Ch. 11 and 13: Care for IV Lines (Nurs 309)

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

1. Administer sodium polystyrene sulfonate 15 g orally.

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. Which clinical finding indicates that the treatment has been successful? 1. Clear breath sounds. 2. Positive pedal pulses. 3. Normal potassium level. 4. Increased urine specific gravity.

1. Clear breath sounds.

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 graduated RN delegate to the unlicensed assistive personnel? SELECT ALL THAT APPLY. 1. Providing oral care every 3 to 4 hours. 2. Monitoring for indication of dehydration. 3. Administering 0.45% normal 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. Providing oral care every 3 to 4 hours. 4. Record urine output when client voids. 6. Help the client change position every 2 hours.

The nursing care plan for an older client with dehydration includes interventions for oral health. Which interventions are with the scope of practice for an LPN/LVN? 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 client is awake. 6. Seeking a dietary consult to increase fluids on meal trays.

1. Reminding the client to avoid commercial mouthwashes. 2. Encouraging mouth rinsing with warm saline. 4. Observing the lips, tongue, and mucous membranes. 5. Providing mouth care every 2 hours while client is awake.

A nurse is reviewing a client's serum electrolyte laboratory report. What is a comparison between blood plasma and interstitial fluid? 1. They both contain the same kinds of ions. 2. Plasma exerts lower osmotic pressure than does interstitial fluid. 3. Plasma contains more of each kind of ion than does interstitial fluid. 4. Sodium is higher in plasma, whereas potassium is higher in interstitial fluid.

1. They both contain the same kinds of ions.

How should a nurse prepare an IV piggyback medication for administration to a client receiving an IV infusion? SELECT ALL THAT APPLY. 1. Wear clean gloves to check the IV site. 2. Rotate the bag after adding the medication. 3. Use 100 mL of fluid to mix the medication. 4. Change the needle before adding the medication. 5. Place the IVPB at a lower level than the existing IV. 6. Use a sterile technique when preparing the medication.

1. Wear clean gloves to check the IV site. 2. Rotate the bag after adding the medication. 6. Use a sterile technique when preparing the medication.

A nurse is reviewing the laboratory 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? 1. Osmotic pressure of the blood. 2. Acid-base balance of the body. 3. Low bacterial levels in the urine. 4. Normal red blood cell production.

2. Acid-base balance of the body.

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? 1. Rapid, thready pulse. 2. Distended jugular veins. 3. Elevated hematocrit level. 4. Increased serum sodium level.

2. Distended jugular veins.

A nurse explains to an obese client that the rapid weight-loss during the first week after initiating a diet is because of fluid loss. The weight of extracellular body fluid is approximately 20% if the total body weight of an average individual. Which component of the extracellular fluid contributes the greatest proportion to this amount? 1. Plasma 2. Interstitial 3. Dense tissue 4. Body secretions

2. Interstitial

A client is receiving an IV infusion of 5% dextrose in water. The client losses weight and develops negative nitrogen balance. What nutritional problem prompts the nurse to notify the health care provider? 1. Excessive carbohydrate intake. 2. Lack of protein supplementation. 3. Insufficient intake of water-soluble vitamins. 4. Increased concentration of electrolytes in cells.

2. Lack of protein supplementation.

A client reports vomiting and diarrhea for 3 days. What clinical finding most accurately indicate that the client has fluid deficit? 1. Presence of dry skin. 2. Loss of body weight. 3. Decrease in blood pressure. 4. Altered general appearance.

2. Loss of body weight.

The client has a fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by the RN to unlicensed assistive personnel? 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. Providing straws and offering fluids between meals.

An experienced LPN/LVN reports to the RN that a client's blood pressure and heart rate have decreased, and when his face is 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. Review the client's morning calcium level.

A nurse is caring for a client with ascities who is receiving albumin. What infusion rate and oral fluid intake should the nurse expect to have the greatest theraputic effect? 1. Slow IV rate and liberal fluid intake. 2. Slow IV rate and restricted fluid intake. 3. Rapid IV rate and withheld fluid intake. 4. Rapid IV rate and moderate fluid intake.

2. Slow IV rate and restricted fluid intake.

A client's serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first? 1. Call the laboratory to repeat the test. 2. Take vital signs and notify the health care provider. 3. Inform the cardiac arrest team to place them on alert. 4. Take an electrocardiogram and have lidocane available.

2. Take vital signs and notify the health care provider.

A nurse is caring for a client with diarrhea. In which clinical indicator does the nurse anticipate a decrease? 1. Pulse rate 2. Tissue turgor 3. Specific gravity 4. Body temperature

2. Tissue turgor

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 2-3 L of fluids everyday." 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. "I will drink coffee and cola drinks throughout the day."

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply.. 1. Tetany 2. Seizures 3. Diarrhea 4. Weakness 5. Dysrhythmias

3. Diarrhea 4. Weakness 5. Dysrhythmias

A nurse is caring for a client with ascities. What does the nurse consider to be the cause of the ascities? 1. Portal hypotension. 2. Kidney malfunction. 3. Diminished plasma protein level. 4. Decreased production of potassium.

3. Diminished plasma protein level.

A nurse is concerned that a client is at risk for developing hyperkalemia. Which disease does this client have that caused this concern? 1. Crohn's 2. Cushings 3. End-stage renal 4. GERD

3. End-stage renal

A nurse administers an IV solution of 0.45% sodium chloride. In what category of fluids does this solution belong? 1. Isotonic 2. Isomeric 3. Hypotoic 4. Hypertonic

3. Hypotoic

For what clinical indicator should a nurse assess a client who is having a gastric lavage? 1. Decreased serum pH. 2. Increased serum oxygen level. 3. Increased serum bicarbonate level. 4. Decreased serum osmotic pressure.

3. Increased serum bicarbonate level.

A nurse adds 20 mEq of potassium chloride to the IV solution of a client with diabetic ketoacidosis. What is the primary purpose for administering this drug? 1. Treat hyperpnea 2. Prevent flaccid paralysis 3. Replace excessive losses 4. Treat cardiac dysrhythmias

3. Replace excessive losses

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.

31 gtt/min.

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

4. Contact and notify the health care provider immediately.

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? 1. Decrease in tissue hydrostatic pressure. 2. Increase in plasma hydrostatic pressure. 3. Increase in tissue colloid pressure. 4. Decrease in plasma colloid oncotic pressure.

4. Decrease in plasma colloid oncotic pressure.

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 new product was a more effective antibacterial than alcohol and Betadine. The nurse has a sample of the new product. How should the nurse proceed? 1. Use the new product sample when changing the dressing. 2. Cleanse the site with alcohol first and then the Betadine. 3. Cleanse the site with the new product first, then follow the agency's protocol. 4. Follow the agency's policy unless it is contradicted by a health care provider.

4. Follow the agency's policy unless it is contradicted by a health care provider's order.er's order.

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

4. IV 5% dextrose in water to run at 250 mL/hr.

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? 1. Oral psyllium (Metamucil) 2. Oral potassium 3. Parenteral half normal saline 4. Parenteral albumin (Albuminar)

4. Parenteral albumin (Albuminar)

A nurse assess a client's serum electrolyte levels in the laboratory report. Which electrolyte in intracellular fluid should the nurse consider most important? 1. Sodium 2. Calcium 3. Chloride 4. Potassium

4. Potassium

The RN is reviewing the client's morning laboratory results. Which of the 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. Serum magnesium level of 0.8 mEq/L

There was 200 mL left in a client IV bag when a nurse started the shift. When there was 50 mL left in the bag, the nurse hung a new IV bag containing 1000 mL and discarded the 50 mL from the previous bag. The client recieved two IVPB's 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. How many mL's of IV fluid did the client receive during the shift. (Illustration shows 400 mL left) Record your answer as a whole number.

950 mL.

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: 1. Potassium 2. Bicarbonate 3. Carbon dioxide 4. Sodium chloride

2. Bicarbonate

The intake and output of a client over an 8-hour period (8 AM - 4 PM): 8AM- IV with D5W infusing and 900 mL left in bag. 8:30AM- 150 mL voided 9AM to 3PM- 200 mL gastric tube formula and 50 mL water Q3H 1 PM- 220 mL voided 3:15PM- 235 mL voided 4PM- IV with 550 mL left in bag What is the difference between the client's intake and output? Record with nearest whole number.

495 mL

An intravenous piggyback (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 the answer using a whole number. _____ gtts/min

Solve the problem by using the following formula: Drops per minute = total number of drops / total time in minutes Drops per minute = 50 mL x 15 (drop factor) / 20 mintes = 750 / 20 = 37.5. Round the answer to 38 drops per minute.