1. Vital signs: Orthostatic Changes
The nurse plans to assess Clara for orthostatic vital sign changes.
What action will the nurse take first?
Assist Clara to a standing position. Incorrect
During orthostatic vital sign measurement the client should be placed in another position.
Position Clara in a supine position. Correct
Orthostatic vital signs are measured in each position: lying, sitting, and standing. The client's vital signs are first assessed in
the supine position so that changes that occur when the client sits and stands can be determined.
Elevate the head of Clara's bed.
The client is assisted to a sitting position after vital signs are first measured in another position.
Dangle Clara's feet at the bedside.
The client is assisted to a sitting position after vital signs are first measured in another position.
The nurse takes the first blood pressure measurement.
After recording the first blood pressure measurement, what action will the nurse take?
Count the client's radial pulse rate. Correct
Both the blood pressure and pulse rate are typically measured in each position: lying, sitting, and standing.
Remove the blood pressure cuff.
After the blood pressure cuff is deflated, it is left in the same position on the same arm for all three blood pressure readings.
Help the client change positions.
Another action should be taken before assisting the client to change positions.
Assess for an auscultatory gap.
Assessment for an auscultatory gap is done while the blood pressure measurement is being taken.
Since Clara has a fluid volume deficit, the nurse anticipates a decrease in which vital sign when Clara moves from a lying to a
standing position?
Respiratory rate.
Respiratory rate is unlikely to be affected by a change in position.
Blood pressure. Correct
Fluid volume deficit often causes orthostatic hypotension and tachycardia. Because the client may experience dizziness with
orthostatic hypotension, the nurse should take additional safety precautions during this assessment.
Temperature.
Temperature is unlikely to be affected by a change in position.
Pulse rate.
The client's pulse rate is likely to increase upon standing in response to a change in another vital sign.
In addition to obtaining Clara's vital signs, the nurse performs additional assessments.
For ongoing evaluation of Clara's fluid volume status, it is most important to obtain which assessment data?
Urine color.
This provides valuable assessment data related to fluid volume, but it is not the most important data for ongoing evaluation of
fluid volume.
Capillary refill.
This provides valuable assessment data regarding adequacy of tissue perfusion, which may be impacted by fluid volume, but
it is not the most important assessment related to fluid volume.
Body weight. Correct
Daily weights provide the most important data about fluid volume status, so an initial weight upon admission must be
obtained.
Skin turgor. Incorrect
This provides valuable assessment data related to fluid volume, but it is not the most important data for ongoing evaluation of
fluid volume.
The nurse continues to assess the client and observes that Clara's skin tents when a fold of skin over her sternum is pinched.
What action should the nurse implement?
Confirm this finding by pinching the skin on her hand.
2. The elderly frequently experience inelastic skin turgor of the hands, so this is not a valuable indicator of fluid volume status.
Notify the healthcare provider that the client is now retaining fluid.
Tenting is not a sign of fluid retention.
Advise Clara that the fluid deficit seems to be worsening.
Tenting is an expected finding in a client with fluid volume deficit.
Document the presence of inelastic skin turgor. Correct
Skin turgor is best assessed in the elderly by gently pinching a fold of skin over the sternum. Inelastic turgor is an expected
finding in a client with fluid volume deficit. Additional findings may include weakness, confusion, and tachycardia.
Clara's daughter reports that her mother usually weighs about 150 lbs. and is 5 feet, 4 inches in height. The nurse weighs Clara and
obtains a measurement of 65 kg.
The nurse explains to Clara's daughter that Clara has lost approximately how many pounds?
3.
Try your calculation again. Remember the conversion factor from kilograms to pounds.
5.
Try your calculation again. Remember the conversion factor from kilograms to pounds.
7. Correct
65 kg × 2.2 = 143 lbs. 150 lbs. - 143 lbs. = 7 lbs. This represents an approximate weight loss of 7 pounds.
9.
Try your calculation again. Remember the conversion factor from kilograms to pounds.
Correct
The nurse then explains that Clara's weight loss represents approximately how many liters of fluid loss?
2
Try your calculation again.
3 Correct
7/2.2 = 3.2 kg. Each kilogram of body weight lost or gained is equivalent to approximately 1 liter of fluid.
4 Incorrect
Try your calculation again.
5
Try your calculation again.
The nurse discusses factors that contributed to Clara's fluid volume deficit with Clara and her daughter.
Which problem often occurs in the elderly and may have contributed to the fluid volume deficit Clara is experiencing?
Decreased hepatic blood flow. Correct
Decreased hepatic blood flow commonly occurs in the elderly. This decreases drug metabolism, which allows drugs to
remain in the body longer and produces a greater drug effect.
Decreased drug absorption.
Factors such as decreased gastrointestinal (GI) motility and decreased GI acidity lead to changes in drug absorption time, but
generally, actual drug absorption is not decreased.
Decreased drug half-life.
Decreased metabolism in the elderly often leads to an increase in the half-life of drugs taken by them.
Decreased GI acidity.
Decreased GI acidity often occurs in the elderly, but this would not be a contributing factor for this client's fluid volume
deficit.
The nurse is aware that the elderly often experience an increase in the amount of free, unbound drug molecules, which has the
potential to increase the pharmacological effects of the drug.
Which lab test will the nurse monitor to determine if this may be a factor contributing to Clara's problem?
Serum creatinine. Incorrect
The client's serum creatinine level will not provide useful data regarding the potential for increased amounts of free, unbound
drug molecules.
Serum protein. Correct
Drug molecules may be distributed through the body bound to plasma protein molecules. A decrease in serum protein levels
is an indication that there may be an increase in free, unbound drug molecules in the bloodstream.
Hemoglobin.
3. The client's hemoglobin level will not provide useful data regarding the potential for increased amounts of free, unbound
drug molecules.
Hematocrit.
The client's hematocrit level will not provide useful data regarding the potential for increased amounts of free, unbound drug
molecules.
What action should the nurse take?
Hang 0.9% Normal Saline at 100 ml/hour.
The nurse does not have the authority to change the prescription unilaterally.
Begin infusing the solution at a keep-open rate.
Even this slow rate of administration has the potential to be harmful in this situation.
Start the intravenous solution as prescribed.
This solution may be harmful to this client.
Consult with the healthcare provider about the prescription. Correct
Three percent saline is a hypertonic solution, which will pull fluid from the interstitial and intracellular spaces into the
bloodstream. It is usually prescribed for severe hyponatremia (sodium <115 mEq/L). Since Clara is already experiencing a
fluid volume deficit, this IV solution could worsen her condition. The nurse should consult with the healthcare provider about
this prescription.
A short while later, a prescription for 0.9% Normal Saline at 100 ml/hour is received. Clara's primary nurse is at lunch, so another
nurse hangs the solution. When checking Clara upon returning from lunch, the primary nurse observes that a solution of 5% Dextrose
and 0.9% Normal Saline is infusing at 125 ml/hour.
What action should the primary nurse implement?
Obtain a container of 0.9% Normal Saline to hang when the present solution has finished infusing.
This action will not correct the errors that occurred.
Decrease the infusion rate of the present solution to 75 ml/hour to compensate for the error made.
This action will not correct the errors that occurred.
Stop the IV solution currently infusing and monitor the client for signs of an anaphylactic reaction.
The client is unlikely to have an anaphylactic reaction. However, this does not completely correct the error.
Change the currently infusing solution to 0.9% Normal Saline and change the rate to 100 ml/hour. Correct
Two errors have occurred: the wrong solution and the wrong rate of administration. These errors should both be corrected.
12.ID: 682828816
What additional action should the primary nurse take?
Discuss the consequences of the error with the hospital legal counsel.
It is not necessary for the nurse to discuss medication errors with a lawyer.
Notify the healthcare provider of the error in treatment that occurred. Correct
Since the prescription was not initially followed, the healthcare provider should be notified in case a change in the treatment
plan is warranted.
Report to the hospital pharmacist that a variance report was written.
The variance report will be used by the healthcare agency for risk management purposes.
Notify the hospital educator of the need for staff training about IV fluids.
A pattern of medication errors may indicate the need for additional staff training, but this situation does not provide sufficient
information to warrant that intervention.
The nurse who made the errors is very upset about writing a variance (incident) report and states, "I've never made an error before.
What if I get fired?"
How should the primary nurse respond?
"The variance report will show that this is your first medication error."
The variance report provides information about the specific event, not the pattern of errors made by an individual nurse.
"As long as you understand your error, we can disregard this report."
The variance report provides important data for the healthcare agency.
"Since no harm was done to the client, the variance report will not matter."
The variance report provides important data for the healthcare agency's risk management program.
"Variance reports are used to find ways to prevent further errors." Correct
4. Variance reports are used by the risk management department of healthcare agencies to look for patterns that contribute to
errors so that preventive measures can be instituted.
4.ID: 682828806
What intervention should the nurse take next?
Apply light pressure above the site. Incorrect
This will create further obstruction.
Lower the IV solution below the site.
This is often helpful to check for the presence of a blood flashback, indicating the IV is still infusing in the vein. However,
another action should be taken first.
Straighten the joint above the site. Correct
Obstruction is often caused by client movement, resulting in a bend in the client's proximal joint. Therefore, this noninvasive
measure should be the next action taken by the nurse.
Change the IV site dressing.
Although dressing that is too tight may obstruct the flow of the IV solution, another action should be taken first.
The nurse resolves the obstruction, and the IV solution begins to infuse.
The next day the nurse observes that the IV insertion site is inflamed and tender. The label on the IV site indicates the current IV has
been in place for 36 hours.
What action should the nurse take?
Continue the IV with the arm elevated on a pillow.
This action will not improve the situation.
Remove the IV and restart it in a different location. Correct
The client is experiencing phlebitis, which can lead to further complications if left untreated. Since the nurse has the
responsibility to take action when IV site complications occur, the IV should be discontinued, action should be taken for the
inflammation according to agency policy, and a new IV should be started at a different site.
Notify the healthcare provider that the IV site appears inflamed. Incorrect
The nurse is authorized to take needed action when an IV site complication occurs.
Complete a variance report regarding the IV site.
Variance (incident) reports are completed when a situation takes place that is inconsistent with the routine care of a client. An
error in treatment has not occurred. IV site complications are an anticipated adverse effect of treatment and do not require the
completion of a variance report.
16.ID: 682827896
When assessing the IV site, what step of the nursing process did the nurse use?
Analyze the data. Correct
The nurse analyzes the assessment data to determine if characteristics occur that define a problem. A problem is then stated, a
goal is established, and interventions are planned and implemented.
Plan interventions.
This is not the next step in the nursing process.
Determine the problem. Incorrect
This is not the next step in the nursing process.
Establish a goal.
This is not the next step in the nursing process.
Which problem did the nurse identify as most pertinent in that situation?
Risk for impaired skin integrity.
Impaired skin integrity already exists at the IV insertion site.
Risk for injury (thrombus formation). Correct
The phlebitis at the IV site places Clara at high risk for thrombus formation. So, the nurse identified this problem, established
the goal that the risk for injury will be reduced, and implemented the interventions of removing the IV and providing care at
the site of inflammation.
Fluid volume deficit.
While this is pertinent to Clara's overall plan of care, it was not the priority problem in that situation.
Infection. Incorrect
Phlebitis is an inflammatory process, not an infectious process.
In addition to the milk, which item should be measured as fluid intake?
5. Scrambled eggs.
Scrambled eggs are not measured as fluid intake.
Bowl of oatmeal.
Oatmeal is not measured as fluid intake.
Fresh orange. Incorrect
An orange is not measured as fluid intake.
Only the milk. Correct
Oral fluid intake includes only foods that are liquid at room temperature.
When Clara was first admitted, the healthcare provider did not include intake and output measurement in the initial prescriptions, but
the primary nurse initiated this assessment activity.
Now that Clara is taking oral fluids well, what action should the nurse implement?
Notify the healthcare provider that a prescription to continue intake and output measurement is needed.
The nurse may initiate and maintain intake and output measurement without a prescription from the healthcare provider.
Continue the measurement of the client's fluid intake and output. Correct
Since Clara is still receiving a significant volume of IV fluids, she remains at risk for fluid volume alterations. The nurse may
initiate and maintain intake and output measurement without a prescription from the healthcare provider.
Stop measuring the client's fluid intake and output as long as she takes oral fluids.
Clara remains at risk for fluid volume alterations even though she is taking oral fluids.
Measure the client's fluid output, but discontinue measuring fluid intake.
The measurement of Clara's fluid intake should not be discontinued because she is still at risk for fluid volume alterations.
20.ID: 682827881
Which assessment is important for the nurse to perform?
Auscultate the client's breath sounds. Correct
Fluid volume excess often causes abnormal breath sounds. Fluid collection in the lungs can impair oxygen exchange and
result in hypoxemia.
Measure the client's tympanic temperature.
Changes in temperature as the result of fluid volume excess are generally not significant.
Compare the client's muscle strength bilaterally.
This is not a significant assessment to perform for suspected fluid volume excess.
Ask the client if she is experiencing any syncope. Incorrect
This is not a significant assessment to perform for suspected fluid volume excess.
The nurse also observes that Clara's feet and ankles are swollen. When the nurse presses a finger over the client's ankle (bony
prominence), a 4 mm indentation appears.
How will the nurse document this finding?
Large amount of edema in the lower extremities.
The client is experiencing edema, but this documentation does not provide the best description of the edema.
2+ pitting edema present around ankles and feet. Correct
This documentation concisely describes the degree of indentation present and its location.
Stage 2 pressure ulcer forming due to ankle edema.
The indentation is not an indication of a stage 2 pressure ulcer.
Blanching and induration present bilaterally.
Neither blanching nor induration are indicated by this assessment.
22.ID: 682827873
Which change in Clara's pulse will the nurse anticipate?
Increase in rate and volume. Correct
As fluid volume increases to the point of fluid volume excess, the client will develop tachycardia (increase in rate) and a
bounding pulse (increase in volume).
Decrease in rate and volume.
These are not the typical changes with fluid volume excess.
Increase in rate, but no change in the volume.
6. These are not the typical changes with fluid volume excess.
Decrease in rate, but no change in the volume.
These are not the typical changes with fluid volume excess.
Further findings include oxygen saturation level of 90%, serum sodium of 140 mEq/L, and serum potassium of 3 mEq/L. The nurse
reports the findings to the healthcare provider and receives several prescriptions.
Which prescription should the nurse question?
Furosemide (Lasix) 40 mg IV push now.
The administration of a diuretic is an expected prescription for a client with fluid volume excess.
Potassium chloride 40 mEq IV push now. Correct
Clara's serum potassium is low. She needs potassium replacement, but potassium chloride should never be administered IV
push. A prescription for potassium chloride diluted in an IV solution to be administered over several hours should be
obtained from the healthcare provider.
Decrease the Normal Saline to 30 ml/hour.
Decreasing intravenous fluid intake is an expected prescription for a client with fluid volume excess.
Administer oxygen per nasal cannula at 2 L/minute. Incorrect
Clara's oxygen saturation level is lower than the desired range (95% to 100%). The administration of oxygen via nasal
cannula is an expected prescription.
24.ID: 682827865
It is most important for the nurse to monitor which lab value?
Hemoglobin. Incorrect
Hydrochlorothiazide, a diuretic, will not significantly impact this lab value.
White blood cell count.
Hydrochlorothiazide, a diuretic, will not significantly impact this lab value.
Serum potassium. Correct
Hydrochlorothiazide, a potassium-wasting diuretic, may cause significant hypokalemia. Use of hydrochlorothiazide may also
result in a decrease in serum magnesium and sodium and an increase in serum calcium and glucose.
Prothrombin Time (PT/INR).
Hydrochlorothiazide, a diuretic, will not significantly impact this lab value.
Before Clara's discharge, the nurse provides client teaching related to the prescribed hydrochlorothiazide (HydroDIURIL).
Pharmacology: Diuretics
Clara's fluid volume excess improves and the prescription for hydrochlorothiazide (HydroDIURIL) 12.5 mg PO daily is restarted.
The nurse will emphasize the importance of taking this medication only once a day, on what schedule?
Before eating breakfast. Incorrect
It is not recommended to take hydrochlorothiazide on an empty stomach.
With breakfast. Correct
To reduce the likelihood of nocturia, the client should be instructed to take diuretics in the morning. Additionally, taking the
medication with food may reduce adverse effects, such as nausea.
After lunch.
This is not the best time of day to take a diuretic.
At bedtime.
This is not the best time of day to take a diuretic.
Incorrect
Since Clara is receiving a diuretic that contributes to the loss of potassium, the nurse must provide dietary teaching. Which food(s)
selected by the client indicate an understanding of potassium-rich foods? (Select all that apply.)
Baked potato Correct
1 long potato contains 844 mg potassium. This shows that the client has an understanding of potassium-rich foods.
Green beans Incorrect
1/2 cup of green beans contains 100 mg potassium. This selection shows that the client does not have a good understanding
of potassium-rich foods.
Chicken breast
4oz of chicken breast contains 458 mg potassium. This selection shows that the client does not have a good understanding of
potassium-rich foods.
7. Apple
1 apple contains 159 mg of potassium. This selection shows that the client does not have a good understanding of potassium-
rich foods.
Grapefruit juice
Correct
8 oz of grapefruit juice contains 825 mg of potassium. This shows that the client has an understanding of potassium-rich
foods.
What action should the nurse take?
Observe the tablet to see if it is scored. Correct
A scored tablet can safely be divided so that the client may receive the prescribed dose. Hydrochlorothiazide is a scored
tablet. The nurse should also assess Clara's ability to break the tablet because 25 mg is the lowest tablet strength available.
Notify the pharmacist of the error.
The tablet may not be available in the smaller dose. Another nursing action should be taken.
Hold the medication until the right dose is available.
The tablet may not be available in the smaller dose. Another nursing action should be taken.
Document the change in dose on the medication record.
The prescribed dose has not been changed. Administration of the entire tablet would result in a medication error.
Upon entering Clara's room with the medication, the nurse checks Clara's identification band. Clara states, "You take care of me every
day. Why do you keep looking at my identification?"
What is the best response by the nurse?
"It is hospital policy to always check client identification."
While this is probably correct, it is more beneficial to explain the rationale for the action to the client.
"Your healthcare provider has asked that we always perform this check."
This is a nursing action, not an action prescribed by the healthcare provider.
"Wearing an identification band is important for all patients."
This is true but does not provide client teaching that explains the importance of checking the identification band.
"This is a double-check to ensure that no errors occur." Correct
This response provides the best client teaching. The client can participate in the plan of care more actively if explanations for
interventions are provided.
