An adult client has developed food poisoning. The client reports multiple
instances of vomiting and diarrhea for the past 12 hours. On inspection, the
client is diaphoretic and blood pressure is 88/46 mm Hg. What intervention
would the nurse anticipate?
peripheral IV access to administer medications intravenously
administration of IV fluids on an outpatient basis
peripheral IV access for drawing blood cultures
peripheral IV access for fluid replacement ANS✔✔ peripheral IV access for
fluid replacement
The client's combination of hypotension, vomiting, and diarrhea most likely
indicates a need for IV fluid replacement. The client may or may not require
medications. IV access is not normally established for the purpose of
drawing blood cultures. IV medications are sometimes administered on an
outpatient basis, but it is less common for fluids to be administered this
way.
Chloride is a common anion, which is a negatively charged ion. Magnesium,
potassium, and calcium are cations, or positively charged ions.
The nurse is assessing a client's intravenous line and notes small air
bubbles within the tubing. What is the priority nursing action?
Milk the air in the direction of the drip chamber.
Twist the tubing around a pencil.
Tap the tubing below the air bubbles.
Tighten the roller clamp to stop the infusion. ANS✔✔ Tighten the roller
clamp to stop the infusion.
The priority nursing action is to tighten the roller clamp on the tubing as this
action prevents forward movement of air. All other options are appropriate
to remove the air once the tubing has been clamped.
A 50-year-old client with hypertension is being treated with a diuretic. The
client reports muscle weakness and fatigue and the nurse's assessment
reveals an irregular heart rate. The nurse should assess the client's levels of
which electrolyte?
calcium
phosphorous
potassium
chloride ANS✔✔ potassium
, Solution 2024/2025
Pepper
Diuretics, commonly given to treat high blood pressure and heart failure,
can cause an extracellular deficit or loss of electrolytes including potassium,
calcium, and magnesium. Signs of potassium deficit, or hypokalemia,
include muscle weakness, fatigue and arrythmias.
A nurse is reviewing the dietary intake of a client prescribed a potassium-
sparing diuretic. The client tells the nurse that they had a banana, yogurt,
and bran cereal for breakfast and a turkey sandwich with a glass of milk for
lunch. The intake of which food would be a cause for concern?
banana
turkey
milk
yogurt ANS✔✔ banana
Bananas are high in potassium and would place the client receiving a
potassium-sparing diuretic at risk for increased potassium levels. Milk and
yogurt are good sources of calcium and phosphorus and would not be a
concern. Turkey provides protein and would not be problematic.
A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids
during a 24-hour period. In evaluating this client's urine output for the same
24-hour period, the nurse realizes that it should total approximately how
many mL?
500
1,000
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