A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site?

Question 1 of 5

A. Leave the hair intact B. Shave the area. C. Clip the hair in the area. D. Remove the hair with a depilatory.

Correct Answer: C

Rationale: The correct answer is C: Clip the hair in the area. Clipping the hair is the most appropriate option as it reduces the risk of infection during IV insertion by minimizing the presence of bacteria that may be trapped in the hair. Shaving (B) can cause micro-abrasions leading to increased infection risk. Leaving the hair intact (A) can also trap bacteria. Using a depilatory (D) can cause skin irritation and should be avoided. In summary, clipping the hair is the best option to maintain a clean and safe environment for IV insertion.

Question 2 of 5

A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients teaching?

A. You will need to wear a sling on your arm while the device is in place B. There is no risk of infection because sterile technique will be used during insertion. C. . Ask all providers to vigorously clean the connections prior to accessing the device. D. You will not be able to take a bath with this vascular access device.

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. Choice C is correct because it emphasizes the importance of cleaning connections before accessing the device to prevent infection. 2. Sterile technique during insertion cannot guarantee no risk of infection (Choice B). 3. Wearing a sling is unnecessary for a central vascular access device (Choice A). 4. The statement about not being able to take a bath is not accurate and is not a common restriction (Choice D).

Question 3 of 5

You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)?

A. Increased serum sodium B. Decreased serum potassium C. Decreased hemoglobin D. Increased platelets

Correct Answer: A

Rationale: The correct answer is A: Increased serum sodium. High serum sodium levels trigger the release of antidiuretic hormone (ADH) from the pituitary gland to help retain water in the body and maintain fluid balance. This is a physiological response to prevent further dehydration. Decreased serum potassium (choice B), decreased hemoglobin (choice C), and increased platelets (choice D) do not directly stimulate the release of ADH. Hence, they are incorrect choices in this scenario.

Question 4 of 5

When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur?

A. Active transport of hydrogen ions across the capillary walls B. Pressure of the blood in the renal capillaries C. Action of the dissolved particles contained in a unit of blood D. Hydrostatic pressure resulting from the pumping action of the heart

Correct Answer: D

Rationale: Rationale: The correct answer is D. Hydrostatic pressure resulting from the pumping action of the heart causes water and electrolytes to move from the arterial capillary bed to the interstitial fluid. This occurs due to the force exerted by the heart's pumping action, pushing fluid out of the capillaries into the interstitial space. This process is known as filtration and is essential for maintaining fluid balance in the body. Summary of other choices: A: Active transport of hydrogen ions does not directly cause the movement of water and electrolytes between capillaries and interstitial fluid. B: The pressure in renal capillaries specifically relates to the kidneys, not the general movement of water and electrolytes in the body. C: The dissolved particles in blood do not directly contribute to the movement of water and electrolytes between capillaries and interstitial fluid.

Question 5 of 5

The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit

A. Diarrhea B. Dilute urine C. Increased muscle tone D. Joint pain

Correct Answer: B

Rationale: The correct answer is B: Dilute urine. Hypokalemia can lead to kidney dysfunction, causing the kidneys to excrete more water along with electrolytes, resulting in dilute urine. This is a manifestation of the body's attempt to compensate for low potassium levels by excreting excess water. The other choices are incorrect because: A) Diarrhea is more commonly associated with hyperkalemia, not hypokalemia. C) Increased muscle tone is not a typical sign of hypokalemia; rather, hypokalemia can lead to muscle weakness or paralysis due to impaired muscle function. D) Joint pain is not a typical symptom of hypokalemia; joint pain is more commonly associated with other conditions such as arthritis or inflammation.

Similar Questions

The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit

You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration?

A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first?

You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance?

A nurse is assessing a client with hypokalemia and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first?

ATI Fluid Electrolyte and Acid-Base Regulation

Skildor

ATI RN