AH2 Exam #3 with Verified Solutions
The nurse is assessing a client for local complications of emesis, and Hemovac drainage. Which nursing action is best to
intravenous therapy. Which are local complications? Select all maintain an acceptable fluid balance?
that apply.
Suggest a fluid restriction.
Extravasation Encourage oral fluids.
Infection Remove the Hemovac.
Hematoma Offer a prescribed antiemetic medication. - ANSWER -
Phlebitis Offer a prescribed antiemetic medication.
Air embolism - ANSWER -Extravasation
Hematoma
Phlebitis
The nurse is reviewing lab work on a newly admitted client.
Which of the following diagnostic studies confirm the nursing
diagnosis of Deficient Fluid Volume? Select all that apply.
A nurse caring for a patient who is receiving an IV solution via a
central vein suspects the complication of an air embolism. An elevated hematocrit level
Which of the following are signs and symptoms consistent with A low urine specific gravity Electrolyte imbalance
that diagnosis? Select all that apply. Low protein level in the urine Absence of ketones in urine -
ANSWER -An elevated hematocrit level
Crackles on auscultation Electrolyte imbalance
Cyanosis
Hypertension
Shoulder pain
Dyspnea A physician orders regular insulin 10 units I.V. along with 50 ml
Tachycardia - ANSWER -Shoulder pain of dextrose 50% for a client with acute renal failure. What
Dyspnea electrolyte imbalance is this client most likely experiencing?
Cyanosis
Tachycardia Hypercalcemia
Hypernatremia
Hyperglycemia
Hyperkalemia - ANSWER -Hyperkalemia
A client is experiencing edema in the tissue. The nurse is
correct in anticipating which tonicity of intravenous fluid?
Isotonic fluid A client with pancreatic cancer has the following blood chemistry
No intravenous solution profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN):
Hypertonic solution 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium:
Hypotonic solution - ANSWER -Hypertonic solution 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result
should the nurse identify as critical and report immediately?
CO2
A client with an intravenous infusion is rubbing his arm. The Sodium
nurse assesses the site and decides to discontinue the current Chloride
infusion because of concern that the client has developed Potassium - ANSWER -Potassium
phlebitis. Which of the following clinical manifestations would
the nurse assess with phlebitis? Select all that apply.
Cool area around the insertion site Reddened area along the The nurse is working on a burns unit and an acutely ill client is
path of the vein exhibiting signs and symptoms of third spacing. Based on this
Tender area around the insertion site Ecchymosis at the change in status, the nurse should expect the client to exhibit
insertion site Rapid, shallow respirations - ANSWER - signs and symptoms of what imbalance?
Reddened area along the path of the vein
Tender area around the insertion site Metabolic alkalosis Hypermagnesemia
Hypercalcemia
Hypovolemia - ANSWER -Hypovolemia
The nurse is adding the intake and output results for a client
diagnosed with dehydration. The nurse notes a 24-hour intake
of 1500 mL/day between oral fluids and intravenous solutions. While assessing a client's peripheral IV site, the nurse observes
The output total is calculated as 2800 mL/day from urine output, edema around the insertion site. How should the nurse
, AH2 Exam #3 with Verified Solutions
document this complication related to IV therapy? ANSWER -ensure that the tubing is firmly anchored to the
client's skin.
Air emboli
Phlebitis
Infiltration
Fluid overload - ANSWER -Infiltration The nurse is caring for a client who is to receive IV
daunorubicin, a chemotherapeutic agent. The nurse starts the
infusion and checks the insertion site as per protocol. During the
most recent check, the nurse observes that the IV has infiltrated
The physician has prescribed a peripheral IV to be inserted so the nurse stops the infusion. What is the nurse's priority
before the client goes for computed tomography. What should concern with this infiltration?
the nurse do when selecting a site on the hand or arm for
insertion of an IV catheter? Extravasation of the medication Discomfort to the client
Blanching at the site
Choose a hairless site if available. Consider potential effects on Hypersensitivity reaction to the medication - ANSWER -
the client's mobility when selecting a site. Have the client briefly Extravasation of the medication
hold his arm over his head before insertion.
Leave the tourniquet on for at least 3 minutes. -
ANSWER -Consider potential effects on the client's
mobility when selecting a site. A patient with severe hypervolemia is prescribed a loop diuretic.
The nurse knows that this drug can cause a significant loss of
sodium and has to be carefully monitored. Which of the following
drugs is most likely the one that was prescribed?
A nurse in the neurologic ICU has received a prescription to
infuse a hypertonic solution into a client with increased Lasix
intracranial pressure. This solution will increase the number of Hydrodiuril
dissolved particles in the client's blood, creating pressure for Mykrox
fluids in the tissues to shift into the capillaries and increase the Zaroxolyn - ANSWER -Lasix
blood volume. This process is best described as which of the
following?
Hydrostatic pressure Which of the following is the most common cause of
Osmosis and osmolality symptomatic hypomagnesemia in the United States?
Diffusion
Active transport - ANSWER -Osmosis and osmolality Alcoholism
Intestinal resection
Inflammatory bowel disease
Loss of gastric acid - ANSWER -Alcoholism
The surgical nurse is caring for a client who is postoperative
day 1 following a thyroidectomy. The client reports tingling in
her lips and fingers. She states that she has an intermittent
spasm in her wrist and hand and she exhibits increased muscle Your client has a diagnosis of hypervolemia. What would be an
tone. What electrolyte imbalance should the nurse first suspect? important intervention that you would initiate?
Hypophosphatemia Give medications that promote fluid retention.
Hypocalcemia Limit sodium and water intake.
Hypermagnesemia Assess for dehydration.
Hyperkalemia - ANSWER -Hypocalcemia Teach client behaviors that decrease urination. -
ANSWER -Limit sodium and water intake.
The nurse is caring for a client who has a peripheral IV in place
for fluid replacement. When caring for the client's IV site, the A client was admitted to the hospital unit after 2 days of vomiting
nurse should: and diarrhea. The client's spouse became alarmed when the
client demonstrated confusion and elevated temperature, and
ensure that anticoagulants are placed on hold for the duration of reported "dry mouth." The nurse suspects the client is
IV therapy. replace the IV dressing with a new, clean dressing if experiencing which condition?
it is soiled.
ensure that the tubing is firmly anchored to the client's skin. dehydration
periodically remove hair from 2 cm around the IV site. - hypervolemia
The nurse is assessing a client for local complications of emesis, and Hemovac drainage. Which nursing action is best to
intravenous therapy. Which are local complications? Select all maintain an acceptable fluid balance?
that apply.
Suggest a fluid restriction.
Extravasation Encourage oral fluids.
Infection Remove the Hemovac.
Hematoma Offer a prescribed antiemetic medication. - ANSWER -
Phlebitis Offer a prescribed antiemetic medication.
Air embolism - ANSWER -Extravasation
Hematoma
Phlebitis
The nurse is reviewing lab work on a newly admitted client.
Which of the following diagnostic studies confirm the nursing
diagnosis of Deficient Fluid Volume? Select all that apply.
A nurse caring for a patient who is receiving an IV solution via a
central vein suspects the complication of an air embolism. An elevated hematocrit level
Which of the following are signs and symptoms consistent with A low urine specific gravity Electrolyte imbalance
that diagnosis? Select all that apply. Low protein level in the urine Absence of ketones in urine -
ANSWER -An elevated hematocrit level
Crackles on auscultation Electrolyte imbalance
Cyanosis
Hypertension
Shoulder pain
Dyspnea A physician orders regular insulin 10 units I.V. along with 50 ml
Tachycardia - ANSWER -Shoulder pain of dextrose 50% for a client with acute renal failure. What
Dyspnea electrolyte imbalance is this client most likely experiencing?
Cyanosis
Tachycardia Hypercalcemia
Hypernatremia
Hyperglycemia
Hyperkalemia - ANSWER -Hyperkalemia
A client is experiencing edema in the tissue. The nurse is
correct in anticipating which tonicity of intravenous fluid?
Isotonic fluid A client with pancreatic cancer has the following blood chemistry
No intravenous solution profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN):
Hypertonic solution 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium:
Hypotonic solution - ANSWER -Hypertonic solution 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result
should the nurse identify as critical and report immediately?
CO2
A client with an intravenous infusion is rubbing his arm. The Sodium
nurse assesses the site and decides to discontinue the current Chloride
infusion because of concern that the client has developed Potassium - ANSWER -Potassium
phlebitis. Which of the following clinical manifestations would
the nurse assess with phlebitis? Select all that apply.
Cool area around the insertion site Reddened area along the The nurse is working on a burns unit and an acutely ill client is
path of the vein exhibiting signs and symptoms of third spacing. Based on this
Tender area around the insertion site Ecchymosis at the change in status, the nurse should expect the client to exhibit
insertion site Rapid, shallow respirations - ANSWER - signs and symptoms of what imbalance?
Reddened area along the path of the vein
Tender area around the insertion site Metabolic alkalosis Hypermagnesemia
Hypercalcemia
Hypovolemia - ANSWER -Hypovolemia
The nurse is adding the intake and output results for a client
diagnosed with dehydration. The nurse notes a 24-hour intake
of 1500 mL/day between oral fluids and intravenous solutions. While assessing a client's peripheral IV site, the nurse observes
The output total is calculated as 2800 mL/day from urine output, edema around the insertion site. How should the nurse
, AH2 Exam #3 with Verified Solutions
document this complication related to IV therapy? ANSWER -ensure that the tubing is firmly anchored to the
client's skin.
Air emboli
Phlebitis
Infiltration
Fluid overload - ANSWER -Infiltration The nurse is caring for a client who is to receive IV
daunorubicin, a chemotherapeutic agent. The nurse starts the
infusion and checks the insertion site as per protocol. During the
most recent check, the nurse observes that the IV has infiltrated
The physician has prescribed a peripheral IV to be inserted so the nurse stops the infusion. What is the nurse's priority
before the client goes for computed tomography. What should concern with this infiltration?
the nurse do when selecting a site on the hand or arm for
insertion of an IV catheter? Extravasation of the medication Discomfort to the client
Blanching at the site
Choose a hairless site if available. Consider potential effects on Hypersensitivity reaction to the medication - ANSWER -
the client's mobility when selecting a site. Have the client briefly Extravasation of the medication
hold his arm over his head before insertion.
Leave the tourniquet on for at least 3 minutes. -
ANSWER -Consider potential effects on the client's
mobility when selecting a site. A patient with severe hypervolemia is prescribed a loop diuretic.
The nurse knows that this drug can cause a significant loss of
sodium and has to be carefully monitored. Which of the following
drugs is most likely the one that was prescribed?
A nurse in the neurologic ICU has received a prescription to
infuse a hypertonic solution into a client with increased Lasix
intracranial pressure. This solution will increase the number of Hydrodiuril
dissolved particles in the client's blood, creating pressure for Mykrox
fluids in the tissues to shift into the capillaries and increase the Zaroxolyn - ANSWER -Lasix
blood volume. This process is best described as which of the
following?
Hydrostatic pressure Which of the following is the most common cause of
Osmosis and osmolality symptomatic hypomagnesemia in the United States?
Diffusion
Active transport - ANSWER -Osmosis and osmolality Alcoholism
Intestinal resection
Inflammatory bowel disease
Loss of gastric acid - ANSWER -Alcoholism
The surgical nurse is caring for a client who is postoperative
day 1 following a thyroidectomy. The client reports tingling in
her lips and fingers. She states that she has an intermittent
spasm in her wrist and hand and she exhibits increased muscle Your client has a diagnosis of hypervolemia. What would be an
tone. What electrolyte imbalance should the nurse first suspect? important intervention that you would initiate?
Hypophosphatemia Give medications that promote fluid retention.
Hypocalcemia Limit sodium and water intake.
Hypermagnesemia Assess for dehydration.
Hyperkalemia - ANSWER -Hypocalcemia Teach client behaviors that decrease urination. -
ANSWER -Limit sodium and water intake.
The nurse is caring for a client who has a peripheral IV in place
for fluid replacement. When caring for the client's IV site, the A client was admitted to the hospital unit after 2 days of vomiting
nurse should: and diarrhea. The client's spouse became alarmed when the
client demonstrated confusion and elevated temperature, and
ensure that anticoagulants are placed on hold for the duration of reported "dry mouth." The nurse suspects the client is
IV therapy. replace the IV dressing with a new, clean dressing if experiencing which condition?
it is soiled.
ensure that the tubing is firmly anchored to the client's skin. dehydration
periodically remove hair from 2 cm around the IV site. - hypervolemia
