Chapter 52 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 52

Question 1

Type: MCSA

The 154-pound adult client has had vomiting and diarrhea for 4 days secondary to a viral infection. What hourly urine measurement would indicate that efforts to rehydrate this client have not yet been successful and should continue?

1. 35 mL per hour

2. 80 mL per hour

3. 50 mL per hour

4. 30 mL per hour

Rationale 1: This is the expected urine output and would be considered successful.

Rationale 2: This volume of urine output means efforts to rehydrate the client have been successful.

Rationale 3: This volume of urine output indicates efforts to rehydrate the client have been successful.

Rationale 4: Normal urine output for adult clients is at least 0.5 mL/kg/hour. This client weighs 70 kg, so adequate urine output would be 35 mL/hour. A urine output of 30/mL/hr indicates that efforts at rehydration have not been successful.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1. Discuss the function, distribution, composition, movement, and regulation of fluids and electrolytes in the body.

MNL Learning Outcome: 4.13.2. Explain the factors that regulate body fluids and electrolytes.

Page Number: 1313

Question 2

Type: MCSA

The nurse suspects that a clients body is attempting to correct an acidbase imbalance. How will this imbalance be corrected?

1. Slow but efficient respiratory regulation will occur.

2. Primary regulation is through GI system losses.

3. Kidney regulation is powerfully effective.

4. The cardiovascular system is the major buffer.

Rationale 1: Respiratory regulation is rapid, but temporary.

Rationale 2: The gastrointestinal system is not involved in the regulation of acidbase balance.

Rationale 3: Renal regulation is slower, but powerfully effective.

Rationale 4: The cardiovascular system is not involved in the regulation of acidbase balance.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Describe the regulation of acidbase balance in the body, including the roles of buffers, the lungs, and the kidneys.

MNL Learning Outcome: 4.13.3. Examine the processes and components that maintain acidbase balance.

Page Number: 1317

Question 3

Type: MCSA

The nurse is caring for a client who is recovering from surgery. Which intervention should the nurse implement to decrease the clients possibility of developing hypercalcemia?

1. Measure vital signs every 4 hours.

2. Assist the client to turn, cough, and deep breathe every 2 hours.

3. Assist the client to ambulate around the room at least three times daily.

4. Irrigate the clients nasogastric tube every 2 hours.

Rationale 1: Measuring vital signs will not decrease the possibility of developing hypercalcemia.

Rationale 2: Turning, coughing, and deep breathing every 2 hours will not prevent the development of hypercalcemia.

Rationale 3: Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching of calcium from the bones into the serum.

Rationale 4: Irrigating the nasogastric tube every 2 hours is not going to prevent the development of hypercalcemia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Implement measures to correct imbalances of fluids, electrolytes, acids, and bases, such as enteral or parenteral replacements and blood transfusions.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1323

Question 4

Type: MCSA

The client is admitted to the acute care unit with a phosphorus level of 2.3 mg/dL. Which nursing intervention would support this clients homeostasis?

1. Encourage consumption of milk and yogurt.

2. Enforce strict isolation protocols.

3. Encourage consumption of a high-calorie carbohydrate diet.

4. Strain all urine.

Rationale 1: A phosphorus level of 2.3 is low and the client needs additional phosphorus. Provision of phosphorus-rich foods such as milk and yogurt is a good way to provide that additional phosphorus.

Rationale 2: There is no indication of the need to place this client in strict isolation.

Rationale 3: A high-carbohydrate diet is not going to improve this clients phosphorus level.

Rationale 4: Straining all urine is not going to improve this clients phosphorus level.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Implement measures to correct imbalances of fluids, electrolytes, acids, and bases, such as enteral or parenteral replacements and blood transfusions.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1324

Question 5

Type: MCSA

The mother of a 1-month-old infant is concerned because the infant has had vomiting and diarrhea for 2 days. What instruction should the nurse give this infants mother?

1. Have the infant be seen by a physician

2. Give the infant at least 2 ounces of juice every 2 hours.

3. Measure the infants urine output for 24 hours.

4. Provide the infant with 50 mL of glucose water.

Rationale 1: Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to health care providers for evaluation.

Rationale 2: Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, nor is juice the best choice of fluid.

Rationale 3: Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated.

Rationale 4: Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, nor is glucose water the best choice of fluid.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Implement measures to correct imbalances of fluids, electrolytes, acids, and bases, such as enteral or parenteral replacements and blood transfusions.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1317

Question 6

Type: MCSA

A client has had a subclavian central venous catheter inserted. What should the nurse assess as a priority for this clients care?

1. Presence of bibasilar crackles

2. Tachycardia

3. Decreased pedal pulses

Rationale 1: Bibasilar crackles may develop secondary to fluid overload or to the disease process, but would not be particularly evident just after placement of the subclavian catheter.

Rationale 2: Because insertion of a subclavian central venous catheter may result in hemothorax, pneumothorax, cardiac perforation, thrombosis, or infection, the priority finding for planning care is tachycardia.

Rationale 3: A decrease in pedal pulses would not be associated with the placement of a subclavian catheter.

Rationale 4: A headache would not be associated with the placement of a subclavian catheter.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Collect assessment data related to clients fluid, electrolyte, and acidbase balances.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1339

Question 7

Type: MCSA

The nurse is caring for a client who is receiving intravenous fluids that are not regulated on an electronic controller. In order to calculate the rate of the IV flow in drops per minute, the nurse must know the number of drops per milliliter of fluid the tubing delivers. Where should the nurse look for this information?

1. On the packaging of the tubing

2. In the charting from the nurse who started the infusion

3. In the drug reference book

4. On the roller clamp of the tubing

Rationale 1: The drop factor (number of drops per milliliter of fluid) of tubing is located on the packaging.

Rationale 2: The nurse would not document the drop factor of the intravenous tubing.

Rationale 3: The drop factor would not be in a drug reference book.

Rationale 4: The drop factor would not be on the roller clamp of the intravenous tubing.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Verbalize the steps used in: b. Monitoring an intravenous infusion.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1348

Question 8

Type: FIB

The physician has ordered 50 mL of an IV solution to infuse over the next 20 minutes. In order to accurately infuse this solution, the nurse should set the electronic controller to deliver how many mL/hr?

Rationale: 50 mL/20 minutes = x mL/60 minutes. 3000/20 = 150 mL/hr

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Verbalize the steps used in: b. Monitoring an intravenous infusion.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1349

Question 9

Type: FIB

The nurse is to administer 75 mL of an antibiotic solution by IV over the next 30 minutes. The tubing has a drop factor of 20. How many drops per minute should the nurse set the controller to deliver?

Correct Answer: 50 drops per minute

Rationale: 75 mL/1 hour 20 drops/30 minutes = 50 drops per minute.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Verbalize the steps used in: b. Monitoring an intravenous infusion.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1349

Question 10

Type: MCSA

The nurse is caring for a client who is receiving IV therapy at a rate of 10 mL/hour. The 500-mL IV bottle was hung at 0900 Monday morning when the IV catheter was initiated. It is now 0900 on Tuesday morning. What nursing action should be taken?

1. Refigure the rate of the IV.

2. Infuse the remaining IV fluid before hanging a new bag.

3. Discard the remaining IV fluid and hang a new bag.

4. Discontinue the IV site and restart an IV in the opposite hand.

Rationale 1: There is no need to refigure the rate of the IV.

Rationale 2: The nurse should not infuse the remaining IV fluid before hanging a new bag.

Rationale 3: The remaining IV fluid should be discarded and a new bag hung. IV fluid should be changed every 24 hours, regardless of how much solution remains. This helps to minimize the risk of contamination.

Rationale 4: There is no need to restart the IV in the opposite hand.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Verbalize the steps used in: c. Changing an intravenous container, tubing, and dressing.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1352

Question 11

Type: MCSA

A client tells the nurse about passing out after following a fasting diet for 5 days. Which acidbase imbalance should the nurse expect to assess in this client?

1. Respiratory acidosis

2. Respiratory alkalosis

3. Metabolic acidosis

4. Metabolic alkalosis

Rationale 1: Starvation would not result in respiratory acidosis.

Rationale 2: Starvation would not result in respiratory alkalosis.

Rationale 3: A client who is fasting is at risk for development of metabolic acidosis. The body recognizes fasting as starvation and begins to metabolize its own proteins into ketones, which are metabolic acids.

Rationale 4: Starvation would not result in metabolic alkalosis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Discuss risk factors for, and causes and effects of, fluid, electrolyte, and acidbase imbalances.

MNL Learning Outcome: 4.13.3. Examine the processes and components that maintain acidbase balance.

Page Number: 1325

Question 12

Type: MCSA

A client is admitted to the hospital after vomiting for 3 days. Which arterial blood gas results should the nurse expect to find in this client?

1. pH 7.30; PaCO2 50; HCO3 27

2. pH 7.47; PaCO2 43; HCO3 28

3. pH 7.43; PaCO2 50; HCO3 28

4. pH 7.47; PaCO2 30; HCO3 23

Rationale 1: The nurse would expect that this client is alkalotic because stomach acids have been lost, so the pH would be above 7.45. This is a metabolic problem, so the PaCO2 is likely normal. The HCO3 will likely be high (above 26). The only option that includes all of these parameters is pH 7.47; PaCO2 43; HCO3 28.

Rationale 2: The nurse would expect that this client is alkalotic because stomach acids have been lost, so the pH would be above 7.45. This is a metabolic problem, so the PaCO2 is likely normal. The HCO3 will likely be high (above 26). The only option that includes all of these parameters is pH 7.47; PaCO2 43; HCO3 28.

Rationale 3: The nurse would expect that this client is alkalotic because stomach acids have been lost, so the pH would be above 7.45. This is a metabolic problem, so the PaCO2 is likely normal. The HCO3 will likely be high (above 26). The only option that includes all of these parameters is pH 7.47; PaCO2 43; HCO3 28.

Rationale 4: The nurse would expect that this client is alkalotic because stomach acids have been lost, so the pH would be above 7.45. This is a metabolic problem, so the PaCO2 is likely normal. The HCO3 will likely be high (above 26). The only option that includes all of these parameters is pH 7.47; PaCO2 43; HCO3 28.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify factors affecting normal body fluid, electrolyte, and acidbase balance.

MNL Learning Outcome: 4.13.3. Examine the processes and components that maintain acidbase balance.

Page Number: 1326

Question 13

Type: MCSA

The clients arterial blood gas report reveals a pH of 6.58. How does the nurse evaluate this value?

1. There is a slight elevation.

2. This value is incompatible with life.

3. This is a low normal value.

4. This value is extremely elevated.

Rationale 1: The bodys pH range is normally 7.35 to 7.45. This is not an elevation.

Rationale 2: The bodys pH range is normally 7.35 to 7.45. Values lower than 6.8 or higher than 7.8 are generally considered incompatible with life. If the nurse assesses that this client is physiologically more stable than would be expected with this pH, the possibility of a lab error should be considered.

Rationale 3: The bodys pH range is normally 7.35 to 7.45. Values lower than 6.8 or higher than 7.8 are generally considered incompatible with life.

Rationale 4: The bodys pH range is normally 7.35 to 7.45. This value is not extremely elevated.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 3. Identify factors affecting normal body fluid, electrolyte, and acidbase balance.

MNL Learning Outcome: 4.13.3. Examine the processes and components that maintain acidbase balance.

Page Number: 1325

Question 14

Type: MCSA

A client has experienced a narcotic overdose. What acidbase imbalance should the nurse expect to observe in this client?

1. Respiratory acidosis

2. Respiratory alkalosis

3. Metabolic acidosis

4. Metabolic alkalosis

Rationale 1: Because narcotics generally act to decrease or suppress respirations, this client is probably hypoventilating. The expected acidbase imbalance would be respiratory acidosis.

Rationale 2: Respiratory alkalosis is associated with hyperventilation.

Rationale 3: This imbalance occurs with too much acid in the body. The respirations will increase. It is not typically seen in a client experiencing a narcotic overdose.

Rationale 4: This imbalance is seen in those with prolonged periods of vomiting or other conditions where the body loses acid.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify factors affecting normal body fluid, electrolyte, and acidbase balance.

MNL Learning Outcome: 4.13.3. Examine the processes and components that maintain acidbase balance.

Page Number: 1325

Question 15

Type: MCSA

Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client complains of a headache. The nurse assesses that the client has slight shortness of breath and feels warm to the touch. What action by the nurse is priority?

1. Notify the clients physician.

2. Discontinue the transfusion.

3. Slow the rate of the transfusion.

4. Prepare to resuscitate the client.

Rationale 1: This would not be the nurses first action.

Rationale 2: The priority intervention is to discontinue the transfusion. If this client is having a transfusion reaction, it will be better to limit the amount of blood transfused. The nurse would also contact the physician to collaborate on further treatment, but this action should be after the transfusion is discontinued.

Rationale 3: Slowing the rate of the transfusion allows additional blood to be infused.

Rationale 4: At this point, there is no need to prepare for resuscitation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Implement measures to correct imbalances of fluids, electrolytes, acids, and bases, such as enteral or parenteral replacements and blood transfusions.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1359

Question 16

Type: MCSA

A client on diuretic therapy has a serum potassium level of 3.4 mg/dL. Which food should the nurse encourage this client to choose from the dinner menu?

1. Baked chicken

2. Green beans

3. Cantaloupe

4. Iced tea

Rationale 1: A potassium level of 3.4 is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, the highest in potassium is cantaloupe.

Rationale 2: A potassium level of 3.4 is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, the highest in potassium is cantaloupe.

Rationale 3: A potassium level of 3.4 is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, the highest in potassium is cantaloupe.

Rationale 4: A potassium level of 3.4 is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, the highest in potassium is cantaloupe.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Teach clients measures to maintain fluid and electrolyte balance.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1315

Question 17

Type: MCSA

A client has orders for the administration of IV fluid at a keep vein open rate in preparation for administration of IV antibiotics starting at noon. When the nurse goes to the room to start the IV, the UAP is preparing to bathe the client. What should the nurse do?

1. Instruct the UAP to wait until the IV is started to bathe the client.

2. Let the UAP start the bath on the opposite side of where the nurse will be starting the IV.

3. Tell the UAP to notify the nurse as soon as the bath is completed.

4. Give the UAP permission to skip the clients bath for today.

Rationale 1: Because this IV is being initiated to support the administration of IV antibiotic therapy that is not scheduled to start until noon, the nurse should let the UAP give the bath and then start the IV.

Rationale 2: Having the UAP bathing one side of the client while the nurse starts the IV on the opposite side would be uncomfortable and stressful for the client and could potentially compromise client modesty. This action would also not protect the IV site from movement while the UAP completes the bath.

Rationale 3: Because this IV is being initiated to support the administration of IV antibiotic therapy that is not scheduled to start until noon, the nurse should let the UAP give the bath and then start the IV. This will protect the IV site from movement during the bath.

Rationale 4: There is no reason to skip the bath.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Verbalize the steps used in: a. Starting an intravenous infusion.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1344

Question 18

Type: MCSA

The nurse is preparing to start an IV in the hand of a client who has very small veins. Which actions would be useful in dilating the veins?

1. Position the hand at heart level.

2. Stroke the vein.

3. Have the client clench and unclench the fist.

4. Slap the back of the clients hand.

5. Massage the vein.

Rationale 1: The hand should be lower than the heart to dilate the vein.

Rationale 2: Stroking the vein helps to dilate the vein.

Rationale 3: Having the client clench and unclench the fist is a strategy used to help dilate a vein.

Rationale 4: Slapping the vein is contraindicated and may actually reduce venous filling.

Rationale 5: Massaging the vein helps with vein dilation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Verbalize the steps used in: a. Starting an intravenous infusion.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1345

Question 19

Type: MCSA

The client complains of burning along the vein in which a medicated IV is infusing. Upon assessment, the nurse finds the IV site is slightly reddened, but not warmer than the surrounding skin, and without swelling. What action should be taken by the nurse?

1. Slow the IV infusion and reassess the area in 15 minutes.

2. Apply ice over the IV site and vein.

3. Discontinue the IV and place a warm pack on the area.

4. Call the physician for direction.

Rationale 1: Simply slowing the IV will not prevent further damage to the vein and will also alter the amount of IV fluid and medication the client is receiving.

Rationale 2: Ice is not indicated in the treatment of phlebitis.

Rationale 3: This assessment likely indicates the beginning of phlebitis. The nurse should discontinue the IV and place either a warm or cool pack on the area.

Rationale 4: This assessment and evaluation are within the scope of nursing practice, so at this point, collaboration with the physician is not necessary.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Verbalize the steps used in: b. Monitoring an intravenous infusion.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1352

Question 20

Type: MCSA

The client who has an IV with an intermittent infusion lock in place wishes to shower. What action should be taken by the nurse?

1. Have the UAP discontinue the lock.

2. Cover the lock with an occlusive dressing.

3. Place a piece of cloth tape under the lock, wrapping the top in a U shape.

4. Tell the client that a bed bath is necessary until the IV is discontinued.

Rationale 1: UAP cannot discontinue the lock.

Rationale 2: The client can shower if the lock is covered with an occlusive dressing.

Rationale 3: Cloth tape will not protect the lock.

Rationale 4: The client can shower if the lock is covered with an occlusive dressing.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Verbalize the steps used in: e. Changing an intravenous catheter to an intermittent infusion lock.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1341

Question 21

Type: MCSA

The nurse is collecting equipment to administer a unit of packed red blood cells. Which IV fluid should be used to initiate the IV for this transfusion?

1. 1,000 mL of lactated Ringers solution

2. 250 mL of normal saline

3. 500 mL of 5% dextrose and water

4. 100 mL of 5% dextrose and 1/2 normal saline

Rationale 1: Blood and blood products should only be administered with normal saline. Other IV fluids may cause damage to the cells being administered.

Rationale 2: Blood and blood products should only be administered with normal saline. Other IV fluids may cause damage to the cells being administered.

Rationale 3: Blood and blood products should only be administered with normal saline. Other IV fluids may cause damage to the cells being administered.

Rationale 4: Blood and blood products should only be administered with normal saline. Other IV fluids may cause damage to the cells being administered.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Verbalize the steps used in: f. Initiating, maintaining, and terminating a blood transfusion using a Y-set.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1359

Question 22

Type: MCSA

After obtaining a unit of packed red blood cells for a client, the nurse learns the client needed to leave the care area for an emergency x-ray. What action should the nurse take?

1. Set up the blood with the IV fluid and y-tubing and place it on the IV stand in the clients room to initiate immediately after the client returns.

2. Place the blood in the unit refrigerator until the client returns.

3. Return the blood to the laboratory blood bank until the client returns.

4. Set up the blood with the IV fluid and y-tubing and place it in the unit medication room to initiate immediately after the client returns.

Rationale 1: Blood should not be held at room temperature for more than 30 minutes before the transfusion is initiated.

Rationale 2: The unit refrigerator is not climate controlled for blood storage.

Rationale 3: Blood should not be held at room temperature for more than 30 minutes before the transfusion is initiated. The unit must be returned to the laboratory blood bank until the client has returned from x-ray.

Rationale 4: Blood should not be held at room temperature for more than 30 minutes before the transfusion is initiated.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Verbalize the steps used in: f. Initiating, maintaining, and terminating a blood transfusion using a Y-set.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1362

Question 23

Type: MCSA

The nurse initiates a blood transfusion for a client. What action should the nurse take next?

1. Stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion.

2. Assign the UAP to sit with the client for 15 minutes.

3. Advise the client to notify the nurse if he experiences any chilling, nausea, flushing, or rapid heart rate.

4. Return to the room and take a set of vital signs in 15 minutes.

Rationale 1: The nurse should stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion.

Rationale 2: The nurse cannot delegate this assessment to the UAP.

Rationale 3: The client should be advised of reactions to report, but this self-reporting is more indicated after the nurse is no longer in constant attendance.

Rationale 4: The nurse should stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion. The nurse cannot delegate this assessment to the UAP.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Verbalize the steps used in: f. Initiating, maintaining, and terminating a blood transfusion using a Y-set.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1362

Question 24

Type: MCSA

The nurse is providing discharge instructions to a client who has been started on furosemide (Lasix) once daily. What information is essential to include in this information?

1. Take the medication at bedtime.

2. Avoid high-potassium foods.

3. Stand up slowly from a sitting position.

4. Do not take this medication on the days you take digitalis (Lanoxin).

Rationale 1: The medication should be taken in the morning to prevent awakening at night to void.

Rationale 2: The client should be encouraged to eat potassium-rich foods and will probably be prescribed a potassium supplement.

Rationale 3: Clients who are taking diuretics must make position changes slowly in order to minimize dizziness from orthostatic hypotension.

Rationale 4: Although clients who take digitalis (Lanoxin) and furosemide (Lasix) are at higher risk for the development of digitalis toxicity, the medications are often taken concurrently. The client and health care provider must monitor these clients closely for the development of digitalis toxicity.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Teach clients measures to maintain fluid and electrolyte balance.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1321

Question 25

Type: MCSA

The nurse is reviewing orders for parenteral potassium. Which order is safe for the nurse to implement?

1. Add 20 mEq of KCL to 1,000 mL of IV fluid

2. 10 mEq KCL IV over 12 minutes

3. Dilute 20 mEq KCL in 3 mL of NS and give IV push

4. 10 mEq KCL SQ

Rationale 1: Parenteral potassium should be well diluted and given IV.

Rationale 2: If given in concentrated form, parenteral potassium is lethal to the client.

Rationale 3: Parenteral potassium should be well diluted and given IV. It is not given SQ, by IV push, or in limited dilution (such as 20 mEq in 25 mL of fluid).

Rationale 4: Parenteral potassium should be well diluted and given IV. It is not given SQ, by IV push, or in limited dilution (such as 20 mEq in 25 mL of fluid).

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Implement measures to correct imbalances of fluids, electrolytes, acids, and bases, such as enteral or parenteral replacements and blood transfusions.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1321

Question 26

Type: MCSA

The client has been placed on a 1200-mL oral fluid restriction. How should the nurse plan for this restriction?

1. Allow 600 mL from 73, 400 mL from 311, and 200 mL from 117.

2. Instruct the client that the 1200 mL of fluid placed in the bedside pitcher must last until tomorrow.

3. Offer the client softer, cold foods such as sherbet and custard.

4. Remove fluids from diet trays and offer them only between meals.

Rationale 1: The amount of fluid allowed should be divided between the three major times of the day (73, 311, 117). This helps by taking into consideration meals and medication administration.

Rationale 2: The client should be given a choice regarding consumption of fluids at mealtime.

Rationale 3: Sherbet and custard are counted as liquids and should be avoided.

Rationale 4: The client should be given a choice regarding consumption of fluids at mealtime.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8. Implement measures to correct imbalances of fluids, electrolytes, acids, and bases, such as enteral or parenteral replacements and blood transfusions.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1334

Question 27

Type: MCSA

The nurse is caring for an 80-year-old client with the medical diagnosis of heart failure. The client has edema, orthopnea, and confusion. Which nursing diagnosis is most appropriate for this client?

1. Heart Failure related to edema, as evidenced by confusion

2. Fluid Volume Deficit related to loss of fluids, as evidenced by edema

3. Excess Fluid Volume related to retention of fluids, as evidenced by edema and orthopnea

4. Excess Fluid Volume related to congestive heart failure, as evidenced by edema and confusion

Rationale 1: Heart failure is a medical diagnosis, not a nursing diagnosis.

Rationale 2: This client does not exhibit fluid volume deficit.

Rationale 3: Edema and orthopnea are assessment findings associated with excess fluid volume.

Rationale 4: Congestive heart failure is a medical diagnosis and cannot be used as the related to factor in a nursing diagnosis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 6. Identify examples of nursing diagnoses, outcomes, and interventions for clients with altered fluid, electrolyte, or acidbase balance.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1319

Question 28

Type: MCSA

The nurse wants to assess a client for orthostatic hypotension. What action should the nurse take?

1. Assess the client for dependent edema and then raise the legs to the level of the heart and reassess for edema.

2. Measure the clients heart rate and blood pressure in both the sitting and standing position.

3. Measure the clients blood pressure before, during, and after administration of a normal saline fluid challenge.

4. Raise the clients legs above heart level and measure the blood pressure.

Rationale 1: Assessment of edema is not a part of the assessment of orthostatic hypotension.

Rationale 2: The nurse should measure the clients blood pressure and heart rate in the sitting position and then again in the standing position.

Rationale 3: Normal saline challenges are often administered to clients who are dehydrated, but they are not part of assessment of orthostatic hypotension.

Rationale 4: The nurse should measure the clients blood pressure and heart rate in the sitting position and then again in the standing position.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Collect assessment data related to clients fluid, electrolyte, and acidbase balances.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1329

Question 29

Type: MCSA

The nurse is caring for a client who is being mechanically ventilated. Arterial blood gas analysis reveals respiratory acidosis. Which change in ventilator settings should the nurse anticipate?

1. Decrease in oxygen delivery

2. Decreased tidal volume of each breath

3. Increased respiratory rate

4. Increase in humidification of inspired air

Rationale 1: Decreasing oxygen will not decrease CO2 levels.

Rationale 2: Decreasing the tidal volume will not decrease CO2 levels.

Rationale 3: This client needs to blow off more CO2; therefore the respiratory rate would be increased.

Rationale 4: Increasing the humidification will not decrease CO2 levels.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8. Implement measures to correct imbalances of fluids, electrolytes, acids, and bases, such as enteral or parenteral replacements and blood transfusions.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1325

Question 30

Type: MCSA

An older client receiving intravenous fluids at 175 ml/hr is demonstrating crackles, shortness of breath, and distended neck veins. The nurse recognizes these findings as being which complication of intravenous fluid therapy?

1. An allergic reaction to the antibiotics in the fluid

2. Fluid volume excess

3. Pulmonary embolism

4. Speed shock

Rationale 1: The information provided does not support that the client is receiving an antibiotic.

Rationale 2: Fluid volume excess may occur if clients, especially the very young or elderly, receive IV fluid rapidly.

Rationale 3: The information provided does not support the development of a pulmonary embolism.

Rationale 4: The client has been receiving fluids at the established rate and would not be experiencing symptoms of speed shock.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 9. Evaluate the effect of nursing and collaborative interventions on clients fluid, electrolyte, or acidbase balance.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1319

Question 31

Type: MCMA

A client sustained a significant loss of blood after a motor vehicle accident. The nurse notes that the clients urine output has decreased and suspects that which hormones have influenced this clients fluid balance?

Standard Text: Select all that apply.

1. Aldosterone

2. Angiotensin

3. Antidiuretic hormone

4. Estrogen

5. Progesterone

Rationale 1: Aldosterone promotes sodium retention in the distal nephron, reducing urine output.

Rationale 2: Angiotensin acts directly on the nephrons to promote sodium and water retention.

Rationale 3: When serum osmolality rises, antidiuretic hormone is produced, causing the collecting ducts to become more permeable to water. This increased permeability allows more water to be reabsorbed into the blood. As more water is reabsorbed, urine output falls and serum osmolality decreases, because the water dilutes body fluids.

Rationale 4: Estrogen is not a hormone that participates in fluid balance in the body.

Rationale 5: Progesterone is not a hormone that participates in fluid balance in the body.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Discuss the function, distribution, composition, movement, and regulation of fluids and electrolytes in the body.

MNL Learning Outcome: 4.13.1. Examine the processes involved in the bodys maintenance of fluid and electrolyte balance.

Page Number: 1313

Question 32

Type: MCMA

A client tells the nurse about rarely feeling thirsty. The nurse realizes that further assessment is needed to evaluate

Standard Text: Select all that apply.

1. status of osmotic pressure.

2. vascular volume.

3. presence of angiotensin.

4. urine output.

5. body weight.

Rationale 1: A number of stimuli trigger the thirst center, including the osmotic pressure of body fluids.

Rationale 2: A number of stimuli trigger the thirst center, including vascular volume.

Rationale 3: A number of stimuli trigger the thirst center, including angiotensin.

Rationale 4: Urine output does not trigger the thirst center.

Rationale 5: Body weight does not trigger the thirst center.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Discuss the function, distribution, composition, movement, and regulation of fluids and electrolytes in the body.

MNL Learning Outcome: 4.13.1. Examine the processes involved in the bodys maintenance of fluid and electrolyte balance.

Page Number: 1312

Question 33

Type: MCMA
The nurse is preparing to discontinue a clients intravenous infusion. Which actions should the nurse take when removing the catheter from the vein?

Standard Text: Select all that apply.

1. Pull the catheter out in line with the vein

2. Apply pressure to the site while removing the catheter.

3. Pull the catheter out at an angle perpendicular to the vein.

4. Bend the clients elbow if bleeding at the site persists after removal.

5. Apply pressure to the site after the catheter is removed for 2 to 3 minutes.

Rationale 1: When removing an intravenous catheter, the nurse should pull the catheter out in line with the vein. This avoids injury to the vein.

Rationale 2: Pressure should not be applied to the site while removing the catheter.

Rationale 3: When removing an intravenous catheter, the nurse should pull the catheter out in line with the vein. An angle perpendicular to the vein will injure the vein.

Rationale 4: Hold the clients arm above heart level, not bending at the elbow, if any bleeding persists. Raising the limb decreases blood flow to the area.

Rationale 5: After removing the catheter, immediately apply firm pressure to the site, using sterile gauze, for 2 to 3 minutes. Pressure helps stop the bleeding and prevents hematoma formation.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Verbalize the steps used in: d. Discontinuing an intravenous infusion.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1354

Question 34

Type: MCMA
A client is receiving a continuous intravenous infusion. What should the nurse document in the medical record about this infusion?

Standard Text: Select all that apply.

1. Latest body temperature

2. Type of solution and flow rate

3. Total intravenous intake for the shift

4. Status of the intravenous catheter site

5. Results of blood pressure measurement

Rationale 1: Body temperature may help determine fluid status; however, this is not documented in the medical record related to the clients continuous intravenous fluid infusion.

Rationale 2: The type of solution and flow rate should be documented.

Rationale 3: Total intravenous intake for the shift should be documented according to agency policy.

Rationale 4: The status of the intravenous insertion site should be documented.

Rationale 5: Blood pressure may help determine fluid status; however, this is not documented in the medical record related to the clients continuous intravenous fluid infusion.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12. Demonstrate appropriate documentation and reporting of fluid, electrolyte and acidbase balance activities.

MNL Learning Outcome: 4.13.4. Implement the nursing process to maintain or restore normal fluid and electrolyte balance.

Page Number: 1352