NUR 107 EXAM 3
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?
300 Ml/day
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 nurse flushing a capped, peripheral venous access device finds that the IV does not flush easily. What is the appropriate intervention in this situation? A) If infiltration or phlebitis is present, apply a sterile dressing to the site. B) Aspirate and attempt to flush the line again. C) If resistance remains after aspirating and flushing, forcefully flush the line. D) If catheter has pulled out a short distance, push back in and flush line again.
B) Aspirate and attempt to flush the line again.
A nurse is changing a peripheral venous access dressing for a client. What is a recommended step in this procedure? A) Observe clean technique to minimize the possibility of contamination. B) Cleanse the site thoroughly with gauze saturated with sterile saline. C) Apply chlorhexidine using a gentle back and forth motion. D) Wipe or blot the site dry and allow to dry completely before covering.
C) Apply chlorhexidine using a gentle back and forth motion.
Which is a common anion?
Chloride
A nurse inadvertently partially dislodges a PICC line when changing the dressing. What would be the appropriate intervention in this situation? A) Swab the line with sterile saline and gently reinsert the line. B) Sedate the client, remove the PICC line, and then notify the physician. C) Set up a sonogram for the client to determine the end point of the line. D) Reapply the dressing and notify the physician for further instructions.
D) Reapply the dressing and notify the physician for further instructions.
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?
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?
Discontinue the IV and relocate it to another site.
A nurse is caring for an older adult client who is to be discharged from the health care facility. The client has been prescribed an oxygen concentrator at home to continue oxygen therapy. What instructions would the nurse tell the client regarding the use of the oxygen concentrator in the home? Select all that apply.
Do not smoke, or use oxygen where open flames, such as a gas stove, are in use. The oxygen concentrator needs to be used in a grounded electrical plug. The oxygen concentrator is portable and cost-effective.
After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client?
Every 72 hours
What is main concern with too much fluid intake?
Hyponatremia
A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status?
Measuring weight daily.
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
Which client will have more adipose tissue and less fluid? A) A woman B) A man C) An infant D) A child
Woman
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?
a newly admitted 88-year-old with a 2-day history of vomiting and loose stools
What is the lab test commonly used in the assessment and treatment of acid-base balance?
arterial blood gas
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?
decreased blood volume and intracellular dehydration
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
Edema happens when there is which fluid volume imbalance?
extracellular fluid volume excess
A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which fluid and electrolyte imbalances?
fluid volume excess and acidosis
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?
hypertonic
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
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:
increase in fat cells.
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 ventilation through the lungs.
Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3−, 14 mEq/L?
metabolic acidosis
A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess?
moist crackles heard upon auscultation
A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply.
0.33% NaCl (⅓-strength normal saline), and 0.45% NaCl (½-strength normal saline) are used to treat hypernatremia. -5% dextrose in 0.9% NaCl is used to treat SIADH and can temporarily be used to treat hypovolemia if plasma expander is not available. 0.9% NaCl (normal saline) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. 5% dextrose in Lactated Ringer's solution replaces electrolytes and shifts fluid from the intracellular compartment into the intravascular space, expanding vascular volume.
What commonly used intravenous solution is hypotonic?
0.45% NaCl
A nurse is preparing to insert an intravenous (IV) catheter into a client's arm. At which angle relative to the client's skin should the catheter be inserted?
10-15 degrees
When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document?
2 Grade 2 phlebitis presents with pain at access site with erythema and/or edema. Grade 1 presents as erythema at access site with or without pain. Grade 3 presents as grade 2 with a streak formation and palpable venous cord. Grade 4 presents as grade 3 with a palpable venous cord >1 in and with purulent drainage.
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 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?
2600 mL
A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6-mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented?
3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection. - 1+ is a slight indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal. 2+ is a 4-mm pit that lasts longer than 1+ with fairly normal contour. 4+ is a deep pit (8 mm) that remains for a prolonged time after pressing with frank swelling.
Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion? A) Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea B) Congestive Heart Failure related to edema C) Fluid Volume Excess related to loss of sodium and potassium D) Fluid Volume Deficit related to congestive heart failure, as evidenced by shortness of breath
A) Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea
Which individual with diarrhea for three days is most likely to suffer from fluid and electrolyte imbalance? A) Infant B) School-age child C) Adolescent D) Young adult
A) Infant
A client has a physician's order for n.p.o (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose? A) replace fluid and electrolytes B) administer blood products C) provide protein supplements D) treat the client's infection
A) replace fluid and electrolytes
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 reports coldness around the infusion site. What IV complication does this describe? A) infiltration B) sepsis C) thrombus D) speed shock
A) Infiltration
A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient?
Administer oral K supplements as ordered.
The ambulatory client is scheduled for a thoracentesis to be performed at the bedside. What actions would the nurse take for this procedure? Select all that apply.
Assess the client for respiratory distress postprocedure. Obtain a thoracentesis tray, a local anesthetic, and a partial vacuum bottle. Ensure a consent form has been signed for the thoracentesis.
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.
A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which actions should the nurse perform to avoid further complications and provide relief to the client? A) Administer oxygen. B) Call for help. C) Discontinue the IV promptly. D) Elevate the affected arm.
C) Discontinue the IV promptly.
The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is: A) fluid volume deficit. B) myocardial Infarction. C) fluid volume excess. D) atelectasis.
C) fluid volume excess.
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
Question 2 of 5 A client is hypotensive secondary to hypovolemia resulting from dehydration. Based on the nurse's knowledge about intravenous solutions, the nurse would expect the physician to prescribe which type of solution?
Isotonic
A nurse carefully assesses the acid-base balance of a patient whose carbonic acid (H2CO3) level is decreased. This is most likely a patient with damage to the:
Lungs
A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? Select all that apply.
Monitor the client's respiratory rate. Check the symmetry of the client's chest. Observe the breathing pattern and effort.
Which finding best indicates to the nurse that the client has a therapeutic outcome from a recent blood transfusion?
No signs of chills, fever, or shortness of breath
The client is to receive two units of packed red blood cells (PRBC) for anemia following surgery. The nurse is preparing to administer the first unit. What interventions would the nurse take to administer the PRBC safely? Select all that apply.
Obtain baseline vital signs prior to beginning the transfusion. Verify client identification and blood product information with a second nurse. Wear clean gloves when spiking the blood container with the administration set. Check that informed consent has been obtained from the client.
The client has a sodium level of 131 mEq/L and has been placed on fluid restrictions of 1000 mL per day. What interventions would the nurse include in the plan of care to assist the client in adhering to the fluid restriction? Select all that apply.
Offer the client fluids in small containers. Provide a moisturizer for the lips and mouth. Remove the water pitcher from the client's bedside.
A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings?
Put on gloves; remove the catheter
A nurse is caring for a client who is experiencing fluid volume deficit. Which signs should the nurse document as part of the assessment that correlates with a fluid volume deficit? Select all that apply.
Reduced skin turgor Decreased blood pressure Decreased urine output Increased pulse rate
A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms?
Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent.
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?
Stop the transfusion and infuse normal saline using a new administration set.
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.
The primary extracellular electrolytes are:
sodium, chloride, and bicarbonate.
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:
winged infusion needle
While in the dining room at the hospital, the nurse notes a client has forceful coughs. Which actions would the nurse take to assist this client? Select all that apply.
Allow the client to cough. Assess for a weak, ineffective cough.
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 nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation?
Remove the IV from the site and start at another location.
The client is being discharged and has a prescription to have the PICC (peripherally inserted central catheter) discontinued prior to discharge. The nurse has checked the chart. The PICC has been inserted in the client's arm to the 30 cm mark. What interventions would the nurse include when discontinuing the PICC? Select all that apply.
Remove the catheter slowly, keeping the catheter parallel to the client's skin. Measure the catheter and ensure 30 cm of the catheter has been removed.
Arterial blood gases have been drawn on the client. The nurse reviews the results. • pH is 7.31 • PaO2 92 mm Hg • PaCO2 50 mm Hg • HCO3 28 mEq/L (mmol/L) How will the nurse interpret these ABG results? Select all that apply.
Respiratory Acidosis Partial Compensation
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 nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client?
Gauze dressing