Fluid, Electrolyte, and Acid-Base Balance - Potter and Perry Chapter 42

1. An IV fluid is infusing more slowly than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select All)

a. Infiltration at vascular access device site

b. Patient lying on tubing

c. Roller clamp wide open

d. Tubing kinked in bedrails

e. Circulatory overload

a. Infiltration at vascular access device site

b. Patient lying on tubing

d. Tubing kinked in bedrails

2. Which patients does a nurse plan to teach regarding water restriction?

a. 23-yr old with extracellular fluid vol. (ECV) deficit

b. 34-YR old with hyponatremia

c. 47-yr old with hypercalcemia

d. 69-yr old with metabolic acidosis

b. 34-YR old with hyponatremia

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

a. Apply warm moist compress

b. Monitory the patient's BP

c. Aspirate the infusion fluid form the VAD

d. Stop the infusion and discontinue the IV infusion

d. Stop the infusion and discontinue the IV infusion

4. When delegating the I&O measurement to NAP, a nurse instructs them to record what information for ice chips?

a. The total volume

b. 2/3 Volume

c. ½ Volume

d. ¼ Volume

c. ½ Volume

5. Which assessment does a nurse interpret as a transfusion reaction?

a. Crackles in dependent lobes of lungs

b. High fever, severe hypotension

c. Anxiety, itching, confusion

d. Chills, tachycardia, and flushing

d. Chills, tachycardia, and flushing

6. What assessment does a nurse make before hanging a IV fluid that contains potassium?

a. Urine output

b. Arterial blood gases

c. Fullness of neck veins

d. LOC- level of consciousness

a. Urine output

7. The healthcare provider order is 500 mL of 0.9% NaCL IV over 4 hours. Which rate does a nurse program into the infusion pump?

a. 125 mL/hr

b. 167 mL/hr

c. 200 mL/hr

d. 1000 mL/hr

a. 125 mL/hr

8. An older patient is receiving IV 0.9% NaCl. A nurse detects new onset of crackles in the lung bases. What is the priority action?

a. Notify a health care provider

b. Record in medical record

c. Decrease the IV flow rate

d. Discontinue the IV site

c. Decrease the IV flow rate

9. Place the following steps for discontinuing an IV access in the correct order:

a. Perform hand hygiene and apply gloves

b. Explain procedure to patient

c. Remove IV site dressing and tape

d. Use 2 ID's for patient

e. Stop infusion and clamp tubing

f. Carefully check healthcare order

g. Clean site, withdraw catheter, apply pressure.

f. Carefully check healthcare order

d. Use 2 ID's for patient

b. Explain procedure to patient

a. Perform hand hygiene and apply gloves

e. Stop infusion and clamp tubing

c. Remove IV site dressing and tape

g. Clean site, withdraw catheter, apply pressure.

A nurse is assessing the clinical markers of vascular volume. Which patient may require intravenous (IV) therapy due to extracellular fluid volume deficit?

1

A patient with a full pulse rate

2

A patient with dark yellow urine

3

A patient with increased blood pressure

4

A patient with crackles in the lobe of the lung

2

A patient with dark yellow urine

The registered nurse is instructing a nursing student about the interventions that must be performed when there is any evidence of complication due to infusion therapy. Which instruction would the nurse follow for a patient with circulatory overload?

1

"Reduce the intravenous (IV) flow."

2

"Elevate the extremity."

3

"Disconnect the IV tubing."

4

"Discontinue the IV infusion."

1

"Reduce the intravenous (IV) flow."

Which location selected for venipuncture would increase the risk of lymphedema?

1

A fragile dorsal vein in an older patient

2

A site distal to a previous venipuncture site

3

An extremity affected previously by paralysis

4

An area with a tender, infected wound

3

An extremity affected previously by paralysis

Which complication of intravenous (IV) therapy indicates the need for pressure at the site?

1

Bleeding

2

Phlebitis

3

Infection

4

Fluid overload

1

Bleeding

Which action can be performed to prevent the risk of dislodging the catheter during intravenous (IV) therapy?

1

Inserting a volume-control device into the IV container

2

Curling the loop of short or long IV tubing alongside the arm

3

Instructing the patient to avoid raising the arm with the catheter

4

Attaching the distal end of the IV tubing to a needleless connector

2

Curling the loop of short or long IV tubing alongside the arm

The health care provider's order is 1000 mL 0.9% NaCl IV over 6 hours. Which rate should the nurse program into the infusion pump?

1

125 mL/hr

2

167 mL/hr

3

200 mL/hr

4

1000 mL/h

2

167 mL/hr

Which grade on the phlebitis scale is given to a patient with pain at the infusion site and erythema?

1

Grade 1

2

Grade 2

3

Grade 3

4

Grade 4

2

Grade 2

Which type of dextrose solution is considered isotonic?

1

Dextrose 5% in water

2

Dextrose 10% in water

3

Dextrose 5% in 0.9% sodium chloride

4

Dextrose 5% in 0.45% sodium chloride

1

Dextrose 5% in water

While caring for a patient who is on intravenous (IV) therapy, the nurse finds that the skin around the catheter site is taut, blanched, cool to the touch, and edematous. Which complication is evident?

1

Phlebitis

2

Bleeding

3

Infiltration

4

Local infection

3

Infiltration

Which immediate intervention would be beneficial in a patient who developed redness and pain at the infusion site?

1

Stopping the infusion

2

Elevating the extremity

3

Applying warmth to the site

4

Notifying the health care provider

1

Stopping the infusion

Which saline solution draws water from cells into the extracellular fluid (ECF) by osmosis?

1

5% sodium chloride

2

0.9% sodium chloride

3

0.45% sodium chloride

4

0.225% sodium chloride

1

5% sodium chloride

Which clinical criteria of phlebitis should receive a grade of 3?

1

Formation of streak

2

Pain at access site with only erythema

3

Palpable venous cord greater than 2.54 cm

4

Erythema at access site with or without pain

1

Formation of streak

Which statement is true regarding vascular access devices (VADs)?

1

The word "central" applies to the insertion site.

2

Central catheters are used for fluid restoration.

3

Peripheral catheters are used for long-term antibiotic administration.

4

Peripheral catheters are more effective for administration of large volumes of fluids.

2

Central catheters are used for fluid restoration.