IV & IV Solutions
Name the types of isotonic solutions
0.9% NS
D5W
LR
-Same effect as body fluids
What are the potential complications of IV therapy?
Infiltration
Phlebitis
Infection
Catheter Embolus
Air Embolus
Fluid Overload
Venous Spasm
Which ones are local and which are systemic?
Which blood type is the universal donor?
_______ , is a complications for TPN that poses a risk for fluid shifts placing clients at increased risk of fluid volume excess
a) circulatory overload
b) fluid imbalance
c)metabolic complications
d)phlebitis
B- fluid imbalance
Which of the following symptoms would indicate hypoxia in a client? (Select all that apply.)
A. Restlessness
B. Bradycardia
C. Cyanosis
D. Increased level of consciousness
E. Tachycardia
Answers: A. Restlessness, C. Cyanosis, E. Tachycardia
Rationale: Restlessness, cyanosis, and tachycardia are signs of hypoxia. Bradycardia and an increased level of consciousness are not typical indicators of hypoxia.
What is a hypertonic solution and its concentration?
-it drains fluid into the intravascular compartments
3%NS
True/False:
IV fluids and vesicants can cause infiltration leading to extravasation
True
Vesicant:chemotherapy drugs, promethazine, vancomycin, dopamine
Which solution is ONLY compatible with blood transfusion?
0.9% NS
A nurse is caring for a client who is receiving TPN. The current bad of solution was hung 24 hrs ago and 400ml is remaining in the bag. which of the following actions should the nurse take?
a) remove the current bag and hand a new bag
b)infuse the raining solution at the current rate and then hand a new bag
c)increase the infusion rate so that remaining solution is admin w/in an hr and then hand a new bag
d)remove the current bad and hand a bad of LR
A, CORRECT
when taking actions for a client who is receiving TPN, the nurse should replace the container of what has been hanging for 23 hrs w/ a new bad of TPN to prevent infection
During tracheostomy care, the nurse should include which of the following steps to ensure airway patency and prevent complications?
A. Perform tracheostomy suctioning as needed to clear secretions
B. Remove the tracheostomy tube for cleaning every 4 hours
C. Apply intermittent suction for no more than 30 seconds
D. Avoid hyperoxygenating the patient before suctioning
Answer: A. Perform tracheostomy suctioning as needed to clear secretions
Rationale: Tracheostomy suctioning should be performed as needed to maintain airway patency and prevent complications. Suction should be applied for no more than 10-15 seconds.
What does this phrase mean, "Hippos are big" and "kids are hyperactive from eating too much sugary raisins, need to play outside"
-Hypo make cells look like a big O
-Hyperactive makes kids burn more calories making them smaller (Hyper makes cells shrink smaller)
All are complications of blood transfusion except:
febrile transfusion reactionacute hemolytic transfusion reaction
allergic transfusion reaction
Circulatory overload
bacterial transfusion reaction
All are complications of blood transfusion
True or False:
Prior to transfusion, 1 RN can identify the correct blood products and client by asking for the pt's name and DOB.
False.
prior to transfusion, 2 RN's must verify the correct blood product by looking at the hospital ID number and the number ID on the pt's arm band to ensure the numbers match.
What is EFAD?
Essential fatty acid deficiency
Occurs in pt's who receives PN or TPO w/o lipids emulsion
A nurse is preparing to perform nasopharyngeal suctioning on an adult client. What is the correct distance to insert the catheter?
A. 10 cm (4 inches)
B. 12 cm (5 inches)
C. 16 cm (6.5 inches)
D. 20 cm (8 inches)
Answer: C. 16 cm (6.5 inches)
Rationale: For adults, the catheter should be inserted approximately 16 cm (6.5 inches) for nasopharyngeal suctioning.
Why IV therapy?
maintain/correct fluid&electrolyte imbalance
admin medications
admin blood transfusion
parenternal nutrition
admin diagnostic agents
When do you need to use a BVM?
During an Accidental decannulation.
ventilate the client w/ a BVM (bag-valve-mask) "ambu bag"
How long must you stay with the patient at the beginning of blood transfusion? and why?
Remain w/ pt for the first 15 minutes
Reactions occurs most often during the first 15 mins.
True or False:
TPN is an isotonic solution
False
TPN is a hyertonic solution
What are the signs and symptoms of severe respiratory distress in a neonate that a nurse should monitor for? (Select all that apply.)
A. Grunting
B. Lethargy
C. Tachycardia
D. Mottled skin color
E. Coughing
Answers: A. Grunting, B. Lethargy, D. Mottled skin color
Rationale: Grunting, lethargy, and mottled skin color are signs of severe respiratory distress in a neonate. Tachycardia is common but not as specific, and coughing is less typical in neonates with severe distress.
What do we need to check Solutions for?
Expiration date
imperfections
cloudiness
foreign objects correlation of ordered volume w/ volume present in the bad
If ______ occurs, continuous bubbles appear in the water-seal chamber
air leaks
A nurse is carin for a client who is receiving a blood transfusion. which of the following actions should the nurse take if the client develops manifestations of an allergic transfusion reaction? SATA
a)stop the infusion
b)monitor for HTN
c)maintain an IV infusion w/ 0.9% NaCl
d)position the client in an upright position w/ the feet lower than the heart
e) admin diphenhydramine
A,C,E correct:
rationale:
when taking actions for a client who is developing manifestations of an allergic reaction, the nurse should stop the infusion and admin antihistamine. maintain an IV infusion of 0.9% NaCl.
a nurse is caring for a pt receiving TPN. Which of the following assessmen is the highest priority?
a) daily wgt
b) BG level
c) I&O's
d) VS
B- CORRECT,
monitoring BG is highest priority b/c pt is at risk for hyperglycemia w/ TPN
A nurse is caring for a quadriplegic client. Which of the following interventions is most important for maintaining airway clearance?
A. Encourage fluid intake
B. Perform chest physiotherapy
C. Monitor daily weight
D. Administer antibiotics as prescribed
Answer: B. Perform chest physiotherapy
Rationale: Quadriplegic clients may have difficulty clearing their airways independently. Chest physiotherapy helps to mobilize and clear secretions
Chest physiotherapy (CPT) is a treatment used to help clear mucus and secretions from the lungs and airways.