question

Which findings indicate that a patient may have hypervolemia?

answer

increased, bounding pulse. Jugular venous distention. Presence of crackles. Elevated blood pressure. Skin pale and cool to touch.

question

What is the term for a difference in concentration of particles that is greater on the one side of a permeable membrane than the other side?

answer

Concentration gradient.

question

A patient's blood osmolarity is 302 mOsm/L. What manifestation does the nurse expect to see in the patient?

answer

Thirst

question

An older adult patient at risk for fluid and electrolyte problems is vigilantly monitored by the nurse for the first indication of a fluid balance problem. What is this indication?

answer

Mental status changes.

question

What are the consequences for a patient who does not meet the obligatory urine output?

answer

Lethal electrolyte imbalances. Toxic buildup of nitrogen. Acidosis.

question

What is the minimum amount of urine output per day needed to excrete toxic waste products?

answer

400 to 600 mL

question

Patients with which conditions are at greatest risk for deficient fluid volume?

answer

Fever of 103 F. Extensive burns. Thyroid crisis. Continuous fistula drainage. Diabetes insipidus.

question

The nurse is working in a long term care facility where there are numerous patients who are immobile and at risk for dehydration. Which task is best to delegate to the unlicensed assistive personnel?

answer

Offer patients a choice of fluids every 1 to 2 hours.

question

The nurse is assisting a community group to plan a family sports day. In order to prevent dehydration, what beverage does the nurse suggest be supplied?

answer

bottled water

question

Which factors affect the amount and distribution of body fluids?

answer

Age. Gender. Body fat?

question

The nurse is caring for a patient with hypovolemia secondary to severe diarrhea and vomiting. In evaluating the respiratory system for this patient, what does the nurse expect to find on assessment?

answer

Increased respiratory rate, because the body perceives hypovolemia as hypoxia.

question

The nurse is assessing skin turgor in a 65 year old patient. What is the correct technique to use with this patient?

answer

Pinch the skin over the sternum and observe for tenting and resumption of skin to its normal position after release.

question

The emergency department nurse is caring for a patient who was brought in for significant alcohol intoxication and minor trauma to the wrist. What will serial hematocrits for this patient likely show?

answer

Hemoconcentration

question

The nurse is caring for several older adult patients who are at risk for dehydration. Which task can be delegated to the UAP?

answer

Stay with patients while they drink and note the exact amount ingested.

question

The nurse assessing a patient notes a bounding pulse quality, neck vein distention when supine, presence of crackles in the lungs and increasing peripheral edema. What fluid disorder do these findings reflect?

answer

Fluid volume excess.

question

A patient is at risk for fluid volume excess and dependent edema. Which task does the nurse delegate to the UAP?

answer

Assist the patient to change position every 2 hours.

question

The nurse is reviewing orders for several patients who have risk for fluid volume excess. For which patient condition does the nurse question an order for diuretics?

answer

End- stage renal disease

question

The UAP reports to the nurse that a patient being evaluated for kidney problems has produced a large amount of pale yellow urine. What does the nurse do next?

answer

Assess the patient for signs of fluid imbalance and check the specific gravity of the urine.

question

On admission, a patient with pulmonary edema weighed 151 lbs; now the patient's weight is 149 lbs. Assuming the patient was weighed both times with the same clothing, same scale, and same time of day, how many milliliters of fluid does the nurse estimate the patient has lost?

answer

1,000

question

The nurse is giving discharge instructions to the patient with advanced heart failure who is at continued risk for fluid volume excess. For which physical change does the nurse instruct the patient to call the health care provider?

answer

Greater than 3 lbs. gained in a week or greater than 1 to 2 lbs. Gained in a 24 hour period.

question

The nurse is caring for several patients at risk for falls because of fluid and electrolyte imbalances. Which task related to patient safety and fall prevention does the nurse delegate to the UAP?

answer

Help the incontinent patient to toilet every 1 to 2 hours.

question

The nurse is assessing a patient's urine specific gravity. The value is 1.035. How does the nurse interpret this result?

answer

Dehydration

question

What are the functions of potassium in the body?

answer

Intracellular osmolarity and volume. Regulates glucose use and storage. Helps maintain normal cardiac rhythm.

question

Which statements are true about electrolyte chloride and its role in the cellular environment of the body?

answer

It maintains plasma acid balance. It provides electroneutrality in relation to sodium. Chloride imbalances occur with alterations in body water volume.

question

What impacts does sodium have on body function?

answer

Maintains electroneutrality. Regulates water balance. Regulates plasma osmolarity.

question

What impacts does phosphorus have in the body?

answer

Activates vitamins and enzymes. Assists in the formation of adenosine triphosphate (ATP). Assists in cell growth and metabolism.

question

The electrolyte magnesium is responsible for which functions?

answer

Carbohydrate metabolism. Contraction of skeletal muscle. Formation of ATP.

question

A patient is talking to the nurse about sodium intake. Which statement by the patient indicates and understanding of high sodium food sources?

answer

"I love Chinese food, but I gave it up because of the soy sauce."

question

Which statement best explains how ADH affects urine output?

answer

It increases permeability to water in the tubules causing a decrease in urine output.

question

A patient with hyponatremia would have which gastrointestinal findings upon assessment?

answer

Hyperactive bowel sounds on auscultation mostly in the left lower quadrant. Bowel movements that are frequent and watery. Abdominal cramping.

question

The nurse is caring for a patient with severe hypocalcemia. What safety measures does the nurse put in place for this patient?

answer

Turn on a bed alarm when the patient is in bed. Place the patient on a low bed. Ensure the side rails are up when the patients in bed.

question

Which patients are at risk for developing hyponatremia?

answer

Postoperative patient who has been NPO for 24 hours with no IV fluid infusing. Patient receiving excessive intravenous fluids with 5% dextrose. Diabetic patient with blood glucose of 250 mg/dL Tennis player in 100 F weather who has been drinking water.

question

The nurse is evaluating the lab results of a patient with hyperaldosteronism. What abnormal electrolyte finding does the nurse expect to see?

answer

Hypernatremia.

question

The UAP informs the nurse that a patient with hypernatremia who was initially confused and disoriented on admission to the hospital is now trying to pull out the IV access and Foley catheter. What is the nurse's first action.

answer

Assess the patient.

question

Patients with which conditions are at risk for developing hypernatremia?

answer

Severe diarrhea. Poor kidney function. Profound diaphoresis.

question

The provider has ordered therapy for a patient with low sodium and signs of hypervolemia. Which diuretic is best for this patient?

answer

Conivaptan (Vaprisol)

question

The nurse is assessing a patient with a mild increase in sodium level. What early manifestations does the nurse observe in this patient?

answer

Muscle twitching and irregular muscle contractions.

question

The nurse is caring for a patient with hypernatremia caused by fluid and sodium losses. What type of IV solution is best for treating this patient?

answer

0.45% sodium chloride

question

Which serum value does the nurse expect to see for a patient with hyponatremia?

answer

Sodium less than 136 mEq/L

question

The nurse is caring for psychiatric patient who is continuously drinking water. The nurse monitors for which complication related to potential hyponatremia?

answer

Change in mental status/increased intracranial pressure.

question

What interventions are appropriate for a patient with mild hypernatremia caused by excessive fluid loss?

answer

Hypotonic intravenous infusion. Ensure adequate water intake.

question

The nurse is caring for several patients at risk for fluid and electrolyte imbalances. Which patient problem or condition can result in a relative hypernatremia.

answer

NPO Status

question

The nurse is caring for an older adult patient whose serum sodium level is 150 mEq/L. The nurse assesses the patient for which common manifestations associated with this sodium level?

answer

Increased pulse rate. Muscle weakness.

question

Which precaution or intervention does the nurse teach a patient at continued risk for hypernatremia?

answer

Read labels on canned or packaged foods to determine sodium content.

question

The nurse identifies the priority problem of potential for injury for a patient with hyponatremia. What is the etiology of this priority patient problem?

answer

Altered mental capabilities

question

A patient with renal failure that results in hypernatremia will require which interventions?

answer

Administration of furosemide (Lasix). Hemodialysis. Dietary sodium restriction.

question

The nurse is teaching a patient to recognize foods that are high in sodium. Which food items does the nurse use as examples?

answer

Soup with saltine crackers. Bacon and eggs. Egg roll with soy sauce.

question

A hospitalized patient who is known to be homeless has been diagnosed with severe malnutrition, end stage renal disease, and anemia. He is transfused with 3 units of packed red blood cells. Which potential electrolyte imbalance does the nurse anticipate to occur in this patient?

answer

Hyperkalemia

question

A newly admitted patient with congestive heart failure has a potassium level of 5.7 mEq/L. How does the nurse identify contributing factors for the electrolyte imbalance?

answer

Obtain a list of the patient's home medications. Assess the patient for hyperkalemia. Ask about the patient's method of taking medications at home.

question

A young adult patient is in the early stages of being treated for severe burns. Which electrolyte imbalance does the nurse expect to assess in this patient?

answer

Hyperkalemia

question

A patient with hypokalemia is likely to have which conditions?

answer

Metabolic alkalosis. Chronic obstructive pulmonary disease. Paralytic ileus.

question

The nurse is taking care of a trauma patient who was in a motor vehicle accident. The patient has a history of hypertension, which is managed with spironolactone (Aldactone). This patient is at risk for developing which electrolyte imbalance?

answer

Hyperkalemia.

question

A patient with lung cancer is admitted to the hospital for respiratory distress. Which imbalance does the nurse expect this patient to have?

answer

Respiratory acidosis.

question

Which serum laboratory value does the nurse expect to see in the patient with hypokalemia?

answer

Potassium less than 3.5 mEq/L

question

The patient's potassium level is 2.5 mEq/L. Which clinical findings does the nurse expect to see when assessing this patient?

answer

General skeletal muscle weakness. Lethargy. Weak hand grasps.

question

The nurse administering potassium to a patient carefully monitors the infusion because of the risk for which condition?

answer

Cardiac dysrhythmia

question

Which changes on a patient's electrocardiogram reflect hyperkalemia?

answer

Tall peaked T waves

question

The nurse is teaching the patient about hypokalemia. Which statement by the patient indicates a correct understanding of the treatment of hypokalemia?

answer

"When I take the liquid potassium in the evening, I'll eat a snack beforehand."

question

The nurse is caring for a patient who takes potassium and digoxin. For what reason does the nurse monitor both laboratory results?

answer

Digoxin toxicity can result if hypokalemia is present.

question

Which serum laboratory value does the nurse expect to see in a patient with hyperkalemia?

answer

Potassium greater than 5.0 mEq/L

question

A patient has an elevated potassium level. Which assessment findings are associated with hyperkalemia?

answer

Numbness in hands, feet, and around the mouth. Frequent, explosive diarrhea stools. Irregular heart rate and hypotension.

question

The nurse is teaching a patient with hypokalemia about foods high in potassium. Which food items does the nurse recommend to this patient?

answer

Soybeans. Potatoes. Cantaloupe.

question

A patient's serum potassium value is below 2.8 mEq/L. The patient is also on digoxin. The nurse quickly assesses the patient for which cardiac problem before notifying the provider?

answer

Cardiac dysrhythmia.

question

Which potassium levels are within normal limits?

answer

3.5 mmol/L. 4.5 mmol/L. 5.0 mmol/L.

question

A patient has hyperkalemia resulting from dehydration. Which additional laboratory findings does the nurse anticipate for this patient?

answer

Increased hematocrit and hemoglobin levels.

question

A 65 year old patient has a potassium laboratory value of 5.0 mEq/L. How does the nurse interpret this value?

answer

Normal for the patient's age

question

A patient's potassium level is low. What change in the cardiovascular system does the nurse expect to see related to hypokalemia?

answer

Weak, thready pulse.

question

Plasma is part of which components?

answer

Extracellular compartment. Interstitial fluid. Intravascular fluid.

question

Which fluid has the highest corresponding electrolyte content?

answer

Extracellular fluid is highest in sodium and chloride.

question

Which component has a high content of potassium and phosphorus?

answer

Intracellular fluid

question

A patient with low potassium must have an IV potassium infusion. The pharmacy sends a 250 mL IV bag of dextrose in water with 40 mEq of potassium. The label is marked "to infuse over 1 hour." What is the nurse's best action?

answer

Double check the provider's order and call the pharmacy.

question

An older adult patient needs an oral potassium solution, but is refusing it because it has a strong and unpleasant taste. What is the best strategy the nurse uses to administer the drug?

answer

Ask the patient's preference of juice and mix the drug with a small amount.

question

A patient has a low potassium level and the provider has ordered an IV infusion. Before starting an IV potassium infusion, what does the nurse assess?

answer

Intravenous line patency

question

Which foods will the nurse instruct a patient with kidney disease and hyperkalemia to avoid?

answer

Dried beans. Potatoes. Cantaloupe.

question

Which assessment findings are related to prolonged hypercalcemia?

answer

Prolonged bradycardia. Shortened QT interval. Impaired blood flow. Profound muscle weakness.

question

Which nursing interventions apply to patients with hypercalcemia?

answer

Administer IV normal saline (0.9% sodium chloride). Measure the abdominal girth. Monitor for ECG changes.

question

The nurse is reviewing the laboratory calcium level results for a patient. Which value indicates mild hypocalcemia?

answer

8.0 mg/dL

question

A patient with a recent history of anterior neck injury reports muscle twitching and spasms with tingling in the lips, nose, and ears. The nurse suspects these symptoms may be caused by which condition?

answer

Hypocalcemia

question

Which conditions cause a patient to be at risk for hypocalcemia

answer

Crohn's disease. Acute pancreatitis. Removal or destruction of parathyroid glands. Immobility.

question

The nurse is assessing the patient with a risk for hypocalcemia. What is the correct technique to test for Chvostek's sign?

answer

Tap the patient's face just below in front of the ear to trigger facial twitching of one side of the mouth, nose, and cheek.

question

The nurse is caring for several patients with electrolyte imbalances. Which intervention is included in the plan of care for a patient with hypocalcemia?

answer

Placing the patient on seizure precautions.

question

Which clinical condition can result from hypocalcemia?

answer

Increased intestinal and gastric motility

question

Which patient is at greatest risk of developing hypocalcemia?

answer

60 year old African American woman with a recent ileostomy.

question

Which is a preventive measure for patients at risk for developing hypocalcemia?

answer

Increase daily dietary calcium and vitamin D intake.

question

The patient who has undergone which surgical procedure is most at risk for hypocalcemia?

answer

Thyroidectomy

question

Which medication order does the nurse clarify before administering the drug to a patient with hypomagnesemia?

answer

Magnesium sulfate 1 g IM every 6 hours for four doses.

question

Which are typical nursing assessment findings for a patient with hypocalcemia?

answer

Positive Chvostek's sign. Diarrhea. Prolonged ST interval. Elevated T Wave

question

Which intervention does the nurse implement for a patient with hypocalcemia?

answer

Provided adequate intake of vitamin D and calcium rich foods.

question

A patient has chronic kidney disease. Which electrolyte imbalance often associated with hypocalcemia and CKD does the nurse monitor for?

answer

Hyperphosphatemia

question

A patient with hypocalcemia is in need of supplemental diet therapy. Which foods does the nurse recommend to provide both calcium and vitamin D?

answer

Cheese. Milk.

question

A patient shows a positive Trousseau's or Chovestek's sign. The nurse prepares to give the patient which urgent treatment?

answer

IV Calcium

question

Which are preventive nursing interventions for a patient at risk for developing hypercalcemia?

answer

Administer D5W. Ensure adequate hydration. Discourage weight bearing activity such as walking.

question

The nurse caring for a patient with hypercalcemia anticipates orders for which medications?

answer

Calcitonin (Calcimar). Furosemide (Lasix). Plicamycin (Mithracin).

question

The nurse instructs the UAP to use precautions with moving and using a lift sheet for which patient with an electrolyte imbalance?

answer

Older woman with hypocalcemia.

question

A patient's lab results show a decrease in serum phosphorus level. The nurse expects to see a reciprocal increased change in which serum level?

answer

Calcium

question

Which intervention does the nurse include for a patient with moderate hypophosphatemia?

answer

Administration of oral Vitamin D and phosphorus supplements.

question

Which manifestations reflect severe hypophosphatemia?

answer

Profound muscle weakness. Irritability. Cardiac muscle damage.

question

Which factors can cause hyperphophatemia?

answer

Tumor lysis syndrome. Hypoparathyroidism. Decreased renal excretion.

question

What are common causes of hypophosphate-emia?

answer

Hypercalcemia. Uncontrolled diabetes. Use of magnesium based antacids

question

A patient with which condition would need priority nursing assessment?

answer

Irritability

question

The health care provider orders magnesium sulfate for a patient with severe hypomagnesemia. What is the preferred route of administration for this drug?

answer

Intravenous

question

The nurse is assessing a patient with severe hypermagnesemia. Which assessment findings are associated with this electrolyte imbalance?

answer

Bradycarida and hypotension.

question

A patient in the hospital has a severely elevated magnesium level. Which intervention should the nurse complete first?

answer

Discontinue parenteral magnesium.

question

A patient has a magnesium level of 0.8 mg/dL. Which treatment does the nurse expect to be ordered for this patient?

answer

IV magnesium sulfate and discontinuation of diuretic therapy.

question

The nurse monitors the effectiveness of magnesium sulfate by assessing which factor every hour?

answer

Deep tendon reflexes.

question

Which condition places a patient at risk for hypocalcemia, hyperkalemia, and hypernatremia?

answer

Chronic kidney disease.

question

A patient with congestive heart failure is receiving a loop diuretic. The nurse monitors for which electrolyte imbalances?

answer

Hypocalcemia. Hypokalemia. Hyponatremia.

question

The nurse is preparing to start an infusion of 10% dextrose. Why would the nurse infuse the solution through a central line?

answer

Osmolarity of the solution could cause phlebitis or thrombosis.

question

A patient is in the hospital for his first chemotherapy treatment for lung cancer. Which IV access methods are appropriate for this patient?

answer

Peripherally inserted central catheter. Tunneled central venous catheter. Implanted port.

question

A patient has a peripherally inserted central catheter placed and is ordered to receive IV cisplatin (platinol). The drug has infiltrated into the tissue and redness is observed in the right lower side of the neck. What is the nurse'es first action?

answer

Stop infusion and disconnect the IV line from the administration set.

question

The nurse is preparing to give a patient IV drug therapy. What information does the nurse need before administering the drug?

answer

Indications, contraindications, and precautions for IV therapy. Appropriate dilution, pH, and osmolarity of solution. Rate of infusion and dosage of drugs. Compatibility with other IV medications. Specifics of monitoring because of immediate effect.

question

The charge nurse is reviewing IV therapy orders. What information must be included in each order?

answer

Specific type of solution. Rate of administration. Specific drug dose to be added to the solution.

question

The nurse must insert a short peripheral IV catheter. In order to decrease the risk of deep vein thrombosis or phlebitis, which vein does the nurse choose for the infusion site?

answer

Forearm.

question

A patient requires IV therapy via a peripheral line. What considerations does the nurse use when inserting the peripheral IV?

answer

Start with more distal sites, such as the hand veins. Choose the patient's nondominant arm. Do not use the arm if the patient had a mastectomy on that side. Avoid placing an IV over the palm side of the wrist.

question

The nurse is assessing a patient's IV site and identifies signs and symptoms of infiltration. What is the first action that the nurse implements for this patient?

answer

Stops the infusion.

question

Which items does the nurse include in the documentation after completing the insertion of a PICC?

answer

Type of dressing applied. Type of IV access device used. Location and vein that was used for insertion.

question

The nurse is selecting a site for peripheral IV insertion. Which patient condition influences the choice of left versus right upper extremity?

answer

Regular renal dialysis with a shunt in the left upper forearm.

question

The nurse is attempting to insert a peripheral IV when the patient reports tingling and a feeling like "pins and needles." What does the nurse do next?

answer

Stop immediately, remove the catheter and choose a new site.

question

A patient has been on prolonged steroid therapy. In assessing the patient for IV insertion. What finding does the nurse expect see?

answer

Ecchymosis and possibly a hematoma

question

Under what circumstances does the nurse elect to use only one secondary set rather than a secondary set for each medication?

answer

When the medications are compatible.

question

When using an intermittent administration set to deliver medications, how often does the infusion Nurses Society recommend that the set be changed?

answer

Every 24 hours.

question

The nurse is supervising a student nurse who is preparing an IV bag with IV administration tubing. For which action by the student nurse must the charge nurse intervene?

answer

The student touches the tubing spike.

question

The nurse is caring for a patient with a Groshong catheter. According the manufacturer's recommendations, which technique does the nurse use in maintaining this type of catheter?

answer

Flush the catheter with saline.

question

A patient has a PICC placed by an IV therapy nurse at the bedside. Before using the catheter, how is its placement verified?

answer

A chest x - ray is taken, which shows the catheter tip in the lower superior vena cava.

question

A patient requires a nontunneled percutaneous central catheter. What is the nurse's role in this procedure?

answer

Place the patient in Trendelburg position.

question

A patient requires and infusion of packed red blood cells. Which factor allows the nurse to infuse the PRBCs through the patient's PICC?

answer

Lumen size of the PICC is 4 Fr or larger

question

Which patient is the most likely candidate for a tunneled central venous catheter?

answer

Patient in need of permanent parental nutrition

question

Which nursing interventions are implemented when caring for a patient with an implanted port?

answer

Before puncture, palpate the port to locate the septum.

question

A 65 year old patient has been receiving IV fluids at 100mL/hr of D5 1/2% normal saline for the past 3 days, along with IV antibiotic therapy. After receiving the new antibiotic, the patient reports chills and a headache. On assessment, the patient's temperature is elevated. What complication do these assessment findings indicate?

answer

Catheter related infection in the blood.

question

A patient has a central line inserted in the vena cava. The nurse assesses the patient for which potential complications related to the procedure?

answer

Hemothorax. Air embolism.

question

The nurse is helping the provider insert a central line when the patient develops chest pain and shortness of breath with decreased breath sounds and restlessness. What does the nurse do next?

answer

Administer oxygen, remove the catheter, place an occlusive dressing, and order a STAT chest X-Ray.

question

A triple-lumen catheter central line is inserted in a patient. What does the nurse do immediately after the procedure?

answer

Get a portable chest x-ray and hold IV fluids until results are obtained.

question

After a tubing change to a patient's central line, the line is later found to be disconnected from the catheter. The patient develops chest pain and restlessness, heart rate of 120bpm, BP drops to 90/40mmHg, and O2 Sats. are 89%. What does the nurse do next?

answer

Place the patient in Trendelenburg position on the left side, clamp the catheter, and notify the provider.

question

Which nursing interventions are essential to prevent an infection in a patient with a central line?

answer

Use aseptic technique when administering medications and changing tubing. Use sterile technique when inserting a central line. Use proper handwashing and nonsterile gloves before coming into contact with a central line.

question

A patient with an implanted port is discharged home and will receive long term therapy on an outpatient basis. How frequently must the port be flushed between courses of therapy?

answer

Monthly.

question

The nurse is preparing to deliver IV infusion therapy through an implanted port. What technique does the nurse use to access the port?

answer

Palpate the port to locate the septum, scrub, and then access with a Huber needle.

question

A patient is to be discharged home with an implanted port and needs discharge instructions on prescribed medication administration. Which instructions must the nurse give to the patient and family member who will be assisting the patient?

answer

The skin will be punctured over the port when the port is accessed. When the port is not accessed, no dressing needs to be applied. The port must be flushed after each use.

question

The nurse is preparing to administer IV infusion therapy to a patient. When is the choice of using a glass container appropriate?

answer

When the drug is incompatible with a plastic container.

question

A patient requires a 2 month course of antibiotics to treat a resistant infection. Which device is chosen for this therapy?

answer

PICC

question

The nurse is attaching an administration set to a central venous catheter. Which type of equipment decreases the risk of accidental disconnection or leakage?

answer

Luer-Lok connector

question

The nurse is adding a filter to an IV administration setup. Where is the best place to add the filter to the IV line?

answer

As close as possible to the catheter hub.

question

Which safety measures does the nurse apply to decrease the risk of catheter related blood stream infection (CR-BSI) related to needleless systems?

answer

Do not tape connections between tubing sets. Use evidence-based hand hygiene guidelines from the CDC and the Occupational Safety and Health Administration (OSHA). Minimize traffic in and out of the patient's room during insertion of the device.

question

A patient is receiving IV therapy via an infusion pump. What is a nursing responsibility related to the therapy and equipment?

answer

Monitor the patient's infusion site and rate.

question

Which characteristics apply to IV infusion pumps?

answer

Delivers fluids under pressure. Is pole-mounted or ambulatory and portable. Is best for accurate infusion.

question

The nurse is assessing a patient's IV insertion site. What features must the nurse look for during the assessment?

answer

Observe for redness and swelling. Check that the dressing is clean and dry. Ensure that the dressing is clean and dry. Observe for hardness or drainage.

question

A patient's central venous IV site is covered with a transparent membrane dressing. How often does the nurse change this dressing?

answer

At least every 7 days.

question

A patient is ordered to receive peripheral parenteral nutrition (PPN). What type of access device is appropriate for this patient?

answer

PICC

question

An external long term IV catheter is required for hemodialysis of a hospitalized patient. Which statements are true about this patient's venous access device?

answer

It should not be used for administration of other fluids or medications except in an emergency. Venous thrombosis is a common problem with hemodialysis access. A tunneled catheter with large lumen is required for hemodialysis.

question

The nurse has removed the dressing form a patient's central venous catheter site. In order to monitor the catheter position, what does the nurse do?

answer

Note the length of the catheter external to the insertion site.

question

The nurse is caring for a patient with a central venous catheter. What measure does the nurse use to prevent air emboli when changing the administration set or connectors?

answer

The patient lies flat so the catheter site is below the heart. Use the pinch clamp that can be closed during the procedure. Ask the patient to perform the Valsalva maneuver by holding the breath and bearing down.

question

After assessing the patency of a patient's IV catheter, the nurse attempts to flush the catheter and meets resistance. What does the nurse do next?

answer

Stop the flush attempt and discontinue the IV.

question

The nurse is flushing a patient's short peripheral IV catheter. What does the nurse typically use for this procedure?

answer

3 mL of normal saline.

question

The patient is ready for discharge. Which accommodations must the nurse follow to remove the patient's peripheral catheter?

answer

Hold pressure on the site until hemostasis is achieved. Assess the catheter tip to make sure it is intact and completely removed. Slowly withdraw the catheter from the skin. Remove the peripheral catheter dressing. Document catheter removal and appearance of IV site.

question

The nurse is attempting to remove a PICC line and feels resistance. What technique does the nurse use first to attempt to resolve this problem?

answer

Use simple distraction techniques and deep breathing.

question

The nurse is assessing a short peripheral catheter after removal and it appears that the catheter tip is missing. What does the nurse do next?

answer

Assess the patient for symptoms of emboli.

question

A patient has a local complication from a peripheral IV access with 0.9% normal saline infusing at 100 mL/hour. What does the nurse assess at the insertion site?

answer

A red streak is present proximal to the site. Edema is present proximal to the site. The IV fluids are not infusing.

question

The nurse is caring for the patient receiving arterial therapy via the carotid artery. What important nursing action is specific to this therapy?

answer

Perform frequent neurologic assessments.

question

Which statements are correct about intraperitoneal infusion (IP)?

answer

Sterile technique is used with IP access and supplies. IP can be accessed by a catheter with an implanted port and large internal lumens. Strict aseptic technique is used with IP access and supplies. IP is used for patients who are receiving chemotherapy agents.

question

During intraperitoneal therapy, a patient reports nausea and vomiting. What does the nurse do next?

answer

Reduce the flow rate and give antiemetics.

question

In what position does the nurse place a patient before starting intraperitoneal therapy?

answer

Semi-Fowler's.

question

Hypodermoclysis can be used for a patient under which types of circumstances?

answer

If the patient requires palliative care. For IV fluid replacement that is less than 2000 mL. When a subcutaneous IV infusion is warranted. When short term fluid volume replacement is warranted.

question

The nurse is preparing to start a hypodermoclysis treatment on a patient. What is the preferred insertion site?

answer

Area under the clavicle

question

The home health nurse is adjusting the rate for a hypodermoclysis treatment. What is the usual maximum rate for this therapy?

answer

80 mL/hr.

question

The home health nurse is caring for a patient receiving hypodermoclysis therapy. How often are the subcutaneous sites rotated?

answer

At least once a week.

question

The nurse is caring for a patient receiving intrathecal pain medication. Which agent is preferred for cleaning the access site?

answer

Povidone Iodine.

question

A patient is receiving epidural medication therapy. The nurse assesses for which potential problem specific to this type of therapy?

answer

Meningitis

question

A patient is brought to the emergency department after a serious motor vehicle accident. Which factor makes the patient a candidate for intraosseous (IO) therapy?

answer

IV access cannot be achieved within a few minutes.

question

A patient has an IO needle in place. Why does the nurse advocate for removal of the device within 24 hours after insertion?

answer

There is an increased risk for osteomyelitis.

question

The patient has an order for a unit of PRBCs. Which priority action must the nurse complete before starting this infusion?

answer

Check patient identification with another RN using two identifiers.

question

You are caring for four clients who are receiving IV infusions of normal saline. Which client is at highest risk for bloodstream infection?

answer

Client who has a nontunneled central line in the left internal jugular vein.

question

A nurse is assigned to change a central line dressing. The agency policy is to clean the site with Betadine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede Betadine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and Betadine. The nurse has a sample of the new product. How should the nurse proceed?

answer

Follow the agency's policy unless it is contradicted by a health care provider's order.

question

How should a nurse prepare an IV piggback medication for administration to a client receiving an IV infusion?

answer

Wear clean gloves to check the IV site. Rotate the bag after adding the medication. Use a sterile technique when preparing the medication.

question

A nurse administers an intravenous solution of 0.45% sodium chloride. In what category of fluids does this solution belong?

answer

Hypotonic

question

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess?

answer

Distended jugular veins.

question

A nurse is caring for a client with diarrhea. In which clinical indicator does the nurse anticipate a decrease?

answer

Loss of body weight.

question

A nurse is reviewing a client's serum electrolyte laboratory report. What is a comparison between blood plasma and interstitial fluid?

answer

They both contain the same kinds of ions.

question

A nurse explains to an obese client that the rapid weight loss during the first week after initiating a diet is because of fluid loss. The weight of extracellular body fluid is approximately 20% of the total body weight of an average individual. Which component of the extracellular fluid contributes the greatest proportion to this amount?

answer

Interstitial

question

A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider MOST important?

answer

Postassium

question

A nurse is reviewing the laboratory report of a client with a tentative diagnosis of kidney failure. What mechanism does the nurse expect to be maintained when ammonia is excreted by healthy kidneys?

answer

Acid base balance of the body

question

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful?

answer

Clear breath sounds

question

A nurse is caring for a client with albuminuria resulting in edema. What pressure change does the nurse determine as the cause of edema?

answer

Decrease in plasma colloid oncotic pressure.

question

A nurse is reviewing the health care provider's orders for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which order should the nurse question?

answer

Parenteral albumin (Albuminar)

question

A nurse is analyzing how a hyperglycemic client's blood glucose can be lowered. The nurse considers that the chemical that buffers the client's excessive acetoacetic acid is:

answer

Bicarbonate.

question

For what clinical indicator should a nurse assess a client who is having a gastric lavage?

answer

Increased serum bicarbonate level.

question

A nurse is concerned that a client is at risk for developing hyperkalemia. Which disease does the client have that has caused this concern?

answer

End-stage renal

question

A client's serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement FIRST?

answer

Take vital signs and notify the health care provider.

question

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit?

answer

Diarrhea. Weakness. Dysrhythmias.

question

A nurse adds 20 mEq of potassium chloride to the IV solution of a client with diabetic ketoacidosis. What is the primary purpose for administering this drug?

answer

Replace excessive losses.

question

The intake and output of a client over an 8 hour period is: IV infusing 900 mL left in bag. 150 mL urine voided. 200 mL gastricc tube formula. 50 mL water at q3h intervals. 220 mL voided. 235 mL voided. IV with 550 mL left in bag. What is the difference between the client's intake and output?

answer

495 m/L

question

A nurse is caring for a client with ascites. What does the nurse consider to be the cause of the ascites?

answer

Diminished plasma protein level.

question

A client loses weight and develops a negative nitrogen balance. What nutritional problem prompts the nurse to notify the health are provider?

answer

Lack of protein supplementation.

question

An IV solution of 1000 mL 5% dextrose in water is to be infused at 125 mL/hr to correct a client's fluid imbalance. The infusion set delivers 15 drops/mL. To ensure that the solution will infuse over an 8 hour period, at how many drops per minute should the nurse set the rate of flow?

answer

31 gtt/min

question

A nurse is caring for a client with ascites who is receiving albumin. What infusion rate and oral fluid intake should the nurse expect to have the greatest therapeutic effect?

answer

Slow IV rate and restricted fluid intake.

question

An intravenous piggyback of cefazolin 500 mg in 50 mL of 5% dextrose in water is to be administered over a 20 minute period. The tubing has a drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run?

answer

38 gtt/min.

Nursing – Care of IV lines (iggy ch 11 & 13) – Flashcards

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