Advanced Skills Exam: IV Lines

The RN is providing care for a client diagnosed with dehydration and hypovolemic shock. Which prescribed intervention from the health care provider should the RN question? 1. Blood pressure every 15 minutes 2. Place two 18-gauge IV lines 3. Oxygen at 3 L via nasal cannula 4. IV 5% destrose in water (D5W) to run at 250 mL/hr.

4 To correct hypovolemic shock with dehydration, the client needs IV fluids that are isotonic and will increase intravascular volume, such as normal saline. With D5W, the body rapidly metabolizes the dextrose and the solution becomes hypotonic. All of the other interventions are appropriate for a client with shock.

A nurse if reviewing a client's serum electrolyte labs report. What is a comparison between blood plasma and interstitial fluid? A. They both contain the same kinds of ions B. Plasma exerts lower osmotic pressure than does interstitial fluid C. Plasma contains more of each kind of ion than does interstitial fluids D. Sodium is higher in plasma, whereas potassium is higher in interstitial fluids

A Blood plasma and interstitial fluid are both part of the extracellular fluid and are of the same ionic composition.

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume? A. Rapid, thread pulse B. Distended jugular vein C. Elevated hematocrit level D. Increased serum sodium level

B Because of fluid overload in the intravascular space, the neck veins become visibly distended.

For what clinical indicator should a nurse assess a client who is having a gastric lavage? A. A decreased serum pH B. Increased serum oxygen level C. Increased serum bicarbonate level D. A decreased serum osmotic pressure

C Gastric lavage causes an excessive loss of gastric fluid, resulting in excessive loss of hydrochlorid acid (HCL) that can lead to alkalosis; the HCL is not available to neutralize the sodium bicarbonate (NaHCO3) secreted into the duodenum by the pancreas. The intestinal tract absorbs the excess bicarbonate, and alkalosis results.

A nurse administers an intravenous solution of 0.35% sodium chloride. In what category of fluids does this solution belong? A. Isotonic B. Isomeric C. Hypotonic D. Hypertonic

C Hypotonic solutions are less concentrated than body fluids. (Contain less than 0.85 g of sodium chloride in each 100mL)

A nurse adds 20 mEg of potassium chloride to the IV solution of a client with diabetic ketoacidosis. What is the primary purpose for administering this drug? A. Treat hyperpnea B. Prevent flaccid paralysis C. Replace excessive losses D. Treat cardiac dysthymias

C Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore, potassium, along with the replacement fluids, is needed.

A nurse is concerned that a client is at risk for developing hyperkalemia. Which disease does the client have that had caused this concern? A. Crohns B. Cushing C. End-stage renal D. Gastroesophageal reflux

C One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis.

A nurse is caring for a client with ascites. What does the nurse consider to be the cause of ascites? A. Portal hypotension B. Kidney malfunction C. Diminished plasma protein level D. Decreased production of potassium

C The liver manufactures albumin, the major plasma protein. A deficit of this protein lowers the osmotic (oncotic) pressure in the intravascular space, leading to a fluid shift.

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. a. Tetany B. Seizures C. Diarrhea D. Weakness E. Dysrhythmias

CDE Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and dysrhythmias.

A client's potassium level is 6.7 mEq/L. Which intervention should the nurse delegate to the first-year student nurse whom they are supervising? 1. Administer sodium polystyrene sulfonate 15 g orally. 2. Administer spironolactone 25 mg orally. 3. Assess the electrocardiogram (ECG) strip for tall T waves. 4. Administer potassium 10 mEq orally.

1 The client's potassium level is high (normal range is 3.5-5 mEq/L) Sodium polystyrene sulfonate removes potassium from the body through the gastrointestinal system. Spironolactone is a potassium-sparing diuretic that may cause the client's potassium level to go even higher. A KCl supplement can also raise the potassium level even higher. The beginning nursing student does not have the skill to asses ECG strips.

The nursing care plan for an older client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? Select all that apply. 1. Reminding the client to avoid commercial mouthwashes. 2. Encouraging mouth rinsing with warm saline. 3. Assess skin turgor by pinching the skin over the back of the hand. 4. Observing the lips, tongue, and mucous membranes. 5. Providing mouth care every 2 hours while the client is awake. 6. Seeking a dietary consult to increase fluids on meal trays.

1, 2, 4, 5 The LPN/LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPNs/LVNs are permitted to perform assessment. The client should always be reminded to avoid most commercial mouthwashes, which contain agents such as alcohol. To assess skin turgor in an older adult, skin tenting is best checked by pinching the skin over the sternum or on the forehead rather than the back of the hand. With aging, the skin loses elasticity and tents on hands and arms even when the adult is well hydrated. Initiating a dietary consult is within the purview of the RN or health care provider

The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to a new-graduated RN. Which actions can the new-graduate RN delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Providing oral care every 3 to 4 hours. 2. Monitoring for indications of dehydration. 3. Administering 0.45% saline by IV line. 4. Record urine output when client voids. 5. Assessing daily weights for trends. 6. Help the client change position every 2 hours.

1, 4, 6 Providing oral care, assisting clients to reposition, and recording urine output are within the scope of practice of the UAP. Monitoring and assessing clients, as well as administering IV fluids, require the additional education and skills of the RN.

An experienced LPN/LVN reports to the RN that a client's blood pressure and heart rate have decreased, and when his face was assessed, on side twitches. What action should the RN take at this time? 1. Reassess the client's blood pressure and heart rate. 2. Review the client's morning calcium level. 3. Request a neurologic consult today. 4. Check the client's pupillary reaction to light.

2 A positive Chvostek sign (facial twitching of one side of the mouth, nose, and cheek in response to tapping the face just below and in front of the ear) is a neurologic manifestation of hypocalcemia. The heart rate may be slower or slightly faster than normal, with a weak, thready pulse. Severe hypocalcemia causes severe hypotension. The LPN/LVN is experienced and possesses the skills to accurately measure vital signs.

The client has fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by the RN to unlicensed assistive personnel (UAP)? 1. Administering IV fluids as prescribed by the physician 2. Providing straws and offering fluids between meals 3. Developing a plan for added fluid intake over 24 hours 4. Teaching family members to assist the client with fluid intake

2 UAPs can reinforce additional fluid intake when it is part of the care plan. Administering IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice for an RN.

Which statement by a client with hypovolemia related to dehydration is the best indicator to the nurse of the need for additional teaching? 1. "I will drink 2 to 3 L of fluids every day." 2. "I will drink a glass of water whenever I feel thirsty." 3. "I will drink coffee and cola drinks throughout the day." 4. "I will avoid drinks containing alcohol."

3 Mild dehydration is very common among healthy adults and is corrected or prevented easily by matching fluid intake with fluid output. Teach all adults to drink more fluids, especially water. Beverages with caffeine can increase fluid loss, as can drinks containing alcohol. These beverages should not be used to prevent or treat dehydration.

An IV solution of 1000 mL 5% dextrose in water is to be infused at 125 mL/hr to correct a client's fluid imbalance. The infusion set delivers 15 drops/mL. To ensure that the solution will infuse over an 8-hour period, at how many drops per minute should the nurse set the rate of flow? Record your answer using a whole number. _________ gtt/min.

31 gtts/min 15 x 125= 1875 drops per hour 1875 / 60= 31.25 drops per minute Rounding rules lead to 31 drops per minute

An IVPB of cefazolin (Kefzol) 500 mg in 50 mL of 5% dextrose in water is to be administered over a 20-minute period. The tubing has a drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run? Record your answer using a whole number. __________ gtt/min.

38 gtts/min 50 x 15= 750 drops 750 / 20 minutes= 37.5 Rounding rules lead to 38 drops per minute

The RN is reviewing the client's morning laboratory results. Which of these results is of most concern? 1. Serum potassium level of 5.2 mEq/L 2. Serum sodium level of 134 mEq/L 3. Serum calcium level of 10.6 mEq/L 4. Serum magnesium level of 0.8 mEq/L

4 Although all of these laboratory values are outside of the normal range, the magnesium level is furthest from normal. With a magnesium level this low, the client is at risk for ECG changes and life-threatening ventricular dysrhythmias.

The unlicensed assistive personnel (UAP) reports to the nurse that a client's urine output for the past 24 hours has been only 360 mL. What is the nurse's priority action at this time? 1. Place an 18-gauge IV in the nondominant arm. 2. Elevate the client's head of bed at least 45 degrees. 3. Instruct the UAP to provide the client with a pitcher of ice water. 4. Contact and notify the health care provider immediately.

4 The minimum amount of urine per day needed to excrete toxic waste products is 400 to 600 mL. This minimum volume is called the obligatory urine output. If the 24-hour urine output falls below the obligatory output amount, wastes are retained and can cause lethal electrolyte imbalances, acidosis, and a toxic buildup of nitrogen. The client may need additional fluids (IV or oral) after the cause of the low urine output is determined. Elevating the head of the bed will not help with urine output. Notifying the health care provider is the first priority in this case.

The intake and output of a client over an eight-hour period is: 0800: Intravenous with D5W infusing; 900 mL left in bag; 0830: 150 mL voided; 0900-1500: 200 mL gastric tube formula + 50 mL water at q3h intervals; 1300: 220 mL voided; 1515: 235 mL voided; 1600: IV has 550 mL left in bag. What is the difference between the client's intake and output? Record the answer using a whole number. _________ mL

495 mL Intake: 350 mL IV fluids; 600 mL of NGT feeding; 150 mL water via NGT TOTAL INTAKE: 1100 mL Output: 150 mL void; 220 mL void; 235 mL void TOTAL OUTPUT: 605 mL 1100-605=495 mL

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful? A. Clear breath sounds B. Positive pedal pulses C. Normal potassium level D. Increased urine specific gravity

A Excess fluid can move into the lungs, causing crackles; clear breath sounds support that treatment was effective.

How should a nurse prepare an IV piggyback (IVPB) medication for administration to a client receiving an IV infusion? Select all that apply. A. Wear clean gloves to check the IV site B. Rotate the bag after adding the medications C. Use 100mL of fluid to mix the medication D. Change the needle before adding the medication E. Place the IVPB at a lower level than the existing IV F. Use a sterile technique when preparing the medication

ABF Clean gloves should be worn to check the IV site because there is a risk of coming into contact with the client's blood. Ensuring that the medication is mixed is important. Rotating the bag is one way, although there are others. Because IV solutions enter the body's internal environment, all solutions and medications using this route must be sterile to prevent the introduction of microbes.

A client is receiving an IV infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. What nutritional problem prompts the nurse to notify the health care provider? A. Excessive carbohydrate intake B. Lack of protein supplementation C. Insufficient intake of water-soluble vitamins D. Increased concentration of electrolytes in cells

B An infusion of dextrose in water does not provide proteins required for tissue growth, repair, and maintenance; therefore, tissue breakdown occurs to supply the essential amino acids.

A client reports vomiting and diarrhea for 3 days. What clinical finding will most accurately indicate that the client has a fluid deficit? A. A presence of dry skin B. Loss of body weight C. Decreased in BP D. Altered general appearance

B Dehydration is most readily and accurately measured by serial assessments of body weight; 1 L of fluid weighs 2.2 lbs.

A nurse explains to an obese client that the rapid weight loss during the first week after initiating a diet is because of the fluid loss. The weight of extracellular body fluid is approximately 20% of the total body weight of an average individual. Which component of the extracellular fluid contributes the greatest proportion to this amount? A. Plasma B. Interstitial C. Dense tissue D. Body secretions

B Interstitial fluid constitutes about 16% of body weight, which is 10 to 12 L in an adult male of 150 lbs.

A nurse is caring for a client with diarrhea. In which clinical indicator does the nurse anticipate a decrease? A. Pulse rate B. Tissue turgor C. Specific gravity D. Body temperature

B Skin elasticity will decrease because of a decrease in interstitial fluid.

A nurse is analyzing how a hyperglycemic client's blood glucose can be lowered. The nurse considers that the chemical that buffers the client's excessive acetoacetic acid is: A. Potassium B. Bicarbonate C. Carbon dioxide D. Sodium chloride

B Sodium bicarbonate is a base and one of the major buffers in the body.

A client's serum potassium level has increased to 5.8 mEq/L. what action should the nurse implement first? A. Call the lab to repeat the test B. Take vital signs and notify the health care provider C. Inform the cardiac arrest team to place them on alert D. Take an electrocardiogram and have lidocaine available

B Vital signs monitor cardiorespiratory status; hyperkalemia causes cardiac dysrhythmias. The health care provider should be notified because medical intervention may be necessary.

A nurse is caring for a client with ascites who is receiving albumin. What infusion rate and oral fluid intake should the nurse expect to have the greatest therapeutic effect? A. Slow IV rate and liberal fluid intake B. Slow IV rate and restricted fluid intake C. Rapid IV rate and withheld fluid intake D. Rapid IV rate and moderate fluid intake

B When albumin is administered slowly and oral fluid intake is restricted, fluid moves from the interstitial spaces into the circulatory system so it can be eliminated by the kidneys. Administration should not exceed 5 to 10 mL/min.

A nurse is assigned to change a central line dressing, the agency policy is to clean the site with Betadine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede Betadine in a dressing change. In addition, an article in a nursing journal stated that a new product was more effective antibacterial than alcohol then Betadine. The nurse had a sample of the new product. How should the nurse proceed? A. Use the new product sample when changing the dressing B. Cleanse the site with alcohol first and then with Betadine C. Cleanse the site with the new product first and then follow the agency's protocol D. Follow the agency's protocol unless it is contradicted by a health care provider's orders

D Agency policy determines procedures; if the procedure is out of date or problematic, the nurse should contact the health care provider for a change in the order.

A nurse is reviewing the health care provider's orders for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which order should the nurse question? A. Oral psyllium (Metamucil) B. Oral potassium supplement C. Parental half normal saline D. Parental albumin (Albuminar)

D Albumin is hypertonic and will draw additional fluid from the tissues into the intravascular space.

A nurse is caring for a client with albuminuria resulting in edema, what pressure change does the nurse determine as the cause of the edema? A. Decreased in tissue hydrostatic pressure B. Increased in plasma hydrostatic pressure C. Increase in tissue colloid oncotic pressure D. Decreased in plasma colloid oncotic pressure

D Because the plasma colloidal oncotic pressure (COP) is the major force drawing fluid from the interstitial spaces back into the capillaries, a drop in COP caused by albuminuria results in edema.

A nurse assesses a client's serum electrolyte levels in the lab report. What electrolyte in intracellular fluid should the nurse consider most important? A. Sodium B. Calcium C. Chloride D. Potassium

D The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a critical factor in the cell's ability to function

There was 200 mL left in a client's IV bag when a nurse started the shift. When there was 50 mL left in this bag, the nurse hung a new IV bag containing 1000 mL and discarded the 50 mL from the previous bag. The client received two IVPBs during the shift; each contained 100 mL. At the end of the shift the nurse looks at the IV to document the client's IV fluid intake for the shift, noting there was 400 mL left in the bag. How many mLs of IV fluid did the client receive during the shift? Record your answer as a whole number.

950 mL IV Bag #1: 150 mL IVPB: 100 x 2= 200mL IV Bag #2: 600 mL

A nurse is reviewing the lab report of a client with a tentative diagnosis of kidney failure. What mechanism does the nurse expect to be maintained when ammonia is excreted by healthy kidneys? A. Osmotic pressure of the blood B. Acid-base balance of the body C. Low bacterial levels in the urine D. Normal red blood cell production

B The excreted ammonia combines with hydrogen ions in the glomerular filtrate to form ammonium ions, which are excreted from the body. This mechanism helps rid the body of excess hydrogen, maintaining acid-base balance.