.9 mg/dL (3.2 mmol/L) What laboratory value is of highest concern to the nurse? sodium 137 mEq/L (137 mmol/L) potassium 4.6 mEq/L (4.6 mmol/L) chloride 94 mEq/L (94 mmol/L) calcium 12.9 mg/dL (3.2 mmol/L)

calcium 12.9 mg/dL (3.2 mmol/L)

A client with emphysema is at a greater risk for developing which acid-base imbalance? chronic respiratory acidosis metabolic alkalosis metabolic acidosis respiratory alkalosis

chronic respiratory acidosis

A client with ascites is receiving TPN until the condition clears. IV lipid emulsions would be contraindicated in a client with which condition? egg allergy sulfa allergy skin infection cardiac disease

egg allergy

The nurse is caring for a client who has a peripheral IV in place for fluid replacement. When caring for the client's IV site, the nurse should: ensure that anticoagulants are placed on hold for the duration of IV therapy. replace the IV dressing with a new, clean dressing if it is soiled. ensure that the tubing is firmly anchored to the client's skin. periodically remove hair from 2 cm around the IV site.

ensure that the tubing is firmly anchored to the client's skin.

A client has experienced a closed head injury causing cerebral edema. Which fluid would the nurse expect to see administered to decrease the client's cerebral edema? hypertonic solution hypotonic solution isotonic solution colloid solutions

hypertonic solution

A client reports muscle cramps in the calves and feeling "tired a lot." The client is taking ethacrynic acid (Edecrin) for hypertension. Based on these symptoms, the client will be evaluated for which electrolyte imbalance? hypokalemia hyperkalemia hypocalcemia hypercalcemia

hypokalemia

Early signs of hypervolemia include a decrease in blood pressure. thirst. moist breath sounds. increased breathing effort and weight gain.

increased breathing effort and weight gain.

A client with cancer is being treated on the oncology unit for bilateral breast cancer. The client is undergoing chemotherapy. The nurse notes the client's serum calcium concentration is 12.3 mg/dL (3.08 mmol/L). Given this laboratory finding, the nurse should suspect that the malignancy is causing the electrolyte imbalance. client's diet is lacking in calcium-rich food products. client may be developing hyperaldosteronism. client has a history of alcohol abuse.

malignancy is causing the electrolyte imbalance.

A home healthcare client who is in a coma requires extended IV fluid therapy. Which peripheral access device would be most appropriate for administering this therapy? midline catheter butterfly needle over-the-needle catheter through-the-needle catheter

midline catheter

Fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area? osmosis filtration evaporation active transport

osmosis

To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply. pH PaCO2 HCO3 Glucose Na+ K+

pH PaCO2 HCO3

Which set of arterial blood gas (ABG) results requires further investigation? pH 7.38, partial pressure of arterial carbon dioxide (PaCO2) 36 mm Hg, partial pressure of arterial oxygen (PaO2) 95 mm Hg, bicarbonate (HCO3-) 24 mEq/L pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L pH 7.44, PaCO2 43 mm Hg, PaO2 99 mm Hg, and HCO3- 26 mEq/L pH 7.35, PaCO2 40 mm Hg, PaO2 91 mm Hg, and HCO3- 22 mEq/L

pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L

A client has a history of congestive heart failure (CHF) and arthritis that causes significant discomfort. The physician has prescribed daily doses of NSAIDS to fight inflammation and pain. The client has developed a GI bleed as a result of the medication, and blood values indicate the need for a transfusion. Considering the client's history, which colloid solution would the nurse expect to be administered? packed cells whole blood blood products plasma expanders

packed cells

A client with cellulitis is being discharged and is to receive intravenous antibiotic therapy at home. Which type of access device should the client receive for this medication therapy? butterfly needle central venous catheter over-the-needle catheter peripherally inserted central catheter (PICC)

peripherally inserted central catheter (PICC)

A nurse needs to perform venipuncture on a client who has poor skin turgor. To prevent skin trauma at the venipuncture site, the nurse should: place a soft cloth between the tourniquet and the skin. not use a tourniquet on this older client. avoid using antiseptic on the client to prevent skin irritation. choose a vein in the client's foot as the venipuncture site.

place a soft cloth between the tourniquet and the skin.

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: metabolic acidosis. metabolic alkalosis. respiratory acidosis. respiratory alkalosis.

respiratory alkalosis.

A client is admitted with dehydration. In client education, the nurse reinforces how much oral fluid an adult needs daily. Balancing fluid intake with fluid output helps to keep the body healthy. What type of fluid loss is an insensible loss? sweating breathing perspiration bowel elimination

sweating breathing perspiration

A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting? third-spacing pitting edema anasarca hypovolemia

third-spacing

The nurse is planning care for an older adult client. Which of the following would require the nurse to assess for chronic respiratory acidosis? decreased renal function erratic meal patterns thoracic skeletal change overuse of sodium bicarbonate

thoracic skeletal change

A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching? tingling sensation in the fingers polyuria flank pain hypertension

tingling sensation in the fingers

The nurse notes that intravenous fluid orders for a client have been discontinued. For which reason will the nurse convert the peripheral catheter site to a medication lock? use for emergency medications prepare for resumption of IV fluids transfuse total parenteral nutrition (TPN) adhere to the expectation that all clients have IV access

use for emergency medications

A client is receiving total parenteral nutrition. The physician order includes lipid emulsion administration (contained in glass bottles) on Monday, Wednesday, and Friday. What type of IV tubing would the nurse select for the lipid administration? vented tubing unvented tubing macro drip tubing None of the options is correct.

vented tubing