T 1 AD Flashcards


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1

The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse?

Client behavior that changes from anxious to lethargic

Deep furrows on the surface of the tongue

Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched

Urine output of 950 mL for the past 24 hours

Client behavior that changes from anxious to lethargic

**Immediate intervention by the nurse is required when a client's behavior changes from anxious to lethargic. This change in mental status suggests poor cerebral blood flow and fluid shifts within the brain cells. Immediate intervention is needed to prevent further cerebral dysfunction.Deep furrows on the surface of the tongue, poor skin turgor, and low urine output are all caused by the fluid volume deficit, but do not indicate complications of dehydration that are immediately life-threatening.

2

A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure (CHF). What nursing actions are indicated at this time?
Select all that apply.

Place the client on bed rest.
Evaluate the electrolyte levels.
Administer the ordered diuretic.
assess for orthostatic hypotension.
initiate cardiac monitoring

Place the client on bed rest
Evaluate the electrolyte levels
Assess for orthostatic hypotension
Initiate cardiac monitoring

**Nursing actions indicated at this time include: placing the client on bedrest and assisting the client out of bed, evaluating electrolyte levels, assessing for orthostatic hypotension, and applying a cardiac monitor. Safety is required to prevent falls due to weakness from a likely fluid volume deficit and electrolyte imbalance. The nurse should review the laboratory and diagnostic results to detect likely loss of sodium, potassium, and magnesium secondary to diarrhea and diuretic us. Fluid volume deficit is likely with diarrhea and diuretic use and leads to fluid and electrolyte imbalances, especially hypokalemia. Assessing for orthostatic changes will confirm presence of volume deficit. Monitoring for

inverted T wave or presence of U wave on the ECG as well as dysrhythmias is indicated when hypokalemia is anticipated.Diuretics increase loss of fluids and electrolytes. The nurse would question this order in the presence of assessment data indicating fluid loss from the diuretics and diarrhea.

3

A client with hypokalemia has a prescription for parenteral potassium chloride (KCl). Which of these interventions does the nurse use to safely administer KCl?
Select all that apply.

Use a potassium infusion prepared by a registered pharmacist.
Assess for burning or redness during infusion.
Infuse at a rate of no more than 10 mEq per hour.
Administer only through a central venous catheter.
Administer by IV push only during cardiac arrest.

Use a potassium infusion prepared by a registered pharmacist.
Assess for burning or redness during infusion.
Infuse at a rate of no more than 10 mEq per hour.

**Interventions to safely administer KCl to a client with hypokalemia include: using a pharmacy prepared potassium infusion, checking the client for any burning or redness during infusion, and infusing the IV at not more than 10 mEq per hour. The Joint Commission's National Client Safety Goals mandates that concentrated potassium be diluted and added to IV solutions only in the pharmacy by a registered pharmacist and that vials of concentrated potassium not be available in client care areas. IV potassium solutions irritate veins and cause phlebitis. Assess the IV site hourly, and ask the client whether he or she feels burning or pain at the site. The presence of pain or burning at the insertion site may require a new intravenous to be started. A dose of KCl 5-10 mEq/hour, no more than 20 mEq/hr is recommended.Potassium may be administered by peripheral or central vein. There is no circumstance where potassium is given by IV push.

4

The nurse is caring for a client who is receiving a loop diuretic for treatment of heart failure. Which of these actions will be included in the plan of care?
Select all that apply.

Assess daily weights.
Encourage consumption of citrus fruits.
Weigh the client weekly.
Monitor serum potassium.
Discourage intake of spinach.
Monitor for bradycardia.

Assess daily weights
Encourage consumption of citrus fruits
Monitor serum potassium.

**Actions for the nurse to include when caring for a client taking a loop diuretic for heart failure include: assessing daily weights, encouraging consumption of citrus fruits, and monitoring the client's serum potassium. High-ceiling (loop) diuretics remove excess fluid and are potassium-depleting drugs. Consuming citrus fruit, green leafy vegetables, cantaloupe, tomato, and other food with potassium is indicated while receiving this type of diuretic to compensate for urinary loss of potassium.The client must be weighed at the same time each day, using the same scale and wearing approximately the same amount of clothes. Green leafy vegetables such as spinach contain potassium and are encouraged. The diuretic itself has no effect on the heart rate, however potassium depletion caused by the diuretic may cause cardiac irritability with a weak and thready pulse.

5

The nurse is caring for a client who takes furosemide (Lasix) and digoxin (Lanoxin). The client's potassium (K+) level is 2.5 mEq/L (2.5 mmol/L). Which additional assessment will the nurse make?

Heart rate

Blood pressure (BP)

Increases in edema

Sodium level

Heart rate

**The nurse must assess the heart rate for bradycardia related to digoxin and irritability or irregularity related to hypokalemia. Hypokalemia increases the sensitivity of cardiac muscle to digoxin and may result in digoxin toxicity, even when the digoxin level is within the therapeutic range. The nurse also assesses for GI symptoms such as diarrhea, and other symptoms of toxicity to digoxin.The BP may decrease with low potassium level but monitoring the pulse is essential. The diuretic would reduce edema, therefore assessing the heart rate is the priority. High serum sodium levels would not be expected in this scenario unless fluid volume deficit is present.

6

Furosemide (Lasix) has been ordered for a client with heart failure, shortness of breath, and 3+ pitting edema of the lower extremities. Which assessment finding indicates to the nurse that the medication has been effective?

The client's potassium level is 5.1 mEq/L (5.1 mmol/L).

The client's heart rate is 101 beats per minute.

The client is free from adventitious breath sounds.

The client has experienced a weight gain of 1 pound (0.5 kg).

The client is free from adventitious breath sounds.

**The nurse recognizes that Furosemide is effective when the client is free from adventitious breath sounds such as crackles. Other positive outcomes to the diuretic include normal heart rate, weight loss with resolution of edema, and increased urine output.A potassium value of 5.1 mEq/L or (5.1 mmol/L) is normal. Changes in potassium levels such as hypokalemia are side effects of furosemide, not therapeutic effects. Although a fall in the client's BP may occur with the decrease in body fluid, this is not the priority. Tachycardia may occur during episodes of fluid volume excess or deficit and does not directly indicate the medication has been effective. Weight loss, rather than weight gain, is often the effect of Furosemide, caused by the diuresis.

7

The nurse is discussing safety when administering bumetanide with a nursing student. The nurse recognizes that the student understands side effects of this medication when the student makes which statement?

"The client's PT and INR may be prolonged while taking this medication."

"The client may develop hypoglycemia during treatment."

"Inverted T waves and a U wave may appear on the ECG."

"I need to tell the client to avoid salt substitutes."

"Inverted T waves and a U wave may appear on the ECG."

**The nursing student understands the side effects of Bumex when commenting that inverted T waves and a U wave may appear on the EKG. Hypokalemia may cause depressed ST segments, flat or inverted T waves or the presence of a U wave on the ECG as well as dysrhythmias. High-ceiling (loop) diuretics, such as furosemide (Lasix, furosemide), promote loss of water, sodium, and potassium.PT and INR are typically prolonged with therapy with warfarin (Coumadin) or individuals with liver disease. Hypoglycemia may occur with oral hypoglycemic medications or insulin. Salt substitutes are typically avoided when the client has hyperkalemia or is taking an ACE inhibitor because many substitutes contain potassium chloride.

8

The nurse is teaching a client who is taking a potassium-sparing diuretic about precautions while taking this medication. Which of these does the nurse teach the client to avoid or use cautiously?
Select all that apply.

Apples
Bananas
ACE inhibitors
Grapes
Salt substitute

Bananas
ACE Inhibitors
Salt substitute

**While taking a potassium-sparing diuretic, the nurse teaches the client to avoid bananas, ACE inhibitors, and salt substitutes. Other foods high in potassium include cantaloupe, kiwi, oranges, avocados, broccoli, dried beans, lima beans, mushrooms, potatoes, seaweed, soybeans, and spinach. Salt substitutes contain potassium and may predispose the client to hyperkalemia.Apples and grapes are considered lower potassium-containing foods.

9

The nurse is assessing a client with a sodium level of 118 mEq/L (118 mmol/L). Which activity takes priority?

Monitoring urine output

encouraging sodium rich fluids and foods throughout the day

instructing the client not to ambulate without assistance

assessing deep tendon reflexes

instructing the client not to ambulate without assistance

**Safety is the priority in this instance. Instructing the client not to ambulate without assistance is the priority for a client with a sodium level of 118 mEq/L (118 mmol/L). This sodium level denotes severe hyponatremia which makes depolarization slower and cell membranes less excitable. This is manifested as general muscle weakness which is worse in the legs and arms. Additionally, this client may have developed confusion from cerebral edema.Monitoring urine output needs to be done but is not the priority action in this situation. Generally, fluid is restricted, rather than sodium rich foods offered, to minimize the hyponatremia. While the nurse may assess muscle strength and deep tendon reflex responses, safety is the priority.

10

The nurse is infusing 3% saline for a client with syndrome of inappropriate secretion (SIADH). Which of these complications does the nurse report to the primary care provider?

Peripheral edema

Crackles ½ way up the lung fields

Serum osmolarity of 294 mOsm/kg (294 mmol/kg)

Urine output of 1300 mL over 24 hours

Crackles ½ way up the lung fields

**The nurse needs to report to the PCP crackles heard ½ way up the lung fields when assessed on a client with SIADH receiving an infusion of 3% saline. When a hyperosmotic IV solution such as 3% saline is infused, the interstitial fluid is pulled into the circulation in an attempt to dilute the blood. As a result, the plasma volume expands. The nurse needs to evaluate the client for fluid volume excess and symptoms of heart failure including crackles.Peripheral edema may occur with SIADH. A serum osmolarity of 294 mOsm/kg (294 mmol/kg) is normal. A urine output of 1300 mL over 24 hours is considered normal.

11

The nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical?

Monitoring 24-hour urine output

Asking the client about feeling depressed

Assessing the blood pressure hourly

Monitoring the serum calcium levels

Assessing the blood pressure hourly

**Assessing hourly blood pressures is critical when caring for a client receiving IV magnesium sulfate. Hypotension is a sign/symptom of hypermagnesemia during magnesium infusion.Most clients who have fluid and electrolyte problems will be monitored for intake and output, and will not immediately indicate problems with magnesium overdose. Low magnesium levels can cause psychological depression, but assessing this parameter as the levels are restored would not safely assess a safe dose or an overdose. Although administration of magnesium sulfate can cause a drop in calcium levels, this occurs over a period of time and would not be the best way to assess magnesium toxicity.

12

A client is brought to the emergency department for increasing weakness and muscle twitching. The laboratory results include a potassium level of 7.0 mEq/L (7.0 mmol/L). Which assessments does the nurse make?
Select all that apply.

History of liver disease
Use of salt substitute
Use of an ACE inhibitor
Potassium-sparing diuretics
Prescription for insulin

Use of salt substitute
Use of an ACE inhibitor
Potassium-sparing diuretics

**When caring for an ED client with an elevated potassium level, the nurse needs to assess the client for any use of salt substitutes, any use of ACE inhibitors or potassium-sparing diuretics, as well as kidney disease.History of liver disease does not increase the client's potassium level. Insulin, which moves potassium into the cell, can be used as a treatment for hyperkalemia, in addition to diabetes. Taking insulin would lower the potassium level.

13

After receiving change-of-shift report, which client does the RN assess first?

A client with nausea and vomiting who complains of abdominal cramps

A client with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst

A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg

A client with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL

A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg

**The nurse must first assess the client receiving IV diuretics whose blood pressure is 88/52 mm Hg. This client with hypotension may have developed hypoperfusion caused by hypovolemia. Immediate interventions are needed.The client with nausea and vomiting, the client with an NG tube complaining of thirst, and the client receiving normal saline with an hourly urine output of 75 mL/hr have problems which are not urgent at this time.

14

The primary care provider writes prescriptions for a client who is admitted with a serum potassium level of 6.9 mEq/L (6.9 mmol/L). What does the nurse implement first?

Administer sodium polystyrene sulfonate (Kayexalate) orally.

Ensure that a potassium-restricted diet is ordered.

Place the client on a cardiac monitor.

Teach the client about foods that are high in potassium.

Place the client on a cardiac monitor.

**The nurse must first place this client on a monitor. Because hyperkalemia can lead to life-threatening bradycardia, placing the client on a cardiac monitor permits early intervention in the event of dysrhythmias.Administering a potassium-reducing medication, recommending a potassium-restricted diet, and teaching the client about diet are appropriate but will not immediately decrease the serum potassium level and do not need to be implemented as quickly as monitoring cardiac rhythm.

15

The 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)?

Assessing oral mucosa for dryness

Choosing appropriate oral fluids

Monitoring skin turgor for tenting

Offering fluids to drink every hour

Offering fluids to drink every hour

**Offering oral fluids every hour is within the scope of practice for a UAP.Assessments of oral mucosa, selection of appropriate fluids, and assessment of skin turgor would be done by licensed nursing staff, who have the needed education and scope of practice to implement these more complex actions.

16

The nurse at a long-term care facility is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. Which of these should be included in the education session?

"Be careful not to overload them with too many oral fluids."

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

"Restrict their fluids if they are incontinent."

"Wake them every 2 hours during the night with a drink."

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

**The long-term care nurse teaches the UAPs to frequently offer older adults fluids that they prefer and on a regular basis. Because of the decreased thirst mechanism, older adults can become dehydrated and must be offered oral fluids every 2 hours. The likelihood of their accepting the fluid increases if it is one they prefer.Risk of overhydration, especially with oral fluids, is minimal. Fluids would never be restricted even if the client is incontinent. Restricting fluids to incontinent clients is a common mistake made by UAP in long-term care environments. It is not necessary to disturb older adults during their sleep to offer fluids. However, they should be offered a drink during waking hours at frequent intervals (e.g., every 2 hours).

17

The nurse is preparing a client a diagnosis of congestive heart failure (CHF) for discharge. Which statement by the client indicates a correct understanding of self-management of CHF?

"I can gain 2 pounds (1 kg) of water a day without risk."

"I should call my provider if I gain more than 1 pound (0.5 kg) a week."

"Weighing myself daily can determine if my caloric intake is adequate."

"Weighing myself daily can reveal increased fluid retention."

"Weighing myself daily can reveal increased fluid retention."

**The client with CHF should weigh himself daily to observe for increasing fluid retention, which may not be visible. Rapid weight gain is the best indicator of fluid retention and overload. Each pound (0.5 kg) of weight gained (after the first half-pound [0.2 kg]) equates to 500 mL of retained water. The client must be weighed at the same time every day (before breakfast), and on the same scale.The client would call the primary care provider if more than 1 or 2 pounds (0.5 or 1 kg) are gained in a 24-hour period or if more than 3 pounds (1.4 kg) are gained in 1 week. Daily weights are not an indication of effective dieting for purposes of weight loss or gain. They will show fluid retention after an especially high sodium intake (in a client with fluid retention problems), but caloric intake is related to food intake rather than fluid retention problems.

18

The nurse is caring for a group of clients on a medical surgical unit. Which newly written prescription will the nurse administer first?

Intravenous normal saline to a client with a serum sodium of 132 mEq/L (132 mmol/L)

Oral calcium supplements to a client with severe osteoporosis

Oral phosphorus supplements to a client with acute hypophosphatemia

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

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

**The nurse must first administer oral potassium supplements to the client with hypokalemia. Even minor changes in serum potassium levels can cause life-threatening dysrhythmias.The electrolyte disturbances (sodium level of 132 and low phosphorus level) and the need for calcium in the other clients are not immediately life-threatening.

19

The step-down unit receives a new admission who has 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 diabetes educator

C. RN who has floated from the intensive care unit

20

The nurse is caring for a group of clients with electrolytes and blood chemistry abnormalities. Which client will the nurse see first?

A. The client with a random glucose reading of 123.

B. The client who has a magnesium level of 2.1

C. The client whose potassium is 6.2.

D. The client with a sodium level of 143

C. The client whose potassium is 6.2

21

The client with hypermagnesemia is seen in the emergency department. Which of these interventions is most appropriate?

A. Monitor for hyperactive reflexes

B. Prepare for endotracheal intubation

C. institute teaching on avoiding magnesium rich foods

D. Place the client on a cardiac monitor

D. Place the client on a cardiac monitor

22

Which client is most appropriate for the nurse manager of the medical-surgical unit to assign to the LPN/LVN?

A client admitted with dehydration who has a heart rate of 126 beats/min

A client just admitted with hyperkalemia who takes a potassium-sparing diuretic at home

A client admitted yesterday with heart failure with dependent pedal edema

A client admitted yesterday with heart failure with dependent pedal edema

**The most appropriate client to assign to the LPN/LVN is the 64-year-old client admitted yesterday with heart failure and dependent pedal edema. This client is the most stable of all the four clients.Dehydration, tachycardia, potassium overload, and GI signs and symptoms in a client indicate that he or she is unstable. Care must be given by the RN who can carry out assessments, prescriptions, and participate interdisciplinary collaboration as needed.

23

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?

Calcium level of 9.5 mg/dL (2.4 mmol/L)

Magnesium level of 4.1 mEq/L (2.1 mmol/L)

Potassium level of 6.0 mEq/L (6.0 mmol/L)

Sodium level of 120 mEq/L (120 mmol/L)

Calcium level of 9.5 mg/dL (2.4 mmol/L)

**The client with a calcium level of 9.5 mg/dL (2.4 mmol/L), a normal value, would be assigned to the LPN/LVN.A magnesium level of 4.1 mEq/L (2.1 mmol/L) (normal is 1.8-2.6 mEq/L [0.74-1.07 mmol/L]) and potassium level of 6.0 mEq/L (6.0 mmol/L) pose risk for dysrhythmia, and a sodium level of 120 mEq/L (120 mmol/L) may cause serious cerebral dysfunction requiring assessments and/or interventions by the RN.

24

The nurse is caring for an older adult with hypernatremia. Which of these interventions does the nurse perform first?

Restrict the client's intake of sodium

Administer a diuretic

Monitor the serum osmolarity

Encourage fluid intake

Encourage fluid intake

**When caring for an older adult with hypernatremia, the nurse first encourages the client to take more fluid. Encouraging fluids in the older adult is important to prevent dehydration with resulting concentrated sodium levels.Hypernatremia and fluid loss typically occur in tandem in the older adult. Restricting sodium does not replace fluids needed by many elderly clients. A diuretic will worsen the fluid volume deficit the client is experiencing. Monitoring the osmolarity will detect an abnormality, but not resolve the problem.

25

The RN is caring for a client who is severely dehydrated. Which nursing action can be delegated to the unlicensed assistive personnel (UAP)?

Consulting with a health care provider about a client's laboratory results

Infusing 500 mL of normal saline over 60 minutes

Monitoring IV fluid to maintain the drip rate at 75 mL/hr

Providing oral care every 1 to 2 hours

Providing oral care every 1 to 2 hours

**Appropriate intervention by an UAP to a client who is severely dehydrated is to provide oral care every 1 to 2 hours. Frequent oral care is important for a client with fluid volume deficit.Consulting with a primary care provider about a client's laboratory results, infusing 500 mL of normal saline, and monitoring IV fluids are complex actions and would be performed by licensed personnel.

26

The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which client is most appropriate to assign to the LPN/LVN?

A 44-year-old with congestive heart failure (CHF) who has gained 3 pounds (1.4 kg) since the previous day

A 58-year-old with chronic renal failure (CRF) who has a serum potassium level of 6 mEq/L (6.0 mmol/L)

A 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/kg (300 mmol/kg)

An 80-year-old with 3+ peripheral edema and crackles throughout the posterior chest

A 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/kg (300 mmol/kg)

**The most appropriate client for the nurse to assign to the LPV/LVN is the 76-year-old adult with poor skin turgor and a serum osmolarity of 300 mOsm/kg (300 mmol/kg). Although the 76-year-old client has poor skin turgor, the serum osmolarity indicates normal fluid balance. This client is the most stable of the four clients described.The 44-year-old with CHF who has gained 3 pounds (1.4 kg) since the previous day requires additional assessments and interventions which should be performed by an RN. The data about the 58-year-old client with CRF and a serum potassium level of 6 mEq/L (6.0 mmol/L) has a risk for dysrhythmia and instability. Assessments and interventions performed by an RN are also needed on this client. The data about the 80-year-old client with edema and congested lungs indicate that the client is not stable, requiring ongoing assessments and interventions by an RN.

27

The nurse is caring for a client receiving lactated Ringer's solution IV for rehydration. Which assessments will the nurse monitor during intravenous therapy?
Select all that apply.

Blood serum glucose
Blood pressure
Pulse rate and quality
Urinary output
Urine specific gravity

Blood pressure
Pulse rate and quality
Urinary output
Urine specific gravity

**The two most important areas to monitor during rehydration are pulse rate and quality and urine output. In addition, decreasing specific gravity of urine is also an indication of rehydration. Blood pressure is another important vital sign to monitor during rehydration.Blood glucose changes do not have a direct relation to a client's hydration status; lactated ringers are free from glucose.

28

The rapid response team (RRT) is called to the bedside of a client with heart rate of 38 beats per minute and a potassium level of 7.0 mEq/L (7.0 mmol/L). For which medication will the nurse anticipate a prescription?

Insulin

atropine

Sodium polystyrene sulfonate (Kayexalate)

potassium phosphate

Insulin

**The rapid response nurse expects to administer a combination of 20 units of regular insulin in 100 mL of 20% dextrose in water. This may be prescribed to promote movement of potassium from the blood into the intracellular fluid.While atropine will treat bradycardia, it does not address the underlying cause of bradycardia which is likely hyperkalemia. Sodium polystyrene sulfonate (Kayexalate)may be used for hyperkalemia, but it will not act quickly enough in an emergency. Additional potassium such as contained in potassium phosphate will make the client's condition more critical.
atropine

29

A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first?

Draws blood for laboratory tests

Elevates the head of the bed

Places the extremities in a dependent position

Puts the client in a side-lying position

Elevates the head of the bed

**The nurse first needs to elevate the client's head of bed when caring for a client with fluid overload. Remember to follow the ABC's and perform interventions that promote lung expansion and oxygenation to relieve symptoms of fluid overload.Drawing blood for laboratory tests may be indicated, but would not be performed first. Placing the extremities in a dependent position increases peripheral edema, and positioning the client in a side-lying position increases the work of breathing.

30

An older adult is admitted to the medical surgical unit with dehydration. The nurse performs which of these assessments to determine whether the client is safe for independent ambulation?

Assesses for dry oral mucous membranes

Checks for orthostatic blood pressure changes

Notes pulse rate is 72 beats/min and bounding

Evaluates that the serum potassium level is 4.0 mEq/L (4.0 mmol/L)

Checks for orthostatic blood pressure changes

**When caring an older adult admitted for dehydration, the nurse determines if the client is safe for independent ambulation by assessing for orthostatic blood pressure. Blood pressure measured with the client lying, then sitting, and finally standing is done to detect orthostatic or postural changes. During low blood volume states, especially when standing, insufficient blood flow to the brain may cause hypotension and tachycardia upon arising. This may cause light-headedness and dizziness, which increases the risk for falls, especially in older adults.Assessment of oral mucous membranes and the pulse rate can detect symptoms of dehydration, but these are not the best ways to assess for a fall risk. Checking serum potassium does ensure safety for ambulation nor assess for fall risk.

31

The nurse is assessing fluid balance in the client with heart failure. Which of these strategies will the nurse employ?

Ask the client how much fluid was consumed yesterday.

Place an indwelling catheter to measure urine output.

Auscultate the lungs for adventitious sounds.

Weigh the client daily, at the same time.

Weigh the client daily, at the same time.

**When assessing fluid balance on a client with heart failure the nurse must weigh the client at the same time every day. Changes in daily weights are the best indicators of fluid losses or gains. A weight change of 1 pound (0.5 kg) corresponds to a fluid volume change of about 500 mL therefore the weight must be compared to intake and output.The nurse must weigh the client rather than rely on client estimate or memory. An indwelling catheter poses a risk for catheter associated urinary tract infection, and is reserved for specific reasons. Auscultating for adventitious lung sounds or crackles will demonstrate fluid overload, but may not immediately show up.

32

A client is admitted to the hospital with dehydration secondary to influenza and vomiting. The provider orders an intravenous (IV) potassium replacement for potassium level of 2.7 mEq/L (2.7 mmol/L). Which of these best practice techniques does the nurse include when administering this medication?
Select all that apply.

Ensuring that the concentration is no greater than 1?9?mEq/10?9?mL of solution
Use a vein in the hand for better flow
Use an IV pump to deliver the medication
Check IV access for blood return after the infusion
Push the medication over 5 minutes

Ensuring that the concentration is no greater than 1?9?mEq/10?9?mL of solution
Use an IV pump to deliver the medication

**Best practice technique for administering IV potassium replacement is to ensure that the concentration is no greater than 1 mEq/10 mL of solution. A pump or controller device must be used to deliver the medication to prevent rapid infusion and complications of hyperkalemia, including cardiac arrest.Potassium must be infused via a large vein with a high volume of flow, avoiding the hand. The maximum recommended infusion rate of potassium is 5 to 10 mEq/hr. This rate is never to exceed 20 mEq/hr. Potassium would never be administered via IV push. Assess the IV access for placement and an adequate blood return before administering potassium-containing solutions.

33

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?

Assessment of muscle tone and strength

Education about potassium-rich foods

Instruction on the proper use of drugs

Measurement of the client's weight

Measurement of the client's weight

**The intervention that can be delegated to the home health aide is to measure the client's weight. Measuring the client's intake and output and reporting it to the RN helps determines if the plan of care has been effective.Assessment, education, and instruction are higher-level nursing actions within the scope of practice of the professional nurse.

34

The nurse is caring for a client receiving lactated Ringer's solution IV for rehydration. Which assessments will the nurse monitor during intravenous therapy? Select all that apply

A. Blood serum glucose

B. Blood pressure

C. pulse rate and quality

D. Urinary output

E. Urine specific gravity

B. Blood presure

C. Pulse rate and quality

D. urinary output

E. Urine specific gravity

35

The nurse is caring for a client with acute respiratory failure and PaCO2 level of 88 mm Hg For which of these signs and symptoms will the nurse assess? Select all that apply

A. Hyperactivity

B. Headache

C. Shallow breathing

D. PH 7.49

E. Fatigue

B. Headache

C. Shallow breathing

E. Fatigue

When caring for a client with acute respiratory failure and respiratory acidosis, the nurse would assess for lethargy, flushing, headache, shallow breathing, and fatigue. Clients experiencing acidosis have problems associated with the decreased function of excitable membranes. Generally, the client with respiratory acidosis will be lethargic rather than hyperactive and have a ph less than 7.35, which is a characteristic of acidosis.

36

When caring for a client who has the following blood gas results, which of these interventions does the nurse plan to use to correct the acid base disturbance? pH 7.47—pCO2 37 mm hg- HCO3 30 mEq/L (30 mmol/L)—pO2 88mm hg

A. Endotracheal suctioning

B. Apply Oxygen

C. Administer an antiemetic

D. Administering sodium Bicarbonate

administering an antiemetic

This blood gas demonstrates metabolic alkalosis typically caused by vomiting or NG suction. The client loses potassium and retains bicarbonate; an antiemetic will reduce vomiting and correct the imbalance.Endotracheal suction is indicated for retained respiratory secretions, which would be reflected as a respiratory acidosis. The pO2 is between 80 and 100 mmHg, which is normal, supplementary oxygen is not required. Sodium bicarbonate is used to treat metabolic acidosis in certain situations.

37

The nurse is caring for a client with long standing emphysema and respiratory acidosis. For which of these compensatory mechanisms will the nurse assess?

A. Decreased Rate of breathing

B. Increased loss of bicarbonate through the kidney

C. Decreased depth breathing

D. Decreased loss of bicarbonate through the kidney

Decreased loss of bicarbonate through the kidney

The compensatory mechanism the nurse anticipates is present in the client with long standing emphysema and respiratory acidosis is conservation of bicarbonate. A partially compensated respiratory acidosis will typically result.Increased loss of bicarbonate through the kidney, decreased rate, and depth of breathing will promote acidosis.
Question 7 of 10

38

Which of these findings causes the critical care nurse to notify the primary care provider (PCP) for evaluation for intubation?

Increasing somnolence
The critical nurse notifies the primary health care provider for somnolence consistent with worsening respiratory acidosis. Other client findings related to worsening respiratory acidosis caused by CO2 retention include: headache, fatigue, lethargy, and decreased respirations which may require intubation and mechanical ventilation.Pallor is a sign of hypoxemia, lack of oxygen to the tissues. As pallor may occur with anemia, this finding alone does not represent a need for intubation. Deep respirations and bounding pulse are not consistent with respiratory acidosis.

39

When caring for a client with a burn injury and eschar banding the chest, the nurse plans to observe the client for which of these acid base disturbances?

A. Respiratory acidosis

B. Respiratory alkalosis

C. Metabolic acidosis

D. Metabolic alkalosis

Respiratory acidosis

The nurse plans to observe the client with a burn injury and eschar banding the chest for respiratory acidosis related to decreased chest excursion. Circumferential eschar will result in hypoventilation, accumulation of carbon dioxide and resulting respiratory acidosis.Respiratory alkalosis is caused by hyperventilation, increased rate or depth of breathing, causing carbon dioxide to be eliminated in excess. Metabolic acid base disturbances are usually caused by renal issues.

40

The nurse is caring for a group of clients. Which client will the nurse carefully observe for signs and symptoms of hyperkalemia?

the client who has metabolic acidosis

The nurse would carefully observe for signs of metabolic acidosis in a client with hyperkalemia. Hyperkalemia occurs as the body attempts to buffer the acidosis by moving hydrogen ions into the cells. An equal number of potassium ions move from the cells into the blood to maintain intracellular electroneutrality, resulting in hyperkalemia.The client receiving TPN is at risk for metabolic alkalosis due to an increase in base components. Metabolic alkalosis is associated with hypochloremia rather than hyperkalemia. The client with profuse vomiting or taking a diuretic is also at risk for metabolic alkalosis and hypokalemia.

41

The nursing assistant reports that the client with metabolic acidosis due to kidney failure is breathing rapidly and deeply. The nurse explains this to the nursing assistant in which of these manners?

A. The client is acting out and we should pay him no mind

B. Rapid breathing is a way to compensate for acidosis caused by his condition

C. Normally a client with this disorder will breathe slowly, I will go assess him

D. Deep breathing is a symptom of diabetes; I will check his blood glucose.

Rapid breathing is a way to compensate for acidosis caused by his condition"

The nurse explains that kussmaul or rapid and deep breathing helps the body compensate for metabolic acidosis by blowing off the CO2 or respiratory acid through the lungs. This will also increase the body's pH level.The client would not be judged for acting out without a clear understanding of the underlying client's cause. Slow respirations are not consistent with metabolic acidosis, however, may cause respiratory acidosis. Deep breathing (Kussmaul breathing) is a compensatory mechanism for metabolic acidosis ocurring with DKA or kidney disease.

42

The nurse is caring for a client who has developed postoperative respiratory acidosis. Which of these interventions will the nurse use to help correct this problem?

A. Medicate for pain

B. Encourage use of incentive spirometer

C. Perform finger stick blood glucose

D. Encourage protein intake

Encourage use of incentive spirometer.

The intervention that will best help the client with postoperative respiratory acidosis is to encourage the client to use the incentive spirometer. Respiratory acidosis is caused by hypoventilation. Improving ventilation through lung expansion, suctioning, or upright positioning will help to resolve this.While pain medication may make use of the incentive spirometer easier, narcotic analgesics may suppress respirations and worsen acidosis. There is no indication the client has an unstable blood glucose level. Protein intake facilitates wound healing, not resolution of acidosis.

43

The nurse and nursing student are caring for a client with a new diagnosis of diabetes whose blood glucose is 974 mg/dL (54.1 mmol/L). Which of these statements indicates the student understands the relationship between blood glucose and acid base balance?

"The hyperglycemia is caused by inability of glucose to enter the cell causing a starvation state and break down of fats"

The nursing student understands the relationship between blood glucose and acid base balance when the student states that hyperglycemia is caused by inability of glucose to enter the cell causing a starvation state and break down of fats. Glucose cannot enter the cell to provide energy without the presence of insulin. The body begins to break down fat for energy which produces ketones and causes ketoacidosis.The client with ketoacidosis will hyperventilate, breathing more rapidly and deeply to rid the body of respiratory acids such as CO2. This process buffers the acidosis. A hyperosmolar state does occur, however the acid base balance is still affected. CO2 is retained when the client's inability to ventilate or remove CO2 effectively occurs. Hypercarbia, CO2 retention, is generally caused by problems affecting the pulmonary system.

44

The nurse is caring for a client with sepsis and impending septic shock. Which of these interventions will help prevent lactic acidosis?

A. Ensure adequate oxygenation

B. Restrict carbohydrates

C. Supplement postassium

D. Monitor hemoglobin

ensure adequate oxygenation
When caring for a client with sepsis and impending shock the nurse will ensure adequate oxygenation to help prevent lactic acidosis. Cellular metabolism under anaerobic (no oxygen) conditions forms lactic acid. Shock states are due to a lack of cellular perfusion and delivery of oxygen to the tissues. Providing adequate oxygenation and perfusion will help to reverse the need for the body to make ATP without oxygen which causes lactic acid to accumulate.Carbohydrate metabolism forms carbon dioxide (CO2) and carbohydrate restriction will not prevent lactic acidosis, a form of metabolic acidosis. Supplementing potassium may worsen hyperkalemia, as this is an expected finding during episodes of metabolic acidosis. While hemoglobin is a weak buffer, monitoring the value will not prevent an acid-base disturbance.

45

The nurse is documenting peripheral venous catheter insertion for a client. What does the nurse include in the note? Select all that apply.

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

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

46

The nurse assessing a client's peripheral IV site obtains and documents information about it. Which assessment data indicate the need for immediate nursing intervention?

A. Client states, "It really hurt when the nurse put the IV in."
B. The vein feels hard and cordlike above the insertion site.
C. Transparent dressing was changed 5 days ago.
D. Tubing for the IV was last changed 72 hours ago.

The vein feels hard and cordlike above the insertion site.

A hard, cordlike vein suggests phlebitis at the IV site and indicates an immediate need for nursing intervention. The IV should be discontinued and restarted at another site.It is common for IVs to cause pain during insertion. An intact transparent dressing requires changing only every 7 days. Tubing for peripheral IVs should be changed every 72 to 96 hours.

47

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.

Skin in older adults tends to be thin. Tape or dressings used with IV therapy can compromise skin integrity.Placement on the back of the dominant hand is contraindicated because hand movement can increase the risk of catheter dislodgement. An angle smaller than 25 degrees is required for venipuncture success in older adults. This technique is less likely to puncture through the older adult client's vein. Clipping, and not shaving, the hair around the insertion site typically is necessary only for younger men.

48

When flushing a client's central line with normal saline, the nurse feels resistance. Which action does the nurse take first?

A. Decrease the pressure being used to flush the line.
B. Obtain a 10-mL syringe and reattempt flushing the line.
C. Stop flushing and try to aspirate blood from the line.
D. Use "push-pull" pressure applied to the syringe while flushing the line.

Stop flushing and try to aspirate blood from the line.

The nurse's first step is to stop flushing and try to aspirate blood from the line. If resistance is felt when flushing any IV line, the nurse should stop and further assess the line. Aspiration of blood would indicate that the central line is intact and is not obstructed by thrombus.Decreasing the pressure to flush the line is not appropriate. Continuing or reattempting to flush the line, or using a push-pull action on the syringe, might result in thrombus or injection of particulate matter into the client's circulation.

49

The nurse is administering a drug to a client through an implanted port. Before giving the medication, what does the nurse do to ensure safety?

A. Administer 5 mL of a heparinized solution.
B. Check for blood return.
C. Flush the port with 10 mL of normal saline.
D. Palpate the port for stability.

Check for blood return.

To ensure safety, before a drug is given through an implanted port, the nurse must first check for blood return. If no blood return is observed, the drug should be held until patency is reestablished.If no blood return is observed, the drug should be held until patency is reestablished. Ports are flushed with heparin or saline after, rather than before, use. The port is palpated for stability, but this action alone does not ensure the client's safety.

50

A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does the nurse teach the new graduate nurse to use for this client?

A. Midline catheter
B. Tunneled percutaneous central catheter
C. Peripherally inserted central catheter
D. Short peripheral catheter

Midline catheter

For a client with fragile veins (which occur with long-term corticosteroid use) and the need for a catheter for 5 days, the midline catheter is the best choice.Tunneled central catheters usually are used for clients who require IV access for longer periods. Peripherally inserted central catheters usually are used for clients who require IV access for longer periods. A short peripheral catheter is likely to infiltrate before 5 days in a client with fragile veins, requiring reinsertion.

51

The 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

First, the nurse contacts the health care provider who ordered it. The nurse is legally and professionally responsible for accuracy and has the duty to verify the order with the health care provider who ordered it.The nurse can consult the charge nurse, but this is not the definitive action that the nurse should take. Contacting the pharmacy is not the best action that the nurse should take. Giving (or starting) the fluid when the order is questionable is not appropriate and could possibly harm the client.

52

The 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 (32-km) 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 (32-km) running schedule as I have for the past 10 years."

The statement by the client stating that his or her normal running schedule can continue indicates a need for further education. Excessive physical activity can dislodge the PICC and should be avoided.Clients with PICCs should be able to perform normal activities of daily living. PICCs have low complication rates because the insertion site is in the upper extremity. The dry skin of the arm has fewer types and numbers of microorganisms, leading to lower rates of infection. PICC lines can be used long term (months).

53

Which client does the charge nurse on a medical-surgical unit assign to the LPN/LVN?

A. Cardiac client who has a diltiazem (Cardizem) IV infusion being titrated to maintain a heart rate between 60 and 80 beats/min
B. Diabetic client admitted for hyperglycemia who is on an IV insulin drip and needs frequent glucose checks
C. Older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours
D. Postoperative client receiving blood products after excessive blood loss during surgery

Older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours

The older client admitted for confusion with a heparin lock is the most stable and requires basic monitoring of the IV site for common complications such as phlebitis and local infection, which would be familiar to an LPN/LVN.The cardiac client with a diltiazem (Cardizem) IV infusion, the diabetic client on an IV insulin drip, and the postoperative client receiving blood products all are not stable and will require ongoing assessments and adjustments in IV therapy that should be performed by an RN.

54

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. Anticipate an order to discontinue the intraosseous IV and start an epidural IV.
B. Call the previous hospital to verify the date.
C. Immediately discontinue the intraosseous IV.
D. Nothing; this is a long-term treatment.

Anticipate an order to discontinue the intraosseous IV and start an epidural IV.

The admitting nurse would first anticipate an order to discontinue the intraosseous IV and start an epidural IV. The intraosseous route should be used only during the immediate period of resuscitation and should not be used for longer than 24 hours. Alternative IV routes, such as epidural access, should then be considered for pain management.The nurse should know what to do in this client's situation without contacting the previous hospital. Other client data, such as the date and time that the burn occurred, should validate the date and time of insertion of the IV. Discontinuing the IV is not the priority in this situation—the client is in a precarious fluid balance situation. One IV access should not be stopped until another is established. This type of IV is not used for long-term therapy; an action must be taken.

55

A severely dehydrated client requires a rapid infusion of normal saline and needs a midline IV placed. Which staff member does the emergency department (ED) charge nurse assign to complete this task?
A. RN who is certified in the administration of oral and infused chemotherapy medications
B. RN with 2 years of experience in the ED who is skilled at insertion of short peripheral catheters
C. RN with 10 years of experience on a medical-surgical unit who has cared for many clients requiring IV infusions

D. RN with certified registered nurse infusion (CRNI) certification who is assigned to the ED for the day

RN with certified registered nurse infusion (CRNI) certification who is assigned to the ED for the day

The nurse with CRNI certification is most likely to be able to quickly insert a midline catheter for a client who is dehydrated.The chemotherapy nurse and the ED nurse have the appropriate scope of practice, but will not be as skilled in inserting a midline IV catheter. The medical-surgical nurse may be skilled at inserting short peripheral catheters, but will not be skilled in inserting midline IV catheters.

56

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 solution?

A. 24
B. 22
C. 18
D. 14

18
An 18-gauge catheter is the size of choice for clients who will undergo surgery. If they need to receive fluids rapidly, or if they need to receive more viscous fluids (such as blood or blood products), a lumen of this size would accommodate those needs.Neither a 24-gauge nor a 22-gauge catheter is an appropriate size (too small) for clients who will undergo surgery. If it becomes necessary to administer fluids to the client rapidly, another IV would be needed with a larger needle—18, for example. Administering through the smallest gauge necessary is usually best practice, unless the client may be going into hypovolemic status (shock). A 14-gauge catheter is an extremely large-gauge needle that is very damaging to the vein.

57

A client is to receive an IV solution of 5% dextrose and 0.45% 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

The safest method is to administer the solution with an infusion pump. Infusion pumps are used for drugs or fluids under pressure. They accurately measure the volume of fluid being infused.A controller is a stationary, pole-mounted electronic device that uses a sensor to monitor fluid flow and detect when flow has been interrupted. Because controllers rely completely on gravity to create fluid flow and do not create pressure, they do not ensure infusion but only control the drip rate. A glass container is necessary to use only with IV solutions that may cling to the plastic bag. This IV solution does not cling to plastic bags. A syringe pump does not hold sufficient volume to be practical in this situation.

58

The nurse is starting a peripheral IV catheter on a recently admitted client. What actions does the nurse perform before insertion of the line? Select all that apply.

A. Apply povidone-iodine to clean skin, dry for 2 minutes.
B. Clean the skin around the site.
C. Prepare the skin with 70% alcohol or chlorhexidine.
D. Shave the hair around the area of insertion.
E. Wear clean gloves and touch the site only with fingertips after applying antiseptics.

A. Apply povidone-iodine to clean skin, dry for 2 minutes.
B. Clean the skin around the site.
C. Prepare the skin with 70% alcohol or chlorhexidine.

59

The 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

The cephalic vein of the forearm is the insertion site chosen most often. For same-day surgery, the cephalic or basilic vein allows insertion of a larger IV catheter while allowing movement of the arm without impairing intravenous flow.Peripheral venous catheters should never be inserted into the back of the hand in an older adult because the veins are brittle. Peripheral venous catheters should never be inserted into the lower arm on the same side as a radical mastectomy because they interfere with limited circulation. Catheters are typically inserted into the subclavian vein by the health care provider, not by the nurse.

60

A client admitted to the intensive care unit is expected to remain for 3 weeks. The nurse has orders to start an IV. Which vascular access device is best for this client?

A. Midline catheter
B. Peripherally inserted central catheter (PICC)
C. Short peripheral catheter
D. Tunneled central catheter

Midline catheter

Midline catheters are the best device for this client. These catheters are used for therapies lasting from 1 to 4 weeks.PICCs are typically used when IV therapy is expected to last for months. Short peripheral catheters are allowed to dwell (stay in) for 72 to 96 hours, but they then require removal and insertion at another venous site. Tunneled central catheters must be inserted by a health care provider. Nurses are typically not qualified to start tunneled central catheters.

61

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 (2.5 cm) 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

Grade 3 indicates pain at the access site with erythema and/or edema and streak formation with a 1' palpable cord.Grade 1 indicates only erythema with or without pain; the client has additional symptoms. Grade 2 indicates only pain at the access site with erythema and/or edema; the client has additional symptoms. Grade 4 indicates pain at the access site with erythema and/or edema, streak formation, a palpable venous cord longer than 1 inch (2.5 cm), and purulent drainage. No purulent drainage is present in this client, and the palpable cord is 1 inch (2.5 cm) in length.

62

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. Change the set immediately.
B. Change the set in about 4 hours.
C. Change the set in the next 12 to 24 hours.
D. Nothing; the set is for long-term use.

Change the set in about 4 hours.

Because both ends of the set are being manipulated with each dose, standards of practice dictate that the set should be changed every 24 hours, so the set should be changed in about 4 hours.It is not necessary to change out the set immediately, but it must be changed before the next 12 to 24 hours.

63

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, a government agency, 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' exposure to contaminated needles."
D. "They minimize clients' exposure to contaminated needles."

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

The nurse informs the client that needleless IVs were designed to protect health care personnel from exposure to contaminated needles.The Occupational Safety and Health Administration (OSHA) requires the use of devices with engineered safety mechanisms only. It does not mandate that they be needleless. Saving time and money is not the purpose of the needleless IV, and it was not designed to protect clients from exposure to contaminated needles.

64

The 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 dispensed
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

To ensure safety, blood must be checked by two qualified health care professionals, usually two registered nurses.Administering an incorrectly matched unit of blood creates great consequences for the client and is considered to be a sentinel event. It requires a great amount of follow-up and often changing of policies to improve safety. The Joint Commission requires that the client provide two identifiers, but they are the name and date of birth or some other identifying data, depending on the facility; saying and spelling the name is only one identifier. Although a check is provided at the blood bank, this is not the one that is done before administration to the client. Clients do need to have normal saline running with blood, but this is not considered to be part of the safety check before administration of blood and blood products.

65

A client is admitted to the cardiothoracic surgical intensive care unit 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 determine patency of the client's arterial line?

A. Blood pressure
B. Capillary refill and pulse
C. Neurologic function
D. Questioning the client about the pain level at the site

Capillary refill and pulse

Capillary refill and pulse should be assessed to ensure that the arterial line is not occluding the artery.Blood pressure and neurologic function are not pertinent to the client's arterial line. Although the client's comfort level is important with an arterial line, it is not a determinant of patency of the line.

66

A 70-year-old client with severe dehydration is ordered an infusion of an isotonic solution at 250 mL/hr through a midline IV catheter. After 2 hours, the nurse notes that the client has crackles throughout all lung fields. Which action does the nurse take first?

A. Assess the midline IV insertion site.
B. Have the client cough and deep-breathe.
C. Notify the health care provider about the crackles.
D. Slow the rate of the IV infusion.

Slow the rate of the IV infusion.

The presence of crackles throughout the lungs is a sign of possible fluid overload. The nurse should slow the rate of infusion and further assess for indicators of volume overload and/or respiratory distress.The presence of crackles throughout the lungs is a sign of possible fluid overload. The nurse should slow the rate of infusion and further assess for indicators of volume overload and/or respiratory distress. Assessing the site and having the client cough and deep-breathe are not appropriate. Crackles do not disappear with coughing. Notifying the provider may be appropriate, but is not the initial actions for this client.

67

The nurse is revising an agency's recommended central line catheter-related bloodstream infection prevention (CR-BSI) bundle. Which actions decrease the client's risk for this complication? Select all that apply.

A. During insertion, draping the area around the site with a sterile barrier
B. Immediately removing the client's venous access device (VAD) when it is no longer needed
C. Making certain that observers of the insertion are instructed to look away during the procedure
D. Thorough hand hygiene (i.e., no quick scrub) before insertion

Immediately removing the client's venous access device (VAD) when it is no longer needed, Thorough hand hygiene (i.e., no quick scrub) before insertion, Using chlorhexidine for skin disinfection

68

The 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. Assess the insertion site.
B. Check connections.
C. Check the infusion rate.
D. Discontinue the IV and start another.

Assess the insertion site.

The initial response by the nurse is to assess the insertion site. The purpose of this action is to check for patency, which is the priority. IV assessments typically begin at the insertion site and move "up" the line from the insertion site to the tubing, to the tubing's connection to the bag.Checking the IV connection is important, but is not the priority in this situation. Checking the infusion rate is not the priority. Discontinuing the IV to start another may be required, but it may be possible to "save" the IV, and the problem may be positional or involve a loose connection.

69

The nurse is inserting a peripheral intravenous (IV) catheter. Which client statement is of greatest concern during this procedure?

A. "I hate having IVs started."
B. "It hurts when you are inserting the line."
C. "My hand tingles when you poke me."
D. "My IV lines never last very long."

My hand tingles when you poke me."

The client's statement about a tingling feeling indicates possible nerve puncture and is of greatest concern to the nurse. To avoid further nerve damage, the nurse should stop immediately, remove the IV catheter, and choose a new site.Statements such as, "I hate having IVs started," "It hurts when you are inserting the line," and "My IVs never last very long," are addressed with teaching about the importance of proper protection of the site.