NAMA : sri winarta

NIM :1814201220

Questions :

1. What do you call the condition if the body fluid more than body requirement ?
a. Over hydration c. rehydration
b. Dehydration d. normal hydration
Jawab : A

2. The balance that the body maintains between fluid intake and fluid output is called ?
a. homeostasis c. encouragement
b. approximately d. normal balance
Jawab : D

3. Fluid output may occur via ?

a. Catheter or urinate d. respiration
b. Emesis e. all is true
c. Stool
Jawab : A

4. Fluid may be lost through Skin. It’s called ?

a. Noticeable water lost c. obligatory lost
b. Insensible water lost d. voluntary lost
Jawab : A

5. Some uses / purposes of IVT as : except ?

a. fluid and electrolyte replacement and blood transfusion therapy
b. drug administration,
c. ready access in emergencyparenteral nutrition
d. over hydration correction
Jawab : A

6. Patients’ fluid requirements will increase: except ?

 a. in hot weather, and with a pyrexia (high temperature)
b. if a urinary catheter is in situ
c. if constipated
d. client with puffy
e. if there is fluid loss from the gastro-intestinal tract, such as diarrhea, vomiting, or
nasogastric or wound drainage.
Jawab : E

7. Weak, irregular pulse, breathlessness and cough, expectorating white or pink frothy
sputum discomfort and restlessness, edema, particularly around ankles and sacrum,
distended neck veins raised / increase blood pressure ?
a. Fluid overload d. lack of electrolyte
b. Over hydration e. insufficient fluid
c. A and b is true
Jawab : C

8. This isotonic fluid provides fluid replacement without disturbing the electrolyte balance
and provides energy ?
a. 5% dextrose in water c. lactated ringer
b. Normal saline d. normal saline in water
Jawab : A

9. Substances may be used to expand intravascular volume, and plasma volume such as :
ecept ?
a. blood and its derivatives
b. artificial colloids such as dextrans,
c. hydroxyethyl starch (HES) and gelatin derivatives.
d. lactated ringered
Jawab : B

10. Patients who are temporarily unable to eat so, the infusion solution can be used ?
a. dextrose 10% d. sodium chloride 0,9 %
b. dextrose 20% e. potassium chloride 10%
c. A and B is true
 Jawab : D

11. Cannula has slipped out of the vein or the vein has collapsed, causing a blockage and
backflow of fluid into the interstitial spaces is called ?
a. Infiltration c. speed shock
b. Bacteraemia d. phlebitis
Jawab : B

12. Septicaemia is condition when ?

a. pathogenic bacterial toxins in the blood. C. blood clot in blood
b. bacteria in blood d. air bubble in blood
Jawab : B

13. Caused by the rapid infusion of an IV drug resulting in a toxic blood concentration ?
a. allergic reaction c. Circulatory overload
b. speed shock d. Emboli
Jawab : A

14. Suitable diagnoses for dehydration ?

a. alteration of breathing pattern related to foreign material occlude the airway
b. Discomfort related to chest pain
c. impairment of verbal communication
d. dehydration related to prolonged diarrhea indicated by bad skin turgor, weak, rapid
and weak pulse, sunken eye lids
e. lack of body fluid related to excessive bleeding. Indicated by CRT less than 3
second, pallor, rapid and weak pulse
Jawab : E

Case I : Mr. Elliot, 53 Years old, receive IV therapy for fluid replacement for RL 20 drops
perminute. Nurse on duty will change the IV back for the second IV back and
0
found the following condition : P; 110 x / I, BP : 90 / 60 mmHg, RR: 28x/I, T : 37
C. Patient complained of Flushed face, headache, dizziness, chest tightness,
tachycardia/ rapid pulse and hypotension.
15. Above Condition is indicated that …….happened :
a. allergic reaction c. Circulatory overload
b. speed shock d. Emboli
Jawab : B

16. What is the suitable management for above case :

a. Stop infusion. Provide symptomatic relief, e.g. sitting up, oxygen therapy. Take
vital signs. May need to be given an antidote. Inform medical staff. Prevent by
administering through a pump, burette or by syringe driver.
b. Discontinue infusion immediately. Call for urgent assistance. Take vital signs.
Maintain airway. Administer epinephrine according to local policy. Prevent by
taking a thorough history of allergy, and monitor patient closely when giving
potential allergens
c. Stop infusion, change administration set. Prevent by checking drug compatibility
before administration. Inform medical staff.
d. Stop IV. Call for assistance. Take vital signs. Turn patient onto left-hand side to
encourage air to rise into the right atrium. If cannula end is visible attempt to
retrieve it.
e. Discontinue IV, send the cannula for Microscopy Culture and Sensitivity. Use
smallest possible cannula to reduce local irritation. Prevention includes careful
aseptic site preparation and sterile dressing. Change cannula, dressing and
administration set every 48–72 hours. Monitor temperature and pulse every 4 hours
for early detection.
Jawab : A

Case II : 3 days after infusion insertion of infusion on mr. Elliot, nurse on duty find :
Swelling, inflammation, redness, tense and hard vein (induration), possibly
purulent discharge at cannula exit site. On laboratory result obtain WBC ( white
blood cells count ) : 13000.

17. Base on above case, what happened to Mr. Elliot :

a. Phlebitis c. Circulatory overload
 b. speed shock d. Emboli
Jawab : A
18. What is the probably causes of above case ?
a. The inner lining of the vein is irritated by: chemical such as a drug, or acidic
infusion such as potassium chloride, physical irritation from the type of cannula
used, the poor placement of a cannula
b. too many attempts at cannulation, or bandaging or splinting too tightly or in an
abnormal position
c. mechanical irritation from poor fixation. Once inflamed the vein may then become
infected.
d. too much fluid has been infused and the patient is not able to disperse it naturally
Jawab : A

19. What does nurse should do to handle this problems ?

a. Stop infusion. Provide symptomatic relief, e.g. sitting up, oxygen therapy. Take
vital signs. May need to be given an antidote. Inform medical staff. Prevent by
administering through a pump, burette or by syringe driver.
b. Discontinue infusion immediately. Call for urgent assistance. Take vital signs.
Maintain airway. Administer epinephrine according to local policy. Prevent by
taking a thorough history of allergy, and monitor patient closely when giving
potential allergens
c. Stop infusion, change administration set. Prevent by checking drug compatibility
before administration. Inform medical staff.
d. Stop IV. Call for assistance. Take vital signs. Turn patient onto left-hand side to
encourage air to rise into the right atrium. If cannula end is visible attempt to
retrieve it.
e. Discontinue IV, send the cannula for Microscopy Culture and Sensitivity. Use
smallest possible cannula to reduce local irritation. Prevention includes careful
aseptic site preparation and sterile dressing. Change cannula, dressing and
administration set every 48–72 hours. Monitor temperature and pulse every 4
hours for early detection.
Jawab : D
20. When a foreign body enters the circulation and travels until it occludes a small vessel:is
called ?
a. emboli c. thrombophlebitis
b. phlebitis d. induration
Jawab : A

21. Probably causes of dehydration are : except ?

a. prolonged vomit d. excessive fluid gain
b. certain disease e. bleedin
c. lack fluid intake
Jawab : D

22. fluid can be eliminated through :abnormal ways except ?

a. urine or feces d. orally, drinks or food
b. WSD, Wound drainage e. naso Gastric tube, emesis
c. surgical pad, drain,
Jawab : C

Case III : Mrs. Anne , 38 years old was admitted to hospital with long excessive bleeding.
She need fluid replacement for fluid and blood lost. Doctor suggested to insert Sodium
chloride and HES 500 ml/8 hours. Nurse try to administer the infusion. The blood vessels
invisible, because of constriction of vein. Nurse try to administer it all the way to cover the
blood and fluid need. She attempts many times for cannulation or insert the IV chateter. And
Splint it well because she afraid of dislocation occurred. Few Hours after the insertion Mrs.
Anne Complained of numbness, pain in her right arm, tingling.

23. What happened with Mrs. Anne ?

a. Phlebitis c. Circulatory overload
b. speed shock d. nerve injury
Jawab : D

24. What is the probable cause :except ?

a. infiltration
 b. poor dressing procedures around insertion site
c. too many attempts at cannulation, or
d. bandaging or splinting too tightly or in an abnormal position
e. poor location of cannula
Jawab : B

25. What that is HES stand for :

a. hydroxyethyl starch c. heddon ethylence starch
b. hyper extra sell d. high extract sell
Jawab : A

26. What hat is HES for ?

a. To expand intravascular volume c. to increase blood
perfusion
b. to increase extra vascular volume d. to decrease superficial
tense
Jawab : A

27. Nurse on duty need to adjust the IV flow for ?

a. 21 ( dpm )drops/minute c. 30 dpm
b. 41 ( dpm )drops/minute d. 24 dpm
Jawab : C
Cross Match :

1.tolong berguling ke sisi kiri a. immerse your feet in this basin F

2. berbaring telentang ( supine position ) b. lay onto your tummy D
3. Prone position c.clench your fingers / make a fist B
4. dorsal recumbent d.Lay flat on your back E
5. rendam kaki anda pada kom ini e. lay flat on your back and flex your A
both knee
6. kepalkan jari- jari anda a. Roll your body to right site C
b. Extent your elbow
8. luruskan lengan anda h. take your shirt off G
9.melihat ke atas i. lift your right leg K
10. angkat tangan anda j. raise your arm J
11. semi fowler k. look upward L
12. buka baju anda I will Raise your head level for 45 H
degree
13. angkat kaki anda m. wriggling your fingers I
14. gulung lengan baju anda keatas n. spread your fingers P
15. melangkah ke sini o. step up over here O
16. tarik nafas dalam p. roll your sleeve up R
17. lebarkan jari anda q. can you feel sensation on your leg ? N
18.bisakah anda merasakan rasa pada kaki r. take a deep breath Q
anda?
19. gerakkan kaki anda s. move your leg S
20. hindari luka dari basah t. avoid wound from getting wet T