CHAPTER 42 EAQ - STUDY QUESTIONS

A patient had 200 mL of ice chips and 900 mL intravenous (IV) fluid during the nurse's shift. Which total intake should the nurse record? 700 mL 900 mL 1000 mL 1100 mL

1000 mL - Add one half the volume of ice chips to other intake to calculate total intake.

The arterial pH of a patient is 7.3. How should the nurse record this pH in the patient case record? Alkalosis Acidosis Neutral pH Normal pH

Acidosis - The normal acceptable range of pH for human beings is between 7.35 and 7.45.

The nurse is caring for a patient with generalized body edema. Which hormones directly influence renal fluid excretion? Select all that apply. Renin Aldosterone Angiotensin II Antidiuretic hormone Atrial natriuretic peptide

Aldosterone Antidiuretic hormone Atrial natriuretic peptide

he nurse is caring for a patient diagnosed with chronic heart failure. The nurse understands that the patient is at risk of developing extracellular fluid volume (ECF) excess. Which clinical findings would the nurse observe in this patient? Select all that apply. Ankle edema Postural hypotension Overnight weight loss Overnight weight gain Neck veins full when upright

Ankle edema Overnight weight gain Neck veins full when upright

The nurse finds fresh blood at a venipuncture site in a patient and pooling of fluids under the extremity. Which should be the immediate nursing action? Culture the blood at the venipuncture site. Assess for intactness of the intravenous (IV) system. Start a new line even if the catheter is in place. Apply a pressure dressing if the catheter is dislodged.

Assess for intactness of the intravenous (IV) system.

A patient has intestinal inflammation and reports frequent diarrhea. Which nursing intervention would be most beneficial in this situation? Avoiding high-fiber food Providing oral fluids at the preferred temperature Avoiding sudden position changes Offering fluid frequently in small amounts as tolerated

Avoiding high-fiber food.

The nurse is caring for a patient who has an intravenous (IV) line for fluid therapy. About which potential complications should the nurse be vigilant while assessing the patient? Select all that apply. Pallor Bleeding Phlebitis Infection Jaundice

Bleeding Phlebitis Infection

Which laboratory findings can be seen in a patient with clinical dehydration? Select all that apply. Blood urea nitrogen (BUN) of 28 mg/dL Urine specific gravity of 1.150 Serum sodium level of 160 mEq/L Serum osmolality of 270 mOsm/kg Blood urea nitrogen (BUN) of 9 mg/dL

Blood urea nitrogen (BUN) of 28 mg/dl Urine specific gravity of 1.150 Serum sodium level of 160 mEq/L

How can the nurse prevent the development of febrile nonhemolytic reactions in the patient during blood transfusions? Select all that apply. By adjusting the transfusion volume By pretreating with antipyretics By pretreating with antihistamine By implementing blood-banking standards By considering leukocyte-poor blood products

By pretreating with antipyretics By considering leukocyte-poor blood products

A patient reports numbness and a tingling sensation in the fingers and toes. The nurse observes facial muscle contractions in response to a tap on the facial nerve. The patient's electrocardiogram shows a prolonged ST segment. Which electrolyte imbalance does the nurse suspect? Sodium Calcium Potassium Magnesium

Calcium Chvostek's sign is associated with the contraction of facial muscles in response to a tap over the facial nerve. It is a test for hypocalcemia, which causes numbness and tingling in the fingers and toes. An electrocardiogram of a patient with hypocalcemia may show prolonged QT due to prolongation of the ST segment.

After reviewing a patient's laboratory test reports, the nurse documents excessive extracellular fluid volume. Which diseases may have caused the condition? Select all that apply. Cirrhosis Heart failure Hemorrhage Adrenal insufficiency Acute oliguric renal disease

Cirrhosis Heart failure Acute oliguric renal disease This condition occurs when there is sodium and water retention in the kidney, which occurs in patients with cirrhosis, heart failure, and acute oliguric renal disease.

A patient has come to the hospital because of gastroenteritis. Which assessments should the nurse perform on this patient? Select all that apply. Examine oral mucosa. Measure chest expansion. Measure urine output. Assess hemoglobin levels. Measure blood pressure and pulse.

Examine oral mucosa. Measure urine output. Measure blood pressure and pulse.

A patient on antidepressant therapy has developed hyponatremia. Which drug might have led to this condition? Losartan Captopril Fluoxetine Furosemide

Fluoxetine

A patient who has an intravenous line has pain at the access site associated with erythema, edema, red streaks, and a palpable vein. What grade should the nurse assign while entering the phlebitis grade in the patient's record? Grade 1 Grade 2 Grade 3 Grade 4

Grade 3

Which factor can be a risk for causing extracellular volume deficit (ECV)? Hemorrhage Sodium-rich diet Intravenous therapy Oliguric renal disease

Hemorrhage

A patient is experiencing a malignancy in which the malignant cells secrete chemicals similar to parathyroid hormone. Which condition does the patient most likely have? Hyperkalemia Hypernatremia Hypercalcemia Hypermagnesemia

Hypercalcemia Increased levels of parathyroid hormone may cause shifting of the calcium from the bones to the extracellular space, leading to hypercalcemia.

Which fluid electrolyte imbalance may develop in a patient who consumes spironolactone? Hypokalemia Hyperkalemia Hyponatremia Hypomagnesemia

Hyperkalemia

What condition may be suspected in a patient with end-stage renal disease? Hypokalemia Hypercalcemia Hypomagnesemia Hypermagnesemia

Hypermagnesemia

After assessing a patient with gastroenteritis, the nurse documents nausea related to gastric irritation. Which symptom supports the nurse's documentation? Select all that apply. Increased salivation Decreased skin turgor Little interest in eating Heart rate of 102 bpm Dry oral mucous membranes

Increased salivation Little interest in eating

The nurse is learning about fluid, electrolyte, and acid-base balance. Which clinical findings would the nurse evaluate in a patient with hypomagnesemia? Select all that apply. Lethargy Insomnia Muscle cramps Hypoactive deep tendon reflexes Hyperactive deep tendon reflexes

Insomnia Muscle cramps Hyperactive deep tendon reflexes

A patient has had chronic diarrhea for 3 months and also suffers from repeated bouts of vomiting. The laboratory reports indicate hypokalemia. Which food items should the nurse include in the patient's diet to help correct hypokalemia? Select all that apply. Instant coffee Milk Potatoes Processed foods Canned fish with bones

Instant coffee Potatoes

A patient has developed circulatory overload. Which therapies should the nurse expect to be prescribed for this patient? Select all that apply. Oxygen Ambulation Diuretics Vasopressors Glucocorticoids

Oxygen Diuretics

The nurse is examining a patient with hypocalcemia. For which clinical findings should the nurse look during the assessment? Select all that apply. Abdominal distension Positive Chvostek's sign Positive Trousseau's sign Muscle twitching and cramping Bilateral muscle weakness in quadriceps

Positive Chvostek's sign Positive Troosseau's sign Muscle twitching and cramping

The nurse is caring for a patient undergoing intravenous therapy. The nurse suspects that the patient is developing phlebitis. Which findings would the nurse expect to observe in this patient? Select all that apply. Red streak along the vein Tenderness and pain Swelling at catheter-skin entry point Fresh blood evident at venipuncture site Warmth along vein course starting at access site

Red streak along the vein Tenderness and pain Warmth along vein course starting at access site

A patient who was started on intravenous (IV) fluids to correct dehydration develops shortness of breath. On auscultation, the nurse finds crackles in the dependent portion of the lungs and dependent edema. Which interventions are appropriate in correcting the fluid and electrolyte imbalance in the patient? Select all that apply. Aspirate fluid from lungs. Reduce the IV flow rate. Elevate the foot end of bed. Notify the primary health care provider. Administer diuretics if prescribed.

Reduce the IV flow rate. Notify the primary health care provider. Administer diuretics if prescribed.

When caring for a patient undergoing intravenous therapy, the nurse observes redness and swelling around the intravenous (IV) catheter insertion site. A purulent drainage is also present. Which immediate actions should the nurse perform? Select all that apply. Apply pressure to the dressing over the site. Raise the head of the bed and administer oxygen. Remove the catheter and preserve for culture. Start a new intravenous (IV) line in another extremity. Clean the site with alcohol and apply sterile dressing.

Remove the catheter and preserve for culture. Start a new intravenous (IV) line in another extremity. Clean the site with alcohol and apply sterile dressing.

A patient has a partial pressure of carbon dioxide (PaCO 2) of 30 mm Hg. What does this value indicate about the patient's condition? CO 2 has accumulated in the blood. The PaCO 2 is lower than normal. The patient is hypoventilating. The patient has impaired renal function.

The PaCO2 is lower than normal. The normal range of PaCO2 is 33-45 mmHg.

Why are older adults prone to dehydration? They sweat more in hot weather. Their lungs evaporate more water during respiration. The ability of their kidneys to concentrate urine decreases. Water absorption from their gastrointestinal (GI) tract decreases.

The ability of their kidneys to concentrate urine decreases.

A patient has been brought to the hospital in an unconscious state. On assessment, the nurse learns that the patient has engaged in binge drinking, and the lab reports reveal a high anion gap level. What can the nurse interpret about the patient's metabolic status? The patient has metabolic acidosis. The patient has metabolic alkalosis. The patient has respiratory acidosis. The patient has respiratory alkalosis.

The patient has metabolic acidosis.

A patient reports abdominal cramps and diarrhea. The patient's serum potassium level is 6.8 mEq/L. What might the nurse infer from this finding? Select all that apply. The patient is on corticosteroid therapy. The patient is on antidepressant therapy. The patient is taking a potassium-sparing diuretic. The patient is taking an angiotensin-converting enzyme inhibitor. The patient is on nonsteroidal antiinflammatory drug therapy.

The patient is taking a potassium-sparing diuretic. The patient is taking an angiotensin-converting enzyme inhibitor. The normal potassium level ranges from 3.5 to 5mEq/L. A potassium level greater than 5 mEq/L indicates hyperkalemia, which can manifest as abdominal cramping and diarrhea. Hyperkalemia may develop when a potassium-sparing diuretic or angiotensin-converting enzyme inhibitor increases the potassium level.

The physician orders parenteral nutrition and orders use of a hyperosmolar solution. How should the nurse administer the solution to the patient? Use central IV catheter. Use peripheral IV catheter. Use gastrostomy tube. Use jejunostomy tube.

Use central IV catheter.

The nurse is teaching a team of student nurses about acid-base balance. Which statements by the nurse are appropriate? Select all that apply. "The kidneys excrete all acids produced in the patient's body." "Patients with obstructive lung diseases may have more acid in the blood." "Patients experience deeper respirations when the carbon dioxide level in the blood rises." "Patients experience shallow respirations when the carbon dioxide level in the blood rises." "Patients with kidney disease have difficulty excreting metabolic acids."

"Patients with obstructive lung diseases may have more acid in the blood." "Patients experience deeper respirations when the carbon dioxide level in the blood rises." "Patients with kidney disease have difficulty excreting metabolic acids."

On assessment, a patient is found to have extracellular fluid volume (ECF) depletion associated with dehydration of cells. Which fluids might the nurse choose to correct both extracellular fluid volume depletion and cellular dehydration? Select all that apply. 5% dextrose in lactated Ringer's 0.9% sodium chloride 0.45% sodium chloride 0.225% sodium chloride 3% and 5% sodium chloride

0.45% sodium chloride 0.225% sodium chloride Sodium chloride solutions of 0.225% and 0.45% are hypotonic in nature and are used to correct both extracellular fluid volume depletion and cellular dehydration

A health care provider is planning to transfuse a patient with a unit of packed red blood cells. Which solution should the health care provider hang with the transfusion? 5% dextrose in water 0.9% sodium chloride 5% dextrose in 0.9% sodium chloride 5% dextrose in lactated Ringer's solution

0.9% sodium chloride - The only solution appropriate for administration with whole blood or blood products.

How much fluid does an adult lose through feces?

100mL Even though fluid intake is likely 3 to 6 liters, only 100 mL of fluid is lost through feces.

The nurse assesses four patients. Which patient is at greatest risk for the development of hypocalcemia? 56-year-old with acute kidney renal failure 40-year-old with appendicitis 28-year-old with acute pancreatitis 65-year-old with hypertension and asthma

28-year-old with acute pancreatitis People who have acute pancreatitis frequently develop hypocalcemia because calcium binds to undigested fat in their feces and is excreted. This process decreases absorption of dietary calcium and also increases calcium output by preventing resorption of calcium contained in gastrointestinal fluids.

Which patient being cared for by the nurse is at the highest risk of developing respiratory acidosis? A patient with hypokalemia A patient with pulmonary fibrosis A patient with salicylate overdose A patient with chronic obstructive pulmonary disease (COPD)

A patient with chronic obstructive pulmonary disease (COPD)

Which nursing interventions can the nurse use to promote comfort for a patient with nausea, loss of appetite, and increased salivation? Select all that apply. Administer prescribed antiemetics. Avoid sudden position changes. Provide a comfortable environment. Perform oral care every 2 to 4 hours. Give at least a cup of oral fluid hourly

Administer prescribed antiemetics. Avoid sudden position changes. Provide a comfortable environment. Perform oral care every 2 to 4 hours.

The nurse is preparing a patient for blood transfusion. Which drugs should the nurse keep on standby for managing blood transfusion reactions? Select all that apply. Digoxin Thrombin Vasodilators Antihistamines Corticosteroids

Antihistamines Corticosteroids

A patient has had chronic diarrhea for 3 months. He also is experiencing repeated bouts of vomiting. The laboratory reports indicate hypokalemia. Which signs is the nurse likely to find during examination? Select all that apply. Positive Chvostek's sign Hyperactive reflexes Numbness of circumoral region Bilateral muscle weakness Signs of digoxin toxicity at normal digoxin levels

Bilateral muscle weakness Signs of digoxin toxicity at normal digoxin levels

Which assessment findings in a patient on intravenous therapy indicate infiltration? Select all that apply. Bleeding Blanched skin Edematous skin Purulent drainage Redness of the skin

Blanched skin Edematous skin

A patient with inflammation develops edema. Arrange the sequence of events that occur during the development of edema in the correct order. Increase in capillary hydrostatic pressure Increase in capillary blood flow Increase in interstitial colloidal osmotic pressure Leakage of colloids into the interstitial space

Correct order: Increase in capillary blood flow Leakage of colloids into the interstitial space Increase in capillary hydrostatic pressure Increase in interstitial colloidal osmotic pressure

A patient suffering from gastroenteritis has tachycardia, hypotension, oliguria, and dark-colored urine. The lab reports reveal increased hematocrit, elevated blood urea nitrogen, and increased specific gravity of the urine. What is the probable electrolyte disturbance in the patient? Low levels of sodium in the body Low levels of potassium in the body Decreased extracellular fluids with normal tonicity Combined hypernatremia and extracellular volume depletion

Decreased extracellular fluids with normal tonicity.

While caring for a patient with gastroenteritis, the nurse finds a supine blood pressure of 90/58 mm Hg and a heart rate of 102 bpm. What condition does the nurse suspect? Risk for impaired skin integrity Nausea related to gastric irritation Deficient fluid volume related to vomiting Diarrhea related to intestinal inflammation

Deficient fluid volume related to vomiting

A patient is dehydrated and needs an infusion of isotonic fluids to correct dehydration. Which intravenous fluid is appropriate for this patient? Dextrose 5% in water (D 5W) Dextrose 10% in water (D 10W) Dextrose 5% in lactated Ringer's (D 5LR) Dextrose 5% in 0.9% sodium chloride (D 5NS; D 50.9% NaCl)

Dextrose 5% in water (D 5W)

The nurse is teaching a group of patients about the importance of fluid and electrolyte balance in a health awareness program. About which common causes of hypokalemia would the nurse educate the patients? Select all that apply. Diarrhea Acute oliguria Repeated vomiting Calcium-deficient diet Glucocorticoid therapy

Diarrhea Repeated vomiting Glucocorticoid therapy

A patient with blood type O needs platelets. What should the nurse consider when choosing a donor for platelet transfusion? Rh compatibility is excluded. Donor can be of any blood group. Donor should be of blood group O. Donor can be exempted from screening for infections.

Donor should be of blood group O.

A patient has a pH value of 7.25. Which possible pathological and physiological changes may occur in this patient? Select all that apply. Enzyme dysfunction Pruritis Anemia Impaired hemoglobin function Death

Enzyme dysfunction Impaired hemoglobin function Death

A patient develops an anaphylactic reaction following initiation of a blood transfusion. Which primary drug should the nurse use for the patient? Epinephrine Vasopressor Antihistamine Glucocorticoid

Epinephrine

The nurse finds that a patient has sudden weight gain, confusion, and edema in the dependent areas. Upon auscultation, the nurse finds crackles in the lungs. What condition does the nurse suspect? Extracellular fluid volume (ECV) excess Hypernatremia Clinical dehydration Extracellular fluid volume (ECV) deficit

Extracellular fluid volume (ECV) excess

While caring for a patient on intravenous therapy, the nurse elevates the patient's extremity. What is the rationale behind this intervention? Phlebitis Extravasation Local infection Circulatory overload

Extravasation

How might a serum calcium concentration of 12.2 mg/dL manifest in a patient? Select all that apply. Fatigue Anorexia Dysphagia Hypotension Laryngospasm

Fatigue Anorexia HYPERCALCEMIA - Normal calcium range 8.4-10.5

Patients should be taught to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid? Tap water or bottled water Fluid that has sodium (salt) in it Fluid that has K +and HCO 3 - in it Coffee or tea, whichever they prefer

Fluid that has sodium (salt) in it

A patient needs a blood transfusion but is apprehensive due to fear of developing sepsis. Which nursing interventions are helpful in preventing transfusion-related sepsis? Administer antibiotics. Educate patient about blood transfusion. Wear gloves during the procedure. Follow blood-banking standards.

Follow blood-banking standards.

A patient's electrocardiogram report indicates a prolonged QT interval. Which electrolyte imbalance does the nurse suspect? Hyperkalemia Hypocalcemia Hypomagnesemia Hypermagnesemia

Hypomagnesemia

A patient is experiencing the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). For which electrolyte disturbance should the nurse evaluate the patient? Hypernatremia Hyponatremia Hemoconcentration Increased serum osmolality

Hyponatremia

A patient with a history of depression is on antidepressant therapy. Which electrolyte abnormality is most likely to occur in this patient? Hyponatremia Hyperkalemia Hypercalcemia Hypomagnesemia

Hyponatremia Commonly used medications can cause alterations in the electrolytes. Administration of drugs such as antidepressants and selective serotonin reuptake inhibitors (SSRI) will decrease sodium levels in the blood; this is known as hyponatremia.

The nurse is caring for a patient who has suffered burns on the chest and back. The nurse suspects that the patient has developed extracellular fluid volume (ECF) deficit. Which clinical findings are likely to be seen in this patient? Select all that apply. Hypotension Cold, clammy skin Sudden weight gain Dry mucous membranes Crackles in dependent portion of lungs

Hypotension Cold, clammy skin Dry Mucous membranes

A patient's laboratory reports indicate a sodium level of 120 mEq/L in the blood. Which drug is most likely responsible for this condition? Ibuprofen Carbenicillin Spironolactone Magnesium hydroxide

Ibuprofen The normal level of sodium in the blood ranges from 136 to 145 mEq/L. A level of 120 mEq/L indicates hyponatremia. This condition is caused by nonsteroidal antiinflammatory drugs such as ibuprofen

The nurse is caring for a patient who is suffering from diarrhea due to intestinal inflammation. Upon assessment, the nurse notes that the patient has had watery stools with abdominal cramping 10 times since the previous day. Which appropriate actions should the nurse take? Select all that apply. Measure stool output. Advise high-fiber food. Advise easily digestible food. Advise reduced fluid intake. Administer antidiarrheal as ordered.

Measure stool output. Advise easily digestible food. Administer antidiarrheal as ordered.

A patient has more than six episodes of diarrhea a day, associated with intestinal cramping, hyperactive bowel sounds on auscultation, and brown stools. Which nursing interventions are appropriate in this situation? Select all that apply. Measure stool output. Administer antiemetics. Discourage use of high-fiber foods. Encourage easily digestible food. Withhold antidiarrheal agents.

Measure stool output. Discourage use of high-fiber foods. Encourage easily digestible food.

A patient who has not been eating for more than a week presents with abdominal pain. On examination, the patient is confused and disoriented. Which metabolic event is most likely responsible for such presentation? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Metabolic acidosis

To which acid-base imbalance is a patient with diabetes prone? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Metabolic acidosis

A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are pH, 7.20; PaCO 2, 21 mm Hg; PaO 2, 92 mm Hg; and HCO 3 -, 8. What do these laboratory values indicate? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Metabolic acidosis - The low pH indicates acidosis. The low PaCO 2 is caused by the hyperventilation, either from primary respiratory alkalosis (not compatible with the measured pH) or as a compensation for metabolic acidosis. The low HCO 3 - indicates metabolic acidosis or compensation for respiratory alkalosis (again, not compatible with the measured pH). Thus, metabolic acidosis is the correct interpretation.

The nurse is caring for an 89-year-old patient. The patient is very weak and refuses to eat. When preparing to insert the intravenous (IV) line, which site should the nurse select first, considering the patient's age? Any prominent vein on the hand Any prominent vein on the foot Most distal appropriate site on the inner arm Most proximal appropriate site on the inner arm

Most distal appropriate site on the inner arm.

The nurse avoids sudden position changes for a patient with gastroenteritis. Which risk is the nurse avoiding? Nausea Diarrhea Vomiting Impaired skin integrity

Nausea

The nurse advises a patient to consume dark green, leafy vegetables and whole grains. What might be the patient's condition? Muscle weakness Cardiac dysrhythmia End-stage renal disease Neuromuscular excitability

Neuromuscular excitability

A patient who had an intravenous (IV) line complains of purulent discharge at the catheter skin entry point. The nurse notices redness, localized warmth, and swelling at the catheter entry point. How should the nurse manage this situation? Select all that apply. Obtain drainage for culture. Cleanse the skin with alcohol. Apply cold compresses. Apply a sterile dressing. Administer steroids to reduce inflammation.

Obtain drainage for culture. Cleanse the skin with alcohol. Apply a sterile dressing.

Which are the best ways to evaluate an elevated serum potassium level in a patient with renal failure? Select all that apply. Measure urine output. Obtain serial serum potassium levels. Evaluate the patient's level of consciousness. Monitor the patient's electrocardiogram (ECG) strips. Evaluate muscle strength.

Obtain serial serum potassium levels. Monitor the patient's electrocardiogram (ECG) strips.

A patient with gastroenteritis is experiencing dehydration due to vomiting and diarrhea. Which nursing intervention requires correction? Initiating ordered peripheral IV and administering 1,000 mL 0.9% NaCl with 10 mEq KCl Providing oral fluids at a temperature the patient prefers Offering fluid frequently in large amounts as tolerated Providing antiemetics as ordered

Offering fluid frequently in large amounts as tolerated.

The nurse is assessing a group of patients for the risk of fluid and electrolyte imbalance. Which patients are considered to be at an increased risk? Select all that apply. Older adult patients Overweight patients Healthy adult patients Patients with skin lesions Patients with low platelet count

Older adult patients Patients with skin leasions Patients with low platelet count

The health care provider's order is 1000 mL 0.9% NaCl with 20 mEq K + intravenously over 8 hours. Which assessment finding should cause the nurse to clarify the order with the health care provider before hanging this fluid? Flat neck veins Tachycardia Hypotension Oliguria

Oliguria Administration of KCl (increased K + intake) to a person who has oliguria (decreased K + output) can cause hyperkalemia.

The nurse is reviewing the arterial blood gas report of a patient. Which is correct regarding partial pressure of carbon dioxide (PaCO 2)? PaCO 2 is a measure of how well the lungs are excreting CO 2 PaCO 2 is a measure of how well the kidneys are excreting metabolic acids. PaCO 2 is a measure of how well gas exchange is occurring in the lungs. PaCO 2 is the ability of hemoglobin to carry as much O 2 as possible.

PaCO2 is a measure of how well the lungs are excreting CO2

After assessing a patient, the nurse documents grade 2 phlebitis. What clinical symptom supports the nurse's documentation? Pain at the access site with erythema. Erythema at the access site without pain. Pain at the access site with erythema, streak formation, and a palpable venous cord. Pain at the access site with erythema, streak formation, a palpable venous cord, and purulent drainage.

Pain at the access site with erythema.

fter assessing a patient, the nurse documents grade 2 phlebitis. What clinical symptom supports the nurse's documentation? Pain at the access site with erythema Erythema at the access site without pain Pain at the access site with erythema, streak formation, and a palpable venous cord Pain at the access site with erythema, streak formation, a palpable venous cord, and purulent drainage

Pain at the access site with erythema.

The nurse works in an acute care facility. Which patients should the nurse monitor for development of hypokalemia? Select all that apply. Patients with adrenal insufficiency Patients with end-stage renal disease Patients with diarrhea Patients with vomiting Patients using potassium-wasting diuretics

Patients with diarrhea Patients with vomiting Patients using potassium-wasting diuretics Hypokalemia is common when potassium output is increased. Diarrhea and vomiting can increase potassium loss through the gastrointestinal tract. Potassium-wasting diuretics may increase potassium loss in urine.

The nurse is caring for a patient who has an accumulation of fluid in the pleural cavity. The nurse understands that this fluid is transcellular fluid secreted by epithelial cells. Which bodily fluids are examples of transcellular fluids? Select all that apply. Serum Plasma Peritoneal fluid Synovial fluid Cerebrospinal fluid

Peritoneal fluid Synovial fluid Cerebrospinal fluid

A patient with chronic infective diarrhea has skin redness on the perianal area due to constant exposure to stool. The patient also has reduced skin turgor and reports dizziness. Which interventions would be helpful to promote patient comfort? Select all that apply. Avoid foods high in fiber. Provide easily digestible food. Position the patient off the inflamed area. Apply moisture barriers to the skin. Provide the bedpan carefully.

Position the patient off the inflamed area. Apply moisture barriers to the skin. Provide the bedpan carefully.

A patient is receiving treatment for chronic diarrhea. The nurse advises the patient to eat food items rich in potassium. What is the reason behind promoting a potassium-rich diet? Potassium improves smooth, skeletal, and cardiac muscle function. Potassium is necessary for production of adenosine triphosphate (ATP). Potassium decreases muscle wasting. Potassium acts as a cofactor for various enzymes.

Potassium improves smooth, skeletal, and cardiac muscle function.

A patient reports abdominal cramps and diarrhea. The patient's serum potassium level is 6.3 mEq/L. What changes would be observed on an electrocardiogram? Select all that apply. Prolonged PR Peaked T waves Presence of U wave ST segment depression Widened QRS complex

Prolonged PR Peaked T waves Widened QRS complex

A patient with diabetic ketoacidosis is breathing rapidly and deeply. Intravenous (IV) fluids and other treatments have just been started. What should the nurse do about this patient's breathing? Notify the health care provider that the patient is hyperventilating. Provide frequent oral care to keep the mucous membranes moist. Ask the patient to breathe slower and help to calm down and relax. Assess the patient for pain and request an order for a sedative.

Provide frequent oral care to keep the mucous membranes moist.

A patient with gastroenteritis experiences light-headedness on sitting upright. On assessment, the blood pressure is 90/50 mm Hg in the supine position, pulse rate is 110 beats/minute, and the oral mucous membranes are dry. How should the nurse promote fluid and electrolyte balance in the patient? Select all that apply. Provide oral fluids. Administer ordered 0.9% NaCl. Promote excess fluid intake. Administer antidiarrheal agents. Provide a comfortable environment.

Provide oral fluids. Administer ordered 0.9% NaCl.

A nurse finds circulatory overload in a patient on intravenous infusion. Which intervention would benefit this patient? Elevating the extremity Raising the head of the bed Applying a warm and moist compress Starting a new intravenous line in another extremity

Raising the head of the bed

While caring for a patient on an intravenous (IV) catheter, the nurse finds redness, heat, and swelling at the catheter-skin entry point with purulent drainage. Which nursing intervention would be beneficial for the patient? Elevating the extremity Assessing whether the intravenous system is intact Starting a new intravenous line in another extremity Monitoring vital signs and laboratory reports of serum levels

Starting a new intravenous line in another extremity.

The nurse is caring for an 89-year-old patient. The patient is very weak and refuses to eat. Intravenous (IV) therapy is planned to restore fluid and electrolyte balance. The nurse performs a venipuncture and initiates the prescribed fluid therapy. After a few hours, the nurse finds that the patient has developed phlebitis. What should the nurse do? Select all that apply. Assess whether the IV system is intact. Stop infusion and discontinue the IV line. Start a new IV line in another extremity. Apply a cold compress at the site. Monitor vital signs and laboratory reports of serum levels.

Stop infusion and discontinue the IV line. Start a new IV line in another extremity.

A patient is receiving intravenous fluids. The nurse finds that the intravenous (IV) fluid has extravasated from an IV line. Which should be the immediate nursing actions? Select all that apply. Stop the infusion immediately. Avoid elevating the extremity. Stop use and start using IV line after 4 hours. Discontinue infusion for nonvesicant drugs. Aspirate the drug from catheter for vesicant drugs.

Stop the infusion immediately. Discontinue infusion for nonvesicant drugs. Aspirate the drug from catheter for vesicant drugs.

A patient complains of pain in an extremity that had a running intravenous (IV) line. On examination, the nurse observes redness and warmth along the course of the vein starting at the access site. How should the nurse promote comfort in this patient? Select all that apply. Stop the infusion. Discontinue the IV line. Apply cold compresses. Reuse the same line after some time. Set up a new line distal to the original.

Stop the infusion. Discontinue the IV line.

A patient develops acute intravascular hemolytic transfusion reaction following transfusion with incompatible blood. Which treatment strategies should be included in the patient's management? Select all that apply. Stop the transfusion immediately. Maintain the blood pressure (BP) at the normal range. Avoid keeping the intravenous (IV) line connected. Administer diuretics. Insert an indwelling urinary catheter.

Stop the transfusion immediately. Maintain the blood pressure (BP) at the normal range. Administer diuretics. Insert an indwelling urinary catheter.

A patient presents with muscle twitching and cramping. On examination, the health care provider diagnoses the patient with calcium deficiency. Which dietary instructions should the nurse give to this patient? Select all that apply. Supplement with vitamin D. Avoid broccoli and oranges. Increase the intake of dairy products. Increase the intake of canned fish with bones. Increase consumption of dark green vegetables.

Supplement with vitamin D. Increase the intake of dairy products. Increase the intake of canned fish with bones.

The nurse is teaching a group of nursing students about the acid-base regulation process. What should the nurse teach the students regarding the excretion of carbonic acid from the body? The liver excretes carbonic acid. The lungs excrete carbonic acid. The kidneys excrete carbonic acid. The intestines excrete carbonic acid.

The lungs excrete carbonic acid.