NR-226 Patient Care Fundamentals - Set 2 - Part 1

Correct Answer: Drink on a schedule rather than awaiting thirst

Thirst becomes blunted with age, so an older adult who waits to feel thirsty is already depleted. Scheduled drinking through the day keeps intake ahead of loss, especially during hot weather. Option b is incorrect because the thirst mechanism is exactly what fails in aging, and relying on it is what produced this admission. The sensation lags well behind actual fluid loss in older adults. Option c is incorrect because deliberately cutting evening fluid to avoid bathroom trips is a common habit that drives older adults into deficit. The nurse should ask about it and discourage it, not endorse it. Option d is incorrect because large losses carry sodium and potassium away with the water. Oral rehydration solutions replace both, while plain water alone can worsen a sodium disturbance after heavy sweating or diarrhea.

Correct Answer: Overload reflects volume, and speed shock reflects rate

Circulatory overload is too much total fluid for the circulation to hold, building over time. Speed shock is a substance delivered too fast, striking within seconds and independent of how much volume was given. Option a is incorrect because it swaps the two mechanisms. Crackles and jugular venous distension come from a circulation holding more fluid than it can manage, not from the speed at which it arrived. Option b is incorrect because a rapid intravenous push may involve only a few milliliters. Volume alone cannot explain a reaction that appears in seconds, and the two complications are managed differently once identified. Option d is incorrect because a normal, correct rate still overloads a client whose heart or kidneys cannot keep pace. Blaming speed for both misses the reason older adults and heart failure clients overload so readily.

Correct Answer: The integrity of the removed catheter

Discontinuation charting records the date, time, reason, catheter integrity, site appearance, dressing and client tolerance. Confirming that the catheter came out intact is the entry that proves no fragment was left behind. Option b is incorrect because a sodium level belongs to the record of fluid and electrolyte therapy, not to the removal note. Nothing about pulling a catheter is documented by an electrolyte result. Option c is incorrect because the inserter's name is charted at insertion, along with the gauge, length, site and number of attempts. By itself it says nothing about how the removal went or what the site looks like. Option d is incorrect because equipment branding has no bearing on client care or safety. What the record needs is the solution, the rate, the volume infused and the client's response, none of which a brand name supplies.

Correct Answer: Notify the provider and anticipate isotonic fluid

The weight gain with hypotension, tachycardia, flat neck veins and falling urine output is third spacing. Fluid has shifted out of the vessels, so the client needs isotonic replacement, not fluid removal. Option a is incorrect because restricting fluids treats hypervolemia, and this client is intravascularly dry despite the higher scale reading. Withholding fluid while perfusion is already failing would drive the blood pressure lower still. Option b is incorrect because a diuretic pulls volume from the compartment that is already depleted. The trapped fluid sits in the interstitium and the peritoneum, where the kidney cannot reach it, so shock would deepen. Option d is incorrect because these values describe circulatory failure in progress, not an expected postoperative course. Watching without reporting delays the isotonic replacement this client needs and allows renal hypoperfusion to continue.

Correct Answer: The potassium is a vesicant that destroys tissue

Leaked saline is an infiltration and the tissue reabsorbs it. Concentrated potassium is a vesicant, so the same leak becomes an extravasation, producing burning, blistering and, over hours to days, skin sloughing and necrosis. Option b is incorrect because volume is not what separates these events. The mechanical failure is identical, and a few milliliters of a caustic drug can injure far more tissue than a liter of saline. Option c is incorrect because isotonic saline in subcutaneous tissue is reabsorbed, which is exactly why elevation and a compress are used after an infiltration. The saline client faces swelling and discomfort, not tissue loss. Option d is incorrect because a drug that has escaped the vein is no longer entering the bloodstream. The danger sits in the tissue it is dissolving, not in a systemic electrolyte level that will rise.

Correct Answer: Believe the weight and assess for retention

Intake and output systematically undercounts, since insensible loss cannot be measured and unreported drinks slip past the record. When the two disagree, the weight is the arbiter, so the nurse assesses lungs, neck veins and edema. Option a is incorrect because it treats the weaker measurement as the truth. A gain of more than two pounds in a day represents about a liter of retained fluid and calls for assessment, not observation. Option b is incorrect because an evening weight is not comparable to a morning one taken after voiding and before eating. Repeating it at the wrong time introduces error instead of resolving the discrepancy. Option d is incorrect because dismissing the scale removes the single most reliable indicator of fluid status from the picture. Equipment error is worth ruling out, but only after the client has been assessed.

Correct Answer: Inspect the removed catheter tip for integrity

The catheter is examined to confirm the tip came out whole. A shortened or ragged tip means a fragment remains in the circulation, and that finding calls for a tourniquet high on the limb, bed rest and immediate notification. Option a is incorrect because rubbing a recently cannulated vein risks dislodging a clot into the circulation. Massage is specifically withheld when thrombophlebitis is suspected, and it offers no benefit after a routine removal. Option b is incorrect because heat belongs to the treatment of phlebitis, where an inflamed vein wall needs vasodilation and comfort. A site that came out cleanly with no redness requires observation, not therapy. Option c is incorrect because charting the infused volume is part of the record but is not the next physical step. Documentation happens after the nurse confirms nothing was left inside the vein.

Correct Answer: The client who swallows safely and tolerates sips

Oral fluid is the safest and most physiologic route, so a client who can swallow safely and keep sips down does not need a vein opened. Offer small amounts frequently instead. Option b is incorrect because ongoing vomiting means swallowed fluid does not stay down, and losses continue faster than drinking can replace them. That client needs intravenous replacement and treatment of the cause. Option c is incorrect because a falling level of consciousness threatens the airway. Giving fluid by mouth to a client who cannot protect that airway risks aspiration, so the intravenous route is chosen. Option d is incorrect because a fasting order forbids oral intake before anesthesia. Maintenance fluid for that client is delivered intravenously until the surgical team clears them to drink again.

Correct Answer: Slow the infusion and sit the client upright

Hypertonic saline deliberately expands intravascular volume, and new crackles with dyspnea signal that the circulation cannot hold it. Slowing the infusion and raising the client upright eases breathing while the provider is notified. Option a is incorrect because a faster rate pours more volume into a circulation already backing up into the lungs. Hypertonic saline is titrated by protocol, never accelerated to empty a bag. Option b is incorrect because the sodium level is drawn on protocol and will still be needed. A laboratory result takes time, and breathing outranks chemistry when the client is struggling right now. Option c is incorrect because adding oral fluid to a client in circulatory overload increases the very volume causing the crackles. Sodium correction here is managed by the prescribed infusion, not by drinking.

Correct Answer: Water enters the cells and they swell

Half-normal saline dilutes the extracellular fluid, so water follows the osmotic gradient into the cells and they swell. That rehydration of shrunken cells is the whole point of treating hypernatremia with this fluid. Option a is incorrect because cells shrink when the extracellular fluid becomes more concentrated than the cell interior, which is what hypertonic saline does. Half-normal saline is dilute and drives water the opposite direction. Option b is incorrect because only an isotonic solution leaves cell size unchanged by staying in the extracellular compartment. A solution with half the sodium of plasma cannot hold its water there. Option d is incorrect because interstitial movement describes where isotonic crystalloid distributes after infusion. Hypotonic fluid does not stop at the interstitium; it continues across cell membranes because the gradient pulls it inward.

Correct Answer: The sacrum and posterior thighs

Gravity determines where interstitial fluid collects, and in a client lying in bed the lowest areas are the sacrum, buttocks and posterior thighs. Checking only the ankles misses the edema entirely. Option a is incorrect because the dorsum of the foot is a dependent site only when a client sits or walks. After days in bed, fluid has moved posteriorly and the feet may look deceptively normal. Option b is incorrect because pretibial testing works well in an ambulatory client whose fluid pools in the lower legs. Position dictates the assessment site, and this client's position has moved the fluid elsewhere. Option c is incorrect because the ankle is the classic site for a client who has been upright, not one confined to bed. Relying on it here produces a falsely reassuring assessment and a missed finding.

Correct Answer: The dextrose is metabolized, leaving only free water

Cells take up the dextrose and burn it within a short time, so what remains is free water that spreads through total body water. Under a hundred milliliters of each liter stays intravascular. Option a is incorrect because free water dilutes sodium rather than raising it. Excess dextrose in water is a classic cause of dilutional hyponatremia, which moves the sodium in the opposite direction. Option c is incorrect because citrate is the anticoagulant that binds calcium in banked blood, and lactated Ringer's is the fluid that supplies calcium. Dextrose plays no part in that interaction at all. Option d is incorrect because the bag is labeled isotonic and the solution never behaves as a hypertonic one inside the client. Once the sugar is gone the fluid acts hypotonic, which is the whole problem.

Correct Answer: Two thirds of body water is inside the cells.

Intracellular fluid holds about two thirds of total body water, roughly forty percent of body weight, while extracellular fluid holds the remaining third. The cell is the body's largest water reservoir by a wide margin. Option b is incorrect because plasma is the smallest of the fluid spaces, about one quarter of extracellular fluid and only five percent of body weight. Roughly three and a half liters of plasma is all that circulates. Option c is incorrect because the interstitium, although three times larger than the plasma space, still belongs to extracellular fluid and therefore accounts for only part of the smaller one third share. Option d is incorrect because intracellular fluid is about twice the extracellular volume, not its equal. The sodium and potassium difference across the cell membrane is held there by the sodium potassium pump rather than by compartment size.

Correct Answer: Dry mucous membranes with dark concentrated urine

Loss of gastrointestinal fluid depletes the extracellular compartment, so secretory glands have less water available and the kidney conserves water under antidiuretic hormone, producing dry membranes and dark, concentrated urine. Option a is incorrect because bounding pulses and jugular distension belong to fluid volume excess, where extra volume raises central venous pressure. A client losing gastrointestinal fluid shows a thready pulse and flat neck veins instead. Option b is incorrect because that pairing describes a client whose fluid balance is intact. Nothing here reflects the three days of losses, and normal findings cannot be the expected result of significant gastrointestinal depletion. Option d is incorrect because deficit narrows the pulse pressure as compensatory vasoconstriction raises the diastolic reading, and that same vasoconstriction leaves the skin cool, pale and clammy rather than warm and flushed.

Correct Answer: Assess lung sounds and check for edema

A one kilogram gain in a day is about one liter of retained fluid and is clinically significant. The nurse assesses where that fluid has gone by listening to the lungs and inspecting dependent areas. Option b is incorrect because a weight taken after a meal includes the food and drink just consumed, which destroys comparability with yesterday's reading. The morning weight was already obtained under correct conditions. Option c is incorrect because a week's delay abandons the very advantage daily weighing offers, which is catching retention before it is visible. Charting without assessing also leaves the finding unexplained in the record. Option d is incorrect because stopping fluids is a treatment decision that no single weight justifies, and it can harm a client whose gain has another explanation. Assessment comes before any restriction is imposed.

Correct Answer: Crackles in the lung bases bilaterally

Extra volume raises pulmonary capillary hydrostatic pressure, pushing fluid into the alveoli. Air opening those fluid-filled alveoli produces crackles, and gravity puts them in the bases first, making them a reliable sign of excess. Option a is incorrect because collapsed neck veins and a thready pulse mean the vascular compartment is underfilled. Excess volume distends the jugular veins and produces a full, bounding pulse instead. Option c is incorrect because sunken eyes and a dry axilla come from interstitial water loss, the picture of deficit. A client retaining fluid shows puffiness and taut, shiny skin rather than hollowed features. Option d is incorrect because slow refill and pallor reflect peripheral vasoconstriction defending a falling cardiac output. Perfusion of the skin is usually adequate when the problem is too much circulating volume.

Correct Answer: Hold the next dose and notify the provider

Dizziness on sitting, a climbing heart rate and a falling potassium point to over-diuresis. Giving another dose would deepen both the volume loss and the hypokalemia, so the nurse holds it and reports. Option a is incorrect because a client who is dizzy sitting at the edge of the bed is a fall waiting to happen. Walking in the corridor without assistance invites syncope and injury. Option b is incorrect because adding sodium back would pull water into the extracellular space and undo the treatment for heart failure. The potassium is what needs replacing here, not the sodium. Option d is incorrect because further restriction pushes a client who has already lost too much volume toward hypovolemia. Diuresis has overshot the target, and the plan now needs slowing rather than pressing forward.

Correct Answer: Assist the client to the bathroom before starting

Helping a client to the bathroom before the transfusion starts is basic assistance within the assistive role, and it prevents an interruption during the first critical minutes. Verification steps remain with the nurse. Option a is incorrect because bedside identification is part of the two-person verification that agency policy restricts to licensed personnel. It is the single step that prevents a fatal ABO mismatch. Option b is incorrect because matching the unit number, blood group and expiration against the tag calls for clinical judgment about any discrepancy. Assistive personnel are not prepared to decide what a mismatch means. Option c is incorrect because judging whether a unit shows clots, leaks or abnormal color is an assessment. Deciding that a product is unfit to hang belongs to the nurse, who then calls the blood bank.

Correct Answer: Cerebral edema from water entering brain cells

Half-normal saline is hypotonic, so free water shifts into brain cells inside a rigid skull. The swelling raises intracranial pressure directly, which is why this fluid is contraindicated after head injury. Option a is incorrect because overload follows large sodium loads and rapid isotonic or hypertonic infusion in a client with cardiac or renal limits. Dilute saline leaves the vessel rather than filling it. Option b is incorrect because that acidosis develops after several liters of normal saline, whose chloride sits well above plasma. Half-normal saline carries half that chloride, so the acid-base risk described here does not apply. Option d is incorrect because demyelination results from raising a chronically low sodium too quickly, usually with hypertonic saline. Nothing in this order raises sodium; the danger runs in the opposite direction entirely.

Correct Answer: Intravenous isotonic fluid through a peripheral line

Oral replacement fails when the client cannot keep fluid down and is already showing orthostatic symptoms. Losses at that rate need an isotonic solution delivered directly into the vascular space. Option a is incorrect because rehydration solution is excellent when swallowing works. Here the fluid does not stay down, so the electrolytes and water it contains never reach the circulation in useful amounts. Option c is incorrect because clear liquids depend on the same swallowing route that is currently failing. A client who cannot retain what is swallowed gains nothing from a smaller oral volume. Option d is incorrect because adding salt and water by mouth still relies on absorption the gut is not providing during severe diarrhea. Dietary change is a prevention strategy, not treatment for an acute deficit.