Prep U chapter 40

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate? - "Infiltration is the inflammation of the vein, while phlebitis is a localized irritation." - "Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein." -"Infiltration is a localized blood clot, and phlebitis occurs when an IV is improperly placed." -"Infiltration occurs when an IV is improperly placed, and phlebitis indicates circulatory overload."

"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? Increased sodium levels Increased potassium levels Decreased potassium levels Decreased oxygen levels

Decreased potassium levels Explanation: Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.

A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing? Respiratory alkalosis Respiratory acidosis Metabolic alkalosis Metabolic acidosis

Metabolic alkalosis

The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client? excessive use of laxatives diaphoresis renal failure increased cardiac output

renal failure Explanation: Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit.

The primary extracellular electrolytes are:

sodium, chloride, and bicarbonate.

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs? An implanted central venous access device (CVAD) A peripheral venous catheter inserted to the antecubital fossa A peripheral venous catheter inserted to the cephalic vein A midline peripheral catheter

An implanted central venous access device (CVAD) Implanted CVADs are ideal for long-term uses such as chemotherapy. The short-term nature of peripheral IVs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of chemotherapy. Because of the caustic nature of most chemotherapy agents, peripheral IV's are not appropriate.

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? Elevate the client's head. Apply a warm compress. Position the client on the left side. Apply antiseptic and a dressing.

Apply a warm compress. Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.

What is the lab test commonly used in the assessment and treatment of acid-base balance?

Arterial blood gas Explanation: ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. T

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level? Fluid volume excess Pulmonary embolus Cardiac dysrhythmias Tetany

Cardiac dysrhythmias Explanation: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.

During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect? -hemolytic transfusion reaction: incompatibility of blood product -allergic reaction: allergy to transfused blood -febrile reaction: fever develops during infusion -bacterial reaction: bacteria present in the blood

Correct response: hemolytic transfusion reaction: incompatibility of blood product Explanation: The listed symptoms occur when a blood product is incompatible. Hives, itching, and anaphylaxis occur in allergic reactions; fever, chills, headache, and malaise occur in febrile reactions. In a bacterial reaction, fever; hypertension; dry, flushed skin; and abdominal pain occur.

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation? -Notify the primary care provider immediately because these are signs of speed shock. -Notify the primary care provider immediately for possible fluid overload. -Check all clamps on the tubing and check tubing for any kinking. -Place the client in the Trendelenburg position to keep the client's airway open.

Notify the primary care provider immediately for possible fluid overload. Explanation: If the client's lung sounds were previously clear, but now some crackles in the bases are auscultated: Notify the primary care provider immediately because the client may be exhibiting signs of fluid overload. The Trendelenburg position is not used to rectify this complication, but to help raise the blood pressure of a client with hypotension.

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the siderail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate? -Remove the IV catheter and reinsert another in a different location. -Decontaminate the visible portion of the catheter, and then gently reinsert. - Apply a new dressing and observe for signs of infection over the next several hours. -Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air.

Remove the IV catheter and reinsert another in a different location. Explanation: An IV catheter should not be reinserted. Whether the IV is salvageable depends on how much of the catheter remains in the vein. Because this catheter has been almost completely pulled out of the insertion site, it should be discarded and a new one inserted at a different location. It is not acceptable simply to apply a new dressing and leave the catheter sticking out of the site

A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What is the nurse's most appropriate action? Discontinue the IV. Attempt to aspirate. Flush with 3-mL normal saline. Slow the rate of infusion by 50%.

discontinue the IV infiltration is the escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall. Signs and symptoms include swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Likely, the IV needs to be discontinued if there is a combination of swelling and pallor. Aspiration is never performed from a peripheral IV. Flushing or slowing the infusion will not alleviate this problem.

The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate? isotonic hypotonic hypertonic plasma

hypertonic Explanation: Because a hypertonic solution has a greater osmolarity, water moves out of the cells and is drawn into the intravascular compartment, causing the cells to shrink. Because of a lower osmolarity, a hypotonic solution in the intravascular space moves out of the intravascular space and into intracellular fluid, causing cells to swell and possibly burst. An isotonic fluid remains in the intravascular compartment. Plasma is an isotonic solution.

A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client? hypertonic solution colloid solution isotonic solution hypotonic solution

hypertonic solution Explanation: Hypertonic solutions are used in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly because it is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. Hypotonic solutions are administered to clients with fluid losses in excess of fluid intake, such as those who have diarrhea or vomiting. Isotonic solution is generally administered to maintain fluid balance in clients who may not be able to eat or drink for a short period. Colloid solutions are used to replace circulating blood volume because the suspended molecules pull fluid from other compartments. However, these solutions are not related to clients with cerebral edema.

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?

isotonic

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of:

phlebitis

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? platelets granulocytes albumin cryoprecipitate

platelets

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?

potassium

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action? Assess oxygen levels. Stop the transfusion. Assess for visible rash. Call for assistance.

stop the transfusion Life-threatening transfusion reactions generally occur within the first 5 to 15 minutes of the infusion, so the nurse or someone designated by the nurse usually remains with the client during this critical time. Whenever a transfusion reaction is suspected or identified, the nurse's first step is to stop the transfusion, thereby limiting the amount of blood to which the client is exposed. All other options should occur after the transfusion is stopped.