potter & Perry chapter 42

An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.)

1. Infiltration at vascular access device (VAD) site

2. Patient lying on tubing

3. Roller clamp wide open

4. Tubing kinked in bedrails

5. Circulatory overload

1,2,4

The nurse assesses pain and redness at a vascular access device (VAD) site. Which action is taken first?

1. Apply a warm, moist compress.

2. Aspirate the infusing fluid from the VAD.

3. Report the situation to the health care provider.

4. Discontinue the intravenous infusion.

4

When delegating input and output (I&O) measurement to assistive personnel, the nurse instructs them to record what information for ice chips?

1. Two-thirds of the volume

2. One-half of the volume

3. One-quarter of the volume

4. Two times the volume

2

What assessments does a nurse make before hanging an intravenous (IV) fluid that contains potassium? (Select all that apply.)

1. Urine output

2. Arterial blood gases

3. Fullness of neck veins

4. Serum potassium laboratory value in EHR

5. Level of consciousness

1,4

The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate does the nurse program into the infusion pump?

1. 100 mL/hr

2. 125 mL/hr

3. 167 mL/hr

4. 200 mL/hr

2

An older-adult patient is receiving intravenous (IV) 0.9% NaCl. The nurse detects new onset of crackles in the lung bases. What is the priority action?

1. Notify a health care provider.

2. Decrease the IV flow rate.

3. Lower the head of the bed.

4. Discontinue the IV site.

2

Place the following steps for discontinuing intravenous (IV) access in the correct order:

1. Perform hand hygiene and apply gloves.

2. Explain procedure to patient.

3. Remove IV site dressing and tape.

4. Use two identifiers to ensure correct patient.

5. Stop the infusion and clamp the tubing.

6. Carefully check the health care provider's order.

7. Clean the site, withdraw the catheter, and apply pressure.

6,4,2,1,5,3,7

A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions? (Select all that apply.)

1. Fall prevention interventions

2. Teaching regarding sodium restriction

3. Encouraging increased fluid intake

4. Monitoring for constipation

5. Explaining how to take daily weights

1,4

Which assessment does the nurse use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit?

1. Dryness of mucous membranes

2. Skin turgor

3. Fullness of neck veins when supine

4. Fullness of neck veins when upright

3