A nurse monitoring a client's IV infusion auscultates the client's lung sounds
and finds crackles in the bases of lungs that were previously clear. What would
be the appropriate intervention in this situation?
a) Check all clamps on the tubing and check the tubing for any kinking.
b) Notify the primary care provider immediately because these are signs of
speed shock.
c) Notify the primary care provider immediately for possible fluid overload.
d) No intervention is necessary as this is a normal finding with IV infusion. -
ANSWER Correct response: Notify the primary care provider immediately for
possible fluid overload.
Explanation: If the client's lung sounds were previously clear, but now some
crackles in the bases are auscultated, notify the primary care provider
immediately. The client may be exhibiting signs of fluid overload. Be prepared
to tell the health care provider what the past intake and output totals were, as
well as the vital signs and pulse oximetry findings of the client.
The client is admitted to the nurse's unit with a diagnosis of heart failure. His
heart is not pumping effectively, which is resulting in oedema and coarse
crackles in his lungs. The term for this condition is which of the following?
a) Fluid volume deficit
b) Myocardial Infarction
c) Fluid volume excess
d) Atelectasis - ANSWER Correct response: Fluid volume excess
Explanation:
A common cause of fluid volume excess is failure of the heart to function as a
pump, resulting in accumulation of fluid in the lungs and dependent parts of the
, body. Fluid volume deficit does not manifest itself as edema and abnormal lung
sounds, but results in poor skin turgor, sunken eyes, and dry mucous
membranes. Atelectasis is a collapse of the lung and does not have to do with
fluid abnormalities. Myocardial infarction results from a blocked coronary
artery and may result in heart failure, but is not a term for fluid volume excess.
The primary extracellular electrolytes are:
a) Sodium, chloride, and bicarbonate
b) Phosphorous, calcium, and phosphate
c) Magnesium, sulfate, and carbon
d) Potassium, phosphate, and sulfate - ANSWER Explanation: The primary
extracellular electrolytes are sodium, chloride, and bicarbonate.
Mr Powell, a dehydrated 35 year old has intravenous fluid running at 250 cc/h.
for rapid rehydration. He is complaining of burning at the site. You see no
redness, swelling, heat, or coolness upon inspection. You suspect
a) Infiltration
b) That the fluid is infusing too rapidly for comfort
c) That something is wrong with the IV fluid
d) Phlebitis - ANSWER Explanation:
The fluid is infusing too rapidly. You should slow the infusion to 200 cc/h.
When a client age 80 years who takes diuretics for management of hypertension
informs the nurse that she takes laxatives daily to promote bowel movements,
the nurse assesses the client for possible symptoms of what?
a) Hypothyroidism
b) Hypoglycemia
c) Hypokalemia
d) Hypocalcemia - ANSWER Explanation:
The frequent use of laxatives and diuretics promotes the excretion of potassium
and magnesium from the body, increasing the risk for fluid and electrolyte
deficits.
A nurse inadvertently partially dislodges a PICC line when changing the
dressing. What would be the appropriate intervention in this situation?
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