Share This Link

Review the results of serum electrolytes: Results aren’t available yet; delaying access/treatment for labs risks worsening hypovolemia. Draw labs after IV access is obtained.

Offer the woman foods high in sodium and potassium: Not appropriate in an actively vomiting, lethargic patient; risk of aspiration and likely intolerance. Electrolytes should be replaced parenterally initially.

Administer an antiemetic: Helpful, but you need IV access to give it promptly and fluids are the higher priority for stabilization.

xplaining the mechanisms involved in transporting fluids: This provides knowledge but doesn’t directly improve fluid intake. Education alone may not translate into behavior.

Keeping fluids readily available for the patient: Accessibility is the most effective measure because it promotes actual drinking behavior. Fluids placed within reach make adherence easier.

Planning to offer most fluids in the evening: Ineffective and potentially problematic. Concentrating fluids late in the day increases nocturia and risk of disturbed sleep/falls, especially in older adults.

This catheter usually remains in place for 2 to 3 months: Nontunneled percutaneous central lines are short‑term (usually days to a few weeks). Longer-term central access (months) is achieved with tunneled catheters or implanted ports/PICCs.

The catheter is introduced via the basilic or cephalic veins in the antecubital space: Basilic/cephalic antecubital veins are used for peripheral IVs or PICC insertion. Nontunneled CVCs are typically inserted into central veins (internal jugular, subclavian, or sometimes femoral).

Nursing responsibility includes accessing the catheter with an angled needle: Accessing with an angled (Huber) needle is how implanted ports are accessed. Nontunneled CVCs have external lumens and are accessed directly.

Respiratory acidosis (carbonic acid excess): This condition is caused by CO₂ retention (hypoventilation). Asking the patient to breathe more slowly would further increase PaCO₂ and worsen the acidosis.

Metabolic acidosis (bicarbonate deficit): In metabolic acidosis the body compensates by increasing ventilation to blow off CO₂ (Kussmaul respirations when severe). Instructing slower breathing would reduce compensation and worsen acidemia.

Metabolic alkalosis (bicarbonate excess): Although retaining CO₂ (by breathing more slowly) can provide some respiratory compensation for metabolic alkalosis, this is not the typical or primary nursing intervention to treat metabolic alkalosis. T

Carrots and squash: These contain potassium but are generally moderate sources compared with fruits like bananas and many dried fruits. They are not the classic foods singled out as the highest-risk items.

Canned soups and potato chips: These are typically high in sodium, not the highest potassium sources. They may be unhealthy for other reasons (HTN, fluid retention) but are not the prototypical high-K foods to avoid first.

Whole-grain cereals and milk: Milk contains potassium (moderate amount) and some cereals contain potassium, but these are generally not as concentrated as bananas/dried fruits/potatoes.

Dorsal aspect of either foot: Foot veins are generally avoided in adults unless no upper-extremity sites are available (higher risk of thrombosis and slower flow). In trauma, you prefer a proximal upper-extremity site first.

Right hand: The right arm has a cast; avoid inserting an IV into or distal to a cast because of impaired circulation, risk of infection, and difficulty assessing the site.

Left forearm: The left forearm could be used, but the antecubital site provides larger, more proximal veins appropriate for rapid resuscitation- making the left antecubital more appropriate in a multisystem trauma situation.

Changing the IV catheter and entry site daily: Routine daily removal/reinsertion is unnecessary and may increase patient discomfort and infection risk.

Changing the tubing every 8 hours: Tubing change intervals are set by facility/infection-control guidelines and are usually less frequent than every 8 hours for standard continuous infusions.

Increasing the rate to catch up if the correct amount has not been infused at the end of the shift: You should not speed an infusion without a new order- that risks fluid overload or incorrect medication dosing. Instead, notify the provider and document reasons for the delay.

After the blood is all infused: Waiting until the end risks missing a severe early reaction; if a reaction occurs during the transfusion it can be life-threatening and requires immediate action.

Every hour: Hourly checks may be done after the initial period in some settings, but they are not sufficient to catch the most dangerous early reactions.

Every 15 minutes: Although frequent monitoring is good, the exam-focused, high-yield timing is the initial 15-minute check (and then regularly per protocol).

Apply a warm, moist compress: This is an appropriate treatment for phlebitis (after stopping the infusion) because it helps decrease inflammation and discomfort, but it is not the first action. You must first stop the infusion.

Aspirate the infusing fluid from the VAD: Aspirating the line is not the immediate priority and is not a standard first step for suspected phlebitis or local infection. Removing the IV and stopping the infusion comes first.

Report the situation to the health care provider: Reporting is important, but only after you’ve secured the patient (stopped the infusion and removed the catheter if indicated). Immediate safety actions come before notification.

wo-thirds of the volume: This is not the standard conversion used in clinical practice.

One-quarter of the volume: This underestimates intake and is not the standard conversion.

Two times the volume: This would grossly overestimate fluid intake.

etabolic acidosis: Metabolic acidosis would show decreased HCO₃⁻ (usually <22). Here HCO₃⁻ is normal (24).

Metabolic alkalosis: That would be alkalemia (pH >7.45) with increased HCO₃⁻.

Respiratory alkalosis: Respiratory alkalosis would have low PaCO₂ and high pH.