ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 13 : Intravenous Therapy Questions
Question 1 of 5
The nursing instructor is teaching student nurses about venipuncture techniques and possible complications from the procedure. What can happen if the venipuncture device is left in the clients' vein too long?
Correct Answer: A
Rationale: Because the venous access device traumatizes the vein wall and disturbs the flow of blood cells in the vein, there is a potential for phlebitis, inflammation of the vein, and thrombus formation (development of a clot). Gangrene is not an issue; necrosis of the skin depends on the fluid being infused and if it has infiltrated; and warm compresses are used, not cold packs.
Question 2 of 5
Which provides the best practice for the graduate nurse in the administration and regulation of intravenous fluids to clients?
Correct Answer: D
Rationale: The state nurse practice act specifies the qualifications and regulations for scope of practice of nurses. In addition, the nurse must follow the policies/procedures of the institution in which the nurse is presently employed. The nursing supervisor should be able to provide guidance to a new employee but is not the ultimate authority. The nursing instructor prepares the educational track for learning but does not provide guidance in employment situations. The physician initiates the orders for IV therapy but does not provide nursing guidance.
Question 3 of 5
The nurse would expect to hang which of the following intravenous (IV) solution to a client with cerebral edema?
Correct Answer: D
Rationale: With cerebral edema, minimizing the fluid in the cells can be accomplished with the use of hypertonic solutions. Hypertonic solutions act by pulling the fluid from the cells to the blood vessels. Isotonic solutions stay within the blood vessels and do not minimize ascites. Hypotonic solutions are lower in osmolarity and shift fluids from the blood vessels to the cells.
Question 4 of 5
A client is brought to the emergency department with full-thickness burns to $27\%$ of the body. The nurse knows to prepare intravenous (IV) fluid administration from which solution group?
Correct Answer: C
Rationale: Lower osmolarity solutions are hypotonic solutions and will shift fluid from the blood vessels to the cells (where damage has occurred). Isotonic solutions will assist in preventing hypovolemia but will not rescue the damaged cells and prevent further dehydration. Higher osmolarity solutions are hypertonic and will pull fluid from the cells to the blood vessels.
Question 5 of 5
A client is scheduled for a test that requires an NPO status and has been ordered $5\%$ dextrose in water (D,W). The nurse understands which of the following to be the best rationale for this action?
Correct Answer: A
Rationale: Isotonic solutions, such as $\mathrm{D}_5 \mathrm{~W}$, are administered for maintenance of fluid balance. Hypotonic solutions do provide fluid to the cells, but this is not the purpose for D5W. Hypertonic solutions are used to pull fluid into the blood vessels and are not used to replace lost fluids.