Fundamentals---Mock---Ch. 42
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Questions and Answers

A patient is experiencing dehydration. While planning care, the nurse considers that the majority of the patient’s total water volume exists in with compartment?

  • Intracellular (correct)
  • Extracellular
  • Intravascular
  • Transcellular
  • The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which process is the nurse describing?

  • Osmosis (correct)
  • Filtration
  • Diffusion
  • Active transport
  • The nurse observes edema in a patient who is experiencing venous congestion as a result of right heart failure. Which type of pressure facilitated the formation of the patient’s edema?

  • Osmotic
  • Oncotic
  • Hydrostatic (correct)
  • Concentration
  • The nurse administers an intravenous (IV) hypertonic solution to a patient expects the fluid shift to occur in what direction?

    <p>From intracellular to extracellular (A)</p> Signup and view all the answers

    A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the first one?

    1. Clean site.
    2. Select vein.
    3. Apply tourniquet.
    4. Release tourniquet.
    5. Reapply tourniquet.
    6. Advance and secure.
    7. Insert vascular access device.

    <p>3, 2, 4, 1, 5, 7, 6 (D)</p> Signup and view all the answers

    The nurse is laboratory blood results will expect to observe which cation in the most abundance?

    <p>Sodium (A)</p> Signup and view all the answers

    The nurse receives the patient’s most recent blood work results. Which laboratory value is of greatest concern?

    <p>Calcium of 15.5 mg/dL (B)</p> Signup and view all the answers

    The nurse observes that the patient’s calcium is elevated. When checking the phosphate level, what does the nurse expect to see?

    <p>A decrease (B)</p> Signup and view all the answers

    Four patients arrive at the emergency department at the same time. Which patient will the nurse see first?

    <p>An infant with temperature of 102.2F and diarrhea for 3 days (A)</p> Signup and view all the answers

    The patient has an intravenous (IV) line and the nurse needs to remove the gown. In which order will the nurse perform the steps, starting with the first one?

    1. Remove the sleeve of the gown from the arm without the IV.
    2. Remove the sleeve of the gown from the arm with the IV.
    3. Remove the IV solution container from its stand.
    4. Pass the IV bag and tubing through the sleeve.

    <p>1, 2, 3, 4 (A)</p> Signup and view all the answers

    A 2-year-old child has ingested a quantity of a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child?

    <p>Respiratory acidosis (B)</p> Signup and view all the answers

    A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe?

    <p>Metabolic alkalosis (B)</p> Signup and view all the answers

    A nurse is caring for a patient whose electrocardiogram (ECG) presents with changes characteristic of hypokalemia. Which assessment finding will the nurse expect?

    <p>Abdominal distention (B)</p> Signup and view all the answers

    The nurse is assessing a patient and notes crackles in the lung bases and neck vein distention. Which action will the nurse take first?

    <p>Raise head of bed. (C)</p> Signup and view all the answers

    A patient receiving chemotherapy has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate?

    <p>&quot;How many times a day do you urinate?&quot; (D)</p> Signup and view all the answers

    The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare?

    <p>0.45% sodium chloride (1/2 NS) (A)</p> Signup and view all the answers

    The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients?

    <p>Weigh the patients every morning before breakfast. (C)</p> Signup and view all the answers

    A nurse is caring for a patient diagnosed with cancer who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan?

    <p>Replace fluid, electrolytes, and nutrients. (C)</p> Signup and view all the answers

    A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare?

    <p>0.9% sodium chloride (NS) (C)</p> Signup and view all the answers

    The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement?

    <p>Serum sodium concentration returns to normal. (C)</p> Signup and view all the answers

    Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit?

    <p>Postural hypotension (B)</p> Signup and view all the answers

    A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. Which rate will the nurse calculate for the minute flow rate (drops/min)?

    <p>125 drops/min (C)</p> Signup and view all the answers

    A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 50 mL/hr. At what time should the infusion be completed?

    <p>2345 Monday (B)</p> Signup and view all the answers

    Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit?

    <p>Postural hypotension (B)</p> Signup and view all the answers

    A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. Which rate will the nurse calculate for the minute flow rate (drops/min)?

    <p>125 drops/min (C)</p> Signup and view all the answers

    A nurse caring for a diabetic patient with a bowel obstruction has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output. The patient has voided 400 mL of urine. After reporting these values to the health care provider, which order does the nurse anticipate?

    <p>Add a potassium supplement to replace loss from output. (A)</p> Signup and view all the answers

    A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the nurse is flushing the patient’s peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse’s initial action?

    <p>Discontinue the IV. (D)</p> Signup and view all the answers

    A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)?

    <p>Uses chlorhexidine skin antisepsis prior to insertion. (D)</p> Signup and view all the answers

    The nurse is caring for a group of patients. Which patient will the nurse see first?

    <p>A patient with D5W hanging with the blood (A)</p> Signup and view all the answers

    A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately?

    <p>Temperature 101.3F (B)</p> Signup and view all the answers

    A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let the blood infuse?

    <p>4 hours (C)</p> Signup and view all the answers

    A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, which is the nurse’s next action?

    <p>Start normal saline at rate to keep vein open using new tubing. (D)</p> Signup and view all the answers

    A nurse assessing a patient who is receiving a blood transfusion finds that the patient is anxiously fidgeting in bed. The patient is afebrile but dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions?

    <p>Fluid volume excess (A)</p> Signup and view all the answers

    A nurse preparing to start a blood transfusion will use which type of tubing?

    <p>One with a filter to ensure that clots do not enter the patient (C)</p> Signup and view all the answers

    The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority?

    <p>Cardiac (D)</p> Signup and view all the answers

    Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?

    <p>Tingling of extremities with possible tetany (D)</p> Signup and view all the answers

    A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? (Select all that apply.)

    <p>Check for contraindications to the extremity. (A), Choose a vein with minimal curvature. (B), Avoid areas of flexion. (D)</p> Signup and view all the answers

    Which assessments will alert the nurse that a patient’s IV has infiltrated? (Select all that apply.)

    <p>Edema of the extremity near the insertion site (A), Skin discolored or pale in appearance (B), Skin cool to the touch (D)</p> Signup and view all the answers

    A nurse is discontinuing a patient’s peripheral IV access. Which actions should the nurse take? (Select all that apply.)

    <p>Stop the infusion before removing the IV catheter. (B), Keep the catheter parallel to the skin while removing it. (C), Apply pressure to the site for 2 to 3 minutes after removal. (D)</p> Signup and view all the answers

    Flashcards

    Intracellular

    The compartment where most of the body's water is located.

    Osmosis

    The passive movement of water across a semipermeable membrane from an area of lower solute concentration to an area of higher solute concentration.

    Hydrostatic pressure

    The pressure exerted by a fluid against the walls of its container.

    Hypertonic solution

    A solution with a higher concentration of solutes than the intracellular fluid.

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    IV therapy steps

    The order of steps when starting a peripheral IV: apply tourniquet, select vein, release tourniquet, clean site, reapply tourniquet, insert vascular access device, advance and secure.

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    Most abundant cation

    Sodium is the most abundant cation in the body.

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    Abnormal calcium

    A calcium level of 15.5 mg/dL is considered dangerously high.

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    Calcium and phosphate

    When calcium levels are elevated, phosphate levels are typically lowered.

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    Priority patient

    An infant with a temperature of 102.2F and diarrhea for 3 days needs immediate attention.

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    Removing gown with IV

    Steps: Remove the sleeve of the gown from the arm without the IV, remove the sleeve from the arm with the IV, remove the IV solution container from its stand, pass the IV bag and tubing through the sleeve.

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    Respiratory acidosis

    An acid-base imbalance that occurs when the lungs can't remove enough carbon dioxide from the body.

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    Metabolic alkalosis

    An acid-base imbalance that occurs when the body loses too much acid or gains too much base.

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    Hypokalemia and ECG

    Electrocardiogram changes characteristic of hypokalemia can include a flattened T wave.

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    Crackles and neck distention

    These findings usually signify fluid overload and require prompt attention.

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    Chemotherapy-related weight gain

    Sudden weight gain in a patient receiving chemotherapy can indicate fluid retention. Asking about urination frequency is crucial.

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    Hypotonic IV solution

    A solution with a lower concentration of solutes than the intracellular fluid.

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    Monitoring fluid volume

    Daily weight measurement is the most effective way to monitor fluid volume status in both heart failure and dehydration risk.

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    TPN purpose

    Total parenteral nutrition (TPN) is mainly used to provide fluids, electrolytes, and nutrients when patients can't eat.

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    Isotonic IV therapy

    A solution with the same concentration of solutes as the intracellular fluid.

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    Hypernatremia goal

    The goal of fluid therapy for hypernatremia is to bring the serum sodium concentration back to normal.

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    Extracellular fluid volume deficit

    A shortage of fluid in the extracellular space.

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    Microdrip gravity drip

    A type of IV tubing that delivers fluid drops in small amounts.

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    IV infusion time

    A 250-mL IV bag infusing at 50 mL/hr will finish in 5 hours.

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    Fluid balance

    Ensuring that intake matches output is crucial for patients with certain conditions.

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    IV infiltration

    A complication where IV fluid leaks into the surrounding tissue.

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    CLABSI prevention

    Chlorhexidine skin antisepsis is a crucial step in reducing central line-associated bloodstream infections.

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    Priority patient

    A patient with D5W hanging with the blood needs immediate attention.

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    Blood transfusion reaction

    An immediate temperature increase of 101.3F during a blood transfusion is a serious symptom that requires prompt action.

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    Blood transfusion time

    The maximum time to infuse a bag of packed red blood cells is 4 hours.

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    Acute hemolytic reaction

    Discontinue the blood transfusion, start normal saline at rate to keep vein open using new tubing.

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    Fluid volume excess

    A complication characterized by fluid overload with symptoms like dyspnea, crackles, jugular vein distention.

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    Blood transfusion tubing

    Use tubing with a filter to ensure that clots do not enter the patient.

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    Hyperkalemia and priority system

    The cardiac system is the priority for assessment in a patient with hyperkalemia.

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    Electrolyte imbalance

    The patient may present with tingling of extremities, possibly tetany.

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    IV site selection

    Check for contraindications to the extremity, ensure the vein is visible and palpable, assess the site for signs of infection.

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    IV infiltration

    Look for edema around the IV site, coolness to the touch, pain, slowed infusion rate.

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    Discontinuing IV

    Stop the infusion, remove the IV catheter, apply pressure to the site, assess for bleeding, document the procedure.

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