IV
The nurse is providing intravenous (IV) push meperidine (Demerol) through a free-flowing IV line and notes a hazy appearance in the tubing. The nurse’s first intervention would be to:
Select one:
a. Put all doses of meperidine on hold.
b. Notify the supervisor.
c. Discontinue the IV site.
d. Stop the infusion.
d. Stop the infusion.
The nurse is providing care for a patient who is receiving a blood transfusion. Pre- transfusion vital signs were blood pressure (BP), 144/78 mm Hg; temperature (T), 98.4°F; pulse (P), 86; respirations (R), 14. Now, approximately an hour after the transfusion was initiated, the patient’s vital signs are BP, 168/92 mm Hg; P, 98; R, 20. Next, the nurse should first:
Select one:
a. Slow the transfusion rate.
b. Notify the physician.
c. Record the vital signs.
d. Listen to the patient’s breath sounds.
d. Listen to the patient’s breath sounds.
The nurse who is caring for a patient with an infusion of D5 1/2NS 1000 mL with 20 mEq KCL at 100 mL/hr notes that there is slight swelling at the insertion site and no blood return when aspirating at the injection port closest to the IV site. Which of the following problems does the nurse suspect?
Select one:
a. Thrombophlebitis
b. Fluid overload
c. Air embolism
d. Infiltration
d. Infiltration
A nurse knows that there is a risk for cerebral edema, increased intracranial pressure, rupture of brain cells, and death if there is an infusion of an excessive volume of:
Select one:
a. Hypertonic solution.
b. Any of the above.
c. Hypotonic solution.
d. Isotonic solution.
c. Hypotonic solution.
The nurse asks the patient about allergies before cleansing the skin with which of the following solutions?
Select one:
a. 70% isopropyl alcohol
b. 2% tincture of iodine
c. 10% povidone-iodine
d. 2% aqueous chlorhexidine gluconate
c. 10% povidone-iodine
The nurse is providing care for a patient with an allergy to corn. Which of the following solutions, if ordered by the physician, would the nurse question?
Select one:
a. Dextrose 5% in water (D5W)
b. 0.9% sodium chloride (NS)
c. 0.45% sodium chloride (1/2NS)
d. Lactated Ringer’s (LR)
a. Dextrose 5% in water (D5W)
The nurse assumes responsibility for a blood transfusion that was initiated 2.5 hours ago. The patient is tolerating the procedure well, and there is roughly 50% of the blood remaining. The best action by the nurse is to:
Select one:
a. Increase the transfusion rate.
b. Chart the current vital signs.
c. Notify the charge nurse.
d. Stop the infusion and return the unused blood to the blood bank.
a. Increase the transfusion rate.
The nurse is caring for a patient who reports that the intravenous (IV) site is sore. The nurse notes swelling and tenderness at the site, as well as a red streak up the arm. The nurse’s care should include:
Select one:
a. Requesting a new order for IV antibiotics to be infused at the site.
b. Sending the IV catheter and tubing to the laboratory for analysis.
c. Applying an ice pack to the area.
d. Discontinuing the IV and applying warm packs.
d. Discontinuing the IV and applying warm packs.
A nurse knows that if a patient needs intravenous (IV) fluid replacement because of low blood volume, he or she should be given:
Select one:
a. A hypertonic solution.
b. An isotonic solution.
c. Any of the above.
d. A hypotonic solution.
a. A hypertonic solution.
The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently?
Select one:
a. Every hour
b. Every 2 hours
c. Every 3 hours
d. Every 4 hours
b. Every 2 hours
Which of the following intravenous solutions is most similar to the electrolyte content of the blood?
Select one:
a. 0.22% sodium chloride (1/4NS)
b. Dextrose 5% in 0.45% sodium chloride (D5 1/2NS)
c. Lactated Ringer’s (LR)
d. Dextrose 5% in water (D5W)
c. Lactated Ringer’s (LR)
The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item?
Select one:
a. Skin color
b. Latest hematocrit level
c. Vital signs
d. Oxygen saturation
c. Vital signs
A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started?
Select one:
a. 30 minutes
b. 5 minutes
c. 45 minutes
d. 15 minutes
d. 15 minutes
The nurse is doing a routine assessment of a client’s peripheral intravenous (IV) site. The nurse notes that the site is cool, pale and swollen and that the IV has stopped running. The nurse determines that which has probably occurred?
Select one:
a. Thrombosis
b. Infection
c. Infiltration
d. Phlebitis
c. Infiltration
The purpose of drawing lab tubes in a specific order is because of
Select one:
a. the higher power
b. NCBON
c. IDK?
d. additives in the tubes
d. additives in the tubes
When administering medication via intravenous (IV) push, the nurse:
Select one:
a. Must ensure that the medication remains undiluted before administering it.
b. May delegate the administration to an LVN or LPN.
c. Must research the length of time over which the medication must be administered.
d. Must administer the medication quickly to assure that it takes effect rapidly.
c. Must research the length of time over which the medication must be administered.
A client who is receiving a blood transfusion rings the call bell for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings?
Select one:
a. Bacteremia
b. Fluid overload
c. Hypovolemic shock
d. Transfusion reaction
d. Transfusion reaction
The nurse is assisting with caring for a client who is receiving a unit of packed red blood cell ( PRBCs). The nurse should tell the client that it is most important to report which sign immediately?
Select one:
a. Mild discomfort at the catheter site
b. Sore throat or earache
c. Unusual sleepiness or fatigue
d. Chills, itching or rash
d. Chills, itching or rash
How long should the tourniquet be left in place?
Select one:
a. forever
b. 5 minutes
c. as long as it takes
d. 1 minute
d. 1 minute
A nurse knows that a patient who needs an IV to provide simple water replacement because of lack of fluid intake should be given:
Select one:
a. A hypotonic solution.
b. A hypertonic solution.
c. An isotonic solution.
d. Plain water.
c. An isotonic solution.
The nurse asks a nursing student to help initiate a transfusion. Which of the following would require immediate intervention?
Select one:
a. The student verifies the patient’s name, birth date, and blood identification tags.
b. The student is using Y-tubing for the transfusion.
c. The patient’s blood type is A-positive, and the student’s blood type is A-negative.
d. The tubing is hanging and primed with D5 LR.
d. The tubing is hanging and primed with D5 LR.
The nurse is providing care to a patient who is receiving a blood transfusion and who becomes acutely short of breath and anxious within a few minutes of the nurse’s initiating the transfusion. Which of the following actions will be included in the nurse’s care? Select all that apply.
Select one or more:
a. Frequent checks of the vital signs
b. Sending tubing and unused blood to the blood bank
c. Stopping the blood transfusion and notifying the physician
d. Obtaining a urine sample for analysis
b. Sending tubing and unused blood to the blood bank
c. Stopping the blood transfusion and notifying the physician
d. Obtaining a urine sample for analysis
When selecting a vein for phlebotomy, which of the following are true? Select all that apply.
Select one or more:
a. Avoid areas where the vein is crooked or feels hard and ropelike.
b. Use the right arm of a patient who has an IV in the right arm.
c. Use the right arm of a patient who has had a left mastectomy.
d. Use the vein that looks the largest, no matter what its condition.
e. The site of choice is the dorsal side of the hand.
a. Avoid areas where the vein is crooked or feels hard and ropelike.
c. Use the right arm of a patient who has had a left mastectomy.
The nurse takes a client’s temperature before giving a blood transfusion. The temperature is 100° F (37.7° C) orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?
Select one:
a. The blood will be held, and the primary health care provider (PHCP) will be notified.
b. The transfusion will begin as prescribed.
c. The transfusion will begin after the administration of an antihistamine.
d. The transfusion will begin after the administration of 650 mg of acetaminophen.
a. The blood will be held, and the primary health care provider (PHCP) will be notified.