Deck 56: Fluids and Electrolytes

Question 1

The nurse is teaching a client on the importance of monitoring intake and output at home. Which statement will the nurse include in the client teaching?

A)"Weigh at two different times during the day in order to see a change."
B)"If your weight goes up more than one pound in a day, contact your health care provider."
C)"If you notice sticky mucus membranes, contact your health care provider."
D)"Weigh with two different scales in order to compare results."

Answer 1

"If you notice sticky mucus membranes, contact your health care provider."

Question 2

The nurse is setting up an intravenous infusion for a client and the nurse has set the IV pump according to the health care provider's orders. How will the nurse best verify that the drops/minute rate is correct?

A)Verify the tubing size and adjust accordingly.
B)Verify the flow rate on the infusion pump.
C)Count the drops in the drip chamber for 6 seconds and multiply by 10.
D)Count the drops in the drip chamber for 15 seconds and multiply by 4.

Answer 2

Count the drops in the drip chamber for 15 seconds and multiply by 4.

Question 3

The nurse administers intravenous fluid therapy using a Dial-A-Flo device. What is a disadvantage of this device that the nurse recognizes?

A)It does not control the size of the drops delivered.
B)It does not allow for a fixed flow rate.
C)It does not allow a specified number of drops in the drip chamber.
D)It does not allow visual calculation of the flow rate.

Answer 3

It does not control the size of the drops delivered.

Question 4

The nurse cares for a client with an intravenous infusion of D5NS. Which complications will the nurse closely monitor the client for? Select all that apply.

A)Increased serum sodium
B)Decreased serum potassium
C)Fluid overload
D)Hypotension
E)Increased serum chloride

Question 5

The nurse removes a client's intravenous catheter and notes the tip of the catheter is broken. The nurse palpates the client's arm and feels the broken piece. Which action should the nurse take?

A)Apply ice to the insertion site.
B)Raise the client's arm above the heart.
C)Apply a pressure dressing on the insertion site.
D)Apply a tourniquet above the insertion site.

Question 6

The nurse needs to obtain blood samples from the client's central line for blood analysis. Place the steps of the procedure in correct order.

A)Withdraw 10 mL of blood and discard.
B)Flush with 5 mL normal saline.
C)Inject 5mL heparin.
D)Draw up the required blood and transfer to the appropriate containers.
E)Clean the infusion access port according to policy for 10 seconds.
F)Clean the infusion access port according to policy for 30 seconds

Question 7

The nurse prepares to change the client's central line dressing and replace the injection cap. Which position will the nurse place the client?

A)Supine
B)Upright
C)High-Fowler's
D)Side-lying

Question 8

The nurse is assisting the health care provider insert a central line for the client. During the procedure, the client reports sudden shortness of breath and the client's SpO₂ falls to 88% on room air. Which actions will the nurse take? Select all that apply.

A)Place the client in the left side-lying position.
B)Lower the client's head of the bed.
C)Raise the client's head of the bed.
D)Apply 100% oxygen via mask.
E)Prepare for intubation and mechanical ventilation.

Question 9

The nurse cares for a client who is sedated, intubated, mechanically ventilated, and has a central line. While repositioning the client, the central line is disrupted. Place the steps in correct order in response to the clinical scenario.

A)Place the client in supine position.
B)Clamp the affected lumen with a soft-tipped clamp.
C)Place a strip of tape over the catheter.
D)Notify the health care provider.

Question 10

A novice nurse performs care of a client's central line. Which action by the novice nurse requires intervention by the nurse preceptor?

A)Changing a clean gauze dressing that is 48 hours old.
B)Changing a clean transparent dressing that is 72 hours old.
C)Scrubbing the insertion site with antimicrobial solution for 30 seconds.
D)Placing an impregnated antimicrobial dressing on the insertion site.

Question 11

The nurse plans teaching for the client on methods of encouraging fluid intake. Which statements will the nurse include? Select all that apply.

A)"Consume 180 mL of water daily."
B)"Limit your alcohol intake."
C)"Avoid excess amounts of fluids high in salt."
D)"Moderate caffeine intake is acceptable."
E)"Consume 6-8 glasses of water daily."

Question 12

The nurse prepares to change the client's central line dressing. Place the steps of the procedure in correct order.

A)Remove the old dressing.
B)Remove and discard gloves; perform hand hygiene.
C)Don a mask and have the client don a mask.
D)Apply the new dressing.
E)Cleanse the site.

Question 13

The nurse is caring for a client who is receiving intravenous therapy with an infusion pump. An occlusion alarm sounds. Which things will the nurse check? Select all that apply.

A)IV site
B)Pinched tubing
C)Closed clamp
D)Client positioning
E)Bubbles in the tubing

Question 14

A nurse attempts to flush the lumen of a triple lumen central catheter and notes severe resistance to flushing. Which diagnostic procedure does the nurse anticipate when assessing the correct placement of the central line?

A)Chest CT
B)Fluoroscopy
C)Chest X-ray
D)Endoscopy

Question 15

The nurse prepares to insert an intravenous catheter in an older adult client. Which action should the nurse take?

A)Use a tourniquet prior to assessing the insertion site.
B)Keep a tourniquet applied until the infusion set is attached.
C)Insert the catheter in a distal vein.
D)Insert the catheter in a proximal vein.

Question 16

The nurse cares for a client with a central venous catheter. Which action by the nurse is incorrect when maintaining the client's central line?

A)Wiping the access port with an antimicrobial swab for 30 seconds.
B)Using a 5-mL syringe to flush the catheter.
C)Flushing the catheter before and after each dose of medication.
D)Using a push-pause-push motion to flush the catheter.

Question 17

Calculate the flow rate of the following intravenous therapy prescription: 3 liters 09.% normal saline over 24 hours.

A)125 mL/hr
B)100 mL/hr
C)250 mL/hr
D)90 mL/hr

Question 18

The nurse prepares to administer a medication through the client's central line. Per hospital policy, the nurse must use heparin to keep the line patent. Place the steps in the correct order for administering medication through the central line.

A)Administer the medication.
B)Flush the catheter with 5-mL saline.
C)Flush the catheter with heparin.
D)Flush the catheter with 10-mL saline.

Question 19

The nurse cares for a client with a triple lumen central line who develops a fever, which the nurse suspects is from the central line. Which nursing actions are appropriate? Select all that apply.

A)Replace the infusing TPN with normal saline.
B)Change the IV tubing.
C)Remove the IV using sterile technique.
D)Change the IV dressing.
E)Culture the insertion site using sterile technique.

Question 20

The nurse cares for a client with a PICC line that requires a dressing change. Place the procedure steps in the correct order the nurse will perform.

A)Remove old transparent dressing.
B)Discard old dressing and gloves.
C)Perform hand hygiene and don clean gloves.
D)Assess the exit site.
E)Perform hand hygiene and don sterile gloves.
F)Clean the exit site and catheter with antimicrobial swabs; allow to dry.
G) Place securement device and cover exit site with transparent dressing.

Question 21

The nurse cares for a client with traumatic injuries due to a motor vehicle accident. The nurse wants to increase the intravenous flow rate of intravenous fluids infusing. Which actions will the nurse take? Select all that apply.

A)Insert a large bore IV catheter.
B)Warm the IV fluid prior to infusing.
C)Cool the IV fluid prior to infusing.
D)Insert a long IV catheter.
E)Use a macrodrip IV tubing set.

Question 22

After removing a client's intravenous catheter from the upper extremity, the nurse notes the client has persistent bleeding despite applying firm pressure. Which action will the nurse take?

A)Hold the client's arm above the level of the heart.
B)Place the client's arm in the dependent position.
C)Lower the client's head of the bed.
D)Apply a tourniquet to the client's arm.

Question 23

The nurse attempts to secure and stabilize an IV catheter and dressing of an older adult client. Which nursing action is appropriate?

A)Use roll-type gauze to cover the IV site.
B)Apply skin protector solution prior to dressing the IV site.
C)Use extra tape to attach to the client's skin.
D)Apply lotion to the client's skin prior to dressing the IV site.