Question 1

A nurse is changing a peripheral venous access dressing for a client. Which of the following is a recommended step in this procedure?

Accepted Answer

A)   Observe clean technique to minimize the possibility of contamination.
B)   Cleanse site thoroughly with sterile saline, or according to facility policy.
C)   Apply chlorhexidine using a back and forth friction scrub for at least 30 seconds.
D)   Wipe or blot the site dry and allow to dry completely before covering.E) B) and C)
F) All of the above

Question 2

A nurse reads the laboratory report and notes that the client has hyponatremia. What physical assessment should be made?

Accepted Answer

A)   Observe skin color and texture.
B)   Auscultate bowel sounds.
C)   Percuss lung density.
D)   Monitor for GI symptoms.E) B) and C)
F) All of the above

Question 3

A specially trained nurse has inserted a PICC line. What would be done next?

Accepted Answer

A)   Start administration of prescribed fluids.
B)   Explain the procedure to the client and family.
C)   Place the client on restricted oral fluids.
D)   Send the client to the radiology department.E) B) and D)
F) None of the above

Question 4

Which client will have more adipose tissue and less fluid?

Accepted Answer

A)   A woman
B)   A man
C)   An infant
D)   A childE) B) and D)
F) B) and C)

Question 5

Based on knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. Why would the nurse do this?

Accepted Answer

A)   Infants have less total body fluid and ECF than adults.
B)   Infants have more total body fluid and ECF than adults.
C)   Infants drink less fluid than adults.
D)   Infants lose more fluids through output than adults.E) B) and D)
F) A) and C)

Question 6

A nurse inadvertently partially dislodges a PICC line when changing the dressing. What would be the appropriate intervention in this situation?

Accepted Answer

A)   Swab the line with sterile saline and gently reinsert the line.
B)   Sedate the client, remove the PICC line, and then notify the physician.
C)   Set up a sonogram for the client to determine the end point of the line.
D)   Reapply the dressing and notify the physician for further instructions.E) A) and D)
F) All of the above

Question 7

Which question about fluid balance would be appropriate when conducting a health history for a client?

Accepted Answer

A)   "Describe your usual urination habits."
B)   "Describe your problems with constipation."
C)   "How did you feel when your calcium was low?"
D)   "Do you eat fruits and vegetables each day?"E) C) and D)
F) None of the above A

Question 8

A client scheduled for surgery has arranged for an autologous transfusion. What type of blood transfusion is this?

Accepted Answer

A)   The client's family members have been donors.
B)   The client donates his or her own blood.
C)   The client's blood has been rendered sterile.
D)   The client will only need fluids, not blood.E) None of the above
F) C) and D)

Question 9

A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information?

Accepted Answer

A)   Compare the client's intake with the normal range of adult fluid intake.
B)   Report the exact milliliter of intake to the physician's office nurse.
C)   Compare the total intake and output of fluids for the 24 hours.
D)   Ensure that the information is included in the verbal end-of-shift report.E) C) and D)
F) B) and D)

Question 10

A nurse assessing the IV site of a client observes swelling and pallor around the site, and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What IV complication does this describe?

Accepted Answer

A)   Infiltration
B)   Sepsis
C)   Thrombus
D)   Speed shockE) A) and D)
F) A) and C) A

Question 11

A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which of the following actions should the nurse perform to avoid further complications and provide relief to the client?

Accepted Answer

A)   Administer oxygen.
B)   Call for help.
C)   Discontinue the IV promptly.
D)   Elevate the affected arm.E) A) and C)
F) A) and B)

Question 12

A client is having a blood transfusion, but the fluid is dripping very slowly. The blood has been infusing for more than four hours. What should the nurse do next?

Accepted Answer

A)   Continue with the transfusion and document the drip rate.
B)   Report to the next shift the amount of blood left to infuse.
C)   Take and record vital signs more often.
D)   Discontinue the blood transfusion.E) B) and D)
F) B) and C)

Question 13

A nurse flushing a capped, peripheral venous access device finds that the IV does not flush easily. What is the appropriate intervention in this situation?

Accepted Answer

A)   If infiltration or phlebitis is present, apply a sterile dressing to the site.
B)   Aspirate and attempt to flush the line again.
C)   If resistance remains after aspirating and flushing, forcefully flush the line.
D)   If catheter has pulled out a short distance, push back in and flush line again.E) None of the above
F) A) and C)

Question 14

The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is which of the following?

Accepted Answer

A)   Fluid volume deficit
B)   Myocardial Infarction
C)   Fluid volume excess
D)   AtelectasisE) A) and B)
F) All of the above

Question 15

A client with dehydration is being administered IV fluids. During her rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible?

Accepted Answer

A)   Phlebitis
B)   Thrombus formation
C)   Pulmonary embolus
D)   Air embolismE) A) and B)
F) None of the above

Question 16

A client has an order to restrict fluids. What is one comfort measure nurses can implement for this client to alleviate a common problem?

Accepted Answer

A)   Back rubs
B)   Chewing gum
C)   Hair care
D)   Oral hygieneE) C) and D)
F) A) and C)

Question 17

What is the average adult fluid intake and loss in each 24 hours?

Accepted Answer

A)   500 to 1,000 mL
B)   1,000 to 1,500 mL
C)   1,500 to 2,000 mL
D)   1,500 to 3500 mLE) All of the above
F) B) and D) D

Question 18

Which client would be the most likely candidate for the administration of total parenteral nutrition?

Accepted Answer

A)   A client with severe pancreatitis
B)   A client with a myocardial infarction
C)   A client with hepatitis B
D)   A client with mild malnutritionE) None of the above
F) C) and D)

Question 19

A nurse is initiating a peripheral venous access IV infusion ordered for a client presurgically. In what position would the nurse place the client to perform this skill?

Accepted Answer

A)   High-Fowler's
B)   Low-Fowler's
C)   Sims'
D)   Dorsal recumbentE) B) and D)
F) None of the above

Question 20

A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider?

Accepted Answer

A)   The nurse should use new tubing when attaching additional IV solutions.
B)   As one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 10 mL of fluid remains in the original container.
C)   It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order.
D)   Generally, the nurse should change the administration sets of simple IV solutions every 24 hours.E) All of the above
F) B) and D)

Exam 39: Fluid, Electrolyte, and Acid-Base Balance

A nurse is changing a peripheral venous access dressing for a client. Which of the following is a recommended step in this procedure?

Correct AnswerverifiedShow Answer

A nurse reads the laboratory report and notes that the client has hyponatremia. What physical assessment should be made?

Correct AnswerverifiedShow Answer

A specially trained nurse has inserted a PICC line. What would be done next?

Correct AnswerverifiedShow Answer

Which client will have more adipose tissue and less fluid?

Correct AnswerverifiedShow Answer

Based on knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. Why would the nurse do this?

Correct AnswerverifiedShow Answer

A nurse inadvertently partially dislodges a PICC line when changing the dressing. What would be the appropriate intervention in this situation?

Correct AnswerverifiedShow Answer

Which question about fluid balance would be appropriate when conducting a health history for a client?

Correct AnswerverifiedA

A client scheduled for surgery has arranged for an autologous transfusion. What type of blood transfusion is this?

Correct AnswerverifiedShow Answer

A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information?

Correct AnswerverifiedShow Answer

A nurse assessing the IV site of a client observes swelling and pallor around the site, and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What IV complication does this describe?

Correct AnswerverifiedA

A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which of the following actions should the nurse perform to avoid further complications and provide relief to the client?

Correct AnswerverifiedShow Answer

A client is having a blood transfusion, but the fluid is dripping very slowly. The blood has been infusing for more than four hours. What should the nurse do next?

Correct AnswerverifiedShow Answer

A nurse flushing a capped, peripheral venous access device finds that the IV does not flush easily. What is the appropriate intervention in this situation?

Correct AnswerverifiedShow Answer

The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is which of the following?

Correct AnswerverifiedShow Answer

A client with dehydration is being administered IV fluids. During her rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible?

Correct AnswerverifiedShow Answer

A client has an order to restrict fluids. What is one comfort measure nurses can implement for this client to alleviate a common problem?

Correct AnswerverifiedShow Answer

What is the average adult fluid intake and loss in each 24 hours?

Correct AnswerverifiedD

Which client would be the most likely candidate for the administration of total parenteral nutrition?

Correct AnswerverifiedShow Answer

A nurse is initiating a peripheral venous access IV infusion ordered for a client presurgically. In what position would the nurse place the client to perform this skill?

Correct AnswerverifiedShow Answer

A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider?

Correct AnswerverifiedShow Answer

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