a patient has a parenteral nutrition infusion of 25 dextrose a student nurse asks the nurse why a peripherally inserted central catheter was inserted
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Nursing Elites

HESI RN

Adult Health 2 HESI Quizlet

1. A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate?

Correct answer: C

Rationale: The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.

2. An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?

Correct answer: C

Rationale: The correct answer is C. The elevated serum sodium level (154 mEq/L) is consistent with the patient's neurologic symptoms of restlessness, agitation, and weakness, indicating a need for immediate action to prevent complications like seizures. The potassium level (3.4 mEq/L) and calcium level (7.8 mg/dL) are slightly off from normal but do not require immediate action. The phosphate level (4.8 mg/dL) is normal and not related to the symptoms presented by the patient.

3. A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?

Correct answer: D

Rationale: Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the presence of sediment and blood in the urine should also be reported, but they are not as immediately dangerous as the presence of fluid in the alveoli, which compromises gas exchange and can lead to respiratory failure.

4. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

Correct answer: A

Rationale: The correct answer is A: "Blood pressure is 90/40 mm Hg." A low blood pressure reading of 90/40 mm Hg indicates that the patient may be developing hypovolemic shock due to intravascular fluid loss from the burn injury. This finding is of utmost concern as it suggests systemic hypoperfusion, requiring immediate intervention to prevent complications. Choices B, C, and D also indicate signs of dehydration and the need to increase fluid intake; however, they are not as urgent as addressing the hypotension and potential shock presented in choice A.

5. The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? (Select all that apply)

Correct answer: A

Rationale: The correct answer is A: apple juice. Clear liquids like apple juice and orange juice are suitable for a client following a clear liquid diet and Mormon beliefs. Options B and D, black coffee and hot chocolate, contain caffeine, which may not align with the client's religious dietary restrictions. Therefore, these options should be avoided for this client.

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