Nsg 331Med-Surg (Adult Client in Community/Acute Care)
Marian University EAQ Fluid & Electrolytes Questions
With Complete Solutions
A nurse finds circulatory overload in a patient on intravenous
infusion. Which intervention would benefit this patient?
a. Elevating the extremity
b. Raising the head of the bed
c. Applying a warm and moist compress
d. Starting a new intravenous line in another extremity Correct
Answers b. Raising the head of the bed
Rationale: Circulatory overload of intravenous solution occurs
due to infusion at a too rapid rate or an infusion of too much
solution. Circulatory overload causes excessive extracellular
volume. Raising the head of the bed will help a patient in this
case. Elevating the extremity of the patient reduces
extravasations. A warm, moist compress is applied for phlebitis.
Starting a new intravenous line in another extremity is
considered appropriate when the patient's extremity develops
local infection.
A nurse teaches a patient with dehydration about maintaining
safe intravenous therapy at home. Which statement made by the
patient indicates a need for further learning?
a. "I should perform isometric exercises daily for 30 minutes."
,b. "I should cover the injection site with plastic to prevent the
site from getting wet during a shower."
c. "I should apply pressure to the injection site with sterile gauze
if the catheter falls out."
d. "I should immediately report inflammation and itching at the
injection site." Correct Answers a. "I should perform isometric
exercises daily for 30 minutes."
Rationale: A patient who is undergoing intravenous therapy
should not perform isometric exercises because it may lead to
bleeding and injury at the injection site. During a shower, the
patient should protect the injection site and dressing from
getting wet by covering it with plastic. Applying pressure with
sterile gauze at the injection site if the catheter falls out helps to
reduce bleeding. Inflammation and itching at the injection site
may be an indication of infection and phlebitis; the patient
should report these manifestations immediately.
A patient develops a mild allergic reaction during a blood
transfusion. Which should the nurse administer to manage this
allergic reaction?
a. Sympathomimetics
b. Corticosteroids
c. Antihistamines
,d. Vasoconstrictors Correct Answers c. Antihistamines
Rationale: Mild allergic reactions during blood transfusion are
managed by administering antihistamines. Antihistamines
prevent the release of histamine from the cells, thereby
preventing the allergic reaction from getting worse. Epinephrine
(a sympathomimetic) is used only in patients with anaphylaxis.
Corticosteroids usually do not have an immediate action and are
usually not required for mild allergic reactions. Vasopressors are
required only during sepsis related to blood transfusion.
A patient develops acute intravascular hemolytic transfusion
reaction following transfusion with incompatible blood. Which
treatment strategies should be included in the patient's
management? (Select all that apply).
a. Stop the transfusion immediately.
b. Maintain the blood pressure (BP) at the normal range.
c. Avoid keeping the intravenous (IV) line connected.
d. Administer diuretics.
e. Insert an indwelling urinary catheter. Correct Answers a.
Stop the transfusion immediately.
b. Maintain the blood pressure (BP) at the normal range.
d. Administer diuretics.
, e. Insert an indwelling urinary catheter.
Rationale: When a patient develops acute intravascular
hemolytic transfusion reaction due to a mismatched transfusion,
the transfusion should be stopped immediately to prevent further
worsening of the condition. The blood bag and transfusion set
should be saved for further investigation. The blood pressure
(BP) should be maintained to the normal range to ensure
perfusion to vital organs. To maintain urinary flow, the nurse
may administer diuretics if prescribed. An indwelling urinary
catheter may be inserted for hourly monitoring of urine output.
The intravenous (IV) line must be kept open by infusing normal
saline through new tubing.
A patient develops an anaphylactic reaction following initiation
of a blood transfusion. Which primary drug should the nurse use
for the patient?
a. Epinephrine
b. Vasopressor
c. Antihistamine
d. Glucocorticoid Correct Answers a. Epinephrine
Rationale: Blood transfusions may cause anaphylactic reactions.
Epinephrine is the drug of choice, because it relieves all of the
clinical features of anaphylaxis. Vasopressors do not control the
dyspnea and wheezing of anaphylaxis. They are used to control
blood pressure. Antihistamines and glucocorticoids may be used
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