40
A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells? As fast as the client can tolerate 75 mL/hr for the first 15 minutes, then 200 mL/hr 1 unit over 2 to 3 hours, no longer than 4 hours 200 mL/hr
1 unit over 2 to 3 hours, no longer than 4 hours
A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)? Metabolic acidosis Respiratory alkalosis Respiratory acidosis Metabolic alkalosis
Metabolic alkalosis
The nurse is educating a client with hypokalemia on why it is important to maintain potassium balance. Which does the nurse include in the teaching? cardiac function skeletal function auditory function optic function
cardiac function
A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status? daily electrolyte monitoring daily BUN and serum creatinine monitoring output measurements daily weights
daily weights
During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible? hypovolemia hypervolemia edema circulatory overload
hypovolemia
The primary extracellular electrolytes are: potassium, phosphate, and sulfate. magnesium, sulfate, and carbon. sodium, chloride, and bicarbonate. phosphorous, calcium, and phosphate.
sodium, chloride, and bicarbonate.
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: blood transfusion therapy. cellular hydration. total parenteral nutrition. volume expander.
total parenteral nutrition.
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? Metabolic acidosis Respiratory acidosis Respiratory alkalosis Metabolic alkalosis
Metabolic alkalosis
A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse? Check the client's vital signs. Stop the transfusion and infuse normal saline using the blood tubing. Notify the health care provider of the client's response. Stop the transfusion and infuse normal saline using a new administration set.
Stop the transfusion and infuse normal saline using a new administration set.
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? hypotonic hypertonic colloid isotonic
isotonic
The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing? hypotonic hypotonic, followed by isotonic isotonic hypertonic
hypertonic A hypertonic solution is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. This causes cells and tissue spaces to shrink. Hypertonic solutions are used infrequently, except in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly. The nurse does not anticipate using isotonic fluids.
The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding? pH: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l) pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l) pH: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l) pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)
pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)
A nurse is assessing clients across the lifespan for fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances? School-age children Infants Toddlers Adolescents SUBMIT ANSWER
Infants
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? increased blood volume and extracellular overhydration decreased blood volume and extracellular overhydration increased blood volume and intracellular dehydration decreased blood volume and intracellular dehydration
decreased blood volume and intracellular dehydration
The process of filtration begins at the: Loop of Henle. Bowman's capsule. glomerulus. collecting ducts.
glomerulus.
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? hypertonic plasma hypotonic isotonic
hypertonic
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? isotonic solution hypotonic solution colloid solution hypertonic solution
hypertonic solution
A nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 4.5 mg/dL (2.6 mEq/L)Based on these levels, the nurse would identify which imbalance? hypermagnesemia hyponatremia hypokalemia hypercalcemia
hypokalemia All of the levels listed are within normal ranges except for potassium, which is decreased (normal range is 3.5 to 5.3 mEq/L; 3.5 to 5.3 mmol/L). Therefore, the client has hypokalemia.
The physician writes an order for intravenous fluids to infuse at 150 mL per hour. If the drop factor of the tubing is 10, at how many drops per minute should the fluid infuse? Record your answer using a whole number.
25 Amount to infuse in milliliters x rate of infusion in minutes / drop factor of tubing = drops per minute 150 mL x 60 minutes / 10 drop factor = 25 drops per minute
When providing chemotherapeutic agents, which catheter is accessed with a non-coring needle? Hickman catheter Peripheral central catheter Implanted venous access catheter Groshong catheter
Implanted venous access catheter Implanted venous access catheters are accessed with a non-coring needle such as a Huber point needle.
A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison? 2,600 mL 2,300 mL 1,500 mL 1,800 mL
2,600 mL The average adult daily fluid source is: 1,300 mL from ingested water, 1,000 mL from ingested food, and 300 mL from metabolic oxidation, totaling 2,600 mL fluid.
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate? 50 gtt/min 40 gtt/min 20 gtt/min 30 gtt/min
50 gtt/min
The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate? 100 mL/hr 103 gtts/hr 13 mL/hr 83 mL/hr
83 mL/hr
A client is receiving a transfusion of packed red blood cells, and the nurse has obtained the first set of vital signs after initiating the transfusion. These closely match the pretransfusion vital signs with the exception of a 1°F (0.5°C) increase in the oral temperature. The client denies other symptoms and is not in distress. What is the nurse's most appropriate action? Call the blood bank and obtain diagnostic tubes. Discontinue transfusion immediately, and infuse normal saline with new tubing. Administer acetaminophen as prescribed. Promptly discontinue the transfusion, and remove the client's IV.
Administer acetaminophen as prescribed. If the client's only sign or symptom is an increase in temperature, which is less than 2°F (1°C), there is no need to wholly discontinue the transfusion. The health care provider should be informed, however; and the client may receive acetaminophen or an antihistamine, as prescribed. A febrile reaction includes a fever of 2°F (1°C) or higher, tachycardia, and presence of headaches or backache.
A nurse is assessing a client after surgery and obtains the client's vital signs: pulse rate is 65 bpm, blood pressure is 122/76 mm Hg in the supine position. The nurse then obtains the client's vital signs on standing. Which finding would alert the nurse to the possibility of a an ECF volume deficit? Select all that apply. Blood pressure 126/80 mm Hg Pulse rate 72 bpm Blood pressure 112/70 mm Hg Blood pressure 104/68 mm Hg Pulse rate 90 bpm
Blood pressure 104/68 mm Hg Pulse rate 90 bpm
A nurse must administer an isotonic intravenous solution to a client who has lost fluid. Which fluids are isotonic? Select all that apply. 0.9% NaCl (normal saline) Lactated Ringer's solution 5% dextrose in lactated Ringer's solution 0.33% NaCl (1/3-strength normal saline) 0.45% NaCl (½-strength saline)
Lactated Ringer's solution 0.9% NaCl (normal saline) The following IV fluids are isotonic: 0.9% NaCl (normal saline) and lactated Ringer's solution (LR). The IV fluids 0.45% NaCl (½ strength saline) 0.33% NaCl (1/3 strength normal saline) are hypotonic. The IV fluids 5% dextrose in 0.45% NaCl and 5% dextrose in lactated Ringer's solution are hypertonic.
Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply. Hypervolemia management Monitoring edema Fluid restriction Intravenous therapy Electrolyte management Nutrition management
Nutrition management Intravenous therapy Electrolyte management
A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? "I need to drink no more than 1,000 mL/day" "I should drink 2,500 mL/day of fluid." "I should drink 1,500 mL/day of fluid." "I should drink more than 3,500 mL/day of fluid."
"I should drink 2,500 mL/day of fluid."
A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? "I've been taking antacids almost every 2 hours over the past several days." "I've had a GI virus for the past 3 days with severe diarrhea." "I was breathing so fast because I was so anxious and in so much pain." "I've had a fever for the past 3 days that just doesn't seem to go away."
"I've been taking antacids almost every 2 hours over the past several days."
What commonly used intravenous solution is hypotonic? 0.9% NaCl 10% dextrose in water lactated Ringer's 0.45% NaCl
0.45% NaCl
Which IV solutions would the nurse expect to be ordered for a client who has hypovolemia? Select all that apply. 5% dextrose in water (D5W) 10% dextrose in water (D10W) 5% dextrose in 0.9% NaCl 0.45% NaCl (½-strength normal saline) Lactated Ringer's solution 0.9% NaCl (normal saline)
0.9% NaCl (normal saline) Lactated Ringer's solution 5% dextrose in 0.9% NaCl 0.9% NaCl (normal saline) and Lactated Ringer's solution are isotonic solutions that have a total osmolality close to that of the ECF and help replace the ECF in the treatment of hypovolemia. 5% dextrose in 0.9% NaCl is a hypertonic solution that can temporarily be used to treat hypovolemia if plasma expander is not available. 10% dextrose in water (D10W) is a hypertonic solution that is used in peripheral parenteral nutrition. 0.45% NaCl (½-strength normal saline) is a hypotonic solution that provides Na+, Cl-', and free water and is used as a basic fluid for maintenance needs. 5% dextrose in water (D5W) is used in fluid loss, dehydration and hypernatremia, and should not be used in excessive volumes because it does not contain any sodium.
A nurse is calculating the output of a client with renal failure and takes into account all modes of fluid loss. When addressing the client's insensible fluid loss via respiration, which amount would the nurse anticipate as the usual average? 100 to 200 mL/day 300 mL/day 200 mL/day 1500 mL/day
300 mL/day
The nurse is calculating the infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtt [drops]/1mL. What is the infusion rate? 25 gtt/min 42 gtt/min 125 gtt/min 20 gtt/min
42 gtt/min When infusing by gravity, divide the total volume in mL (1,000 mL) by the total time in minutes (480 minutes) times the drop factor, which is given as 20 gtt/mL. The correct answer is 42 gtt/min.
The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client? Ask client to perform Valsalva maneuver. Apply pressure to insertion site for at least 3 minutes. Apply petroleum-based ointment and sterile occlusive dressing. Instruct client to remain flat for 30 minutes.
Apply pressure to insertion site for at least 3 minutes.
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? Increased sodium levels Decreased oxygen levels Increased potassium levels Decreased potassium levels
Decreased potassium levels
A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation? Stop the infusion, cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site. Discontinue the IV and relocate it to another site. Call the primary care provider to see whether anti-inflammatory drugs should be administered. Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV
Discontinue the IV and relocate it to another site.
A client needs an intravenous fluid that will pull fluids into the vascular space. What type of fluid does the nurse prepare to administer as prescribed? Hypotonic Hypertonic Osmolar Isotonic
Hypertonic
The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. Location of the IV catheter access Manufacturer of the IV catheter Type of IV solution Client's reaction to the procedure Rate of the IV solution Gauge and length of the IV catheter
Location of the IV catheter access Client's reaction to the procedure Type of IV solution Gauge and length of the IV catheter Rate of the IV solution
Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert? Muscle weakness, fatigue, and dysrhythmias Diminished cognitive ability and hypertension Muscle weakness, fatigue, and constipation Nausea, vomiting, and constipation
Muscle weakness, fatigue, and dysrhythmias
Which finding best indicates to the nurse that the client has a therapeutic outcome from a recent blood transfusion? Steady gait while ambulating Blood pressure increases to 90/48 mm Hg Slight flushing of the face No signs of chills, fever, or shortness of breath
No signs of chills, fever, or shortness of breath
As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action?
Not wearing gloves when performing the intervention
The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect? Infiltration Phlebitis Air embolism Sepsis
Phlebitis
A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action? Slow the rate of IV fluids. Remove the IV. Apply a warm compress. Elevate the arm.
Remove the IV.
The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). On rounds, the nurse notes that the client's IV site and arm are swollen and cool to the touch. Based on these assessment findings, what will the nurse do next? Decrease the rate of the intravenous fluids. Remove the peripheral intravenous catheter. Elevate the swollen extremity on a pillow. Place a warm compress over the swollen site.
Remove the peripheral intravenous catheter.
During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first? Stop the transfusion immediately. Prepare to give an antihistamine. Infuse saline at a rapid rate. Administer oxygen.
Stop the transfusion immediately.
The nurse has inserted a client's peripheral IV catheter and is now flushing the device. What is the nurse's best action?
The nurse should stabilize the catheter while flushing, making sure not to contaminate by touching the port. Reaching over a client to perform this actions is poor body mechanics.
The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present? Urine becomes more diluted. The renal system retains more water. The client has a decreased sensation of thirst. The frequency of voiding increases.
The renal system retains more water.
The nurse has inserted a peripheral intravenous catheter. When applying a transparent dressing, what is the nurse's best action? (pictures of where to place the clear film over the peripheral intravenous catheter. Where is it placed?)
The transparent dressing should be placed in such a manner as to allow full coverage and visibility of the insertion site, without excessively covering the tubing.
Which client would be a candidate for total parenteral nutrition? a postoperative appendectomy client a client with diabetic ketoacidosis a client receiving intravenous antibiotics a client with colitis and bloody diarrhea
a client with colitis and bloody diarrhea
An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use: a winged infusion needle. a central venous access. an intermittent infusion device. an 18-gauge needle.
a winged infusion needle.
Which hormone regulates the extracellular concentration of potassium within the human body? androgen progesterone aldosterone testosterone
aldosterone
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? a man age 50 years an adolescent age 17 years an infant age 4 months a woman age 45 years
an infant age 4 months
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? metabolic acidosis cardiac irregularities increased intracranial pressure (ICP) muscle weakness
cardiac irregularities
A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse likely to find? hyperchloremia hyperphosphatemia hypokalemia hypomagnesemia
hypokalemia
A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by: increasing the excretion of HCO3− into the urine. preventing excretion of acids into the urine. decreasing the excretion of H+ ion into the urine. increasing ventilation through the lungs.
increasing ventilation through the lungs.
The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment? extracellular interstitial intracellular intravascular
intracellular
A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid? transportation of nutrients maintenance of blood volume maintenance of cell size removal of waste
maintenance of cell size
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? palpating the veins on the nondominant hand asking if the client is right or left handed placing the tourniquet on the upper arm for 2 minutes asking the client to pump their fist several times
placing the tourniquet on the upper arm for 2 minutes
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend? 2,500 mL/day 1,500 mL/day 1,000 mL/day 3,500 mL/day
2,500 mL/day
Which is a common anion? potassium calcium magnesium chloride
chloride
A client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action? Change from infusion with an electronic pump to infusion by gravity. Flush the IV with 2 mL of 100 U/mL heparin. Assess the area distal to the IV site for signs and symptoms of deep vein thrombosis. Flush the IV with 3 mL of normal saline.
Flush the IV with 3 mL of normal saline.
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? Offer small amounts of preferred beverage frequently. Ask the client every hour to drink more fluid. Leave water on the bedside table. Have a loved one tell the client to drink more.
Offer small amounts of preferred beverage frequently.
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 Calcium Chloride Phosphorous
Potassium
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland? potassium and sodium potassium and chloride calcium and phosphorus chloride and magnesium
calcium and phosphorus
When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's: high magnesium. low potassium. high sodium. low calcium.
low calcium.
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? "Fluid outside cells." "Fluid in the tissue space between and around cells." "Watery plasma, or serum, portion of blood." "Fluid inside cells."
"Fluid in the tissue space between and around cells." Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).
The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome? ECG will show no cardiac dysrhythmias within 24 hours after beginning supplemental K+. Bowel motility will be restored within 24 hours after beginning supplemental K+. ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet.
ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.
A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? Select a primary tubing of about 37 inches (94 cm) long. Use half-instilled IV solutions before infusing a new one. Avoid replacing IV solutions every 24 hours. Ensure that the prescribed solution the expected color and consistency.
Ensure that the prescribed solution the expected color and consistency.
A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address? decreased colloid oncotic pressure blockage of the lymph nodes increased hydrostatic pressure increased capillary permeability
increased hydrostatic pressure
A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? 3,750 3,000 500 1,000
3,000
The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client? diaphoresis increased cardiac output excessive use of laxatives renal failure
renal failure
A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing? 60 drops/mL 30 drops/mL 120 drops/mL 90 drops/mL
60 drops/mL Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of drops/mL).
What is the lab test commonly used in the assessment and treatment of acid-base balance? ABGs CBC BMP BUN
Arterial blood gas ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. The complete blood cell count measures the components of the blood, focusing on the red and white blood cells. The urinalysis assesses the components of the urine. Basic metabolic panel (BMP) assess kidney function (BUN and creatinine), sodium and potassium levels, and blood glucose level
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. Position the client on the left side. Restart infusion in another vein and apply a warm compress. Apply antiseptic and a dressing.
Restart infusion in another vein and apply a warm compress.
A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving? Packed red blood cells A hypertonic solution A hypotonic solution An isotonic solution
A hypotonic solution Because hypotonic solutions are dilute, the water in the solution passes through the semipermeable membrane of blood cells, causing them to swell. This temporarily increases blood pressure as it expands the circulating volume. Hypertonic solutions draw water out of body cells while isotonic solutions have little effect on the distribution of body fluids. Blood transfusions do not cause the entry of water into body cells.
The nurse is monitoring intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the I&O record? Select all that apply. barbecue sandwich cup of ice cream bowl of chili infusion of intravenous solution 100 mL from melted ice chips serving of jello
100 mL from melted ice chips serving of jello infusion of intravenous solution cup of ice cream The nurse will document all fluid intake and fluid loss. This includes drinking liquids and intravenous fluids. The liquid equivalent of melted ice chips is fluid intake. Foods that are liquid by the time they are swallowed, such as gelatin, ice cream, and thin cooked cereal, are documented as fluid intake. A bowl of chili is a solid food as is a barbecue sandwich. While the amount eaten may be documented in the chart, it is not part of the fluid intake.
The nursing instructor is discussing IV fluid overload with the nursing students. What will the nurse include in her discussion? Select all that apply. The infusion rate must be carefully monitored during the administration of blood. A symptom of fluid overload is distended neck veins. Fluid overload is more likely in very young children. The client will likely develop a fever in the presence of fluid overload. The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client.
Fluid overload is more likely in very young children. The infusion rate must be carefully monitored during the administration of blood. A symptom of fluid overload is distended neck veins. The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client.
A nurse selects the basilic vein as the intended site for the insertion of an IV catheter. The nurse understands that which bone would act as natural splints to allow the client greater freedom of movement? Select all that apply. Radius Ulna Carpal Humerus Scaphoid
Radius Ulna
During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect? febrile reaction: fever develops during infusion bacterial reaction: bacteria present in the blood allergic reaction: allergy to transfused blood hemolytic transfusion reaction: incompatibility of blood product
hemolytic transfusion reaction: incompatibility of blood product 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 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? A midline peripheral catheter A peripheral venous catheter inserted to the cephalic vein An implanted central venous access device (CVAD) A peripheral venous catheter inserted to the antecubital fossa
An implanted central venous access device (CVAD)
What is the lab test commonly used in the assessment and treatment of acid-base balance? Arterial blood gas Basic metabolic panel Urinalysis Complete blood count
Arterial blood gas
A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply. Deciding the size of the IV catheter. Determining the amount of IV solution. Prescribing the kind of IV solution. Administering the IV solution. Deciding the location of the IV catheter.
Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution.
A nurse is providing care to a client who has been vomiting for the past 2 days. The nurse would assess this client for which imbalance? Select all that apply. Metabolic alkalosis Hypokalemia Respiratory acidosis Hypernatremia Hypercalcemia
Metabolic alkalosis Hypokalemia
Which statement most accurately describes the process of osmosis?
Water moves from an area of lower solute concentration to an area of higher solute concentration. Osmosis is the primary method of transporting body fluids, in which water moves from an area of lesser solute concentration and more water to an area of greater solute concentration and less water. Solutes do not move during osmosis. Plasma proteins do not facilitate the reabsorption of fluid into the capillaries, but assist with colloid osmotic pressure, which is related to, but not synonymous with, the process of osmosis.
A nurse is preparing the site for insertion of a peripheral venous catheter using chlorhexidine. Which actions would be appropriate for the nurse to do? Select all that apply. rub in a side to side motion rub in a circular motion use a back and forth motion apply deep pressure apply alcohol after the chlorhexidine
use a back and forth motion rub in a side to side motion
The nurse working at the blood bank is speaking with a potential blood donor client. The client has been living in South America where there was a Zika outbreak. Which statement by the nurse is most appropriate? "As long as you did not receive any blood transfusions while living in South America, you may donate blood." "To prevent the spread of microorganisms, anyone who has lived out of the country for over 6 months is unable to donate blood." "While living in South America, you may have been exposed to a lot of different diseases, which makes you ineligible to donate blood." "Because you lived in South America for more than 3 months, there is risk of transmitting the Zika virus through blood transfusions."
"Because you lived in South America for more than 3 months, there is risk of transmitting the Zika virus through blood transfusions."
A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? "I've had a fever for the past 3 days that just doesn't seem to go away." "I've had a GI virus for the past 3 days with severe diarrhea." "I've been taking antacids almost every 2 hours over the past several days." "I was breathing so fast because I was so anxious and in so much pain."
"I've been taking antacids almost every 2 hours over the past several days."
A nurse is teaching a client regarding a newly implanted venous access system. Which statement by the nurse is incorrect? "You won't have to endure any more needlesticks." "Implanted catheters have a self-sealing port." "The implanted venous access is hidden under the skin." "The catheter will need to be flushed periodically with heparin."
"You won't have to endure any more needlesticks."
The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr 160 gtt/min 100 gtt/min 60 gtt/min 600 gtt/min
100 gtt/min 100gtt/min is the correct rate. 1000 mL divided by 10 hours = 100 mL per hour x 60 gtt/minute, divided by 60 minutes/hour.
The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate? 100 mL/hr 13 mL/hr 103 gtts/hr 83 mL/hr
83 mL/hr
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 side rail. 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 is the appropriate action for the nurse? Remove the IV catheter and reinsert another in a different location. Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air. 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.
Remove the IV catheter and reinsert another in a different location.
A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area? Sacral area Abdomen Hands Face
Sacral area
The nurse is inserting a medication lock for a client receiving intermittent intravenous antibiotics. To prevent the locked intravenous catheter from becoming obstructed between uses, which action will the nurse take during this procedure? Apply pressure over the tip of the catheter or needle. Swab the rubber port on the medication lock with alcohol. Slowly remove the syringe before the fluid is completely instilled. Apply pressure to the venipuncture site for 30 to 45 seconds.
Slowly remove the syringe before the fluid is completely instilled.
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? Allow nothing by mouth. Give the client a glass of orange juice with added sugar. Encourage fluid intake. Start an IV of normal saline as prescribed.
Start an IV of normal saline as prescribed.
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? Call for assistance. Assess oxygen levels. Stop the transfusion. Assess for visible rash.
Stop the transfusion.
The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean? The client has anti-A antibodies. The client has both anti-A and anti-B antibodies. The client is a universal donor. The client has anti-B antibodies.
The client has anti-A antibodies.
A client's course of intravenous medications have been completed and the nurse is removing the IV catheter. What is the nurse's best action? (pictures of removing IV catheter bare hands, gloves starting from bottom while other hand stabilizes the port gloves starting from bottom gloves starting from bottom while other hand is holding the arm.)
The nurse should carefully remove the tape from the outside to the insertion point while supporting the catheter. Gloves should be worn.
The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action? Twist the tubing around a pencil. Milk the air in the direction of the drip chamber. Tap the tubing below the air bubbles. Tighten the roller clamp to stop the infusion.
Tighten the roller clamp to stop the infusion.
What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution? (Picture of nurse scanning a bag of IV solution at computer)
To assure the IV solution is appropriate for this administration The nurse is engaged in the scanning of the bar code associated with the selected IV solution. This activity will help assure the solution is the one prescribed and that the expiration date is not expired. This information helps assure the selected solution is appropriate for this IV prescription. Scanning the bar code does not contribute to the affective administration of the solution. While appropriate goals, neither effective time management nor effective nursing care is the priority goal in this particular situation.
A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that they had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern? yogurt banana turkey milk
banana
A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? distended neck veins fingerprinting over sternum nausea and vomiting muscle twitching
distended neck veins
The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers as well as showing signs of tetany. Which imbalance does the nurse suspect? hypokalemia hypocalcemia hypermagnesemia hypophosphatemia
hypocalcemia The parathyroid gland regulates calcium levels, and partial removal can cause hypocalcemia. Hypocalcemia is manifested by numbness and tingling as well as tetany. The signs and symptoms do not relate to altered magnesium or potassium levels. Calcium and phosphorus have an inverse relationship, so with low calcium, the nurse will expect a high, not a low, phosphorus level.
A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of: hypothyroidism. hypokalemia. hypoglycemia. hypocalcemia.
hypokalemia.
The nurse is caring for Mrs. Roberts, an 86-year-old client, who fell at home and was not found for 2 days. Mrs. Roberts is severely dehydrated. The nurse is aware that older adults are at increased risk for fluid imbalance due to: smaller stomach capacity. increase in muscle mass. increase in fat cells. decreased skin area.
increase in fat cells.
Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking? diminished cognitive ability and hypertension muscle cramping and tetany muscle weakness, fatigue, and constipation nausea, vomiting, and constipation
muscle cramping and tetany Manifestations of hypocalcemia include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia.
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: an infiltration. phlebitis. a systemic blood infection. rapid fluid administration.
phlebitis
A client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells? normal saline solution granulocytes plasma albumin
plasma The infusion of plasma helps restore and replace the clotting factors that are lost with the infusion of large amounts of packed red blood cells. Albumin pulls third-spaced fluid by increasing colloidal osmotic pressure but does not restore clotting factors. The infusion of granulocytes improves the ability of the body to overcome infection. Normal saline is an isotonic solution that replaces fluid loss but does not replace clotting factors.
A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? albumin cryoprecipitate granulocytes platelets
platelets