Question 1

When continuous IV infusion of a drug is desired, a nurse understands that which of the following is true? Select all that apply.

Accepted Answer

A,C,E

Question 2

The nurse asks a nursing student to help initiate a transfusion.Which of the following are parts of this process? Select all that apply.

Accepted Answer

A) It is standard practice for two RNs to double-check the order for a transfusion to ensure patient safety and correct blood product administration. C) Y-tubing is specifically used for blood transfusions, allowing for normal saline to be used to prime the tubing and to flush the line after the transfusion. D) Verifying the client's name, birth date, and blood identification tags is a critical step in ensuring the correct patient receives the correct blood product, reducing the risk of transfusion reactions. E) Assessing the client's vital signs before the infusion begins establishes a baseline, which is important for monitoring for any adverse reactions during the transfusion. B) is incorrect because blood products should be primed with normal saline, not D5 LR, to prevent hemolysis of red blood cells.

Question 3

The nurse is providing care for a client 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 client's vital signs are BP, 168/92 mm Hg; P, 98; R, 20.Next, the nurse should:

Accepted Answer

The nurse should listen to the client's breath sounds to assess for any signs of fluid overload or transfusion reaction, given the increase in blood pressure and respiratory rate.

Question 4

The nurse is caring for the client who has allergies to corn and shellfish.Which of the following should the nurse NOT use with the client? Select all that apply.

Accepted Answer

Povidone-iodine and tincture of iodine contain iodine, which is related to shellfish allergies. Dextrose is derived from corn, which should be avoided in clients with corn allergies.

Question 5

The nurse may administer which of the following IV solutions via a peripheral vein? Select all that apply.

Accepted Answer

10% dextrose and 5% dextrose in 0.45% sodium chloride are appropriate for peripheral vein administration as they are not highly concentrated or hypertonic solutions.

Question 6

A nurse knows that a client who needs an IV to provide simple water replacement because of lack of fluid intake should be given which of the following?

Accepted Answer

A hypotonic solution is appropriate for a client needing simple water replacement due to lack of fluid intake. Hypotonic solutions have a lower concentration of solutes compared to the body's cells, allowing water to move into the cells to hydrate them.

Question 7

The nurse who is caring for a client with an infusion of D5 1/2NS 1,000 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?

Accepted Answer

The slight swelling at the insertion site and the absence of blood return when aspirating suggest infiltration, where the IV fluid is leaking into the surrounding tissue instead of the vein.

Question 8

A nurse caring for several clients in the emergency department.The nurse will plan to monitor the rate of infusion and assess the condition of an IV site every hour for which of the following clients? Select all that apply.

Accepted Answer

Infants, elderly clients, and those prone to circulatory fluid overload require close monitoring of IV sites due to their increased risk of complications.

Question 9

The nurse is caring for a client who reports that the 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 which of the following? Select all that apply.

Accepted Answer

The answer of The nurse is caring for a client...

Question 10

The nurse is providing IV push meperidine (Demerol)through a free-flowing IV line and notes a hazy appearance in the tubing.It is necessary to:

Accepted Answer

A hazy appearance in the IV tubing after administering a medication like meperidine (Demerol) could indicate a precipitate formation, which can be harmful if infused. Stopping the infusion is the immediate action to prevent any potential harm to the patient.

Question 11

The nurse who is working on a medical-surgical floor recognizes that vesicant precautions should be taken with which of the following? Select all that apply.

Accepted Answer

The answer of The nurse who is working on a...

Question 12

The nurse is providing care to a client 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.

Accepted Answer

The nurse should immediately stop the blood transfusion and notify the physician as a first step in response to signs of a possible transfusion reaction, such as acute shortness of breath and anxiety. Frequent checks of the vital signs are necessary to monitor the patient's condition closely. Sending the tubing and unused blood to the blood bank is important for investigation of the reaction. Obtaining a urine sample for analysis can help in identifying hemolysis if that is the cause of the reaction. Discontinuing the IV site is not recommended as the site may be needed for administration of medications or fluids to treat the reaction.

Question 13

Which of the following clients would likely receive packed red blood cells? Select all that apply.

Accepted Answer

Packed red blood cells are typically given to clients with acute blood loss to restore hemoglobin levels and to clients with symptomatic anemia to improve oxygen-carrying capacity.

Question 14

A nurse could correctly provide which of the following via IV therapy as part of a maintenance fluid?

Accepted Answer

Water, in the form of saline or dextrose solutions, is used in IV therapy for maintenance fluids to ensure hydration and electrolyte balance.

Question 15

Under the supervision of the RN, the LPN/LVN discusses the IV push route of administration to the client.Which statements by the LPN/LVN are accurate? Select all that apply.

Accepted Answer

The answer of Under the supervision of the RN, the...

Question 16

The nurse is caring for a client with an IV.The client begins to have redness and swelling at the IV site.The client also complains of burning and tenderness at the IV site.Which does the nurse suspect?

Accepted Answer

Phlebitis is characterized by redness, swelling, and tenderness at the IV site, which matches the symptoms described.

Question 17

The nurse assumes responsibility for a blood transfusion that was initiated 2.5 hours ago.The client is tolerating the procedure well, and there is roughly 50% of the blood remaining.The best action by the nurse is to:

Accepted Answer

The standard practice for blood transfusions is to complete them within 4 hours to reduce the risk of bacterial growth. Since the transfusion has been running for 2.5 hours and only 50% is infused, increasing the rate is necessary to ensure completion within the safe time frame.

Question 18

The nurse is providing care for a client who has a central line and a suspected air embolism.The best action by the nurse is to:

Accepted Answer

Placing the client on her left side in the Trendelenburg position helps to trap air in the apex of the right atrium, preventing it from entering the pulmonary artery and causing further complications. This position is recommended for managing air embolisms.

Question 19

The health-care provider orders that a client who is dehydrated receive lactated ringer's solution (LR).Which statement made by the nurse indicates an understanding of safety items to consider?

Accepted Answer

The nurse should confirm what other medications the client is on to avoid any potential interactions with the lactated ringer's solution.

Quiz 38: Intravenous Therapy