the nurse is preparing to insert a peripheral iv catheter into a patient who will require fluids and iv antibiotics how should the nurse always start

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?

A. Leave one hand ungloved to assess the site.
B. Cleanse the skin with normal saline.
C. Ask the patient about allergies to latex or iodine.
D. Remove excessive hair from the selected site.

Correct answer: C

Rationale:

2. A client with a serum potassium of 7.5 mEq/L and cardiovascular changes needs immediate intervention. Which prescription should the nurse implement first?

A. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g 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.

Correct answer: C

Rationale: In a client with a serum potassium level of 7.5 mEq/L and cardiovascular changes, the priority intervention is to lower the potassium level quickly to prevent life-threatening complications like arrhythmias. The correct answer is to prepare to administer dextrose 20% and 10 units of regular insulin IV push. This combination helps shift potassium from the extracellular to the intracellular space, reducing serum potassium levels rapidly. Administering sodium polystyrene sulfate (Kayexalate) by mouth may take several hours to work, making it a less effective immediate intervention. Providing a heart-healthy, low-potassium diet is important for long-term management but is not the most urgent action in this situation. While hemodialysis is a definitive treatment for hyperkalemia, it is not the first-line intervention for acute management of high potassium levels with cardiovascular manifestations.

3. An increase in capillary blood pressure would tend to:

A. increase interstitial fluid volume.
B. increase plasma volume.
C. decrease interstitial fluid volume.
D. increase plasma volume and decrease interstitial fluid volume.

Correct answer: A

Rationale: An increase in capillary blood pressure leads to a higher force pushing fluid out of the capillaries into the interstitial space, thereby increasing interstitial fluid volume. Choice B is incorrect because capillary blood pressure affects the movement of fluid into the interstitial space, not into the plasma. Choice C is incorrect as an increase in capillary blood pressure would not decrease interstitial fluid volume. Choice D is incorrect as it combines contradictory effects when capillary blood pressure increases.

4. The nurse who assesses the patient's peripheral IV site and notes edema around the insertion site will document which complication related to IV therapy?

A. Air emboli
B. Phlebitis
C. Infiltration
D. Fluid overload

Correct answer: C

Rationale: Infiltration is the administration of non-vesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the vein's wall. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort, and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli (Choice A) involves air entering the bloodstream. Phlebitis (Choice B) is inflammation of a vein. Fluid overload (Choice D) is an excessive volume of fluid in the circulatory system.