a nurse is caring for a client who has just had a central venous access line inserted which action should the nurse take next

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next?

A. Begin the prescribed infusion via the new access
B. Ensure an x-ray is completed to confirm placement.
C. Check medication calculations with a second RN.
D. Make sure the solution is appropriate for a central line

Correct answer: B

Rationale:

2. Which of the following statements is correct?

A. People with less body fat have more body water.
B. Infants have more water per pound than adults.
C. Females have more body water per pound than males.
D. Infants have the same water content per pound as adults.

Correct answer: A

Rationale: The correct statement is that people with less body fat have more body water. This is because fat tissue contains less water compared to lean tissue, so individuals with less body fat generally have a higher percentage of body water. Choice B is incorrect as infants actually have more water per pound than adults due to their higher body water content. Choice C is incorrect as males typically have more body water per pound than females. Choice D is incorrect as infants have a higher water content per pound compared to adults.

3. While assessing a patient's peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?

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

Correct answer: C

Rationale: Infiltration is the administration of a nonvesicant solution or medication into the surrounding tissue, typically due to the dislodgement or perforation of the vein wall by the IV cannula. It is characterized by edema around the insertion site, leakage of IV fluid, discomfort, coolness, and a decrease in flow rate. In this scenario, the presence of edema indicates infiltration, not air emboli, phlebitis, or fluid overload. Air emboli refer to air bubbles in the bloodstream, phlebitis is inflammation of the vein, and fluid overload is an excessive volume of fluid in the circulatory system.

4. During a visit to an 84-year-old woman recovering from hip surgery, the nurse notices signs of confusion and poor skin turgor. The woman mentions she limits water intake to avoid nighttime bathroom trips. The nurse should explain to the woman that:

A. She will need her medications adjusted and be readmitted for a complete workup.
B. Limiting fluids can lead to body imbalances causing confusion; perhaps adjusting fluid intake timing is necessary.
C. Post-surgical confusion is common, and it's safe not to urinate at night.
D. Confusion after surgery is typical in the elderly due to sleep loss.

Correct answer: B

Rationale: The correct answer is B. In elderly patients, fluid and electrolyte imbalances can manifest with subtle signs like confusion. Limiting fluids can lead to such imbalances, affecting cognitive function. Adjusting the timing of fluid intake can help maintain hydration without causing nighttime disruptions. Choices A, C, and D are incorrect. Choice A suggests unnecessary hospital readmission and medication adjustments without addressing the root cause. Choice C wrongly normalizes the confusion and fails to address the potential issue of fluid restriction. Choice D incorrectly attributes confusion solely to sleep loss without considering the impact of fluid balance.