fluid and electrolytes and infusion therapy
a pt is hypotensive. the pt ECR demonstrates a HR of 52 bpm and prolonged PR interval with widened QRS complex. which lab results are consistent with these findings?
hyperkalemia hypercalcemia hypermagnesmia
which electrolyte imbalance would the nurse anticipate for a patient with dehydration? SATA
hyperkalemia hypernatremia
which electrolyte imbalance would the nurse anticipate for a patient admitted with fluid volume overload? SATA
hypokalemia hyponatremia hypochloremia
regarding flushing the peripheral iv catheter to maintain patency of the lumens, which statement requires correction?
i will stop the flushing procedure if the catheter lumen yields a blood return
a nurse assesses a client who started on intraperitoneal therapy 5 days ago. client reports abdominal pain and feeling warm. which complication could this be?
infection
a patient states "the ace inhibitor medication makes me urinate all the time i didn't think it was the water pill." which response would the nurse make?
" this medication causes greater excretion of water and sodium in your urine"
a MedSurg nurse is concerned about the incidence of complications related to iv therapy, including bloodstream infection. which intervention would the nurse suggest to management?
initiate a dedicated team to insert access devices
after documenting the assessment findings below for a pt with dehydration secondary to diarrhea from chrons disease, which action would the nurse perform first?
initiate ringers lactate at 125ml/hr
which vein would the nurse select for a midline catheter?
median antecubital
which lab test would demonstrate effectiveness of diuretic therapy for a patient admitted with fluid overload from heart failure?
natriuretic peptide
a patient is receiving long term intra-arterial infusion therapy of methotrexate through the carotid artery. which assessment is most important for the nurse to include?
neurologic assessment
a pt is recieving continious infusion of 5% dextrose and 0.45% NS with 20 mEq potassium chloride at 50ml/hr in the right cephalic vein. which action made by the AP obtaining vs requires correction?
obtaining BP in the right arm
which newly written prescription would the nurse administer first?
oral potassium chloride to a pt whose serum potassium is 3
after reviewing four assigned pts health records, which pt would the nurse prioritize as having the highest risk for fluid imbalance?
patient a- 40 year old man with hypertension and 2ndand 3rd degree burns on 25% of body
the nurse is reviewing assessment data of a pt and observes a hard, cord like vein which complication of iv therapy would the nurse suspect?
phlebitis
after a pts iv infusion is discontinued, the nurse observes a swollen extremity and redness at the site. which action would the nurse take?
place a cold compress over the site
a nurse prepares to insert a peripheral venous catheter in an older adult client. what action should the nurse take to protect the clients skin?
place a washcloth between the skin and tourniquet
the hcp writes prescriptions for a pt who is admitted with a serum potassium level of 6.9. which action would the nurse implement first?
place pt on cardiac monitor
a nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. after removing the device, which action should the nurse take to relieve the pain?
place warm compress on site
A nurse cares for a client who has a serum potassium level of 7.5 and is exhibiting cardiovascular changes. which prescription should the nurse implement first?
prepare to administer dextrose 20% and 10 units of regular insulin iv push
a nurse is caring for a client who is having a subclavian cvc inserted. client reports chest pain and difficulty breathing. after administering oxygen, what does the nurse do next?
prepare to assist with chest tube
a nurse assesses a client who has a radial artery catheter. which assessment should the nurse complete first?
presence of an ulnar pulse
which assessment finding indicates the need for continued fluid replacement therapy in a pt diagnosed with dehydration? SATA
pulse pressure of 28mmHg urine output of 400 ml/day
A nurse teaches a client who is at risk for mild hypernatremia. which statement should the nurse include in the clients teaching?
read food labels to determine sodium content
the nurse is caring for a pt receiving a dose of IV vancomycin. which action would the nurse take after noticing swelling and coolness around the catheter insertion site? SATA
remove catheter. apply cold compress. discontinue infusion.
a nurse is caring for a client who is receiving an epidural infusion for pain management. which assessment requires immediate intervention?
report headache and stiff neck
After teaching a client to increase dietary potassium, a nurse assesses the clients understanding. which meal indicates the client understands the teaching?
sausage, one slice of whole wheat toast, half cup of raisins, milk
after reviewing the hcp orders, which action would the nurse perform first for a patient who just underwent placement of a PICC at bedside?
schedule an xray
after reviewing the lab results for a patient admitted with fluid and electrolyte imbalances secondary to celiac disease, which intervention would the nurse implement first?
start telemetry monitoring
a nurse assesses a clients peripheral iv site, notes edema and tenderness above site. which action should the nurse take next?
stop the infusion of iv fluids
a pt is admitted to the ED with severe injuries to the neck and upper body. the provider has prescribed iv fluids and antibiotics. it is suggested to insert a Non tunneled percutaneous cvc, which response is correct?
that device is not appropriate for this pr because trauma to the neck or chest prohibits the use of the positioning needed for the insertion process.
the nurse is inserting VAD in 4 pts. which pt is most likely to receive a midline catheter?
the pt that requires iv heparin for 10 days to treat a blood clot
which observation would require the nurse to delay injection of a drug through an implanted port?
there is no blood return when the needle is inserted through the septum
a pt recieving iv therapy through a central catheter has developed a swollen extremity and engorged peripheral veins of the ipsilateral chest. which complication would the nurse expect?
thrombosis
a nurse prepares to administer a blood transfusion to a client. which components must be present on the blood label?
unique facility identifier lot number abo group and RH type of donor
a nurse delegates care to a uap. which statement should the nurse include when delegating hygiene for a client who has a vascular access device?
use a plastic bag to cover extremity
which parameter of iv therapy would the nurse document? SATA
vein that was used for insertion date and time of insertion name of nurse who inserted the device
which condition would cause pain and numbness at the insertion site of a peripherally inserted central catheter?
venous spasm
which statement made by the nurse shows accurate knowledge about the care of older adults who are receiving iv therapy? SATA
"i will avoid selecting a site with a hard, cordlike vein." " i will use skin protectant solution between the skin and dressing"
which information would the nurse include when teaching a patient about maintaining fluid balance?
"your intake and output have the most influence on your bodys fluid balance"
the nurse is assigned to insert a PICC line in the following four pts to preform long term iv therapy. which pt would require a different type of venous access placed?
25 year old man fractured right femur with osteomyelitis using crutches
after the administration of iv fluids the pt experiences fluid overload and peripheral edema. which serum osmolarity level of iv fluid is the likely cause of the change in pt condition?
280 mOsm/l
A nurse is assessing clients for fluid and electrolyte imbalances. which client should the nurse assess first for potential hyponatremia?
34 year old NPO status who is receiving IV D5W
which pt would the nurse manager of medsurg unit assign to the lpn?
64 year old admitted yesterday with HF who has depressed pedal edema
which person attending on an all day outdoor festival on a hot august day is at risk for dehydration?
72 year old who is 20 lb overweight
A nurse teaches a patient in a community center about risk for dehydration. which patient is at greatest risk for dehydration?
A 76 year old who is cognitively impaired
a pt who is recieving peripheral iv therapy has blanching, edema and fluid leakage around the iv insertion site. which action would the nurse take? SATA
apply a sterile dressing. apply a cold compress. remove iv catheter. encourage pt to elevate extremity
a nurse teaches a client who is prescribed a central vascular access device. which statement should the nurse include in teaching?
ask all providers to vigorously clean connections prior to accessing device.
for a pt with SIADH secretion, which intervention would the nurse implement first based on information obtained from the health record?
assess respirstory status
A nurse is assessing a client with hypokalemia and notes that the clients hand grip strength has diminished since the previous assessment 1 hr ago. which action should the nurse implement first?
assess the clients respiratory rate, rhythm and depth
which finiding for a 70 year old pt admitted to the unit with severe dehydration requires immediate intervention by the nurse?
behavior changes from anxious to lethargic and confused
a pts monitoring lab results show a serum ionized calcium level of 2.85. which parameter would the nurse assess based on this result?
blood clotting
if the nurse draws blood from the venipuncture site proximal to the catheter which situation could occur?
blood test may be altered
which parameter would lead to a recommendation for fluid replacement therapy for a dehydrated pt?
body temp of 104 for more than 8 hours
which electrolyte imbalance would the nurse anticipate in association with a serum magnesium of 1.1?
calcium 7.8
a nurse responds to an iv pump alarm related to increased pressure. which action should the nurse take first?
check the catheter for kinks
A nurse is assessing clients on a MedSurg unit. which client is at risk for hypokalemia?
client with pancreatitis who has continuous NG suctioning.
a nurse assesses a client who had intraosseous catheter placed in left leg. which assessment finding is of greatest concern?
clients left lower extremity is cool to the touch
a nurse is caring for a client who has a calcium level of 14. which provider order should the nurse implement first?
connect client to cardiac monitor
which finding indicates that a patient may have recieved iv fluids at a rate greater than the amount the pts system can accomodate? SATA
cough edema sob
a nurse is caring for an older adult who is admitted with moderate dehydration. which intervention should the nurse implement to prevent injury while in the hospital?
dangle client on bedside before ambulating
an older adult patient presents to the emergency room with confusion, altered loc, dry mouth, scaly skin. which finding in pts history would be significant?
decreased intake of liquids and gelatin
A nurse is evaluating a client who is being treated for dehydration. which assessment result should the nurse correlate with a therapeutic response to the treatment plan?
decreased orthostatic light headedness and dizziness
which finding would indicate the effectiveness of furosemide therapy prescribed for a pt diagnosed with fluid overload? SATA
decreased weight increased urine output
the nurse is providing care to a patient who is experiencing severe N/V/D. which conditions is the patient at risk for developing? SATA
dehydration hypokalemia hypernatremia
A nurse is caring for a client who has the following lab results: potassium 3.4 mEq/l, calcium 8.5, sodium 144. which assessment should the nurse complete first?
depth of respirations
a pt with a cvc reports back pain between the shoulder blades. which action would the nurse take first?
discontinue all infusions and flush the catheter
during an iv drug infusion, pt develops a flushed face, an irregular pulse, then reports lightheadedness. which action would the nurse perform?
discontinue the infusion
which immediate complication of venipuncture would the nurse anticipate in an older adult pt receiving steroid therapy?
ecchymosis
which item will the nurse include when documenting a patients fluid intake? SATA
enemas oral fluids irrigation fluids
A nurse is caring for a client who just has a central venous access line inserted. which action should the nurse take next?
ensure an Xray be completed to confirm placement.
which nursing intervention is consistent with safe administration of iv potassium to a patient with hypokalemia? SATA
evaluate HR and regularity establish and evaluate patency of large vein obtain an iv pump plan to access the RR and O2 every hour
which assessment finding indicates that a patient is dehydrated? SATA
fever poor skin turgor low blood pressure concentrated urine
which action would the nurse include in the plan of care to prevent lumens of CVC from occluding?
flush with normal saline
a nurse is assessing clients on a MedSurg unit. which clients are at risk for hypophosphatemia?
A. 36 year old malnourished B. 42 year old with uncontrolled diabetes E. 76 year old taking antacids
a nurse is assessing a client who has an electrolyte imbalance related to renal failure. for which potential complication of this electrolyte imbalance should the nurse assess?
A. ECG Changes D. Paralytic ileus E. skeletal muscle weakness
A nurse is caring for clients with electrolyte imbalances on med surg unit. which clinical manifestations are correctly paired with the contributing imbalance?
A. hypokalemia flaccid paralysis with respiratory depression C. Hypercalcemia positive trousseaus and Chvostek sign
while assessing a client's iv site, the nurse observes a streak of red along vein path and palpates 4 cm venous cord. how do you document this?
grade 3 phlebitis at iv site
a nurse assist with insertion of a cvad. which actions should the nurse ensure are completed to prevent a catheter-related blood stream infection?
A. include a review for the need of the device each day in the clients plan of care. B. remind the provider to perform hand hygiene prior to starting the procedure. D. ask everyone in the room to wear a surgical mask during the procedure.
a nurse assesses a patient who is admitted for treatment of fluid overload. which manifestations should the nurse expect to find?
A. increased pulse rate B. distended neck veins E. skeletal muscle weakness
which complications should the nurse assess for picc lines?
A. phlebitis C. thrombophlebitis
After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the clients understanding. which food choice for lunch indicates the client correctly understood the teaching?
grilled chicken breast with glazed carrots
A nurse is assessing clients on medsurg unit. which adult client should the nurse identify as being the greatest risk for insensible water loss?
Anxious pt who is tachypnea
A nurse is caring for a client who exhibits dehydration-induced confusion. which intervention should the nurse implement first?
Apply mask or nasal cannula
a nurse teaches a client who is being discharged home with a PICC. what statement should the nurse include in teaching?
Avoid carrying granchild with arm that has a central catheter
a nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. for which potential complications should the nurse assess?
B. potassium level 5.4 E. blood osmolality of 250
A nurse develops a plan of care for a client who has a history of hypocalcemia. what interventions should the nurse include in this client care plan?
B. use a draw sheet to reposition the client in bed. D. provide nonslip wear when getting out of bed.
a nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II. for which expected therapeutic effect should the nurse assess?
BP decreases from 180/72 to 144/50
a client at risk for developing hyperkalemia states, "i love fruit and usually eat it every day, but now i cant because of my high potassium." how should the nurse respond?
Berries, cherries, apples, and peaches are low in potassium
after administering 40 mEq of potassium chloride, a nurse evaluates the clients response. which manifestations indicate that treatment is improving the clients hypokalemia?
C. strong productive cough E. U waves present on ECG
after reviewing the health care record and hcp orders which infusion device would the nurse recommend for a pt who will receive home iv therapy?
ambulatory pump
After teaching a client who is being treated for dehydration, a nurse assess the clients understanding. which statement indicates a client correctly understanding the teaching?
I will weigh myself each morning before i eat or drink
which pt goal would the nurse establish when providing care for a pt admitted with hypocalcemia secondary to chrons disease and severe diarrhea?
Negative Chvostek sign
a nurse is assessing clients who have iv therapy. which assessment finding for a PICC requires immediate attention?
Upper extremity swelling is noted
which a patient on a medsurg unit is at increased risk for insensible water loss?
a pt receiving continuous GI suctioning postoperatively.
a 92 year old woman is admitted from a long term care facility for treatment of dehydration. SATA
activate the bed alarm orient pr frequently asses for orthostatic hypotension place bed in lowest position with brakes locked
a pt who is receiving iv fluid replacement therapy has a bounding pulse, difficulty breathing, and distended neck veins in the upright position. which intervention would the nurse plan for the pt?
administering diuretic therapy
a hypertensive pt was brought to the ED with a HR of 115 and an abnorml ECG showing a shortened QT interval. the lab findings show a serum calcium level of 11. which intervention would help stabalize the pt? SATA
administering high ceiling or loop diuretics administering 0.9 % NS IV
the nurse is reviewing the health record for a pt before initiating iv therapy. which finding would affect the location for inserting a peripheral iv catheter?
age, arm of dominance, iv fluid, presence of joint flexion
which hormone regulates sodium balance? SATA
aldosterone natriuretic peptide antidiuretic hormone
