Deck 16: Fluid and Blood Infusion Therapy

Question 1

The nurse would initiate which method to facilitate drying of the antiseptic solution applied to the intravenous site?

A) Fan the area
B) Blot the area
C) Blow on the area
D) Allow the area to dry itself

Answer 1

Allow the area to dry itself

Question 2

A patient complains of heaviness and swelling in the extremity of the intravenous infusion. The nurse assesses that the skin around the site is stretched, firm, and cool. What primary nursing intervention is indicated?

A) Flush the catheter.
B) Document the finding.
C) Notify the physician.
D) Discontinue the catheter.

Answer 2

Discontinue the catheter.

Question 3

The flow rate for an IV line is ordered at 60 mL/hr via gravity. The nurse starts the infusion with an infusion set with a drip factor of 10 gtts/mL. The IV should run at _______ drops per minute.

Answer 3

10

Question 4

The nurse is preparing to discharge a patient after infusing chemotherapy through an implanted port. What instructions for port care would the nurse provide?

A) Apply a nonadhering dressing weekly.
B) Apply a sterile dressing every 2 days.
C) Place a clean bandage daily.
D) No dressings are necessary.

Question 5

The nurse has successfully completed insertion of a peripheral venous catheter. Documentation following the procedure includes which information?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Method of securing the catheter
B) Size, length, and type of catheter
C) Patient complaints of pain during the procedure
D) Patient participation in the procedure
E) Complications of the procedure

Question 6

The nurse is caring for a patient who suddenly developed severe respiratory distress after a blood transfusion. The health provider makes the diagnosis of transfusion-related acute lung injury (TRALI). The nurse explains which implication of this diagnosis?

A) The patient can never have another transfusion again from any donor.
B) If transfusions are necessary, it will be important to use specially screened blood from which white blood cells have been removed.
C) The patient can never have another transfusion from the same donor.
D) Close family members of the patient should never have a blood transfusion.

Question 7

A patient receiving peripheral intravenous therapy is mobile but having difficulty maneuvering the intravenous infusion pump. The nurse would choose which add-on device to allow greater mobility for the patient?

A) A multiflow adapter
B) An extension set
C) A stopcock
D) A filter device

Question 8

Prior to initiating infusion therapy, which nursing diagnosis is the nurse most likely to incorporate into the patient's plan of care?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Risk for Infection
B) Alteration in Comfort
C) Impaired Gas Exchange
D) Fluid Volume Deficit
E) Ineffective Individual Coping

Question 9

The nurse is caring for an 80-year-old patient who is receiving a unit of whole blood. During the transfusion the nurse prioritizes assessment for which possible complication?

A) Liver failure
B) Infection
C) Fluid overload
D) Thrombosis

Question 10

Following insertion of a peripheral vascular device, the patient immediately complains of shortness of breath, chest pain, and palpitations. What is the nurse's initial intervention?

A) Obtain radiographic studies.
B) Notify the physician.
C) Place a tourniquet proximal to the site.
D) Obtain vital signs.

Question 11

The alarm of a patient's infusion delivery system is sounding. The nurse should assess for which conditions?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Air in the line
B) Occlusion of the tubing
C) Infusion complete
D) Wrong fluid being infused
E) Free flow

Question 12

Which intervention would the nurse perform to help prevent an air embolism in a patient receiving intravenous fluid therapy?

A) Open the clamps on administration sets as they are being changed.
B) Wait until solution containers are empty before changing.
C) Use irrigation-type connections on all tubing.
D) Purge air from the system before initiating the infusion.

Question 13

Which nursing diagnosis would explain the purpose of using a self-sheathing stylet catheter?

A) Risk for Fluid Volume Deficit
B) Risk for Injury
C) Risk for Altered Nutrition
D) Risk for Infection

Question 14

A patient admitted 14 hours ago following a motorcycle accident has received 20 units of blood due to massive hemorrhage. Nursing assessment for which complications is essential?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Coagulation imbalances
B) Acid-base imbalance
C) Hypocalcemia
D) Elevated blood ammonia titers
E) Hypokalemia

Question 15

A patient's peripheral intravenous catheter has infiltrated several times during an 8-hour shift. The nurse realizes that the patient needs a central venous access device. Which intravascular devices could a properly trained nurse insert under the guidelines of the infusion nursing standards of practice?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) A triple-lumen catheter
B) A peripherally inserted central catheter
C) A tunneled noncuffed catheter
D) An implanted port
E) A midline catheter

Question 16

The nurse is caring for a patient receiving medication directly into the cerebrospinal fluid. The nurse correctly describes this procedure as involving which type of catheter?

A) An intraspinal catheter
B) An intrathecal catheter
C) A subcutaneous infusion set
D) An intraosseous catheter

Question 17

The nurse inspects the intravenous catheter after removal. Documentation would include which information?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Length of catheter
B) Condition of access caps
C) Type of catheter
D) Condition of catheter
E) Size of catheter

Question 18

The nurse understands that the osmotic makeup of the blood has an effect on the composition of interstitial spaces. Because of this factor, the nurse plans to assess the patient for which complication?

A) Transfusion reaction
B) Hypovolemia
C) Infection
D) Circulatory overload

Question 19

The patient asks why the physician ordered only red blood cells (packed RBCs) instead of the entire unit of whole blood. What rationale should the nurse provide?

A) RBCs are useful for patients who are experiencing a depletion of clotting factors.
B) It is the only blood that is left in the blood bank.
C) It is an optimal method of transfusing only the specific component needed by the patient.
D) RBCs are useful in preventing transfusion reactions.

Question 20

Which nursing diagnosis would the nurse include in the plan of care for a patient with a catheter embolism?

A) Ineffective Coping
B) Fluid Volume Deficit
C) Impaired Skin Integrity
D) Alteration in Comfort

Question 21

A patient is to receive Factor VIIa. How will the nurse plan to administer this factor?

A) By IV bolus
B) By slow IV infusion
C) Subcutaneously
D) Rapid IV drip

Question 22

Which patient statement indicates the need for further teaching about blood transfusions?

A) "There is no risk of a disease being transmitted through the transfusion of someone else's blood."
B) "There is still some risk of contracting hepatitis B through a blood transfusion."
C) "There is still some risk of contracting hepatitis C through a blood transfusion."
D) "There is a period of time when HIV-contaminated blood will test negative."

Question 23

Which technique should the nurse use when infusing fresh frozen plasma?

A) Administer slowly.
B) Give through a filter.
C) Agitate the bag periodically.
D) Give IV push.

Question 24

The nurse is planning to administer 10 units of platelets to a patient with thrombocytopenia. The nurse plans to have a platelet count drawn within _______ minutes of the end of the transfusion.

Question 25

A patient has received a unit of packed red blood cells. If the patient is not bleeding, the nurse would expect that the hematocrit would rise _____ %.

Question 26

A patient had an acute hemolytic transfusion reaction that resulted in death. When discussing this situation with nursing staff, the manager should consider which possible causes of this reaction?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Nurse's error when checking the blood
B) WBC incompatibility
C) ABO incompatibility of the donor and recipient
D) Recipient's sensitivity to foreign plasma proteins
E) Contaminated blood

Question 27

A unit of packed red blood cells was ordered for a patient. Twenty minutes after the blood began infusing, the patient developed dyspnea, chest pain, bloody urine, and a decrease in blood pressure. The nurse would characterize this as which type of transfusion reaction?

A) Allergic
B) Febrile nonhemolytic
C) Delayed hemolytic
D) Acute hemolytic

Question 28

A patient is in critical need of additional blood transfusions related to massive hemorrhage. The blood bank has no blood that matches the patient's type. The nurse would agree to administer non-type-specific blood if the patient has which blood type?

A) B
B) AB
C) A
D) O

Question 29

The nurse has chosen the nursing diagnosis Risk of Injury for a patient who will likely need several blood transfusions to treat gastrointestinal bleeding. What rationale would the nurse provide for this choice?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) There is a risk of dehydration.
B) The patient has a risk of iron overload.
C) There is risk of hemolysis of red blood cells.
D) There is a risk for social isolation.
E) There is a risk for hearing loss.

Question 30

The policy and procedure for blood administration call for giving no more than 30 mL in the first 15 minutes. To give that much through tubing with 10 gtts/mL, what would the drip rate be?

A) 60 gtts/min
B) 20 gtts/min
C) 12 gtts/min
D) 5 gtts/min

Question 31

A patient has been prescribed 3 units of packed red blood cells. How should the nurse proceed?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Start an IV site with an 18-gauge catheter.
B) Obtain special Y-type tubing.
C) Attach D5NS to the selected tubing and prime the line.
D) Warm the blood for at least one hour before beginning the transfusion.
E) Stay with the patient for the first 15 minutes of the transfusion.