Chapter 42 Fundamental – Flashcards
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What are examples of transcellular fluids? Select all that apply. 1 Synovial fluid 2 Peritoneal fluid 3 Cerebrospinal fluid 4 Fluid outside the cells 5 Fluid outside the blood vessels
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1,2.3
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A patient with chronic diarrhea shows Chvostek's sign. What might be the reason behind the patient's condition? Select all that apply. 1 Hypokalemia 2 Hypocalcemia 3 Hyponatremia 4 Hypomagnesemia 5 Hypophosphatemia
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2,4
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Which ions are cations? Select all that apply. 1 Sodium 2 Calcium 3 Chloride 4 Potassium 5 Bicarbonate
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124
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A patient on intravenous fluids develops shortness of breath and edema of the extremities. Upon auscultation, the nurse hears crackles in the dependent parts of the lungs. Which nursing intervention is beneficial in this condition? 1 Reducing the flow rate 2 Starting a new line in another extremity 3 Applying a warm and moist compress at the site 4 Removing the catheter and applying sterile dressing
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1
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A patient with a 3% sodium chloride intravenous line develops shortness of breath and edema in the extremities. Upon auscultation, the nurse hears crackling sounds in the dependent parts of the lungs. Which nursing interventions are beneficial in this condition? Select all that apply. 1 Discontinuing the infusion 2 Elevating the head of the bed 3 Notifying the health care provider 4 Starting a new line in another extremity 5 Removing the line and applying sterile dressing
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1,2,3
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The skin of a patient taking intravenous fluids appears blanched, cool to the touch, and edematous. Upon touch, the patient reports pain. Which complication does this represent? 1 Phlebitis 2 Extravasation 3 Local infection 4 Circulatory overloa
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2
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A patient who is undergoing intravenous therapy develops redness, inflammation, and swelling at the catheter site. After further assessment, the nurse finds purulent drainage from the injection site. Which nursing interventions are useful in this situation? Select all that apply. 1 Elevating the extremity 2 Cleaning the skin with alcohol 3 Raising the head of the patient's bed 4 Applying a pressure dressing over the site 5 Inserting a new intravenous line in another extremity
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2, 5
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patient with a head injury is admitted to the emergency unit. The laboratory test reports reveal the patient's sodium level as 109 mEq/L. Which condition does the patient have? 1 Diabetes insipidus 2 Fatal cardiac dysrhythmias 3 Type B chronic obstructive pulmonary disease 4 Syndrome of inappropriate antidiuretic hormone
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4
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A patient develops a mild allergic reaction during a blood transfusion. Which should the nurse administer to manage this allergic reaction? 1 Sympathomimetics 2 Corticosteroids 3 Antihistamines 4 Vasoconstrictors
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3
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Which fluid electrolyte imbalance may develop in a patient who consumes spironolactone? 1 Hypokalemia 2 Hyperkalemia 3 Hyponatremia 4 Hypomagnesemia
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2
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What is the normal range of values of phosphate in human blood? 1 1.5 to 2.5 mEq/L 2 2.7 to 4.5 mg/dL 3 3.5 to 5.0 mEq/L 4 4.5 to 5.3 mg/dL
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2
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A patient with a cardiac history is taking the diuretic furosemide and is seen in the emergency department for muscle weakness. Which laboratory value should the nurse assess first? 1 Serum albumin 2 Serum sodium 3 Hematocrit 4 Serum potassium
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4 Potassium-wasting diuretics such as furosemide increase potassium urinary output and can cause hypokalemia unless potassium intake also increases. Hypokalemia causes muscle weakness.
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Which factor can be a risk for causing extracellular volume deficit (ECV)? 1 Hemorrhage 2 Sodium-rich diet 3 Intravenous therapy 4 Oliguric renal disease
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1
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Which drugs can cause hypokalemia? Select all that apply. 1 Captopril 2 Fluoxetine 3 Prednisone 4 Furosemide 5 Spironolactone
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3,4
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A patient has extracellular volume deficit due to diarrhea. How should the nurse correct the volume deficit in the patient? 1 Provide caffeinated fluids. 2 Provide low-sodium fluids. 3 Provide fluids that contain lactose. 4 Provide fluids that contain sodium
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4
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Which activities can the nurse delegate to nursing assistive personnel (NAP)? Select all that apply. 1 Measuring oral intake and urine output 2 Preparing intravenous (IV) tubing for routine change 3 Reporting an IV container that is low in fluid 4 Changing an IV fluid container 5 Reporting an electronic infusion device alarm
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1,3,5
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After reviewing a patient's laboratory reports, the nurse instructs him or her to consume dairy products. Which electrolytic imbalance may have prompted this instruction? 1 Hypokalemia 2 Hyperkalemia 3 Hypocalcemia 4 Hypercalcemia
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3
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ow much fluid is lost daily through feces in a healthy adult? Record your answer using a whole number. __________ mL
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100 mL of fluid is excreted through feces daily
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Which patient is most at risk of developing hypokalemia? 1 Patient with cancer 2 Patient with oliguria 3 Patient with diarrhea 4 Patient with acute pancreatitis
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3
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Which defining characteristics are consistent with fluid volume deficit? 1 A weight loss of 1 lb (0.5 kg) in 1 week, pale yellow urine 2 Engorged neck veins when upright, bradycardia 3 Dry mucous membranes, thready pulse, tachycardia 4 Bounding radial pulse, flat neck veins when supine
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3
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What does hypocalemia cause
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Cats go numb
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Which clinical criteria of phlebitis should receive a grade of 3? 1 Formation of streak 2 Pain at access site with only erythema 3 Palpable venous cord greater than 2.54 cm 4 Erythema at access site with or without pain
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1
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Which complication of intravenous (IV) therapy indicates the need for pressure at the site? 1 Bleeding 2 Phlebitis 3 Infection 4 Fluid overload
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1
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Which action can be performed to prevent the risk of dislodging the catheter during intravenous (IV) therapy? 1 Inserting a volume-control device into the IV container 2 Curling the loop of short or long IV tubing alongside the arm 3 Instructing the patient to avoid raising the arm with the catheter 4 Attaching the distal end of the IV tubing to a needleless connector
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2
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Which type of dextrose solution is considered isotonic? 1 Dextrose 5% in water 2 Dextrose 10% in water 3 Dextrose 5% in 0.9% sodium chloride 4 Dextrose 5% in 0.45% sodium chloride
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1
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Which immediate intervention would be beneficial in a patient who developed redness and pain at the infusion site? 1 Stopping the infusion 2 Elevating the extremity 3 Applying warmth to the site 4 Notifying the health care provider
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1
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The primary health care provider orders the nurse to culture the drainage from an area on a patient's skin. Which complication of intravenous therapy should the nurse suspect? 1 Phlebitis 2 Bleeding 3 Local infection 4 Circulatory overload
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3
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The health care provider's order is 1000 mL 0.9% NaCl IV over 6 hours. Which rate should the nurse program into the infusion pump? 1 125 mL/hr 2 167 mL/hr 3 200 mL/hr 4 1000 mL/hr
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2
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A nurse is assessing the clinical markers of vascular volume. Which patient may require intravenous (IV) therapy due to extracellular fluid volume deficit? 1 A patient with a full pulse rate 2 A patient with dark yellow urine 3 A patient with increased blood pressure 4 A patient with crackles in the lobe of the lung
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2
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The registered nurse is instructing a nursing student about the interventions that must be performed when there is any evidence of complication due to infusion therapy. Which instruction would the nurse follow for a patient with circulatory overload? 1 "Reduce the intravenous (IV) flow." 2 "Elevate the extremity." 3 "Disconnect the IV tubing." 4 "Discontinue the IV infusion."
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1
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Which statement is true regarding vascular access devices (VADs)? 1 The word "central" applies to the insertion site. 2 Central catheters are used for fluid restoration. 3 Peripheral catheters are used for long-term antibiotic administration. 4 Peripheral catheters are more effective for administration of large volumes of fluids
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2
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Before initiating intravenous (IV) therapy, for which clinical markers of interstitial volume would the nurse assess? 1 Skin turgor 2 Urine output 3 Capillary refill 4 Auscultation of lungs
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1
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Which complication involves the entry of an intravenous solution containing a vesicant drug into the subcutaneous tissue around the venipuncture site? 1 Bleeding 2 Phlebitis 3 Infiltration 4 Extravasation
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4
