Class Eighteen Chapter 40 Prep U ACTUAL

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? -83 mL/hr -13 mL/hr -100 mL/hr -103 gtts/hr

83 mL/hr

A nurse flushing a capped peripheral venous access device finds that the IV does not flush easily. What is the most appropriate intervention in this situation? - If resistance remains after aspirating and flushing, forcefully flush the line. - If catheter has pulled out a short distance, push it back in and reflush the line. - Aspirate and attempt to flush the line again. - If infiltration or phlebitis is present, apply a sterile dressing to the site.

Aspirate and attempt to flush the line again.

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he 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? - Turkey - Milk - Banana - Yogurt

Banana

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. Which action should the nurse take to help alleviate the edema? - Deeply massage the legs - Elevate the legs - Request additional salt be added to the diet - Direct the client to remain on bed rest

Elevate the legs

A woman aged 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires: - an access route to replace fluids in combination with blood products. - replacement of fluids for those lost from vomiting and diarrhea. - an access route to administer medications intravenously. - intravenous fluids to be administered on an outpatient basis.

replacement of fluids for those lost from vomiting and diarrhea

While obtaining a health history from a client, which question is most appropriate for the nurse to ask the client to assess fluid balance? - "How much do you typically urinate during the day?" - "How often do you usually have a bowel movement?" - "How often do you experience leg cramps? - "How much coffee do you drink during a typical day?"

"How much do you typically urinate during the day?"

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate? - "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." - "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."

A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation? - 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 spot. - Call the physician and ask if anti-inflammatory drugs should be administered. - Cleanse the site with alcohol and apply transparent polyurethane dressing over the entry site.

Discontinue the IV and relocate it to another spot.

The nurse is preparing to administer fluid replacement to a client. Which action should the nurse take first? - Calculate the number of drops per minute. - Verify the prescription for type of solution and amount of infusion. - Regulate the rate of administration. - Check for the availability of an IV pump.

Verify the prescription for type of solution and amount of infusion.

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as: - hyponatremia. - hypokalemia. - hypernatremia. - hyperkalemia.

hyponatremia.

An older adult client with hypokalemia is being discharged to the home of a caregiver. Which information should the nurse include in the family teaching? - Include more cheese in the diet. - Include more bread in the diet. - Include more bananas in the diet. - Include more canned vegetables in the diet.

include more bananas in the diet.

Which individual with diarrhea for three days is most likely to suffer from fluid and electrolyte imbalance? - Young adult - Infant - Adolescent - School-age child

infant