Prep U #4
The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade? a) 3+ b) 1+ c) 2+ d) 4+
b) 1+
The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present? a) The renal system retains more water b) The frequency of voiding increases c) The client has a decreased sensation of thirst d) Urine becomes more diluted
a) the renal system retains more water
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: a) hypocalcemia b) hypokalemia c) hypothyroidism d) hypoglycemia
b) hypokalemia
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, which amount would the nurse anticipate as the usual average? a) 1500 mL/day b) 100-200 mL/day c) 200 mL/day d) 300-400 mL/day
d) 300-400 mL/day
The nurse is calculating the infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtts/min. What is the infusion rate? a) 25 gtts/min b) 125 gtts/min c) 20 gtts/min d) 42 gtts/min
d) 42 gtts/min
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. a) Deciding the location of the IV catheter b) Prescribing the kind of IV solution c) Deciding the size of the IV catheter d) Determining the amount of IV solution e) Administering the IV solution
a) deciding the location of the IV catheter c) deciding the size of the IV catheter e) administering the IV solution
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland? a) potassium and chloride b) calcium and phosphorus c) chloride and magnesium d) potassium and sodium
b) calcium and phosphorus
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? a) Hypotonic b) Hypertonic c) Isotonic d) Plasma
b) hypertonic
The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment? a) Intravascular b) Intracellular c) Interstitial d) Extracellular
b) intacellular
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)? a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory alkalosis d) Respiratory acidosis
b) metabolic alkalosis
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? a) unfortunately, your own blood cannot be reinfused during surgery b) this surgery has a very low chance of hemorrhage, so you will not need blood c) we now have artificial blood products, so giving your own blood is not necessary d) let me refer you to the blood bank so they can provide you with information
d) let me refer you to the blood bank so they can provide you with information
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? a) Distended neck veins b) Fingerprinting over sternum c) Muscle twitching d) Nausea and vomiting
a) distended neck veins
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? a) Metabolic alkalosis b) Metabolic acidosis c) Respiratory acidosis d) Respiratory alkalosis
a) metabolic alkalosis
A decrease in arterial blood pressure will result in the release of: a) renin b) insulin c) thrombus d) protein
a) renin
The primary extracellular electrolytes are: a) sodium, chloride, bicarbonate b) potassium, phosphate, sulfate c) phosphorous, calcium, phosphate d) magnesium, sulfate, carbon
a) sodium, chloride, bicarbonate
The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean? a) The client has anti-A antibodies b) The client has both anti-A and anti-B antibodies c) The client is a universal donor d) The client has anti-B antibodies
a) the client has anti-A antibodies
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: a) Decreased skin area b) Increase in fat cells c) Smaller stomach capacity d) Increase in muscle mass
b) increase in fat cells
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? a) elevate the arm b) remove the IV c) apply a warm compress d) slow the rate of IV fluids
b) remove the IV
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 BP is 88/50 and she is diaphoretic. She requires: a) an access route to replace fluids in combination with blood products b) replacement of fluids for those lost from vomit and diarrhea c) IV fluids to be administered on an outpatient basis d) an access route to administer meds intravenously
b) replacement of fluids for those lost from vomit and diarrhea
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend? a) 1,000 mL/day b) 1,500 mL/day c) 2,500 mL/day d) 3,500 mL/day
c) 2,500 mL/day
A physician orders an infusion of 250mL of NS in 100 minutes. The set is 20gtt/mL. What is the flow rate? a) 40 gtt/min b) 20 gtt/min c) 50 gtt/min d) 30 gtt/min
c) 50 gtt/min
During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect? a) Bacterial reaction: bacteria present in the blood b) Febrile reaction: fever develops during infusion c) Hemolytic transfusion reaction: incompatibility of blood product d) Allergic reaction: allergy to transfused blood
c) hemolytic transfusion reaction: incompatibility of blood product
A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client? a) Colloid solution b) Hypotonic solution c) Hypertonic solution d) Isotonic solution
c) hypertonic solution
A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse most likely find? a) Hypomagnesemia b) Hyperchloremia c) Hypokalemia d) Hypernatremia
c) hypokalemia
The nurse is caring for a client whose blood type is B-. Which donor blood type does the nurse confirm as compatible for this client? a) B+ b) A+ c) AB- d) O-
d) O-
How is control over the extracellular concentration of potassium within the human body is exerted? a) Progesterone b) Testosterone c) Albumin d) Aldosterone
d) aldosterone
A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid? a) Maintenance of blood volume b) Transportation of nutrients c) Removal of waste d) Maintenance of cell size
d) maintenance of cell size
Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His lab results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert? a) diminished cognitive ability and HTN b) muscle weakness, fatigue, and constipation c) nausea, vomiting, and constipation d) muscle weakness, fatigue, and dysrhythmias
d) muscle weakness, fatigue, and dysrhythmias
A client with chronic anemia is admitted for the administration of blood. What would the nurse expect the physician to order? a) white blood cells b) D5W 1000 mL c) whole blood d) packed cells e) platelets
d) packed cells
The physician writes an order for intravenous fluids to infuse at 150 mL per hour. If the drop factor of the tubing is 10, at how many drops per minute should the fluid infuse?
25 drops/min
The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome? a) ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. b) Bowel motility will be restored within 24 hours after beginning supplemental K+. c) ECG will show no cardiac dysrhythmias within 24 hours after beginning supplemental K+. d) Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet
a) ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutions, coffee, tea, and other K+ rich foods from diet
A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? a) I should drink 2,500 mL/day of fluid b) I should drink more than 3,500 mL/day of fluid c) I should drink 1,500 mL/day of fluid d) I need to drink no more than 1,000 mL/day
a) I should drink 2,500 mL/day of fluid
A nurse is caring for a client who is on total parenteral nutrition (TPN). Which clients are candidates for TPN? Select all that apply. a) Clients with liver and renal failure b) Clients who have not eaten for a day c) Clients with major trauma or burns d) Clients who are recovering from cataract surgery e) Clients with inflammatory bowel disease
a) clients with liver and renal failure c) clients with major trauma or burns e) clients with inflammatory bowel disease
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? a) decreased blood volume and intracellular dehydration b) decreased blood volume and extracellular overhydration c) increased blood volume and intracellular dehydration d) increased blood volume and extracellular overhydration
a) decreased blood volume and intracellular dehydration
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: a) electrolytes b) colloid solution c) interstitial fluid d) nonelectrolytes
a) electrolytes
A nurse is required to initiate IV therapy for a client. Which of the following should the nurse consider before starting the IV? a) ensure that the prescribed solution is clear and transparent b) use half-instilled IV solution before infusing a new one c) select a primary tubing of about 37 in (97 cm) long d) avoid replacing IV solutions every 24 hours
a) ensure that the prescribed solution is clear and transparent
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: a) Fluid overload b) Anaphylaxis c) Pulmonary embolism d) Allergic reaction
a) fluid overload
1) 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: 5.75 mg/dL (1.8 mEq/L) Based on these levels, the nurse would identify which imbalance? a) Hypokalemia b) Hypercalcemia c) Hypermagnesemia d) Hyponatremia
a) hypokalemia
Many chronic medical problems adversely affect a person's ability to maintain normal fluid, electrolyte, and acid-base homeostasis. What describes complications related to liver disease? a) Increased plasma levels of antidiuretic hormone lead to water excess b) The secretion of aldosterone and antidiuretic hormone is stimulated due to a lowered blood pressure, which results in extracellular fluid volume and water excess c) A disruption of acid-base balance occurs. A disruption in this organ's ability to excrete carbon dioxide causes the pH of the person's blood to fall d) There may be an abnormal loss or accumulation of sodium, chloride, potassium, and fluid in the body, resulting in extracellular fluid and water excesses or deficits. Hyperkalemia and hypocalcemia are common, and metabolic acidosis occurs in this disease's final stage.
a) increased plasma levels of antidiuretic hormone lead to water excess
Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking? a) Muscle cramping and tetany b) Muscle weakness, fatigue, and constipation c) Nausea, vomiting, and constipation d) Diminished cognitive ability and hypertension
a) muscle cramping and tetany
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? a) ordering type of solution, additive, amount, and duration b) preparing solution for administration c) performing venipuncture d) regulating the rate of administration
a) ordering type of solution, additive, amount, and duration
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? a) 75 mL/hr for the first 15 min, then 200 mL/hr b) 1 unit over 2-3 hrs, no longer than 4 hrs c) as fast as the client can tolerate d) 200 mL/hr
b) 1 unit over 2-3 hrs, no longer than 4 hrs
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? a) 12 cm H2O b) 3.5 cm H2O c) 5 cm H2O d) 9.5 cm H2O
b) 3.5 cm H2O
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? a) 90 drops/mL b) 60 drops/mL c) 30 drops/mL d) 120 drops/mL
b) 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? a) 167 gtt/min b) 83 gtt/min c) 42 gtt/min d) 5,000 gtt/min
b) 83 gtt/min
A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? a) I was breathing so fast because I was so anxious and in so much pain b) I've been taking antacids almost every 2 hours over the past several days c) I've had a fever for the past 3 days that just doesn't seem to go away d) I've had a GI virus for the past 3 days with severe diarrhea
b) I've been taking antacids almost every 2 hours over the past several days
The nurse is caring for a client whose blood type is A-. Which donor blood type does the nurse confirm as compatible for this client? a) B+ b) O- c) A+ d) AB-
b) O-
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? a) risk for infection related to inadequate personal hygiene b) acute confusion related to cerebral edema c) constipation related to immobility d) pain related to surgical incision
b) acute confusion related to cerebral edema
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? a) Apply a petroleum-based ointment and sterile occlusive dressing b) Apply pressure to insertion site for at least 3 minutes c) Instruct client to remain flat for 30 minutes d) Ask client to perform Valsalva maneuve
b) apply pressure to insertion site for at least 3 minutes
A registered nurse is overseeing the care of numerous clients on a busy acute medicine unit. Which task would be most safe to delegate to an LPN? a)removing a client's PICC in anticipation of the client's discharge b) changing the dressing on a client's peripheral IV site c) deaccessing a client's implanted port d) initiating a client's transfusion of packed red blood cells
b) changing the dressing on a client's peripheral IV site
The nurse is monitoring intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the I&O record? Select all that apply. a) Barbeque sandwich b) Cup of ice cream c) Serving of jello d) Infusion of intravenous solution e) 100 mL from melted ice chips f) Bowl of chili
b) cup of ice cream c) serving of jello d) infusion of IV solution e) 100 mL from melted ice chips
Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply. a) Monitoring edema b) Electrolyte management c) Nutrition management d) Hypervolemia management e) Fluid restriction d) Intravenous therapy
b) electrolyte management c) nutrition management f) intravenous therapy
The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing? a) Hypotonic, followed by isotonic b) Hypertonic c) Isotonic d) Hypotonic
b) hypertonic
Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium? a) If sodium is low, it means that there is not enough water b) Sodium is regulated by the renin-angiotensin-aldosterone system c) Normal serum sodium levels range from 145 to 155 mEq/L (145 to 155 mmol/L) d) Sodium is not regulated by natriuretic peptides
b) sodium is regulated by the renin-angiotensin-aldosterone system
A client has been prescribed 2 units of packed red blood cells. A type and cross-match has been performed and the first unit has arrived on the floor from the blood bank. When administering this client's blood transfusion, the nurse should perform which actions? Select all that apply. a) Obtain appropriate tubing and prime it with normal saline or lactated Ringer's b) Start the administration slowly for the first 15 minutes of the transfusion c) Take baseline vital signs and expect slight increases in blood pressure and heart rate after the infusion begins d) Collect the last 5 mL of the packed cells and send to the laboratory for culturing e) Ask another nurse to assist with confirming the order, blood group, and other vital information
b) start the administration slowly for the first 15 minutes of the transfusion e) ask another nurse to assist with confirming the order, blood group, and other vital information
The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. a) Manufacturer of the IV catheter b) Type of IV solution c) Rate of the IV solution d) Location of the IV catheter access e) Client's reaction to the procedure f) Gauge and length of the IV catheter
b) type of IV solution c) rate of the IV solution d) location of the IV catheter access e) client's reaction to the procedure f) gauge and length of the IV catheter
A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? a) 500 b) 3,750 c) 3,000 d) 1,000
c) 3,000
The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? a) I have never given blood before b) my blood type is B+ c) I received a blood transfusion in the United Kingdom d) my spouse would also like to donate blood
c) I received a blood transfusion in the United Kingdom
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? a) a 60 year old who is 3 days post MI and has been stable b) a 47 year old who had a colon resection yesterday and is reporting pain c) a newly admitted 88 year old with a 2 day history of vomiting and loose stools d) a 20 year old, 2 days postop open appendectomy who refuses to ambulate today
c) a newly admitted 88 year old with a 2 day history of vomiting and loose stools
What is the initial purpose of the action in which the nurse is engaging, during the preparation for the administration of a prescribed IV solution? a) avoiding contamination of the IV solution b) allowing for easy access to the entry site c) allowing for effective access to the solution d) avoiding the need for assistance with IV solution administration
c) allowing for effective access to the solution
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? a) a peripheral venous catheter inserted to the antecubital fossa b) a peripheral venous catheter inserted to the cephalic vein c) an implanted central venous access device (CVAD) d) a midline peripheral catheter
c) an implanted central venous access device (CVAD)
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? a) A man age 50 years b) A woman age 45 years c) An infant age 4 months d) An adolescent age 17 years
c) an infant age 4 months
When caring for a client who is on IV therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? a) apply antiseptic and a dressing b) elevate the client's head c) apply a warm compress d) position the client on the left side
c) apply a warm compress
What is the lab test commonly used in the assessment and treatment of acid-base balance? a) complete blood count b) basic metabolic panel c) arterial blood gas d) urinalysis
c) arterial blood gas
A nurse is performing a venipuncture on an older client. The client has visible veins that appear to roll. What nursing technique is most appropriate? a) Select a large-gauge needle b) Consider venipuncture in the foot where veins are less visible c) Avoid use of a tourniquet d) Use the client's nondominant hand to hold the vein in place
c) avoid use of a tourniquet
A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? a) muscle weakness b) metabolic acidosis c) cardiac irregularities d) increased intracranial pressure (ICP)
c) cardiac irregularities
A client is taking a diuretic. When implementing client education, what information should be included? a) decreased O2 levels b) increased sodium levels c) decreased K+ levels d) increased K+ levels
c) decreased K+ levels
edema happens when there is which fluid volume imbalance? a) water deficit b) extracellular fluid volume deficit c) extracellular fluid volume excess d) water excess
c) extracellular fluid volume excess
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? a) circulatory overload b) allergic reaction c) febrile reaction d) hemolytic reaction
c) febrile reaction
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? a) fluid inside cells b) fluid outside cells c) fluid in the tissue space between and around cells d) watery plasma, or serum, portion of blood
c) fluid in the tissue space between and around cells
A client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action? a) Change from infusion with an electronic pump to infusion by gravity b) Flush the IV with 2mL of 100 U/mL heparin c) Flush the IV with 3 mL of normal saline d) assess the area distal to the IV site for signs and symptoms of deep vein thrombosis
c) flush the IV with 3 mL of normal saline
Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance? a) renal retention of H ions b) hypoventilation c) increased respiratory rate d) increased excretion of bicarbonate ions by the kidneys
c) increased respiratory rate
The nurse is administering 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? a) sepsis b) infiltration c) phlebitis d) air embolism
c) phlebitis
Upon assessment of a client's peripheral IV 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: a) rapid fluid administration b) a systemic blood infection c) phlebitis d) an infiltration
c) phlebitis
The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client? a) Increased cardiac output b) Diaphoresis c) Renal failure d) Excessive use of laxatives
c) renal failure
What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution? a) To provide for effective time management in the administration of the prescribed IV solution b) To demonstrate effective nursing care in the administration of the prescribed IV solution c) To assure the IV solution is appropriate for this administration d) To assure effective administration of the prescribed IV solution
c) to assure the IV solution is appropriate for this administration
Which statement most accurately describes the process of osmosis? a) Water shifts from high-solute areas to areas of lower solute concentration b) Solutes pass through semipermeable membranes to areas of lower concentration c) Water moves from an area of lower solute concentration to an area of higher solute concentration d) Plasma proteins facilitate the reabsorption of fluids into the capillaries
c) water moves from an area of lower solute concentration to an area of higher solute concentration
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? a) estimate the amount of fluid that you think was excreted into the undergarment b) you only record urine output in an adult undergarment; you do not record diarrhea output c) 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) d) we do not record fluids absorbed into undergarments
c) weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47kg) = 1 pint (475 mL)
Which client would be a candidate for total parenteral nutrition? a) A client receiving intravenous antibiotics b) A client with DKA c) A postoperative appendectomy client d) A client with colitis and bloody diarrhea
d) a client with colitis and bloody diarrhea
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? a) dairy products b) bread products c)processed meat d) apricots
d) apricots
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? a) milk b) yogurt c) turkey d) banana
d) banana
Which is a common anion? a) potassium b) calcium c) magnesium d) chloride
d) chloride
A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status? a) Daily BUN and serum creatinine monitoring b) Daily electrolyte monitoring c) Output measurements d) Daily weights
d) daily weights
The process of filtration begins at the: a) loop of Henle b) Bowman's capsule c) collecting ducts d) glomerulus
d) glomerulus
During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible? a) Edema b) Hypovolemia c) Circulatory overload d) Hypervolemia
d) hypervolemia
A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate? a) infiltration is the inflammation of the vein, while phlebitis is a localized irritation b) infiltration occurs when an IV is improperly placed, and phlebitis indicates circulatory overload c) infiltration is a localized blood clot, and phlebitis occurs when an IV is improperly placed d) infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein
d) infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein
Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? a) colloid b) hypotonic c) hypertonic d) isotonic
d) isotonic
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: a) High magnesium b) High sodium c) Low potassium d) Low calcium
d) low calcium
The nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action? a) by applying stabilizing pressure to the catheter b) by pulling the dressing toward the insertion site c) not performing the intervention under sterile conditions d) not wearing gloves when performing this intervention
d) 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? a) continue to use the current IV tubing b) tell the client the infusion will be administered later in the shift c) notify the health care provider to request a new prescription for an IV infusion d) obtain new IV tubing and spike the infusion bag without touching the tip of the tubing
d) obtain new IV 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? a) have a loved one tell the client to drink more b) leave water on the bedside table c) ask the client every hour to drink more fluid d) offer small amounts of preferred beverage frequently
d) offer small amounts of preferred beverage frequently
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? a) asking the client to pump their fist several times b) asking if the client is right or left handed c) palpating the veins on the nondominant hand d) placing the tourniquet on the upper arm for 2 minutes
d) placing the tourniquet on the upper arm for 2 minutes
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? a) Apply a new dressing and observe for signs of infection over the next several hours b) Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air c) Decontaminate the visible portion of the catheter, and then gently reinsert d) Remove the IV catheter and reinsert another in a different location
d) remove the IV catheter and reinsert another in a different location
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? a) Prepare to give an antihistamine b) Infuse saline at a rapid rate c) Administer oxygen d) Stop the transfusion immediately
d) stop the transfusion immediately
The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy should the nurse do first? a) prepare solution for administration b) perform venipuncture c) regulate the rate of administration d) verify the orders for type of solution and amount of infusion
d) verify the orders for type of solution and amount of infusion
