medications and IV lines Nclex review

A client receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On data collection, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which has occurred?

Infiltration

The nurse checks the peripheral intravenous (IV) site dressing and notes that it is damp and that the tape is loose. Which is the first action by the nurse?

Check that the tubing is securely attached.

Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 24 hours to increase urine output and maintain the client's blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previously known data?

Crackles in the lungs

The nurse is caring for a client who had a small bowel resection the previous day and has continuous gastric suction attached to the nasogastric tube. Which intravenous solution should the nurse anticipate to be prescribed for the client?

Lactated Ringer's solution

The nurse is assisting in caring for a client who is receiving morphine sulfate by continuous intravenous infusion. The nurse ensures that which medication is readily available if a morphine overdose occurs?

Nalmefene

A client with a peripheral intravenous (IV) site calls the nurse to the room and tells the nurse, "The IV is not running right." Which findings would indicate an infiltrated IV? Select all that apply.

1.Cool to touch 4.Swelling at the site 5.May not have a blood return

The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item?

Sterile 2 × 2 gauze

A nursing student is assisting the clinic nurse with the administration of immunizations in the well-baby clinic. The student is asked to administer a measles, mumps, and rubella (MMR) vaccine to a child and prepares to administer the vaccine in which way?

Subcutaneously in the upper arm

The nurse has a prescription to give ear drops to a 2-year-old child. To administer the drops, the nurse should pull the pinna of the ear in which direction?

Downward and backward

A client uses the call system to notify the nurse to say that "the IV hurts and my left hand is swollen." The nurse assesses the site and determines infiltration has occurred. In order of priority, which actions should the nurse take? Arrange the actions in the order they should be performed. All options must be used.

1 Stop the infusion 2 Remove the intravenous catheter 3 Apply a compress to the site. 4 Notify the registered nurse to start a new IV on the right extremity.

The nurse is preparing a continuous intravenous (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 medication cart. Which is the appropriate action by the nurse?

Change the IV tubing.

The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. The nurse planning the work assignment for the shift makes a notation to check the IV sites of these clients at which time interval?

Every hour

Skin breakdown occurs on a client's hand at the site of an intravenous catheter that had medication infusing. The nurse determines that which adverse effect occurred? Refer to figure.

Extravasation

The nurse administering medications to a client notes a prescription to give a subcutaneous dose of heparin sodium. The nurse should perform which action to give this medication safely?

Give the injection using a 25- to 27-gauge, ½-inch needle.

The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred?

Infiltration

A client is scheduled for insertion of a peripherally inserted central catheter (PICC), and the nurse explains the advantages of this catheter. Which statement by the client indicates a lack of understanding about this type of catheter?

It is specifically designed for short-term use.

A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The licensed practical nurse (LPN) inspects the site and determines that the client has developed phlebitis. The LPN should plan to avoid which action in the care of this client?

Prepare to start a new line in a proximal portion of the same vein.

An adult client is admitted to the emergency department with acute extensive partial thickness burns to the lower extremities. The nurse anticipates the primary health care provider will initially prescribe which medications and route for pain control? Select all that apply.

3.Hydromorphone intravenously 4.Morphine sulfate intravenously

The nurse is checking the date of an intravenous (IV) insertion in a client. The insertion date on the dressing is 2/9 (February 9). The nurse calculates that the site should be changed on which date?

2/12

A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed for this client?

5% dextrose in lactated Ringer's solution

The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which?

Phlebitis of the vein

The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. Which is the most appropriate action?

Remove the IV.

The nurse is caring for a client with liver disease. Laboratory studies are performed, and the client's serum calcium level is 13 mg/dL. The nurse checks to see that which medication is available in the stock medication supply area on the clinical nursing unit that may be needed to treat this calcium imbalance?

Calcitonin

The critical care nurse is caring for a client with a subclavian central line catheter. The nurse knows that a specific central-line bundle was developed to reduce the client's risk for developing a catheter-related bloodstream infection (CLABSI). The interventions include which essential actions? Select all that apply.

1.Strict hand washing 4.Optimal catheter site selection 5.Strict sterile technique with maximal barrier precautions during placement

A client who is receiving antineoplastic medication by the intravenous (IV) route complains of pain at the insertion site of the IV. The nurse inspects the site and finds the area is swollen and reddened. The nurse further observes that the solution is no longer infusing. The nurse immediately takes which priority nursing action?

Notifies the registered nurse (RN)

A client rings the call light and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? Select all that apply.

1.Remove the IV catheter at that site. 2.Apply warm moist packs to the site. 3.Notify the primary health care provider (PHCP). 5.Document the occurrence, actions taken, and the client's response.

The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. Based on these findings, the nurse plans to take which initial nursing action?

Remove the IV.