210 Exam 2
A nurse is caring for a child who has bacterial endocarditis. The child is scheduled to receive moderate-term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include when teaching the child's parent? A. "The PICC line will last for several weeks with proper care." B. "The public health nurse will rotate the insertion site every 3 days." C. "You will need to ensure the arm board is in place at all times." D. "Your child will go to the operating room to have the line placed."
A. "The PICC line will last for several weeks with proper care."
A nurse is discontinuing a peripheral IV catheter. Upon removal, the nurse should assess the catheter for which of the following? A.An intact catheter tip B.Catheter erosion C.Blood within the catheter D.Discoloration of the catheter
A. An intact catheter tip The tip of the catheter can break off, thus creating an embolus. To limit the movement of the embolus, the nurse should apply a tourniquet high on the extremity where the IV line was located and notify the provider immediately.
A nurse is preparing to administer an IV injection to a client. For which of the following reasons should the nurse inject the medication slowly? A. To reduce toxicity risk B. To improve absorption pattern C. To prevent medication dilution D. To protect against embolism
A. To reduce toxicity risk Prior to injecting an IV medication, the nurse should plan to infuse the medication slowly over 1 minute to reduce the risk for toxicity to the central nervous system (CNS). Manifestations of CNS toxicity can become evident as soon as 15 seconds after initiating the injection. If the injection is done slowly, only a small amount of the total dose will have been administered when manifestations of toxicity appear. If the nurse is able to discontinue the administration immediately, adverse effects can be much less severe than if the entire dose had been given quickly.
A nurse is updating the plan of care for a client who is to receive total parenteral nutrition (TPN). Which of the following actions should the nurse include in the plan? (Select all that apply.) A. Weigh the client daily B. Obtain a serum blood glucose every 4 hr C. Apply a new dressing to the client's IV site every 5 days D. Change the IV tubing every 24 hr E. Infuse the TPN through a peripheral IV site
A. Weigh the client daily B. Obtain a serum blood glucose every 4 hr D. Change the IV tubing every 24 hr The nurse should weigh the client daily while receiving TPN. Clients who are receiving TPN are typically malnourished; therefore, the client's weight needs to be monitored closely. Fluid retention can also be an indication that the client is not digesting the TPN, and the rate of the transfusion might need to be decreased. The nurse should also obtain the client's serum blood glucose; insulin can be given if needed. Finally, the nurse should change the client's IV tubing every 24 hours to prevent bacteria from developing in the client's tubing.
A nurse is teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching? A."I'll wear nonsterile gloves." B."I'll use adhesive remover each time." C."I'll take my pain pill after I change the dressing." D."I'll fold the dressing with the soiled surface facing outward."
A."I'll wear nonsterile gloves." Wearing gloves prevents the spread of microorganisms outside of the dressings and onto the client's hands. The gloves the client uses can be clean and do not need to be sterile unless the provider specifically prescribes sterile gloves for dressing changes.
A home health nurse and an assistive personnel (AP) are discussing the care needs of a client. Which of the following statements by the AP requires intervention by the nurse? A.'I will change the client's PICC line dressing on my next visit." B."Bathing the client is something that I can do without assistance." C."I will assist the client in ambulating outdoors each time I visit." D."Next time I visit, I plan to clean up the clutter in the client's bedroom."
A.'I will change the client's PICC line dressing on my next visit." Changing IV dressings is not within the AP's scope of practice. The nurse should investigate this statement.
A nurse is preparing to administer a hydromorphone IV infusion to a client for pain. Which of the following actions should the nurse take? A.Administer the medication over 4 to 5 minutes B.Place the client in a high-Fowler's position C.Assess the client's pain level after administering the medication D.Review the client's last set of vital signs
A.Administer the medication over 4 to 5 minutes The nurse should administer the IV injection of this opioid medication over 4 to 5 minutes to prevent the adverse effects of the medication such as respiratory depression and cardiac arrest.
A nurse has just inserted a peripheral IV catheter. Which of the following actions should the nurse take to secure the catheter? A.Apply an IV securement device. B.Wrap tape around the circumference of the client's arm. C.Place a piece of paper tape over the insertion site. D. Tape the IV catheter's hub securely to the client's skin.
A.Apply an IV securement device. An IV securement device will help the IV to stay in place and prevent dislodgement.
A nurse is caring for a client who has a central venous catheter. When flushing the catheter, the nurse should use a 10-mL syringe to prevent which of the following complications associated with central vascular access devices? A.Catheter rupture B.Catheter migration C.Phlebitis D.Pneumothorax
A.Catheter rupture When injecting fluid through a catheter, a smaller syringe generates more pressure than a larger syringe does. Therefore, to reduce the risk of catheter rupture, syringes that are 10-mL or larger are recommended for flushing or injecting fluid into a central venous catheter.
A nurse is preparing to administer an epinephrine IV bolus to a client. Which of the following should the nurse verify before initiating the IV medication? A.Concentration of the formulation B.Reversibility of the medication C.Potential barriers to absorption D.Gastric emptying time
A.Concentration of the formulation The nurse should verify the concentration of the formulation of the medication prior to administration. Epinephrine can be injected through several routes, and a solution prepared for use by a certain route can differ in concentration from others. Solutions intended for subcutaneous administration are generally concentrated, whereas solutions intended for intravenous use are dilute. If a solution prepared for subcutaneous administration is administered intravenously, the result could be fatal because intravenous administration of concentrated epinephrine can overstimulate the heart and blood vessels, causing severe hypertension, cerebral hemorrhage, stroke, and death.
A nurse is assessing a client who has isotonic dehydration. Which of the following findings should the nurse expect? A.Increased hematocrit level B. Bradycardia C. Distended neck veins D. Decreased urine specific gravity
A.Increased hematocrit level The nurse should expect the client to have an increased hematocrit level due to hemoconcentration caused by reduced plasma fluid volume.
A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? A.Sudden onset of dyspnea B.Tracheal deviation C.Bradycardia D.Difficulty swallowing
A.Sudden onset of dyspnea Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs.
A nurse is caring for a client who is developing acute pulmonary edema and has a new prescription for furosemide 40 mg IV bolus. The nurse should plan to administer the medication using which of the following methods? A.Undiluted administered over 2 min B.Diluted administered over 20 min C.Undiluted administered as rapidly as possible D.Diluted administered over 5 min
A.Undiluted administered over 2 min The nurse should plan to administer low-dose furosemide therapy (e.g. 40 mg undiluted via IV bolus) at a rate of 20 mg/min or a dose of 40 mg over 2 min
A nurse is caring for a client who requires long-term central venous access and is an avid swimmer. Which of the following central venous access devices is the best choice for this client? A. A tunneled central catheter B. An implanted port C. A nontunneled percutaneous central catheter\ D. A peripherally inserted central catheter
B. An implanted port Because the entire device lies beneath the skin, the client can be immersed in water when the device is not in use without any increased risk for infection. This is the best choice for clients who wish to continue aquatic activities.
A nurse administers the first dose of a client's prescribed antibiotic via intermittent IV bolus. During the first 10 to 15 min of administration, which of the following assessments is the nurse's priority? A.Assess the IV site for redness or swelling. B.Assess the client for a systemic allergic reaction. C.Assess the IV dressing for signs of leakage. D.Assess the client's limb for signs of discomfort.
B. Assess the client for a systemic allergic reaction. The greatest risk to this client is anaphylaxis. Therefore, the priority assessment is to assess the client for a systemic allergic reaction. Clients can experience a systemic allergic reaction rapidly with IV antibiotics and should be observed for the first 10 to 15 min for manifestations.
A nurse is caring for a client who has bronchitis and a prescription for a mucolytic agent. Which of the following findings should the nurse identify as an adverse effect of this type of medication? A. Fluid overload B. Bronchospasm C. Electrolyte imbalance D. Tachycardia
B. Bronchospasm The nurse should identify that bronchospasm is an adverse reaction to a mucolytic agent. Mucolytic agents such as a hypertonic saline solution or acetylcysteine can irritate the airways, resulting in bronchospasm while producing a cough and thinning mucus secretions.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take? A. Administer 0.9% sodium chloride until TPN is available from the pharmacy B. Check the client's capillary blood glucose level every 4 hr C. Obtain the client's weight each week D. Change the IV tubing every 3 days
B. Check the client's capillary blood glucose level every 4 hr The nurse should check the client's capillary blood glucose level every 4 hours or according to facility policy due to the client's risk of hyperglycemia while receiving TPN. The dextrose concentration in TPN increases the risk of this complication.
A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis? A."I'll wrap the old dressing in a paper bag and put it in the trash." B."I'll wash my hands before I remove the old dressing and again before putting on the new one.". C."I'll need to take a pain pill 30 minutes before I change the dressing." D."I'll wear sterile gloves when I apply the new dressing."
B."I'll wash my hands before I remove the old dressing and again before putting on the new one." It is essential that the client understands the importance of hand hygiene before, during, and after any handling of the wound or its dressings.
A nurse is caring for a client who is in early stage renal failure and has a prescription for the infusion of IV fluids. Which of the following IV fluids does the nurse anticipate a prescription for and why? A.10% dextrose in water because it pulls fluid from the cells and increases vascular volume B.0.45% sodium chloride because it dilutes extracellular fluid and rehydrates the cells C.0.9% sodium chloride because it replaces extracellular volume and maintains intravascular volume D. 3% sodium chloride because it draws fluid into blood vessels and reduces interstitial compartments
B.0.45% sodium chloride because it dilutes extracellular fluid and rehydrates the cells Infusing a hypotonic solution, such as 0.45% sodium chloride, moves fluid into the cells, thus enlarging and rehydrating them.
A nurse is inserting a peripheral IV catheter and observes a blood return in the flashback chamber after puncturing the skin and selected vein. Which of the following actions should the nurse perform next? A.Secure the catheter to the skin with a transparent dressing. B.Advance the catheter into the vein with the finger hub. C.Release the tourniquet from the client's arm. D.Attach a primed piece of extension tubing to the catheter.
B.Advance the catheter into the vein with the finger hub. Once blood return is observed in the flashback chamber, the over-the-needle catheter should be advanced into the vein using the finger hub.
A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select? A.Select a vein in the client's dominant arm B.Choose the most proximal vein in the extremity C.Choose a vein that is soft on palpation D.Select a site distal to previous venipuncture attempts
B.Choose the most proximal vein in the extremity The nurse should select a vein that is soft and has a "bouncy" feeling when pressure is released upon palpation
A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A.Redness at the infusion site B.Edema at the infusion site C.Warmth at the infusion site D.Oozing of blood at the infusion site
B.Edema at the infusion site Edema due to fluid entering subcutaneous tissue is an indication of infiltration
A nurse is caring for a client who has a central venous catheter and suddenly develops dyspnea, tachycardia, and dizziness. The nurse suspects an air embolism and clamps the catheter immediately. The nurse should reposition the client into which of the following positions? A.Supine with a pillow beneath the knees B.On their left side in Trendelenburg position C.Upright and leaning over the overbed table D. On their right side with the head of the bed elevated 15°
B.On their left side in Trendelenburg position This position helps trap the air in the apex of the right atrium rather than allowing it to enter the right ventricle and, from there, move to the pulmonary arterial system.
A nurse is caring for a client who has a pelvic fracture. The client reports sudden shortness of breath, stabbing chest pain, and feelings of doom. This client is experiencing which of the following complications? A.Pneumonia B.Pulmonary embolus C.Tension pneumothorax D.Tuberculosis
B.Pulmonary embolus Immobility following musculoskeletal trauma places the client at an increased risk of pulmonary embolus. The client might also exhibit tachycardia and chest petechiae and have a decreased SaO2. The nurse should notify the rapid response team immediately.
A nurse is evaluating a client's understanding of discharge teaching about dressing changes. Which of the following actions by the client indicates an understanding of the teaching? A.The client nods and smiles in response to what is being said. B.The client restates the information in her own words. C.The client does not ask questions when given the opportunity. D.The client's body language shows that she is listening to the nurse.
B.The client restates the information in her own words When the client restates the information in her own words, the nurse can assess the client's understanding of the teaching. The nurse can observe and listen for gaps in understanding and proceed to correct items as necess
A nurse is caring for a client who is receiving 0.9% sodium chloride IV at 75 mL/hr through a triple lumen central venous access device. The IV pump alarm sounds, indicating that there is an occlusion. Which of the following actions should the nurse take first? A.Call the provider who inserted the catheter. B.Flush the line with a 10-mL syringe of heparin. C.Check the line at or above the hub for kinked tubing that is creating a resistance to flow. D.Reposition the client.
C. Check the line at or above the hub for kinked tubing that is creating a resistance to flow. The first action the nurse should take when using the nursing process is to assess the client's IV line at or above the hub for kinked tubing that is creating a resistance to the flow of the infusion. This is most likely the problem and should be where the nurse checks first.
A nurse is assessing a client who is receiving 0.9% sodium chloride IV at 125 mL/hr. Which of the following should the nurse recognize as a possible complication related to the IV therapy? A. Petechiae is present over the IV site. B. The skin is cool over the IV site. C. Client reports coughing and shortness of breath. D. Client's blood pressure is lower than normal.
C. Client reports coughing and shortness of breath. Coughing and shortness of breath are manifestations of fluid overload. The nurse should slow the IV and notify the provider.
A nurse is caring for a client who has a peripherally inserted central catheter (PICC) in place. Which of the following actions should the nurse take when handling this central venous access device? (Select all that apply.) A. Use a 5 mL syringe to flush the line B. Cleanse the insertion site with half-strength hydrogen peroxide C. Flush the line with sterile 0.9% sodium chloride before and after medication administration D. Access the PICC for blood sampling E. Perform a heparin flush of the line at least daily when not in use
C. Flush the line with sterile 0.9% sodium chloride before and after medication administration D. Access the PICC for blood sampling E. Perform a heparin flush of the line at least daily when not in use The nurse should flush the line with 10 mL of sterile 0.9% sodium chloride solution before and after administering medication through the PICC. The nurse should use a PICC to deliver fluids, medications, and total parenteral nutrition to the client. The PICC is also used to obtain blood samples, and the nurse should practice the appropriate technique to access and flush the line. Ideally, blood samples should come from a 4 French lumen catheter or larger.PICCs can remain in place for months or years. When not actively in use, the nurse should perform heparin flushes at least daily to prevent clotting within the line.
A nurse is caring for a client who has a peripherally inserted central catheter (PICC) line. The nurse should identify that which of the following information is true about this type of IV route? A.A PICC line is a midline catheter used to administer blood. B.A PICC line is a catheter that allows for infusion of IV fluids without an infusion pump. C.A PICC line is a long catheter inserted through the veins of the antecubital fossa. D.A PICC line is a catheter that is used for emergent or trauma situations.
C.A PICC line is a long catheter inserted through the veins of the antecubital fossa. PICC lines have lower complication rates because they are inserted in the upper extremity.
A nurse in the emergency department is caring for a client who was in a motor-vehicle crash. The provider determines that the client needs immediate central venous access for fluid and blood replacement. Which of the following central venous access devices should the nurse anticipate being inserted? A.A tunneled central catheter B.An implanted port C.A nontunneled percutaneous central catheter D. A peripherally inserted central catheter
C.A nontunneled percutaneous central catheter This type of central catheter is ideal for emergency situations where short-term (less than 6 weeks) central venous access is required for multiple therapies. This is the appropriate choice for this client.
A nurse assesses a client's IV insertion site and finds that it is red, warm, and slightly edematous. Which of the following actions should the nurse take? A.Check for a blood return. B.Elevate the extremity. C.Discontinue the IV line. D.Apply warm, moist heat.
C.Discontinue the IV line. The client has classic signs of phlebitis, an inflammation of the vein. The IV line must be discontinued immediately to reduce the risk of thrombophlebitis and embolism.
A nurse is assessing a client who has increased intracranial pressure and has received intravenous mannitol. Which of the following findings indicates a therapeutic effect of this medication? A.Decreased blood glucose B.Decreased bronchospasms C.Increased urine output D.Increased temperature
C.Increased urine output Mannitol is an osmotic diuretic used to reduce intracranial pressure by mobilizing intracranial fluid and inhibiting the reabsorption of water and electrolytes in the kidneys. Increased urine output and decreased intracranial pressure are therapeutic effects of this medication.
A nurse is removing a client's IV catheter. Which of the following actions should the nurse take? A.Apply firm pressure over the vein. B.Leave the roller clamp slightly open C.Pull the catheter straight back from the insertion site. D.Lift the hub slightly upward away from the skin.
C.Pull the catheter straight back from the insertion site. With the catheter stabilized and using a slow, steady movement, the nurse should withdraw the catheter straight back and away from the insertion site, making sure to keep the hub parallel to the skin.
A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse take? A.Change the infusion tubing B.Flush the IV catheter C.Remove the IV catheter D.Apply a cool compress to the site
C.Remove the IV catheter This client's manifestations suggest phlebitis. The nurse should stop the infusion and remove the IV catheter immediately. The nurse should then apply warm compresses to the site.
A nurse is monitoring a client who has cancer and is receiving chemotherapy by peripheral IV infusion. The client reports pain at the insertion site, and the nurse notes fluid leaking around the catheter. Which of the following actions should the nurse take first? A.Take a photograph of the peripheral IV site B.Obtain and record the client's vital signs C.Stop the infusion D.Identify all medications administered through the IV site for the past 24 hr
C.Stop the infusion When applying the urgent versus nonurgent priority-setting framework, the nurse should consider urgent needs to be the priority because they pose more of a threat to the client. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. Many chemotherapy medications are vesicants that can cause extensive tissue damage if extravasation occurs; therefore, the nurse's first action should be to stop the infusion immediately.
A nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? A.Redness at the IV catheter entry site B.Palpable cord along the vein used for the infusion C.Taut skin around the IV catheter site that is cool to the touch D.Bleeding at the IV insertion site
C.Taut skin around the IV catheter site that is cool to the touch A client who has taut skin around the IV catheter site that is cool to the touch might have an infiltrated IV site. The nurse should stop the IV infusion, elevate the extremity, and apply a warm moist compress or a cold compress (according to the type of infiltration).
A nurse is caring for a client who has a central venous access device in place. Which of the following routine interventions should the nurse use to prevent lumen occlusion? A.Apply a skin securement device to the catheter. B.Remove the dressing from the insertion site slowly and carefully. C.Use a pulsatile action while flushing. D.Have the client lie flat when changing administration sets or injection caps.
C.Use a pulsatile action while flushing. Using a pulsatile action technique while flushing assists with the prevention of occlusion by removing possible solid deposits within the lumen.
A nurse is caring for a client who is receiving dextrose in 5% water with 20 mEq of potassium chloride at 75 mL/hr. The provider has prescribed 1 g ceftriaxone IV. When preparing to administer this medication by intermittent IV bolus, which of the following actions should the nurse take first? A.Obtain the client's vital signs. B.Determine the client's level of consciousness. C.Verify the medication's compatibility with the primary IV solution. D.Check the amount of IV solution in the primary bag.
C.Verify the medication's compatibility with the primary IV solution .The greatest risk to this client is injury from precipitate in the IV solution. Therefore, the first action the nurse should take is to assess the medication's compatibility with the primary solution. If the medication is not compatible with the primary solution, a precipitate can form in the IV tubing, preventing medication administration.
A nurse is planning to administer fluids to a client who has 25% total body surface area burns. The client has no prior medical history. Which of the following intravenous fluids is contraindicated for this client? A. Whole blood B. Lactated Ringer's C. Dextran 40 in 0.9% sodium chloride D. 0.45% sodium chloride
D. 0.45% sodium chloride The nurse should identify that 0.45% sodium chloride is a hypotonic solution and is contraindicated for clients who have burns. Hypotonic fluid has an osmolarity value of <270 mOsm/L, which is less than the expected reference range of the osmolarity value for plasma and body fluid of 285 to 295 mOsm/L. Administering a hypotonic solution to this client can cause third-spacing of fluid.
A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? A. 0.45% sodium chloride B. Dextrose 5% in 0.9% sodium chloride C. Dextrose 10% in water D. 0.9% sodium chloride
D. 0.9% sodium chloride Solutions of 0.9% sodium chloride, as well as Lactated Ringer's solution, are used for fluid volume replacement. Sodium chloride (a crystalloid) is a physiologically isotonic solution that replaces lost volume in the bloodstream and is the only solution to use when infusing blood products.
A nurse is administering a medication parenterally to a client. Which of the following techniques should the nurse use to reduce fluctuations in plasma medication levels? A. Gradually increasing the dose with the dosing interval B. Administering a single loading IM dose C. Using a large fluid-volume IV dose D. Administering a continuous infusion of the dose
D. Administering a continuous infusion of the dose By administering a medication by continuous infusion, plasma levels stay nearly constant, thus reducing fluctuations in plasma levels.
A nurse has just initiated an IV infusion and is teaching the client about possible complications. The nurse should include that which of the following findings is an indication of early infiltration? A.Moisture B.Bruising C.Tingling D. Coolness
D. Coolness Coolness is a classic sign of infiltration, along with swelling, pallor, and possibly tenderness. Infiltration is a leakage of IV solution out of the intravascular compartment and into the surrounding tissue.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? A. Hypertension B. Excessive thirst C. Fever D. Diaphoresis
D. Diaphoresis The nurse should recognize that this client has the potential to develop hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger.
A nurse has just initiated a new peripheral IV infusion with 5% dextrose in water for continuous infusion. How often should the nurse plan to replace the primary infusion tubing? A.Every 24 hr B.Every 48 hr C.Every 72 hr D.Every 96 hr
D. Every 96 hr The Centers for Disease Control and Prevention and the Infusion Nurses' Society recommend changing the IV tubing no more than once every 96 hr unless the tubing has been contaminated, punctured, or obstructed.
Which of the following actions should a nurse take when converting an IV infusion to a saline lock? A.Open the roller clamp of the primary infusion to prime the saline lock. B.Apply pressure with a syringe to clear resistance in the IV catheter. C.Attach secondary tubing to allow mobility. D. Flush the IV catheter to confirm patency.
D. Flush the IV catheter to confirm patency. It is essential to attach the primed saline lock adapter to the extension tubing and to flush the tubing with normal saline to confirm patency.
A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take? A. Change the tube feeding bag every 48 hours B. Chill the formula prior to administration C. Increase the infusion rate D. Request a prescription for an isotonic enteral nutrition formula
D. Request a prescription for an isotonic enteral nutrition formula The nurse should assist a client who develops diarrhea while receiving NG tube feedings by consulting with the provider and the dietitian regarding changing the client's formula to an isotonic formula. This formulation can be easier for the client to digest and can decrease diarrhea.
A nurse is caring for a client who is receiving IV ampicillin and develops urticaria and dyspnea. Which of the following actions should the nurse take first? A. Elevate the client's feet and legs B. Administer epinephrine C. Infuse 0.9% sodium chloride D. Stop the medication infusion
D. Stop the medication infusion The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The greatest risk to this client is an allergic reaction that can progress to anaphylaxis. The nurse should stop the infusion immediately to halt further exposure of the client to the allergen.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) through a central line. Which of the following actions should the nurse perform? A. Change the tubing every 12 hr B. Check the client's blood glucose every 8 hr C. Apply a new dressing to the IV site every 76 hr D. Weigh the client daily
D. Weigh the client daily The nurse should weigh the client who is receiving TPN daily due to the risk of fluid and electrolyte imbalances.
A charge nurse is observing a newly licensed nurse administer an IV medication to a client who has an implanted venous access port. Which of the following observations requires intervention by the charge nurse? A.A dressing is not applied to the port site after use. B.A 22-gauge non-coring needle is used to access the port. C.Blood return is noted prior to administering the medication. D.A solution of 5 mL heparin 1,000 units/mL has been prepared.
D.A solution of 5 mL heparin 1,000 units/mL has been prepared. Implanted ports should be flushed after each use and at least once a month when not in use. This practice is sometimes referred to as "locking" or "de-accessing." It is performed to prevent the formation of blood clots in the catheter, which would disrupt the proper functioning of the catheter. The solution of 5 mL heparin should be 100 units/mL; therefore, this action requires intervention by the charge nurse.
A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take? A.Clean the incision from bottom to top B.Apply sterile gloves prior to opening dressing packages C.Remove the tape by pulling away from the wound D.Clean the drain site from the center outward
D.Clean the drain site from the center outward The nurse should clean the drain site from the center outward to avoid introducing microorganisms from the periphery of the wound into the center of the wound
A nurse is caring for a client who has an implanted port that needs to be accessed for an infusion. Which of the following actions should the nurse take? A. Use a standard medium-gauge needle to access the port. B. Insert the primed needle into the port at a 45° angle. C.Withdraw the needle after insertion, leaving the needle's sheath in place for the infusion. D.Cover the device and the needle with a sterile transparent dressing.
D.Cover the device and the needle with a sterile transparent dressing. Once the implanted port has been accessed, the needle must be supported and anchored. The needle should be covered with a transparent dressing to secure the needle.
A nurse is assessing a client who is receiving a continuous morphine IV infusion and finds the client's respiratory rate has decreased from 20/min to 12/min. Which of the following actions should the nurse take? A.Flush the IV line with saline B.Administer flumazenil C.Lower the head of the bed D.Slow the rate of the infusion
D.Slow the rate of the infusion The nurse should decrease the infusion rate to reduce the amount of morphine the client receives and limit the risk of respiratory depression.
A nurse is preparing to obtain a blood sample from a client who has a triple-lumen central catheter in place. Which of the following actions should the nurse take? A. Discard the first 35 mL of aspirated blood before collecting the sample. B.Place the client in Trendelenburg position while withdrawing the blood sample. C. Withdraw the blood sample from the lumen that has the smallest diameter. D.Turn off the distal infusions for 1 to 5 min before obtaining the blood sample.
D.Turn off the distal infusions for 1 to 5 min before obtaining the blood sample. To help ensure that the laboratory results will not be altered by the solutions infusing through the central access device, it is recommended that the nurse stop the distal infusions and clamp the tubing for 1 to 5 min before obtaining the blood sample. How long to stop the infusion varies with the type of infusion.
A nurse is preparing to administer an IV medication to a client. The nurse should identify that which of the following is a disadvantage of administering IV medications? A.IV medications are irreversible. B.IV medications have a slow onset. C.IV medications bypass the liver. D.IV medications have less bioavailability.
A. IV medications are irreversible. Once an IV medication has been injected, it cannot be retrieved. If the dose is excessive or the client is allergic, the consequences can be fatal.
A nurse is caring for a client who was admitted to the hospital for same day surgery and has a new prescription for continuous IV therapy. Which of the following actions should the nurse take when administering the IV therapy? A.Place a cold compress over the vein. B.Inspect the IV solution for fluid color, clarity, and expiration date. C.Apply a tourniquet 1 to 2 inches above the selected insertion site. D. Secure an armboard to the client's extremity.
B. Inspect the IV solution for fluid color, clarity, and expiration date. All IV solutions must be free of contaminants and particles and current for usage.
A nurse is preparing a client who is scheduled for an intravenous pyelogram (IVP). Which of the following findings should the nurse report to the provider? A.Allergy to egg products B.Vomiting and diarrhea for the last 6 hr C.Serum potassium of 3.6 mEq/L D.Serum creatinine of 1.2 mg/dL
B.Vomiting and diarrhea for the last 6 hr Vomiting and diarrhea for 6 hours deplete the client's fluid volume, which results in dehydration that can cause renal failure following a procedure that uses contrast dye. Therefore, the nurse should notify the provider.
A nurse is assessing a child who is receiving IV chemotherapy. Assessment findings include extravasation of the tissues surrounding the IV insertion site. In which order should the nurse take the following actions?
Step 1: Extravasation is the infusion of vesicant solutions or medications into surrounding tissues. After observing extravasation, the nurse should first stop the infusion. Step 2: Then elevate the extremity. Step 3: The nurse should notify the provider. Step 4: Remove the IV line. Treatment of extravasation varies according to the vesicant and might involve the infusion of an antidote through the IV line into the tissues. Therefore, the IV line is not removed until the provider's prescriptions have been initiated.
