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20 Cards in this Set

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A nurse has an order to hang an IV bag of 1000 ml 5% dextrosein water with 20 mEq potassium chloride. The nurse should plan to do which of the following immediately after injecting the potassium chloride into the port of the IV bag?
1. attach the tubing to the client
2. check the solution for yellowish discoloration
3. rotate the bag gently
4. place the time tape on the IV
3
After adding a med to a bag of IV solution, the nurse shoudl agitate or rotate the bag gently to mix the med evenly in the solution. Then attach a med label., then place a time tape on the bag,. The IV solution should have been checked for discoloation b4 the med was added.
The tubing is attached to the client last.
A nurse is inserting an IV line into a client's vien. After the initial stick the nurse continues to advance the catheter if the nurse notes that?
1. the catheter advances easily
2. blood return shows in the backflash chamber of the catheter
3. the vein is distended under the needle
4. the client does not complain of discomfort
2
The IV has entered the lumen of the vein successfully when blood backflash shows. The vein should have been distended by the tourniguet b4 the vein was cannulated. Clt discomfort varies with the client, the site and the nurse's insertion technique. and is not a reliable measure of catheter placement. The nurse should not advance the cateter until placement in the vein is verified by blood return
A client is scheduled for insertion of a peripherally inserted central catheter (PICC). The nurse has explained the advantages of this catheter to the client.
Which statement by the client indicates a need for further eplanation
1. "There is less pain and discomfort"
2. "this type of catheter is very reliable."
3. It is reasonable in cost."
4."It is specially designed for short-term care
4
PICCS are intended to be used for long-term placement. They are reasonable in cost and reliable. it is less likely to infiltrate and can be used for admin of a number of different types of meds.
A nurse is planning to provide a list of instructions to a client being discharged to home with a PICC. The nurse would avoid writing which of the following incorrect items on the instruction sheet?
1.keep activity level to a minimum while this catheter is in place
2. keep the insertion site protected when in the shower or bath
3. have a repair kit available in the home for use if needed
4. wear a medic-alert tag or bracelet
1
only minor restrictions apply with this type of catheter. he should protect the site during bathing and shoudl carry or wear a Medic-Alert id. he should also have a repair kit because this is for long-term care
A nurse is assessing the IV dressing of a client with a peripheral IV running. The date on the dressing is 7/25. The nurse documents on the client's record that the dressing should be changed on which of the following dates?
1. 7/26
2. 7/28
3. 7/30
4. 8/1
2
change every 48 - 72 hours, 2-3 days.
A nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client's IV site is cool, pale and swollen, and the solution is not infusing. The nurse concludes that which of the following complications has been experienced by the client?
1. Thrombosis
2. Infection
3. Infiltration
4. Phlebitis
3
it is lying in the subcutanous tissue and when the pressure in the tissues exceeds the pressure in the tubing, the solution should stop. corrective action is to remove and start in a new site with new line.
A client rings the call bell and complains of pain at the site of an IV infusion. A nurse assesses the site and determines that the client has developed phlebitis. The nurse avoids which action in the care of this client?
1. applies warm moist packs to the site
2. starts a new IV line in a proximal portion of the same vein
3. discontinues the IV catheter at that site
4. notifies the physician
2
The nurse should discontinue the IV at the phlebitic site and apply warm moist compresses to the area to speed resolution of the inflammation. Because phlebitis has occurred, the nurse also notifies the MD. The nurse should restart the IV in a vein other than the affected site
A client had a 1000 ml bag of 5% dextrose in 0.9% sodium chloride hung at 1500. A nurse making rounds at 15:45 finds the client to be complaining of a pounding headache and to be dyspneic, experiencing chills, apprehensive and with an increased pulse rate. The IV bag has 400 ml remaing. The nurse should take which of the following actions first?
1. sit the client up in bed
2. call the physician
3. slow the IV infusion
4. remove the IV catheter
3
the symptoms are compatible with circulatory overload. This may be verified by notin g that 600 ml has infused in the course of 45 min. The first action of the nurse is to slow the infusion. then elevate the head of the bed to aid breathing, if necessary. Then notify the MD. Do not remove the catheter
The nurse notes that the site of a client's peripheral IV catheter is reddened, warm painful and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client experienced?
1. Hypersensitibity to the IV solution
2. Allergic reaction to the IV catheter material
3. infiltration of the IV line
4. Phlebitis of the vein
4
Phlebitis can be distinguished by client discomfort at the site and by redness, warmth and swelling proximal to the catheter. If phlebitis occures, the nurse should discontinue the IV line and should insert a new IV at a different site. Coolness at the site would be noted if the IV was infiltrated. An allergic reaction produces a rash, redness, and itching. A major reaciton, such as hypersensitivity, can cause dyspnea, a swollen tongue and cyanosis
A physician has written an order to discontinue an IV line. A nurse obtains which of the following supplies from the unit supply area for use in applying pressure to the site after removing the IV catheter?
1. Adhesive bandage
2. sterile 2x2 gauze
3. alcohol swab
4. betadine swab
2
a dry sterile dressing like a 2x2 gauze is used to apply pressure to the d/c IV site. This material is absorbent,k sterile and nonirratating. A betadine swab or an alcohol swab would irritate the opened puncture site and would not stop the blood flow.
A client has just undergone insertion of a central venous catheter at the bedside. A nurse would be sure to check the results of which of the following b4 increasing the flow rate of the IV solution attached to the line from a keep vein open rate to 100 ml/hr?
1. serum electrolytes
2. serum osmolality
3. portable chest x-ray film
4. intake and output record
3
the nurse should assess whether the results of the chest radiograph reveal that the central cath. is in the proper place. This is necessary to prevent infusion of IV fluid into pulmonary or subcutaneous tissues. The other options represent items that are useful for the nurse to be aware of in the general care of this client.
A nurse is preparing a continous IV infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the med cart. Which of the following is the appropriate action by the nurse?
1. wipe the distal end of the tubing with betadine
2. scrub the needleless device with an alcohol swab
3. attach a new needleless device
4. obtain new IV tubing
4
the nurse should obtain a new IV tubing. The needleless device has not been contaminated and does not need replacement or cleansing
A nurse is preparing to insert an IV angiocatheter into a client's inner forearm. Before cannulating the vein, the nurse cleanses the entry site by which of the following motions?
1. scrubbing from the wrist toward the elbow
2. scrubbing from the elbow toward the wrist
3. using a circular motion from the center outward
4. using a circular motion inward toward the center
3
the nurse cleanss the skin by using a circular motion from inward to outward. This is the standard accepted aseptic tech
A client is hypovolemic, and plasma expanders are not availible. A nurse anticipates that which of the following solutions available on the nursing unit will be prescribed by the physician?
1. 5% dextrose in 0.45% sodium chloride
2. 5% dextrose to water
3. 0.9% sodium chloride
4. 0.45% sodium chloride
1
a solution of 5% dextrose in 0.45% sodium chloride is hypertonic. An advantage of hypertonic solutions is that they may be used to treat hypovolemia when plasma expanders are not readily available. options 2 & 3 are isotonic solutions, option 4 is a hypotonic solution
A nurse hears an attending physician asking an intern to prescribe a hypotonic IV solution for a client. Which of the following IV solutions would the nurse expect the intern to prescribe?
1. 0.45% saline (1/2 NS)
2. 5% dextrose in water (D5W)
3. 10% dextrose in water (D10W)
4. 5% dextrose in 0.9% saline (D5 NS)
1
hypotonic solutions contain a lower concentration of salt or more water than an isotonic solution. A solution of 0.45% saline is hypotonic. A solution of 5% dextrose in water is isotonic. Solutions of 10% dextrose in water and 5% dextrose in 0.9% saline are hypertonic solutions, Distilled water is another ex. of hypotonic solutions
A nurse has obtained a unit of blood from the blood bank to transfuse into a clt as ordered. B4 preparing the bl for transfusion , the nurse next looks for which of the following members of tbhe health care team to assist in checdking the unit of blood?
1. blood bank technician
2. registered nurse
3. medical student
4. phlebotomist
2
two RNs or one RN and a licensed practical nurse must check the label on the bl product together against the clt's id number, blood group, and complete name. This minimizes the risk of error in checking infor on the blood bag and thereby minimizes the risk of harm to the clt. A blood bank tech. will verigy date with the nurse when the bl is obtained form the blood bannk but will not verify info on the nursing unit or at the clt's bedside.
A nurse has obtained a unit of blood from the blood bank and has hecked the blood bag properly with another nurse. Just b4 beginning the transfusion, the nurse assesses which of the following items?
1. vital signs
2. latest hematocrit level
3. skin color
4. urine output
1
a change in vital signs during the transfusion may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs before the procedure, every 15 min for the 1st half hour and every half hour thereafter. The other options do not identify assessments that are required just before beginning a trnsfusion
A nurse has just received an order to transfuse a unit of packed red blood cells for an assigned client. In planning coverage for the clt assignment, the nurse asks if another nurse will be available to check on the other assigned clts for how long when the unit of blood is hung?
1. 5 min
2. 15 min
3. 30 min
4. 45 min
2
must remain for the 1st 15 min of a transfusion, which is the most frequent period during which a transfusion reaction may occur. This enables the nurse to detect a reaction and intervene quicdkly. The nurse engages in safe nursing practice by obtaining coverage for the other assigned clts during this time.
A client has an order to recdeive a unit of packed red bl. cells. A nurse would obtain which of the following IV solutions from the IV storage area to hang with the bl product at the clt's bedside?
1. 0.9% sodium chloride
2. Lactated Ringer's
3. 5% dextrose in 0.9% sodium chloride
4. 5% dextrose in 0.45% sodium chloride
1
(normal saline) is a standard isotonic solution that is used to precede and to follow infusion of bl products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red bl cells. Lacated Ringer's is not the solution of choice with this procedure
A nurse is assigned to care for a clt who was just admitted to the hospital for the trmt of iron overload. The nurse reviews the physician's admission orders and anticiptes that the Md will prescribe which med to treat the iron overload?
1. Granisetron (Kyutril)
2. Deferoxamine (Desferal)
3. Ketoconazole (Nizoral)
4. Terbinafine (Lamisil)
2
Deferoxamine is an antidote used to treat iron toxicity.