ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 41 Questions
Question 1 of 5
Which action should be taken to evaluate or verify the integrity of the peripheral IV access site?
Correct Answer: D
Rationale: Assessing skin temperature and tone at the site helps evaluate for signs of infiltration, phlebitis, or infection without disrupting the securement device. Removing the securement device (
A) is unnecessary and risks dislodging the catheter. Documenting negative aspiration (
B) is not a reliable indicator of site integrity. Rotating the site every 72 hours (
C) is a maintenance action, not an evaluation method.
Question 2 of 5
When caring for a patient receiving hemodialysis through an arteriovenous fistula, which action is essential for the nurse to take?
Correct Answer: C
Rationale:
To protect the fistula, BP and venipuncture should be performed on the opposite extremity. IM injections (
A) are not contraindicated. Radial pulse assessment (
B) is safe. Using the fistula for IV medications (
D) is prohibited.
Question 3 of 5
A nurse has begun administering an intravenous antibiotic via the patient's peripheral venous access. Immediately, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings?
Correct Answer: D
Rationale: Edema and coolness indicate infiltration, requiring catheter removal. Repositioning (
A) or raising the pole (
B) worsens infiltration. Applying pressure (
C) is inappropriate. Pulling and reinserting (
D) risks further tissue damage.
Question 4 of 5
How will the nurse interpret the patient's arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3-, 14 mEq/L?
Correct Answer: C
Rationale: Low pH (7.30) indicates acidosis. Normal PaCO2 (36 mm Hg) rules out respiratory causes, and low HCO3- (14 mEq/L) indicates metabolic acidosis. Respiratory acidosis (
A) involves high PaCO2. Respiratory alkalosis (
B) involves low PaCO2 and high pH. Metabolic alkalosis (
D) involves high HCO3- and high pH.
Question 5 of 5
A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient?
Correct Answer: B
Rationale: Hypokalemia requires potassium replacement, such as oral supplements as prescribed. High sodium (
A) is for hyponatremia. Cautioning against potassium-rich foods (
C) is for hyperkalemia. Calcium loss (
D) is unrelated to hypokalemia.