The nurse explains to the client that intravenous fluid administration is used to:

correct an imbalance in fluids or electrolytes.

decrease intravascular volume.

increase third spacing of fluids.

administer enteral fluids.

Answer and Explanation

The Correct Answer is A

A. One of the primary reasons for administering IV fluids is to correct imbalances in fluid volume or electrolyte concentrations. Examples include correcting dehydration, restoring electrolyte levels (such as sodium, potassium), and addressing fluid losses due to vomiting, diarrhea, or excessive sweating.

B. IV fluids are typically used to increase intravascular volume rather than decrease it. In conditions such as hypovolemia (low blood volume), IV fluids are administered to restore blood volume and improve circulation.

C. Third spacing refers to the abnormal accumulation of fluid in interstitial spaces, which can occur in conditions like sepsis, burns, or trauma. IV fluids are not typically administered to increase third spacing; rather, treatment aims to redistribute fluids and improve fluid balance.

D. Enteral fluids are fluids administered directly into the gastrointestinal tract (via oral or tube feeding). IV fluids are administered directly into the bloodstream and are used when enteral administration is not feasible or sufficient.

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Correct Answer is C

Explanation

C. Chvostek's sign is assessed by tapping or lightly percussing the facial nerve (facial muscles) at the angle of the jaw, just in front of the earlobe. A positive Chvostek's sign is indicated by facial twitching, especially around the mouth, nose, and eye, in response to this percussion. It indicates neuromuscular irritability due to low calcium levels.

A. Straining urine is typically done to collect urine for analysis or to detect urinary stones. It does not relate to the assessment of neuromuscular irritability, which is what Chvostek's sign evaluates.

B. This option does not pertain to assessing Chvostek's sign either. Inflating a blood pressure cuff above systolic measurement is a technique used to assess for Trousseau's sign, which is another clinical indicator of hypocalcemia but involves different physiological mechanisms than Chvostek's sign.

D. This option is unrelated to assessing Chvostek's sign or hypocalcemia. Baseline height and weight are typically obtained for nutritional assessment, growth monitoring, or as part of a general health assessment. They do not help in evaluating neuromuscular irritability associated with calcium levels.

A. Administration of an enema B. Administration of an intramuscular injection C. Insertion of a nasogastric tube D. Insertion of an indwelling catheter

Correct Answer is D

Explanation

D. Inserting an indwelling catheter involves placing a tube into the bladder through the urethra. The urethra and urinary tract are sterile areas. Sterile gloves are necessary to prevent introducing pathogens into the urinary tract during catheter insertion.

A. An enema involves introducing a solution into the rectum for therapeutic purposes. It does not require the use of sterile gloves because the rectum and lower gastrointestinal tract are not considered sterile areas.

B. Administering an intramuscular injection involves injecting medication into muscle tissue. It does not require sterile gloves unless the site needs to be cleaned with an antiseptic wipe, in which case non- sterile gloves are sufficient.

C. The insertion of a nasogastric tube also does not typically require sterile gloves, as the gastrointestinal tract is not a sterile environment.

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The nurse explains to the client that intravenous fluid administration is used to:

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a total calcium level of 7.0 mg/dL. To assess for Chvostek's sign, the nurse would:

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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