NR-226 Patient Care Fundamentals - Set 2 - Part 2

Correct Answer: New confusion with a thready pulse

New confusion appearing alongside tachycardia, falling pressure and a thready pulse signals cerebral hypoperfusion, meaning compensation can no longer defend brain perfusion. That combination is the priority finding in fluid volume deficit. Option b is incorrect because dry membranes and thirst are early, expected markers of depletion that confirm the diagnosis without signaling organ failure. They warrant fluid replacement and oral care, not the immediate response reserved for hypoperfusion. Option c is incorrect because tenting reflects interstitial water loss in the skin, a slow-changing finding that supports the assessment picture. Turgor never outranks a neurologic change, and in older adults it is unreliable anyway. Option d is incorrect because concentrated urine shows the kidney doing exactly what antidiuretic hormone and aldosterone tell it to do. It documents deficit and guides monitoring, yet the brain finding carries the greater urgency.

Correct Answer: Measuring and recording the client's oral intake

Measuring oral intake is a standardized task with a predictable outcome and no clinical judgment attached. The nurse keeps assessment, rate changes and teaching, then interprets the recorded intake against output and weight. Option a is incorrect because judging whether a site is infiltrating or inflamed requires the nurse's assessment skill. Assistive personnel may report what they notice, but the evaluation of the finding is never handed off. Option b is incorrect because altering an infusion rate is medication administration. A wrong setting can produce circulatory overload or speed shock within minutes, which places the task well outside the scope of unlicensed staff. Option c is incorrect because client education is a licensed responsibility that depends on assessing what the client already understands. Reinforcing material the nurse has taught is acceptable, but delivering the instruction is not.

Correct Answer: Phlebitis of the vein wall

Erythema, warmth and tenderness tracking along the vein's course, with a firm cordlike vessel, is inflammation of the vein wall. Antibiotics are chemical irritants and a common cause of phlebitis. Option a is incorrect because infiltrated fluid makes the site cool, pale and tautly swollen, with blood return lost. A red streak following the vein is the opposite presentation. Option c is incorrect because air reaching the right heart causes sudden dyspnea, chest pain, hypotension and cyanosis. Air embolism is a systemic emergency, and it produces no visible change along the forearm. Option d is incorrect because speed shock follows delivery of a substance faster than the body can accept, bringing sudden headache, facial flushing, chest tightness and an irregular pulse rather than a local finding.

Correct Answer: Osmosis, since water follows the solute

Osmosis is the passive movement of water across a selectively permeable membrane toward the higher solute concentration. Water leaves the dilute side to dilute the concentrated side until the two concentrations equalize. Option b is incorrect because diffusion describes solute particles spreading down their own gradient, not water shifting. In this demonstration the membrane held the salt back and only water was free to cross. Option c is incorrect because filtration needs a hydrostatic push, and this setup supplied none. It is the mechanism at work in the glomerulus, where blood pressure forces fluid and its dissolved particles across together. Option d is incorrect because nothing in a glass apparatus supplies adenosine triphosphate, and the movement stopped once concentrations matched. Active transport pushes solute uphill and continues only while the cell keeps spending energy.

Correct Answer: Assess the site and slow the prescribed rate

Burning at the site is common with potassium, and the response is to assess the site and slow the rate or dilute further rather than continue unchanged. Potassium is a vesicant at high concentration. Option a is incorrect because telling a client to tolerate pain skips the assessment that distinguishes ordinary vein irritation from an infiltrating vesicant. Reassurance without looking at the site can let tissue injury proceed unnoticed. Option b is incorrect because a faster potassium infusion increases both the vein irritation and the cardiac risk. Rate limits for potassium exist precisely so the drug cannot reach the heart too quickly. Option d is incorrect because warmth belongs to the treatment of phlebitis after a catheter is discontinued. Laying heat over an actively infusing irritant leaves the cause running while treating a symptom.

Correct Answer: Assess airway, breathing and circulation immediately

Assessment precedes intervention unless the client is in arrest. Confirming airway, breathing and circulation with a full set of vital signs tells the nurse how far compensation has failed and what to report. Option a is incorrect because weight and intake records document trend rather than address a client whose brain is no longer being perfused. Those measures belong in ongoing monitoring, not in the first minute of a crisis. Option b is incorrect because sitting a hypotensive client upright drops cerebral perfusion further. High Fowler position relieves pulmonary congestion in volume excess; this client needs to lie flat with the legs raised. Option c is incorrect because a client who cannot be roused cannot safely drink anything. Oral rehydration suits mild deficit in an alert client, while this presentation calls for immediate assessment and intravenous volume.

Correct Answer: Lactated Ringer's at the prescribed rate

Lactated Ringer's is an isotonic, balanced crystalloid used in surgery and for blood loss, expanding the extracellular space without shifting water across cell membranes. Its buffer avoids the chloride load of large saline volumes. Option b is incorrect because half-normal saline is hypotonic, with half the sodium of plasma. It dilutes the extracellular fluid and sends water into cells, which is not what postoperative volume replacement calls for. Option c is incorrect because concentrated saline is hypertonic and belongs to cerebral edema and severe symptomatic hyponatremia. It is a high-alert therapy requiring protocol sodium checks, not a routine postoperative bag. Option d is incorrect because ten percent dextrose in water is hypertonic on the label and treats hypoglycemia. It irritates peripheral veins and reverts to free water, so it replaces no lost volume.

Correct Answer: Hang saline with new tubing at the catheter hub

Normal saline keeps the vein open, but it must run through new tubing attached directly to the catheter hub. Flushing the old set would push more of the offending blood into an already reacting client. Option a is incorrect because the existing line is full of the very product causing the reaction. Driving that column of blood forward delivers another dose of incompatible cells at the worst possible moment. Option b is incorrect because access is needed right now for saline, medications and possible resuscitation. Pulling a working catheter during a hemolytic reaction removes the route the client most depends on. Option d is incorrect because the bag and tubing are evidence. Both go back to the blood bank with the required specimens so the cause can be traced, and throwing them away destroys that investigation.

Correct Answer: Elevate the legs and inspect the skin daily

Raising the legs above the level of the heart lets gravity move interstitial fluid back toward the circulation, and a daily look at stretched, poorly perfused skin catches breakdown while it is still small. Option a is incorrect because an elastic band at the top of a sock constricts the limb and leaves a groove in fragile tissue. Graduated compression belongs in this plan only when a provider prescribes it. Option c is incorrect because crossing the ankles presses on the veins of one leg and keeps both feet below the heart. The position the client hopes will help actually holds fluid in the tissue. Option d is incorrect because firm rubbing over skin that is already stretched and poorly nourished can bruise or tear it. The pressure shifts fluid for a moment and treats none of the retention behind it.

Correct Answer: The first has phlebitis and the second infiltration

Warmth and redness along the vein's course with a cordlike feel is phlebitis, inflammation of the vein wall. Coolness, pallor and taut swelling is infiltration, fluid escaping into subcutaneous tissue. The temperature settles it. Option a is incorrect because it reverses the two pictures. A cordlike, erythematous vein is inflamed, not leaking, and a blanched cool hand holds fluid outside the vessel rather than an irritated wall. Option b is incorrect because extravasation requires a vesicant solution and adds burning pain, marked erythema and blistering. Nothing in the second client's cool, pale, swollen hand suggests tissue destruction from a caustic drug. Option c is incorrect because purulent drainage at the puncture site, not a red streak along the vein, marks infection. Calling the first finding infection skips the simpler explanation of an inflamed vein wall.

Correct Answer: I will call right away if the site swells or leaks.

Swelling and leaking are the earliest signs that fluid is escaping the vein. A family member who reports them immediately allows the infusion to be stopped before the tissue is stretched or damaged further. Option a is incorrect because families are told never to touch the roller clamp or pump. Speeding the rate can push a client into circulatory overload, and a slow bag is a sign to report, not to fix. Option b is incorrect because redness signals phlebitis or infection and needs a call the same day it appears. Delaying a full day lets an inflamed vein or a local infection spread before anyone assesses it. Option d is incorrect because routine site care follows the prescribed dressing schedule and antiseptic, and the dressing is not disturbed daily by a family member. Alcohol swabbing on a whim invites contamination rather than preventing it.

Correct Answer: Fluid is trapped outside the circulating volume

This is third spacing. The fluid never left the body, so weight and girth rise, but it sits in the peritoneum where it cannot perfuse anything, leaving the vessels underfilled. Option b is incorrect because total body water is actually increased here, which is why the scale and the abdominal girth both climbed. The problem is distribution between compartments, not the overall amount. Option c is incorrect because an overfilled vascular compartment raises blood pressure, produces a bounding pulse and distends the jugular veins. Every circulatory value in this scenario points the opposite direction. Option d is incorrect because what shifted out of the vessels in ascites is isotonic fluid, so serum electrolytes and osmolality often stay normal. Low albumin and portal pressure drove this shift, not a rising osmolality.

Correct Answer: The client with hyperglycemia and heavy diuresis

Hyperglycemia pulls glucose into the urine and drags water with it, an osmotic diuresis that strips volume and free water quickly. That client is actively losing fluid now, while the others carry slower or lower risks. Option a is incorrect because corticosteroids do retain sodium and water and can drop potassium, but the effect builds over days. A first dose has not yet produced a disturbance demanding attention ahead of active losses. Option b is incorrect because a stool softener causes gradual gastrointestinal water loss that matters most in an older adult over time. Nothing here signals a rapid change requiring the nurse's first assessment. Option c is incorrect because a maintenance infusion running slowly is designed to hold a client even. It becomes a hazard only in cardiac or renal disease, and neither is described for this client.

Correct Answer: Weigh after voiding and before breakfast daily

A weight is only comparable when the conditions match: same time of day, empty bladder, before eating, same scale, and the same light clothing. Voiding first removes urine that would otherwise read as retained fluid. Option a is incorrect because bed, chair and standing scales are calibrated differently and will not agree with each other. Switching devices between days produces a difference that looks like fluid gain or loss. Option c is incorrect because letting the clock drift means one reading follows breakfast and the next precedes it. The difference then reflects the tray that was eaten, not the client's fluid status. Option d is incorrect because shoes, a robe or heavy clothes add pounds that get misread as retained water. A gown with nothing on the feet keeps the clothing variable out of the trend.

Correct Answer: Normal saline to expand the extracellular volume

Gastric fluid is isotonic, so the loss is volume with a normal concentration. Normal saline replaces that volume and supplies the chloride the kidney needs to correct the alkalosis gastric suction produces. Option a is incorrect because free water is what a client with a high sodium needs. This sodium is normal, and dilute fluid would drift out of the vessel while the blood pressure is already low. Option b is incorrect because concentrated saline treats swollen brain cells from symptomatic hyponatremia. Giving it to a client whose sodium is normal adds an enormous sodium load with no problem to correct. Option c is incorrect because the calories in a liter of that solution are trivial and it does not stay intravascular. A hypotensive client gains almost nothing from a bag that becomes free water.

Correct Answer: Infants carry proportionally more extracellular fluid

Total body water is about seventy to eighty percent of an infant's weight, and a larger share sits outside the cells where it turns over quickly. A small absolute loss is therefore a large percentage loss. Option b is incorrect because immature kidneys concentrate urine poorly, so an infant cannot defend water the way an adult can. That limitation is one of the reasons diarrhea deteriorates so quickly in this age group. Option c is incorrect because metabolic rate is higher in infancy, not slower. A faster metabolism generates more heat and more water turnover, adding to the fluid an infant loses without anyone noticing. Option d is incorrect because a large body surface area relative to weight means an infant evaporates more water per kilogram than an adult. Skin loss is amplified in infancy rather than reduced.

Correct Answer: I can skip cleaning the cap when I am rushed.

Disinfecting the needleless connector before every entry is not optional. Scrubbing the hub is what keeps skin organisms out of a catheter that ends in a central vein, where a single contamination can seed the bloodstream. Option a is incorrect because hand hygiene before and after touching the catheter or the site is exactly what the client should say. That statement shows the teaching succeeded and needs no correction. Option b is incorrect because fever and chills with no other explanation are the classic systemic warning of a bloodstream infection, and the exit site can look perfectly normal. Reporting them promptly is correct behavior. Option d is incorrect because a damp, loosened or soiled dressing must be changed rather than left in place, and the client recognized that. This answer demonstrates understanding, so it is not the statement requiring follow-up.

Correct Answer: Urea crosses membranes and pulls no water

Urea moves freely across cell membranes, so it raises measured osmolality without creating a lasting gradient. It is an ineffective osmole, and tonicity counts only solutes that cannot cross, such as sodium and glucose. Option a is incorrect because the two terms separate exactly when an ineffective osmole is present. Osmolality counts every dissolved particle, while tonicity counts only the ones capable of holding water on one side. Option c is incorrect because nothing described here says the sodium is low, and sodium remains the dominant effective osmole in plasma. A falling sodium would produce cell swelling rather than the stable cells observed. Option d is incorrect because the laboratory measures total particles per kilogram of water, urea included, which is precisely why the reported value is high. Excluding urea would remove the very finding that needs explaining.

Correct Answer: Osmotic demyelination from overly rapid correction

Raising a chronically low sodium faster than the accepted daily limit injures myelin in the brain, producing osmotic demyelination syndrome. The neurological change appearing as the sodium overshoots is the warning sign. Option a is incorrect because that acidosis follows large volumes of normal saline rather than a small, tightly controlled hypertonic infusion. It also presents as an acid-base change on a gas, not as confusion. Option b is incorrect because overload announces itself in the chest and neck. Crackles, distended neck veins and a bounding pulse would be present, and none of those findings appear in this client's picture. Option d is incorrect because brain cells swell when plasma becomes more dilute, which is the danger of hypotonic fluid. Hypertonic saline does the reverse, drawing water out of those cells.

Correct Answer: The infusion rate and any ordered additives

A complete intravenous order names the solution, the rate, the volume and any additives. Without the rate the nurse cannot program the pump, so the order is clarified with the prescriber before anything is hung. Option b is incorrect because a sodium result guides the choice of tonicity but is not part of the order itself. The missing piece here is a prescribed element, not a laboratory value. Option c is incorrect because the volume remaining in the old bag belongs in the intake record. Documenting it matters for the shift total, yet it tells the student nothing about what was prescribed. Option d is incorrect because catheter gauge affects flow and comfort rather than the completeness of a prescription. Checking hardware cannot substitute for the rate the prescriber failed to write.