Fundamentals Quiz 6 Practice
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?
Start an IV of normal saline as prescribed.
What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution?
To assure the IV solution is appropriate for this administration
A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?
"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."
The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response?
"Let me refer you to the blood bank so they can provide you with information."
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. - Administering the IV solution. - Deciding the location of the IV catheter.
TPN
- TPN - Lipid - Filter - Specialized tubing - Per hospital policy
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?
2,500 mL/day
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
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?
Apply pressure to insertion site for at least 3 minutes.
A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?
Avoid salty or excessively sweet fluids.
Which is a common anion? magnesium potassium chloride calcium
Cl -
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?
Discontinue the IV and relocate it to another site.
Which nursing action is performed according to guidelines for aspirating fluid from a small-bore feeding tube?
If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water.
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 alkalosis
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
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?
Phlebitis
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.
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?
"Fluid in the tissue space between and around cells."
A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?
"I should drink 2,500 mL/day of fluid."
A nurse has received a physician's order to insert a nasogastric tube in an adult client. What is the correct order for insertion of a nasogastric tube?
- Measure the insertion distance. - Insert the nasogastric tube to the pharynx. - Have the client tuck his chin to the chest. - Have the client take small sips of water. - Insert the tube to the indicated mark. - Aspirate a small amount of stomach contents and check pH.
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
A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?
Ensure that the prescribed solution is clear and transparent.
A client has had a stroke and will require long-term tube feeding. Which type of feeding tubes would be most appropriate for this client's needs?
Gastrostomy tube
A nurse is caring for a client who is not able to take food orally for 1 week to 10 days. Which type of nutrition is the client likely receive?
Peripheral parenteral nutrition
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?
Remove the IV.
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
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.
How is control over the extracellular concentration of potassium within the human body is exerted?
aldosterone
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:
hypokalemia
What are the three primary components of Parenteral Nutrition?
proteins (amino acids), carbohydrates (dextrose), fats (lipids) additional components include: electrolytes, vitamins, and trace elements
A nurse is caring for four different pediatric clients, all of whom require insertion of an intravenous (IV) catheter. For which client would it be appropriate to insert the IV into the foot?
infant
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today 60-year-old who is 3 days post-myocardial infarction and has been stable. 47-year-old who had a colon resection yesterday and is reporting pain newly admitted 88-year-old with a 2-day history of vomiting and loose stools
newly admitted 88-year-old with a 2-day history of vomiting and loose stools
The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice?
ordering type of solution, additive, amount of infusion, and duration
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: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)
Who might require parenteral nutrition?
patients who: - have nonfunctional GI tracts - are comatose - have high caloric/nutritional needs - are undergoing aggressive cancer therapy - those recovering from: - extensive burns - surgery - sepsis - multiple fractures
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?
placing the tourniquet on the upper arm for 2 minutes
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?
remove the IV
A decrease in arterial blood pressure will result in the release of:
renin
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:
total parenteral nutrition
The primary extracellular electrolytes are:
sodium, chloride, and bicarbonate.
Complications of TPN
- Insertion Problems - central line for TPN - PPN if through PIV (dextrose content changes) - Infection and Sepsis - Usually give TPN with Lipids - Metabolic Alterations - Fluid, electrolyte, and acid-base imbalances - Phlebitis - Hyperlipidemia - Must filter with special tubing - Liver and gallbladder disease - Often taper off/on; depends on orders - ATC (around the clock) or overnight - 2 RN verification per hospital protocol
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)
The nurse is changing the bag of a client's prescribed intravenous solution. What is the nurse's best action?
D - The nurse should invert the IV solution container and remove the cap on the entry site, taking care not to touch the exposed entry site. The bag should not be lying on a table or hanging on the IV pole.
The nurse has inserted a peripheral intravenous catheter. When applying a transparent dressing, what is the nurse's best action?
D - 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.
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:
replacement of fluids for those lost from vomiting and diarrhea.
The nurse is performing an assessment of a client with hypocalcemia who has been admitted to the acute care facility. Which symptom(s) does the nurse document that correlates with the admitting diagnosis? Select all that apply.
- Report of muscle cramps - Report of numbness and tingling of the mouth - Seizure activity - Blood clotting
A nurse explains the homeostatic mechanisms involved in fluid homeostasis to a student nurse. Which statements accurately describe this process? Select all that apply.
- The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the body's needs. - The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acid-base balance. - The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. - The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus.
How can parenteral nutrition be administered?
- centrally through a central venous access device - peripherally through a short-term intravenous access in a peripheral vein
Difference between central and peripheral parenteral nutrition:
- solutions administered via peripheral venous access sites are less concentrated and have a lower osmolarity - peripheral is prescribed for patients who need short-term nutrition lasting less than 2 weeks
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?
1 unit over 2 to 3 hours, no longer than 4 hours
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
100 gtt/min
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?
Decreased potassium levels
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 caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client?
O negative
The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client?
O negative
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.
A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium?
apricots
What is the lab test commonly used in the assessment and treatment of acid-base balance?
arterial blood gas
A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:
electrolytes
Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing?
febrile reaction
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:
low calcium.
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 alkalosis