Potter-Perry Chapter 42 Electrolytes and Fluid Balance cards

1. Approximately two thirds of the body's total water volume exists in the _____ fluid.

a. Intracellular

b. Interstitial

c. Intravascular

d. Transcellular

A

(Intracellular fluid accounts for approximately two thirds of the fluids in the body—about 42% of total body weight. Interstitial fluid, intravascular fluid, and transcellular fluid constitute extra-cellular fluid, which is the fluid outside a cell.)

2. The process of passively moving water from an area of lower particle concentration to an area of higher particle concentration is known as

a. Hydrolysis.

b. Osmosis.

c. Filtration.

d. Active transport.

B

(The process of moving water from an area of low particle concentration to an area of higher par-ticle concentration is known as osmosis. Hydrolysis is not a term related to fluid and electrolyte balance. Filtration is mediated by fluid pressure from an area of higher pressure to an area of lower pressure. Active transport requires metabolic activity and is not passive.)

3. The nurse knows that edema in a patient who has venous congestion from right heart failure is facilitated by an imbalance with regard to _____ pressure.

a. Hydrostatic

b. Osmotic

c. Oncotic

d. Concentration

A

(Venous congestion increases capillary hydrostatic pressure. Increased hydrostatic pressure causes edema by causing increased movement of fluid into the interstitial area. Osmotic and oncotic pressures involve the concentrations of solutes and can contribute to edema in other situations. Concentration pressure is not a nursing term.)

4. The nurse understands that administering a hypertonic solution to a patient will shift wa-ter from the _____ to the _____ space.

a. Intracellular; extracellular

b. Extracellular; intracellular

c. Intravascular; intracellular

d. Intravascular; interstitial

A

(A hypertonic solution has a concentration greater than normal body fluids, so water will shift out of cells because of the osmotic pull of the extra particles. Movement of water into cells occurs when hypotonic fluids are administered. Distribution of fluid between intravascular and intersti-tial spaces occurs by filtration, the net sum of hydrostatic and osmotic pressures.)

5. Which patient is most at risk for sensible water loss?

a. A 7-year-old child with asthma

b. A 24-year-old adult with constipation

c. A 56-year-old patient with gastroenteritis

d. An 80-year-old patient with pneumonia

D

(Sensible water loss consists of fluids lost from the skin through visible perspiration, such as with a resolving fever related to pneumonia. Asthma would be insensible water loss through respira-tion. Gastroenteritis causes diarrhea with its large volume loss. Constipation does not affect fluid loss.)

6. The nurse knows that the most abundant cation in the blood is

a. Sodium.

b. Potassium.

c. Chloride.

d. Magnesium.

A

(Sodium is the most abundant cation in the blood. Potassium is the predominant intracellular cat-ion. Chloride is an anion -negatively charged- rather then a cation -positively charged-. Magne-sium is found predominantly inside cells and in bone.)

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

a. Sodium of 145 mEq/L

b. Calcium of 17.5 mg/dL

c. Potassium of 3.5 mEq/L

d. Chloride of 100 mEq/L

B

(Normal calcium range is 8.5 mg/dL to 10.5 mg/dL; therefore, a value of 17.5 mg/dL is abnormal-ly high and of concern. The rest of the laboratory values are within their normal ranges: sodium 135 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L; chloride 98 to 106 mEq/L.)

8. The nurse would expect a patient with increased levels of serum calcium to also have _____ levels.

a. Increased potassium

b. Decreased phosphate

c. Decreased sodium

d. Increased magnesium

B

(Serum calcium and phosphate have an inverse relationship. When one is elevated, the other de-creases, except in some patients with end-stage renal disease. Increased serum calcium would not necessarily cause changes in levels of potassium, sodium, or magnesium.)

9. The nurse knows that an imbalance of which ion causes acid-base impairment?

a. Hydrogen

b. Calcium

c. Magnesium

d. Sodium

A

(The concentration of hydrogen ions determines pH. Low pH designates an acidic environment. High pH designates an alkaline environment. Calcium, magnesium, and sodium are ions, but their imbalances are not direct acid-base impairments.)

10. The nurse would expect a patient with respiratory acidosis to have an excessive amount of

a. Carbon dioxide.

b. Bicarbonate.

c. Oxygen.

d. Phosphate.

A

(Respiratory acidosis occurs when the lungs are not able to excrete enough carbon dioxide. Car-bon dioxide and water create carbonic acid. A buildup of carbonic acid causes the ECF to be-come more acidic, decreasing the pH. Bicarbonate is normal with uncompensated respiratory ac-idosis or elevated with compensated respiratory acidosis. Excessive oxygen and phosphate are not characteristic of respiratory acidosis.)

11. A 2-year-old child was brought into the emergency department after ingesting several morphine tablets from a bottle in his mother's purse. The nurse knows that the child is at greatest risk for which acid-base imbalance?

a. Respiratory acidosis

b. Respiratory alkalosis

c. Metabolic acidosis

d. Metabolic alkalosis

A

(Morphine overdose can cause respiratory depression and hypoventilation. Hypoventilation results in retention of CO2 and respiratory acidosis. Respiratory alkalosis would result from hyperventi-lation, causing a decrease in CO2 levels. Metabolic acid-base imbalance would be a result of kid-ney dysfunction, vomiting, diarrhea, or other conditions that affect metabolic acids.)

12. A patient was admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. The patient's respiratory rate has decreased to 12 breaths per minute. The nurse would expect the patient to have which of the following arterial blood gas values?

a. pH 7.78, PaCO2 40 mm Hg, HCO3- 30 mEq/L

b. pH 7.52, PaCO2 48 mm Hg, HCO3- 28 mEq/L

c. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L

d. pH 7.25, PaCO2 47 mm Hg, HCO3- 29 mEq/L

B

(Compensated metabolic alkalosis should show alkalosis pH and HCO3- -metabolic- values, with a slightly acidic CO2 -compensatory respiratory acidosis-. In this case, pH 7.52 is alkaline -normal = 7.35 to 7.45-, PaCO2 is acidic -normal 35 to 45 mm Hg-, and HCO3- is elevated -normal = 22 to 26 mEq/L-. A result of pH 7.78, PaCO2 40 mm Hg, HCO3- 30 mEq/L is uncompensated meta-bolic alkalosis. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L is within normal limits. pH 7.25, PaCO2 47 mm Hg, HCO3- 29 mEq/L is compensated respiratory acidosis.)

13. The nurse would not expect full compensation to occur for which acid-base imbalance?

a. Respiratory acidosis

b. Respiratory alkalosis

c. Metabolic acidosis

d. Metabolic alkalosis

B

(Usually the cause of respiratory alkalosis is a temporary event -e.g., an asthma or anxiety attack-. The kidneys take about 24 hours to compensate for an event, so it is unlikely to see much if any compensation for respiratory alkalosis. Respiratory acidosis usually results from longer-term con-ditions such as chronic lung disease, narcotic overdose, or another event that causes respiratory depression. The kidneys still do not respond for about 24 hours, but usually the event is still oc-curring. For both metabolic imbalances, the respiratory system is quick to attempt to compensate: however, it may have difficulty sustaining that compensation.)

14. A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment finding would the nurse expect?

a. Thready peripheral pulses

b. Abdominal distention

c. Dry mucous membranes

d. Flushed skin

B

(Signs and symptoms of hypokalemia are muscle weakness and fatigue, abdominal distention, de-creased bowel sounds, and cardiac dysrhythmias. Thready peripheral pulses indicate hypovole-mia. Dry mucous membranes and flushed skin are indicative of dehydration and hypernatremia.)

15. In which patient would the nurse expect to see a positive Chvostek sign?

a. A 7-year-old child admitted for severe burns

b. A 24-year-old adult admitted for chronic alcohol abuse

c. A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism

d. A 75-year-old patient admitted for a bro-ken hip related to osteoporosis

B

(A positive Chvostek sign is representative of hypocalcemia or hypomagnesemia. Hypomagnese-mia is common with alcohol abuse. Hypocalcemia can be brought on by alcohol abuse and pan-creatitis -which also can be affected by alcohol consumption-. Burn patients frequently experi-ence ECV deficit. Hyperparathyroidism causes hypercalcemia. Immobility is associated with hy-percalcemia.)

16. Which organ system is responsible for compensation of respiratory acidosis?

a. Respiratory

b. Renal

c. Gastrointestinal

d. Endocrine

B

(The kidneys are responsible for respiratory acidosis compensation. A problem with the respiratory system causes respiratory acidosis, so another organ system -renal- needs to compensate. Prob-lems with the gastrointestinal and endocrine systems can cause acid-base imbalances, but these systems cannot compensate for an existing imbalance.)

17. Which laboratory value should the nurse examine when evaluating uncompensated respir-atory alkalosis?

a. PaO2

b. Anion gap

c. PaCO2

d. HCO3-

C

(Uncompensated respiratory imbalances are seen in the PaCO2 levels. PaO2 indicates oxygen sta-tus. Anion gap is used for metabolic acidosis. HCO3- is used to evaluate compensation for respir-atory imbalances or uncompensated metabolic imbalances.)

18. The nurse is caring for a diabetic patient in renal failure. Which laboratory findings would the nurse expect?

a. pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L

b. pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L

c. pH 7.3, PaCO2 47 mm Hg, HCO3- 23 mEq/L

d. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L

A

(Patients in renal failure develop metabolic acidosis. The laboratory values that reflect this are pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L. A laboratory finding of pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L is metabolic alkalosis. pH 7.3, PaCO2 47 mm Hg, HCO3- 23 mEq/L is respira-tory acidosis. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L values are within normal range.)

19. The nurse is assessing a patient and finds crackles in the lung bases and neck vein disten-tion. The nurse gives the patient a diuretic. What electrolyte imbalance is the nurse most con-cerned about?

a. Potassium imbalance

b. Sodium imbalance

c. Calcium imbalance

d. Phosphate imbalance

A

(Using a diuretic can cause excess excretion of potassium, unless it is a potassium-sparing diuretic. The other electrolytes are not excreted in the same way with diuretics.)

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

a. "Are you having difficulty sleeping at night?"

b. "How many calories a day do you con-sume?"

c. "Do you have dry mouth or feel thirsty?"

d. "How many times a day do you urinate?"

D

(A rapid gain in weight usually indicates ECV excess if the person began with normal ECV. Ask-ing the patient about urination habits will illuminate whether the body is trying to excrete the ex-cess fluid, or if renal dysfunction is contributing to ECV excess. Difficulty sleeping at night can occur if the body builds up excessive fluid in the lungs; however, it could also mean that the pa-tient is getting up frequently to urinate, so the question is not specific enough. Caloric intake does not account for rapid weight changes. Dry mouth and thirst accompany ECV deficit, which would be associated with rapid weight loss.)

21. Which fluid order should the nurse question for a patient with a traumatic brain injury?

a. 0.45% sodium chloride

b. 0.9% sodium chloride

c. Lactated Ringer's

d. Dextrose 5% in 0.9% sodium chloride

A

(0.45% sodium chloride is a hypotonic solution, and hypotonic solutions cause cells to swell, which can cause increased intracranial pressure. This can be life threatening for a patient with a traumatic brain injury. The other solutions are physiologically isotonic sodium-containing solu-tions that will expand ECV but will not cause cell swelling. In the fluid container, dextrose 5% in 0.9% sodium chloride is hypertonic, but the dextrose enters cells rapidly, leaving isotonic 0.9% sodium chloride.)

22. The physician asks the nurse to monitor the fluid volume status of a congestive heart failure patient and a patient at risk for clinical dehydration. What is the most effective nursing interven-tion for monitoring both of these patients?

a. Weigh the patients every morning before breakfast.

b. Ask the patients to record their intake and output.

c. Measure the patients' blood pressure every 4 hours.

d. Assess the patients for edema in extremi-ties.

A

(An effective measure of fluid retention or loss is daily weights; each kilogram -2.2 pounds- change is equivalent to 1 liter of fluid gained or lost. This measurement should be performed at the same time every day using the same scale and the same amount of clothing. Although intake and output records are important assessment measures, some patients are not able to keep their own records themselves. Blood pressure can decrease with ECV deficit but will not necessarily increase with recent ECV excess -heart failure patient-. Edema occurs with ECV excess but not with clinical dehydration.)

23. A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, elevated white blood cell count, and oral candidiasis. The nurse knows that the purpose of start-ing total parenteral nutrition (TPN) is to

a. Replace fluid, electrolytes, and nutrients in the patient.

b. Stimulate the patient's appetite to eat.

c. Provide medication to raise the patient's blood pressure.

d. Deliver antibiotics to fight off infection.

A

(Total parenteral nutrition is an intravenous solution composed of nutrients and electrolytes to re-place the ones the patient is not eating. TPN does not stimulate the appetite. TPN does not con-tain blood pressure medication or antibiotics.)

24. A patient presents to the emergency department with the complaint of vomiting and di-arrhea for the past 48 hours. The nurse anticipates which fluid therapy initially?

a. 0.9% sodium chloride

b. Dextrose 10% in water

c. Dextrose 5% in water

d. 0.45% sodium chloride

A

(Patients with prolonged vomiting and diarrhea become hypovolemic. The best solution to replace extracellular volume is 0.9% sodium chloride, which is an isotonic solution. Dextrose 10% in wa-ter, dextrose 5% in water, and 0.45% sodium chloride act as hypotonic solutions in the body. The first consideration is replacing extracellular volume to oxygenate tissues.)

25. A patient with a lower respiratory infection has pH of 7.25, PaCO2 of 55 mm Hg, and HCO3- of 20 mEq/L. The physician has been notified. Which is the priority nursing intervention for this patient?

a. Check the color of the patient's urine output.

b. Place the patient in Trendelenburg posi-tion.

c. Encourage the patient to increase respira-tions.

d. Place the patient in high Fowler's position.

C

(The patient has respiratory acidosis from CO2 retention. Increasing rate and depth of respiration will allow the patient to blow off excess carbon dioxide, and this will begin to correct the imbal-ance. Checking the urine color is not a necessary assessment. The Trendelenburg position likely would make it more difficult for the patient to breathe and should be avoided. Placing the pa-tient in high Fowler's position may make the patient more comfortable, but it is not necessary.)

26. The nurse knows that intravenous fluid therapy has been effective for a patient with hy-pernatremia when

a. Serum sodium concentration returns to normal.

b. Systolic and diastolic blood pressure de-crease.

c. Large amounts of emesis and diarrhea de-crease.

d. Urine output increases to 150 mL/hr.

A

(Hypernatremia is diagnosed by elevated serum sodium concentration. Blood pressure is not an accurate indicator of hypernatremia. Emesis and diarrhea will not stop because of intravenous therapy. Urine output is influenced by many factors, including extracellular fluid volume. A large dilute urine output can cause further hypernatremia.)

27. The nurse would select the dorsal venous plexus of the foot as an IV site for which pa-tient?

a. A 2-year-old child

b. A 22-year-old adult

c. A 50-year-old patient

d. An 80-year-old patient

A

(Use of the foot as an IV site is common in children but is avoided in adults because of the risk for thrombophlebitis.)

28. Which assessment finding should cause a nurse to question administering a sodi-um-containing isotonic intravenous fluid?

a. Blood pressure 102/58

b. Dry mucous membranes

c. Poor skin turgor

d. Pitting edema

D

(Pitting edema indicates that the patient may be retaining excess extracellular fluid, and the nurse should question the type of solution meant to rehydrate the patient. All other options are con-sistent with ECV deficit, and the patient would benefit from a sodium-containing isotonic solu-tion that expands extracellular volume.)

29. A patient is to receive 1500 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. What is the minute flow rate (drops per minute)?

a. 12 gtt/min

b. 24 gtt/min

c. 125 gtt/min

d. 150 gtt/min

C

(Microdrip tubing delivers 60 gtt/mL. Calculation for a rate of 125 mL/hr using microdrip tubing: -125 mL/1 hr--60 gtt/1 mL--1 hr/60 min- = 125 gtt/min.)

30. A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 20 mL/hr. At what time should the infusion be completed?

a. 0645 Tuesday

b. 0675 Tuesday

c. 0715 Tuesday

d. 0735 Tuesday

C

(250 mL divided by 20 mL/hr = 12.5 hr

0.5 hr 60 min = 30 min

1845 + 12 hr 30 min = 3115, which would be 0715 on Tuesday, the following day.)

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

a. Add a potassium supplement to replace loss from output.

b. Decrease the rate of intravenous fluids to 100 mL/hr.

c. Discontinue the nasogastric suctioning.

d. Administer a diuretic to prevent fluid volume excess.

A

(The total fluid intake and output equals 700 mL, which meets the provider goals. Record half the volume of ice chips when calculating intake. Patients with nasogastric suctioning are at risk for potassium deficit, so the nurse would anticipate a potassium supplement to correct this condition. The other measures would be unnecessary because the net fluid volume is equal.)

32. A nurse is caring for a patient who is in hypertensive crisis. When the nurse is flushing the patient's peripheral IV, the patient complains of pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action?

a. Notify the physician.

b. Administer pain medication.

c. Discontinue the IV.

d. Start a new IV line.

D

(The IV site has phlebitis. The nurse should start a new IV before discontinuing the old one be-cause it is important to always have an IV access site in a patient who is in hypertensive crisis. Then the physician can be notified. Pain medication may or may not need to be administered.)

33. A patient was admitted for hypovolemia and has intravenous fluid running at 250 mL/hr. The patient complains

of burning at the IV insertion site. Upon assessment, the nurse does not find redness, swelling, heat, or coolness.

The nurse suspects that the:

a) IV has infiltrated.

b) IV has caused phlebitis.

c) Fluid is infusing too quickly.

d) Patient is allergic to the fluid.

C

34. The nurse is caring for a patient with sepsis. The plan of care for the patient is to administer antibiotics 3 times a day for 4 weeks. What device will be used to administer these antibiotics?

a. A continuous infusion

b. A heparin locked peripheral catheter

c. A PICC line

d. An implanted port catheter

C

(A PICC line is a type of central venous device that can be introduced into a peripheral vein for administration of IV antibiotics for an extended period, over the course of several weeks. A con-tinuous infusion would not take place if the patient received antibiotics only 3 times daily. A pe-ripheral catheter would not be necessary or heparin locked. An implanted port catheter is in-tended for long-term use of venous access over months, or even years.)

35. A nurse is preparing to administer a blood transfusion. Which assessment finding would the nurse report immediately?

a. Blood pressure 120/60

b. Temperature 101.3° F

c. Poor skin turgor and pallor

d. Heart rate of 100 beats per minute

B

(A fever should be reported immediately, and the blood transfusion may be postponed. All other assessment findings are acceptable before starting a blood transfusion.)

36. A nurse has just received a bag of packed red blood cells. The nurse knows that the blood must not remain at room temperature for longer than

a. 30 minutes.

b. 1 hour.

c. 2 hours.

d. 4 hours.

D

(Blood should be allowed to sit at room temperature for a maximum of 4 hours. After 4 hours, risk of bacterial contamination of the blood is increased.)

37. A patient had an acute intravascular hemolytic reaction to a blood transfusion. After dis-continuing the blood transfusion, what is the nurse's next action?

a. Run normal saline through the existing tubing.

b. Start normal saline at TKO rate using new tubing.

c. Discontinue the IV catheter.

d. Return the blood to the blood bank.

B

(The nurse should first attach new tubing and begin running in normal saline at a rate to keep the vein open, in case any sorts of medications need to be delivered through that IV site. The exist-ing tubing should not be used because that would infuse the blood in the tubing into the patient. It is necessary to preserve the IV catheter in place for IV access to treat the patient. After the pa-tient has been assessed and stabilized, the blood can be returned to the blood bank.)

38. A nurse is assessing a patient who is receiving a blood transfusion and finds that the pa-tient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. The nurse recognizes that the patient is experiencing which transfusion complication?

a. Anaphylactic shock

b. Septicemia

c. Fluid volume overload

d. Hemolytic reaction

C

(The signs and symptoms are concurrent with fluid volume overload. Anaphylactic shock would have presented with urticaria, dyspnea, and hypotension. Septicemia would include a fever. A hemolytic reaction would consist of flank pain, chills, and fever.)

39. The nurse selects appropriate tubing for a blood transfusion by ensuring that the tubing has

a. Two-way valves to allow the patient's blood to mix and warm the blood trans-fusing.

b. An injection port to mix additional elec-trolytes into the blood.

c. An air vent to let bubbles in the blood es-cape.

d. A filter to ensure that clots do not enter the patient.

D

(All blood transfusions must have a filter to prevent microemboli from being administered to the patient. The patient's blood should not be aspirated to mix with the infusion blood. The blood should not have air bubbles to vent; if a bag of blood does have bubbles, the nurse should promptly return the blood to the blood bank. The only substance compatible with blood is normal saline; no additives should be mixed with the infusing blood.)

40. The nurse is caring for a patient with hyperkalemia. Which body system would be most important for the nurse plan to monitor closely?

a. Gastrointestinal

b. Neurological

c. Cardiac

d. Respiratory

C

(Potassium balance is necessary for cardiac function. Hyperkalemia places the patient at risk for potentially serious dysrhythmias. Monitoring of gastrointestinal, neurological, and respiratory systems would be indicated for other electrolyte imbalances.)

41. Which assessment finding would the nurse expect for a patient with the following labor-atory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?

a. Lightheadedness when standing up

b. Weak quadriceps muscles

c. Tingling of the extremities and tetany

d. Decreased deep tendon reflexes

C

(This patient has hypocalcemia because the normal calcium range is 8.4 to 10.5 mg/dL. Sodium and potassium values are within their normal ranges: sodium 135 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L. Hypocalcemia causes muscle tetany, positive Trousseau's sign, and tingling of the extremities. Lightheadedness when standing up is a manifestation of ECV deficit or sometimes hypokalemia. Weak quadriceps muscles are associated with potassium imbalances. Decreased deep tendon reflexes are related to hypercalcemia or hypermagnesemia.)

42. A patient informs the nurse that he has the type of diabetes that does not require insulin. The nurse advises the patient to make which dietary change?

a. Drink plenty of fluids throughout the day to stay hydrated.

b. Avoid food high in acid to avoid meta-bolic acidosis.

c. Reduce the quantity of carbohydrates in-gested to lower blood sugar.

d. Include a serving of dairy in each meal to elevate calcium levels.

A

(The patient is indicating that he has diabetes insipidus, which places him at risk for dehydration and hypernatremia. Dehydration should be prevented by drinking plenty of fluids to replace the extra water excreted in the urine. Foods high in acid should be avoided in a patient with GERD. A reduction in carbohydrates applies to type 2 diabetes mellitus patients. Calcium-rich dairy products would be recommended for a hypocalcemic patient.)

1. When selecting a site to insert an intravenous catheter on an adult, the nurse should (Se-lect all that apply.)

a. Start proximally and move distally on the arm.

b. Choose a vein with minimal curvature.

c. Choose the patient's dominant arm.

d. Check for contraindications to the extrem-ity.

e. Select a vein that is rigid.

f. Avoid areas of flexion.

B, D, F

(The nurse should start distally and move proximally, choosing the nondominant arm if possible. The vein should be relatively straight to avoid catheter occlusion. Contraindications to starting an IV catheter are conditions such mastectomy, AV fistula, and central line in the extremity. The nurse should feel for the best location; a good vein should feel spongy, a rigid vein should be avoided because it might have had previous trauma or damage.)

2. Which of the following assessments would indicate that a patient's IV has infiltrated? (Select all that apply.)

a. Edema of the extremity near the insertion site

b. Skin discolored or bruised in appearance

c. Pain and warmth at the insertion site

d. Skin cool to the touch

e. Reddish streak proximal to the insertion site

f. Numbness or loss of sensation

g. Palpable venous cord

A, B, D, F

(Infiltration results in skin that is edematous near the IV insertion site. Skin is cool to the touch and may be bruised or discolored, and the patient may experience some numbness. Pain, warmth, erythema, a reddish streak, and a palpable venous cord are all symptoms of phlebitis.)

3. When discontinuing a peripheral IV access, the nurse should (Select all that apply.)

a. Use scissors to remove the IV site dressing and tape.

b. Keep the catheter parallel to the skin while removing it.

c. Apply firm pressure with sterile gauze during removal.

d. Stop the infusion before removing the IV catheter.

e. Wear sterile gloves and a mask.

f. Apply pressure to the site for 2 to 3 minutes after removal.

B, D, F

(The nurse should stop the infusion before removing the IV catheter, so the fluid does not drip on the patient's skin; keep the catheter parallel to the skin while removing it to reduce trauma to the vein; and apply pressure to the site for 2 to 3 minutes after removal to decrease bleeding from the site. Scissors should not be used because they may accidentally cut the catheter or tubing or may injure the patient. During removal of the IV catheter, light pressure, not firm pressure, is indicat-ed to prevent trauma. Clean gloves are used for discontinuing a peripheral IV access because gloved hands will handle the external dressing, tubing, and tape, which are not sterile.)