Bmc Fluid, Electrolyte, & Acidbase

Front 1

An older adult client is receiving furosemide (Lasix) for treatment of peripheral edema. Which nursing assessment data identify that the client is at risk for falling?

A. Dry oral mucous membranes.
B. Orthostatic blood pressure changes.
C. Pulse rate of 72 beats per minute and bounding.
D. Serum potassium level of 4.0 mEq/L.

Back 1

B. Orthostatic blood pressure changes.

RATIONALE: Blood pressure decreases when changing positions. The client may not have sufficient blood flow to the brain, causing sensations of light-headedness and dizziness. This problem increases the risk of falling, especially in older adults.

Front 2

A client has a low serum potassium level and is ordered a dose of parenteral potassium chloride. How does a nurse safely administer potassium chloride to the client?

A. Administers 5 mEq, intramuscularly.
B. Dilutes 200 mEq in 1 liter of normal saline and infuses at 100 mL/hr.
C. Infuses 10 mEq over a 1-hour period.
D. Pushes 5 mEq through a central access line.

Back 2

C. Infuses 10 mEq over a 1-hour period.

RATIONALE: A dose of sodium chloride 10 mEq given over 1 hour is appropriate for this client.

Front 3

A client is being monitored for daily weights. The night nurse asks the nursing assistant for the morning weight, and the assistant replies, "She was sleeping so well, I didn't want to wake her to get her weight." How does the nurse respond?

A. "Fast thinking! She really needs to rest after the night she had."
B. "Get the information now, or I'll report you for not doing your job."
C. "Never mind. I will do it myself."
D. "Weigh her now. We need her weight daily, at the same time."

Back 3

D. "Weigh her now. We need her weight daily, at the same time."

RATIONALE: The nurse should educate the nursing assistant as to why obtaining the client's weight at the same time each day is important.

Front 4

Which situation can cause a client to experience "insensible water loss"? (Select all that apply.)

A. Diarrhea.
B. Dry, hot weather.
C. Fever.
D. Increased respiratory rate.
E. Nausea.
F. Mechanical ventilation.

Back 4

A. Diarrhea.
B. Dry, hot weather.
C. Fever.
D. Increased respiratory rate.
F. Mechanical ventilation.

RATIONALE: Nausea, with no accompanying vomiting, would not cause insensible water loss.

Front 5

Which client is at increased risk for fluid and electrolyte imbalance? (Select all that apply.)

A. 22-year-old pregnant woman in her third trimester.
B. 24-year-old male athlete.
C. 45-year-old man on diuretics.
D. 47-year-old man traveling to South America in the summer.
E. 76-year-old bedridden woman.

Back 5

C. 45-year-old man on diuretics.
D. 47-year-old man traveling to South America in the summer.
E. 76-year-old bedridden woman.

A pregnant client in the third trimester does have an increase in total body fluids, but this accumulation occurs gradually throughout the pregnancy.

Front 6

A nurse instructs an older adult client to increase intake of dietary potassium when the client is prescribed which classification of drugs?

A. Alpha antangonists.
B. Beta blockers.
C. Corticosteroids.
D. High-ceiling (loop) diuretics.

Back 6

D. High-ceiling (loop) diuretics.

RATIONALE: High-ceiling (loop) diuretics are potassium-depleting drugs. The client should increase intake of dietary potassium to compensate for this depletion.

Front 7

A nurse is instructing a client who is being discharged with a diagnosis of congestive heart failure. Which client statement indicates a correct understanding of CHF?

A. "I can gain 2 pounds of water a day without risk."
B. "I should call my provider if I gain more than 1 pound a week."
C. "Weighing myself daily can determine if my caloric intake is adequate and effective."
D. "Weighing myself daily can reveal increased fluid retention."

Back 7

D. "Weighing myself daily can reveal increased fluid retention."

RATIONALE: Fluid retention may not be visible. Rapid weight gain is the best indicator of fluid retention and overload. Each pound of weight gained (after the first half pound) equate to 500 mL of retained water. The client should be weighed at the same time every day (before breakfast) on the same scale.

Front 8

Which client is at greatest risk for hypernatremia?

A. 17-year-old with a serum blood glucose of 189 mg/dL.
B. 30-year-old on a low salt diet.
C. 42-year-old receiving hypotonic fluids.
D. 54-year-old who is sweating profusely.

Back 8

D. 54-year-old who is sweating profusely.

RATIONALE: Excessive sweating is a common cause of hyponatremia.
Hypotonic fluid administration is a common cause of hyponatremia, not hypernatremia.

Front 9

As adults age, which common physiologic change is likely to alter their hydration status?

A. Adrenal gland growth.
B. Decreased muscle mass.
C. Increased thirst mechanism.
D. Poor skin turgor.

Back 9

B. Decreased muscle mass.

RATIONALE: Decreased muscle masses causes decreased total body water, thus altering hydration status in the older adult.

Front 10

A nurse is reviewing serum electrolytes and blood chemistry for a newly admitted client. Which result causes the greatest concern?

A. Glucose: 97 mg/dL.
B. Magnesium: 2.1 mEq/L.
C. Potassium: 5.9 mEq/L.
D. Sodium: 143 mEq/L.

Back 10

C. Potassium: 5.9 mEq/L.

RATIONALE: A potassium value of 5.9 mEq/L is high (normal lab values are 3.5 to 5.0 mEq/L), and the client should be assessed further.

Front 11

A client with hyperkalemia is being treated with drugs to improve the condition. Which potassium level indicates that therapy is effective?

A. 7.6 mEq/L.
B. 5.6 mEq/L.
C. 4.6 mEq/L.
D. 2.6 mEq/L.

Back 11

C. 4.6 mEq/L.

RATIONALE: A potassium level of 4.6 mEq/L is a normal level indicating that therapy was effective. Normal levels are 3.5 to 5.0 mEq/L.

Front 12

A client is admitted with hypokalemia and muscle weakness. Which assessment does the nurse perform first.\?

A. Blood pressure.
B. Pulse.
C. Respirations.
D. Temperature.

Back 12

C. Respirations.

RATIONALE: Respiratory changes are likely because of weakness of the muscles needed for breathing. Skeletal muscle weakness results in shallow respirations. Thus, respiratory status should be assessed first in any client who might have hypokalemia.

Front 13

A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first?

A. Draws blood for laboratory tests.
B. Elevates the head of the bed.
C. Places the extremities in a dependent position.
D. Puts the client in a side-lying position.

Back 13

B. Elevates the head of the bed.

RATIONALE: Elevating the heaf of the bed will ease breathing for the client.

Front 14

A nurse is assessing a client with hyponatremia. Which finding requires immediate action?

A. Diminished bowel sounds.
B. Heightened acuity.
C. Muscle weakness.
D. Urine output of 35 mL/hr.

Back 14

C. Muscle weakness.

RATIONALE: Muscle weakness in clients with hyponatremia requires immediate action.

If muscle weakness is present, immediately check respiratory effectiveness because ventilation is dependent on adequate strength of the respiratory muscles.

Front 15

A nurse is teaching a group of unlicensed personnel about fluid intake principles for older adults. What does the nurse tell them?

A. "Be careful not to overload them with too many oral fluids."
B. "Offer fluids that they prefer frequently and on a regular schedule."
C. "Restrict their fluids in the evening hours if they are incontinent."
D. "Wake them every 2 hours during the night with a drink."

Back 15

B. "Offer fluids that they prefer frequently and on a regular schedule."

RATIONALE: Because of the decreased thirst mechanism, older adults should be offered oral fluids every 2 hours. The likelihood of their accepting the fluid increases if the fluid is one they prefer.

Front 16

A nurse is caring for a client who is receiving intravenous magnesium sulfate. Which assessment parameter is critical?

A. 24-hour urine output.
B. Asking the client about feeling depressed.
C. Hourly deep tendon reflexes.
D. Monitoring of serum calcium levels.

Back 16

C. Hourly deep tendon reflexes.

RATIONALE: The client who is receiving intravenous magnesium sulfate should be assessed for signs of toxicity every hour by assessment of deep tendon reflexes.

Although administration of Magnesium Sulfate can cause a drop in calcium levels, this occurs over a period of time and would not be the bet way to assess magnesium toxicity.

Front 17

The charge nurse on a med-surg unit is completing assignments for the day shift. Which client is assigned to the LPN?

A. 44-year-old with congestive heart failure who has gained 3 pounds since the preveious day.
B. 58-year-old with chronic renal failure who has a serum potassium level of 6 mEq/L.
C. 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/L.
D. 80-year-old with 3+ peripheral edema who has crackles throughout the posterior chest.

Back 17

C. 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/L.

RATIONALE: Although the client has poor skin turgor, the serum osmolarity indicates that fluid balance is normal. This client is the most stable of the four clients described. (Normal lab values for serum osmolality are 275 to 295 mOsmol/dg.)

Front 18

The client is a 69-year-old woman with uncontrolled diabetes, polyuria, and a blood pressure of 86/46. Which staff member is assigned to care for her?

A. LPN who has floated from the hospital's long-term care unit.
B. LPN who frequently administers medications to multiple clients.
C. RN who has floated from the intensive care unit.
D. RN who usually works as a diabetic educator.

Back 18

C. RN who has floated from the intensive care unit.

RATIONALE: The clinical manifestations suggest that the client is experiencing hypovolemia and possible hypovolemic shock. The RN who floated from the intensive care unit will have extensive experience caring for clients with hypovolemia.

Front 19

A nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed assistive personnel (UAP)?

A. Assessing oral mucosa for dryness
B. Choosing appropriate oral fluids
C. Monitoring skin turgor for tenting
D. Offering fluids to drink every hour

Back 19

D. Offering fluids to drink every hour

RATIONALE: Encouraging a client to take oral fluids is within the scope of practice for UAP.

Front 20

An RN is caring for a client with end-stage liver disease that has resulted in ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)?

A. Assessing skin integrity and abdominal distention
B. Drawing blood from a central venous line for electrolyte studies
C. Evaluating laboratory study results for the presence of hypokalemia
D. Placing the client in a semi-Fowler's position

Back 20

D. Placing the client in a semi-Fowler's position

RATIONALE: Positioning the client in a semi-Fowler's position is included within UAP education and scope of practice, although the RN will need to supervise the UAP in providing care and will evaluate the effect of the semi-Fowler's position on client comfort and breathing.

Front 21

Which newly written physician prescription does the nurse administer first?

A. Intravenous (IV) normal saline to a client with a serum sodium of 132 mEq/L
B. Oral calcium supplements to a client with severe osteoporosis
C. Oral phosphorus supplements to a client with acute hypophosphatemia
D. Oral potassium chloride (KCl) to a client whose serum potassium is 3 mEq/L

Back 21

D. Oral potassium chloride (KCl) to a client whose serum potassium is 3 mEq/L

RATIONALE: Because minor changes in serum potassium level can cause life-threatening dysrhythmias, the first priority should be to administer potassium supplements to the client with hypokalemia.

Front 22

A physician writes orders for a client who is admitted with a serum potassium (K) level of 6.9 mEq/L. What does the nurse implement first?

A. Administering sodium polystyrene sulfonate (Kayexalate) orally.
B. Ensuring that a potassium-restricted diet is ordered.
C. Placing the client on a cardiac monitor.
D. Teaching the client about foods that are high in potassium.

Back 22

C. Placing the client on a cardiac monitor.

RATIONALE: Because hyperkalemia can lead to life-threatening bradycardia, the initial action should be to place the client on a cardiac monitor.

Front 23

The nurse manager of the medical-surgical unit assigns which client to the LPN/LVN?

A. 44-year-old admitted with dehydration who has a heart rate of 126
B. 54-year-old just admitted with hyperkalemia who takes a potassium-sparing diuretic at home
C. 64-year-old admitted yesterday with heart failure who still has dependent pedal edema
D. 74-year-old who has just been admitted with severe nausea, vomiting, and diarrhea

Back 23

C. 64-year-old admitted yesterday with heart failure who still has dependent pedal edema

RATIONALE: Because the client with heart failure is the most stable of the four clients, this client is most appropriate to assign to the LPN/LVN.

Front 24

An RN is caring for a client admitted with dehydration who requires a blood transfusion. Which nursing action does the RN delegate to unlicensed assistive personnel (UAP)?

A. Inserting a small-gauge needle for intravenous (IV) access
B. Evaluating a headache that develops during the transfusion
C. Explaining to the client the purpose of the blood transfusion
D. Obtaining baseline vital signs before blood administration

Back 24

D. Obtaining baseline vital signs before blood administration


RATIONALE: UAP education includes assessment of vital signs.

Front 25

n RN is caring for a client who is severely dehydrated. Which nursing action can be delegated to unlicensed assistive personnel (UAP)?

A. Consulting with a health care provider about a client's lab results
B. Infusing 500 mL of normal saline over 60 minutes
C. Monitoring IV fluid to maintain the drip rate at 75 mL/hr
D. Providing oral care every 1 to 2 hours

Back 25

D. Providing oral care every 1 to 2 hours

RATIONALE: Frequent oral care is an important intervention for a client with fluid volume deficit and is appropriate to delegate to UAP.

Front 26

After receiving change-of-shift report, which client does the RN assess first?

A. 26-year-old with nausea and vomiting who complains of dizziness when standing
B. 36-year-old with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst
C. 46-year-old receiving IV diuretics whose blood pressure is 95/52 mm Hg
D. 56-year-old with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL

Back 26

C. 46-year-old receiving IV diuretics whose blood pressure is 95/52 mm Hg

RATIONALE:

Front 27

An RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse?

A. Client behavior that changes from anxious and restless to lethargic and confused
B. Deep furrows on the surface of the tongue
C. Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched
D. Urine output of 950 mL for the past 24 hours

Back 27

A. Client behavior that changes from anxious and restless to lethargic and confused

RATIONALE: The client's change in level of consciousness suggests poor cerebral blood flow or shrinkage or swelling of brain cells caused by fluid shifts within the brain cells.

These changes indicate a need for immediate intervention to prevent further damage to cerebral function.

Front 28

The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the LPN/LVN?

A. Calcium level of 9.5 mg/dL
B. Magnesium level of 4.1 mEq/L
C. Potassium level of 6.0 mEq/L
D. Sodium level of 120 mEq/L

Back 28

A. Calcium level of 9.5 mg/dL

RATIONALE: Because this client's calcium level is within normal limits, it is appropriate to assign the client to an LPN/LVN.

Front 29

A 90-year-old client with hypermagnesemia is seen in the emergency department (ED). The ED nurse prepares the client for admission to which inpatient unit?

A. Dialysis/Home Care
B. Geriatric/Rehabilitation
C. Medical-Surgical
D. Telemetry/Cardiac Step-Down

Back 29

D. Telemetry/Cardiac Step-Down

RATIONALE: Because hypermagnesemia causes changes in the electrocardiogram that may result in cardiac arrest, the client should be admitted to the Telemetry/Cardiac Step-Down unit.

Front 30

A client with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide?

A. Assessment of muscle tone and strength
B. Education about potassium-rich foods
C. Instruction on the proper use of drugs
D. Measurement of the client's urine output

Back 30

D. Measurement of the client's urine output

RATIONALE:
D. A home health aide may measure the client's intake and output, which then would be reported to the RN.

Front 31

A nurse is planning care for a client with hypocalcemia. Which nursing action is appropriate to delegate to unlicensed assistive personnel (UAP)?

A. Collaborating with the dietitian to provide calcium-rich foods for the client
B. Evaluating the client's laboratory results
C. Implementing Seizure Precautions for the client
D. Transferring the client from the bed to a stretcher using a lift sheet

Back 31

D. Transferring the client from the bed to a stretcher using a lift sheet

RATIONALE: Transferring clients is a nursing skill that is included in UAP education and scope of practice.

Front 32

A client is admitted to the nursing unit with a diagnosis of hypokalemia. Which assessment does the nurse complete first?

A. Auscultating bowel sounds
B. Checking deep tendon reflexes (DTRs)
C. Determining the level of consciousness (LOC)
D. Obtaining a pulse oximetry reading

Back 32

D. Obtaining a pulse oximetry reading

RATIONALE: LOC may change in a client with hypokalemia, but this change is not immediately life threatening.

Front 33

Situation: A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Laboratory results include a potassium level of 7.0 mEq/L. Which medication(s) does the nurse anticipate administering?

A. Insulin (regular insulin) and dextrose (D20W)
B. Loperamide (Imodium)
C. Sodium polystyrene sulfonate (Kayexalate)
D. Supplemental potassium

Back 33

A. Insulin (regular insulin) and dextrose (D20W)

RATIONALE: If potassium levels are high, a combination of 20 units of regular insulin in 100 mL of 20% dextrose may be prescribed to promote movement of potassium from the blood into the intracellular fluid (ICF).

Front 34

Situation: A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Her laboratory results include a potassium level of 7.0 mEq/L. What is the primary goal of drug therapy for this client?

A. Decreasing cardiac contractility and slowing the heart rate
B. Elevating serum potassium levels to a safe range
C. Maintaining proper diuresis and urine output
D. Restoring fluid balance by controlling the causes of dehydration

Back 34

D. Restoring fluid balance by controlling the causes of dehydration

RATIONALE: Hyperkalemia (serum K level of 7.0) will slow the cardiac rate and cause decreased contractility of the heart.

Front 35

Situation: A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His current medications are digoxin (Lanoxin), chlorothiazide (Diuril), and oral potassium supplements. He tells the nurse that he has had flu-like symptoms for the past week and has been unable to drink for the past 48 hours. The physician requests laboratory specimens to be drawn and an isotonic IV to be started. Which IV fluid does the nurse administer?

A. 0.45% saline
B. 5% dextrose in 0.45% saline
C. 5% dextrose in Ringer's lactate
D. 5% dextrose in water (D5W)

Back 35

D. 5% dextrose in water (D5W)

RATIONALE: 0.45% saline is a hypotonic solution.

Front 36

Situation: A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His current medications are digoxin (Lanoxin), chlorothiazide (Diuril), and potassium supplements. He tells a nurse that he has had flu-like symptoms for the past week and has been unable to drink for the past 48 hours. The nurse starts the client's IV and receives laboratory results, which include a potassium level of 2.7 mEq/L. The physician orders an IV potassium supplement. How does the nurse administer this medication?

A. Added to an IV, not to exceed 20 mEq/hr
B. Added to an IV, not to exceed 30 mEq/hr
C. Rapid IV push, a 25-mEq dose
D. Slow IV push, a 30-mEq dose

Back 36

A. Added to an IV, not to exceed 20 mEq/hr

RATIONALE: The maximum recommended infusion rate of potassium is 5 to 10 mEq/hr. This rate is never to exceed 20 mEq/hr under any circumstances

Front 37

Situation: A 70-year-old female is admitted to the hospital with heart failure, shortness-of-breath (SOB), and 3+ pitting edema in her lower extremities. Her current medications are furosemide (Lasix), digoxin (Lanoxin), and an angiotensin-converting enzyme (ACE) inhibitor (Lotensin). She states that she stopped taking her Lasix because she did not think that it was helping her heart failure. Her physician orders furosemide (Lasix) 5 mg IV push. Which client assessment determines that the medication is working?

A. Decreased blood pressure (BP)
B. Increased heart rate
C. Increased urine output
D. Weight gain

Back 37

C. Increased urine output

RATIONALE: When giving Lasix, the nurse monitors the client for response to drug therapy, especially weight loss and increased urine output.

Front 38

Situation: A 70-year-old female is admitted to the hospital with heart failure, shortness-of-breath (SOB), and 3+ pitting edema in her lower extremities. Her medications are furosemide (Lasix), digoxin (Lanoxin), and an angiotensin-converting enzyme (ACE) inhibitor (Lotensin). She states that she stopped taking her Lasix because she did not think that it was helping her heart failure. Her physician orders furosemide (Lasix) 5 mg IV push. Ten (10) hours after receiving the Lasix, the client's potassium (K+) level is 2.5 mEq/L. Knowing all of the client's medications, what problem(s) does the nurse anticipate in this client?

A. Clinical manifestations of digoxin toxicity
B. Increased heart rate and blood pressure (BP)
C. Increased signs of congestive heart failure (CHF)
D. Signs and symptoms of hypernatremia

Back 38

A. Clinical manifestations of digoxin toxicity

RATIONALE: Hypokalemia increases the sensitivity of cardiac muscle to Lanoxin and may result in digoxin toxicity, even when the digoxin level is within the therapeutic range.

Front 39

Situation: A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells a nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). She is receiving lactated Ringer's solution IV for rehydration. What clinical manifestations does the nurse monitor during rehydration of the client? Select all that apply.

A. Blood serum glucose
B. Pulse rate and quality
C. Urinary output
D. Urine specific gravity levels

Back 39

B. Pulse rate and quality
C. Urinary output
D. Urine specific gravity levels

RATIONALE: Blood glucose changes do not have a direct relation to a client's rehydration status.

Front 40

Situation: A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells a nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Her laboratory results include a potassium level of 7.0 mEq/L. What does the nurse include in the client's medication teaching? Select all that apply.

A. Daily weights are a poor indicator of fluid loss or gain.
B. Diuretics can lead to fluid and electrolyte imbalances.
C. Diuretics increase fluid retention.
D. Laxatives can lead to fluid imbalance.

Back 40

B. Diuretics can lead to fluid and electrolyte imbalances.
D. Laxatives can lead to fluid imbalance.


RATIONALE: Daily weight recording is a good indicator of fluid retention.

Clients should be taught to weigh themselves at the same time, in the same clothing, and on the same scale.

Front 41

Situation: A 68-year-old man is admitted to the hospital with dehydration. Initial laboratory results include a potassium level of 2.7 mEq/L. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His medications are digoxin (Lanoxin), chlorothiazide (Diuril), and potassium supplements. In time, he recovers from his dehydration and low potassium levels. He says to the nurse, "I would like to take fewer medications and eat foods that contain high amounts of potassium." What foods does the nurse recommend? Select all that apply.

A. Apples
B. Bananas
C. Broccoli
D. Oranges
E. Spinach

Back 41

B. Bananas
C. Broccoli
D. Oranges
E. Spinach

RATIONALE: oods high in potassium include bananas, cantaloupe, kiwi, oranges, avocados, broccoli, dried beans, lima beans, mushrooms, potatoes, seaweed, soybeans, and spinach.

Front 42

The nurse at a family picnic on a hot day in July is aware that which person is at greatest risk for dehydration while playing softball?

A. 32-year-old male cousin who is a professional hockey player
B. 28-year-old female cousin who has type 1 diabetes mellitus
C. 72-year-old grandmother who is 15 pounds overweight
D. 72-year-old grandfather who takes 81 mg of aspirin daily

Back 42

C. 72-year-old grandmother who is 15 pounds overweight

RATIONALE: The thirst mechanism is less sensitive in older adults, making them more at risk for dehydration.

Women of any age have less total body water than men of similar sizes and ages, because men have more muscle mass than women and women have more body fat. (Muscle cells contain mostly water and fat cells have little water.)

In addition, the grandmother is overweight, with an increased percentage of body fat compared with lean body mass, especially skeletal muscle.

An obese person has less total water than a lean person of the same weight because fat cells contain almost no water.

Front 43

The client who has fluid overload has been taking a diuretic for the past 2 days and now experiences these changes. Which change indicates to the nurse that the diuretic is effective?

A. Weight loss of 7 pounds
B. Heart rate increased from 72 to 80
C. Respiratory rate decreased from 20 to 16
D. Morning blood glucose decreased from 142 mg/dL to 110 mg/dL

Back 43

A. Weight loss of 7 pounds

RATIONALE: Diuretic drugs cause water loss and are often prescribed for edema. One liter of water weighs 2.2 pounds. Weight loss is expected when the client gets rid of the body of excess water.

Front 44

The family of a client with chronic hyponatremia asks if the water restriction is a punishment for his uncooperative behavior. What is the nurse's best response?

A. "No, limiting fluid intake decreases the risk for kidney failure."
B. "No, limiting water intake prevents him from losing too much fluid by vomiting."
C. "No, limiting fluid intake keeps his blood from becoming more dilute and causing other complications."
D. "No, limiting fluid decreases his sense of thirst and prevents him from drinking liquids that contain an excess of sodium."

Back 44

C. "No, limiting fluid intake keeps his blood from becoming more dilute and causing other complications."

RATIONALE: When hyponatremia is caused by fluid overload, as well as possible sodium loss, the extra fluid can dilute serum electrolyte concentrations, especially sodium, to dangerously low levels.

Appropriate therapy aims to reduce the fluid overload by limiting fluids, increasing urine output, and increasing sodium intake.

Front 45

The client receiving insulin and glucose infusion therapy for hyperkalemia now has a serum potassium level of 4.7 mEq/L. What is the nurse's best first action?

A. Assess the client's respiratory status and then notify the Rapid Response Team.
B. Stop the infusion and discontinue the IV access.
C. Continue the infusion at the prescribed rate.
D. Slow the infusion and notify the health care provider.

Back 45

D. Slow the infusion and notify the health care provider.

RATIONALE: The serum potassium is now in the normal range (3.5 to 5.0 mEq/L), but it is at the higher end of normal. The infusion must be slowed to prevent hypokalemia, and the health care provider is notified to determine the target range for this client's serum potassium level.

Front 46

The nurse takes the blood pressure of a client who is being treated for hypocalcemia. When the cuff is tightest, the client's hand develops palmar flexion. After the cuff is deflated, the hand remains in palmar flexion. What is the nurse's best first action?

A. Apply oxygen.
B. Alert the Rapid Response Team.
C. Slow the calcium-containing IV solution.
D. Turn the client onto the side opposite the hand with the flexion.

Back 46

A. Apply oxygen.

RATIONALE: The palmar flexion response (Trousseau's sign) indicates a worsening of the hypocalcemia, and the client is becoming hyperreflexive. This condition is approaching the danger of tetany.

Although the Rapid Response Team should be called, the best first action is to apply oxygen because the skeletal muscle response to hypocalcemia is more severe under hypoxic conditions. Slowing the calcium-containing IV solution would be the worst intervention.

Front 47

Which of these clients would be appropriate to assign to the new nurse working on the unit?

A. A client with diabetic ketoacidosis and change in mental status who has a pH of 7.18
B. A client with emphysema and cellulitis with a PaCO2 level of 58 mm Hg
C. A client with reactive airway disease, wheezing, and a PaO2 level of 62 mm Hg
D. A client with a small bowel obstruction and vomiting with a bicarbonate level of 40 mEq/L

Back 47

B. A client with emphysema and cellulitis with a PaCO2 level of 58 mm Hg

RATIONALE: This finding, although abnormal, is anticipated for a client with chronic obstructive pulmonary disease (COPD) and is stable for a new graduate.

Front 48

A new nurse graduate is caring for a postoperative client with the following arterial blood gases (ABGs): pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation, 96%. Which of these actions by the new graduate is indicated?

A. Encourage the client to use the incentive spirometer and to cough.
B. Administer oxygen by nasal cannula.
C. Request a prescription for sodium bicarbonate from the health care provider.
D. Inform the charge nurse that no changes in therapy are needed.

Back 48

A. Encourage the client to use the incentive spirometer and to cough.

RATIONALE: Respiratory acidosis is caused by CO2 retention and impaired chest expansion secondary to anesthesia. The nurse takes steps to promote CO2 elimination, including maintaining a patent airway and expanding the lungs through breathing techniques.

Front 49

The nurse is caring for a client with hypoxemia and metabolic acidosis. Which of these tasks can be delegated to the nursing assistant who is helping with the client's care?

A. Assess the client's respiratory pattern.
B. Increase the IV normal saline to 120 mL/hr.
C. Titrate O2 to maintain an O2 saturation of 95% to 100%.
D. Apply the pulse oximeter for continuous readings.

Back 49

D. Apply the pulse oximeter for continuous readings.

RATIONALE: Placing a peripheral pulse oximeter is a standardized nursing skill that is within the scope of practice for unlicensed personnel.

Front 50

Which nursing intervention takes priority for a client admitted with severe metabolic acidosis?

A. Perform medication reconciliation.
B. Assess the client's strength in the extremities.
C. Obtain a diet history for the past 3 days.
D. Initiate cardiac monitoring.

Back 50

D. Initiate cardiac monitoring.

RATIONALE: The nurse follows the ABCs and initiates cardiac monitoring to observe for signs of hyperkalemia or cardiac arrest.

Front 51

The nurse is caring for a critically ill client with septic shock. The serum lactate level is 6.2. For which of the following acid-base disturbances should the nurse assess?

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

Back 51

A. Metabolic acidosis

RATIONALE: Increased lactate levels are associated with hypoxia and metabolic acidosis secondary to anaerobic metabolism.

Front 52

The nurse is caring for a client who has taken a large quantity of furosemide (Lasix) to promote weight loss. The nurse anticipates the finding of which acid-base imbalance?

A. PO2 of 78 mm Hg
B. HCO3− of 34 mEq/L
C. PCO2 of 56 mm Hg
D. pH of 7.31

Back 52

B. HCO3− of 34 mEq/L

RATIONALE: Diuretics promote metabolic alkalosis. Normal HCO3 levels are 19 to 25.

Front 53

The nurse is caring for a client with an oxygen saturation of 88% and accessory muscle use. The nurse provides oxygen and anticipates which of these physician orders?

A. Administration of IV sodium bicarbonate
B. Computed tomography (CT) of the chest, stat
C. Intubation and mechanical ventilation
D. Administration of concentrated potassium chloride solution

Back 53

C. Intubation and mechanical ventilation

RATIONALE: Support with mechanical ventilation may be needed for clients who cannot keep their oxygen saturation at 90% or who have respiratory muscle fatigue.

Front 54

The nurse is caring for a group of clients with acidosis. The nurse recognizes that Kussmaul respirations are consistent with which situation?

A. Client receiving mechanical ventilation
B. Use of hydrochlorothiazide
C. Aspirin overdose
D. Administration of sodium bicarbonate

Back 54

C. Aspirin overdose

RATIONALE: When patients go into metabolic acidosis, their blood becomes very acidic. The body uses a number of measures to compensate, including respiratory compensation.

Patients in the early stages may breathe quickly and shallowly. As the acidosis progresses, Kussmaul breathing can develop.

In Kussmaul breathing, patients breathe at a normal or slightly slower rate, but their breaths are much deeper than usual.

This is a form of hyperventilation, causing carbon dioxide levels in the blood to drop while oxygen rises.

Front 55

Which action should the nurse take first for the client who is admitted to the emergency department (ED) with a panic attack and whose blood gases indicate respiratory alkalosis?

A. Encourage the client to take slow breaths.
B. Obtain a prescription for a fluid and electrolyte infusion.
C. Administer oxygen using ED standard orders.
D. Place an emergency cart close to the client's room.

Back 55

A. Encourage the client to take slow breaths.

RATIONALE:

Front 56

To decrease the risk of acid-base imbalance, what goal must the client with diabetes mellitus strive for?

A. Checking blood glucose levels once daily
B. Drinking 3 L of fluid per day
C. Eating regularly, every 4 to 8 hours
D. Maintaining blood glucose level within normal limits

Back 56

D. Maintaining blood glucose level within normal limits

Rationale: Maintaining blood glucose levels within normal limits is the best way to decrease the risk of acid-base imbalance.

Front 57

The nurse reviews the arterial blood gas for the client below. The nurse is most concerned with which value?

CHART EXHIBIT
Laboratory Diagnostic Studies ECG Physical Assessment
ABG: pH, 7.36;
PaCO2, 35; HCO3−, 26;
PaO2, 62 CT of chest: Large
pulmonary embolism Sinus tachycardia Client SOB
Pale, circumoral cyanosis

A. pH
B. PaCO2
C. HCO3−
D. PaO2

Back 57

D. PaO2

RATIONALE:

Front 58

Which client is most likely to exhibit the following ABG results: pH, 7.30; PaCO2, 49; HCO3−, 26; PO2, 76?



A. Client with kidney failure

B. Client taking hydromorphone (Dilaudid)

C. Client with anxiety disorder

D. Client with hyperkalemia

Back 58

B. Client taking hydromorphone (Dilaudid)

Kidney failure causes metabolic acidosis; this ABG reading reflects respiratory acidosis.

Front 59

When caring for a group of clients at risk for respiratory acidosis, the nurse identifies which person as at highest risk?

A. An athlete in training
B. Pregnant woman with hyperemesis gravidarum
C. Person with uncontrolled diabetes
D. Client who smokes cigarettes

Back 59

D. Client who smokes cigarettes

Rationale: Cigarette smoking worsens gas exchange, leading to disorders that contribute to hypoventilation and respiratory acidosis.

Front 60

The nurse teaches a morbidly obese client who has chosen gastric bypass surgery to promote weight loss that he will need to perform monitoring to detect what disturbance consistent with rapid weight loss associated with this procedure?

A. Ketosis
B. Hypoxemia
C. Urinary retention
D. Insufficient ventilation

Back 60

A. Ketosis

Rationale: Starvation, fasting, or following a strict calorie-reduced diet with rapid weight loss contributes to ketone formation and metabolic acidosis.

Front 61

Which acid-base disturbance does the nurse anticipate the client with morbid obesity may develop?

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

Back 61

C. Respiratory acidosis

RATIONALE:

Front 62

When caring for a client with a pulse oximetry level of 89%, which action should the nurse take first?

A. Get the client out of bed.
B. Apply oxygen as prescribed.
C. Notify the client's physician.
D. Auscultate breath sounds.

Back 62

B. Apply oxygen as prescribed.

RATIONALE:

Front 63

The nurse caring for a client who has been NPO for 5 days and receiving only dextrose 5% in lactated Ringer's solution (4 liters daily) reviews the client's most recent arterial blood gas results and observes that the pH is now 7.28. What is the most likely explanation for this finding?



A. Acidosis in response to the presence of excessive ketoacids

B. Acidosis in response to the presence of excessive lactic acid

C. Alkalosis in response to the excessive loss of carbonic acid

D. Alkalosis in response to the excessive loss of sulfuric acid

Back 63

A. Acidosis in response to the presence of excessive ketoacids

Clients who are NPO and receiving only crystalloid solutions (including glucose) are in a condition of starvation. Each liter of 5% dextrose contains only a little over 170 calories. Four liters daily provides approximately 700 calories, not nearly enough to support adult metabolic needs. These clients are breaking down body fat for fuel, which increases the production of ketoacids.

Front 64

A nurse checking an IV fluid order questions its accuracy. What does the nurse do first?

A. Asks the charge nurse about the order
B. Contacts the health care provider who ordered it
C. Contacts the pharmacy for clarification
D. Starts the fluid as ordered, with plans to check it later

Back 64

B. Contacts the health care provider who ordered it

RATIONALE:

Front 65

A client is to receive an IV solution of 5% dextrose and half-normal saline at 125 mL/hr. Which system provides the safest method for the nurse to accurately administer this solution?

A. Controller
B. Glass container
C. Infusion pump
D. Syringe pump

Back 65

C. Infusion pump

RATIONALE:

Front 66

A client who used to work as a nurse asks, "Why is the hospital using a 'fancy new IV' without a needle? That seems expensive." How does the nurse respond?

A. "OSHA, the government, requires us to use this new type of IV."
B. "These systems are designed to save time, not money."
C. "They minimize health care workers' exposures to contaminated needles."
D. "They minimize your exposure to contaminated needles."

Back 66

C. "They minimize health care workers' exposures to contaminated needles."

RATIONALE:

Front 67

A nurse is documenting peripheral venous catheter insertion for a client. What does the nurse include in the note? Select all that apply.

A. Client's name and hospital number
B. Client's response to the insertion
C. Date and time inserted
D. Type and size of device
E. Type of dressing applied
F. Vein that was used for insertion

Back 67

B. Client's response to the insertion
C. Date and time inserted
D. Type and size of device
E. Type of dressing applied
F. Vein that was used for insertion

RATIONALE: The client's ability to adapt to interventions, such as IV insertion, should be noted when the intervention is performed.

Front 68

A nurse is teaching a hospitalized client who is being discharged about how to care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education?

A. "I can continue my 20-mile running schedule as I have for the past 10 years."
B. "I can still go about my normal activities of daily living."
C. "I have less chance of getting an infection because the line is not in my hand."
D. "The PICC line can stay in for months."

Back 68

A. "I can continue my 20-mile running schedule as I have for the past 10 years."

RATIONALE: PICCs have low complication rates because the insertion site is in the upper extremity.

The dry skin of the arm has fewer types and numbers of microorganisms, leading to lower rates of infection.

Front 69

A nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters does the nurse choose most often?

A. Back of the hand for an older adult
B. Cephalic vein of the forearm
C. Lower arm on the side of a radical mastectomy
D. Subclavian vein

Back 69

B. Cephalic vein of the forearm

RATIONALE: For same-day surgery, the cephalic or basilic vein allows insertion of a larger IV catheter while allowing movement of the arm without impairing intravenous flow.

Front 70

A client admitted to the intensive care unit (ICU) is expected to remain for 3 weeks. The nurse has orders to start an IV. Which vascular access device does the nurse choose for this client?

A. Midline catheter
B. Peripherally inserted central catheter (PICC)
C. Short peripheral catheter
D. Tunneled central catheter

Back 70

A. Midline catheter

RATIONALE: PICCs are typically used when IV therapy is expected to last for months.

Front 71

A 22-year-old client is seen in the emergency department (ED) with acute right lower quadrant abdominal pain, nausea, and rebound tenderness. It appears that surgery is imminent. What gauge catheter does the ED nurse choose when starting this client's intravenous (IV) solution?

A. 24
B. 22
C. 18
D. 14

Back 71

C. 18

RATIONALE: An 18-gauge catheter is the size of choice for clients who will undergo surgery.

If they need to receive fluids rapidly, or if they need to receive more viscous fluids (such as blood or blood products), a lumen of this size would accommodate those needs.

Front 72

A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened and begun 20 hours ago. What action does the nurse take?

A. Changes the set immediately
B. Changes the set in about 4 hours
C. Changes the set in the next 12 to 24 hours
D. Nothing; the set is for long-term use

Back 72

B. Changes the set in about 4 hours

RATIONALE: Because both ends of the set are being manipulated with each dose, standards of practice dictate that the set should be changed every 24 hours.

Front 73

A client is seen in the emergency department (ED) with pain, redness, and warmth of the right lower arm. The client was in the ED last week after an accident at work. On the day of the injury, the client was in the ED for 12 hours receiving IV fluids. On close examination, the nurse notes the presence of a palpable cord 1 inch in length and streak formation. How does the nurse classify this client's phlebitis?

A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4

Back 73

C. Grade 3

RATIONALE: Grade 2 indicates only pain at the access site with erythema and/or edema. The client has additional symptoms.

Front 74

A nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What does the nurse do initially?

A. Assesses the insertion site
B. Checks connections
C. Checks the infusion rate
D. Discontinues the IV and starts another

Back 74

A. Assesses the insertion site

RATIONALE: Checking the IV connection is important but is not the priority in this situation.

Front 75

A client is admitted to the cardiothoracic surgical intensive care unit (ICU) after cardiac bypass surgery. The client is still sedated on a ventilator and has an arterial catheter in the right wrist. What assessment does the nurse make to ensure patency of the client's arterial line?

A. Blood pressure
B. Capillary refill and pulse
C. Neurologic function
D. Questions the client about the pain level at the site

Back 75

B. Capillary refill and pulse

RATIONALE: Blood pressure is not pertinent to the client's arterial line.

Front 76

Which statement is true about the special needs of older adults receiving IV therapy?

A. Placement of the catheter on the back of the client's dominant hand is preferred.
B. Skin integrity can be compromised easily by the application of tape or dressings.
C. To avoid rolling the veins, a greater angle of 25 degrees between the skin and the catheter will improve success with venipuncture.
D. When the catheter is inserted into the forearm, excess hair should be shaved before insertion.

Back 76

B. Skin integrity can be compromised easily by the application of tape or dressings.

RATIONALE: An angle smaller than 25 degrees is required for venipuncture success in older adults. This technique is less likely to puncture through the older adult client's vein.

Front 77

A client is being admitted to the burn unit from another hospital. The client has an intraosseous IV that was started 2 days ago, according to the client's medical record. What does the admitting nurse do first?

A. Anticipates an order to discontinue the intraosseous IV and start an epidural IV
B. Calls the previous hospital to verify the date
C. Immediately discontinues the intraosseous IV
D. Nothing; this is a long-term treatment

Back 77

A. Anticipates an order to discontinue the intraosseous IV and start an epidural IV

RATIONALE: An action must be taken. This type of IV is not used for long-term therapy.

Front 78

A nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion?

A. Asks the client to both say and spell his or her full name before starting the blood transfusion
B. Ensures that another qualified health care professional checks the unit before administering
C. Checks the blood identification numbers with the laboratory technician at the Blood Bank at the time it is dispersed
D. Makes certain that an IV solution of 0.9% normal saline is infusing into the client before starting the unit

Back 78

B. Ensures that another qualified health care professional checks the unit before administering

RATIONALE: Clients do need to have normal saline running with blood, but this is not considered to be part of the safety check before administration of blood and blood products.

Front 79

A nurse is starting a peripheral IV catheter on a recently admitted client. What actions does the nurse perform before insertion of the line? Select all that apply.

A. Applies povidone-iodine to clean skin, dries for 2 minutes
B. Cleans the skin around the site
C. Prepares the skin with 70% alcohol or chlorhexidine
D. Shaves the hair around the area of insertion
E. Wears clean gloves and touches the site only with fingertips after applying antiseptics

Back 79

A. Applies povidone-iodine to clean skin, dries for 2 minutes
B. Cleans the skin around the site
C. Prepares the skin with 70% alcohol or chlorhexidine

RATIONALE:
Clipping, rather than shaving, hair around the selected IV site is done. Shaving is abrasive and makes the skin more vulnerable to infection (i.e., microbial invasion).

Front 80

A nurse is administering a drug to a client through an implanted port. Before giving the medication, what does the nurse do to ensure safety?

A. Administers 5 mL of a heparinized solution
B. Checks for blood return
C. Flushes the port with 10 mL of normal saline
D. Palpates the port for stability

Back 80

B. Checks for blood return

RATIONALE: Before a drug is given through an implanted port, it is critical that the nurse checks for blood return. If no blood return is observed, the drug should be held until patency is re-established.

Front 81

Which client does the charge nurse on a medical-surgical unit assign to the LPN/LVN?

A. Cardiac client who has a diltiazem (Cardizem) IV infusion being titrated to maintain a heart rate between 60 and 80
B. Diabetic client admitted for hyperglycemia who is on an IV insulin drip and needs frequent glucose checks
C. Older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours
D. Postoperative client receiving blood products after excessive blood loss during surgery

Back 81

C. Older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours

RATIONALE: This client is the most stable and requires basic monitoring of the IV site for common complications such as phlebitis and local infection, which would be familiar to an LPN/LVN.

Front 82

A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does a nurse teach the new graduate nurse to use for this client?

A. Midline catheter
B. Nontunneled percutaneous central catheter
C. Peripherally inserted central catheter
D. Short peripheral catheter

Back 82

A. Midline catheter

RATIONALE: For a client with fragile veins (which occur with long-term corticosteroid use) and the need for a catheter for 5 days, the midline catheter is the best choice.

Front 83

A nurse assessing a client's peripheral IV site obtains and documents information about it. Which assessment data indicate the need for immediate nursing intervention?

A. Client states, "It really hurt when the nurse put the IV in."
B. The vein feels hard and cordlike above the insertion site.
C. Transparent dressing was changed 5 days ago.
D. Tubing for the IV was last changed 72 hours ago.

Back 83

B. The vein feels hard and cordlike above the insertion site.

RATIONALE: A hard, cordlike vein suggests phlebitis at the IV site. The IV should be discontinued and restarted at another site.

Front 84

When flushing a client's central line with normal saline, a nurse feels resistance. Which action does the nurse take first?

A. Decreases the pressure being used to flush the line
B. Obtains a 10-mL syringe and reattempts flushing the line
C. Stops flushing and tries to aspirate blood from the line
D. Uses "push-pull" pressure applied to the syringe while flushing the line

Back 84

C. Stops flushing and tries to aspirate blood from the line

RATIONALE: When resistance is felt when flushing any IV line, the nurse should stop and further assess the line. Aspiration of blood would indicate that the central line is intact and is not obstructed by thrombus.

Front 85

A severely dehydrated client requires a rapid infusion of normal saline and needs a midline IV line placed. Which staff member does the emergency department (ED) charge nurse assign to complete this task?

A. RN who is certified in the administration of oral and infused chemotherapy medications
B. RN with 2 years of experience in the emergency department who is skilled at insertion of short peripheral catheters
C. RN with 10 years of experience on a medical-surgical unit who has cared for many clients requiring IV infusions
D. RN with certified registered nurse infusion (CRNI) certification who is assigned to the emergency department for the day

Back 85

D. RN with certified registered nurse infusion (CRNI) certification who is assigned to the emergency department for the day

RATIONALE: The nurse with certified registered nurse infusion (CRNI) certification is most likely to be able to quickly insert a midline catheter for a client who is dehydrated.

Front 86

A nurse is inserting a peripheral intravenous (IV) catheter. Which client statement is of greatest concern during this procedure?

A. "I hate having IVs started."
B. "It hurts when you are inserting the line."
C. "My hand tingles when you poke me."
D. "My IV lines never last very long."

Back 86

C. "My hand tingles when you poke me."

RATIONALE: The client's statement indicates possible nerve puncture. To avoid further nerve damage, the nurse should stop immediately, remove the IV catheter, and choose a new site.

Front 87

A 70-year-old with severe dehydration is ordered an infusion of an isotonic solution at 250 mL/hr through a midline IV catheter. After 2 hours, the nurse notes that the client has crackles throughout all lung fields. Which action does the nurse take first?

A. Assesses the midline IV insertion site
B. Has the client cough and deep breathe
C. Notifies the health care provider about the crackles
D. Slows the rate of the IV infusion

Back 87

D. Slows the rate of the IV infusion

RATIONALE: The presence of crackles throughout the lungs is a sign of possible fluid overload. The nurse should slow the rate of infusion and further assess for indicators of volume overload and/or respiratory distress.

Front 88

A nurse is revising an agency's recommended central line catheter-related bloodstream infection prevention (CR-BSI) bundle. Which actions decrease the client's risk for this complication? Select all that apply.

A. During insertion, draping the area around the site with a sterile barrier
B. Immediately removing the client's venous access device (VAD) when it is no longer needed
C. Making certain that observers of the insertion are instructed to look away during the procedure
D. Thorough hand hygiene (i.e., no quick scrub) before insertion
E. Using chlorhexidine for skin disinfection

Back 88

B. Immediately removing the client's venous access device (VAD) when it is no longer needed
D. Thorough hand hygiene (i.e., no quick scrub) before insertion
E. Using chlorhexidine for skin disinfection

RATIONALE:
During the insertion, the whole body (head to toe) of the client is draped with a sterile barrier. Draping only the area around the site will increase risk for infection.

Front 89

A client receiving vancomycin intravenously reports that the peripheral IV insertion site has become painful and reddened. What is the nurse's first action?

A. Report the change to the health care provider.
B. Document the findings in the electronic patient record.
C. Change the IV insertion site to a new location.
D. Stop the infusion of the drug.

Back 89

D. Stop the infusion of the drug.

RATIONALE: The nurse's first action should be to stop the infusion of the medication and then to call the health care provider. Vancomycin (Vancocin) is a venous irritant and has a pH less than 5. Phlebitis occurs when clients require long-term infusion of these drugs in peripheral circulation.