Nurs 341 Exam 1

613 terms by Melwerner 

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Chapters 13, 14, 15, 23, 24, 35, 38, 41, 42, 73

An older adult client is receiving furosemide (Lasix) for treatment of peripheral edema. Which nursing assessment data identify that the client is at risk for falling?
A. Dry oral mucous membranes
B. Orthostatic blood pressure changes
C. Pulse rate of 72 beats/min and bounding
D. Serum potassium level of 4.0 mEq/L

Orthostatic blood pressure changes

A client has a low serum potassium level and is ordered a dose of parenteral potassium chloride (KCl). How does a nurse safely administer KCl to the client?
A. Administers 5 mEq, intramuscularly (IM)
B. Dilutes 200 mEq in 1 liter of normal saline and infuses at 100 mL/hr
C. Infuses 10 mEq over a 1-hour period
D. Pushes 5 mEq through a central access line

Infuses 10 mEq over a 1-hour period

A client is being monitored for daily weights. The night nurse asks the nursing assistant for the morning weight, and the assistant replies, "She was sleeping so well, I didn't want to wake her to get her weight." How does the nurse respond?
A. "Fast thinking! She really needs to rest after the night she had."
B. "Get the information now, or I'll report you for not doing your job."
C. "Never mind-I will do it myself."
D. "Weigh her now. We need her weight daily, at the same time."

"Weigh her now. We need her weight daily, at the same time."

Which situation can cause a client to experience "insensible water loss"? Select all that apply.
A. Diarrhea
B. Dry, hot weather
C. Fever
D. Increased respiratory rate
E. Nausea
F. Mechanical ventilation

Diarrhea
Dry, hot weather
Fever
Increased respiratory rate
Mechanical ventilation

Which client is at increased risk for fluid and electrolyte imbalance? Select all that apply.
A. 22-year-old pregnant woman in her third trimester
B. 24-year-old male athlete
C. 45-year-old man on diuretics
D. 47-year-old man traveling to South America in summer
E. 76-year-old bedridden woman

45-year-old man on diuretics
47-year-old man traveling to South America in summer
76-year-old bedridden woman

A nurse instructs an older adult client to increase intake of dietary potassium when the client is prescribed which classification of drugs?
A. Alpha antagonists
B. Beta blockers
C. Corticosteroids
D. High-ceiling (loop) diuretics

High-ceiling (loop) diuretics

A nurse is instructing a client who is being discharged with a diagnosis of congestive heart failure (CHF). Which client statement indicates a correct understanding of CHF?
A. "I can gain 2 pounds of water a day without risk."
B. "I should call my provider if I gain more than 1 pound a week."
C. "Weighing myself daily can determine if my caloric intake is adequate is effective."
D. "Weighing myself daily can reveal increased fluid retention."

"Weighing myself daily can reveal increased fluid retention."

Which client is at greatest risk for hypernatremia?
A. 17 year-old with a serum blood glucose of 189 mg/dL
B. 30-year-old on a low-salt diet
C. 42-year-old receiving hypotonic fluids
D. 54-year old who is sweating profusely

54-year old who is sweating profusely

As adults age, which common physiologic change is likely to alter their hydration status?
A. Adrenal gland growth
B. Decreased muscle mass
C. Increased thirst mechanism
D. Poor skin turgor

Decreased muscle mass

A nurse is reviewing serum electrolytes and blood chemistry for a newly admitted client. Which result causes the greatest concern?
A. Glucose: 97 mg/dL
B. Magnesium: 2.1 mEq/L
C. Potassium: 5.9 mEq/L
D. Sodium: 143 mEq/L

Potassium: 5.9 mEq/L

A client with hyperkalemia is being treated with drugs to improve the condition. Which potassium level indicates that therapy is effective?
A. 7.6 mEq/L
B. 5.6 mEq/L
C. 4.6 mEq/L
D. 2.6 mEq/L

4.6 mEq/L

A client is admitted with hypokalemia and skeletal muscle weakness. Which assessment does the nurse perform first?
A. Blood pressure
B. Pulse
C. Respirations
D. Temperature

Respirations

A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first?
A. Draws blood for laboratory tests
B. Elevates the head of the bed
C. Places the extremities in a dependent position
D. Puts the client in a side-lying position

Elevates the head of the bed

A nurse is assessing a client with hyponatremia. Which finding requires immediate action?
A. Diminished bowel sounds
B. Heightened acuity
C. Muscular weakness
D. Urine output of 35 mL/hr

Muscular weakness

A nurse is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. What does the nurse tell them?
A. "Be careful not to overload them with too many oral fluids."
B. "Offer fluids that they prefer frequently and on a regular schedule."
C. "Restrict their fluids in the evening hours if they are incontinent."
D. "Wake them every 2 hours during the night with a drink."

"Offer fluids that they prefer frequently and on a regular schedule."

A nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate (MgSO4). Which assessment parameter is critical?
A. 24-hour urine output
B. Asking the client about feeling depressed
C. Hourly deep tendon reflexes (DTRs)
D. Monitoring of serum calcium levels

Hourly deep tendon reflexes (DTRs)

The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which client is assigned to the LPN/LVN?
A. 44-year-old with congestive heart failure (CHF) who has gained 3 pounds since the previous day
B. 58-year-old with chronic renal failure (CRF) who has a serum potassium level of 6 mEq/L
C. 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/L
D. 80-year-old with 3+ peripheral edema who has crackles throughout the posterior chest

76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/L

The client is a 69-year-old woman with uncontrolled diabetes, polyuria, and a blood pressure of 86/46. Which staff member is assigned to care for her?
A. LPN/LVN who has floated from the hospital's long-term care unit
B. LPN/LVN who frequently administers medications to multiple clients
C. RN who has floated from the intensive care unit
D. RN who usually works as a diabetic educator

RN who has floated from the intensive care unit

A nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed assistive personnel (UAP)?
A. Assessing oral mucosa for dryness
B. Choosing appropriate oral fluids
C. Monitoring skin turgor for tenting
D. Offering fluids to drink every hour

Offering fluids to drink every hour

An RN is caring for a client with end-stage liver disease that has resulted in ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)?
A. Assessing skin integrity and abdominal distention
B. Drawing blood from a central venous line for electrolyte studies
C. Evaluating laboratory study results for the presence of hypokalemia
D. Placing the client in a semi-Fowler's position

Placing the client in a semi-Fowler's position

Which newly written physician prescription does the nurse administer first?
A. Intravenous (IV) normal saline to a client with a serum sodium of 132 mEq/L
B. Oral calcium supplements to a client with severe osteoporosis
C. Oral phosphorus supplements to a client with acute hypophosphatemia
D. Oral potassium chloride (KCl) to a client whose serum potassium is 3 mEq/L

Oral potassium chloride (KCl) to a client whose serum potassium is 3 mEq/L

A physician writes orders for a client who is admitted with a serum potassium (K) level of 6.9 mEq/L. What does the nurse implement first?
A. Administering sodium polystyrene sulfonate (Kayexalate) orally.
B. Ensuring that a potassium-restricted diet is ordered.
C. Placing the client on a cardiac monitor.
D. Teaching the client about foods that are high in potassium.

Placing the client on a cardiac monitor.

The nurse manager of the medical-surgical unit assigns which client to the LPN/LVN?
A. 44-year-old admitted with dehydration who has a heart rate of 126
B. 54-year-old just admitted with hyperkalemia who takes a potassium-sparing diuretic at home
C. 64-year-old admitted yesterday with heart failure who still has dependent pedal edema
D. 74-year-old who has just been admitted with severe nausea, vomiting, and diarrhea

64-year-old admitted yesterday with heart failure who still has dependent pedal edema

An RN is caring for a client admitted with dehydration who requires a blood transfusion. Which nursing action does the RN delegate to unlicensed assistive personnel (UAP)?
A. Inserting a small-gauge needle for intravenous (IV) access
B. Evaluating a headache that develops during the transfusion
C. Explaining to the client the purpose of the blood transfusion
D. Obtaining baseline vital signs before blood administration

Obtaining baseline vital signs before blood administration

An RN is caring for a client who is severely dehydrated. Which nursing action can be delegated to unlicensed assistive personnel (UAP)?
A. Consulting with a health care provider about a client's lab results
B. Infusing 500 mL of normal saline over 60 minutes
C. Monitoring IV fluid to maintain the drip rate at 75 mL/hr
D. Providing oral care every 1 to 2 hours

Providing oral care every 1 to 2 hours

After receiving change-of-shift report, which client does the RN assess first?
A. 26-year-old with nausea and vomiting who complains of dizziness when standing
B. 36-year-old with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst
C. 46-year-old receiving IV diuretics whose blood pressure is 95/52 mm Hg
D. 56-year-old with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL

46-year-old receiving IV diuretics whose blood pressure is 95/52 mm Hg

An RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse?
A. Client behavior that changes from anxious and restless to lethargic and confused
B. Deep furrows on the surface of the tongue
C. Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched
D. Urine output of 950 mL for the past 24 hours

Client behavior that changes from anxious and restless to lethargic and confused

The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the LPN/LVN?
A. Calcium level of 9.5 mg/dL
B. Magnesium level of 4.1 mEq/L
C. Potassium level of 6.0 mEq/L
D. Sodium level of 120 mEq/L

Calcium level of 9.5 mg/dL

A 90-year-old client with hypermagnesemia is seen in the emergency department (ED). The ED nurse prepares the client for admission to which inpatient unit?
A. Dialysis/Home Care
B. Geriatric/Rehabilitation
C. Medical-Surgical
D. Telemetry/Cardiac Step-Down

Telemetry/Cardiac Step-Down

A client with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide?
A. Assessment of muscle tone and strength
B. Education about potassium-rich foods
C. Instruction on the proper use of drugs
D. Measurement of the client's urine output

Measurement of the client's urine output

A nurse is planning care for a client with hypocalcemia. Which nursing action is appropriate to delegate to unlicensed assistive personnel (UAP)?
A. Collaborating with the dietitian to provide calcium-rich foods for the client
B. Evaluating the client's laboratory results
C. Implementing Seizure Precautions for the client
D. Transferring the client from the bed to a stretcher using a lift sheet

Transferring the client from the bed to a stretcher using a lift sheet

A client is admitted to the nursing unit with a diagnosis of hypokalemia. Which assessment does the nurse complete first?
A. Auscultating bowel sounds
B. Checking deep tendon reflexes (DTRs)
C. Determining the level of consciousness (LOC)
D. Obtaining a pulse oximetry reading

Obtaining a pulse oximetry reading

A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Laboratory results include a potassium level of 7.0 mEq/L. Which medication(s) does the nurse anticipate administering?
A. Insulin (regular insulin) and dextrose (D20W)
B. Loperamide (Imodium)
C. Sodium polystyrene sulfonate (Kayexalate)
D. Supplemental potassium

Insulin (regular insulin) and dextrose (D20W)

A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Her laboratory results include a potassium level of 7.0 mEq/L. What is the primary goal of drug therapy for this client?
A. Decreasing cardiac contractility and slowing the heart rate
B. Elevating serum potassium levels to a safe range
C. Maintaining proper diuresis and urine output
D. Restoring fluid balance by controlling the causes of dehydration

Restoring fluid balance by controlling the causes of dehydration

A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His current medications are digoxin (Lanoxin), chlorothiazide (Diuril), and oral potassium supplements. He tells the nurse that he has had flu-like symptoms for the past week and has been unable to drink for the past 48 hours. The physician requests laboratory specimens to be drawn and an isotonic IV to be started. Which IV fluid does the nurse administer?
A. 0.45% saline
B. 5% dextrose in 0.45% saline
C. 5% dextrose in Ringer's lactate
D. 5% dextrose in water (D5W)

5% dextrose in water (D5W)

A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His current medications are digoxin (Lanoxin), chlorothiazide (Diuril), and potassium supplements. He tells a nurse that he has had flu-like symptoms for the past week and has been unable to drink for the past 48 hours. The nurse starts the client's IV and receives laboratory results, which include a potassium level of 2.7 mEq/L. The physician orders an IV potassium supplement. How does the nurse administer this medication?
A. Added to an IV, not to exceed 20 mEq/hr
B. Added to an IV, not to exceed 30 mEq/hr
C. Rapid IV push, a 25-mEq dose
D. Slow IV push, a 30-mEq dose

Added to an IV, not to exceed 20 mEq/hr

A 70-year-old female is admitted to the hospital with heart failure, shortness-of-breath (SOB), and 3+ pitting edema in her lower extremities. Her current medications are furosemide (Lasix), digoxin (Lanoxin), and an angiotensin-converting enzyme (ACE) inhibitor (Lotensin). She states that she stopped taking her Lasix because she did not think that it was helping her heart failure. Her physician orders furosemide (Lasix) 5 mg IV push. Which client assessment determines that the medication is working?
A. Decreased blood pressure (BP)
B. Increased heart rate
C. Increased urine output
D. Weight gain

Increased urine output

A 70-year-old female is admitted to the hospital with heart failure, shortness-of-breath (SOB), and 3+ pitting edema in her lower extremities. Her medications are furosemide (Lasix), digoxin (Lanoxin), and an angiotensin-converting enzyme (ACE) inhibitor (Lotensin). She states that she stopped taking her Lasix because she did not think that it was helping her heart failure. Her physician orders furosemide (Lasix) 5 mg IV push. Ten (10) hours after receiving the Lasix, the client's potassium (K+) level is 2.5 mEq/L. Knowing all of the client's medications, what problem(s) does the nurse anticipate in this client?
A. Clinical manifestations of digoxin toxicity
B. Increased heart rate and blood pressure (BP)
C. Increased signs of congestive heart failure (CHF)
D. Signs and symptoms of hypernatremia

Clinical manifestations of digoxin toxicity

A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells a nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). She is receiving lactated Ringer's solution IV for rehydration. What clinical manifestations does the nurse monitor during rehydration of the client? Select all that apply.
A. Blood serum glucose
B. Pulse rate and quality
C. Urinary output
D. Urine specific gravity levels

Pulse rate and quality
Urinary output
Urine specific gravity levels

: A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells a nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Her laboratory results include a potassium level of 7.0 mEq/L. What does the nurse include in the client's medication teaching? Select all that apply.
A. Daily weights are a poor indicator of fluid loss or gain.
B. Diuretics can lead to fluid and electrolyte imbalances.
C. Diuretics increase fluid retention.
D. Laxatives can lead to fluid imbalance.

Diuretics can lead to fluid and electrolyte imbalances.
Laxatives can lead to fluid imbalance.

A 68-year-old man is admitted to the hospital with dehydration. Initial laboratory results include a potassium level of 2.7 mEq/L. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His medications are digoxin (Lanoxin), chlorothiazide (Diuril), and potassium supplements. In time, he recovers from his dehydration and low potassium levels. He says to the nurse, "I would like to take fewer medications and eat foods that contain high amounts of potassium." What foods does the nurse recommend? Select all that apply.
A. Apples
B. Bananas
C. Broccoli
D. Oranges
E. Spinach

Bananas
Broccoli
Oranges
Spinach

The nurse who is conducting an assessment of fluid and electrolyte balance in an older female patient should be certain to question the patient about:
A. Laxative use
B. Sleep patterns
C. Changes in taste
D. Dry mouth

Laxative use

Insensible water loss

water loss from the skin, lungs, and stool that cannot be controlled

The body functions best when the osmolarity of the fluids in all body fluid spaces is close to ____.

300 mOsm/L

hyperosmotic or hypertonic

Describes fluids with osmolarities (solute concentrations) greater than 300 mOsm/L; have a greater osmotic pressure than do isosmotic fluids and tend to pull water from the isosmotic fluid space into the fluid space until an osmotic balance occurs.

hypo-osmotic or hypotonic

Describes fluids with osmolarities of less than 270 mOsm/L. Have a lower osmotic pressure than isosmotic fluids, and water tends to be pulled from the c fluid space into the isosmotic fluid space until an osmotic balance occurs.

Sodium (Na+) blood serum range

136-145 mEq/L

Potassium (K+) blood serum range

3.5-5.0 mEq/L

Calcium (Ca2+) blood serum range

9.0-10.5 mg/dL

Chloride (Cl−) blood serum range

98-106 mEq/L

Magnesium (Mg2+) blood serum range

1.3-2.1 mEq/L

Phosphorus (P) blood serum range

3.0-4.5 mg/dL

The minimum amount of urine per day needed to excrete toxic waste products is ________.

400-600 mL

Aldosterone

a hormone secreted by the adrenal cortex whenever sodium levels in the extracellular fluid (ECF) are decreased. It prevents both water and sodium loss. When it is secreted, it acts on the kidney nephrons, triggering them to reabsorb sodium and water from the urine back into the blood. This action increases blood osmolarity and blood volume. It prevents excessive kidney excretion of sodium. It also helps prevent blood potassium levels from becoming too high.

Antidiuretic hormone (ADH)

produced in the brain and stored in the posterior pituitary gland. Released from the posterior pituitary gland is controlled by the hypothalamus in response to changes in blood osmolarity. It acts directly on kidney tubules and collecting ducts, making them more permeable to water. As a result, more water is reabsorbed by these tubules and returned to the blood, decreasing blood osmolarity by making it more dilute.

Natriuretic peptides (NPs)

hormones secreted by special cells that line the atria of the heart and the ventricles of the heart. These peptides are secreted in response to increased blood volume and blood pressure, which stretch the heart tissue. It binds to receptors in the nephrons, creating effects that are opposite of aldosterone. Kidney reabsorption of sodium is inhibited at the same time that glomerular filtration is increased, causing increased urine output. The outcome is decreased circulating blood volume and decreased blood osmolarity.

When assessing an older patient's hydration status, the nurse expects which assessment finding to be the best indicator of fluid losses or gains?
A. Pretibial edema
B. A weight gain of 2 pounds in one day
C. Poor skin turgor
D. The patient's report of feeling thirsty

A weight gain of 2 pounds in one day

What is the most common type of fluid loss problem?

Isotonic dehydration

What are the most obvious changes that occur with dehydration?

Heart rate increases in an attempt to maintain blood pressure with less blood volume. Peripheral pulses are weak, difficult to find, and easily blocked with light pressure. The blood pressure also decreases, as does the pulse pressure, with a greater decrease in the systolic blood pressure. Skin turgor is poor, with the tent remaining for minutes after pinching the skin, and no skin depressions occur with gentle pressure. The skin is dry and scaly.

A 25-year-old student has been taken to an urgent care clinic because of dehydration. She says she has had "the flu," with vomiting and diarrhea "all night" and admits that she has had very little to eat or drink. She now says the GI symptoms have subsided but she feels weak. The nurse expects which type of rehydration to occur?
A. Oral rehydration therapy with water
B. Oral rehydration therapy with a solution containing glucose and electrolytes
C. Diuretic therapy
D. IV fluid replacement

Oral rehydration therapy with a solution containing glucose and electrolytes

Most problems caused by overhydration are related to _________.

fluid volume excess in the vascular space or dilution of specific electrolytes and blood components.

Any patient with fluid overload, regardless of age, is at risk for these complications.

pulmonary edema and heart failure

While monitoring a patient who has fluid overload, the nurse would be most concerned about which assessment finding?
A. Pitting edema in the feet
B. Neck vein distention
C. Bounding pulse
D. Presence of crackles in the lungs

Presence of crackles in the lungs

The problems caused by hyponatremia involve two mechanisms____________.

reduced excitable membrane depolarization and cellular swelling.

One of the most common causes of low sodium levels is the prolonged use and overuse of _______.

diuretics

________ are the most obvious problems of hyponatremia

Cerebral changes

Which assessment finding will alert the nurse to a worsening of the client's hyponatremia?
A. The client is anxious and combative.
B. Diastolic blood pressure has increased by 8 mm Hg.
C. Bowel sounds are hyperactive in all abdominal quadrants.
D. Deep tendon reflexes have changed from 1+ to 2+.

Bowel sounds are hyperactive in all abdominal quadrants.

________ status should be assessed first in any patient who might have hypokalemia.

Respiratory

Assess respiratory status at least every 2 hours because respiratory insufficiency is a major cause of death.

Prevent accidental overdose of IV potassium by checking and re-checking the concentration of potassium in the IV solution, ensuring that the maximum concentration is no greater than

1 mEq/10 mL of solution.

A dilution no greater than ____ of potassium to ____of solution is recommended for IV administration. The maximum recommended infusion rate is ______; this rate is never to exceed _____ under any circumstances.

1 mEq
10 mL
5 to 10 mEq/hr
20 mEq/hr

_______ changes are the most severe problems from hyperkalemia and are the most common cause of death in patients with hyperkalemia.

Cardiovascular

When taking the blood pressure of a very ill client, the nurse observes that the client's hand undergoes flexion contractions. What is the nurse's primary intervention?
A. Placing the client in a high Fowler's position and administering intravenous fluids
B. Deflating the blood pressure cuff and administer oxygen
C. Documenting the finding as the only action
D. Notifying the health care provider

Deflating the blood pressure cuff and administer oxygen

Lactose intolerance caused by a deficiency of the enzyme lactase occurs in 75% to 90% of all

Asians, Blacks, and American Indians

One indicator of hypocalcemia is a report of

frequent, painful muscle spasms ("charley horses") in the calf or foot during rest or sleep.

To test for Trousseau's sign,

place a blood pressure cuff around the upper arm, inflate the cuff to greater than the patient's systolic pressure, and keep the cuff inflated for 1 to 4 minutes. Under these hypoxic conditions, a positive sign occurs when the hand and fingers go into spasm in palmar flexion

To test for Chvostek's sign,

tap the face just below and in front of the ear (over the facial nerve) to trigger facial twitching of one side of the mouth, nose, and cheek

When lifting or moving a patient with fragile bones,

use a lift sheet rather than pulling the patient.

________ changes are the most serious and life-threatening problems of hypercalcemia.

Cardiovascular

Therefore a change in the amount of plasma phosphorus results in an equal and opposite change in the amount of plasma ______ (and vice versa).

calcium

The manifestations of chronic hypophosphatemia are most evident in the _________

skeletal system.

Bone density is decreased, which leads to fractures and changes in bone shape. These changes are caused by the bone calcium loss that occurs with hypophosphatemia.

The problems caused by hyperphosphatemia center on the _________ that results when serum phosphorus levels increase.

hypocalcemia

The effects of hypomagnesemia are caused by increased membrane excitability and the accompanying __________

serum calcium and potassium imbalances. Excitable membranes, especially nerve cell membranes, may depolarize spontaneously.

The IV route is used because MgSO4 ___________.

causes pain and tissue damage when injected IM.

Patients with severe hypermagnesemia are in grave danger of ________

cardiac arrest.

Most manifestations of hypermagnesemia occur as a result of __________.

reduced membrane excitability.

Hypocalcemia can occur in which ethnic group because of lactose intolerance?

A. Blacks
B. Caucasians
C. Inuits
D. Hispanics

Blacks

The nurse observes that the hand grip of the client with hypophosphatemia has diminished in strength since the last assessment 2 hours ago. What is the nurse's primary intervention?
A. Documents the finding as the only action
B. Assesses respiratory status immediately
C. Applies elastic wraps to the lower extremities
D. Assesses deep tendon reflexes

Assesses respiratory status immediately

What are 5 important facts about infusion therapy?

-Delivery of parenteral meds & fluids
-Via wide variety of catheters
-In wide variety of locations
-Used in multiple procedures
-Delivered in all health care settings

What is the most common route of infusion therapy

IV (Intravenous) Therapy

What does infusion therapy maintain?

-Maintain FLUID BALANCE
-Maintain ELECTROLYTE BALANCE
-Maintain ACID BASE BALANCE

The CDC recommends whom to "initiate and maintain" infusion therapy?

-a SPECIALIZED team of INFUSION NURSES

What does the INFUSION NURSE do?

-"Develop" evidenced based polices & procedures
-"Insert" several types of peripheral & Cardiovascular CATHS
-"Monitor" patient outcomes
-"Educate" staff, patients & families
-"Consult" on product selection & purchasing decisions

Types of INFUSION THERAPY fluid

-IV Solutions
-Parenteral Nutrition
-Blood & Blood Products
-Drugs

How are IV SOLUTIONS "classified"?

-TONICITY (concentration)
-PH

Normal Serum Osmolarity for adults

270-300 mOsm/L

ISOTONIC SOLUTIONS Osmolarity

fluids 270-300 mOsm/L same as body norm mOsm/L

HYPERTONIC SOLUTIONS Osmolarity

fluids GREATER than 300

HYPOTONIC SOLUTIONS Osmolarity

fluids LESS than 270

What is an INFUSATE?

A solution that is infused into the body

ISOTONIC INFUSATE

-Water "DOES NOT" move IN OR OUT of the body cells

ISOTONIC INFUSATE PATIENT RISK

-FLUID OVERLOAD
(especially older adults)

What cause FLUID OVERLOAD in patients receiving ISOTONIC INFUSATE?

-FLUID "ACCUMULATES" in the EXTRACELLULAR CELLS

HYPERTONIC INFUSATE

-Water is moved "OUT" of the body cells "INTO" the bloodstream

What are HYPERTONIC INFUSATES used for?

-"CORRECT" fluid, electrolyte and acid base imbalances

What is an example of HYPERTONIC INFUSATE

-Parental Nutrition

How "MUST" HYPERTONIC INFUSATE be infused?

Via PICC OR CENTRAL LINE

HYPERTONIC INFUSATE PATIENT RISK:

-PHLEBITIS
-INFILTRATION

HYPOTONIC INFUSATE

-Water is moved "INTO" the body cells & "expands" them

HYPOTONIC INFUSATE PATIENT RISK

-PHLEBITIS
-INFILTRATION

PHLEBITIS:

INFLAMMATION OF A VEINS

INFILTRATION:

LEAKAGE OF A NONVESICANT IV SOLUTION/MED INTO THE EXTRAVASCULAR TISSUE

USUAL RANGE of PH of IV SOLUTION

3.5-6.2

CAUTION: A FLUID/MED with PH LESS THAN 5 PLUS MORE THAN 500 mOsm/L

SHOULD NOT BE ADMINISTERED BY VEIN

BlOOD TRANSFUSION are "accomplished" by use of what?

PACKED RED BLOOD CELLS

SENTINEL EVENT:

-ACUTE HEMOLYTIC TRANSFUSION REACTION due to "IMCOMPATIBLE BLOOD TRANSFUSION"

ADVERSE DRUG EFFECT

-UNDESIRABLE AND IMMEDIATE SERIOUS REACTION to the administration of IV MEDS
**(BCMA) HELP REDUCE THIS EFFECT**

What is "REQUIRED" before INFUSION THERAPY "BEGINS"

-PRESCRIPTION

What is the NURSES RESPONSIBILITY in regards to the INFUSION THERAPY PRESCRIPTION?

-Determine that the prescription is "APPROPRIATE" for the PATIENT
-Clarify any QUESTIONS
-Check for ACCURACY
-Check for COMPLETENESS

VAD?

Vascular Access Device

7 Major Types of VAD's

-Short Cath
-Midline Cath
-PICC
-Nontunneled Percutaneous Central Cath
-Implanted Ports
-Hemodialysis Cath

What are the PATIENT RISKS with insertions in the HANDS & FEET?

-DVT
-INFILTRATION

Why should the veins on the hand of an "older"" adult be avoided?

-loss of skin turgor
-poor vein condition

Why should the veins on the "palm" side of the hand be avoided?

-median nerve is located close to the veins
-more painful
-difficult to stabilize

A patient reporting feeling "pins & needles" or numbness during venipuncture, what is indicated?

-nerve puncture

EXTRAVASATION:

leakage of fluid into tissue surrounding a vein

VESICANT

an intravenous medication that causes blisters and tissue injury when it escapes into surrounding tissue

What is used to "FLUSH" MIDLINE CATHS?

ONLY SALINE

Pneumothorax

-air in the pleural cavity caused by a puncture of the lung or chest wall

Pain at access site with erythema and/or oedema
Streak formation
Palpable venous cord

Class 3 Phlebitis

Pain at access site with erythema and/or oedema

Class 2 Phlebitis

Erythema at access site with or without pain

Class 1 Phlebitis

Pain at access site with erythema and/or oedema
Streak formation
Palpable venous cord > 1 inch in length
Purulent drainag

Class 4 Phlebitis

Types of Phebitis

Mechanical
Bacterial
Chemical

1st thing to do after catheter use

Flush catheter with saline or saline followed by heparinized saline

failure to do this causes lumen occlusion
Obtained in single dose containers or prefilled syringes

A nurse checking an IV fluid order questions its accuracy. What does the nurse do first?
A. Asks the charge nurse about the order
B. Contacts the health care provider who ordered it
C. Contacts the pharmacy for clarification
D. Starts the fluid as ordered, with plans to check it later

Contacts the health care provider who ordered it

A client is to receive an IV solution of 5% dextrose and half-normal saline at 125 mL/hr. Which system provides the safest method for the nurse to accurately administer this solution?
A. Controller
B. Glass container
C. Infusion pump
D. Syringe pump

Infusion pump

A client who used to work as a nurse asks, "Why is the hospital using a 'fancy new IV' without a needle? That seems expensive." How does the nurse respond?
A. "OSHA, the government, requires us to use this new type of IV."
B. "These systems are designed to save time, not money."
C. "They minimize health care workers' exposures to contaminated needles."
D. "They minimize your exposure to contaminated needles."

"They minimize health care workers' exposures to contaminated needles."

A nurse is documenting peripheral venous catheter insertion for a client. What does the nurse include in the note? Select all that apply.
A. Client's name and hospital number
B. Client's response to the insertion
C. Date and time inserted
D. Type and size of device
E. Type of dressing applied
F. Vein that was used for insertion

Client's response to the insertion
Date and time inserted
Type and size of device
Type of dressing applied
Vein that was used for insertion

A nurse is teaching a hospitalized client who is being discharged about how to care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education?
A. "I can continue my 20-mile running schedule as I have for the past 10 years."
B. "I can still go about my normal activities of daily living."
C. "I have less chance of getting an infection because the line is not in my hand."
D. "The PICC line can stay in for months."

"I can continue my 20-mile running schedule as I have for the past 10 years."

A nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters does the nurse choose most often?
A. Back of the hand for an older adult
B. Cephalic vein of the forearm
C. Lower arm on the side of a radical mastectomy
D. Subclavian vein

Cephalic vein of the forearm

A client admitted to the intensive care unit (ICU) is expected to remain for 3 weeks. The nurse has orders to start an IV. Which vascular access device does the nurse choose for this client?
A. Midline catheter
B. Peripherally inserted central catheter (PICC)
C. Short peripheral catheter
D. Tunneled central catheter

Midline catheter

A 22-year-old client is seen in the emergency department (ED) with acute right lower quadrant abdominal pain, nausea, and rebound tenderness. It appears that surgery is imminent. What gauge catheter does the ED nurse choose when starting this client's intravenous (IV) solution?
A. 24
B. 22
C. 18
D. 14

18

A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened and begun 20 hours ago. What action does the nurse take?
A. Changes the set immediately
B. Changes the set in about 4 hours
C. Changes the set in the next 12 to 24 hours
D. Nothing; the set is for long-term use

Changes the set in about 4 hours

A client is seen in the emergency department (ED) with pain, redness, and warmth of the right lower arm. The client was in the ED last week after an accident at work. On the day of the injury, the client was in the ED for 12 hours receiving IV fluids. On close examination, the nurse notes the presence of a palpable cord 1 inch in length and streak formation. How does the nurse classify this client's phlebitis?
A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4

Grade 3

A nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What does the nurse do initially?
A. Assesses the insertion site
B. Checks connections
C. Checks the infusion rate
D. Discontinues the IV and starts another

Assesses the insertion site

A client is admitted to the cardiothoracic surgical intensive care unit (ICU) after cardiac bypass surgery. The client is still sedated on a ventilator and has an arterial catheter in the right wrist. What assessment does the nurse make to ensure patency of the client's arterial line?
A. Blood pressure
B. Capillary refill and pulse
C. Neurologic function
D. Questions the client about the pain level at the site

Capillary refill and pulse

Which statement is true about the special needs of older adults receiving IV therapy?
A. Placement of the catheter on the back of the client's dominant hand is preferred.
B. Skin integrity can be compromised easily by the application of tape or dressings.
C. To avoid rolling the veins, a greater angle of 25 degrees between the skin and the catheter will improve success with venipuncture.
D. When the catheter is inserted into the forearm, excess hair should be shaved before insertion.

Skin integrity can be compromised easily by the application of tape or dressings.

A client is being admitted to the burn unit from another hospital. The client has an intraosseous IV that was started 2 days ago, according to the client's medical record. What does the admitting nurse do first?
A. Anticipates an order to discontinue the intraosseous IV and start an epidural IV
B. Calls the previous hospital to verify the date
C. Immediately discontinues the intraosseous IV
D. Nothing; this is a long-term treatment

Anticipates an order to discontinue the intraosseous IV and start an epidural IV

A nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion?
A. Asks the client to both say and spell his or her full name before starting the blood transfusion
B. Ensures that another qualified health care professional checks the unit before administering
C. Checks the blood identification numbers with the laboratory technician at the Blood Bank at the time it is dispersed
D. Makes certain that an IV solution of 0.9% normal saline is infusing into the client before starting the unit

Ensures that another qualified health care professional checks the unit before administering

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