Rational Results Graded A+
where should the RN look for the number of drops per mL of fluid the tubing delivers?
a. on the package of tubing
b. in the drug reference book
c. in the charting from the nurse who started the infusion
d. on the roller clamp of the tubing - CORRECT ANSWER-a. on the package of tubing
how should the nurse plan for a 1200 mL fluid restriction?
a. remove fluid from diet trays and offer them only between meals
b. offer the client soft foods such as sherbert and custard
c. allow 600 mL from 7-3, 400 mL from 3-11, and 20 mL from 11-7
d. tell the pt that fluid placed @ bedside must last until tomorrow - CORRECT
ANSWER-c. allow 600 mL from 7-3, 400 mL from 3-11, and 20 mL from 11-7
what action by RN would be appropriate for pt on fluid restriction of 800 mL a day?
a. check pt bedside table for hoarded cups of fluid/juice
b. allow the pt to order her own meals from the kitchen
c. obtain a urinalysis to check for output
d. do not give the pt any fluid after 5:00 pm - CORRECT ANSWER-b. allow the pt to
order her own meals from the kitchen
which is first intervention when RN observes the IV solution is not infusing?
a. inspect the tubing for kinks
,b. discontinue the IV
c. lower the height of the IV solution container
d. notify the MD - CORRECT ANSWER-a. inspect the tubing for kinks
which intervention should be included in the plan of care for pt with fluid volume
excess?
a. restrict the clients sodium in their diet
b. prepare the patient for hemodialysis
c. do not give the patient intravenous fluids
d. monitor blood glucose levels - CORRECT ANSWER-a. restrict the clients sodium in
their diet
crackles, SOB, and distended neck veins indicate which complication of IV fluid
therapy?
a. impending cardiovascular collapse/ shock
b. pulmonary embolism
c. an allergic reaction to IV fluids
d. fluid volume excess - CORRECT ANSWER-d. fluid volume excess
what is the priority assessment for a pt refusing to eat or drink for several days?
a. increased blood pressure
b. weak, rapid pulse
c. jugular vein distention
d. moist mucous membranes - CORRECT ANSWER-b. weak, rapid pulse
which statement indicates a need for further teaching regarding treatment of
hypokalemia?
,a. i will use avocado in my salads
b. i will stop using my salt substitute
c. i will take potassium in the morning after eating breakfast
d. i will be sure to check my heart rate before i take digoxin - CORRECT ANSWER-b. i
will stop using my salt substitute
which of the following signs or symptoms are most representative of a sodium
imbalance?
a. muscle weakness
b. hyperreflexia
c. mental confusion
d. irregular pulse - CORRECT ANSWER-c. mental confusion
which adaptation would indicate a K deficiency?
a. dry hair
b. muscle weakness
c. increased BP
d. chest pain - CORRECT ANSWER-b. muscle weakness
a reduction in fluid intake will contribute to:
a. frequent urination
b. decreased urine output
c. incontinence of urine
d. retention of urine - CORRECT ANSWER-b. decreased urine output
, the physician should be notified when the pts hourly urinary output falls below what
amt?
a. 20 mL
b. 120 mL
c. 30 mL
d. 60 mL - CORRECT ANSWER-c. 30 mL
patients who are taking diuretics must be encouraged to ingest nutrients rich in what?
a. sodium
b. magnesium
c. calcium
d. potassium - CORRECT ANSWER-d. potassium
which if the following signs is indicative of phlebitits at the IV site?
a. warmth
b. cool
c. pallor
d. bleeding - CORRECT ANSWER-a. warmth
pt c/o tingling in her fingers and toes, muscle cramps, and numbness of extremeties.
issue?
a. calcium deficit
b. chloride deficit
c. sodium excess
d. magnesium excess - CORRECT ANSWER-a. calcium deficit