Unit D-Infusion Therapy and Fluid and Electrolytes

Question 1

A nurse assesses clients at a family practice clinic for risk factors that could lead to

dehydration. Which client is at greatest risk for dehydration?
a. A 36 year old who is prescribed long-term steroid therapy.
b. A 55 year old who recently received intravenous fluids.
c. A 76 year old who is cognitively impaired.
d. An 83 year old with congestive heart failure.

Answer 1

ANS: C
Older adults, because they have less total body water than younger adults, are at greater risk
for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids
independently or cannot make his or her need for fluids known is at high risk for dehydration.
The client with heart failure has a risk for both fluid imbalances. Long-term steroids and
recent IV fluid administration do not increase the risk of dehydration.

Question 2

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which
intervention by the nurse is best?
a. Measure intake and output every 4 hours.
b. Assess client further for fall risk.
c. Increase the IV flow rate to 250 mL/hr.
d. Place the client in a high-Fowler position.

Answer 2

ANS: B
Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing
confusion. The client with dehydration is at risk for falls because of this confusion, orthostatic
hypotension, dysrhythmia, and/or muscle weakness. The nurse’s best response is to do a more
thorough evaluation of the client’s risk for falls. Measuring intake and output may need to
occur more frequently than every 4 hours, but does not address a critical need. The nurse
would not adjust the IV flow rate without a prescription or standing protocol. For an older
adult, this rapid an infusion rate could lead to fluid overload. Sitting the client in a
high-Fowler position may or may not be comfortable but still does not address the most
important issue which is safety.

Question 3

After teaching a client who is being treated for dehydration, a nurse assesses the client’s

understanding. Which statement indicates that the client correctly understood the teaching?
a. “I must drink a quart (liter) of water or other liquid each day.”
b. “I will weigh myself each morning before I eat or drink.”
c. “I will use a salt substitute when making and eating my meals.”
d. “I will not drink liquids after 6 p.m. so I won’t have to get up at night.”

Answer 3

ANS: B
One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of
excess fluid loss or fluid retention. Weight loss greater than 0.5 lb (0.2 kg) daily is indicative
of excessive fluid loss. One liter of fluid a day is insufficient. A salt substitute is not related to
dehydration. Clients may want to limit fluids after dinner so they won’t have to get up, but
this does not address dehydration if the patient drinks the recommended amount of fluid
during the earlier parts of the day.

Question 4

A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse
identify as being at greatest risk for insensible water loss?
a. Client taking furosemide.
b. Anxious client who has tachypnea.
c. Client who is on fluid restrictions.
d. Client who is constipated with abdominal pain.

Answer 4

ANS: B
Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for
insensible water loss include those being mechanically ventilated, those with rapid
respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis,
trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking
furosemide will have increased fluid loss, but not insensible water loss. The other two clients
on a fluid restriction and with constipation are not at risk for insensible fluid loss.

Question 5

A nurse is evaluating a client who is being treated for dehydration. Which assessment result
does the nurse correlate with a therapeutic response to the treatment plan?
a. Increased respiratory rate from 12 to 22 breaths/min
b. Decreased skin turgor on the client’s posterior hand and forehead
c. Increased urine specific gravity from 1.012 to 1.030 g/mL
d. Decreased orthostatic changes when standing

Answer 5

ANS: D
The focus of management for clients with dehydration is to increase fluid volumes to normal.
When blood volume is normal, orthostatic blood pressure and pulse changes will not occur.
This assessment finding shows a therapeutic response to treatment. Increased respirations,
decreased skin turgor, and higher urine specific gravity all are indicators of continuing
dehydration.

Question 6

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client’s
understanding. Which food choice for lunch indicates that the client correctly understood the
teaching?
a. Slices of smoked ham with potato salad
b. Bowl of tomato soup with a grilled cheese sandwich
c. Salami and cheese on whole-wheat crackers
d. Grilled chicken breast with glazed carrots

Answer 6

ANS: D
Clients on restricted sodium diets generally avoid processed, smoked, and pickled foods and
those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and
fresh produce. The ham, tomato soup, salami, and crackers are usually high in sodium.

Question 7

A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse
assess first for potential hyponatremia?
a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions.
b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic.
c. A 67 year old who is experiencing pain and is prescribed ibuprofen.
d. A 73 year old with tachycardia who is receiving digoxin.

Answer 7

ANS: A
Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized
when infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic
solutions can lead to hyponatremia. Because the client is not taking any food or fluids by
mouth (NPO), normal sodium excretion can also lead to hyponatremia. The sulfonamide
antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.

Question 8

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse
include in this client’s teaching?
a. “Have you spouse watch you for irritability and anxiety.”
b. “Notify the clinic if you notice muscle twitching.”
c. “Call your primary health care provider for diarrhea.”
d. “Bake or grill your meat rather than frying it.”

Answer 8

ANS: C
One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be
taught to call the primary health care provider if this is noticed. Irritability and anxiety are
common neurologic signs of hypokalemia. Muscle twitching is related to hypernatremia.
Cooking methods are not a cause of hyponatremia.

Question 9

A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L
(2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and
sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first?
a. Depth of respirations
b. Bowel sounds
c. Grip strength
d. Electrocardiography

Answer 9

ANS: A
A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac
dysrhythmias, and muscle weakness resulting in shallow respirations and decreased
handgrips. The nurse would assess the client’s respiratory status first to ensure that
respirations are sufficient. The respiratory assessment would include rate and depth of
respirations, respiratory effort, and oxygen saturation. The other assessments are important
but are secondary to the client’s respiratory status.

Question 10

A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is
exhibiting cardiovascular changes. Which intervention will the nurse implement first?
a. Prepare to administer patiromer by mouth.
b. Provide a heart-healthy, low-potassium diet.
c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
d. Prepare the client for hemodialysis treatment.

Answer 10

ANS: C
A client with a critically high serum potassium level and cardiac changes would be treated
immediately to reduce the extracellular potassium level. Potassium movement into the cells is
enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will
decrease both serum potassium and glucose levels and therefore would be administered with
dextrose to prevent hypoglycemia. Patiromer may be ordered, but this therapy may take hours
to reduce potassium levels. Dialysis may also be needed, but this treatment will take much
longer to implement and is not the first intervention the nurse would implement. Decreasing
potassium intake may help prevent hyperkalemia in the future but will not decrease the
client’s current potassium level.

Question 11

The nurse is caring for a client who has fluid overload. What action by the nurse takes
priority?
a. Administer high-ceiling (loop) diuretics.
b. Assess the client’s lung sounds every 2 hours.
c. Place a pressure-relieving overlay on the mattress.
d. Weigh the client daily at the same time on the same scale.

Answer 11

ANS:B
All interventions are appropriate for the client who is overhydrated. However, client safety is
the priority. A client with fluid overload can easily go into pulmonary edema, which can be
life threatening. The nurse would closely monitor the client’s respiratory status.

Question 12

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. What action does the nurse take
first?
a. Assess the client’s respiratory rate, rhythm, and depth.
b. Measure the client’s pulse and blood pressure.
c. Document findings and monitor the client.
d. Call the health care primary health care provider.

Answer 12

ANS: A
In a client with hypokalemia, progressive skeletal muscle weakness is associated with
increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is
respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment
first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also
associated with hypokalemia. The client’s pulse and blood pressure would be assessed after
assessing respiratory status. Next, the nurse would call the health care primary health care
provider to obtain orders for potassium replacement. Documenting findings and continuing to
monitor the client would occur during and after potassium replacement therapy.

Question 13

A new nurse is preparing to administer IV potassium to a client with hypokalemia. What
action indicates the nurse needs to review this procedure?
a. Notifies the pharmacy of the IV potassium order.
b. Assesses the client’s IV site every hour during infusion.
c. Sets the IV pump to deliver 30 mEq of potassium an hour.
d. Double-checks the IV bag against the order with the precepting nurse.

Answer 13

ANS: C
IV potassium should not be infused at a rate exceeding 20mEq/hr under any circumstances.
This action shows a need for further knowledge. The other actions are acceptable for this
high-alert drug.

Question 14

A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor
understanding of this condition?
a. Assesses the client’s Chvostek and Trousseau sign.
b. Keeps the client’s room quiet and dimly lit.
c. Moves the client carefully to avoid fracturing bones
d. Administers bisphosphonates as prescribed.

Answer 14

ANS: D
Bisphosphonates are used to treat hypercalcemia. The Chvostek and Trousseau signs are used
to assess for hypocalcemia. Keeping the client in a low stimulus environment is important
because the excitable nervous system cells are overstimulated. Long-standing hypocalcemia
can cause fragile, brittle bones which can be fractured

Question 15

A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L).
Which primary health care provider order does the nurse implement first?
a. Encourage oral fluid intake.
b. Connect the client to a cardiac monitor.
c. Assess urinary output.
d. Administer oral calcitonin

Answer 15

ANS: B
This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and
cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess
for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering
calcitonin are treatments for hypercalcemia, but are not the highest priority

Question 16

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which
intervention will the nurse implement to prevent injury while in the hospital?
a. Ask family members to speak quietly to keep the client calm.
b. Assess urine color, amount, and specific gravity each day.
c. Encourage the client to drink at least 1 L of fluids each shift.
d. Dangle the client on the bedside before ambulating

Answer 16

ANS: D
An older adult with moderate dehydration may experience orthostatic hypotension. The client
needs to dangle on the bedside before ambulating. Although dehydration in an older adult may
cause confusion, speaking quietly will not help the client remain calm or decrease confusion.
Assessing the client’s urine may assist with the diagnosis of dehydration but would not
prevent injury. Clients are encouraged to drink fluids, but 1 L of fluid each shift for an older
adult may cause respiratory distress and symptoms of fluid overload, especially if the client
has heart failure or renal insufficiency.

Question 17

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and
symptoms does the nurse expect to find? (Select all that apply.)
a. Increased pulse rate
b. Distended neck veins
c. Decreased blood pressure
d. Warm and pink skin
e. Skeletal muscle weakness
f. Visual disturbances

Answer 17

ANS: A, B, E, F
Signs and symptoms of fluid overload include increased pulse rate, distended neck veins,
increased blood pressure, pale and cool skin, skeletal muscle weakness, and visual
disturbances. Decreased blood pressure would be seen in dehydration. Warm and pink skin is
a normal finding

Question 18

nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion
and release. For which potential complications will the nurse assess? (Select all that apply.)
a. Urine output of 25 mL/hr
b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L)
c. Urine specific gravity of 1.02 g/mL
d. Serum sodium level of 128 mEq/L (128 mmol/L)
e. Blood osmolality of 250 mOsm/kg (250 mmol/kg

Answer 18

ANS: B, E
Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the
reabsorption of water and sodium in the kidney at the same time that it promotes excretion of
potassium. Any drug or condition that disrupts aldosterone secretion or release increases the
client’s risk for excessive water loss (increased urine output), increased potassium
reabsorption, decreased blood osmolality, and increased urine specific gravity. The client
would not be at risk for sodium imbalance.

Question 19

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For
which potential complications of this electrolyte imbalance does the nurse assess? (Select all
that apply.)
a. Reports of palpitations
b. Slow, shallow respirations
c. Orthostatic hypotension
d. Paralytic ileus
e. Skeletal muscle weakness
f. Tall, peaked T waves on ECG

Answer 19

ANS:A,E,F
Electrolyte imbalances associated with acute renal failure include hyperkalemia. The nurse
would assess for electrocardiogram changes, including tall, peaked T waves, reports of
palpitations or “skipped beats,” diarrhea, and skeletal muscle weakness in clients with
hyperkalemia. The other choices are potential complications of hypokalemia. Respiratory
muscles may be affected with lethally high hyperkalemia.

Question 20

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which
clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance?
(Select all that apply.)
a. Hypokalemia—muscle weakness with respiratory depression
b. Hypermagnesemia—bradycardia and hypotension
c. Hyponatremia—decreased level of consciousness
d. Hypercalcemia—positive Trousseau and Chvostek signs
e. Hypomagnesemia—hyperactive deep tendon reflexes
f. Hypernatremia—weak peripheral pulses

Answer 20

ANS: A, B, C, E, F
Hypokalemia is associated with muscle weakness and respiratory depression.
Hypermagnesemia manifests with bradycardia and hypotension. Hyponatremia can present
with decreased level of consciousness. Hypomagnesemia can be assessed through hyperactive
deep tendon reflexes. Weak peripheral pulses are felt in hypernatremia. Positive Trousseau
and Chvostek signs are seen in hypocalcemia.

Question 21

After administering potassium chloride, a nurse evaluates the client’s response. Which signs
and symptoms indicate that treatment is improving the client’s hypokalemia? (Select all that
apply.)
a. Respiratory rate of 8 breaths/min
b. Absent deep tendon reflexes
c. Strong productive cough
d. Active bowel sounds
e. U waves present on the electrocardiogram (ECG)

Answer 21

ANS: C, D
A strong, productive cough indicates an increase in muscle strength and improved potassium
imbalance. Active bowel sounds also indicate that treatment is working. A respiratory rate of
8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all signs and
symptoms of hypokalemia and do not demonstrate that treatment is working

Question 22

A nurse develops a plan of care for an older client who has a fluid overload. What
interventions will the nurse include in this client’s care plan? (Select all that apply.)
a. Calculate pulse pressure with each blood pressure reading.
b. Assess skin turgor using the back of the client’s hand.
c. Assess for pitting edema in dependent body areas.
d. Monitor trends in the client’s daily weights.
e. Assist the client to change positions frequently.
f. Teach client and family how to read food labels for sodium.

Answer 22

ANS: A, C, D, E, F
Appropriate interventions for the client who has overhydration include calculating the pulse
pressure with each BP reading as this is a sign of cardiovascular involvement, assessing for
pitting edema in the client’s dependent body areas, monitoring trends in the client’s daily
weight as fluid retention is not always visible, protecting the client’s skin by helping him or
her change positions, and teaching the client and family to read food labels some type of
sodium restriction may be required at home. The nurse assesses skin turgor on the chest or
forehead.

Question 23

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which
common causes are correctly paired with the corresponding electrolyte imbalance? (Select all
that apply.)
a. Hypomagnesemia—kidney failure
b. Hyperkalemia—salt substitutes
c. Hyponatremia—heart failure
d. Hypernatremia—hyperaldosteronism
e. Hypocalcemia—diarrhea
f. Hypokalemia—loop diuretics

Answer 23

ANS: B, C, D, E, F
Salt substitutes contain potassium and are a cause of hyperkalemia. Hyponatremia can be
caused by heart failure with fluid overload. Hyperaldosterone is a cause of hypernatremia and
diarrhea causes actual calcium deficits. Loop diuretics excrete potassium. Decreased kidney
function is a cause of magnesium excess, not deficit.

Question 24

A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are
paired with the correct potential imbalance? (Select all that apply.)
a. Sodium: 160 mEq/L (mmol/L): Overhydration
b. Potassium: 5.4 mEq/L (mmol/L): Dehydration
c. Osmolarity: 250 mOsm/L: Overhydration
d. Hematocrit: 68%: Dehydration
e. BUN: 39 mg/dL: Overhydration
f. Magnesium: 0.8 mg/dL: Dehydration

Answer 24

ANS: B, C, D, F
In dehydration, hemoconcentration usually results in higher levels of hemoglobin, hematocrit,
serum osmolarity, glucose, protein, blood urea nitrogen, and electrolytes. The opposite is true
of overhydration. The sodium level is high, indicating dehydration. The potassium level is
high, also indicating possible dehydration. The osmolarity is low, indicating overhydration,
the hematocrit is high indicating dehydration, the BUN is high indicating dehydration, and the
magnesium level is low, indicating possible dehydration and malnutrition from
diarrhea-causing diseases.

Question 25

A nurse assesses a client with diabetes mellitus who is admitted with an acid–base imbalance.
The client’s arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and
HCO3 18 mEq/L (18 mmol/L). Which sign or symptom does the nurse identify as an
example of the client’s compensatory mechanisms?
a. Increased rate and depth of respirations
b. Increased urinary output
c. Increased thirst and hunger
d. Increased release of acids from the kidneys

Answer 25

ANS: A
This client has metabolic acidosis. The respiratory system compensates by increasing its
activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger
are signs and symptoms of hyperglycemia but are not compensatory mechanisms for
acid–base imbalances. The kidneys do not release acids.

Question 26

A nurse assesses a client who is experiencing an acid–base imbalance. The client’s arterial
blood gas values are pH 7.2, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L (19
mmol/L). Which assessment would the nurse perform first?
a. Cardiac rate and rhythm
b. Skin and mucous membranes
c. Musculoskeletal strength
d. Level of orientation

Answer 26

ANS: A
Early cardiovascular changes for a client experiencing moderate acidosis include increased
heart rate and cardiac output. As the acidosis worsens, the heart rate decreases and
electrocardiographic changes will be present. The nurse responds by performing a thorough
cardiovascular assessment. Changes will occur in the integumentary system, musculoskeletal
system, and neurologic system, but assessing for the cardiovascular complications comes first.

Question 27

A nurse assesses a client who is prescribed furosemide for hypertension. For which acid–base
imbalance does the nurse assess to prevent complications of this therapy?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis

Answer 27

ANS: D
Many diuretics, especially loop and thiazide diuretics, increase the excretion of hydrogen ions,
leading to excess acid loss through the renal system. This situation is an actual acid deficit.

Question 28

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. What action
would the nurse take?
a. Monitor daily hemoglobin and hematocrit values.
b. Administer furosemide intravenously.
c. Encourage the client to take deep breaths.
d. Teach the client fall prevention measures.

Answer 28

ANS: D
The most important nursing care for a client who is experiencing moderate metabolic alkalosis
is providing client safety. Client’s with metabolic alkalosis have muscle weakness and are at
risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis.

Question 29

A nurse is assessing a client who has acute pancreatitis and is at risk for an acid–base

imbalance. For which manifestation of this acid–base imbalance would the nurse assess?
a. Agitation
b. Kussmaul respirations
c. Seizures
d. Positive Chvostek sign

Answer 29

ANS: B
The pancreas is a major site of bicarbonate production. Pancreatitis can cause metabolic
acidosis through underproduction of bicarbonate ions. Signs and symptoms of acidosis
include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvostek sign
are signs and symptoms of the electrolyte imbalances that accompany alkalosis

Question 30

A nurse assesses a client who is admitted with an acid–base imbalance. The client’s arterial
blood gas values were pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L
(16 mmol/L). The most recent blood gasses show a drop in the pH. What action does the nurse
take next?
a. Assess client’s rate, rhythm, and depth of respiration.
b. Measure the client’s pulse and blood pressure.
c. Document the findings and continue to monitor.
d. Notify the primary health care provider.

Answer 30

ANS:A
Progressive skeletal muscle weakness is associated with increasing severity of acidosis.
Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to
dysrhythmias (due to hyperkalemia), but these would best be assessed with cardiac
monitoring. Findings would be documented, but simply continuing to monitor is not
sufficient. Before notifying the primary care provider, the nurse must have more data to
report.

Question 31

A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56
mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which clinical situation does
the nurse correlate with these values?
a. Diabetic ketoacidosis in a person with emphysema
b. Bronchial obstruction related to aspiration of a hot dog
c. Anxiety-induced hyperventilation in an adolescent
d. Diarrhea for 36 hours in an older, frail woman

Answer 31

ANS: B
Arterial blood gas values indicate that the client has acidosis with normal levels of
bicarbonate, suggesting that the problem is not metabolic. Arterial concentrations of oxygen
and carbon dioxide are abnormal, with low oxygen and high carbon dioxide levels. Thus, this
client has respiratory acidosis from inadequate gas exchange. The fact that the bicarbonate
level is normal indicates that this is an acute respiratory problem rather than a chronic
problem, because no renal compensation has occurred. The client who would have these ABG
values is the one with the new onset of airway obstruction.

Question 32

A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The
client’s arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3
22 mEq/L (22 mmol/L). What action would the nurse take first?
a. Apply oxygen by mask or nasal cannula.
b. Apply a paper bag over the client’s nose and mouth.
c. Administer 50 mL of sodium bicarbonate intravenously.
d. Administer 50 mL of 20% glucose and 20 units of regular insulin.

Answer 32

ANS: A
This client is severely hypoxic and needs oxygen. Now that the seizure has ended, the client
can breathe again normally, so oxygen administration will rapidly increase the PaO2.
Rebreathing carbon dioxide with a paper bag would make the acidosis worse. Bicarbonate is
only indicated with extremely low pH and serum bicarbonate levels. Glucose and insulin are
administered to decrease the high potassium levels associated with acidosis, but this situation
should reverse itself with oxygen and breathing.

Question 33

After teaching a client who was malnourished and is being discharged, a nurse assesses the
client’s understanding. Which statement indicates that the client correctly understood
teaching to decrease risk for the development of metabolic acidosis?
a. “I will drink at least three glasses of milk each day.”
b. “I will eat three well-balanced meals and a snack daily.”
c. “I will not take pain medication and antihistamines together.”
d. “I will avoid salting my food when cooking or during meals.

Answer 33

ANS: B
Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells
to switch to using fats for fuel and by creating ketoacids as a by-product of excessive fat
metabolism. Eating sufficient calories from all food groups helps reduce this risk. Milk, taking
pain medications with antihistamines, and salting food are not related

Question 34

A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm
Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which client condition does the
nurse correlate with these results?
a. Diarrhea and vomiting for 36 hours
b. Anxiety-induced hyperventilation
c. Chronic obstructive pulmonary disease (COPD)
d. Diabetic ketoacidosis and emphysema

Answer 34

ANS: B
The elevated pH level indicates alkalosis. The bicarbonate level is normal, and so is the
oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would
occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic acidosis
and COPD would lead to respiratory acidosis. The client with emphysema most likely would
have combined metabolic acidosis on top of a mild, chronic respiratory acidosis.

Question 35

After providing discharge teaching, a nurse assesses the client’s understanding regarding
increased risk for metabolic alkalosis. Which statement indicates that the client needs
additional teaching?
a. “I don’t drink milk because it gives me gas and diarrhea.”
b. “I have been taking digoxin every day for the last 15 years.”
c. “I take sodium bicarbonate after every meal to prevent heartburn.”
d. “In hot weather, I sweat so much that I drink six glasses of water each day.”

Answer 35

ANS: C
Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can
cause metabolic alkalosis. Avoiding milk, taking digoxin, and sweating would not lead to
increased risk of metabolic alkalosis.

Question 36

A nurse is caring for a client who is experiencing excessive diarrhea. The client’s arterial
blood gas values are pH 7.18, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L (16
mmol/L). Which primary health care provider order does the nurse expect to receive?
a. Furosemide 40 mg
b. Sodium bicarbonate
c. Mechanical ventilation
d. Indwelling urinary catheter

Answer 36

ANS: B
This client’s arterial blood gas values represent metabolic acidosis related to a loss of
bicarbonate ions from diarrhea. The bicarbonate would be replaced to help restore this client’s
acid–base balance as the pH is below 7.2 and the bicarbonate level is low. Furosemide would
cause an increase in acid fluid and acid elimination via the urinary tract; although this may
improve the client’s pH, the client has excessive diarrhea and cannot afford to lose more fluid.
Mechanical ventilation is used to treat respiratory acidosis for clients who cannot keep their
oxygen saturation at 90%, or who have respiratory muscle fatigue. Mechanical ventilation and
an indwelling urinary catheter would not be prescribed for that client.

Question 37

A nurse evaluates a client’s arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg,
PaCO2 55 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which intervention does the nurse
implement first?
a. Assess the airway.
b. Administer prescribed bronchodilators.
c. Provide oxygen.
d. Administer prescribed mucolytics.

Answer 37

ANS: A
All interventions are important for clients with respiratory acidosis; this is indicated by the
ABGs. However, the priority is assessing and maintaining an airway. Without a patent airway,
other interventions will not be helpful.

Question 38

A nurse is planning care for a client who is hyperventilating. The client’s arterial blood gas
values are pH 7.52, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L (26 mmol/L).
Which question would the nurse ask when developing this client’s plan of care?
a. “Do you take any over-the-counter medications?”
b. “You appear anxious. What is causing your distress?”
c. “Do you have a history of anxiety attacks?”
d. “You are breathing fast. Is this causing you to feel light-headed?

Answer 38

ANS:B
The nurse would assist the client who is experiencing anxiety-induced respiratory alkalosis to
identify causes of the anxiety. The other questions will not identify the cause of the acid–base
imbalance. The other three questions are also yes/no and close-ended.

Question 39

A diabetic client becomes septic after a bowel resection and is having problems with
respiratory distress. The nurse reviews the labs and finds the following ABG results: pH 7.50,
PaCO2 30, HCO3 : 24, and PaO2 68. What does the nurse recognize as the primary factor
causing this the acid–base imbalance?
a. Atelectasis due to respiratory muscle fatigue
b. Hyperventilation due to poor oxygenation
c. Hypoventilation due to morphine PCA
d. Kussmaul respirations due to glucose of 102 mg/dL (5.7 mmol/L)

Answer 39

ANS: B
The ABG results indicate respiratory alkalosis. The client has low oxygenation as indicated by
low partial pressure of arterial oxygen causing a compensatory mechanism of increased
respirations and hyperventilation. Respiratory muscle fatigue and hypoventilation would
cause respiratory acidosis with a low pH and high PaCO2. Kussmaul respirations are
characterized by deep labored breathing and are a compensatory mechanism to metabolic
acidosis, not hypoxemia or alkalosis.

Question 40

A nurse is planning interventions that regulate acid–base balance to ensure that the pH of a
client’s blood remains within the normal range. Which abnormal physiologic functions may
occur if the client experiences an acid–base imbalance? (Select all that apply.)
a. Reduction in the function of hormones
b. Fluid and electrolyte imbalances
c. Increase in the function of selected enzymes
d. Excitable cardiac muscle membranes
e. Increase in the effectiveness of many drugs
f. Changes in GI tract excitability

Answer 40

ANS: A, B, D, F
Acid–base imbalances interfere with normal physiology, including reducing the function of
hormones and enzymes, causing fluid and electrolyte imbalances, causing heart membranes
and GI tract to be more or less excitable, and decreasing the effectiveness of many drugs

Question 41

A nurse assesses a client who is experiencing an acid–base imbalance. The client’s arterial
blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 18 mEq/L (18
mmol/L). For which clinical signs and symptoms would the nurse assess? (Select all that
apply.)
a. Reduced deep tendon reflexes
b. Drowsiness
c. Increased respiratory rate
d. Decreased urinary output
e. Positive Trousseau sign
f. Flaccid paralysis

Answer 41

ANS: A, B, C
Metabolic acidosis causes neuromuscular changes, including reduced muscle tone and deep
tendon reflexes. Clients usually present with lethargy and drowsiness. The respiratory system
will attempt to compensate for the metabolic acidosis; therefore, respirations will increase rate
and depth. Flaccid paralysis can occur. A positive Trousseau sign is associated with alkalosis.
Decreased urine output is not a sign of metabolic acidosis.

Question 42

A nurse is assessing clients who are at risk for acid–base imbalance. Which clients are
correctly paired with the acid–base imbalance? (Select all that apply.)
a. Metabolic alkalosis—young adult who is prescribed intravenous morphine sulfate
for pain
b. Metabolic acidosis—older adult who is following a carbohydrate-free diet
c. Respiratory alkalosis—client on mechanical ventilation at a rate of 28 breaths/min
d. Respiratory acidosis—postoperative client who received 6 units of packed red
blood cells
e. Metabolic alkalosis—older client prescribed antacids for gastroesophageal reflux
disease

Answer 42

ANS: B, C, E
Respiratory acidosis often occurs as the result of underventilation. The client who is taking
opioids, especially IV opioids, is at risk for respiratory depression and respiratory acidosis.
One cause of metabolic acidosis is a strict low-calorie diet or one that is low in carbohydrate
content. Such a diet increases the rate of fat catabolism and results in the formation of
excessive ketoacids. A ventilator set at a high respiratory rate or tidal volume will cause the
client to lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis.
Citrate is a substance used as a preservative in blood products. It is not only a base, but also a
precursor for bicarbonate. Multiple units of packed red blood cells could cause metabolic
alkalosis. Sodium bicarbonate antacids may increase the risk of metabolic alkalosis.

Question 43

A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects
related to an acid–base imbalance would the nurse assess? (Select all that apply.)
a. Positive Chvostek sign
b. Elevated blood pressure
c. Bradycardia
d. Increased muscle strength
e. Anxiety and irritability
f. Tetany

Answer 43

ANS: A, E
A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Signs and
symptoms of metabolic alkalosis include positive Chvostek sign, normal or low blood
pressure, increased heart rate, skeletal muscle weakness, possible tetany and seizures, and
anxiety and irritability

Question 44

A nurse is planning care for a client who is lethargic and confused. The client’s arterial blood
gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 19 mEq/L (19
mmol/L). Which questions would the nurse ask the client and spouse when developing the
plan of care? (Select all that apply.)
a. “Are you taking any antacid medications?”
b. “Is your spouse’s current behavior typical?”
c. “Do you drink any alcoholic beverages?”
d. “Have you been participating in strenuous activity?”
e. “Are you experiencing any shortness of breath?”

Answer 44

ANS: B, C, D
This client’s symptoms of lethargy and confusion are related to a state of metabolic acidosis.
The nurse would ask the client’s spouse or family members if the client’s behavior is typical
for him or her, and establish a baseline for comparison with later assessment findings. The
nurse would also assess for alcohol intake because alcohol can cause metabolic acidosis.
Excessive and strenuous activity can lead to overproduction of hydrogen ions. The other
options are not causes of metabolic acidosis.

Question 45

A nurse is caring for a client who has just had a central venous access line inserted. What
action will the nurse take next?
a. Begin the prescribed infusion via the new access.
b. Ensure that an x-ray is completed to confirm placement.
c. Check medication calculations with a second RN.
d. Make sure that the solution is appropriate for a central line.

Answer 45

ANS: B
A central venous access device, once placed, needs an x-ray confirmation of proper placement
before it is used. The bedside nurse would be responsible for beginning the infusion once
placement has been verified. Any IV solution can be given through a central line.

Question 46

A nurse assesses a client who has a radial artery catheter. Which assessment will the nurse
complete first?
a. Amount of pressure in fluid container
b. Date of catheter tubing change
c. Type of dressing over the site
d. Skin color and capillary refill

Answer 46

ANS: D
An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased
perfusion to the extremity. Assessment of color, warmth, sensation, capillary refill time, and
distal pulses (if appropriate) are assessments for circulation distal to the catheter site. The
nurse would note that there is enough pressure in the fluid container to keep the system
flushed, and would check to see whether the catheter tubing needs to be changed. However,
these are not assessments of greatest concern. The type of dressing over the site would be
noted and most likely prescribed by policy.

Question 47

A nurse teaches a client who is being discharged home with a peripherally inserted central
catheter (PICC). Which statement will the nurse include in this client’s teaching?
a. “Avoid carrying your grandchild with the arm that has the central catheter.”
b. “Be sure to place the arm with the central catheter in a sling during the day.”
c. “Flush the peripherally inserted central catheter line with normal saline daily.”
d. “You can use the arm with the central catheter for most activities of daily living.”

Answer 47

ANS:A
A properly placed PICC (in the antecubital fossa or the basilic vein) allows the client
considerable freedom of movement. Clients can participate in most activities of daily living;
however, heavy lifting can dislodge the catheter or occlude the lumen. Although it is
important to keep the insertion site and tubing dry, the client can shower. The device is
flushed with heparin.

Question 48

A nurse is caring for a client who is receiving an epidural infusion for pain management.
Which assessment finding requires immediate intervention from the nurse?
a. Redness at the catheter insertion site
b. Report of headache and stiff neck
c. Temperature of 100.1° F (37.8° C)
d. Pain rating of 8 on a scale of 0-10

Answer 48

ANS: B
Complications of epidural therapy include infection, bleeding, leakage of cerebrospinal fluid,
occlusion of the catheter lumen, and catheter migration. Headache, neck stiffness, and a
temperature higher than 101° F (37.8° C) are signs of meningitis and would be reported to the
primary health care provider immediately. The other findings are important but do not require
immediate intervention

Question 49

A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which
assessment finding is of greatest concern?
a. The catheter has been in place for 20 hours.
b. The client has poor vascular access in the upper extremities.
c. The catheter is placed in the proximal tibia.
d. The client’s left lower extremity is cool to the touch

Answer 49

ANS: D
Compartment syndrome is a condition in which increased tissue pressure in a confined
anatomic space causes decreased blood flow to the area. A cool extremity can signal the
possibility of this syndrome. All other findings are important; however, the possible
development of compartment syndrome requires immediate intervention because the client
could require amputation of the limb if the nurse does not correctly assess and respond to this
perfusion problem.

Question 50

A nurse is assessing clients who have intravenous therapy prescribed. Which assessment
finding for a client with a peripherally inserted central catheter (PICC) requires immediate
attention?
a. The initial site dressing is 3 days old
b. The PICC was inserted 4 weeks ago.
c. A securement device is absent.
d. Upper extremity swelling is noted.

Answer 50

ANS: D
Upper extremity swelling could indicate infiltration, and the PICC will need to be removed.
The initial dressing over the PICC site would be changed within 24 hours. This does not
require immediate attention, but the swelling does. The dwell time for PICCs can be months
or even years. Securement devices are being used more often now to secure the catheter in
place and prevent complications such as phlebitis and infiltration. The IV lacking one does not
take priority over the client whose arm is swollen.

Question 51

A nurse assesses a client’s peripheral IV site, and notices edema and tenderness above the site.
What action will the nurse take next?
a. Apply cold compresses to the IV site.
b. Elevate the extremity on a pillow.
c. Flush the catheter with normal saline.
d. Stop the infusion of intravenous fluids.

Answer 51

ANS: D
Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of
infiltration include edema and tenderness above the site. The nurse would stop the infusion
and remove the catheter. Cold compresses and elevation of the extremity can be done after the
catheter is discontinued to increase client comfort. Alternatively, warm compresses may be
prescribed per institutional policy and may help speed circulation to the area.

Question 52

While assessing a client’s peripheral IV site, the nurse observes a streak of red along the vein
path and palpates a 1.5 inch (4-cm) venous cord. How will the nurse document this finding?
a. “Grade 3 phlebitis at IV site”
b. “Infection at IV site”
c. “Thrombosed area at IV site”
d. “Infiltration at IV site”

Answer 52

ANS: A
The presence of a red streak and palpable cord indicates grade 3 phlebitis. No information in
the description indicates that infection, thrombosis, or infiltration is present

Question 53

A new nurse is caring for a client receiving drug therapy via a smart pump. What statement by
the new nurse demonstrates the need for more instruction on this technology?
a. “I don’t need to manually calculate IV infusion rates with smart pumps.”
b. “Responding to IV pump alarms is a high priority for client safety.”
c. “The hospital can preprogram the pumps for high-alert drug limits.”
d. “These pumps have a system to prevent fluids from free-flowing into the client.”

Answer 53

ANS: A
The “smarter” the pump is the more programming needs to occur and errors can happen and
systems can fail. Using a programmable pump does not relieve the nurse of his or her
responsibility to monitor the infusion site and rates and ensure the client is receiving the fluids
or medications as prescribed. The Joint Commission continues to include responding to
alarms as a National Patient Safety Goal. Pumps can be preprogrammed so that upper limits
exist for high-alert drugs. All electronic infusion devices have some mechanism for
preventing free flow of fluids if the cassette or tubing is removed from the pump.

Question 54

A nurse prepares to insert a peripheral venous catheter in an older adult. What action will the
nurse take to protect the client’s skin during this procedure?
a. Lower the extremity below the level of the heart.
b. Apply warm compresses to the extremity.
c. Tap the skin lightly and avoid slapping.
d. Place a washcloth between the skin and tourniquet.

Answer 54

ANS: D
To protect the client’s skin, the nurse will place a washcloth or the client’s gown between the
skin and tourniquet. The other interventions are methods to distend the vein but will not
protect the client’s skin

Question 55

A nurse delegates care to an assistive personnel (AP). Which statement will the nurse include
when delegating hygiene for a client who has a vascular access device?
a. “Provide a bed bath instead of letting the client take a shower.”
b. “Use sterile technique when changing the dressing.”
c. “Disconnect the intravenous fluid tubing prior to the client’s bath.”
d. “Use a plastic bag to cover the extremity with the device.”

Answer 55

ANS: D
The nurse will ask the AP to cover the extremity with the vascular access device with a plastic
bag or wrap to keep the dressing and site dry. The client may take a shower or bath with a
vascular device. The nurse will disconnect IV fluid tubing prior to the bath and change the
dressing using sterile technique if necessary. These options are not appropriate to delegate to
the AP.

Question 56

A nurse teaches a client who is prescribed a central vascular access device and is transferring
to a skilled facility for long-term treatment. Which statement will the nurse include in this
client’s 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.”

Answer 56

ANS: C
The nurse would actively engage the client in the prevention of catheter-related bloodstream
infections and taught to remind all providers to perform hand hygiene and vigorously clean
connections prior to accessing the device. The other statements are incorrect.

Question 57

A nurse is caring for a client with a peripheral vascular access device who is experiencing
pain, redness, and swelling at the site. After removing the device, what action will the nurse
take to relieve pain?
a. Administer topical lidocaine to the site.
b. Place warm compresses on the site.
c. Administer prescribed oral pain medication.
d. Massage the site with scented oils

Answer 57

ANS: B
At the first sign of phlebitis, the catheter will be removed and warm compresses used to
relieve pain. The other options are not appropriate for this type of pain.

Question 58

A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client
reports abdominal pain and “feeling warm.” For which complication of this therapy will the
nurse assess the client?
a. Allergic reaction
b. Bowel obstruction
c. Catheter lumen occlusion
d. Infection

Answer 58

ANS: D
Fever, abdominal pain, abdominal rigidity, and rebound tenderness may be present in the
client who has peritonitis related to intraperitoneal therapy. Peritonitis is preventable by using
strict aseptic technique in handling all equipment and infusion supplies. An allergic reaction
would show other signs and symptoms. Bowel obstruction and catheter lumen occlusion can
occur but would present clinically in different ways.

Question 59

A medical-surgical nurse is concerned about the incidence of complications related to IV
therapy, including bloodstream infection. Which intervention will the nurse suggest to the
management team to make the biggest impact on decreasing complications?
a. Initiate a dedicated team to insert access devices.
b. Require additional education for all nurses.
c. Limit the use of peripheral venous access devices.
d. Perform quality control testing on skin preparation products.

Answer 59

ANS: A
The Centers for Disease Control and Prevention recommends having a dedicated IV team to
reduce complications, save money, and improve client satisfaction and outcomes. In-service
education would always be helpful, but it would not have the same outcomes as an IV team.
Limiting the use of various access devices may not be practical. The quality of skin
preparation products is only one aspect of IV insertion that could contribute to infection.

Question 60

A home care nurse prepares to administer intravenous medication to a client. The nurse
assesses the site and reviews the client’s chart prior to administering the medication and notes
it to have been inserted 4 months ago. The site has no redness, warmth, or swelling and
flushes easily. What action does the nurse take?
a. Notify the primary health care provider.
b. Administer the prescribed medication.
c. Discontinue the PICC.
d. Switch the medication to the oral route.

Answer 60

ANS: B
A PICC that is functioning well without inflammation or infection may remain in place for
months. Because the line shows no signs of complications, it is permissible to administer the
IV antibiotic. There is no need to call the primary health care provider or to have the IV
medication changed to an oral route

Question 61

A registered nurse (RN) occasionally delegates client care to licensed practical nurses (LPNs)
or technicians. What information does the RN consider when delegating components of IV
therapy? (Select all that apply.)
a. Each state’s Nurse Practice Act will regulate who can perform care related to IVs.
b. The nurse would check the facility’s Policies and Procedures manual.
c. The LPN’s level of experience primarily guides the decision.
d. Technicians cannot participate in any part of caring for IV infusions.
e. The RN remains accountable for all aspects of IV care and delegated actions.
f. The Infusion Nurses Society has guidelines and standards of IV therapy
competency

Answer 61

ANS: A, B, E, F
The state Nurse Practice Act will have the information the RN needs to determine scope of
practice, and in some states, LPNs and technicians are able to perform specific aspects of IV
therapy. The nurse would also be familiar with facility policies and procedures regarding
delegation of IV therapy. Amount of experience is not a criterion as LPNs and technicians can
have their knowledge and skills verified. The nurse remains accountable for all aspects of IV
therapy include what has been delegated. The Infusion Nurses Society has published
guidelines and standards related to competency for IV therapy.
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
GARDESLAB.

Question 62

A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which
common complications will the nurse assess? (Select all that apply.)
a. Phlebitis
b. Pneumothorax
c. Thrombophlebitis
d. Excessive bleeding
e. Extravasation
f. Pneumothorax
g. Infiltration

Answer 62

ANS: A, C
Although the complication rate with PICCs is fairly low, the most common complications are
phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Excessive bleeding,
infiltration, and extravasation are not common complications. Pneumothorax does not occur.

Question 63

A nurse prepares to administer a blood transfusion to a client, and checks the blood label with
a second registered nurse using the International Society of Blood Transfusion (ISBT)
universal bar-coding system to ensure the right blood for the right client. Which components
must be present on the blood label in bar code and in eye-readable format? (Select all that
apply.)
a. Unique facility identifier
b. Lot number related to the donor
c. Name of the client receiving blood
d. ABO group and Rh type of the donor
e. Blood type of the client receiving blood
f. Signature line for 2-person verification

Answer 63

ANS: A, B, D
The ISBT universal bar-coding system includes four components: (1) the unique facility
identifier, (2) the lot number relating to the donor, (3) the product code, and (4) the ABO
group and Rh type of the donor. Positive identification by two qualified health care providers
is essential although automated bar coding is acceptable in some care areas. However, a
signature line is not required on the blood label.

Question 64

A nurse assists with the insertion of a central vascular access device. Which actions will the
nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that
apply.)
a. Include a review for the need of the device each day in the client’s plan of care.
b. Remind the primary health care provider to perform hand hygiene prior to
insertion if he or she forgets.
c. Cleanse the preferred site with alcohol and let it dry completely before insertion.
d. Ask everyone in the room to wear a surgical mask during the procedure.
e. Plan to complete a sterile dressing change on the device every day.
f. Minimal client draping and barrier precautions as blood loss are minimal.

Answer 64

ANS: A, B, D
The central vascular access device bundle to prevent catheter-related bloodstream infections
includes using a checklist during insertion, performing hand hygiene before inserting the
catheter and anytime someone touches the catheter, using chlorhexidine to disinfect the skin at
the site of insertion, using preferred sites, and reviewing the need for the catheter every day.
The practitioner who inserts the device would wear sterile gloves, gown, and mask, and
anyone in the room would wear a mask. Maximal barrier precautions are used which requires
the client to be draped sterilely from head to toe. The initial dressing on a central vascular
access device is changed in 24 hours. Gauze and tape dressings are changed every 48 hours
and transparent membrane dressings are changed every 5 to 7 days.

Question 65

A nurse prepares to insert a short peripheral venous catheter. What actions will the nurse take
to use best practices? (Select all that apply.)
a. Choose a distal site on the client’s nondominant arm.
b. Verify that the prescription is appropriate for peripheral infusion.
c. Place the venous catheter near an area of joint flexion.
d. Wear a surgical mask during the catheter insertion procedure.
e. Perform hand hygiene before inserting the catheter.
f. Limit unsuccessful attempts by up to three clinicians to one attempt each

Answer 65

ANS: A, B, E
Best practices for the insertion of a short peripheral venous catheter include hand hygiene
prior to the procedure, verification of the prescription for intravenous therapy and its
appropriateness for infusion through a short peripheral catheter, and placement of the catheter
in a distal site, away from an area of joint flexion and when possible in the client’s
nondominant arm. Surgical masks are needed for central venous catheter placement but not
for short peripheral venous catheter placement. Unsuccessful attempts to insert the catheter
should be limited to two per person and no more than four total.