NUR 2313
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?
"Fluid in the tissue space between and around cells."
The nurse is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate?
"Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."
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 nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit?
3.5 cm H2O
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
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
A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min?
83 gtt/min
Respiratory __________ is produced by inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 and increased levels of carbonic acid.
Acidosis
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?
Acute Confusion related to cerebral edema
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 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 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 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?
Banana
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 location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution.
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 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 complains of coldness around the infusion site. What is the nurse's most appropriate action?
Discontinue the IV.
When considering the four main blood types, the nurse is aware that people with type AB blood are often called universal recipients, whereas people with type O blood are often called universal __________.
Donor's
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.
The nurse is preparing to change the IV tubing of a client receiving a peripheral venous IV infusion 5% dextrose and water based on the understanding that IV tubing is generally changed at which interval?
Every 96 hours.
Acidosis occurs when there is a lack of H ions or a gain of base (bicarbonate) and the pH exceeds 7.45.
False
Fluid volume deficit, also known as __________, is caused by a loss of both water and solutes in the same proportion from the extracellular fluid space.
Hypovolemia
The nurse should regularly assess venous access sites to detect common complications of intravenous therapy including ____________, the inadvertent leakage of intravenous solution into the surrounding tissue.
Infiltration
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
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
A nurse is caring for a client who is prescribed a peripheral intravenous (IV) infusion. After reviewing the image, which action is most important for the nurse to take?
Obtain new intravenous tubing and spike the infusion bag without touching the tip of the tubing
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.
Through the process of __________, water (solvent) passes from an area of lesser solute concentration and more water to an area of greater solute concentration and less water until equilibrium is established.
Osmosis
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
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 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
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 client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?
Start an IV of normal saline as prescribed.
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.
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?
Stop the transfusion.
Arterial blood gases are laboratory tests commonly used to determine the adequacy of oxygenation and ventilation, as well as in the assessment and treatment of acid-base imbalance.
True
Lactated Ringer's intravenous solution contains multiple electrolytes in about the same concentrations as found in plasma.
True
Oxygen and carbon dioxide exchange in the lung's alveoli and capillaries occurs by diffusion.
True
Surgical hypoparathyroidism, vitamin D deficiency, and malabsorption are also causes of hypocalcemia.
True
Which client would be a candidate for total parenteral nutrition?
a client with colitis and bloody diarrhea
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
Potassium is needed for neural, muscle, and:
cardiac function
Which is a common anion?
chloride
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 client has been admitted with fluid volume excess related to left-sided heart failure. Which assessment data would the nurse document related to the fluid volume excess? Select all that apply.
distended neck veins crackles in the lungs
Edema happens when there is which fluid volume imbalance?
extracellular fluid volume excess
When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing:
fluid overload.
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?
hypokalemia
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
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 nursing instructor is discussing fluid and electrolyte balance with a group of students. One of the students asks the instructor how fluids move to maintain homeostasis. The instructor formulates her response based on her knowledge that fluid homeostasis can be maintained by which of the following? Select all that apply.
osmosis filtration diffusion active transport
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)
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 who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?
platelets
A decrease in arterial blood pressure will result in the release of:
renin
The primary extracellular electrolytes are:
sodium, chloride, and bicarbonate.
A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. The nurse looks for a large vein when using a needle with a large gauge. What explains the nurse's action?
to prevent compromising circulation
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:
total parenteral nutrition.
A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply.
ventricular dysrhythmia confusion respiratory muscle weakness