NUTRITION FUNDS - copied

A nurse should recognize which of the findings indicates fluid volume excess?

bounding pulse, pitting edema, crackles upon auscultation

A nurse is caring a client who has a central venous catheter and develops acute shortness of breath. Which action should the nurse take first?

clamp the catheter

A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?

temperature

Which of the following findings reported by an LPN indicates to the nurse that the client has phlebitis at the IV insertion site?

the area surrounding the insertion site feels warm to the touch

A nurse is caring for four clients who have drainage tubes. Which of the following should the nurse recognize as being at risk for hypokalemia?

the client who has a nasogastric NG tube to suction

A nurse is monitoring a client who is receiving packed RBCs. The nurse identifies which of the following as an expected finding?

the packed RBCs are connected by Y tubing to normal saline

A nurse is planning care for a client who is to start TPN. Which of the following interventions should the nurse include in the plan of care?

use a 1.2 micron filter when infusing TPN with fat emulsions added

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which solution should the nurse prepare to infuse for this client?

0.45% sodium chloride

What is catheter migration?

change in length of the external catheter

Which findings is a manifestation of phlebitis?

erythema, warmth at insertion site, streak formation

A nurse is administering a transfusion of packed RBC. The nurse suspects a possible hemolytic reaction. After stopping the blood transfusion, what action should NOT be taken next?

starting the transfusion of another unit of blood product

A nursing is caring for a client who is receiving a transfusion of packed red blood cells and suspects that the client is experiencing a hemolytic reaction. What is the priority?

stop the infusion

A nurse is caring for a client who has a single lumen central venous catheter. Which of the following actions should the nurse take when accessing the catheter?

use a 10 mL syringe to flush the catheter

A charge nurse is teaching a new nurse how to intiates IV access on a client. Which of the following actions by the new nurse indicates an understanding of the teaching?

washes hands with soap and water before the procedure

A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting and diarrhea. Which of the following findings should the nurse expect?

weak, irregular pulse

A nurse is teaching a client about a low potassium diet. Which of the following foods should the nurse instruct the client to avoid?

yogurt and orange juice

A nurse is planning to perform a blood transfusion for a client. Which of the following should the nurse take?

- check vital signs before transfusion - insert an IV with a 19 guage needle - check the expiration date of the blood product with a second nurse

A nurse is providing teaching for a client who will be on TPN at home. What instructions should be included?

- keep the TPN refrigerated when not in use - infuse 10% dextrose and water if the solution runs out - maintain TPN infusion rate when behind schedule

A nurse is preparing to administer blood to a client. Which actions should the nurse take to identify the client?

- verify the providers prescription with another RN - scan the barcode on the clients wristband - compare client ID number to the blood component tag number

A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time not exceed how long?

4 hours

A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which transfusion reaction should the nurse suspect?

hemolytic

A nurse is caring for client who is receiving TPN. The pharmacy is delayed in suppling the clients next container. What should the nurse hang until the next container arrives?

Dextrose 10% in water

A nurse is teaching a client who is about to undergo the insertion of a nontunneled central venous access device. Which statement indicates that the client understands the instructions?

I will turn my head in the opposite direction during insertion

During a blood transfusion, the client become apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize these findings to indicate which transfusion reaction?

hemolytic

A nurse enters an older adult client's room to insert a saline lock. The client asks why they need it since they drink plenty of fluids. The nurse should respond how?

Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours.

A nurse is assessing a client who is receiving TPN. Which is a complication of the therapy?

hyperglycemia

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the clients EKG should the nurse interpret as a sign of hypokalemia?

abnormally prominent U wave

A nurse is preparing to administer 2 units of packed RBCs to an older adult client. Which of the following actions should the nurse take?

administer each unit over 3 hr

A nurse is reviewing a client's lab values and discovers the client has a serum potassium of 6.2. Which of the following interventions should the nurse anticipate?

administer sodium polystyrene sulfonate

A nurse is preparing to administer blood to a client. The unit of blood on hand is type B, the client has type AB blood. Which following action should the nurse take?

administer the blood as ordered

A nurse is caring for a client who has cancer is is receiving TPN. Which lab value indicates the treatment is effective?

albumin 4.2

A nurse receives a unit of packed RBCs from a blood bank. The nurse should begin the infusion at which time?

as soon as the nurse can prepare the client and administration set

A nurse is caring for a client who is receiving total parenteral nutrition and develops refeeding syndrome. What laboratory finding should the nurse expect to find?

hypophosphatemia

A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication the client might be experiencing a hemolytic reaction?

hypotension

A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as the best source of potassium?

bananas

A client has a right subclavian central venous catheter. When reconnecting a new administration set, which of the following instructions should the nurse give the client?

bear down while holding breath

A nurse is caring for a client who has prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the clients most recent laboratory results and finds the client's potassium is 5.2. What should the nurse do?

call the prescribing physician and inform her of the client's serum potassium level results

A nurse is reviewing lab results for a client who takes furosemide for hypertension. The nurse notes that the clients potassium level is 3.3. The nurse should monitor for which of the following complications?

cardiac dysrhythmias

A nurse is caring for client who has a central venous catheter and reports hearing a gurgling sound on the side of the catheter insertion. Which of the following complications should the nurse suspect?

catheter migration

A nurse is assessing a client who is receiving TPN therapy via an infusion pump. Which of the following actions should the nurse take?

change the IV tubing every 24 hours

A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the nurse plan to take?

check the clients vitals every hour during the transfusion

A nurse is assessing a client who is receiving a platelet transfusion. Which of the following findings is an adverse effect of the transfusion?

chills

Which antiseptics is the best choice for preparing the client's skin at insertion site?

chlorhexidine

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor?

client has an NG tube to gastric suction

A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a manifestation of acute hemolytic reaction?

client report of low back pain

While assessing a client who is receiving continuous IV therapy, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?

discontinue the existing IV line

A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload.

dyspnea

A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. Which manifestations should the nurse monitor to prevent fluid volume overload?

dyspnea, jugular vein distention, confusion

A nurse is assessing an IV infusion site. What finding should the nurse identify as an indication of an infiltration?

edema in the palm of the hand

A nurse is assessing a client who is receiving a parental lipid infusion. Which of the following findings is a manifestation of fat overload syndrome?

elevated temperature

A nurse is visiting a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?

fatigue

During a blood transfusion the nurse should plan to remain in the clients room to monitor for an infusion reaction for how long?

first 15 minutes

What is catheter rupture?

fluid leaking from the site or pain and swelling during infusion

A nurse is caring for a client who has heart failure and a potassium level of 2.4. The nurse should identify which of the following medications as the cause of the client's low potassium level?

furosemide

A nurse is caring for a client whose serum potassium level is 5.3. Which of the following scheduled medications should the nurse plan to administer?

furosemide

A nurse is monitoring a client who is receiving a blood transfusion. What finding indicates an allergic transfusion reaction?

generalized urticaria

A nurse is preparing to administer potassium chloride to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2. What should the nurse do?

give the ordered KCL as prescribed

A nurse is preparing to administer a unit of red blood cells. The nurse's responsibility is to compare and verify the information on the blood label with the client's information. The nurse should use which of the following as the priority source of verification?

identification wristband

A nurse is admitting a client who has a serum calcium level of 12.3 md/dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment?

lethargy

A nurse is caring for a patient receiving TPN via a PICC. When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

measure the circumference of both upper arms

A nurse is caring for a client who has Crohn's disease and is receiving parenteral nutrition. Which of the following interventions should the nurse include in the care of this client?

monitor daily laboratory values and report as needed

A nurse is assessing a client who has a sodium level of 116. Which of the following findings should the nurse expect?

nausea and vomiting

A nurse is caring for a client who has hypertension and has a potassium level of 6.8. Which of the following actions should the nurse take?

obtain a 12-lead ECG

A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse taken at this time?

place the client on his left side in Trendelenburg position

A nurse is reviewing the lab results of a client who takes furosemide. Which results should the nurse identify as a priority finding?

potassium 2.9

A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?

purulent drainage is noted from the site

A nurse is caring for a client who has a serum potassium level of 5.5. The provider prescribes polystyrene sulfonate. If this medication is effective, the nurse should expect which of the following changes on the client's ECG?

reduction of T wave amplitude

A nurse is preparing to administer a unit of packed red blood cells to a client. Which of the following actions should the nurse plan to take?

remain with the client for the first 15 minutes of the transfusion

A nurse is attempting to flush the IV saline lock for a client. The client reports pain above the catheter site. Which of the following actions should the nurse take?

remove the IV saline lock

A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?

remove the catheter and insert another into a different site

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings is a manifestations of a hemolytic transfusion reaction?

report of low-back pain

A nurse is preparing a client for placement of catheter for TPN. Which of the following sites should the nurse plan to prepare for catheter insertion?

right subclavian vein

A nurse is assessing a client and discovers the infusion pump for the client's TPN is not infusing. What condition should the nurse monitor the client for?

shakiness and diaphoresis

A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes which of the following as a manifestation of hypokalemia?

shallow respirations

A nurse is caring for a client who requires TPN. Which of the following actions should the nurse taken when finding that the TPN solution is infusing too rapidly?

sit the client upright

Which lab value should the nurse report to the provider?

sodium 126

A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8. Which medication should the nurse plan to administer?

sodium polystyrene

Which medication puts clients at risk for both hyperkalemia and hyponatremia?

spironolactone