Exam 4 - Questions

Question 1

Txtbook - Chapter 30: Medications

A nurse administers a dose of an oral medication for hypertension to a patient who immediately vomits after swallowing the pill. What action will the nurse take first?
a. Readminister the medication and notify the health care provider.
b. Obtain the pill in a liquid form for administration.
c. Assess the emesis, looking for the pill.
d. Notify the primary care provider.

Answer 1

c. Assess the emesis, looking for the pill.

Question 2

Txtbook - Chapter 30: Medications

A nurse caring for a group of patients uses measures to reduce discomfort for the patients during injections. Which technique is recommended?

a. Selecting a needle of the largest gauge that is appropriate for the site and solution to be injected
b. Injecting the medication into contracted muscles to reduce pressure and discomfort at the site
c. Using the Z-track technique for intramuscular injections to prevent leakage of medication into the needle track
d. Applying vigorous pressure in a circular motion after the injection to distribute the medication to the intended site

Answer 2

c. Using the Z-track technique for intramuscular injections to prevent leakage of medication into the needle track

Question 3

Txtbook - Chapter 30: Medications

A nurse is administering a pain medication to a patient. In addition to checking the identification bracelet, which active identification strategy reflects best practice?

a. Asking the patient their name and birthdate
b. Reading the patient’s name on the sign over the bed
c. Asking the patient’s roommate to verify the patient’s name
d. Asking, “Are you Mr. Brown?”

Answer 3

a. Asking the patient their name and birthdate

Question 4

Txtbook - Chapter 30: Medications

A nurse is administering a medication to a patient via an enteral feeding tube. Which are accurate guidelines related to this procedure? [Select all that apply]

a. Crushing the enteric-coated pill and mix it in a liquid
b. Initially flushing the tube with 60 mL of very warm water
c. Using the recommended policy to check tube placement in the stomach or intestine
d. Giving each medication separately and flush with water between each drug
e. Lowering the head of the bed to prevent reflux
f. Adjusting the amount of water used if patient’s fluid intake is restricted

Answer 4

c. Using the recommended policy to check tube placement in the stomach or intestine
d. Giving each medication separately and flush with water between each drug
f. Adjusting the amount of water used if patient’s fluid intake is restricted

Question 5

Txtbook - Chapter 30: Medications

A medication prescription reads: “Hydromorphone, 2 mg IV every 3 to 4 hours PRN pain.” The prefilled cartridge is available with a label reading “Hydromorphone 2 mg/1 mL” and a statement that the cartridge contains 1.2 mL of hydromorphone. How should the nurse proceed?

a. Give the entire contents of the cartridge sent by the pharmacy
b. Call the pharmacy and request the proper dose
c. Refuse to give the medication and document refusal in the EHR
d. Discard 0.2 mL before administration; verify the waste with another nurse

Answer 5

d. Discard 0.2 mL before administration; verify the waste with another nurse

Question 6

Txtbook - Chapter 30: Medications

A nurse is administering heparin subcutaneously to a patient. What technique is appropriate for this injection?

a. Aspirating before giving and gently massage after the injection
b. Avoiding aspirating; massaging the site for 1 minute
c. Avoiding aspirating before and massaging after the injection
d. Massaging the injection site; aspirating is unnecessary but will do no harm

Answer 6

c. Avoiding aspirating before and massaging after the injection

Question 7

Txtbook - Chapter 30: Medications

A nurse discovers that a medication error occurred. What is the nurse’s priority?

a. Recording the error on the medication sheet
b. Notifying the physician regarding course of action
c. Assessing the patient for adverse effects of the error
d. Completing an event report, explaining how the mistake was made

Answer 7

c. Assessing the patient for adverse effects of the error

Question 8

Txtbook - Chapter 30: Medications

A nurse in a rehabilitation facility is preparing to administer a skeletal muscle relaxant to a patient recovering from a motor vehicle accident. When the patient states, “I don’t want that pill,” what action will the nurse take next?

a. Encourage the patient to take the pill to help reduce muscle spasm.
b. Explain that the health care provider prescribes only necessary medications.
c. Ask the patient to explain their concern about the medication.
d. Question the patient about allergies and previous medication reactions.

Answer 8

c. Ask the patient to explain their concern about the medication.

Question 9

Txtbook - Chapter 30: Medications

A nurse is preparing to administer medications to a patient transferred from the intensive care unit just as lunch is served. Prior to administering medications to the patient, the nurse takes which action?

a. Performing medication reconciliation
b. morning care has been administered
c. Ordering the patient a meal
d. Taking a report from the nurse sending the patient

Answer 9

a. Performing medication reconciliation

Question 10

Txtbook - Chapter 30: Medications

When administering an IVPB medication using gravity, what action is appropriate for the nurse take?

a. Placing the primary IV bag below the level of the piggyback bag
b. Disconnecting the tubing closest to the patient and flushing the intravenous access
c. Ensuring the piggyback bag is below the main IV bag
d. Closing the roller clamp to the secondary infusion

Answer 10

a. Placing the primary IV bag below the level of the piggyback bag

Question 11

Txtbook - Chapter 31: PeriOp

A nurse in the PACU is preparing to receive a patient from surgery who sustained a ruptured spleen in a motor vehicle accident. Which of these system assessments will take priority?
* Electronic Health Record: Operative Note
* Splenectomy secondary to trauma
* Estimated blood loss 900 mL

a. Neurologic system, ambulatory function
b. Cardiovascular system, vital signs
c. GI system, bowel function
d. Integumentary, skin breakdown

Answer 11

b. Cardiovascular system, vital signs

Question 12

Txtbook - Chapter 31: PeriOp

A nurse is preparing a patient for a cesarean birth using spinal anesthesia. Which effects of anesthesia will the nurse teach the patient to expect? [Select all that apply]

a. Loss of consciousness
b. Inability to speak
c. Reduction or loss of deep tendon reflexes
d. Loss of sensation below the injection
e. Inability to move the lower extremities
f. Prolonged pain relief after other anesthesia wears off

Answer 12

d. Loss of sensation below the injection
e. Inability to move the lower extremities

Question 13

Txtbook - Chapter 31: PeriOp

A nurse has been asked to witness a patient signature on an informed consent form for surgery. What communication from the surgeon does the nurse expect the patient to receive before signing the form? [Select all that apply]

a. Option of nontreatment
b. Underlying disease process and its natural course
c. Notice that once the form is signed, the patient cannot withdraw the consent
d. Explanation of the guaranteed outcome of the procedure or treatment
e. Name and qualifications of the provider of the procedure or treatment
f. Explanation of the risks and benefits of the procedure or treatment

Answer 13

a. Option of nontreatment
b. Underlying disease process and its natural course
e. Name and qualifications of the provider of the procedure or treatment
f. Explanation of the risks and benefits of the procedure or treatment

Question 14

Txtbook - Chapter 31: PeriOp

An older adult who is scheduled for a hip replacement is taking several medications on a regular basis. Which group of medications does the nurse identify as a surgical risk for this patient?

a. Anticoagulants
b. Antacids
c. Laxatives
d. Sedatives

Answer 14

a. Anticoagulants

Question 15

Txtbook - Chapter 31: PeriOp

A nurse is caring for a patient who is obese and has had abdominal surgery. The nurse prioritizes a plan to prevent what postoperative complication?

a. Anesthetic interactions
b. Impaired wound healing
c. Weight gain
d. Flatulence

Answer 15

b. Impaired wound healing

Adipose (fatty) tissue has poor blood supply, which places the obese patient at risk for delayed wound healing, wound infection, and disruption in the integrity of the wound. Medication interactions are not the primary concern and are managed by the nurse anesthetist or anesthesiologist. Postoperative bleeding and flatulence (gas) after anesthesia are concerns for all patients, not just those with obesity.

Question 16

Txtbook - Chapter 31: PeriOp

When caring for a patient who returned from the operating room 8 hours ago, which finding requires follow-up assessment by the nurse?

a. Patient reports discomfort at surgical site, scale of 5/10
b. Patient voids small amounts every 20–30 minutes
c. Patient is sleepy and awakens only to touch
d. Patient reports thirst and dry mouth

Answer 16

b. Patient voids small amounts every 20–30 minutes

This patient is displaying typical signs of urinary retention, voiding small frequent amounts. Discomfort is expected and can be managed with prescribed analgesics. Anesthesia or opioid analgesia promotes sedation from which this patient awakens to touch. Dry mouth and thirst can result from NPO status and possible anticholinergic medication intended to dry respiratory secretions during surgery.

Question 17

Txtbook - Chapter 31: PeriOp

A nurse is providing teaching for a patient scheduled to have same-day surgery. Which teaching method would be most effective in preoperative teaching for ambulatory surgery?

a. Lecture
b. Discussion
c. Audiovisuals
d. Written instructions

Answer 17

d. Written instructions

Question 18

Txtbook - Chapter 31: PeriOp

An adult patient awaiting surgery says to the nurse, “I am so frightened—what if I don’t wake up?” What is the nurse’s best response?

a. “Are you worried about the anesthesia?”
b. “Tell me what concerns you most.”
c. “Your surgeon is great; she operated on my aunt!”
d. “Many people are anxious before surgery.”

Answer 18

b. “Tell me what concerns you most.”

Question 19

Txtbook - Chapter 31: PeriOp

During preoperative teaching about pain management, the patient asks the nurse to explain how a PCA pump works. What will the nurse teach the patient about PCA?

a. “It allows the patient to be completely free of pain during the postoperative period.”
b. “It allows the patient to take unlimited amounts of medication as needed.”
c. “It allows the patient to choose the type of medication given postoperatively.”
d. “It permits the patient to self-administer limited doses of pain medication.”

Answer 19

d. “It permits the patient to self-administer limited doses of pain medication.”

Question 20

Txtbook - Chapter 31: PeriOp

A nurse is planning caring for a patient who had thoracic surgery. Which nursing interventions are most appropriate for patients undergoing this type of surgery?

a. Observing for incisional wound healing
b. Monitoring vital signs, especially pulse and blood pressure
c. Instructing the patient on the proper use of the incentive spirometer
d. Applying antiembolism stockings

Answer 20

a. Observing for incisional wound healing

A thoracic incision, near or overlying the lungs, makes it difficult or painful for patients to take deep breaths and cough. The nurse uses analgesics, repositioning, coughing and deep breathing, and an incentive spirometer to promote respiratory expansion and airway clearance to decrease the risk for respiratory complications

Question 21

Txtbook - Chapter 31: PeriOp

While assessing a patient in the PACU following abdominal surgery, a nurse promptly contacts the surgeon for which of these findings? [Select all that apply]
Electronic Health Record
Vital signs
* 1200: T 97.4, P-89, RR 12, BP/102/70
* 1215: T 97.4, P-92, RR 12, BP/100/68
* 1230: T 97.2, P-112, RR 12, BP/98/60
Intake Output/Hemovac
* 1200: 200 mL 0.9% saline infused 30 mL sanguineous material
* 1215: IV NSS 25 mL 45 mL serosanguineous material
* 1230: IV NSS 25 mL 250 mL bright red blood

a. Tachycardia
b. IV with normal saline solution
c. Wound drainage
d. Patient restless
e. Patient reports incisional pain 8/10

Answer 21

a. Tachycardia
c. Wound drainage
d. Patient restless

Increased wound drainage, restlessness, increasing pulse, and decreasing blood pressure are symptoms of blood loss/hemorrhage and must be promptly identified to prevent shock. Diminished bowel sounds are expected after surgery and anesthesia. Incisional pain is anticipated; the nurse uses prescriptions for analgesia to help resolve pain. Due to NPO status and blood loss from surgery, IV fluids are administered.

Question 22

Txtbook - Chapter 31: PeriOp

A nurse is caring for a postoperative patient who has been on bedrest for 5 days. What interventions will the nurse use to prevent deep vein thrombosis (DVT)? [Select all that apply]

a. Administering analgesics
b. Documenting daily calf circumference
c. Assessing vital signs every 4 hours
d. Encouraging ambulation
e. Applying intermittent pneumatic compression devices (IPCDs)
f. Providing education on pain management

Answer 22

d. Encouraging ambulation

Question 23

Txtbook - Chapter 31: PeriOp

A scrub nurse is assisting a surgeon with a kidney transplant. What are the patient responsibilities of the scrub nurse? [Select all that apply]

a. Maintaining sterile technique
b. Draping and handling instruments and supplies
c. Identifying and assessing the patient on admission
d. Integrating case management
e. Preparing the skin at the surgical site
f. Providing exposure of the operative area

Answer 23

a. Maintaining sterile technique
b. Draping and handling instruments and supplies

Question 24

Txtbook - Chapter 31: PeriOp

A nurse on a surgical unit is aware that older adults develop reduced vital capacity as a result of normal physiologic changes. Based on these changes, which nursing intervention takes priority?

a. Taking and recording vital signs every shift
b. Turning, coughing, and deep breathing every 4 hours
c. Encouraging increased intake of oral fluids
d. Assessing bowel sounds daily

Answer 24

b. Turning, coughing, and deep breathing every 4 hours

Reduced vital capacity in older adults decreases respiratory expansion, increasing the risk for pneumonia and atelectasis. Encouraging the patient to turn, cough, and deep breathe every 4 hours helps to prevent complications

Question 25

# Txtbook - Chapter 31: PeriOp A nurse teaches a patient the rationale for performing leg exercises after surgery. How does the nurse best explain the purpose of the exercises to the patient? a. Improves respiratory function b. Maintains functional abilities c. Provides diversional activities d. Increases venous return

Answer 25

d. Increases venous return ## Footnote Leg exercises promote venous return and decrease complications related to venous stasis causing DVT and help prevent muscle weakness. These exercises also decrease risk for thrombophlebitis and emboli

Question 26

# Txtbook - Chapter 31: PeriOp A nurse is preparing a patient for same-day surgery. Which of these patient-related findings must the nurse report immediately? a. Asking how long after the surgery they can leave the hospital b. Received an oral anticoagulant last night c. Surgeon has not yet filled out the consent form d. Blood pressure is 142/86

Answer 26

b. Received an oral anticoagulant last night

Question 27

# Txtbook - Chapter 41: Fluids, Electrolytes, Acid-Base Balance A nurse on the respiratory unit is interpreting ABGs for several patients. The patient with which problem will the nurse suspect may have developed respiratory alkalosis? a. Hypoxia b. Atelectasis c. Chronic respiratory illness d. Sedative overdose

Answer 27

a. Hypoxia ## Footnote Patients experiencing hypoxia will breathe rapidly, “blowing off” CO2. This drives the pH up reflecting alkalosis related to the respiratory system

Question 28

# Txtbook - Chapter 41: Fluids, Electrolytes, Acid-Base Balance A nurse is caring for a group of patients. The patient with which problem would the nurse identify is at high risk for fluid volume excess? a. Renal failure b. Vomiting c. Hypernatremia d. NPO for surgery

Answer 28

a. Renal failure ## Footnote Patients with renal (kidney) failure are unable to excrete fluids; they typically have oliguria and fluid volume excess. The other patient scenarios typically occur in patients with fluid volume deficit

Question 29

# Txtbook - Chapter 41: Fluids, Electrolytes, Acid-Base Balance A nurse is caring for a patient who has developed hypernatremia. For which intravenous solution would the nurse anticipate a prescription? a. 5% dextrose in 0.9% NaCl b. 0.9% NaCl (normal saline) c. 0.45% NaCl (½-strength normal saline) d. 5% dextrose in lactated Ringer’s solution

Answer 29

c. 0.45% NaCl (½-strength normal saline) ## Footnote A solution of 0.45% NaCl (½-strength normal saline) or 0.33% NaCl (⅓-strength normal saline) are hypotonic fluids used to treat hypernatremia. As there are less particles in the ½-strength saline than in the bloodstream, infusing this fluid will cause the sodium level to decrease. Normal saline (0.9% NaCl) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. Lactated Ringer’s solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. Dextrose (5%) in lactated Ringer’s solution replaces electrolytes and shifts fluid from the intracellular compartment into the intravascular space, expanding vascular volume

Question 30

# Txtbook - Chapter 41: Fluids, Electrolytes, Acid-Base Balance A nurse is caring for a patient in the intensive care unit. How will the nurse interpret the patient’s arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3–, 14 mEq/L? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

Answer 30

c. Metabolic acidosis

Question 31

# Txtbook - Chapter 41: Fluids, Electrolytes, Acid-Base Balance A patient with dehydration has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? a. Explaining the mechanisms of fluid transport in cellular compartments b. Keeping the patient’s preferred fluids readily available for the patient c. Emphasizing the long-term benefit of increasing fluids d. Planning to offer most daily fluids in the evening

Answer 31

b. Keeping the patient’s preferred fluids readily available for the patient ## Footnote Having fluids the patient prefers readily available and within reach helps promote intake. Explanation of the fluid transport mechanisms is inappropriately complex and does not address dehydration. Meeting short-term outcomes rather than long-term outcomes is the priority at this time provides further reinforcement, and additional fluids should be taken earlier in the day

Question 32

# Txtbook - Chapter 41: Fluids, Electrolytes, Acid-Base Balance A nurse is flushing a patient’s peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What action will the nurse take next? a. Removing the IV from the site and start at another location b. Immediately notifying the primary care provider c. Outlining the affected area in ink and monitoring for changes d. Aspirating the catheter and attempting to flush again

Answer 32

a. Removing the IV from the site and start at another location ## Footnote If the peripheral venous access site leaks fluid when flushed, the nurse should remove it from the site; evaluate the need for continued access; and, if clinically necessary, restart the IV in another location. This action is a nursing intervention; the primary care provider does not need to be notified first. The nurse should use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes or aspirate and attempt to flush again if the IV does not flush easily.

Question 33

# Txtbook - Chapter 41: Fluids, Electrolytes, Acid-Base Balance A nurse is monitoring a patient who is receiving an IV infusion of normal saline at 250 mL /hr. The patient is apprehensive and presents with a pounding headache, rapid pulse, chills, and dyspnea. What would be the nurse’s priority intervention related to these symptoms? a. Discontinuing the infusion immediately, monitoring vital signs, and reporting findings to the primary care provider immediately b. Slowing the rate of infusion, notifying the primary care provider immediately, and monitoring vital signs c. Pinching off the catheter or securing the system to prevent entry of air, placing the patient in the Trendelenburg position, and calling for assistance d. Discontinuing the infusion immediately, applying warm compresses to the site, and restarting the IV at another site

Answer 33

a. Discontinuing the infusion immediately, monitoring vital signs, and reporting findings to the primary care provider immediately ## Footnote The nurse is observing the signs and symptoms of speed shock: the body’s reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. The other choices are interventions for fluid overload; air embolus; and phlebitis, respectively.

Question 34

# Txtbook - Chapter 41: Fluids, Electrolytes, Acid-Base Balance A nurse carefully assesses the acid–base balance of a patient whose bicarbonate (HCO3–) level is decreased on the ABG results. This typically occurs in patients with damage to which organ? a. Kidneys b. Lungs c. Adrenal glands d. Brain

Answer 34

b. Lungs ## Footnote The kidney primarily controls the bicarbonate level and, if damaged, can affect acid–base balance. The adrenal glands secrete catecholamines and steroid hormones. The brain may regulate respiration and therefore CO2, not the bicarbonate level

Question 35

# Txtbook - Chapter 41: Fluids, Electrolytes, Acid-Base Balance A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? a. Encouraging foods and fluids with higher sodium content b. Administering oral potassium supplements as prescribed c. Cautioning the patient about eating foods high in potassium content d. Discussing calcium-losing aspects of nicotine and alcohol use

Answer 35

b. Administering oral potassium supplements as prescribed ## Footnote Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering (oral) potassium supplements as prescribed. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.

Question 36

# Txtbook - Chapter 41: Fluids, Electrolytes, Acid-Base Balance A nurse has begun administering an intravenous antibiotic via the patient’s peripheral venous access. Immediately, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse’s next action related to these findings? a. Repositioning the extremity and raise the height of the IV pole b. Applying pressure to the dressing on the IV c. Pulling the catheter out slightly and reinserting it d. Putting on gloves; removing the catheter

Answer 36

d. Putting on gloves; removing the catheter ## Footnote The IV fluid is infiltrating the tissue, suggested by lack of flow, swelling, and the area feeling cool to the touch. The nurse should put on gloves and remove the catheter. The nurse should also use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes and secure gauze with tape over the insertion site without applying pressure. The nurse should assess the area distal to the venous access device for capillary refill, sensation and motor function and restart the IV in a new location. Finally, the nurse should estimate the volume of fluid that escaped into the tissue based on the rate of infusion and length of time since last assessment, notify the primary health care provider and use an appropriate method for clinical management of the infiltrate site, based on infused solution and facility guidelines, and record site assessment and interventions, as well as site for new venous access. Raising the height of the IV pole will increase the pressure causing fluid to flows; however, that will promote further infiltration of fluid

Question 37

# Txtbook - Chapter 41: Fluids, Electrolytes, Acid-Base Balance When caring for a patient receiving hemodialysis through an arteriovenous fistula, which action is essential for the nurse to take? a. Avoiding IM injections b. Not assessing the radial pulse on the same side as the access c. Performing BP and venipuncture on the opposite extremity d. Using the distended portion of the fistula for IV medications

Answer 37

c. Performing BP and venipuncture on the opposite extremity ## Footnote When caring for a patient with an arteriovenous fistula for dialysis, it is essential the nurse does not compress the area. Therefore, no BP or venipuncture is performed in that extremity. The patient may receive IM injections in an area of the body without the access. Taking a radial pulse in the arm with the access will not harm the fistula. The nurse does not use the fistula for any reason other than dialysis; damage to the fistula delays lifesaving dialysis

Question 38

# Txtbook - Chapter 41: Fluids, Electrolytes, Acid-Base Balance A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse’s priority actions related to these symptoms? a. Slowing or stopping the infusion; monitoring vital signs, notifying the health care provider, and placing the patient in an upright position with their feet dependent b. Stopping the transfusion immediately and keeping the vein open with normal saline, notifying the health care provider immediately, and administering antihistamine parenterally as needed c. Stopping the transfusion immediately and keeping the vein open with normal saline, notifying the health care provider, and treating symptoms with acetaminophen d. Stopping the infusion immediately, obtaining a culture of the patient’s blood, monitoring vital signs, notifying the health care provider, and administering antibiotics immediately

Answer 38

a. Slowing or stopping the infusion; monitoring vital signs, notifying the health care provider, and placing the patient in an upright position with their feet dependent ## Footnote The patient is displaying signs and symptoms of circulatory overload: too much fluid volume as a result of the infusion of blood. In the other choices, the nurse is providing interventions for an allergic reaction; responding to a febrile reaction; and providing interventions for a bacterial reaction, respectively

Question 39

# Txtbook - Chapter 41: Fluids, Electrolytes, Acid-Base Balance A nurse is performing physical assessments for patients with fluid imbalance. Which findings indicate a fluid volume excess? [Select all that apply] a. Pinched and drawn facial expression b. Deep, rapid respirations c. Moist crackles heard upon auscultation d. Tachycardia e. Distended neck veins f. Sluggish skin turgor

Answer 39

c. Moist crackles heard upon auscultation d. Tachycardia e. Distended neck veins ## Footnote Moist crackles, neck vein distention, and tachypnea typically indicate fluid volume excess. A person with a severe fluid volume deficit may have a pinched and drawn facial expression. Deep, rapid respirations may be a compensatory mechanism for metabolic acidosis or a primary disorder causing respiratory alkalosis. Tachycardia is usually the earliest sign of the decreased vascular volume associated with fluid volume deficit. Sluggish skin turgor is present with fluid volume deficit

Question 40

# Txtbook - Chapter 41: Fluids, Electrolytes, Acid-Base Balance A nurse is caring for a patient experiencing a fluid volume deficit. What should be included in the recorded intake and output for the patient? [Select all that apply] a. Urine b. Carbonated beverage c. Formed stool d. Vomitus e. Chicken noodle soup f. Pressure wound irrigant

Answer 40

a. Urine b. Carbonated beverage d. Vomitus e. Chicken noodle soup ## Footnote The nurse includes urine, emesis, liquid stool, drainage from wounds, and drains in the output. Intake includes IV fluids, foods, and liquid at room temperature. The liquid portion of the chicken noodle soup can be measured; however, the nurse excludes the solids. Irrigation to a pressure wound is not absorbed; rather, it drains out after cleansing the wound

Question 41

# Txtbook - Chapter 41: Fluids, Electrolytes, Acid-Base Balance A nurse is caring for an older adult with a fluid volume deficit related to decreased thirst sensation. For which signs and symptoms of this health problem will the nurse assess? a. Dependent edema b. Crackles in the lungs c. Neck vein distention d. Weight loss

Answer 41

d. Weight loss ## Footnote Assessing weight is the most sensitive indicator of fluid balance. As fluid is lost, the patient’s weight will decrease. The other options are indicative of fluid excess.

Question 42

# Txtbook - Chapter 41: Fluids, Electrolytes, Acid-Base Balance A nurse on the IV team is making rounds to assess patients receiving IV therapy. Under which circumstance will the nurse recommend an intravenous catheter be discontinued? a. The area surrounding the catheter is bruised. b. The patient’s extremity is cool to touch. c. The site is red, warm, and swollen. d. Part of the catheter (1 mm) is visible under the dressing.

Answer 42

c. The site is red, warm, and swollen. ## Footnote The IV nurse will assess the IV fluids, rate, and site. A site that is red, warm, and swollen may have developed phlebitis, and the IV catheter should be removed. A bruised area surrounding the insertion site is likely associated with the initial insertion and can be monitored. A patient with a cool extremity may be chilly or hypothermic; the nurse assesses the IV site. Having 1 mm of the catheter visible from the insertion site that is covered with an occlusive, transparent dressing does not require immediate action.

Question 43

# ATI eBook - Chapter 48: Dosage Calculation ORAL: A nurse is preparing to administer metoprolol 200 mg PO daily. The amount available is metoprolol 100mg/tablet. How many tablets should the nurse administer?

Answer 43

2 tabs

Question 44

# ATI eBook - Chapter 48: Dosage Calculation LIQUID: A nurse is preparing to administer acetaminophen 320 mg PO q4hr PRN for pain. The amount available is acetaminophen liquid 160mg/mL. How many mL should the nurse administer per dose?

Answer 44

10 mL

Question 45

# ATI eBook - Chapter 48: Dosage Calculation INJECTABLE: A nurse is preparing to administer methylprednisolone 60 mg by IV bolus. The amount available is methylprednisolone injection 40 mg/mL. How many mL should the nurse administer?

Answer 45

1.5 mL

Question 46

# ATI eBook - Chapter 48: Dosage Calculation BY WEIGHT: A nurse is preparing to administer ketorolac 0.5 mg/kg IV bolus q6hr to a school-age child who weighs 66 lb. The amount available is ketorolac injection 30 mg/mL. How many mL should the nurse administer per dose?

Answer 46

0.5 mL

Question 47

# ATI eBook - Chapter 48: Dosage Calculation IV FLOW RATE: A nurse is preparing to administer lactated Ringer’s (LR) IV 100 mL over 15 minutes. The nurse should set the IV infusion pump to deliver how many mL/hr?

Answer 47

400 mL/hr

Question 48

# ATI eBook - Chapter 48: Dosage Calculation IV FLOW RATE: A nurse is preparing to administer dextrose 5% in water (DSW) 1,000 mL IV to infuse over 10 hours. The nurse should set the IV infusion pump to deliver how many mL/hr?

Answer 48

100 mL/hr

Question 49

# ATI eBook - Chapter 48: Dosage Calculation IV DRIP/GTT: A nurse is preparing to administer 0.9% sodium chloride (normal saline) 250 mL IV to infuse over 30 minutes. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min?

Answer 49

83 gtt/min

Question 50

# ATI eBook - Chapter 48: Dosage Calculation IV DRIP/GTT: A nurse is preparing to administer dextrose 5% in lactated Ringer’s (D5LR) 1,000 mL IV to infuse over 6 hours. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min?

Answer 50

42 gtt/min

Question 51

# ATI eBook - Chapter 49: IV Therapy The nurse is teaching a newly licensed nurse how to insert an IV catheter into a client. Which statement by the newly licensed nurse indicates an understanding of the procedure? a. I will cleanse the area of the insertion site in a circular motion starting from the outside to the middle b. I will insert the needle into the client’s skin at an angle of 10-30 degrees with the bevel up c. I will apply pressure 1 inch below the insertion site prior to removing the needle d. I will choose a vein in the antecubital fossa for IV insertion

Answer 51

b. I will insert the needle into the client’s skin at an angle of 10-30 degrees with the bevel up

Question 52

# ATI eBook - Chapter 49: IV Therapy The nurse is teaching a newly licensed nurse about strategies to reduce the risk for IV infection. What strategies should the nurse include? [Select all that apply] a. Perform hand hygiene before and after handling IV systems b. Change IV sites - q72hr [per facility policy] c. Remove catheters as soon as they are no longer clinically necessary to eliminate a portal of entry for pathogens d. Use a sterile needle and/or catheter for each insertion attempt e. Disconnect IV tubing f. Replace IV catheters or tubing when there is a break in surgical aseptic technique g. Do not write on the IV bags because ink can contaminate solution h. Do not allow fluids to hang for more than 24 hours - UNLESS IT’S A CLOSED SYSTEM

Answer 52

a. Perform hand hygiene before and after handling IV systems b. Change IV sites - q72hr [per facility policy] c. Remove catheters as soon as they are no longer clinically necessary to eliminate a portal of entry for pathogens d. Use a sterile needle and/or catheter for each insertion attempt f. Replace IV catheters or tubing when there is a break in surgical aseptic technique g. Do not write on the IV bags because ink can contaminate solution h. Do not allow fluids to hang for more than 24 hours - UNLESS IT’S A CLOSED SYSTEM | DO NOT DISCONNECT IV TUBING ## Footnote E = WRONG

Question 53

# ATI eBook - Chapter 49: IV Therapy The nurse is teaching the new nurse about complications of IV therapy. Sort the following findings into infiltration or phlebitis: Cool to touch Pallor Damp dressing Local swelling at IV site Slowed infusion rate

Answer 53

INFILTRATION

Question 54

# ATI eBook - Chapter 49: IV Therapy The nurse is teaching the new nurse about complications of IV therapy. Sort the following findings into infiltration or phlebitis: Localized warmth Erythema Red line Palpable band at vein site Edema Throbbing, burning, and/or pain at IV site Slowed infusion rate

Answer 54

PHLEBITIS

Question 55

# ATI eBook - Chapter 49: IV Therapy Mrs. Smith is 24 hrs postoperative. Amy answers the call-light for Mrs. Smith. Amy: “Hello, Mrs. Smith. How are you doing?” Mrs. Smith: “I am not feeling well, I have pain in my left arm and I am having chills.” Amy: “Let me take a look at your IV.” Amy notifies John and documents the following information: Client reports not feeling well and is having chills and pain at the IV site. Peripheral IV in left arm is warm to touch. Edema and hardness above the insertion site. Red streaking noted on the client’s arm close to the IV insertion site. Question: The nurse is caring for the client who is receiving IV therapy. Which of the following actions should the nurse plan to take first? a. Obtain a specimen for culture b. Apply a warm compress c. Administer analgesics d. Discontinue the infusion/IV

Answer 55

d. Discontinue the infusion/IV

Question 56

# ATI eBook - Chapter 49: IV Therapy Mrs. Smith is 8 hrs postoperative. Amy performs an assessment on Mrs. Smith. 1515: Amy: “Hello, Mrs. Smith. My name is Amy. How are you feeling?” Mrs. Smith: “I feel a little short of breath.” Amy: “I’m going to listen to your lungs and check your blood pressure and heart rate.”. 1530: Amy: “I’m going to check the circulation in your feet. You have some swelling in your ankles. Have you experienced swelling in your feet before?” Mrs. Smith: “No. Amy notifies John and they call the provider and document the following information: Client is awake, alert, and oriented. Client reports shortness of breath, breath sounds with crackles heard at bases. Blood pressure 158/90 mmHg, HR 106/min, Resp 24/min. Feet warm and pink bilaterally, pedal pulses intact. 2+ pitting edema in ankles bilaterally. Lactated ringers infusing into #20-gauge IV in left arm. Dressing dry and intact. Fluid infusing well. Question: The nurse is assessing the client. Which findings are a manifestation of fluid overload? [Select all that apply] a. Respiratory rate b. Blood pressure c. Heart rate d. Pedal pulses e. Neurological status

Answer 56

a. Respiratory rate b. Blood pressure c. Heart rate

Question 57

# ATI eBook - Chapter 57: Fluid Imbalances A nurse is performing an assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? [Select all that apply] a. Hypothermia b. Bradycardia c. Orthostatic hypotension d. Distended neck veins e. Decreased skin turgor

Answer 57

a. Hypothermia c. Orthostatic hypotension e. Decreased skin turgor

Question 58

# ATI eBook - Chapter 57: Fluid Imbalances The nurse is reviewing the data on the client who has hypovolemia. The nurse should identify which of the following findings is a manifestation of hypovolemia? [Select all that apply] a. Increased Hct b. Increased BP c. Decreased urine specific gravity d. Decreased urine output e. Increased sodidum level

Answer 58

a. Increased Hct d. Decreased urine output e. Increased sodidum level

Question 59

# ATI eBook - Chapter 57: Fluid Imbalances The nurse is planning care for the client who is admitted to an acute care facility with dehydration. What actions should the nurse include in the plan? a. Monitor respiratory rate & O2 saturation b. Administer supplemental O2 as prescribed c. Check urinalysis, CBC, electrolytes d. Daily weight at the same time using the same scale e. Observe for N/V f. Assess BP for postural hypotension g. Encourage client to change positions slowly and ask for help getting out of bed h. Assess neurological status i. I+O j. Assess HR

Answer 59

**ALL OF THE ABOVE/BELOW** a. Monitor respiratory rate & O2 saturation b. Administer supplemental O2 as prescribed c. Check urinalysis, CBC, electrolytes d. Daily weight at the same time using the same scale e. Observe for N/V f. Assess BP for postural hypotension g. Encourage client to change positions slowly and ask for help getting out of bed h. Assess neurological status i. I+O j. Assess HR

Question 60

# ATI eBook - Chapter 57: Fluid Imbalances A nurse is teaching a class about fluid imbalances. Sort the following manifestations into either hypovolemia or hypervolemia. Flat neck veins Sunken eyeballs

Answer 60

HYPOVOLEMIA

Question 61

# ATI eBook - Chapter 57: Fluid Imbalances A nurse is teaching a class about fluid imbalances. Sort the following manifestations into either hypovolemia or hypervolemia. Breath sounds w/ crackles Weight gain Decreased urine specific gravity

Answer 61

HYPERVOLEMIA

Question 62

# ATI eBook - Chapter 57: Fluid Imbalances A nurse on a medical-surgical unit is caring for a group of clients. Sort the following clients to those at risk for hypovolemia or those at risk for hypervolemia. A client who has nasogastric suctioning A client who is taking diuretics

Answer 62

HYPOVOLEMIA

Question 63

# ATI eBook - Chapter 57: Fluid Imbalances A nurse on a medical-surgical unit is caring for a group of clients. Sort the following clients to those at risk for hypovolemia or those at risk for hypervolemia. A client who has Syndrome of Inappropriate Antidiuretic Hormone [SIADH] A client who has cirrhosis

Answer 63

HYPERVOLEMIA

Question 64

# ATI eBook - Chapter 58: Electrolyte Imbalances A nurse is planning care for a client who has hypernatremia. What actions should the nurse include in the plan of care? a. Monitor LOC b. I+O c. Monitor lab results d. Maintain prescribed diet - low sodium / no salt added e. Encourage oral hygiene and fluids f. Administer hypotonic or isotonic IV fluids

Answer 64

**ALL OF THE ABOVE/BELOW** a. Monitor LOC b. I+O c. Monitor lab results d. Maintain prescribed diet - low sodium / no salt added e. Encourage oral hygiene and fluids f. Administer hypotonic or isotonic IV fluids

Question 65

# ATI eBook - Chapter 58: Electrolyte Imbalances A nurse is planning caring for a client who has a potassium level of 5.2 mEq/L (hyperkalemia). What actions should the nurse plan to take? a. ECG monitoring [continuous] b. Monitor / assess dysrhythmias c. Stop IV infusion w/ potassium and withhold oral potassium d. Administer IV fluids w/ dextrose + regular insulin to promote the movement of K+ from ECF to ICF

Answer 65

**ALL OF THE ABOVE/BELOW** a. ECG monitoring [continuous] b. Monitor / assess dysrhythmias c. Stop IV infusion w/ potassium and withhold oral potassium d. Administer IV fluids w/ dextrose + regular insulin to promote the movement of K+ from ECF to ICF

Question 66

# ATI eBook - Chapter 58: Electrolyte Imbalances A nurse is reviewing the electronic medical record of a client who has an electrolyte imbalance. Match the electrolyte imbalance to the associated risk factor: Hypernatremia; Hyponatremia; Hypercalcemia; Hypocalcemia * ** Diabetes insipidus** * Excessive water intake * Hyperparathyroidism * Hypoparathyroidism

Answer 66

HYPERNATREMIA

Question 67

# ATI eBook - Chapter 58: Electrolyte Imbalances A nurse is reviewing the electronic medical record of a client who has an electrolyte imbalance. Match the electrolyte imbalance to the associated risk factor: Hypernatremia; Hyponatremia; Hypercalcemia; Hypocalcemia * Diabetes insipidus *** Excessive water intake** * Hyperparathyroidism * Hypoparathyroidism

Answer 67

HYPONATREMIA

Question 68

# ATI eBook - Chapter 58: Electrolyte Imbalances A nurse is reviewing the electronic medical record of a client who has an electrolyte imbalance. Match the electrolyte imbalance to the associated risk factor: Hypernatremia; Hyponatremia; Hypercalcemia; Hypocalcemia * Diabetes insipidus * Excessive water intake *** Hyperparathyroidism** * Hypoparathyroidism

Answer 68

HYPERCALCEMIA

Question 69

# ATI eBook - Chapter 58: Electrolyte Imbalances A nurse is reviewing the electronic medical record of a client who has an electrolyte imbalance. Match the electrolyte imbalance to the associated risk factor: Hypernatremia; Hyponatremia; Hypercalcemia; Hypocalcemia * Diabetes insipidus * Excessive water intake * Hyperparathyroidism *** Hypoparathyroidism**

Answer 69

HYPOCALCEMIA

Question 70

# ATI eBook - Chapter 58: Electrolyte Imbalances The nurse is caring for the client who has a positive Chvostek’s sign. The nurse should identify that this finding is a manifestation of which of the following electrolyte imbalances? [Select all that apply] a. Hypocalcemia b. Hypomagnesemia c.Hypokalemia d. Hypernatremia e. Hyperkalemia

Answer 70

a. Hypocalcemia b. Hypomagnesemia

Question 71

# ATI eBook - Chapter 58: Electrolyte Imbalances The nurse is reviewing the medical record of the client. The nurse should identify which of the following findings is a risk factor for the development of hypocalcemia? [Select all that apply] a. Bariatric surgery b.Diarrhea c. Thyroid cancer d. Diabetes mellitus e. Hyperlipidemia

Answer 71

a. Bariatric surgery b.Diarrhea c. Thyroid cancer

Question 72

# ATI eBook - Chapter 58: Electrolyte Imbalances A nurse is teaching a class about electrolyte imbalances. Match the electrolyte imbalance to the clinical manifestation - Hypocalcemia; Hypomagnesemia; Hypernatremia; Hyperkalemia *** Tingling around the mouth** * Hypertension * Dry, Swollen tongue * Muscle weakness

Answer 72

HYPOCALCEMIA ## Footnote C = calcium; Chvostek; Cheek tingling

Question 73

# ATI eBook - Chapter 58: Electrolyte Imbalances A nurse is teaching a class about electrolyte imbalances. Match the electrolyte imbalance to the clinical manifestation - Hypocalcemia; Hypomagnesemia; Hypernatremia; Hyperkalemia * Tingling around the mouth *** Hypertension** * Dry, Swollen tongue * Muscle weakness

Answer 73

HYPOMAGNESEMIA

Question 74

# ATI eBook - Chapter 58: Electrolyte Imbalances A nurse is teaching a class about electrolyte imbalances. Match the electrolyte imbalance to the clinical manifestation - Hypocalcemia; Hypomagnesemia; Hypernatremia; Hyperkalemia * Tingling around the mouth * Hypertension *** Dry, Swollen tongue** * Muscle weakness

Answer 74

HYPERNATREMIA

Question 75

# ATI eBook - Chapter 58: Electrolyte Imbalances A nurse is teaching a class about electrolyte imbalances. Match the electrolyte imbalance to the clinical manifestation - Hypocalcemia; Hypomagnesemia; Hypernatremia; Hyperkalemia * Tingling around the mouth * Hypertension * Dry, Swollen tongue *** Muscle weakness**

Answer 75

HYPERKALEMIA

Question 76

# ATI Skills: Central Venous Access Devices A nurse in the emergency department is caring for a client who was in a motor-vehicle crash. The provider determines that the client needs immediate central venous access for fluid and blood replacement. Which of the following central venous access devices should the nurse anticipate being inserted? a. A tunneled central catheter b. An implanted port c. A nontunneled percutaneous central catheter d. A peripherally inserted central catheter

Answer 76

**c. A nontunneled percutaneous central catheter** This type of central catheter is ideal for emergency situations where short-term (less than 6 weeks) central venous access is required for multiple therapies. This is the appropriate choice for this client ## Footnote a. A tunneled central catheter [This type of central catheter is designed for long-term therapy, such as lengthy courses of chemotherapy or parenteral nutrition. There is no indication that this client will require prolonged central venous access. Also, this type of device is not typically inserted quickly in an emergency setting.] b. An implanted port [This type of central catheter is designed for long-term therapy, such as lengthy courses of chemotherapy or parenteral nutrition. There is no indication that this client will require prolonged central venous access. Also, this type of device is not typically inserted quickly in an emergency setting.] d. A peripherally inserted central catheter [This type of central catheter is designed for longer term therapy, such as lengthy courses of chemotherapy or parenteral nutrition. There is no indication that this client will require prolonged central venous access.]

Question 77

# ATI Skills: Central Venous Access Devices A nurse is caring for a client who has a central venous catheter. When flushing the catheter, the nurse should use a 10-mL syringe to prevent which of the following complications associated with central vascular access devices? a. Catheter rupture b. Catheter migration c. Pneumothorax d. Phlebitis

Answer 77

**a. Catheter rupture** When injecting fluid through a catheter, a smaller syringe generates more pressure than a larger syringe does. Therefore, to reduce the risk of catheter rupture, syringes that are 10-mL or larger are recommended for flushing or injecting fluid into a central venous catheter

Question 78

# ATI Skills: Central Venous Access Devices A nurse is preparing to obtain a blood sample from a client who has a triple-lumen central catheter in place. Which of the following actions should the nurse take? a. Discard the first 35 mL of aspirated blood before collecting the sample. b. Place the client in Trendelenburg position while withdrawing the blood sample. c. Withdraw the blood sample from the lumen that has the smallest diameter. d. Turn off the distal infusions for 1 to 5 min before obtaining the blood sample.

Answer 78

d. Turn off the distal infusions for 1 to 5 min before obtaining the blood sample.

Question 79

# ATI Skills: Central Venous Access Devices A nurse is caring for a client who has an implanted port that needs to be accessed for an infusion. Which action should the nurse take? a. Use a standard medium-gauge needle to access the port. b. Insert the primed needle into the port at a 45° angle. c. Withdraw the needle after insertion, leaving the needle's sheath in place for the infusion. d. Cover the device and the needle with a sterile transparent dressing.

Answer 79

**d. Cover the device and the needle with a sterile transparent dressing.** Once the implanted port has been accessed, the needle must be supported and anchored. The needle should be covered with a transparent dressing to secure the needle

Question 80

# ATI Skills: Central Venous Access Devices A nurse is caring for a client who has a central venous catheter and suddenly develops dyspnea, tachycardia, and dizziness. The nurse suspects an air embolism and clamps the catheter immediately. The nurse should reposition the client into which position? a. Supine with a pillow beneath the knees b. On their left side in Trendelenburg position c. Upright and leaning over the overbed table d. On their right side with the HOB elevated 15 degrees

Answer 80

**b. On their left side in Trendelenburg position** This position helps trap the air in the apex of the right atrium rather than allowing it to enter the right ventricle and, from there, move to the pulmonary arterial system

Question 81

# ATI Skills: Central Venous Access Devices A nurse is caring for a client who has a central venous access device in place. Which routine intervention should the nurse use to prevent lumen occlusion? a. Apply a skin securement device to the catheter. b. Remove the dressing from the insertion site slowly and carefully. c. Use a pulsatile action while flushing. d. Have the client lie flat when changing administration sets or injection caps.

Answer 81

**c. Use a pulsatile action while flushing.** Using a pulsatile action technique while flushing assists with the prevention of occlusion by removing possible solid deposits within the lumen. ## Footnote a. Apply a skin securement device to the catheter. [This measure is intended to prevent catheter migration, not lumen occlusion.] b. Remove the dressing from the insertion site slowly and carefully. [This measure is intended to prevent catheter dislodgement, not lumen occlusion.] d. Have the client lie flat when changing administration sets or injection caps. [This measure is intended to prevent air embolism, not lumen occlusion.]

Question 82

# ATI Skills: Central Venous Access Devices A nurse is caring for a client who requires long-term central venous access and is an avid swimmer. Which central venous access device is the best choice for this client? a. A tunneled central catheter b. An implanted port c. A nontunneled percutaneous central catheter d. A peripherally inserted central catheter

Answer 82

b. An implanted port

Question 83

# ATI Skills: IV Therapy A nurse is assessing a client who is receiving 0.9% sodium chloride IV at 125 mL/hr. Which of the following should the nurse recognize as a possible complication related to the IV therapy? a. Petechiae is present over the IV site. b. The skin is cool over the IV site. c. Client reports coughing and shortness of breath. d. Client's blood pressure is lower than normal.

Answer 83

c. Client reports coughing and shortness of breath.

Question 84

# ATI Skills: IV Therapy A nurse is preparing to administer cetriaxone 1 g in 100 mL IV over 30 min. The drip rate is 10 gtt/m. The nurse should set the infusion rate to administer how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Answer 84

33 gtt/min

Question 85

# ATI Skills: IV Therapy A nurse is caring for a client who is receiving dextrose in 5% water with 20 mEq of potassium chloride at 75 mL/hr. The provider has prescribed 1 g ceftriaxone IV. When preparing to administer this medication by intermittent IV bolus, which of the following actions should the nurse take first? a. Obtain the client's vital signs. b. Determine the client's level of consciousness. c. Verify the medication's compatibility with the primary IV solution. d. Check the amount of IV solution in the primary bag.

Answer 85

c. Verify the medication's compatibility with the primary IV solution.

Question 86

# ATI Skills: IV Therapy A nurse is caring for a client who is receiving 0.9% sodium chloride IV at 75 mL/hr through a triple lumen central venous access device. The V pump alarm sounds, indicating that there is an occlusion. Which of the following actions should the nurse take first? a. Call the provider who inserted the catheter. b. Flush the line with a 10-mL syringe of heparin. c. Check the line at or above the hub for kinked tubing that is creating a resistance to flow. d. Reposition the client.

Answer 86

c. Check the line at or above the hub for kinked tubing that is creating a resistance to flow.

Question 87

# ATI Skills: IV Therapy A nurse is preparing to administer an IV medication to a client. The nurse lould identify that which of the following is a disadvantage of administering IV medications? a. IV medications are irreversible. b. IV medications have a slow onset. c. IV medications bypass the liver. d. IV medications have less bioavailability.

Answer 87

a. IV medications are irreversible.

Question 88

# ATI Skills: IV Therapy A nurse is caring for a client who has a peripherally inserted central catheter (PICC) line. The nurse should identify that which of the following information is true about this type of IV route? a. A PICC line is a midline catheter used to administer blood. b. A PICC line is a catheter that allows for infusion of IV fluids without an infusion pump. c. A PICC line is a long catheter inserted through the veins of the antecubital fossa. d. A PICC line is a catheter that is used for emergent or trauma situations.

Answer 88

c. A PICC line is a long catheter inserted through the veins of the antecubital fossa.

Question 89

# ATI Skills: IV Therapy A nurse administers the first dose of a client's prescribed antibiotic via intermittent IV bolus. During the first 10 to 15 min of administration, which of the following assessments is the nurse's priority? a. Assess the IV site for redness or swelling. b. Assess the client for a systemic allergic reaction. c. Assess the IV dressing for signs of leakage. d. Assess the client's limb for signs of discomfort.

Answer 89

b. Assess the client for a systemic allergic reaction.

Question 90

# ATI Skills: IV Therapy A nurse is caring for a client who was admitted to the hospital for same day surgery and has a new prescription for continuous IV therapy. Which of the following actions should the nurse take when administering the IV therapy? a. Place a cold compress over the vein. b .Inspect the IV solution for fluid color, clarity, and expiration date. c. Apply a tourniquet 1 to 2 inches above the selected insertion site. d. Secure an armboard to the client's extremity.

Answer 90

b .Inspect the IV solution for fluid color, clarity, and expiration date.

Question 91

# ATI Skills: IV Therapy Which of the following is the most effective way to make sure you are administering the right medication (fluid) to the right client? a. Ask the client to state her full name and birth date while confirming this with the information on her medication band. b. Compare the information on the client's identification bracelet with data from the client's medical record. c. Address the client by name and observe for signs of recognition, such as nodding her head or verbally agreeing.

Answer 91

b. Compare the information on the client's identification bracelet with data from the client's medical record.

Question 92

# ATI Skills: IV Therapy To be sure that you administer the correct fluid (right medication), verify the prescription and then do which of the following? a. Start the infusion immediately after making the appropriate fluid selection. b. Perform three checks of the right medication with the medication administration record. c. Ask another staff RN to confirm that you have selected the prescribed fluid.

Answer 92

b. Perform three checks of the right medication with the medication administration record.

Question 93

# ATI Skills: IV Therapy To ensure that the infusion continues appropriately and safely, which of the following should you do? a. Assess the client and the infusion at least hourly. b. Instruct ancillary staff to report the client's comments. c. Educate the client about the possible unexpected outcomes of IV therapy.

Answer 93

a. Assess the client and the infusion at least hourly.

Question 94

# ATI Skills: IV Therapy You draw up the medication and the 0.9% sodium chloride flushes each into 10-mL syringes for which of the following reasons? a. The pressure created by syringes any smaller could rupture the PICC line. b. A smaller syringe requires multiple flushes to provide the required 10 mL. c. A smaller syringe cannot exert enough pressure to force the fluid into the line.

Answer 94

a. The pressure created by syringes any smaller could rupture the PICC line.

Question 95

# ATI Skills: IV Therapy To prevent backflow into the line that could cause clotting, you should do which of the following? (Select all that apply.) a. Maintain pressure on the plunger while withdrawing it from the port. b. Clamp off the tubing before removing the syringe from the port. c. Withdraw the flush syringe slowly from the tubing port.

Answer 95

a. Maintain pressure on the plunger while withdrawing it from the port. b. Clamp off the tubing before removing the syringe from the port.

Question 96

# ATI Skills: IV Therapy You assess the client and observe a fine, red rash without pustles on the client’s neck and on both sides of his anterior and posterior thorax. Your immediate priority at this time is to do which of the following? a. Stop the intermittent IV bolus infusion of the medication b. Check the client’s vital signs and report them to the provider c. Ask the client if they have ever taken the medication before

Answer 96

a. Stop the intermittent IV bolus infusion of the medication

Question 96

To ensure that the client's IV site provides the appropriate vascular access, you first ask the client if they are experiencing any pain or tenderness at the site. You then inspect the site for which of the following? (Select all that apply.) a. Erythema b. Edema c. Dark blood d. Temperature variations

Answer 96

a. Erythema b. Edema d. Temperature variations

Question 97

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation Choose the laboratory test to the correct body system: Kidney vs Liver Function: * BUN * CR

Answer 97

KIDNEY Function

Question 98

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation Choose the laboratory test to the correct body system: Kidney vs Liver Function: * Albumin * ALT * Bilirubin * AST

Answer 98

LIVER Function

Question 99

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation A nurse is caring for a client who is admitted to the medical unit for hypokalemia. Which of the following conditions can cause hypokalemia? [Select all that apply] a. Medications b. Chronic kidney disease c. Diabetes ketoacidosis d. Alcohol withdrawal e. Folic acid deficiency

Answer 99

a. Medications b. Chronic kidney disease c. Diabetes ketoacidosis e. Folic acid deficiency

Question 100

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation A nurse is reviewing the medical history of a client who is experiencing hyperkalemia. Which of the following findings put the client at a higher risk for hyperkalemia? (Select all that apply.) a. Use of potassium supplements b. Taking a loop diuretic c. Allergy to bananas d. Kidney failure e. Hemodialysis

Answer 100

a. Use of potassium supplements d. Kidney failure

Question 101

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation A nurse is caring for a client who has hyponatremia. Which of the following findings or interventions should the nurse expect? (Select all that apply.) a. Sodium level of 127 mEq/L b. An rx for the client to drink as much water as possible c. Client reporting headache or fatigue d. Sodium level of 147 mEq/L e. An rx for a urine sodium test

Answer 101

a. Sodium level of 127 mEq/L c. Client reporting headache or fatigue e. An rx for a urine sodium test ## Footnote b. INCORRECT: An rx for the client to drink as much water as possible → USUALLY PLACED ON FLUID RESTRICTIONS!!!

Question 102

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation What is the cause/etiology of an **acute hemolytic reaction**?

Answer 102

Cause: When a client receives blood products that are NOT compatible with their own

Question 103

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation What are the manifestations [s/s] of an acute hemolytic reaction?

Answer 103

* **Back and/or Flank Pain * Fever, Chills * Hematuria [bloody urine]** * Dyspnea * Tachycardia / Inc. HR * Hypotension * Dizziness * Flushing of skin, Diaphoretic

Question 104

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation What are the top 3 priority interventions during an acute hemolytic reaction?

Answer 104

1. STOP THE TRANSFUSION 2. Call for rapid response team 3. Change admin/setup + infuse normal saline (0.9% NaCl)

Question 105

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation A nurse is caring for a client who is receiving intravenous therapy. Which of the following manifestations should the nurse identify as a finding of circulatory overload? [Select all that apply] a. Jugular vein distention b. Cough c. Bradycardia d. Cyanosis e. Hypertension

Answer 105

a. Jugular vein distention b. Cough d. Cyanosis e. Hypertension

Question 106

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation A nurse is taking care of a client who has a PICC line in place. The client is due for a medication to be given through the PICC line, along with a dressing change to the site. The nurse is unsure if this is within their scope of practice. Which of the following actions should the nurse take? a. Administer the medication so it will not be administered late b. Change the dressing and ask another nurse to give the medication c. Refer to the state’s Nurse Practice Act d. Refuse to carry out the orders

Answer 106

c. Refer to the state’s Nurse Practice Act

Question 107

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation ABG Interpretation: pH = 7.42; PaCO2 = 37 mm; HCO3 = 25 mEq/L

Answer 107

Acid-Base Balance :)

Question 108

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation ABG Interpretation: pH = 7.33; PaCO2 = 35 mm; HCO3 = 20 mEq/L

Answer 108

Metabolic Acidosis [partially compensated]

Question 109

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation ABG Interpretation: pH = 7.49; PaCO2 = 32 mm; HCO3 = 24 mEq/L

Answer 109

Respiratory Alkalosis [uncompensated]

Question 110

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation Respiratory Acidosis vs Respiratory Alkalosis: Match the acid-base condition with the correct causes - **RESPIRATORY *ACIDOSIS*** Pulmonary embolism Spinal cord injury Hyperventilation Severe stress

Answer 110

Respiratory ACIDOSIS: * Pulmonary embolism * Spinal cord injury

Question 111

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation Respiratory Acidosis vs Respiratory Alkalosis: Match the acid-base condition with the correct causes - ***RESPIRATORY ALKALOSIS*** Pulmonary embolism Spinal cord injury Hyperventilation Severe stress

Answer 111

Respiratory ALKALOSIS: * Hyperventilation * Severe stress ## Footnote Other causes: * Pregnancy * Sepsis

Question 112

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation Metabolic Acidosis vs Metabolic Alkalosis: Match the acid-base condition with the correct causes - ***METABOLIC ACIDOSIS*** * Severe diarrhea that leads to bicarbonate loss * Low pH and Low bicarbonate * Client takes long, deep breaths * Antacid overuse * High pH and high bicarbonate * Kidneys excrete bicarbonate

Answer 112

Metabolic ACIDOSIS: * Severe diarrhea that leads to bicarbonate loss * Low pH and Low bicarbonate * Client takes long, deep breaths

Question 113

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation Metabolic Acidosis vs Metabolic Alkalosis: Match the acid-base condition with the correct causes - ***METABOLIC ALKALOSIS*** * Severe diarrhea that leads to bicarbonate loss * Low pH and Low bicarbonate * Client takes long, deep breaths * Antacid overuse * High pH and high bicarbonate * Kidneys excrete bicarbonate

Answer 113

Metabolic ALKALOSIS: * Antacid overuse * High pH and high bicarbonate * Kidneys excrete bicarbonate

Question 114

# ATI EF Content: Fluid, Electrolyte, & Acid-Base Regulation A nurse is monitoring a client who has metabolic acidosis after interventions have been initiated. Which step of the nursing process is next? a. Data collection b. Planning c. Evaluation d. Implementation

Answer 114

c. Evaluation

Question 115

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A charge nurse is observing a newly licensed nurse who is preparing to administer a blood transfusion to a client. For which of the following actions by the newly licensed nurse should the charge nurse intervene? a. The nurse selects 0.45% sodium chloride to use to prime the tubing b. The nurse asks another nurse to check the blood unit label and client identification prior to beginning the transfusion c. The nurse uses tubing with a filter for the blood transfusion d. The nurse discards the tubing after the first unit of blood is completed

Answer 115

**a. The nurse selects 0.45% sodium chloride to use to prime the tubing** The charge nurse should intervene if the newly licensed nurse selects 0.45% sodium chloride to prime the tubing. The nurse should identify that 0.9% sodium chloride is the only IV solution that should be used to prime the tubing for blood administration

Question 116

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is receiving report on four clients. The nurse should identify that which client might be experiencing hypomagnesemia? a. A client who has vomited four times during the last 8 hr b. A client who requested an extra breakfast tray to eat c. A client who can ambulate without assistance d. A client who reports extreme thirst

Answer 116

a. A client who has vomited four times during the last 8 hr **N/V =hypomagnesemia** ## Footnote **b. decreased appetite = hypomagnesemia c. difficulty ambulating / weakness = hypomagnesemia d. extreme thirst = hypernatremia**

Question 117

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is caring for a client who is experiencing respiratory alkalosis. Which action should be the goal of treatment for the client? a. Increase the CO2 level b. Increase the RR c. Increase the HCO3 level d. Increase the pH level

Answer 117

a. Increase the CO2 level **A state of respiratory alkalosis indicates that the client's carbon dioxide level is currently below the expected reference range. The goal of treatment should be to raise the level of carbon dioxide level back to within the expected reference range for PaCO2 of 35 to 45 mm Hg** ## Footnote b. Increase the RR [A state of respiratory alkalosis indicates the client is likely experiencing an elevated respiratory rate. Hyperventilation can cause respiratory alkalosis because carbon dioxide is eliminated as expirations increase. The goal of treatment should be to lower the client's respiratory rate.] c. Increase the HCO3 level [A state of respiratory alkalosis indicates that the client's bicarbonate level is currently above the expected reference range. The goal of treatment should be to lower the level of bicarbonate back to within the expected reference range for HCO3- of 21 to 28 mEq/L.] d. Increase the pH level [A state of respiratory alkalosis indicates that the client's pH level is currently above the expected reference range. The goal of treatment should be to lower the pH level to within the expected reference range of 7.35 to 7.45.]

Question 118

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is caring for a client who requires a replacement peripheral IV. The client is dehydrated and requires a smaller gauge catheter than the #20-gauge being replaced. Which of the following gauge catheters should the nurse plan to use? a. 16 G b. 18 G c. 22 G d. 14 G

Answer 118

c. 22 G The nurse should use a #22-gauge catheter as a replacement for the current #20-gauge IV catheter. As the client is dehydrated, it may be difficult to access a peripheral vein with a larger gauge catheter. As the gauge # increases, the actual catheter size decreases

Question 119

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is reviewing laboratory results for a client and notes the following arterial blood gas (ABG) values: pH 7.31, PaCO2 49 mm Hg, and HCO3-25 mEq/L. The nurse should interpret these findings as an indication of which of the following acid-base imbalances? a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis

Answer 119

b. Respiratory acidosis

Question 120

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is assessing a client who is exhibiting signs of a fluid and electrolyte imbalance. Which of the following findings should the nurse identify as a potential cause for the client's fluid and electrolyte imbalance? a. The client reports working in a warehouse in 21.1° C (70° F) temperature. b.The client reports they performed yard work for 8 hr in 35° C (95° F) temperature earlier that day. c. The client reports that their provider decreased their diuretic dose. d.. The client reports they had a 24-hr intestinal virus 2 weeks ago.

Answer 120

b.The client reports they performed yard work for 8 hr in 35° C (95° F) temperature earlier that day. **The nurse should identify that working outside in high temperatures for an extended period can cause profuse sweating and lead to a fluid and electrolyte imbalance**

Question 121

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is caring for a client who is receiving treatment for hyponatremia. The nurse should identify that which of the following findings is an indication that the treatment has been effective? [Select all that apply] a. The client states their muscle spasms are absent. b. The client reports a headache. c. The client denies being confused. d. The client reports being nauseated. e. The client reports feeling tired.

Answer 121

a. The client states their muscle spasms are absent. c. The client denies being confused.

Question 122

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is caring for a client who has a prescription to receive one unit of packed red blood cells. The client's blood type is AB+, and the nurse receives a unit of A- blood from the blood bank. Which of the following actions should the nurse take? a. Return the blood unit as it is not compatible with the client's blood type. b. Stay with the client for 15 min prior to starting the blood transfusion. c. Verify the unit of blood with another nurse. d. Prime the blood tubing with 0.45% sodium chloride.

Answer 122

c. Verify the unit of blood with another nurse.

Question 123

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is caring for a client who has the following arterial blood gas (ABG) values: pH 7.44, PaCOz 37 mm Hg, and HCO3- 24 mEq/L. The nurse should identify that these values are an indication of which of the following? a. Metabolic acidosis b. Respiratory acidosis c. Acid-base balance d. Respiratory alkalosis

Answer 123

c. Acid-base balance

Question 124

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is assessing a client who has been receiving IV therapy for several days and notes that the client's daily weight has increased. The nurse should identify that the client is at increased risk for developing which of the following IV-related complications? a. Phlebitis b. Extraversion c. Air embolism d. Circulatory overload

Answer 124

d. Circulatory overload

Question 125

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is reviewing the arterial blood gas (ABG) values for a client and notes the following results: pH 7.49, PaCO, 39 mm Hg, and HCO3-35 mEq/L. The nurse should interpret this ABG reading as an indication of which of the following acid-base imbalances? a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis

Answer 125

c. Metabolic alkalosis

Question 126

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is reviewing a client's laboratory results. Which of the following results should the nurse report to the provider? a. Potassium 4.5 mEq/L b. Sodium 138 mEq/L c. Magnesium 3 mEq/L d. Calcium 10 mg/dL

Answer 126

c. Magnesium 3 mEq/L

Question 127

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is reviewing a client's latest arterial blood gas (ABG) report. Which of the following values should the nurse identify as the priority to report to the provider? a. pH 7.37 b. PaCO2 43 mm Hg c. HCO3 27 mEq/L d. Pa02 76 mm Hg

Answer 127

d. Pa02 76 mm Hg **When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority value to report to the provider is PaO2 76 mm Hg. This value is below the expected reference range of 80 to 100 mm Hg and could be an indication the client is decompensating**

Question 128

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following complications should the nurse monitor? a. The need for multiple IV sticks b. Infection at the access site c. Dehydration d. Infiltration

Answer 128

b. Infection at the access site

Question 129

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is reviewing prescriptions for a client who needs intravenous fluid replacement therapy due to vomiting and diarrhea. Which of the following fluid prescriptions should the nurse expect to initiate? a. 3% sodium chloride solution b. 0.9% sodium chloride solution c. 0.45% sodium chloride solution d. Dextrose 10% in water

Answer 129

b. 0.9% sodium chloride solution **A 0.9% sodium chloride solution is isotonic and is used for hydration needs such as from vomiting, diarrhea, hemorrhage, and shock. This is the most appropriate solution for the provider to prescribe for this client**

Question 130

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is caring for a client who has heart failure and a prescription to receive a unit of packed red blood cells. The nurse should plan to infuse the blood over which of the following lengths of time? a. 1 hour b. 2 hours c. 4 hours d. 6 hours

Answer 130

c. 4 hours Blood can be administered over a period of 1 to 4 hr. For a client who is at risk for circulatory overload, such as a client who has heart failure, a disorder in which compromised cardiac output results in poor tissue perfusion and fluid overload, the transfusion should be administered slowly (maximum time of 4 hr) to avoid increasing the workload of the heart

Question 131

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is calculating a client's intake and output for the last 4 hr. The client consumed 480 mL of water and 240 mL of coffee. The client has also received IV fluids for 4 hr infusing at 100 mL/hr. Which of the following amounts represents the client's intake over the last 4 hr? a. 1,120 mL b. 720 mL c. 480 mL d. 580 mL

Answer 131

a. 1,120 mL

Question 132

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is preparing to start an IV for a client who has a high risk for bleeding. Which of the following actions should the nurse take? a. Apply a cold compress to the selected IV site. b. Ask the client to hold the extremity up prior to searching for an IV site. c. Ask the client to spread the fingers of the selected extremity. d. Apply a blood pressure cuff set to 30 mm Hg.

Answer 132

d. Apply a blood pressure cuff set to 30 mm Hg.

Question 133

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is reviewing arterial blood gas (ABG) values for a client who is experiencing uncompensated metabolic acidosis. Which of the following ABG values should the nurse expect? [Select all that apply] a. HCO3 19 mEq/L b. pH 7.29 c. PaCO2 49 mm Hg d. pH 7.49 e. PaCO2 35 mm Hg

Answer 133

a. HCO3 19 mEq/L b. pH 7.29 e. PaCO2 35 mm Hg

Question 134

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is caring for a client who has an acid-base imbalance and is experiencing hypoxia. Which of the following actions should the nurse take first? a. Initiate continuous cardiac monitoring. b. Elevate the head of the client's bed. c. Instruct the client to deep breathe and cough. d. Initiate continuous Sp02 monitoring.

Answer 134

b. Elevate the head of the client's bed.

Question 135

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is caring for an older adult client who is experiencing dehydration. The nurse should identify that which of the following factors increases the risk for dehydration in older adult clients? [Select all that apply] a. Decreased kidney function b. Decreased thirst response c. Decreased total body fluid d. Eating watermelon daily e. Eating cucumbers with each meal

Answer 135

a. Decreased kidney function b. Decreased thirst response c. Decreased total body fluid

Question 136

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse caring for a client who is experiencing hypovolemia. Which of the following findings should the nurse identify as the priority to report to the provider? a. Dry mucous membranes b. Decreased urine output c. Report of thirst d. Decrease in level of consciousness

Answer 136

d. Decrease in level of consciousness

Question 137

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse on a pediatric floor is teaching a newly licensed nurse about V therapy. Which of the following information should the nurse include? a. Perform range of motion exercises on the extremity containing the IV site. b. Shave the client's hair if the IV is to be placed in the scalp. c. IV sites can be placed in the lower extremities up to the age of 2 years. d. Monitor the IV site, tubing, and connections every 4 hr.

Answer 137

a. Perform range of motion exercises on the extremity containing the IV site.

Question 138

# ATI EF Questions: Fluid, Electrolyte, & Acid-Base Regulation A nurse is reviewing the latest arterial blood gas (ABG) values for a client who is experiencing metabolic alkalosis. The nurse should identify that this action is part of which of the following steps of the nursing process? a. Planning b. Assessment c. Evaluation d. Implementation

Answer 138

c. Evaluation Reviewing the client's ABG values is part of the evaluation stage of the nursing process. During the evaluation stage, the nurse should determine if the actions taken in the implementation stage were successful in meeting the goals in the client's plan of care

Question 139

# Lecture Questions ABG Interpretation: 23 year-old female brought into the ED with a tib/fib fx. VS: 98.6 T, 112 HR, 26 RR, 117/63 BP, 97% RA. She is very anxious and complains of tingling around the mouth and fingers. ABG: pH = 7.48; CO2 = 32; HCO3 = 24

Answer 139

RESPIRATORY ALKALOSIS S/S: “Complains of TINGLING AROUND THE MOUTH & FINGERS" = HYPOCALCEMIA

Question 140

# Lecture Questions ABG Interpretation: 71-year-old w/ end-stage emphysema is brought into the ED w/ respiratory failure. VS: 99.7 T, 141 HR & IRREGULAR, 42 RR & SHALLOW , 90/50 BP, 82% w/ assisted ventilations. He is cyanotic, eyelids drooping, does not follow objects, moans to painful stimulation. ABG: pH=7.3; CO2 = 85; HCO3 = 40; O2 = 40%

Answer 140

RESPIRATORY ACIDOSIS S/S: cyanotic, decreased LOC

Question 141

# Lecture Questions ABG Interpretation: A 47-year old w/ diabetes has been admitted for a skin wound. VS: 101.6T; 124 HR; 22 RR; 140/86 BP; 94% RA. She is complaining of severe thirst and frequent urination. ABG: pH = 7.28; CO2 = 30; HCO3 = 18

Answer 141

METABOLIC ACIDOSIS S/S: diabetes = risk factor, severe thirst + frequent urination = HYPERNATREMIA

Question 142

# Lecture Questions ABG Interpretation: 4-year old w/ severe dehydration after 24 hours of recurrent vomiting from gastroenteritis. VS: 101.9T; 148 HR; 26 RR; 76/40 BP; 92% RA. Lethargic, sunken eyes, tenting skin turgor, scant + dark urine. ABG: pH = 7.46; CO2 = 36; HCO3 = 30

Answer 142

METABOLIC ALKALOSIS S/S: dehydration, vomiting & inc. HR, RR. Lethargic, sunken eyes, poor skin hydration = HYPONATREMIA

Question 143

# Lecture Questions The nurse is caring for patients on a med surg unit. Which problem puts a patient at risk for fluid volume OVERLOAD? a. NPO for sx b. Liver failure c. Vomiting d. Hypernatremia

Answer 143

d. Hypernatremia

Question 144

# Lecture Questions The nurse is caring for a client with CHF on a telemetry unit. Which is the BEST indicator of fluid balance? a. CBC b. Skin turgor c. Daily weight d. I+O

Answer 144

c. Daily weight

Question 145

# Lecture Questions A nurse is working in the ED and is interpreting ABGs pulled from a patient with suspected DKA. **ABG results: pH = 7.29; CO2 = 44; HCO3 = 18. ** How does the nurse interpret these findings? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic alkalosis d. Metabolic acidosis

Answer 145

d. Metabolic acidosis

Question 146

# Lecture Questions A nurse working in a LTC facility notes that a patient may be experiencing dehydration due to decreased fluid intake. What should the nurse implement? a. Increase fluid offerings in the evening b. Have the patient’s preferred fluids available & within reach c. Explain the pathophysiology of fluid transport for cellular function d. Establish large bore IV access to provide IV fluids

Answer 146

b. Have the patient’s preferred fluids available & within reach

Question 147

# Lecture Questions Match electrolyte with common signs/symptoms: Sodium; Potassium; Calcium; Magnesium * Altered LOC * MS changes * Seizures

Answer 147

***SODIUM*** **Assess NEURO** * Altered LOC * MS changes * Seizures

Question 148

# Lecture Questions Match electrolyte with common signs/symptoms: Sodium; Potassium; Calcium; Magnesium * Dysrhythmias * Muscle weakness * Leg cramping * Paresthesia

Answer 148

***POTASSIUM*** Assess **1. CARDIO;** then 2. Muscle Function * Dysrhythmias * Muscle weakness * Leg cramping * Paresthesia

Question 149

# Lecture Questions Match electrolyte with common signs/symptoms: Sodium; Potassium; Calcium; Magnesium * Tetany [spasms] * Numbness + Tingling of mouth & toes/fingers * Nausea / Vomiting

Answer 149

***CALCIUM*** Assess **1. NEUROMUSCULAR**, identifying characteristic = **bone** + muscle function * Tetany [spasms] * Numbness + Tingling of mouth & toes/fingers * Nausea / Vomiting

Question 150

# Lecture Questions Match electrolyte with common signs/symptoms: Sodium; Potassium; Calcium; Magnesium * DTR affected * Cardiac arrythmia

Answer 150

MAGNESIUM Assess *priority [abnormal HR]*, but **identified for affected REFLEXES = nerves** * DTR affected * Cardiac arrythmia

Question 151

# Lecture Questions ABG Interpretation: pH: 7.38; CO2: 41; HCO3: 23

Answer 151

Acid-Base balance

Question 152

# Lecture Questions ABG Interpretation: pH: 7.5; CO2: 29; HCO3: 26

Answer 152

Respiratory Alkalosis [uncompensated]

Question 153

# Lecture Questions ABG Interpretation: pH: 7.36; CO2: 33; HCO3: 20

Answer 153

Metabolic Acidosis [partially compensated]

Question 154

# Lecture Questions Conversions: 28 mg = ? mcg

Answer 154

28 mg = **28,000 mcg**

Question 155

# Lecture Questions Conversions: 6 tsp = ? mL

Answer 155

6 tsp = **30 mL**

Question 156

# Lecture Questions Conversions: 3 g = ? mg

Answer 156

3 g = **3,000 mg**

Question 157

# Lecture Questions The NP writes an order for a liquid oral med. The order says to administer 15 mg by mouth every 4 hours as needed for a sore throat. Pharmacy dispenses you with 30 mg/ 3 mL. 1. How many mL will you administer per dose? 2. What is max possible dose that can be given in 1 day [24 hr]?

Answer 157

1. How many mL will you administer per dose? **1.5 mL** 2. 2. What is max possible dose that can be given in 1 day? **9 mL [90 mg]**

Question 158

# Lecture Questions A patient is ordered 12.5 mg atenolol PO BID. The pyxis is stocked with 6.25 mg atenolol tabs. How many tabs will you administer per dose?

Answer 158

2 tabs

Question 159

# Lecture Questions You are ordered to give 12.5 mg diphenhydramine IV push NOW. Available is 50 mg/mL. How many mL will you draw up in the syringe to push?

Answer 159

0.25 mL

Question 160

# Quiz A nurse is working in the pre-op suite and is performing an intake assessment for a patient schedule for bilateral reduction mammoplasty. Which of the following findings in the assessment would put the patient at risk for a potential surgical complication? [Select all that apply] Chronic alcohol use WBC 7,500 mm Daily prednisone [steroid] Diabetes Mellitus Type 2 2 PPD smoking history Potassium level 3.7 mEq/dL

Answer 160

Chronic alcohol use Daily prednisone [steroid] Diabetes Mellitus Type 2 2 PPD smoking history

Question 161

# Quiz A nurse can witness the signing of an informed consent for surgery and confirm that the patient is competent. Ultimately, who is responsible for obtaining informed consent for a procedure? Anesthesiologist Circulating Nurse Surgeon [provider] Charge Nurse

Answer 161

Surgeon [provider]

Question 162

# Quiz A patient is being admitted to medical/surgical observation related to hypovolemia after 3 days of vomiting and diarrhea. Which of the following signs should the nurse expect? [Select all that apply] Oliguria Hypotension Weight gain Edema Bradycardia

Answer 162

Oliguria Hypotension

Question 163

# Quiz Match Anesthesia Types: *** Topical or local anesthetic targeted for decreasing pain response in touch in specific area * Client is awake and alert** Local anesthesia General anesthesia Regional anesthesia Moderate/Conscious Sedation

Answer 163

Local anesthesia *** Topical or local anesthetic targeted for decreasing pain response in touch in specific area * Client is awake and alert**

Question 164

# Quiz Match Anesthesia Types: **Multiple medications working on the CNS to evoke LOC, reflexes, and total sensation** Local anesthesia General anesthesia Regional anesthesia Moderate/Conscious Sedation

Answer 164

General anesthesia **multiple medications working on the CNS to evoke LOC, reflexes, and total sensation**

Question 165

# Quiz Match Anesthesia Types: *** Maybe like an epidural block * Anesthetic is injected into sensory nerve to block that pathway * Client is still arousable** Local anesthesia General anesthesia Regional anesthesia Moderate/Conscious Sedation

Answer 165

Regional anesthesia *** Maybe like an epidural block * Anesthetic is injected into sensory nerve to block that pathway * Client is still arousable**

Question 166

# Quiz Match Anesthesia Types: *** Instill IV sedatives, but are short acting * Clients are drowsy/sleepy, but arousable** Local anesthesia General anesthesia Regional anesthesia Moderate/Conscious sedation

Answer 166

Moderate/Conscious sedation *** Instill IV sedatives, but are short acting * Clients are drowsy/sleepy, but arousable**

Question 167

# Quiz A nurse is working in the PACU and reviewing the importance of breathing exercises post operatively to prevent complications like pneumonia and atelectasis. Which of the follow should the nurse include in the teaching? [Select all that apply] * "You should practice coughing and deep breathing at least every 4 hours while awake" * "Since you have an abdominal incision, if you need to cough you should hold a pillow to your abdomen to splint the incision, this will provide support" * "You should practice coughing and deep breathing at least every two hours while awake" * "Inhale through your mouth for deep breathing" * "Sitting upright during breathing exercises is best for lung expansion"

Answer 167

* "Since you have an abdominal incision, if you need to cough you should hold a pillow to your abdomen to splint the incision, this will provide support" * "You should practice coughing and deep breathing at least every two hours while awake" * "Sitting upright during breathing exercises is best for lung expansion"

Question 168

# Quiz Causes/Risk Factors Associated with Acid-Base Imbalances: Resp. Acid; Resp. Alk; Met. Acid; Met. Alk? * COPD * Hypoventilation * Obstructive sleep apnea * Any disease affecting lungs ability to remove CO2

Answer 168

**RESPIRATORY ACIDOSIS** * COPD * Hypoventilation * Obstructive sleep apnea * Any disease affecting lungs ability to remove CO2

Question 169

# Quiz Causes/Risk Factors Associated with Acid-Base Imbalances: Resp. Acid; Resp. Alk; Met. Acid; Met. Alk? * Anxiety * Panic * Fever * Ventilator settings - Hyperventilation

Answer 169

**RESPIRATORY ALKALOSIS** * Anxiety * Panic * Fever * Ventilator settings - Hyperventilation

Question 170

# Quiz Causes/Risk Factors Associated with Acid-Base Imbalances: Resp. Acid; Resp. Alk; Met. Acid; Met. Alk? * Diabetic ketoacidosis * Kidney disease/failure/injury * Severe diarrhea

Answer 170

**METABOLIC ACIDOSIS** * Diabetic ketoacidosis * Kidney disease/failure/injury * Severe diarrhea

Question 171

# Quiz Causes/Risk Factors Associated with Acid-Base Imbalances: Resp. Acid; Resp. Alk; Met. Acid; Met. Alk? * Nausea/Vomiting * Excessive antacid [TUMS] use * NG tube for decompression/suctioning

Answer 171

**METABOLIC ALKALOSIS** * Nausea/Vomiting * Excessive antacid [TUMS] use * NG tube for decompression/suctioning

Question 172

# Quiz Match electrolyte findings [hypo vs hyper] w/ manifestations: Sodium [Na]; Potassium [K]; Calcium [Ca]; Magnesium [Mg] * Confusion * Restlessness * Hypotension * Seizure

Answer 172

**HYPONATREMIA** * Confusion * Restlessness * Hypotension * Seizure

Question 173

# Quiz Match electrolyte findings [hypo vs hyper] w/ manifestations: Sodium [Na]; Potassium [K]; Calcium [Ca]; Magnesium [Mg] * Hypertension * Excessive thirst * Edema * Anxiety

Answer 173

**HYPERNATREMIA** * Hypertension * Excessive thirst * Edema * Anxiety

Question 174

# Quiz Match electrolyte findings [hypo vs hyper] w/ manifestations: Sodium [Na]; Potassium [K]; Calcium [Ca]; Magnesium [Mg] * ECG changes * Diarrhea * Abd. cramping * Maybe even paralysis in extremities [paresthesia]

Answer 174

**HYPERKALEMIA** * ECG changes * Diarrhea * Abd. cramping * Maybe even paralysis in extremities [paresthesia]

Question 175

# Quiz Match electrolyte findings [hypo vs hyper] w/ manifestations: Sodium [Na]; Potassium [K]; Calcium [Ca]; Magnesium [Mg] * Thready, weak, irregular pulse * Constipation * GI cramping * Weakness

Answer 175

**HYPOKALEMIA** * Thready, weak, irregular pulse * Constipation * GI cramping * Weakness

Question 176

# Quiz Match electrolyte findings [hypo vs hyper] w/ manifestations: Sodium [Na]; Potassium [K]; Calcium [Ca]; Magnesium [Mg] * Flank pain * Kidney stone * Bone pain * GI upset

Answer 176

**HYPERCALCEMIA** * Flank pain * Kidney stone * Bone pain * GI upset

Question 177

# Quiz Match electrolyte findings [hypo vs hyper] w/ manifestations: Sodium [Na]; Potassium [K]; Calcium [Ca]; Magnesium [Mg] * Muscle cramping / Tetany [spasms] * + Chvostek sign

Answer 177

**HYPOCALCEMIA** * Muscle cramping / Tetany [spasms] * + Chvostek sign

Question 178

# Quiz Match electrolyte findings [hypo vs hyper] w/ manifestations: Sodium [Na]; Potassium [K]; Calcium [Ca]; Magnesium [Mg] * Lethargy * Bradycardia * Hypotension * Decreased reflexes - DTR depressed

Answer 178

**HYPERMAGNESEMIA** * Lethargy * Bradycardia * Hypotension * Decreased reflexes - DTR depressed

Question 179

# Quiz Match electrolyte findings [hypo vs hyper] w/ manifestations: Sodium [Na]; Potassium [K]; Calcium [Ca]; Magnesium [Mg] * Tremors * Personality changes * Irritability * Hyperreflexia * Nystagmus

Answer 179

**HYPOMAGNESEMIA** * Tremors * Personality changes * Irritability * Hyperreflexia * Nystagmus

Question 180

# Quiz Dosage Calculation: Order: Acetaminophen 240 mg PO Available: Acetaminophen 160 mg/5 mL Question: How many mL will you administer?

Answer 180

7.5 mL

Question 181

# Quiz Med Math: Order: 1,000 mL of 0.9% NS to infuse over 8 hours Question: What is the IV flow rate in mL/hr?

Answer 181

125 mL/hr

Question 182

# Quiz Dosage Calculation: Order: Ceftriaxone 50 mg/kg IM once daily Patient weight: 22 kg Question: How many mg of Ceftriaxone will you administer?

Answer 182

1,100 mg

Question 183

# Quiz Dosage Calculation: Order: Heparin 7,500 units subcutaneously Available: Heparin 10,000 units/mL Question: How many mL will you administer?

Answer 183

0.75 mL

Question 184

# Quiz Med Math: A nurse is preparing to administer Cephalexin 200 mL IV to infuse over 6 hr. The nurse should set the IV pump to deliver how many mL/hr?

Answer 184

33 mL/hr

Question 185

# Quiz Med Math: A nurse is programming an IV pump to deliver 20 mg of a medication. The medication comes from the pharmacy as 20 mg in 100 mL D5W with instructions to infuse over 30 minutes. What rate will the nurse program the pump to deliver the medication in mL/hr?

Answer 185

200 mL

Question 186

# Quiz A nurse is working in the PACU and assessing clients who are freshly out of the OR. Which of the following patients would the nurse be most concerned with a potential hemorrhage? * Patient stating 8/10 pain at incision site * Patient BP 89/58, HR 114 * Patient sleepy, but spontaneously arousable * Patient BP 102/64, HR 99

Answer 186

Patient BP 89/58, HR 114

Question 187

# Quiz A nurse is visiting a client in the home setting after herniotomy 7 days ago. Which of the following findings should the nurse report off to the provider immediately? * Pt pain level 6/10 before pain Rx * Pt able to ambulate 60 ft unassisted * Pt using incentive spirometer q 4 hours * R calf edematous with reported tenderness

Answer 187

R calf edematous with reported tenderness

Question 188

# Quiz A nurse is working on a medical surgical unit and caring for a client with fluid volume excess related to CHF exacerbation. The patient is receiving diuretics and is slowly improving. Which of the following is the best indicator of fluid volume changes? * Vital signs * Patient weight * Urinary output * Edema

Answer 188

Patient weight

Question 189

# Quiz A nurse is caring for a patient with fluid volume excess. Which of the following should the nurse expect in the patient's plan of care? [Select all that apply] * Encourage PO fluids * Daily weights * IV fluid administration * Sodium restriction

Answer 189

**Daily weights** Sodium restriction

Question 190

# Quiz Which of the following are moderators of acid-base balance....regulate hydrogen ions? [Select all that apply] Respiratory system Buffer system Interstitial fluid compartments Renal system Cardiac output

Answer 190

Respiratory system Buffer system Renal system

Question 191

# Quiz A nurse is caring for a patient with an exacerbation of COPD. Respiratory therapy is bedside and has just placed a CPAP on the patient and drawn an ABG from L radial artery. The nurse notes dressing to L wrist saturated with blood 5 min after the ABG draw. What is the nurses priority action? * Call the provider * Administer Vitamin K * Reinforce the dressing * Apply firm manual pressure to the site

Answer 191

**Apply firm manual pressure to the site**

Question 192

# Quiz A nurse is caring for a patient with hyponatremia related to poor PO intake. Which of the following orders would the nurse question? 0.45% NS IV infusion at 63 mL/hr 2 mg Na+ tablet PO BID 3% NaCl IV infusion at 20 mL/hr Free salt protocol

Answer 192

0.45% NS IV infusion at 63 mL/hr

Question 193

# Quiz A nurse is preparing to administer 1 unit PRBCs for a client with a hemoglobin of 6.5. Which of the following actions should the charge nurse intervene? * The nurse has a nursing student sit with the client for the first 15 minutes of administration to observe for complications * The nurse has another RN to verify patient and blood products * The nurse stops the infusion when the patient notes flank pain and feeling flushed * The nurse obtains a set of VS prior to administration

Answer 193

**The nurse has a nursing student sit with the client for the first 15 minutes of administration to observe for complications**

Question 194

# Quiz A nurse is performing q1 hour IV site assessments while a patient is receiving a continuous 0.9% NS infusion at 125 mL/hr. The nurse notes redness in a linear pattern and patient reports burning at the insertion site. What is the nursing priority action? * Stop the infusion * Elevate the extremity * Remove the IV catheter * Prepare epinephrine to reverse s/s of allergy

Answer 194

**STOP the infusion**

Question 195

# Quiz Which of the following questions should the nurse include in a pain assessment? [Select all that apply] * "Is the pain constant or does it come and go?" * "Where is your pain located?" * "If you are in pain, why are you not crying?" * "What helps to alleviate the pain?" * "What does the pain feel like?" * "How severe is the pain? Can you rate it on a scale of 0-10? 0 is no pain and 10 is the worst pain of your life" * "What makes the pain worse?"

Answer 195

* "Is the pain constant or does it come and go?" * "Where is your pain located?" * "What helps to alleviate the pain?" * "What does the pain feel like?" * "How severe is the pain? Can you rate it on a scale of 0-10? 0 is no pain and 10 is the worst pain of your life" * "What makes the pain worse?"

Question 196

# Quiz A patient reports they are having pain in bilateral feet that feels like burning, and pins and needles, which makes it difficult to walk. Which of the following types of pain does the nurses suspect? * Acute pain * Electrical pain * Phantom pain * Neuropathic pain

Answer 196

**Neuropathic** pain

Question 197

# Quiz A nurse is discharging a patient home from the ambulatory surgical center after a right hip arthroscopy. The patient is being sent home with tylenol, ibuprofen, and oxycodone for pain management. Which of the following statements by the patient indicates a need for further teaching? * "If I take the oxycodone at 9am, I should be fine to drive to lunch in Rutland by 12" * "If I experience constipation, I will ensure to drink fluids and can take a stool softener and mild laxative" * "If I have excess oxycodone, I will contact my pharmacy about safe disposal instructions and locations" * "I will only take these medications as prescribed"

Answer 197

**"If I take the oxycodone at 9am, I should be fine to drive to lunch in Rutland by 12"**