NSG 371 Chapter 40
A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? - "I've had a GI virus for the past 3 days with severe diarrhea." - "I've had a fever for the past 3 days that just doesn't seem to go away." - "I was breathing so fast because I was so anxious and in so much pain." - "I've been taking antacids almost every 2 hours over the past several days."
"I've been taking antacids almost every 2 hours over the past several days." Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit (known as contraction alkalosis). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes. Hyperventilation, commonly caused by anxiety or pain, would lead to respiratory alkalosis. Fever, which increases carbon dioxide excretion, would also be associated with respiratory alkalosis. Severe diarrhea is associated with metabolic acidosis.
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? - "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)." - "You only record urine output in an adult undergarment; you do not record diarrhea output." - "We do not record fluids absorbed into undergarments." - "Estimate the amount of fluid that you think was excreted into the undergarment."
"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)." Fluid output is the sum of liquid eliminated from the body, including urine, emesis (vomitus), blood loss, diarrhea, wound or tube drainage, and aspirated irrigations. In cases in which an accurate assessment is critical to a client's treatment, the nurse weighs wet linens, pads, diapers, or dressings, and subtracts the weight of a similar dry item. An estimate of fluid loss is based on the equivalent: 1 lb (0.47 kg) = 1 pint (475 mL).
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? - 200 mL/hr - 75 mL/hr for the first 15 minutes, then 200 mL/hr - As fast as the client can tolerate - 1 unit over 2 to 3 hours, no longer than 4 hours
1 unit over 2 to 3 hours, no longer than 4 hours
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 160 gtt/min 100 gtt/min 60 gtt/min 600 gtt/min
100 gtt/min 100gtt/min is the correct rate. 1000 mL divided by 10 hours = 100 mL per hour x 60 gtt/minute, divided by 60 minutes/hour.
A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison? 1,800 mL 2,600 mL 2,300 mL 1,500 mL
2,600 mL The average adult daily fluid source is: 1,300 mL from ingested water, 1,000 mL from ingested food, and 300 mL from metabolic oxidation, totaling 2,600 mL fluid.
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? 1,000 500 3,000 3,750
3,000 Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.
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? 12 cm H2O 9.5 cm H2O 3.5 cm H2O 5 cm H2O
3.5 cm H2O The normal pressure is approximately 4 to 11 cm H2O. An increase in the pressure, such as a reading of 12 cm H2O may indicate an ECF volume excess or heart failure. A decrease in pressure, such as 3.5 cm H2O, may indicate an ECF volume deficit.
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 40 gtt/min 20 gtt/min 30 gtt/min
50 gtt/min The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.
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? 30 drops/mL 120 drops/mL 90 drops/mL 60 drops/mL
60 drops/mL Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of 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? 83 gtt/min 42 gtt/min 5,000 gtt/min 167 gtt/min
83 gtt/min The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes. 250 mL × 20 gtt/mL ÷ 60 min = 83 gtt/min
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? - Constipation related to immobility - Pain related to surgical incision - Acute Confusion related to cerebral edema - Risk for Infection related to inadequate personal hygiene
Acute Confusion related to cerebral edema Edema in and around the brain increases intracranial pressure, leading to the likelihood of confusion. Constipation related to immobility, Pain related to surgical incision, Risk for Infection related to inadequate personal hygiene are nursing diagnoses that have no connection to fluid and electrolyte imbalance.
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? - Position the client on the left side. - Apply antiseptic and a dressing. - Apply a warm compress. - Elevate the client's head.
Apply a warm compress. Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.
The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level? -Fluid volume excess -Pulmonary embolus -Cardiac dysrhythmias -Tetany
Cardiac dysrhythmias Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.
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. - Determining the amount of IV solution. - Administering the IV solution. - Deciding the location of the IV catheter. - Deciding the size of the IV catheter. - Prescribing the kind of IV solution.
Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution.
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? - Stop the infusion, cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site. - Call the primary care provider to see whether anti-inflammatory drugs should be administered. - 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 - Discontinue the IV and relocate it to another site.
Discontinue the IV and relocate it to another site. The nurse should inspect the IV site for the presence of phlebitis (inflammation), infection, or infiltration and discontinue and relocate the IV if any of these signs are noted. Cleansing will not resolve this common complication of therapy.
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. - Insert a larger gauge IV catheter and transfer the infusion to the new insertion site. - Continue to infuse the PRBCs until they are completely infused. - Fully open the roller clamp on the infusion set and infuse the remaining PRBCs as rapidly as possible.
Discontinue the infusion and record the volume left in the blood bag. Transfusions must be completed within 4 hours due to the potential for bacterial growth in a blood product at room temperature.
A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? - Avoid replacing IV solutions every 24 hours. - Ensure that the prescribed solution is clear and transparent. - Use half-instilled IV solutions before infusing a new one. - Select a primary tubing of about 37 inches (94 cm) long.
Ensure that the prescribed solution is clear and transparent. Before preparing the solution, the nurse should inspect the container and determine that the solution is clear and transparent, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached. The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled.
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? Hypokalemia Hypermagnesemia Hyponatremia Hypercalcemia
Hypokalemia All of the levels listed are within normal ranges except for potassium, which is decreased (normal range is 3.5 to 5.3 mEq/L; 3.5 to 5.3 mmol/L). Therefore the client has hypokalemia.
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 acidosis - Metabolic alkalosis - Respiratory acidosis - Respiratory alkalosis
Metabolic alkalosis Endocrine disorders and ingestion of large amounts of antacids cause metabolic alkalosis.
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)? - Metabolic acidosis - Respiratory acidosis - Metabolic alkalosis - Respiratory alkalosis
Metabolic alkalosis Metabolic alkalosis is associated with an excess of HCO3, a decrease in H+ ions, or both, in the extracellular fluid (ECF). This may be the result of excessive acid losses or increased base ingestion or retention. Loss of stomach acid may result in this condition. Metabolic acidosis is a proportionate deficit of bicarbonate in ECF. The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate such as in diarrhea. Respiratory acidosis is when the carbon dioxide level is high and the ph is low. Respiratory alkalosis is when the carbon dioxide level is low and the ph is high.
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? - Potassium - Phosphorous - Sodium - Chloride
Potassium Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium.
A client's course of intravenous medications have been completed and the nurse is removing the IV catheter. What is the nurse's best action?
The nurse should carefully remove the tape from the outside to the insertion point while supporting the catheter. Gloves should be worn.
The nurse has inserted a peripheral intravenous catheter. When applying a transparent dressing, what is the nurse's best action?
The transparent dressing should be placed in such a manner as to allow full coverage and visibility of the insertion site, without excessively covering the tubing.
Which statement most accurately describes the process of osmosis? - Plasma proteins facilitate the reabsorption of fluids into the capillaries. - Water moves from an area of lower solute concentration to an area of higher solute concentration. - Solutes pass through semipermeable membranes to areas of lower concentration. - Water shifts from high-solute areas to areas of lower solute concentration.
Water moves from an area of lower solute concentration to an area of higher solute concentration. Osmosis is the primary method of transporting body fluids, in which water moves from an area of lesser solute concentration and more water to an area of greater solute concentration and less water. Solutes do not move during osmosis. Plasma proteins do not facilitate the reabsorption of fluid into the capillaries, but assist with colloid osmotic pressure, which is related to, but not synonymous with, the process of osmosis.
How is control over the extracellular concentration of potassium within the human body is exerted? albumin. progesterone. testosterone. aldosterone.
aldosterone Aldosterone exerts major control over the extracellular concentration of potassium. It also enhances renal secretion of potassium.
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? - a woman age 45 years - a man age 50 years - an infant age 4 months - an adolescent age 17 years
an infant age 4 months An infant has considerably more total body fluid and extracellular fluid (ECF) than does an adult. Because ECF is more easily lost from the body than intracellular fluid, infants are more prone to fluid volume deficits. An adolescent at 17 years is considered to have an adultlike body system similar to the 45-and 50-year-old.
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? - potassium and chloride - chloride and magnesium - calcium and phosphorus - potassium and sodium
calcium and phosphorus The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances. Sodium, chloride, and potassium are regulated by the kidneys and affected by fluid balance.
Potassium is needed for neural, muscle, and: -optic function. -auditory function. -cardiac function. -skeletal function.
cardiac function. Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles.
Which client(s) would be an appropriate candidate for total parenteral nutrition (TPN)? Select all that apply. - client with anorexia nervosa - client who has full-thickness (third-degree) burns over 40% of the body - client with peptic ulcer disease - client who had gastric surgery and is unable to eat for a few weeks - client who has cholelithiasis
client who has full-thickness (third-degree) burns over 40% of the body client who had gastric surgery and is unable to eat for a few weeks client with anorexia nervosa A client with severe burns, as well as a client who has had gastric surgery, would both be a candidate for TPN. TPN is designed for clients who are severely malnourished who will not be able to eat for a long period. A client with anorexia nervosa would also be an appropriate candidate for TPN. A client who has peptic ulcer disease will be able to eat after initiation of a medication regimen. A client who has cholelithiasis (gallstones) is able to feed onself through standard means.
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? - decreased blood volume and intracellular dehydration - decreased blood volume and extracellular overhydration - increased blood volume and intracellular dehydration - increased blood volume and extracellular overhydration
decreased blood volume and intracellular dehydration Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume. When a client does not drink, the body begins intracellular dehydration and the client becomes thirsty. There is no extracellular dehydration.
After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client? every 24 hours every 12 hours every 36 hours every 72 hours
every 72 hours IV tubings are generally changed every 72 hours or as per the facility's policy. Solutions are replaced when they finish infusing or every 24 hours, whichever occurs first. IV tubings are not replaced after every solution is over or after every 12, 24, or 36 hours.
Edema happens when there is which fluid volume imbalance? - extracellular fluid volume deficit - water excess - extracellular fluid volume excess - water deficit
extracellular fluid volume excess When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.
When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing: - pulmonary embolism. - anaphylaxis. - fluid overload. - allergic reaction.
fluid overload. Fluid overload can occur when blood components are infused too quickly or too voluminously. Symptoms include increased venous pressure, distended neck veins, dyspnea, coughing, and abnormal breath sounds.
During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect? - hemolytic transfusion reaction: incompatibility of blood product - bacterial reaction: bacteria present in the blood - febrile reaction: fever develops during infusion - allergic reaction: allergy to transfused blood
hemolytic transfusion reaction: incompatibility of blood product The listed symptoms occur when a blood product is incompatible. Hives, itching, and anaphylaxis occur in allergic reactions; fever, chills, headache, and malaise occur in febrile reactions. In a bacterial reaction, fever; hypertension; dry, flushed skin; and abdominal pain occur.
Which solution 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? isotonic hypotonic colloid hypertonic
isotonic Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.
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: - low calcium. - high sodium. - high magnesium. - low potassium.
low calcium. Normal total serum calcium levels range between 8.9 and 10.1 mg/dL (2.225 to 2.525 mmol/L).
The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths per minute. Which arterial blood gas data does the nurse anticipate finding? pH: 7.60; PaCO2: 64; HCO3: 42 pH: 7.32; PaCO2: 26; HCO3: 18 pH: 7.32; PaCO2: 28; HCO3: 24 pH: 7.28; PaCO2: 52; HCO3: 32
pH: 7.60; PaCO2: 64; HCO3: 42 In metabolic alkalosis, arterial blood gas results are anticipated to reflect pH greater than 7.45; a high HCO3, such as 64; and a high PaCO2, such as 42. The numbers correlate with metabolic alkalosis, which is indicated by the hyperventilation and the retention of CO2. The other blood gas findings do not correlate with metabolic alkalosis.
A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? platelets cryoprecipitate granulocytes albumin
platelets Platelets are administered to restore or improve the ability to control bleeding. Granulocytes are used to overcome or treat infection. Albumin is used to pull third-spaced fluid by increasing colloidal osmotic pressure. Cryoprecipitate is used to treat clotting disorders like hemophilia.
The primary extracellular electrolytes are: - potassium, phosphate, and sulfate. - sodium, chloride, and bicarbonate. - phosphorous, calcium, and phosphate. - magnesium, sulfate, and carbon.
sodium, chloride, and bicarbonate.
The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? - "I have never given blood before." - "My spouse would also like to donate blood." - "My blood type is B positive." - "I received a blood transfusion in the United Kingdom."
"I received a blood transfusion in the United Kingdom." Because blood is one possible mode of transmitting prions from animals to humans and humans to humans, the collection of blood is banned from anyone who has lived in the UK for a total of 3 months or longer since 1980, lived anywhere in Europe for a total of 6 months since 1980, or received a blood transfusion in the UK. The other statements do not require nursing intervention.
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend? 2,500 mL/day 1,000 mL/day 1,500 mL/day 3,500 mL/day
2,500 mL/day In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss. 1,000 mL/day and 1,500 mL/day are too low, and 3,500 mL/day is too high.
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? - Instruct client to remain flat for 30 minutes. - Ask client to perform Valsalva maneuver. - Apply pressure to insertion site for at least 3 minutes. - Apply petroleum-based ointment and sterile occlusive dressing.
Apply pressure to insertion site for at least 3 minutes. The nurse recognizes that the client prescribed warfarin is at risk for bleeding and individualizes care by applying pressure to the insertion site for longer than the minimum recommended 1 minute. The remaining interventions are appropriate for all clients when discontinuing a PICC line; they do not individualize care for the client prescribed warfarin.
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? - Infuse saline at a rapid rate. - Administer oxygen. - Prepare to give an antihistamine. - Stop the transfusion immediately.
Stop the transfusion immediately. The nurse needs to stop the transfusion immediately. The nurse should prepare to give an antihistamine because these signs and symptoms are indicative of an allergic reaction to the transfusion, infuse saline at a rapid rate, and administer oxygen if the client shows signs of incompatibility.
The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client? - renal failure - increased cardiac output - excessive use of laxatives - diaphoresis
renal failure Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit.
A decrease in arterial blood pressure will result in the release of: -protein. -thrombus. -renin. -insulin.
renin Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.
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? - "We now have artificial blood products, so giving your own blood is not necessary." - "Let me refer you to the blood bank so they can provide you with information." - "Unfortunately, your own blood cannot be reinfused during surgery." - "This surgery has a very low chance of hemorrhage, so you will not need blood."
"Let me refer you to the blood bank so they can provide you with information." Referring the client to a blood bank is the appropriate response. Most blood given to clients comes from public donors. In some cases, when a person anticipates the potential need for blood in the near future or when procedures are used to reclaim blood from wound drainage, the client's own blood may be reinfused.
The nurse is monitoring intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the I&O record? Select all that apply. - bowl of chili - serving of jello - cup of ice cream - 100 mL from melted ice chips - infusion of intravenous solution - barbecue sandwich
100 mL from melted ice chips serving of jello infusion of intravenous solution cup of ice cream The nurse will document all fluid intake and fluid loss. This includes drinking liquids and intravenous fluids. The liquid equivalent of melted ice chips is fluid intake. Foods that are liquid by the time they are swallowed, such as gelatin, ice cream, and thin cooked cereal, are documented as fluid intake. A bowl of chili is a solid food as is a barbecue sandwich. While the amount eaten may be documented in the chart, it is not part of the fluid intake.
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? -Avoid salty or excessively sweet fluids. -Use regular gum and hard candy. -Eat crackers and bread. -Use an alcohol-based mouthwash to moisten your mouth.
Avoid salty or excessively sweet fluids. To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, may increase the client's feeling of thirst. Allowing the client to rinse the mouth frequently may decrease thirst, but this should be done with water, not alcohol-based, mouthwashes, which would have a drying effect.
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? - Increased potassium levels - Increased sodium levels - Decreased potassium levels - Decreased oxygen levels
Decreased potassium levels Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.
The nurse is preparing to initiate an infusion of packed red blood cells (PRBCs). While observing the information on the blood bag, it is essential to verify which information with another nurse? Select all that apply. - Patency of the client's venous access device - Client's room number - Client's vital signs - Number on the client's identification band - Name on the client's identification band
Number on the client's identification band Name on the client's identification band Two nurses must compare and validate the following information with the medical record, client identification band, and the blood product label: medical prescription for transfusion of blood product, informed consent, client identification number, client name, blood group and type, and expiration date. The client's vital signs and room number and the patency of the venous access device are not required to be validated by two nurses.
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? -Ask the client every hour to drink more fluid. -Offer small amounts of preferred beverage frequently. -Have a loved one tell the client to drink more. -Leave water on the bedside table.
Offer small amounts of preferred beverage frequently. Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. This intervention will assist in keeping oral mucosa moist and providing hydration needs.
A nurse is caring for a client who is not able to take food orally for 1 week to 10 days. Which type of nutrition is the client likely receive? - Total parenteral nutrition - Nasogastric feed - Peripheral parenteral nutrition - Metabolizing nutrition
Peripheral parenteral nutrition The client requires peripheral parenteral nutrition. Peripheral parenteral nutrition provides temporary nutritional support of approximately 2000 to 2500 calories daily. It can meet a client's metabolic needs when oral intake is interrupted for 7 to 10 days, or it can be used as a supplement during a transitional period as a client begins to resume eating. Total parenteral nutrition (TPN) is preferred for clients who are severely malnourished or may not be able to consume food or liquids for a long period. Metabolizing nutrition is a way to replenish and supply water to the body. A nasogastric feed is administered through narrow tubing that is inserted through the client's nose into the stomach; it is better suited for short-term nutrition.
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? -Remove the IV catheter and reinsert another in a different location. -Decontaminate the visible portion of the catheter, and then gently reinsert. -Apply a new dressing and observe for signs of infection over the next several hours. -Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air.
Remove the IV catheter and reinsert another in a different location. An IV catheter should not be reinserted. Whether the IV is salvageable depends on how much of the catheter remains in the vein. Because this catheter has been almost completely pulled out of the insertion site, it should be discarded and a new one inserted at a different location. It is not acceptable simply to apply a new dressing and leave the catheter sticking out of the site.
The nurse is performing an assessment of a client with hypocalcemia who has been admitted to the acute care facility. Which symptom(s) does the nurse document that correlates with the admitting diagnosis? Select all that apply. - Report of numbness and tingling of the mouth - Report of muscle cramps - Report of excessive urination - Blood clotting - Seizure activity - Slurred speech
Report of muscle cramps Report of numbness and tingling of the mouth Seizure activity Blood clotting Calcium is important in wound healing, synaptic transmission in nervous tissue, membrane excitability, and is essential for blood clotting. Manifestations of hypocalcemia include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures. Slurred speech and reports of excessive urination are indicative of hypercalcemia.
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? - Allow nothing by mouth. - Start an IV of normal saline as prescribed. - Encourage fluid intake. - Give the client a glass of orange juice with added sugar.
Start an IV of normal saline as prescribed. To treat a client with hypovolemia, the nurse should obtain an IV bag with normal saline (0.9% sodium chloride) as prescribed. Fluid intake by mouth will not provide fluid quickly enough for the desired effect but should be attempted if feasible, in addition to an IV. Orange juice with additional sugar may be given to a person with low blood sugar.
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? - a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today - a newly admitted 88-year-old with a 2-day history of vomiting and loose stools - a 47-year-old who had a colon resection yesterday and is reporting pain - a 60-year-old who is 3 days post-myocardial infarction and has been stable.
a newly admitted 88-year-old with a 2-day history of vomiting and loose stools Young children, older adults, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. It is important to ambulate after surgery, but this can be addressed after assessment of the 88-year-old. The stable MI client presents no emergent needs at the present. The pain is important to address and should be addressed next or simultaneously (asking a colleague to give pain med).
During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible? - hypovolemia - circulatory overload - edema - hypervolemia
hypovolemia The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN). Hypervolemia means a higher-than-normal volume of water in the intravascular fluid compartment and is another example of a fluid imbalance that would manifest itself with different signs and symptoms. Edema develops when excess fluid is distributed to the interstitial space.
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: -cellular hydration. -volume expander. -total parenteral nutrition. -blood transfusion therapy.
total parenteral nutrition. is administered into the venous system.
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 - increased blood pressure - slightly distended neck veins - bounding pulse
weight gain of 0.75 kg in a day Although increased blood pressure, bounding pulse, and distended neck veins are signs of ECF volume excess, rapid weight gain (more than 0.5 kg per day) is the most significant symptom indicating ECF volume excess. A weight gain of 1 kg reflects retention of 1 L of ECF. Additionally, because the veins are very distensible, large volumes of fluid can be retained without any increase in blood pressure or changes in pulse or neck veins.