NR-226 Patient Care Fundamentals - Set 2 - Part 3

Correct Answer: A bag of normal saline

Only normal saline is compatible with blood products. It matches the tonicity of the cells and contains no calcium or free water, so the red cells stay intact in the tubing. Option a is incorrect because dextrose in water delivers free water once the sugar is metabolized, and free water lyses red cells and causes pseudoagglutination. Manufacturer labeling states this restriction outright. Option b is incorrect because lactated Ringer's carries calcium, which overcomes the citrate anticoagulant in the stored unit. Clots can form in the line, so this fluid never shares tubing with blood. Option c is incorrect because half-normal saline is hypotonic. Its dilute sodium content pulls water into the transfused cells and damages them, which is why the standard is a solution matching plasma tonicity.

Correct Answer: Notify the provider and obtain blood cultures

Fever, rigors, confusion and hypotension with a normal-looking site describe a central line-associated bloodstream infection. The nurse notifies the provider and draws cultures from the line and peripherally so antibiotics can be targeted. Option a is incorrect because warm compresses treat phlebitis, an inflamed vein wall. This site shows no inflammation at all, and heat over the skin does nothing for organisms already circulating in the blood. Option c is incorrect because pulling a central line is a provider decision that may follow culture results. Removing it independently also destroys the access needed for antibiotics and fluid in a client whose pressure is falling. Option d is incorrect because changing an infusion rate is not a nursing decision made without an order. Fluid may well be needed, but the priority is identifying the organism before it is diluted by treatment.

Correct Answer: Sit on the bed edge before standing up

Standing pools blood in the legs, and a depleted circulation cannot compensate quickly. Dangling at the bedside gives the cardiovascular system time to adjust before the client bears weight, which prevents syncope and falls. Option b is incorrect because rising fast is precisely what triggers the postural drop. Speed gives the baroreceptors no chance to respond, and the client is most likely to faint in those first seconds. Option c is incorrect because less fluid means less circulating volume, which makes the postural drop worse rather than better. The client needs adequate intake plus a safe technique for changing position. Option d is incorrect because sleeping upright in a chair is advice for orthopnea in fluid overload, a different problem entirely. It does nothing for postural hypotension and adds pressure injury and stiffness risk.

Correct Answer: Institute fall precautions and assist with all transfers

A sustained systolic drop on standing with a compensatory heart rate rise indicates the vascular volume cannot support the shift of blood to the legs. This client will faint on standing, so safety comes first. Option a is incorrect because an orthostatic drop of this size is a finding to act on, not a normal variant. Charting it alone leaves a client who is about to fall unprotected. Option c is incorrect because unassisted walking is exactly what produces syncope in a volume-depleted client. Independent ambulation belongs in the plan once pressures stabilize, and until then the client should dangle before standing. Option d is incorrect because holding fluid worsens the very deficit that caused the postural drop. Replacement, whether oral or intravenous, is the treatment, and restricting intake would push the pressure down further.

Correct Answer: Report burning, swelling or coolness at the site

Pain, burning, swelling, coolness, redness or leaking are the early signs of infiltration, phlebitis or infection. A client who reports them promptly lets the nurse act before tissue injury or infection advances. Option a is incorrect because a saturated dressing means fluid has already been leaking for some time. Waiting for that much drainage lets an infiltration progress well beyond the point where it could have been caught. Option b is incorrect because clients are taught never to touch the roller clamp or the pump settings. Changing the rate independently risks circulatory overload or speed shock, and a slowing flow signals a problem to report. Option d is incorrect because redness and tenderness are not normal at an intravenous site. Teaching a client to expect them for days trains the client to ignore the earliest evidence of phlebitis or infection.

Correct Answer: Hold the fluid and clarify with the provider

Hypotonic fluid leaves the vessel almost immediately, deepening the hypovolemia of a burn and flooding an interstitium that is already leaking. The order is unsafe, so the nurse holds it and clarifies before infusing. Option a is incorrect because monitoring does not correct a fluid that is wrong for the injury. Watching urine drop while dilute fluid runs would document the harm rather than prevent it. Option b is incorrect because rate is not the defect in this prescription. A pump controls how fast a harmful solution enters, and burn resuscitation calls for lactated Ringer's rather than dilute saline. Option c is incorrect because nothing is ever added to a bag on the nurse's own judgment, and potassium in particular waits for urine output and a prescriber's order. That step compounds the error.

Correct Answer: Insensible losses rise and must be estimated

Fever and rapid breathing both drive up evaporative loss from skin and lungs. These losses never reach the record, so the nurse raises the estimate and leans on daily weight rather than the intake and output totals. Option a is incorrect because the record holds only what can be poured, weighed or read from a container. Water vapor leaving through breath and skin escapes the chart entirely, which is the whole difficulty here. Option b is incorrect because a raised body temperature increases evaporation rather than reducing it. Teaching the opposite would lead the graduate to underestimate a client who can lose a liter a day this way. Option d is incorrect because narrowing attention to urine ignores two routes that are wide open in this client. Lungs and skin are carrying water away steadily, and no urine measurement will reveal that.

Correct Answer: Elevated hematocrit with an elevated blood urea nitrogen

Water leaves while the solids remain, so everything measured as a concentration climbs. Hematocrit rises from hemoconcentration and urea nitrogen rises because reduced renal perfusion increases urea reabsorption, the classic prerenal pattern. Option a is incorrect because falling hematocrit and urea nitrogen describe hemodilution, which belongs to fluid volume excess. Losing gastric fluid concentrates the blood rather than watering it down, so both values move upward. Option b is incorrect because a dilute specific gravity would mean the kidney is excreting free water. With volume depleted, antidiuretic hormone drives maximum water reabsorption and the urine becomes concentrated instead. Option c is incorrect because it mixes the two pictures together. The rising hematocrit fits depletion, yet dilute urine contradicts it, since a kidney conserving water raises specific gravity well past normal.

Correct Answer: Treat the new confusion as a fluid problem

New confusion in an older adult is a fluid or electrolyte problem until proven otherwise, and self imposed restriction to avoid the bathroom is a common cause. The nurse acts on the deficit rather than on the mental change alone. Option a is incorrect because aging alone does not produce a sudden change in alertness over a week. Filing it as normal would leave a treatable deficit to progress toward hypovolemia and a fall. Option c is incorrect because skin over the hand loses elasticity with age and tents in a well hydrated older adult. If turgor is checked, the sternum or forehead is the site, and the result only supports other findings. Option d is incorrect because endorsing the restriction reinforces the behavior that created this picture. Continence can be managed by shifting fluids toward the earlier part of the day rather than by drinking less overall.

Correct Answer: Slow the infusion and sit the client up

Breathing outranks everything else. Slowing or stopping the infusion halts the volume load, and high Fowler's position eases the work of breathing and reduces venous return, treating the problem before anything is reported or measured. Option b is incorrect because notifying the provider is essential and a diuretic is likely ordered, yet the phone call comes after the nurse has acted on the breathing problem already in front of her. Option c is incorrect because pulling the catheter destroys the access route needed for an intravenous diuretic and emergency medications. The line is slowed to a keep-vein-open rate, never removed, during circulatory overload. Option d is incorrect because the assessment findings already establish the diagnosis. Gathering more numbers while fluid keeps pouring into an overloaded circulation delays the one intervention that stops the process from worsening.