Exam 1 Eaq Questions

While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation? A. Stop the blood transfusion immediately. B. Report to the primary healthcare provider. C. Recheck identifying tags and numbers on the client. D. Maintain a patent intravenous (IV) line with saline solution

A. Stop the blood transfusion immediately. An incompatible blood transfusion can result in an acute hemolytic reaction in the client. During acute hemolytic reactions, the nurse should stop a blood transfusion as a priority nursing intervention. After stopping the blood transfusion, the nurse should report it to the primary healthcare provider. The nurse can then recheck the client's identifying tags and numbers and maintain a patent IV line with saline solution.

The health care provider prescribes 1000 mL of total parenteral nutrition to be administered in 12 hours. Based on this prescription, how many milliliters of solution should be administered per hour? A. 83 mL/hr B. 100 mL/hr C. 108 mL/hr D. 125 mL/hr

A. 83 mL/hr

A nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? A. A 59-year-old who had a knee replacement B. A 60-year-old who has bacterial pneumonia C. A 68-year-old who had emergency dental surgery D. A 76-year-old who has a history of thrombocytopenia

A. A 59-year-old who had a knee replacement Clients who have had a joint replacement have decreased mobility; they are at risk for developing thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodged into the circulation

A client develops thrombophlebitis in the right calf. Bed rest is prescribed, and an IV of heparin is initiated. What drug action will the nurse include when describing the purpose of this drug to the client? A. Prevents extension of the clot B. Reduces the size of the thrombus C. Dissolves the blood clot in the vein D. Facilitates absorption of red blood cells

A. Prevents extension of the clot Heparin interferes with activation of prothrombin to thrombin and inhibits aggregation of platelets. Heparin does not reduce the size of a thrombus. Heparin does not dissolve blood clots in the veins. Heparin does not facilitate the absorption of red blood cells.

A client with esophageal cancer is to receive total parenteral nutrition. A right subclavian catheter is inserted. What is the primary reason total parenteral nutrition is infused through a central line rather than a peripheral line? A. It prevents the development of infection. B. There is less chance of this infusion infiltrating. C. It is more convenient so clients can use their hands. D. The large amount of blood helps dilute the concentrated solution.

D. The large amount of blood helps dilute the concentrated solution. Unless diluted by the increased blood flow, the highly concentrated solution can cause injury to the veins. The potential of infection is high with parenteral nutrition because of the increased glucose levels.

A blood transfusion of packed cells has been prescribed for a client. The client shows signs of hemolytic reaction. Place the appropriate nursing actions in order. 1. Change the intravenous (IV) administration set. 2. Stop the transfusion. 3. Notify the primary healthcare provider and blood bank. 4. Run 0.9% normal saline at a rapid rate.

1. Stop the transfusion. 2. Change the intravenous (IV) administration set. 3. Run 0.9% normal saline at a rapid rate. 4. Notify the primary healthcare provider and blood bank. The priority is to stop the transfusion. Failure to do so will make the reaction worse. Changing the IV administration set will prevent infusing any blood product remaining in tubing. Running normal saline rapidly will help to decrease shock and hypotension. Notifying the primary healthcare provider and blood bank would be the last step because this would take longer than the first three choices.

During administration of a whole blood transfusion, the client begins to complain of shortness of breath. The nurse notes the presence of jugular venous distension, bibasilar crackles, and tachycardia. Prioritize the following nursing actions. 1. Apply oxygen via nasal cannula 2. Elevate the head of the bed to 45 degrees 3. Document findings in the client record 4. Reduce the flow rate of the transfusion 5. Administer furosemide (Lasix) per provider prescription

1.Elevate the head of the bed to 45 degrees 2.Apply oxygen via nasal cannula 3.Reduce the flow rate of the transfusion 4.Administer furosemide (Lasix) per provider prescription 5.Document findings in the client record These symptoms represent circulatory overload. First, the nurse's priority is to facilitate gas exchange by elevating the head of the bed, then applying oxygen. Next, the transfusion rate should be slowed to reduce further circulatory overload and client compromise, followed by the administration of a diuretic to reduce circulating volume. Lastly, the findings and interventions should be documented accordingly.

A client with a gastric hemorrhage is scheduled to receive two units of whole blood. List the nurse's activities in the order that they should be performed when administering a blood transfusion. 1. Obtain venous access, preferably with a 19-gauge needle or larger. 2. Ask another nurse to check the blood identification at the client's bedside. 3. Run the blood at a slower rate during the first 10 minutes of the transfusion. 4. Prime the blood infusion set tubing with normal saline at the bedside. 5. Verify that a type and crossmatch blood sample has been sent to the lab.

1.Verify that a type and crossmatch blood sample has been sent to the lab. 2.Obtain venous access, preferably with a 19-gauge needle or larger. 3.Prime the blood infusion set tubing with normal saline at the bedside. 4.Ask another nurse to check the blood identification at the client's bedside. 5.Run the blood at a slower rate during the first 10 minutes of the transfusion. First, the nurse should ensure that a type and crossmatch blood sample (called a clot) has been sent to the lab to identify the client's blood type. This should be done first because it could take some time to be completed. Also, if a clot has not yet been sent, it can be collected and sent immediately to save waiting time to receive the blood. Secondly, the nurse must ensure there is peripheral intravenous (PIV) access with a large enough gauge needle (19-gauge or larger) to prevent destruction to the blood cells. After the PIV has been established, the blood tubing should be hung at the bedside and the lines primed with normal saline. Once the blood is brought to the unit, it must be verified by two nurses who check the blood and the client's identification before blood administration can begin. Starting the transfusion at a slow rate for the first 10 to 15 minutes provides time to monitor the client for a developing transfusion reaction before too much blood has been administered.

A platelet transfusion is to be administered to a child with acute lymphocytic leukemia. What will the nurse do first? A. Administer the platelets rapidly through the intravenous (IV) line B. Set the IV pump to run for 8 hours C. Flush the IV line with a dextrose solution D. Check the vital signs every 2 hours during the transfusion

A. Administer the platelets rapidly through the intravenous (IV) line Platelets are fragile and should be administered as quickly as possible

A client with malabsorption syndrome is admitted to the hospital for medical intervention. A subclavian catheter is inserted, and the client is started on total parenteral nutrition (TPN). What should the nurse teach the client in order to prevent the most common complication of TPN? A. Avoid disturbing the dressing or getting it wet. B. Keep the head as still as possible whenever moving. C. Regulate the flow rate on the infusion pump as necessary. D. Monitor daily weights at the same time while wearing the same clothing.

A. Avoid disturbing the dressing or getting it wet. Disturbing the dressing may expose the area to pathogens. Infection is the most common complication; sterile technique at the catheter insertion site must be maintained. Keeping the head still is not necessary; the catheter is sutured in place, and reasonable movement is permitted. The client should be taught to leave the infusion pump set at the rate prescribed by the healthcare provider and to call the nurse if the alarm rings. Excessive weight gain or loss is not a complication of total parenteral nutrition.

A client with inflammatory bowel disease is receiving total parenteral nutrition (TPN) via an infusion pump. What is most important for the nurse to do when administering TPN? A. Change the TPN solution bag every 24 hours, even if there is solution left in the bag. B. Monitor the client's blood glucose level every 2 hours at the bedside with a glucometer. C. Instruct the client to breathe shallowly when changing the TPN tubing using sterile techniques. D. Speed up the rate of the TPN infusion if the amount delivered has fallen behind the prescribed hourly rate.

A. Change the TPN solution bag every 24 hours, even if there is solution left in the bag. TPN solutions are high in glucose and are administered at room temperature, factors that increase the risk of microbial growth

Following surgery, total parenteral nutrition is instituted via a central venous infusion. During the fourth hour of the infusion the client complains of nausea, fatigue, and a headache. The hourly urine output is twice the amount of the previous hour. After contacting the primary health care provider, what is the next action the nurse should take? A. Check the serum glucose level. B. Obtain an oxygen saturation level. C. Administer a prescribed analgesic. D. Prepare the client for immediate surgery for possible bowel obstruction.

A. Check the serum glucose level. Rapid administration can cause glucose overload, leading to osmotic diuresis and dehydration. There is no indication of hypoxia. Signs of bowel obstruction are not present. The client's headache should disappear with oral fluid replacement; analgesics are not indicated

The nurse is caring for a client with sepsis who is hemodynamically stable. The client is complaining of abdominal pain. Which of these primary health care provider prescriptions should the nurse do first? A. Draw peripheral blood cultures. B. Administer levofloxacin 500 mg intravenously over 30 minutes. C. Administer 1 L intravenous bolus of Ringer's lactate over 30 minutes. D. Take the client to x-ray for an abdominal computed tomography (CT) scan.

A. Draw peripheral blood cultures. This question requires the learner to recall the priority treatments for clients with sepsis. Mortality in septic clients increases by 7.6% for every hour an antibiotic is delayed. Because this client is hemodynamically stable, the priority is to draw the blood cultures so the antibiotic can be initiated as soon as possible. Administering the antibiotic before obtaining blood cultures could mask the infection, delaying appropriate treatment. Taking the client to x-ray before obtaining the blood cultures would delay antibiotic initiation.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse should assess for which complications? Select all that apply. A. Infection B. Hyperglycemia C. ABO incompatibility D. Electrolyte imbalance E. Cardiac dysrhythmias

A. Infection B. Hyperglycemia D. Electrolyte imbalance The concentration of glucose in the solution is an excellent culture medium that promotes the growth of microorganisms. Hyperglycemia is a common complication with TPN because of the high-glucose formulas used; blood glucose levels need to be monitored carefully during therapy. TPN formulas may need to be adjusted daily based on the client's daily electrolyte levels. ABO incompatibility is not associated with TPN. Cardiac dysrhythmias are not related to TPN.

A healthcare provider prescribes two units of blood for a client who is bleeding. Which nursing interventions are necessary before the blood transfusion is administered? Select all that apply. A. Obtain the client's vital signs. B. Monitor hemoglobin and hematocrit levels. C. Allow the blood to reach room temperature. D. Determine typing and cross-matching of blood. E. Use a Y-type infusion set to initiate 0.9% normal saline

A. Obtain the client's vital signs. D. Determine typing and cross-matching of blood. E. Use a Y-type infusion set to initiate 0.9% normal saline Obtaining the client's vital signs provides a baseline and should be done before the transfusion is initiated. Prior to beginning the transfusion, the nurse and another hospital-approved personnel should double-check client identification and blood product identification (blood unit number, blood type and crossmatch data like Rh factor along with expiration date) with another licensed nurse. Using a Y-type infusion set with 0.9% saline on one side of the Y is necessary to prevent an acute immunologic reaction if the donated blood is not compatible with the client's blood. A Y-type infusion set is specific for blood administration. It has a special blood filter, the drop factor is different, and it allows for quick shutoff and the administration of normal saline in the event of a transfusion reaction.

A nurse is caring for a client who is receiving total parenteral nutrition. Which responses indicate that the client is experiencing hyperglycemia? Select all that apply. A. Polyuria B. Polydipsia C. Paralytic ileus D. Respiratory rate of 24 breaths/min E. Serum glucose of 105 mg/dL (5.8 mmol/L

A. Polyuria B. Polydipsia D. Respiratory rate of 24 breaths/min

The nurse is caring for a client who has undergone a total hip replacement. The nurse recognizes which clinical manifestations that indicate a pulmonary embolism? Select all that apply. A. Sudden chest pain B. Flushing of the face C. Elevation of temperature D. Abrupt onset of shortness of breath E. Pain rating increase from 2 to 8 in the hip

A. Sudden chest pain D. Abrupt onset of shortness of breath Sudden chest pain is caused by decreased oxygenation to pulmonary tissues. Because capillary perfusion is blocked by the pulmonary embolus, oxygen saturation drops and the client experiences shortness of breath, dyspnea, and tachypnea. Flushing of the face and fever are not classic signs of pulmonary embolus. The pain associated with pulmonary embolus generally is sudden in onset, severe, and located in the chest, not the hip.

What points should be considered when a client with a respiratory disorder undergoes a spiral-computed tomography (CT) scan to diagnose a pulmonary embolism? Select all that apply. A. The test involves the administration of a contrast medium. B. Clients should have their hydration levels assessed. C. Clients are instructed to lie still on a hard table. D. Clients are served shellfish before the test. E. A client's serum creatinine level is evaluated after the test.

A. The test involves the administration of a contrast medium. B. Clients should have their hydration levels assessed. C. Clients are instructed to lie still on a hard table. A contrast medium may be given intravenously when performing a spiral-computed tomography (CT). The nurse should make sure that the client is well hydrated before and after the procedure to help flush out the contrast medium. The nurse should instruct the client to lie still on the hard table and that the scanner will revolve around the body with clicking noises. The nurse should assess if the client is allergic to shellfish because the contrast medium used is iodine-based. The nurse should evaluate the client's blood urea nitrogen and serum creatinine before the test to assess renal function.

A client is receiving total parenteral nutrition (TPN) through a central venous access device. The nurse discovers that the TPN bag is empty and the next bag has not been received yet from the pharmacy. What is the most appropriate action for the nurse to take? A. Perform a finger stick glucose test and call the primary healthcare provider with the results. B. Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag. C. Discontinue the infusion and flush the IV line with saline solution until the next TPN bag is ready. D. Hang a bag of 5% dextrose at a keep-open rate and notify the nurse manager of the occurrence.

B. Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag. Clients receiving TPN require monitoring of blood glucose because the TPN solution contains a high concentration of dextrose. In response to the high-dextrose TPN solution, the pancreas increases production of insulin to meet the glucose demands. In this situation, the current TPN infusion is completed, and the nurse should infuse 10% dextrose to compensate for the loss while the next TPN bag is being prepared. If this action is not taken, the client could experience a profound hypoglycemic reaction.

After a deep vein thrombosis developed in a postpartum client, an intravenous (IV) infusion of heparin therapy was instituted 2 days ago. The client's activated partial thromboplastin time (aPTT) is now 98 seconds. What should the nurse do next? A. Increase the IV rate of heparin. B. Interrupt the infusion and notify the primary healthcare provider of the aPTT result. C. Document the result on the medical record and recheck the aPTT in 4 hours. D. Call the primary healthcare provider to obtain a prescription for a low-molecular-weight heparin

B. Interrupt the infusion and notify the primary healthcare provider of the aPTT result. The heparin should be withheld, because 98 seconds is almost three times the normal time it takes a fibrin clot to form (25 to 36 seconds), and prolonged bleeding may result; the therapeutic range for heparin is one-and-a-half to two times the normal range. The primary healthcare provider should be notified. The dosage of heparin must not be increased, because the client already has received too much. Documenting the result on the medical record and rechecking the aPTT in 4 hours is an unsafe option. Continuing the infusion could result in hemorrhage. The medication does not have to be changed; it should be stopped temporarily until the aPTT is within the therapeutic range.

A client is receiving fresh frozen plasma (FFP). The nurse would expect to see improvement in which condition? A. Thrombocytopenia B. Oxygen deficiency C. Clotting factor deficiency D. Low hemoglobin

C. Clotting factor deficiency FFP is an unconcentrated form of blood plasma containing all of the clotting factors except platelets. It can be used to supplement red blood cells (RBCs) when other blood products are not available or to correct a bleeding problem of unknown cause. Thrombocytopenia is a condition of low platelet count and is not treated with FFP. An oxygen deficiency and low hemoglobin may be improved indirectly with FFP, but it is not a definitive treatment.

While receiving a blood transfusion, a client develops flank pain, chills, and fever. What type of transfusion reaction does the nurse conclude that the client probably is experiencing? A. Allergic B. Pyrogenic C. Hemolytic D. Anaphylactic

C. Hemolytic A hemolytic transfusion reaction results from a recipient's antibodies that are incompatible with transfused red blood cells; it is called a type II hypersensitivity. The clinical findings are a result of red blood cell hemolysis, agglutination, and capillary plugging. An allergic transfusion reaction is the result of an immune sensitivity to foreign serum protein; it is called a type I hypersensitivity, and associated clinical findings include urticaria, wheezing, dyspnea, and shock. Bacterial pyrogens are present in contaminated blood and can cause a febrile transfusion reaction; associated clinical findings include fever and chills, but not flank pain. An anaphylactic reaction may occur with an allergic transfusion reaction.

Warfarin is prescribed for a client who has been receiving intravenous (IV) heparin for a partial occlusion of the left common carotid artery. The client expresses concern about why both drugs are needed at the same time. What rationale does the nurse include to address the client's concern? A. This permits the administration of smaller doses of each medication. B. Giving both drugs allows clot dissolution while preventing new clot formation. C. Heparin provides anticoagulant effects until warfarin reaches therapeutic levels. D. Administration of heparin with warfarin provides immediate and maximum protection against clot formation.

C. Heparin provides anticoagulant effects until warfarin reaches therapeutic levels. Warfarin is administered orally for 2 to 3 days to achieve the desired effect on the international normalized ratio (INR) level before heparin is discontinued. These drugs do not dissolve clots already present. Because each drug affects a different part of the coagulation mechanism, dosages must be adjusted separately. That this approach immediately provides maximum protection against clot formation does not account for the reason for the administration of both drugs; warfarin will not exert an immediate therapeutic effect.

A client with a history of pulmonary emboli is taking warfarin daily. The nurse teaches the client about foods that are appropriate to consume when taking this medication. The nurse evaluates that the client needs further teaching when the client makes which statement? A. "Eggs provide a good source of iron, which is needed to prevent anemia." B. "Yellow vegetables are high in vitamin A and should be included in the diet." C. "Fish and shrimp are iodine-rich food sources that can prevent hypothyroidism." D. "Dark green leafy vegetables are high in vitamin K so I should eat them more often."

D. "Dark green leafy vegetables are high in vitamin K so I should eat them more often." Foods high in vitamin K should be limited to the usual amounts eaten by the client when establishing the prothrombin time/international normalized ratio (PT/INR) because vitamin K is part of the body's blood-clotting mechanism and will counter the effects of warfarin if eaten in excess. Foods containing protein, iron, vitamin A, and iodine are permitted because they are unrelated to blood clotting.

A nurse is caring for a client who is a victim of trauma and is to receive a blood transfusion. How should the nurse respond when the client expresses fear that acquired immunodeficiency syndrome (AIDS) may be acquired as a result of the blood transfusion? A. "The blood is treated with radiation to kill the virus." B. "The ability to directly identify HIV has eliminated this concern." C. "Consideration should be given to donating your own blood for transfusion." D. "Screening for the human immunodeficiency virus (HIV) antibodies has minimized this risk."

D. "Screening for the human immunodeficiency virus (HIV) antibodies has minimized this risk." Although blood is screened for the antibodies, there is a period between the time a potential donor is infected and the time when antibodies are detectable; there is still a risk, but it is minimal.

A nurse is assessing several clients. Which client will require parenteral nutrition? A. A client with brain neoplasm B. A client with anorexia nervosa C. A client with inflammatory bowel disease D. A client with severe malabsorption disorder

D. A client with severe malabsorption disorder A client with severe malabsorption disorder requires parenteral nutrition. Clients with a brain neoplasm, anorexia nervosa, or inflammatory bowel disease will require enteral nutrition.

A client receiving a blood transfusion that was just initiated reports urticaria and difficulty breathing. The heart rate has increased, the blood pressure is falling, and the client is becoming extremely apprehensive. Which type of shock does the nurse suspect the client is experiencing? A. Septic shock B. Cardiogenic shock C. Neurogenic shock D. Anaphylactic shock

D. Anaphylactic shock Anaphylactic shock occurs when the body has a hypersensitivity to an antigen. This may lead to death quickly. Common causes are blood products, insect stings, antibiotics, and shellfish. Septic shock is caused by a systemic infection and release of endotoxins. Cardiogenic shock is when the heart fails to pump and demonstrates symptoms of heart failure, such as pulmonary edema. Neurogenic shock is caused by problems with the nervous system and usually occurs because of damage of the spinal cord.

A nurse is assigned to change a central line dressing. The agency policy is to clean the site with povidone-iodine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede povidone-iodine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and povidone-iodine. The nurse has a sample of the new product. How should the nurse proceed? A. Use the new product sample when changing the dressing. B. Cleanse the site with alcohol first and then with povidone-iodine. C. Cleanse the site with the new product first and then follow the agency's protocol. D. Follow the agency's policy unless it is contradicted by a primary healthcare provider's prescription.

D. Follow the agency's policy unless it is contradicted by a primary healthcare provider's prescription. Agency policy determines procedures; if the procedure is out of date or problematic, the nurse should contact the primary healthcare provider for a change in the prescription. The nurse cannot use another product without a primary healthcare provider's prescription. The nurse will be risking liability if agency policy is not followed unless the prescription is changed by the primary healthcare provider.

A client had a total knee replacement several days ago and has been receiving warfarin sodium therapy. An international normalized ratio (INR) is performed each afternoon, and the evening warfarin sodium dose is prescribed by the healthcare provider on a daily basis. The nurse identifies that the afternoon INR is 4.6. Which is the next action the nurse should take? A. Assist with meal planning to decrease the intake of foods high in vitamin K B. Obtain a blood specimen to have a partial thromboplastin time performed C. Contact the healthcare provider to request the day's dosage of warfarin sodium D. Maintain the client on bed rest until the healthcare provider reviews the laboratory results

D. Maintain the client on bed rest until the healthcare provider reviews the laboratory results An INR of 4.6 is higher than the desired therapeutic level of 2 to 3.5. It is prudent to maintain bed rest to prevent injury until the healthcare provider evaluates the client's INR result. Decreasing the intake of food high in vitamin K is contraindicated; vitamin K is the antidote for warfarin sodium. The client should have a consistent, limited intake of food high in vitamin K. A partial thromboplastin time is performed to evaluate a client's response to the administration of heparin. Another dose of warfarin sodium may be contraindicated in light of the client's increased INR result.

A client with cellulitis of the leg asks why bed rest has been prescribed to prevent sepsis. Which purpose will the nurse explain to the client? A. This decreases catabolism to promote healing at the site of injury. B. This lowers the metabolic rate in an attempt to help reduce the fever. C. This reduces the energy demands on the body in the presence of infection. D. This limits muscle contractions that may force causative organisms into the bloodstream.

D. This limits muscle contractions that may force causative organisms into the bloodstream. Exercise will promote extension of the local infection from the leg into the circulation, causing septicemia (sepsis). Although bed rest does decrease catabolism to promote healing at the site of injury, it is not the purpose for bed rest in this situation. Although bed rest does reduce the energy demands on the body in the presence of infection and lowers metabolic rate, it is not the purpose for bed rest in this situation.