Funds Exam

Fluids in the interstitial spaces are called: A. Intracellular fluids B. Extracellular fluids C. Electrolytes D. Intravascular fluids

B. Extracellular Fluids

The nurse is preparing to administer a unit of packed red blood cells to a client. Which type of IV fluid should be used to facilitate the infusion of blood for this client? A. Lactated Ringer's B. Normal saline C. Dextrose 5% and water D. Dextrose 5% and normal saline

B. NS

An older widow with lung cancer is now in the terminal stage of her illness. Her family is puzzled by her mood changes and apparent anger at them. The nurse explains to the family that the client is doing what? Trying to avoid her situation Coping with her impending death Attempting to reduce family dependence on her Hurting because the family will not take her home to die

Coping with her impending death

The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. What is the pathophysiological reason for the excessive edema? Shift of fluid into the interstitial spaces Weakening of the cell wall Increased intravascular compliance Increased intracellular fluid volume

shift of fluid into the interstitial spaces

A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator? Pulse rate Tissue turgor Specific gravity Body temperature

tissue turgor

8. The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate does a nurse program into the infusion pump? 1. 125 mL/hr 2. 167 mL/hr 3. 200 mL/hr 4. 1000 mL/hr

1. 125 mL/hr

11. A patient has severe hypercalcemia. What are the priority nursing interventions? (Select all that apply.) 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increased fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights

1. Fall prevention interventions 3. Encouraging increased fluid intake 4. Monitoring for constipation

A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions? (Select all that apply.) 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increased fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights

1. Fall prevention interventions 4. Monitoring for constipation

A registered nurse is teaching a nursing student how to assess for edema. Which statement made by the student indicates the need for further education? "Edema results in the separation of skin from pigmented and vascular tissue." "Pitting edema leaves an indentation on the site of application of pressure." "Trauma or impaired venous return should be suspected in clients with edema." "If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given."

"If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given."

7. What assessment does a nurse make before hanging an intravenous (IV) fluid that contains potassium? 1. Urine output 2. Arterial blood gases 3. Fullness of neck veins 4. Level of consciousness

1. Urine output

Which patients does a nurse plan to teach regarding water restriction? 1. A 23-year-old with extracellular fluid volume (ECV) deficit 2. A 34-year-old with hyponatremia 3. A 47-year-old with hypercalcemia 4. A 69-year-old with metabolic acidosis

2. A 34-year-old with hyponatremia

9. An older-adult patient is receiving intravenous (IV) 0.9% NaCl. A nurse detects new onset of crackles in the lung bases. What is the priority action? 1. Notify a health care provider 2. Record in medical record 3. Decrease the IV flow rate 4. Discontinue the IV site

3. Decrease the IV flow rate

Which assessment does a nurse use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit? 1. Dryness of mucous membranes 2. Presence or absence of edema 3. Fullness of neck veins when supine 4. Fullness of neck veins when upright

3. Fullness of neck veins when supine

When delegating input and output (I&O) measurement to nursing assistive personnel, a nurse instructs them to record what information for ice chips? 1. The total volume 2. Two-thirds of the volume 3. One-half of the volume 4. One-quarter of the volume

3. One-half of the volume

A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and image, 24. The nurse interprets these laboratory values to indicate: 1. Metabolic acidosis. 2. Metabolic alkalosis. 3. Respiratory acidosis. 4. Respiratory alkalosis.

3. Respiratory acidosis.

A patient is hyperventilating from acute pain and hypoxia. Interventions to manage his pain and oxygenation will decrease his risk of which acid-base imbalance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

4. Respiratory alkalosis

A nurse assesses pain and redness at a vascular access device (VAD) site. Which action is taken first? 1. Apply a warm, moist compress 2. Monitor the patient's blood pressure 3. Aspirate the infusing fluid from the VAD 4. Stop the infusion and discontinue the intravenous infusion

4. Stop the infusion and discontinue the intravenous infusion

The nurse notes that his assigned patient has some blood clotting dysfunction. Which electrolyte could be responsible for this dysfunction? Potassium Magnesium Calcium Chloride

C. Calcium

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? Crohn disease Cushing disease End-stage renal disease Gastroesophageal reflux disease

End-stage renal disease

When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is what? Sodium Potassium Calcium Calcitonin

Potassium

A client is receiving fresh frozen plasma (FFP). The nurse would expect to see improvement in which condition? Thrombocytopenia Oxygen deficiency Clotting factor deficiency Low hemoglobin

clotting factor deficiency

Which of the following clients is most at risk for fluid imbalance? A. An infant with diarrhea B. An adolescent mowing the lawn on a hot day C. A healthy 70-year-old man with a fractured wrist D. A middle-aged woman who is vomiting

A. And infant with diarrhea

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply. Diplopia Skin rash Leg cramps Tachycardia Muscle weakness

leg cramp muscle weakenss

A client is to receive a transfusion of packed red blood cells (PRBCs). The nurse should prepare for the transfusion by priming the blood IV tubing with which solution? Lactated Ringer solution 5% dextrose and water 0.9% normal saline 0.45% normal saline

0.9% normal saline

A client with terminal cancer says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more and regain strength." Which stage of grieving does the nurse concludes the client is experiencing? Bargaining Frustration Depression Rationalization

Bargaining

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? Skin turgor Intake and output results Client's report about fluid intake Blood lab results

Blood lab results

For an individual experiencing an intracellular fluid deficit, an appropriate intervention would be : A. Restrict fluids B. Administer diuretics as ordered C. Observe for an increase in temperature D. Observe for dyspnea and shortness of breath

C. Observe for an increase in temperature

Which of the following stimulates the thirst center in the hypothalamus? A. High blood pressure B. Decreased release of angiotensin II C. Release of antidiuretic hormone from the pituitary gland D. Decreased blood volume

D. Decreased blood volume

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? Monitor for signs of electrolyte imbalance. Change the tube at least once every 48 hours. Connect the nasogastric tube to high continuous suction. Assess placement by injecting 10 mL of water into the tube.

Monitor for signs of electrolyte imbalance.

5. A nurse assesses four patients. Which patient has greatest risk for hypomagnesemia? 1. A 72-year-old with chronic alcoholism 2. A 79-year-old with bone cancer 3. A 41-year-old with hypernatremia 4. A 46-year-old with respiratory acidosis

1. A 72-year-old with chronic alcoholism

An intravenous (IV) fluid is infusing more slowly than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.) 1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 3. Roller clamp wide open 4. Tubing kinked in bedrails 5. Circulatory overload

1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 4. Tubing kinked in bedrails

The intake and output of a client over an 8-hour period (from 0800 to 1600) is as follows: 150 mL urine voided at 0800; 220 mL urine voided at 1200; 235 mL urine voided at 1600; 200 mL gastric tube formula + 50 mL water administered initially and then repeated x 2; IV had 900 mL in the bag at 0800, and 550 mL remains in the bag at 1600. What is the difference between the client's intake and output? Record your answer using a whole number.

495 ml

A nurse is admitting a client to the unit from the emergency room. The nurse asks the client about past medical history. What phase of the nursing process is the nurse in? Assessment Planning Implementation Evaluation

Assessment

You are the nurse caring for a patient admitted with dehydration? Which of the following orders would you anticipate the physician to write? (Select all that apply) Lasix 40mg IVP BID 0.9 % Normal saline Bolus Increase fluid intake Routine vital signs

B, C, D

A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? Select all that apply. Chemotherapy Repositioning Regular oral care Blood transfusion Radiation therapy

Chemotherapy Blood transfusion Radiation therapy

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful? Clear breath sounds Positive pedal pulses Normal potassium level Decreased urine specific gravity

Clear breath sounds

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. Tetany Seizures Confusion Weakness Dysrhythmias

Confusion Weakness Dysrhythmias

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload? Crackles in the lungs Decreased heart rate Decreased blood pressure Cyanosis

Crackles in the lungs

The nurse understands that the action of an antidiuretic hormone (ADH) is to do what? Reduce blood volume Decrease water loss in urine Increase urine output Initiate the thirst mechanism

Decrease water loss in urine

A client is receiving total parenteral nutrition (TPN) through a central venous access device. The nurse discovers that the TPN bag is empty and the next bag has not been received yet from the pharmacy. What is the most appropriate action for the nurse to take? Perform a finger stick glucose test and call the primary healthcare provider with the results. Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag. Discontinue the infusion and flush the IV line with saline solution until the next TPN bag is ready. Hang a bag of 5% dextrose at a keep-open rate and notify the nurse manager of the occurrence.

Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag.

An elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client and orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation? The nurse should wait for the court's order to give blood to the client. The nurse should proceed with the transfusion in order to save the client's life. The nurse should inform the primary healthcare provider and not give blood to the client. The nurse should explain to the family member that the client needs this transfusion.

The nurse should inform the primary healthcare provider and not give blood to the client.

At the beginning of the shift at 7:00 am, a client has 650 mL of normal saline solution left in the intravenous bag, which is infusing at 125 mL/hr. At 9:30 am the healthcare provider changes the IV solution to lactated Ringer solution, which is to infuse at 100 mL/hr. What total amount of intravenous solution should the client have received by the end of the 8-hour shift? Record your answer using a whole number.

863 mL

You are taking care of a patient with a potassium level of 6.4? What are some things you would anticipate a physician to order?

We could give a potassium wasting diuretic...look up some to see which would be appropriate. We could also give Kayexalate to a patient which will excrete K+ through the feces.

6. Which assessment does a nurse interpret as a transfusion reaction? 1. Crackles in dependent lobes of lungs 2. High fever, severe hypotension 3. Anxiety, itching, confusion 4. Chills, tachycardia, and flushing

4. Chills, tachycardia, and flushing

The nurse who is working during the 8:00 am to 4:00 pm shift must document a client's fluid intake and output. An intravenous drip is infusing at 50 mL per hour. The client drinks 4 oz of orange juice and 6 oz of tea at 8:30 am and vomits 200 mL at 9:00 am. At 10:00 am the client drinks 60 mL of water with medications; the client voids 550 mL of urine at 11:00 am. At 12:30 pm, 3 oz of soup and 4 oz of ice cream are ingested. The client voids 450 mL at 2:00 pm. Calculate the total intake for the 8:00 am to 4:00 pm shift. Record your answer using a whole number.

970 mL

When individuals are in a well or healthy state, their fluid output should be: A. Approximately the same as their fluid intake B. Correlated very little with their fluid intake C. Higher than their fluid intake D. Lower than their fluid intake

A. Approximately the same as their fluid intake

A client's weight has increased in one day by approximately two pounds. The nurse knows that this increase in weight should equal approximately how much fluid? A. 500 cc B. 1 L C. 300 ml D. 2 L

B. 1 liter

Plasma proteins help contain blood within the blood vessels by exerting: A. Filtration pressure B. Hydrostatic pressure C. Colloid osmotic pressure D. Diffusion pressure

C. Colloid osmotic pressure

The movement of particles from an area of high solute concentration to an area of lower solute concentration is: A. Filtration B. Hydrostatic pressure C. Diffusion D. Osmosis

C. Diffusion

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration? Sunken eyes Dry, flaky skin Change in mental status Decreased bowel sounds

Change in mental status

A hospice nurse is caring for a dying client and the client's family members during the developing awareness stage of grief. What is the most important thing about the family that the nurse should assess before providing care? Cohesiveness Educational level Cultural background Socioeconomic status

Cultural background

A nurse is assessing the grief response of a family member whose relative has died. What must the nurse consider first about the family to conduct an effective assessment? Personality traits Educational level Socioeconomic class Cultural background

Cultural background

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? Rapid, thready pulse Distended jugular veins Elevated hematocrit level Increased serum sodium level

JVD

What interventions should the nurse perform while caring for an actively dying client? Select all that apply. Admit the client in hospice care. Perform aggressive laboratory tests. Provide client and family reassurance. Keep the client undisturbed for long time. Perform symptom management in the client.

Provide client and family reassurance. Perform symptom management in the client.

When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what? Sodium Potassium Chloride Calcium

Sodium

When the nurse arrives at 8:00 am, a client has a 1000 mL bag of D5W hanging, with 450 mL infused during the prior shift. The IV infusion is to deliver 100 mL per hour. At 11:00 am the healthcare provider changes the prescription for the intravenous solution to 1000 mL 0.9% sodium chloride to be administered at 75 mL per hour and changes the dietary order from nothing by mouth to clear liquids. From 1:00 pm to the end of the 12-hour shift at 8:00 pm, the client has 4 oz (120 mL) of apple juice, a half cup of tea, a half cup of gelatin, and 6 oz (180 mL) of water. How many milliliters should the nurse document as the client's total fluid intake for the 12-hour shift? Record your answer using a whole number.

1515 ml

A patient was recently told he has terminal lung cancer with a very poor prognosis. The nurse begins an assessment . The patient begins to explain to the nurse how he is planning a family trip to Australia in 2 years. The nurse identifies this as what stage of the grief cycle? Denial Anger Bargaining Depression Acceptance

A. Denial

The nurse explains the Cheyne-Stokes breathing pattern to a student nurse. The nurse knows the student nurse needs further education when the student states: "Cheyne-Stokes respirations commonly occur in patients in metabolic acidosis" "Cheyne-stokes respirations commonly occur in patient with uncontrolled diabetes" "Cheyne-Stokes respirations commonly occur in patients actively dying" "Cheyne-Stokes respirations commonly occur in patients with fluid volume overload"

C. Respiration pattern in patients that are actively dying.

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as what? Vesicular Bronchial Crackles Rhonchi

Crackles

A client has been admitted with a medical diagnosis of dehydration secondary to diuretic therapy. What nursing physical assessment criteria would the nurse expect to find? A. Distended neck and peripheral veins B. Increased BP with clear breath sounds C. Fill bounding pulse with increased rate D. Dry mucous membranes with decreased salivation

D. Dry mucous membranes with decreased salivation

The nurse is waiting for 1 unit of packed red blood cells to arrive for her patient. The nurse calls the blood bank and they say it may take a little more than an hour to send the blood. What is an appropriate IV fluid to administer to the patient while waiting? 0.45% Normal Saline D5W 0.9% normal saline Lactated ringers

D. LR

A client is diagnosed with third space syndrome. What does this mean? A. Fluid has shifted into the vascular space. B. There is an isotonic fluid volume excess. C. The client had a 10 lb. water weight loss. D. The client may have fluid in his peritoneal cavity.

D. The client may have fluid in his peritoneal cavity Rationale: Remember 3rd spacing is when fluid is "hanging out" and moved from the vascular space into the interstitial space

A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what client data or assessment finding? Skin condition Fluid and electrolyte balance Food intake Fluid intake and output

Fluid and electrolyte balance

Which nursing interventions enhance comfort in an imminently dying client in the hospital? Select all that apply. Frequently repositioning the client Maintaining oral hygiene in the client Limiting frequent visits of the family members Measuring the vital signs of client frequently Applying body lotion to the client's skin daily

Frequently repositioning the client Maintaining oral hygiene in the client Applying body lotion to the client's skin daily

A client reports vomiting and diarrhea for 3 days. Which clinical indicator is most commonly used to determine whether the client has a fluid deficit? Presence of dry skin Loss of body weight Decrease in blood pressure Altered general appearance

Loss of body weight

What are the principal ions found in the extracellular fluids? A. Sodium and chloride B. Potassium and phosphate C. Sodium and potassium D. Potassium and protein

Sodium and Chloride

The nurse reviews the medical record of a client who is eligible to receive end-of-life care. What are the criteria for a client to receive this type of care? Select all that apply. When the client is nearing death When the expected death of the client is within 6 months When the client seeks no aggressive disease management When a family member has signed an informed consent form When the client has been issued a "do not resuscitate" order

When the expected death of the client is within 6 months When the client seeks no aggressive disease management When the client has been issued a "do not resuscitate" order

A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte? Sodium Calcium Potassium Phosphorus

calcium

The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of what? Hypercalcemia Hypocalcemia Hyperkalemia Hypokalemia

hypokalemia

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing? Hypernatremia Hyponatremia Hyperkalemia Hypokalemia

hyponatremia

A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present? Headache Pallor Paresthesias Blurred vision

paresthesias

A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important? Sodium Calcium Chloride Potassium

potassium