NG/IV Assessement (mosby)

A nurse is evaluating the efectivessness of of treatment for a client with excessive fluid volume. What clinical finding indicates that 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

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

1. They both contain the same kind of ions.

A nurse is analyzing how a hyperglycemic client's blood glucose can be lowered. The nurse considers that the chemical that bufferes the client's excessive aceroaetic acid is: 1. Potassium 2. Bicarbonate 3. Carbon Dioxide 4. Sodium Chloride

2. Bicarbonate

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. Increase serum sodium levels

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 extracellulat body fluid is approximately 20% of the toatl bodyw eight of an average individual. Which components of the extracellaular fluid contributes the greatest proportion to this amount? 1. Plasma 2. Interstital 3. Dense Tissue 4. Body Secretions

2. Interstital

A client is recieving 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? 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

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

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

3. Increased serum bicarbonate level

Two hours after a subtotal gastrecotomy, the nurse identifies that the drainage from the client's nasogastric tube is bright red. What should the nurse do FIRST? 1. Notfy the health care provider 2. Clamp the nasogastric tube for one hour 3. Determine that this is an expected finding. 4. Irrigate the nasogastric tube with iced saline

Determine this is an expected finding

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 recenetly attended a conference that presented information that alcohol should percede betadine in a dressing change. In addition, an article in a nursing sceince journal stated that a new product was 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 chaning the dressing. 2. Cleanse the site with alcohol first and then with betadine. 3. Cleanse the site with the new product first and then follow the agency's protocol. 4. Follow the agencys policy unless it is contradicted by a health care provider's order.

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

A Client is to have a Gastric gavage. In which position should the nurse place the client when the nasogastric tube is being inserted? 1. Supine 2. Mid-Fowler 3. High-Fowler 4. Trendelenburg

High-fowler

A nurse assesses a clients serum electrolyte levels in the labratory report. What electrolyte in intracellular fluid should the nurse consider most important ? 1. Sodium 2. Calcium 3. Chloride 4. Potassium

4. Potassium

How should a nurse prepare and IV piggyback (IVPB) medication for administration to a client recieving an IV infusion? SATA 1. Wear clean gloves to check the IV site 2. Rotate the Bad after adding the medication 3. Use 100 mL of Fluid to mix the medication. 4. Chnage the needle before adding the medication. 5. Place the IVBP 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 Bad after adding the medication 6. USe a sterile technique when preparing the medication.

How should a nurse prepare and IV piggyback (IVPB) medication for administration to a client recieving an IV infusion? SATA 1. Wear clean gloves to check the IV site 2. Rotate the Bad after adding the medication 3. Use 100 mL of Fluid to mix the medication. 4. Chnage the needle before adding the medication. 5. Place the IVBP 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.

An IV solution of 1000 mL 5 % dextrowse 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 ar how mant drops per minute should the nurse set the rate of flow? Record your answer using a whole number. _______gtt/min

1000 mL x 15/8 x 60 = 15,000/480 = 31.25 = 31 gtts/min

A client reports vomiting and diarrhea for 3 days. What clinical finding will most accurately indicate that the client has a 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.

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 charge nurse or health care provider. 3. Inform the cardiac arrest team to place them on alert. 4. Take an electrocardiogram and have lidocaine available

2. Take vital signs and notify the charge nurse or 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

A nurse is reviewing the labratory 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

A nurse is concerned that a client is at risk for developing hyperkalemam. Which disease does this client have that caused this concern? 1. Crohns 2. Cushings 3. End-Stage renal cancer 4. Gastroesophageal Reflux

3. End-Stage renal cancer

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

3. Relax excessive losses

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

3. Replace excessive losses

After a partial gastrectomy is performed, a client is returned from the postanesthesia care unit to the surgical unit with an IV solution infusing and a nasogastric tube in place. The nurse identifies that there is no nasogastric drainage for 30 minutes. There is an order for instillation of the nasogastri tube prn. The nurse should instill. 1. 30 mL of normal saline and continue the suction 2. 20 mL of air and clamp off the suction for 1 hour 3. 50 mL of saline and increase the pressure of the suction 4. 15 mL of distilled water and disconnect the suction for 30 mins

30 mL of normal saline and continue the suction

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

38 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

A nurse is caring for a client with albuminuria resulting in edema. What pressure change does the nurse determine is the cause of the edema. 1. Decrease in tissue hydrostatic pressure 2. Increase in plasma hydrostatic pressure 3. Increase in tissue colloid osmotic pressure 4. Decrease in plasma colloid osmotic pressure

4. Decrease in plasma colloid osmotic pressure

A nurse is caring for a client with albuminuria resulting in edema. What pressure change does the nurse determine is the cause of the edema. 1. Decrease in tissue hydrostatic pressure 2. Increase in plasma hydrostatic pressure 3. Increase in tsssue colloid osmotic pressure 4. Decrease in plasma colloid osmotic pressure

4. Decrease in plasma colloid osmotic pressure