Question 1

Yesterday morning the patient weighed 169.4 lb (77 kg).This morning the patient weighs 171.6 lb (78 kg).The nurse determines that the patient has gained _____ liter(s)of fluid.

Accepted Answer

The answer of Yesterday morning the patient weighed 169.4 lb...

Question 2

A nurse is mentoring a new nurse who is learning to start IVs.The nurse tells the new nurse that in case the patient needs subsequent venipuncture sites,the best place to initially start an IV is the:

Accepted Answer

Initially place IV catheters at the most distal point,which allows for the use of proximal sites later if the patient needs a venipuncture site change (INS,2011).Use the most distal site in the nondominant arm,if possible.Vascular access device placement in the dominant arm interferes with activities of daily living.

Question 3

When a nurse is selecting a vein for IV placement,what is the most appropriate action?

Accepted Answer

Use the most distal site in the nondominant arm,if possible.Select a well-dilated vein.Methods to foster venous distention include place the extremity in a dependent position if possible and stroke from distal to proximal below the proposed venipuncture site.Apply warmth to the extremity for several minutes,for example,with a warm washcloth.Vigorous friction and multiple tapping of a vein,especially in older adults,can cause hematoma and/or venous constriction.Avoid vein selection in areas with tenderness,pain,infection,or wounds,or extremities affected by previous stroke (CVA),paralysis,mastectomy,or dialysis graft.Choose a site that will not interfere with the patient's activities of daily living (ADLs).

Question 4

A nurse is caring for a patient after a bowel resection.The nurse plans assessment based on the knowledge that body fluids maintain balance through homeostasis,which includes what processes? (Select all that apply.)

Accepted Answer

Fluid homeostasis is the dynamic interplay of three processes: fluid intake and absorption,fluid distribution,and fluid output.Our daily fluid output consists of hypotonic sodium-containing fluid.To maintain fluid balance,we must have an intake of an equivalent amount of hypotonic sodium-containing fluid (water plus foods with some salt).Fluid is not catabolized (broken down into components to release energy)in the body.

Question 5

A patient has a peripheral IV.The nurse should assess the IV site for what primary signs and symptoms of infiltration? (Select all that apply.)

Accepted Answer

An infiltration occurs when IV fluids leak into the subcutaneous tissue around the venipuncture site because the catheter tip no longer is in the vein.Infiltration causes swelling (from increased interstitial fluid),paleness,and coolness (from decreased circulation)around the venipuncture site.The IV infusion may slow or stop.Pain may occur,increasing as the infiltration progresses.Phlebitis is inflammation of a vein.Signs and symptoms include redness,tenderness,and warmth along the course of the vein starting at the access site,with possibly a red streak and/or palpable cord along the vein.

Question 6

During a clinical rotation at an orthopedic unit,a nursing student is caring for a 67-year-old patient who has undergone a knee replacement.The patient is complaining of pain at the IV site.The nursing student assesses the site and finds that the site is cool and pale.The student stops the IV and reports the situation to the nurse.What does the nursing student suspect?

Accepted Answer

An infiltration occurs when IV fluids leak into the subcutaneous tissue around the venipuncture site because the catheter tip no longer is in the vein.Infiltration causes swelling (from increased interstitial fluid),paleness,and coolness (from decreased circulation)around the venipuncture site.The IV infusion may slow or stop.Pain may occur,increasing as the infiltration progresses.Phlebitis is inflammation of a vein.Signs and symptoms include redness,tenderness,and warmth along the course of the vein starting at the access site,with possibly a red streak and/or palpable cord along the vein.Phlebitis can be dangerous because blood clots (thrombophlebitis)can form,increasing the risk for an embolus,a clot that becomes dislodged and can travel to the lungs.Local infection at the VAD site is possible.The insertion site will be red and/or edematous; exudate may occur.

Question 7

A 15-year-old adolescent has been recently diagnosed with cancer.The patient will be receiving IV chemotherapy for several weeks.Which vascular access device should be used for short-term administration of his IV fluid?

Accepted Answer

Peripheral catheters are for short-term use (e.g.,to restore fluid volume).Devices for long-term use include central lines,peripherally inserted central catheters (PICCs),and implanted ports.These devices are more effective than peripheral catheters for administering PN and medications and solutions that are irritating to veins.

Question 8

The nurse is working for a medical unit in a hospital.The nurse is responsible for obtaining intake and output measurements for patients.What items should be considered intake? (Select all that apply.)

Accepted Answer

Fluid intake includes all liquids that a person eats (e.g.,gelatin,ice cream,broth),drinks (e.g.,juice,coffee,tea,water),or receives through nasogastric or jejunostomy feeding tubes.Intravenous fluids (continuous and intermittent)and blood components also count as intake.A patient receiving tube feedings may receive numerous liquid medications; water will be used to flush the tube before and/or after the medications.Liquid output includes urine,diarrhea,vomitus,gastric suction,and blood and drainage from postsurgical wounds,burns,or other tubes.

Question 9

A patient complains of chills,dizziness,and feeling hot during a blood transfusion.What are the nurse's most appropriate actions? (Select all that apply.)

Accepted Answer

STOP (do not slow down)the transfusion immediately even when you just suspect a reaction.Remain with the patient,observing signs and symptoms and monitoring vital signs as often as every 5 minutes.Immediately notify the health care provider or emergency response team and the blood bank.

Question 10

The nurse suspects that the patient is experiencing a blood transfusion reaction.The nurse stops the infusion but is concerned about losing the IV line if blood clots in the catheter.The nurse should:

Accepted Answer

Remove the blood component and tubing containing the blood product.Replace them with new primed tubing with a container of 0.9% sodium chloride (normal saline).Connect tubing to hub of IV catheter.Do not turn off the blood and simply turn on the 0.9% sodium chloride (normal saline)that is connected to the Y-tubing infusion set.This would cause blood remaining in the Y-tubing to infuse into the patient.Even a small amount of mismatched blood can cause a major reaction.Keep the IV site in case it becomes difficult to start another.Maintain a patent IV line using 0.9% normal saline.

Question 11

The nurse is caring for an 84-year-old patient who gets hemodialysis 3 days a week.He is taking corticosteroids and has multiple bruises on his extremities.The patient needs an IV started.When starting the IV,the nurse should:

Accepted Answer

When assessing patients for potential venipuncture sites,consider conditions that exclude certain sites.For example,because older adults and patients receiving corticosteroids have fragile veins,avoid sites that are easily bumped or moved,such as the dorsal surface of the hand.Venipuncture is contraindicated in a site that has signs of inflammation,infiltration,or thrombosis.An infected site is red,tender,swollen,and possibly warm to the touch.Avoid using an extremity with a vascular (dialysis)graft or fistula or on the same side as a mastectomy (breast surgery).Intravenous insertion in a foot vein is used with children but should be avoided in adults because of the danger of thrombophlebitis.

Question 12

A patient is diagnosed with renal insufficiency.The results of an ABG analysis indicate metabolic acidosis.In metabolic acidosis,the nurse would expect the pH to decrease to less than _____ and the bicarbonate level to decrease to less than _____.

Accepted Answer

The answer of A patient is diagnosed with renal insufficiency.The...

Quiz 18: Fluid,Electrolyte,and Acid-Base Balances