Chapter 39 Summary Questions

1. A nurse is caring for an older patient with type II diabetes who is living in a long-term care facility. The nurse determines that the patient’s fluid intake and output is approximately 1200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. “Try to drink at least six to eight glasses of water each day.” “Try to limit your fluid intake to one quart of water daily.” “Limit sugar, salt, and alcohol in your diet.” “Report side effects of medications you are taking, especially diarrhea.” “Temporarily increase foods containing caffeine for their diuretic effect.” “Weigh yourself daily and report any changes in your weight.” 2. A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient’s legs, the nurse documents: “Pitting edema; 6 mm pit; pit remains several seconds after pressing with obvious skin swelling.” What grade of edema has this nurse documented? 1+ pitting edema 2+ pitting edema 3+ pitting edema 4+ pitting edema 3. A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. 5% dextrose in water (D5W) 0.9% NaCl (normal saline) Lactated Ringer’s solution 0.33% NaCl (¹∕³-strength normal saline) 0.45% NaCl (½-strength normal saline) 10% dextrose in water (D10W) 4. A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient’s fluid balance status? Recording intake and output Testing skin turgor Reviewing the complete blood count Measuring weight daily 5. Which acid–base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3−, 14 mEq/L? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis p. 1544 p. 1545 6. A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? Explaining the mechanisms involved in transporting fluids to and from intracellular compartments Keeping fluids readily available for the patient Emphasizing the long-term outcome of increasing fluids when the patient returns home Planning to offer most daily fluids in the evening 7. A nurse is caring for a patient who has fluid imbalance related to the development of ascites. Which imbalances would the nurse monitor for in this patient? Select all that apply. Extracellular fluid volume deficit Protein deficit Metabolic alkalosis Sodium deficit Plasma-to-interstitial fluid shift Metabolic acidosis 8. A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse’s priority intervention related to these symptoms? Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. Discontinue the infusion immediately, apply warm, moist compresses to the site, and restart the IV at another site. 9. A nurse carefully assesses the acid–base balance of a patient who is unable to effectively control his carbonic acid supply. This is most likely a patient with damage to which of the following? Kidneys Lungs Adrenal glands Blood vessels 10. A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? Encourage foods and fluids with high sodium content. Administer oral K supplements as ordered. Caution the patient about eating foods high in potassium content. Discuss calcium-losing aspects of nicotine and alcohol use. 11. A nurse is administering 500 mL of saline solution to a patient over 10 hours. The administration set delivers 60 gtts/min. Determine the infusion rate to administer via gravity infusion. Place your answer on the line provided below. ___________________________ 12. A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse’s next action related to these findings? Reposition the extremity and raise the height of the IV pole. Apply pressure to the dressing on the IV. Pull the catheter out slightly and reinsert it. Put on gloves; remove the catheter; apply pressure with a sterile pad. 13. When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document? 1 2 3 4 14. A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse’s priority actions related to these symptoms? Slow or stop the infusion; monitor vital signs, notify the physician, place the patient in upright position with feet dependent. Stop the transfusion immediately and keep the vein open with normal saline, notify the physician stat, administer antihistamine parenterally as needed. Stop the transfusion immediately and keep the vein open with normal saline, notify the physician, and treat symptoms. Stop the infusion immediately, obtain a culture of the patient’s blood, monitor vital signs, notify the physician, administer antibiotics stat. 15. A nurse is flushing a patient’s implanted port after administering medications. The nurse observes that the port flushes, but does not have a blood return. What would be the nurse’s next action based on these findings? Gently push down on the needle and flush it a second time. Stop flushing and remove the needle; notify the primary care provider. Ask the patient to perform a Valsalva maneuver; change the patient position. Close the clamp; wait 3 minutes, try flushing the port again. (Taylor 1544-1545) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.