Nursing Chapter 52 Global Rationale Cognitive Level Applying Client Need

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.

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.

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 Ringer’s 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

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 client’s 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.

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.

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).

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 1–2 minutes

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

4. 10 mEq KCL SQ

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 7–3, 400 mL from 3–11, and 200 mL from 11–7.

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.

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

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 client’s heart rate and blood pressure in both the sitting and standing position.

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

4. Raise the client’s legs above heart level and measure the blood pressure.

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

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

Question 31

Type: MCMA

A client sustained a significant loss of blood after a motor vehicle accident. The nurse notes that the client’s urine

output has decreased and suspects that which hormones have influenced this client’s fluid balance?

Standard Text: Select all that apply.

1. Aldosterone

2. Angiotensin

3. Antidiuretic hormone

4. Estrogen

5. Progesterone

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.

Question 33

Type: MCMA

The nurse is preparing to discontinue a client’s 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 client’s 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.

Question 34

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