(Test Bank) Level Of Cognitive Ability - Analysis 2000 Questions And Answers

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1. A nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for deficient fluid volume? * a) A client with a colostomy b) A client with congestive heart failure c) A client with decreased kidney function d) A client receiving frequent wound irrigations R: Causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insuf ficient IV fluid replacement, drain ing fistulas, and the presence of an ileostomy or colostomy. A client with congestive heart failure or decreased kidney function, or a client receiving frequent wound irrigations, is at risk for excess fluid volume. 2. A nurse caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition? a) Lung congestion b) Decreased hematocrit c) Increased blood pressure * d) Decreased central venous pressure (CVP) R: Assessment findings in a client with a deficient fluid volume include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry muc ous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H 2O. A client with dehydration has a low CVP. The assessment findings in options 1, 2, and 3 are seen in a client with excess fluid volume. 3. A nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for excess fluid volume? a) The client taking diureti cs * b) The client with renal failure c) The client with an ileostomy d) The client who requires gastrointestinal suctioning R: The causes of excess fluid volume include decreased kidney function, congestive heart failure, the use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for deficient fluid volume. 4. The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present? a) Weight loss b) Flat neck and hand veins * c) An increase in blood pressure d) A decreased central venous pressure (CVP) R: Assessment findings associated with excess fl uid volume include cough, dy spnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, an elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and a decreased hematocrit. Options 1, 2, and 4 identify signs noted in deficient fluid volume. 5. A nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client’s record and determines that the client was at risk for developing the potassium deficit because the client: a) Has renal failure. * b) Requires nasogastric suction. c) Has a history of Addison’s disease. d) Is taking a potassium -sparing diuretic. R: Potassium -rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with r enal failure or Addison’s disease and the client taking a potassium -sparing diuretic are at risk for hyperkalemia. 6. A nurse reviews a client’s electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Whic h of the following would the nurse note on the electrocardiogram as a result of the laboratory value? * a) U waves b) Absent P waves c) Elevated T waves d) Elevated ST segment R: A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalan ce and is potentially life threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia. 7. A nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium? a) Obtaining a controlled IV infusion pump b) Monitoring urine output during administration c) Diluting in appropriate amount of normal saline * d) Preparing the medication for bolus administration R: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via a pump or controller. The usual concentration of IV potassium chloride is 20 to 40 mEq/L . Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilut ion in normal saline is recommended, but dextrose solution is avoided because this type of solution increases intracellular potassium shifting. The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored closely becaus e potassium chloride is irritating to the veins and the risk of phlebitis exists. The nurse monitors urinary output during administration and contacts the physician if the urinary output is less than 30 mL/hr. 8. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client’s laboratory report. The nurse understands that which client is at highest risk for the development of a potassium value at this level? a) The client with colitis b) The client with Cushing’s syndrome c) The client who has been overusing laxatives * d) The client who has sustained a traumatic burn R: A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Clients who experience cellular shifting of potas sium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing’s syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia. 9. A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value? a) ST depression b) Inverted T wave c) Prominent U wave * d) Tall peaked T waves R: A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Electrocardiographic changes include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. 10. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client’s laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level? a) The client with renal failure * b) The client who is taking diuretics c) The client with hyperaldosteronism d) The client who is taking corticosteroids R: Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyponatremia c an occur in the client taking diuretics. The client taking corticosteroids and the client with renal failure or hyperaldosteronism are at risk for hypernatremia. 11. A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present? a) Dry skin b) Decreased urinary output * c) Hyperactive bowel sounds d) Increased specific gravity of the urine R: Hyperactive bowel sounds indicate hyponatremia. Options 1, 2, and 4 are signs of hypernatremia. In hyponatremia, increase d urinary output and decreased specific gravity of the urine would be noted. Dry skin occurs in deficient fluid volume. 12. A nurse is reviewing a client’s laboratory report and notes that the serum calcium level is 4.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level? * a) Prolonged bed rest b) Renal insufficiency c) Hyperparathyroidism d) Exces sive ingestion of vitamin D R: The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 4.0 mg/dL is experiencing hypocalcemia. The excessive ingestion of vitamin D and hyperparathyroidism are causative factors associated with hypercalcemia. End -stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Prolonged bed rest is a c ause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. 13. A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifest ations would the nurse expect to note in the client? * a) Twitching b) Negative Trousseau’s sign c) Hypoactive bowel sounds d) Hypoactive deep tendon reflexes R: Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexe s, and a positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. 14. A nurse caring for a client with hypocalcemia would expect to note which of the following changes on the electrocardiogram? a) Widened T wave b) Prominent U wave * c) Prolonged QT interval d) Shortened ST segment R: Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with hypokalemia. 15. A nurse caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which electrocardiographic change would the nurse expect to note based on the magnesium level? a) Prominent U waves b) Prolonged PR interval 3 3 3 3 * c) Depressed ST segment d) Widened QRS complexes R: The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL indicates hypomagnesemia. In hypomagnesemia, the nurse would note tall T waves and a depressed ST segment. Options 2 and 4 would be noted in a client experiencing hypermagnesemia. Prominent U waves occur with hypokalemia. 16. A nurse reviews a client’s laboratory report and notes that the client’s serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level? * a) Alcoholism b) Renal insufficiency c) Hypoparathyroidism d) Tumor lysis syndrome R: The normal serum phosphorus level is 2.7 to 4.5 mg/dL. The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminu m hydroxide –based or magnesium - based antacids. Malnutrition is associated w ith alcoholism. Hypoparathyroidism, tumor lysis syndrome, and renal insufficiency are causative factors of hyperphosphatemia. 17. A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 6 breaths/min. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/min. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which of the following? a) A decreased pH and an increased CO 2 b) An increased pH and a decreased CO 2 c) A decreased pH and a decreased HCO – * d) An increased pH with an increased HCO – R: Clients experiencing nausea and vomiti ng would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO – to increase. Symptoms experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition. Option 3 reflects a metabolic acidotic condition. 18. A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Pco 2 is 90 mm Hg, and HCO – is 22 mEq/L. The nurse interprets the results as indicating which condition? a) Metabolic acidosis with compensation b) Respiratory acidosis with compensation c) Metabolic acidosis without compensation * d) Respiratory acidosis without compensation R: The aci d-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Pco 2 is 35 to 45 mm Hg. In respiratory acidosis the pH is decreased and the Pco 2 is elevated. The normal bicarbonate (HCO 3–) level is 22 to 27 mEq/L. Because the bicarbonate is still within normal limits, the kidneys 3 have not had time to adjust for this acid-base disturbance. Therefore, the condition is without compensation. Options 1, 2, and 3 are incorrect. 19. A nurse reviews the blood gas results of a client with Guillain -Barré syndrome. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which of the following validates the nurse’s findings? * a) pH 7.25, PCO 2 50 mm Hg b) pH 7.35, PCO 2 40 mm Hg c) pH 7.50, PCO 2 52 mm Hg d) pH 7.52, PCO 228 mm Hg R: The normal pH is 7.35 to 7.45. The normal PCO 2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is decreased and the PCO 2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition. Option 4 identifies respiratory alkalosis. 20. A nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PCO 2of 30 mm Hg, and HCO – of 22 mEq/L. The nurse analyzes these results as indicating which condition? a) Metabolic acido sis, compensated * b) Respiratory alkalosis, compensated c) Metabolic alkalosis, uncompensated d) Respiratory acidosis, uncompensated R: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the PCO 2. In thi s situation, the pH is at the high end of the normal value and the PCO 2 is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis. Compensation occurs when the pH returns to a normal value. Because the pH is in the normal range at the high end, com pensation has occurred. 21. A client is brought to the emergency room stating that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to do which of the following next? a) Prepares to administer an antidote b) Draws a sample for type and crossmatch and transfuse the client c) Draws a sample for an activated partial t hromboplastin time (aPTT) level * d) Draws a sample for prothrombin (PT) and international normalized ratio (INR) level R: The next action is to draw a sample for PT and INR level to determine the client’s anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client if an antidote (vitamin K) or blood transfusion is needed. The aPTT monitors the effects of heparin therapy. 22. The nurse is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of: a) 45 units/L b) 100 units/L * c) 300 units/L d) 500 units/L R: The normal serum amylase level is 25 to 151 units/L. With chronic ca ses of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Options 1 and 2 are within normal limits. Option 4 is an extremely elevated level seen in acute pancreatitis. 23. A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to: a) 3 mg/dL * b) 15 mg/dL c) 29 mg/dL d) 35 mg/dL R: The normal blood urea nitrogen level is 8 to 25 mg/dL. Values such as those in options 3 and 4 reflect continued dehydration. Option 1 reflects a lower than normal value, which may occur with fluid volume overload, among other conditions. 24. A client arrives in the emergency room complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL. The nurse interprets that this result indicates a: a) Normal level b) Low value that indicates possible gastritis * c) Level that indicates a myocardial infarction d) Level that indicates the presence of possible angina R: Troponin is a regulatory protein found in striated muscle. The troponins function together in the con tractile apparatus for striated muscle in skeletal muscle and in the myocardium. Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. A troponin T value that is higher than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction. A normal troponin I level is lower than 0.6 ng/mL. 25. An adult client has had laboratory work done as part of a routine physical examination. The nurse interprets that the client may have a mild degree of renal insuf ficiency if which of the following serum creatinine levels is noted? a) 0.2 mg/dL b) 0.5 mg/dL * c) 1.9 mg/dL d) 3.5 mg/dL R: The normal serum creatinine level for adults is 0.6 to 1.3 mg/dL. The client with a mild degree of renal insufficiency would have a sligh tly elevated level. A creatinine level of 0.2 mg/dL is low, and a level of 0.5 mg/dL is just below normal. A creatin ine level of 3.5 mg/dL may be associated with acute or chronic renal failure. 26. A client with atrial fibrillation who is receiving maintenanc e therapy of warfarin sodium (Coumadin) has a prothrombin time of 35 seconds. Based on the prothrombin time, the nurse anticipates which of the following orders? a) Adding a dose of heparin sodium * b) Holding the next dose of warfarin c) Increasing the next dose of warfarin d) Administering the next dose of warfarin R: The normal prothrombin time (PT) is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds (female adult). A therapeutic PT level is 1.5 to 2.0 times higher than the normal level. Because the valu e of 35 seconds is high (and perhaps near the critical range), the nurse should anticipate that the client would not receive further doses at this time. 27. A client is receiving a continuous intravenous infusion of hepa rin sodium to treat deep vein thrombosi s. The client’s activated partial thromboplastin (aPTT) time is 65 seconds. The client’s baseline before the initiation of therapy was 30 seconds. The nurse anticipates that which action is needed? a) Discontinuing the heparin infusion b) Increasing the rate of the heparin infusion c) Decreasing the rate of the heparin infusion * d) Leaving the rate of the heparin infusion as is R: The normal activated partial thromboplastin time (aPTT) varies between 20 and 36 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 t imes normal. Thus, the client’s aPTT is within the therapeutic range, and the dose should remain unchanged. 28. An adult client was diagnosed w ith acute pancreatitis 9 days ago. The nurse interprets that the client is recovering from this episode if the serum lipase level decreases to which of the following values, which is just below the upper limit of normal? a) 20 units/L b) 80 units/L * c) 135 units/ L d) 350 units/L R: The normal serum lipase level is 10 to 140 units/L. The client who is recovering from acute pancreatitis usually has elevated lipase levels for about 10 days after the onset of symptoms. This makes lipase a valuable test in monitoring the client’s pancreatic function because serum amylase levels usually return to normal 3 days after the onset of symptoms. Option 3 is the only option that contains a value just below the upper limit of normal. 29. An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is most likely caused by which of the following conditions noted in the client’s history? a) Dehydration b) Heart failure * c) Iron deficiency anemia d) Chronic obstructive pulmonary disease R: The normal hemoglobin level for an adult female client is 12 to 15 g/dL. Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failu re and chronic obstructive pulmonary disease may increas e the hemoglobin level as a result of the body’s need for more oxygen -carrying capacity. 30. The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client’s whi te blood cell count was which of the following? * a) 2,000 cells/ mm3 b) 5,800 cells/ mm3 c) 8,400 cells/ mm3 d) 11,500 cells/ mm3 R: The normal white blood cell count ranges from 4,500 to 11,000/mm3. The client who is immunosuppressed has a decrease in the number o f circulating white blood cells. The nurse implements neutropenic precautions when the client’s values fall sufficiently below the normal level. The specific value for implementin g neutropenic precautions usually is determined by agency policy. Options 2, 3, and 4 are normal values. 31. The nurse instructs a client with renal failure who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? * a) Cream of wheat, blueberries, coffee b) Sausage and eggs, banana, orange juice c) Bacon, cantaloupe melon, tomato juice d) Cured pork, grits, strawberries, orange juice R: The diet for a client with renal failure who is receiving hemodialysis shoul d include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids. Options 2, 3, and 4 are high in sodium, phosphorus and potassium. 32. The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary modifications if she selects which of the following from her menu? a) Nuts and milk b) Coffee and tea c) Cooked rolled oats and fish * d) Oranges and dark green leafy vegetables R: Dark green leafy vegeta bles are a good source of iron and oranges are a good source of vitamin C, which enhances iron absorption. All other options are not food sources that are high in iron and vitamin C. 33. A client who recently has been started on enteral feedings begins to com plain of abdominal cramping, followed by the passage of two liquid stools. A nurse notes that the client has abdominal distention as well. The nurse reviews the nutritional content on the label of the can of feeding to see if it has which of the follow ing ingredients? * a) Lactose b) Sucrose c) Fructose d) Maltose R: Several tube feeding formulas contain lactose. A client with an unreported history of lactose intolerance would develop symptoms such as abdominal cramping, distention, and the passage of liquid stool i n response to nutritional therapy with these formulas. If the client is diagnosed as lactose intolerant, a lactose -free formula should be prescribed by the phys ician. This will resolve the client’s symptoms and promote adequate nutrition for the client. 34. A nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of: * a) Pork b) Milk c) Chicken d) Broccoli R: The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legum es. Milk contains vitamins A, D, and B2. Poultry contains niacin. Broccoli contains vitamins C, E, and K and folic acid. 35. A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hr. A nurse anticipates that which of the following orders regarding the PN solution will accompany the diet order? a) Discontinue the PN. * b) Decrease PN rate to 50 mL/hr. c) Hang 1000 mL 0.9% normal saline. d) Continue current infusion rate orders for PN. R: When a client begins eating a regular diet after a period of receiving parenteral nutrition, the PN is decreased gradually. Parenteral nut rition that is discontinued abruptly can cause hypoglycemia. Clients often have anorexia after being without food for some time, and the digestive tract also is not used to producing the digestive enzymes that will be needed. Gradu ally decreasing the infus ion rate allows the client to remain adequately nourished during the transition to a normal diet and prevents the occurrence of hypoglycemia. Even before clients are started on a solid diet, they are given clear liquids followed by full liquids to further ease the transition. A solution of normal saline will not provide the glucose needed during the transition of discontinuing the PN and also could cause the client to experience hypoglycemia. 36. A client receiving parenteral nutrition (PN) complains of a head ache. A nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse interprets that the client is experiencing which complication of PN therapy? a) Sepsis b) Air embolism * c) Hypervolem ia d) Hyperglycemia R: The client’s signs and symptoms are consistent with hypervolemia. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. The volume also causes neck vein diste ntion and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms presented in the question do not indicate hyperglycemia, air embolism, or sepsis. 37. A nurse enters the room of a client receiving parentera l nutrition (PN) and discovers that the electronic infusion pump has been shut off. After checking the line for patency and restarting the infusion, the nurse assesses the client for which of the following signs and symptoms? a) Fever and chills b) Dyspnea and hypotension c) Weakness, thirst, and excessive urination * d) Weakness, shakiness, diaphoresis, and complaints of hunger R: If the pump that is infusing PN shuts off for a period of time, the nurse assesses the client for signs and symptoms of hypoglycemia. The se signs include weakness, shakiness, headache, anxiety, diaphoresis, and complaints of hunger. The blood glucose level will be lower than 70 mg/dL. The other signs and symptoms described are those of infection (option 1), air embolism (option 2), and hype rglycemia (option 3). 38. A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse next assesses the client to detect the presence of which of the following? a) Thirst b) Polyuria c) Decreased blood pressure * d) Crackles on auscultation of the lungs R: Optimal weight gain on PN is 1 to 2 lb/week. The client who has a weight gain of 5 lb/week while receiving PN is likely to have fluid retention that can result in hypervolemia. Signs of hypervolemia include increased blood pressure, crackles on lung auscultation, a bounding pulse, jugular vein distention , headache, and weight gain more than desired. Options 1 and 2 are associated with hyperglycemia. Option 3 is likely to be noted in deficient fluid volume. 39. A nurse is caring for a group of adult clients on an acute care medical -surgical nursing unit. The nurse understands that which of the following clients would be the least likely candidate for parenteral nutrition (PN)? a) A 66-year-old client with extensive burns * b) A 42-year-old client who has had an open cholecystectomy c) A 27-year-old client with severe exacerbation of Crohn’s disease d) A 35-year-old client with persistent nausea and vomiting from chemotherapy R: Parenteral nutrition is indicated in clients whose gastrointestinal tracts are not functional or who cannot take in a diet enterally for extended periods. Examples of these conditions include those of the clients identified in options 1, 3, and 4. Other clients would be those who have had extensive surgery, have multiple fractures, are septic, or have advanced cancer or acquired immunodeficiency syndrome. The client with the open cholecystectomy is not a candidate because this client would resume a regular diet within a few days following surgery. 40. A client recently diagnosed with a myocardial infarction and impaired renal function is recuperating on the step-down cardiac unit. The client’s blood pressure has been borderline low and intravenous (IV) fluids have been infusing at 100 mL/hr via a central line catheter in the right internal jugular for approximately 24 hours to increase renal output and maintain the blood pressure. On entering the client’s room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that the clie nt is most likely experiencing which com plication of intravenous therapy? a) Hematoma b) Systemic infection c) Electrolyte overload * d) Circulatory overload R: Circulatory (fluid overloa d) is a complication of intravenous therapy. Signs include rapid breathing, dyspnea, a moist cough, and crackles. When circulatory overload is present, the client’s blood pressure would also increase. Hematoma is characterized by ecchymosis, swelling and leakage at the IV insertion site, and hard and painful lumps at the site. Syste mic infection is characterized by chills, fever, malaise, headache, nausea, vomiting, backache, and tachycardia. Signs of electrolyte imbalance depend on the specific electrolyte. 41. A client involved in a motor vehicle crash presents to the emergency depart ment with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which of the following intravenous solutions will most likely be prescribed to increase intravascular volume, replace immediate blood loss, and increase blood pressure? a) 0.45% sodium chloride b) 0.33% sodium chloride c) 0.225% sodium chloride * d) Lactated Ringer’s solution R: The goal of therapy with this client is to expand intravascular volume as quickly as possible. Lactated Ringer’s (hypertonic s olution) would increase intravascular volume and immediately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client’s blood pressure. The solutions in options 1, 2, and 3 would not be given to this clien t because they are hypotonic solutions and, instead of increasing intravascular space, the solutions would move into the cells via osmosis. 42. The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client’s intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which of the following complications has been experienced by the client? a) Infection b) Phlebitis * c) Infiltration d) Thrombosis R: An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling are the results of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line at another site. The other three options are likely to be accompanied by warmth at the site, not coolness. 43. The nurse notes that the sit e of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nu rse documents in the medical record tha t the client experienced: * a) Phlebitis of the vein. b) Infiltration of the IV line. c) Hypersensitivity to the IV solution. d) Allergic reaction to the IV catheter material. R: Phlebitis at an IV site can be distinguished by client discomfort at the site and by re dness, warmth, and swelling proximal to the catheter. If phlebitis occurs, the nurse should discontinue the IV line and insert a new IV line at a different site. Cool ness at the site would be noted if the IV catheter was infiltrated. An allergic reaction p roduces a rash, redness, and itching. A major reaction, such as hypersensitivity, can cause dyspnea, a swollen tongue, and cyanosis. 44. A client is hypovolemic and plasma expanders are not available. The nurse anticipates that which of the following solution s available on the nursing unit will be prescribed by the physician? a) 5% dextrose in water b) 0.9% sodium chloride c) 0.45% sodium chloride * d) 5% dextrose in 0.45% sodium chloride R: A solution of 5% dextrose in 0.45% sodium chloride is hypertonic. An advantage of hypertonic solutions is that they may be used to treat hypovolemia when plasma expanders are not readily available. Options 1 and 2 are isotonic solutions . Option 3 is a hypotonic solution. 45. The nurse hears an attending physician asking an intern to prescribe a hypotonic intravenous (IV) solution for a client. Which of the following IV solutions would the nurse expect the intern to prescribe? a) 5% dextrose in water b) 10% dextrose in water * c) 0.45% sodium chloride d) 5% dextrose in 0.9% sodium chloride R: Hy potonic solutions contain a lower concentration of salt or more water than an isotonic solution. A solution of 0.45% sodium chloride is hypotonic. A solution of 5% dextrose in water (D 5W) is isotonic. Solutions of 10% dextrose in water (D 10W) and 5% dextro se in 0.9% sodium chloride are hypertonic solutions. 46. A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The nurse takes the client’s blood pressure and it is 90/50 mm Hg, from a baseline of 125/78 mm Hg. The client’s tempe rature is 100.8° F orally, from a baseline of 99.2° F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? * a) Septicemia b) Hyperkalemia c) Circulatory overload d) Delayed transfusion reaction R: Septicemia oc curs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. Circu latory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level. 47. The nurse is told by a physician that a client in hypovolemic shock will require plasma expansion. The nurse anticipates receiving an order to transfuse which product? * a) Albumin b) Platelets c) Cryoprecipitate d) Packed red blood cells R: Albumin may be used as a plasma expander. Platelets are used when the client’s platelet count is low. Cryoprecipitate is useful in treating bleeding from hemophilia or disseminated intravascular coagulopathy because it is rich in clotting factors. Packe d red blood cells replace erythrocytes and are not a plasma expander. 48. A physician tells a client that the client needs a blood transfusion and that a blood sample must be drawn first for blood typing and crossmatching. After the physician leaves, the client asks the nurse, “What exactly is a blood type, anyway?” The nurse responds with which of the following statements? * a) “The blood type represents an antigen found on the surface of the red blood cell.” b) “The blood type represents an antibody found on the surface of the red blood cell.” c) “The blood type represents an antibody that normally circulates in the blood plasma.” d) “The blood type represents an antigen that normally circulates in the blood plasma.” R: The major blood types are A, B, AB, and O. The blood type indicates an antigen found on the s urface of the red blood cell. Acute hemolytic transfusion reaction (ABO incompatibility) can occur if a client receives blood that is not compatible with his or her blood type. Acute hemolytic reaction is the most serious adverse reaction to a blood transf usion. 49. The nurse enters a client’s room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that this client most likely is experiencing which complication of blood transfusion therapy? a) Bacteremia b) Hypovolemia