A charge nurse is observing a newly licensed nurse who is preparing to administer a blood
transfusion to a client. For which of the following actions by the newly licensed nurse should
the charge nurse intervene? - ANSWER The nurse selects 0.45% sodium chloride to use to
prime the tubing.
The charge nurse should intervene if the newly licensed nurse selects 0.45% sodium chloride
to prime the tubing. The nurse should identify that 0.9% sodium chloride is the only IV solu-
tion that should be used to prime the tubing for blood administration.
A nurse is receiving report on four clients. The nurse should identify that which of the follow-
ing clients might be experiencing hypomagnesemia? - ANSWER A client who has vomited
four times during the last 8 hr.
Nausea and vomiting are early manifestations of hypomagnesemia.
A nurse is caring for a client who is experiencing respiratory alkalosis. Which of the following
actions should be the goal of treatment for the client? - ANSWER Increase the carbon di-
oxide level.
A state of respiratory alkalosis indicates that the client's carbon dioxide level is currently be-
low the expected reference range. The goal of treatment should be to raise the level of car-
bon dioxide level back to within the expected reference range for PaCO2 of 35 to 45 mm Hg.
A nurse is caring for a client who requires a replacement peripheral IV. The client is dehy-
drated and requires a smaller gauge catheter than the #20-gauge being replace. Which of
the following gauge catheters should the nurse plan to use? - ANSWER #22-gauge
1
, The nurse should use a #22-gauge catheter as a replacement for the current #20-gauge IV
catheter. As the client is dehydrated, it may be difficult to access a peripheral vein with a
larger gauge catheter. As the gauge # increases, the actual catheter size decreases.
A nurse is reviewing laboratory results for a client and notes the following arterial blood gas
(ABG) values: ph: 7.31, PaCO2 49 mm hg, HCO3- mEq/L. The nurse should interpret these
findings as an indication of which of the following acid-base imbalances? - ANSWER Res-
piratory acidosis
This client's ABG values indicate respiratory acidosis. Respiratory acidosis is indicated by a
pH value below the expected reference range of 7.35 to 7.45 and a PaCO2 value above the
expected reference range of 35 to 45 mm Hg.
A nurse is assessing a client who is exhibiting signs of fluid and electrolyte imbalance. Which
of the following findings should the nurse identify as a potential cause for the client's fluid
and electrolyte imbalance? - ANSWER The client reports that they performed yard work
for 8 hr in 35° C (95° F) temperature earlier that day.
The nurse should identify that working outside in high temperatures for an extended period
can cause profuse sweating and lead to a fluid and electrolyte imbalance.
A nurse is caring for a client who is receiving treatment of hyponatremia. The nurse should
identify which of the following findings as an indication that the treatment has been effec-
tive? (select all that apply)
The client states their muscle spasms are absent.
The client reports a headache.
The client denies being confused.
The client reports being nauseated.
The client reports feeling tired. - ANSWER The client states muscle spasms are absent
The client denies being confused
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transfusion to a client. For which of the following actions by the newly licensed nurse should
the charge nurse intervene? - ANSWER The nurse selects 0.45% sodium chloride to use to
prime the tubing.
The charge nurse should intervene if the newly licensed nurse selects 0.45% sodium chloride
to prime the tubing. The nurse should identify that 0.9% sodium chloride is the only IV solu-
tion that should be used to prime the tubing for blood administration.
A nurse is receiving report on four clients. The nurse should identify that which of the follow-
ing clients might be experiencing hypomagnesemia? - ANSWER A client who has vomited
four times during the last 8 hr.
Nausea and vomiting are early manifestations of hypomagnesemia.
A nurse is caring for a client who is experiencing respiratory alkalosis. Which of the following
actions should be the goal of treatment for the client? - ANSWER Increase the carbon di-
oxide level.
A state of respiratory alkalosis indicates that the client's carbon dioxide level is currently be-
low the expected reference range. The goal of treatment should be to raise the level of car-
bon dioxide level back to within the expected reference range for PaCO2 of 35 to 45 mm Hg.
A nurse is caring for a client who requires a replacement peripheral IV. The client is dehy-
drated and requires a smaller gauge catheter than the #20-gauge being replace. Which of
the following gauge catheters should the nurse plan to use? - ANSWER #22-gauge
1
, The nurse should use a #22-gauge catheter as a replacement for the current #20-gauge IV
catheter. As the client is dehydrated, it may be difficult to access a peripheral vein with a
larger gauge catheter. As the gauge # increases, the actual catheter size decreases.
A nurse is reviewing laboratory results for a client and notes the following arterial blood gas
(ABG) values: ph: 7.31, PaCO2 49 mm hg, HCO3- mEq/L. The nurse should interpret these
findings as an indication of which of the following acid-base imbalances? - ANSWER Res-
piratory acidosis
This client's ABG values indicate respiratory acidosis. Respiratory acidosis is indicated by a
pH value below the expected reference range of 7.35 to 7.45 and a PaCO2 value above the
expected reference range of 35 to 45 mm Hg.
A nurse is assessing a client who is exhibiting signs of fluid and electrolyte imbalance. Which
of the following findings should the nurse identify as a potential cause for the client's fluid
and electrolyte imbalance? - ANSWER The client reports that they performed yard work
for 8 hr in 35° C (95° F) temperature earlier that day.
The nurse should identify that working outside in high temperatures for an extended period
can cause profuse sweating and lead to a fluid and electrolyte imbalance.
A nurse is caring for a client who is receiving treatment of hyponatremia. The nurse should
identify which of the following findings as an indication that the treatment has been effec-
tive? (select all that apply)
The client states their muscle spasms are absent.
The client reports a headache.
The client denies being confused.
The client reports being nauseated.
The client reports feeling tired. - ANSWER The client states muscle spasms are absent
The client denies being confused
2
