Chapter 34 Hydration & Homeostasis

Chapter 34 Hydration & Homeostasis

1. After morning care, the nurse lowered the height of the IV container infusing via gravity flow, at the patient’s request. What is the nurse’s next best action?

a. Calculate the new infusion rate.

b. Readjust the infusion rate, as needed.

c. Change the IV site and move it to the other arm.

d. Instruct the client to call when the IV bag is empty.

ANS: B

The rate of an IV infusing via gravity draining will be altered by raising or lowering the IV solution. Thus, if the IV pole is lowered, the rate will need to be verified and adjusted as needed. The drip rate is based on the administration set and prescribed rate and is not affected by the height of the IV solution. The IV site will need to be changed only when clinically indicated. The nurse should not rely on the patient, but should monitor the infusion amount.

Difficulty: Easy Nursing Process: NA Client Need: HPM

Cognitive Level: Application

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PTS: 1

2. The nurse has started to infuse the first of two units of packed red blood cells (prbc) on her patient. What is the nurse’s next best action?

a. Delegate to the NAP to take vital signs every 15 minutes for 1 hour.

b. Infuse the blood at a rate of 100 mL/hr so it will infuse in 4 hours.

c. Infuse an IV solution of lactated Ringer’s with the blood.

d. Remain with the patient for the first 15 minutes of the infusion.

ANS: D

The nurse’s next best action is to stay with the patient and assess for a transfusion reaction, which is more likely with the first 50 mL of the blood. The nurse should not delegate the initial vital sign to the NAP. The only compatible IV solution that can infuse with blood is normal saline (0.9% NS).

Difficulty: Moderate Nursing Process: NA Client Need: PHSI

Cognitive Level: Application

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PTS: 1

3. What is the recommended position for a patient who is experiencing an air embolus because of failure to prime the IV tubing?

a. High-Fowler’s

b. Supine

c. Trendelenburg, on the left side

d. Prone, on the right side

ANS: C

The patient should be put in the Trendelenburg position to prevent air from traveling through the right side of the heart into the pulmonary artery, which could create a blockage in ventricular outflow.