Elect - nursing
Nursing Practice: Child
Bearing/Family Nursing (Arizona
State University)
,1. The use of an infusion pump or controller still requires nursing supervision
and frequent monitoring of the IV infusion to monitor for signs of infiltration.
Assessment of which of the following at the infusion site would lead the
nurse to suspect that infiltration is occurring? Select all that apply.
A) Edema
B) Necrosis
C) Burning
D) Itching
E) Rednes
s Ans: A,
E
Feedback:
It is important for the nurse to monitor frequently for signs of infiltration
while an infusion pump is in use. The signs of infiltration include edema and
redness at the infusion site. A physician orders normal saline for a client to
replace lost fluids due to poor oral intake. The order is for 1000 mL normal
saline to be infused over a period of 6 hours. If the drop factor is 20
drops/mL, the nurse would set the IV flow rate at .
Ans: 56 drops/min
Feedback:
1000 mL/6 hours = 166.7 mL/hr
166.7 mL/hr ◊ 1 hr/60 min = 2.8 mL/min
2.8 mL/min ◊ 20 = (55.5) or 56 drops/min
A physician orders normal saline for a client to replace lost fluids due to poor
oral intake. The order is for 1000 mL D5W to be infused over a period of 4
hours. If the drop factor is 5 drops/mL, the nurse would determine the IV flow
rate to be .
Ans: 21 drops/min
Feedback:
1000 mL/4 hours = 250 mL/hr
250 mL/hr ◊ 1 hr/60 min = 4.17 mL/min
4.17 mL/min ◊ 5 = (20.8) or 21 drops/min
A physician orders levofloxacin (Levaquin) for a client to treat infection. The
order is for levofloxacin (Levaquin) 500 mg/100 mL to be infused over a
period of 1 hour. The IV infusion set has a drop factor of 10 drops/mL. The
nurse would set the infusion flow rate at .
Ans: 17 drops/min
Feedback:
100 mL/1 hour = 100 mL/hr
100 mL/hr ◊ 1 hr/60 min = 1.67 mL/min
1.67 mL/min ◊ 10 = (16.7) or 17 drops/min
A physician orders levofloxacin (Levaquin) for a client to treat infection. The
order is for levofloxacin (Levaquin) 1000 mg/50 mL to be infused over a
period of 1 hour. The IV infusion set delivers 15 drops/mL. The nurse would
set the infusion rate at .
Ans: 13 drops/min
Feedback:
50 mL/1 hour = 50 mL/hr
100 mL/hr ◊ 1 hr/60 min = 0.83 mL/min
,0.83 mL/min ◊ 15 = (12.5) or 13 drops/min
, A nurse is assessing a client receiving a continuous IV infusion. The nurse
suspects that the client is developing fluid overload based on assessment of
which of the following? Select all that apply.
A) Weight loss
B) Decreased blood pressure
C) Distended neck veins
D) Rapid breathing
E) Hypernatrem
ia Ans: C, D
Feedback:
Signs of fluid overload include headache, weakness, blurred vision,
behavioral changes, weight gain, isolated muscle twitching, hyponatremia,
rapid breathing, wheezing, coughing, rise in blood pressure, distended neck
veins, elevated central venous pressure, and convulsions.
A client has developed electrolyte imbalances. The nurse understands that
which of the following would most likely contribute to the client's current
situation? Select all that apply.
A) Vomiting
B) Constipation
C) Surgery
D) Drug administration
E) Diagnostic
tests Ans: A, C,
D, E
Feedback:
The following can result in electrolyte imbalances in a client: vomiting,
diarrhea, surgery, drug administration, and diagnostic tests.
The primary health care provider prescribes potassium to be replaced IV.
When reviewing the client's medication history, the nurse determines that
the underlying reason for this order is most likely the administration of which
of the following drugs? Select all that apply.
A) Furosemide (Lasix)
B) Enalaprilat (Vasotec)
C) Bumetanide (Bumex)
D) Ceftriaxone (Rocephin)
E) Spironolactone
(Aldactone) Ans: A, C
Feedback:
The administration of loop diuretics, like furosemide (Lasix) and bumetanide
(Bumex), causes the excretion of water and potassium and can result in the
need for IV fluid replacement of potassium.
A nurse suspects a client may have hypocalcemia based on assessment of
which of the following? Select all that apply.
A) Hypoactive reflexes
B) Positive Homan's sign
C) Positive Trousseau's sign
Nursing Practice: Child
Bearing/Family Nursing (Arizona
State University)
,1. The use of an infusion pump or controller still requires nursing supervision
and frequent monitoring of the IV infusion to monitor for signs of infiltration.
Assessment of which of the following at the infusion site would lead the
nurse to suspect that infiltration is occurring? Select all that apply.
A) Edema
B) Necrosis
C) Burning
D) Itching
E) Rednes
s Ans: A,
E
Feedback:
It is important for the nurse to monitor frequently for signs of infiltration
while an infusion pump is in use. The signs of infiltration include edema and
redness at the infusion site. A physician orders normal saline for a client to
replace lost fluids due to poor oral intake. The order is for 1000 mL normal
saline to be infused over a period of 6 hours. If the drop factor is 20
drops/mL, the nurse would set the IV flow rate at .
Ans: 56 drops/min
Feedback:
1000 mL/6 hours = 166.7 mL/hr
166.7 mL/hr ◊ 1 hr/60 min = 2.8 mL/min
2.8 mL/min ◊ 20 = (55.5) or 56 drops/min
A physician orders normal saline for a client to replace lost fluids due to poor
oral intake. The order is for 1000 mL D5W to be infused over a period of 4
hours. If the drop factor is 5 drops/mL, the nurse would determine the IV flow
rate to be .
Ans: 21 drops/min
Feedback:
1000 mL/4 hours = 250 mL/hr
250 mL/hr ◊ 1 hr/60 min = 4.17 mL/min
4.17 mL/min ◊ 5 = (20.8) or 21 drops/min
A physician orders levofloxacin (Levaquin) for a client to treat infection. The
order is for levofloxacin (Levaquin) 500 mg/100 mL to be infused over a
period of 1 hour. The IV infusion set has a drop factor of 10 drops/mL. The
nurse would set the infusion flow rate at .
Ans: 17 drops/min
Feedback:
100 mL/1 hour = 100 mL/hr
100 mL/hr ◊ 1 hr/60 min = 1.67 mL/min
1.67 mL/min ◊ 10 = (16.7) or 17 drops/min
A physician orders levofloxacin (Levaquin) for a client to treat infection. The
order is for levofloxacin (Levaquin) 1000 mg/50 mL to be infused over a
period of 1 hour. The IV infusion set delivers 15 drops/mL. The nurse would
set the infusion rate at .
Ans: 13 drops/min
Feedback:
50 mL/1 hour = 50 mL/hr
100 mL/hr ◊ 1 hr/60 min = 0.83 mL/min
,0.83 mL/min ◊ 15 = (12.5) or 13 drops/min
, A nurse is assessing a client receiving a continuous IV infusion. The nurse
suspects that the client is developing fluid overload based on assessment of
which of the following? Select all that apply.
A) Weight loss
B) Decreased blood pressure
C) Distended neck veins
D) Rapid breathing
E) Hypernatrem
ia Ans: C, D
Feedback:
Signs of fluid overload include headache, weakness, blurred vision,
behavioral changes, weight gain, isolated muscle twitching, hyponatremia,
rapid breathing, wheezing, coughing, rise in blood pressure, distended neck
veins, elevated central venous pressure, and convulsions.
A client has developed electrolyte imbalances. The nurse understands that
which of the following would most likely contribute to the client's current
situation? Select all that apply.
A) Vomiting
B) Constipation
C) Surgery
D) Drug administration
E) Diagnostic
tests Ans: A, C,
D, E
Feedback:
The following can result in electrolyte imbalances in a client: vomiting,
diarrhea, surgery, drug administration, and diagnostic tests.
The primary health care provider prescribes potassium to be replaced IV.
When reviewing the client's medication history, the nurse determines that
the underlying reason for this order is most likely the administration of which
of the following drugs? Select all that apply.
A) Furosemide (Lasix)
B) Enalaprilat (Vasotec)
C) Bumetanide (Bumex)
D) Ceftriaxone (Rocephin)
E) Spironolactone
(Aldactone) Ans: A, C
Feedback:
The administration of loop diuretics, like furosemide (Lasix) and bumetanide
(Bumex), causes the excretion of water and potassium and can result in the
need for IV fluid replacement of potassium.
A nurse suspects a client may have hypocalcemia based on assessment of
which of the following? Select all that apply.
A) Hypoactive reflexes
B) Positive Homan's sign
C) Positive Trousseau's sign
