MEDSURG II: Medications and IV therapy

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 health care provider (HCP). 4. Start a new IV line in a proximal portion of the same vein. 5.Document the occurrence, actions taken, and the client's response.

Answer: 1,2,3,5 Rationale: Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection and can cause the development of a clot (thrombophlebitis). The nurse should remove 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 HCP about the IV complication. The nurse should restart the IV in a vein other than the one that has developed phlebitis. Finally, the nurse documents the occurrence, actions taken, and the client's response.

The nurse is performing discharge teaching for a client with a peripherally inserted central catheter (PICC). Which instructions should the nurse include? Select all that apply. 1. Wear a MedicAlert tag or bracelet. 2. Report redness or swelling at the catheter insertion site. 3. Have a repair kit available in the home for use if needed. 4. Keep activity level to a minimum while this catheter is in place. 5.Cover the PICC dressing with plastic when in the shower or bath.

Answer: 1,2,3,5 Rationale: The client should be taught that there are only minor activity restrictions with this catheter. The client should protect the site during bathing and should carry MedicAlert identification. The client should have a repair kit in the home for PRN use, because it is a long-term catheter. Redness or swelling at the catheter insertion site needs to be reported because this could indicate a sign of infection.

A client sustained a burn injury at 7:00 a.m. The client's spouse states that before the burn, the client's body weight was 198 lbs. The health care provider has estimated that the total body surface area (BSA) burned is 83%. Using the Parkland (Baxter) formula (4 mL × kilograms of body mass × percent total BSA), the nurse determines that the total amount of intravenous lactated Ringer's solution that the client will receive by 3 p.m. of the same day on which the burn occurred is which value? Fill in the blank.

Answer: 19,940 mL Rationale: The Parkland (Baxter) formula for estimating fluid requirements is 4 mL × kilograms of body mass × percent total BSA. Half of this total is administered in the first 8 hours after the burn. First, convert pounds to kilograms by dividing 198 lbs by 2.2, which equals 90. Therefore, 4 × 90 × 83 = 29,880 mL, divided by 2 = 14,940 mL.

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? 1. Excessive bleeding 2. Crackles in the lungs 3. Incompatibility of the infusion 4.Chest pain radiating to the left arm

Answer: 2 Rationale: Circulatory (fluid) overload is a complication of IV therapy. Signs include rapid breathing, dyspnea, a moist cough, and crackles. Blood pressure and heart rate also increase if circulatory overload is present. Therefore, since the nurse previously noted rapid breathing and coughing, the nurse should then assess for a moist cough and crackles. Hematoma is another potential complication and is characterized by ecchymosis, swelling, and leakage at the IV insertion site, as well as hard and painful lumps at the site. Allergic reaction is a complication of administration of IV fluids or medication and is characterized by chills, fever, malaise, headache, nausea, vomiting, backache, and tachycardia; this type of reaction could also occur if the IV solutions infused are incompatible; however, there was no indication of multiple solutions being infused simultaneously in this question. Chest pain radiating to the left arm is a classic sign of cardiac compromise and is not specifically related to a complication of IV therapy.

A client with rapid-rate atrial fibrillation has a new prescription for diltiazem hydrochloride by intravenous (IV) bolus followed by a continuous IV infusion of the same medication. What should the nurse plan for with the administration of this medication? 1. Applying a nonrebreather mask 2. Discontinuing the infusion after 24 hours 3. Monitoring the cardiac rhythm every hour 4.Administering the IV bolus over 2 to 3 seconds

Answer: 2 Rationale: Diltiazem hydrochloride is a calcium channel blocker used in the treatment of atrial flutter and fibrillation. It decreases myocardial contractility and workload, thereby decreasing the need for oxygen. A bolus of 0.25 mg/kg is given slowly over 2 minutes, and a continuous infusion of 5 to 10 mg/hour may be administered for up to 24 hours. Therefore, the nurse should prepare to discontinue the infusion after 24 hours. Upon discontinuation of infusion, heart rate reduction may last from 0.5 hours to more than 10 hours (median duration 7 hours). A nonrebreather mask is not necessary. The client's cardiac rhythm is monitored continuously.

The emergency department nurse is preparing to administer fomepizole to a client suspected of having ethylene glycol (antifreeze) intoxication. The nurse obtains the vial of medication and notes that the medication has solidified. Which action should the nurse take? 1. Discard the vial. 2. Run the vial under warm water. 3. Contact the health care provider. 4.Call the pharmacy and request another vial of medication.

Answer: 2 Rationale: Fomepizole is used in the treatment of known or suspected ethylene glycol (antifreeze) intoxication. It is administered via the intravenous (IV) route. It is diluted in at least 100 mL of 0.9% normal saline or 5% dextrose in water and administered over a 30-minute period. If the medication solidifies in the vial, the nurse should run the vial under warm water. The remaining options are inappropriate or unnecessary actions.

A client has a closed head injury with increased intracranial pressure (ICP). The increased ICP is being managed by mannitol 25 g by the intravenous (IV) route every 2 hours. The nurse is planning to administer this medication via IV pump in what manner? 1. Mixed in solution with the IV antibiotics 2. Giving it slowly over 30 to 90 minutes 3. Piggybacked into the packed red blood cells 4.Giving it rapidly over 5 minutes by IV bolus

Answer: 2 Rationale: Mannitol is an osmotic diuretic. When used to treat increased ICP, it is given slowly over 30 to 90 minutes, not rapidly and not via IV bolus. Mannitol should not be mixed in solution with antibiotics, and nothing should be piggybacked with packed red blood cells.

The nurse is assessing a client's peripheral intravenous (IV) site after completion of a vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best? 1. Check for the presence of blood return. 2. Remove the IV site and restart at another site. 3. Document the findings and continue to monitor the IV site. 4. Call the health care provider (HCP) and request that the vancomycin be given orally.

Answer: 2 Rationale: Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and swelling proximal to the catheter. If phlebitis occurs, the nurse should remove the IV line and insert a new IV line at a different site, in a vein other than the one that has developed phlebitis. Checking for the presence of blood return should be done before the administration of vancomycin because this medication is a vesicant. Documenting the findings and continuing to monitor the IV site and calling the HCP and requesting that the vancomycin be given orally do not address the immediate problem. Additionally, there could be indications for the prescription of IV as opposed to oral vancomycin for the client. The HCP should be notified of the complications with the IV site, but not asked for a prescription for oral vancomycin.

A client admitted with hypertensive crisis has an intravenous (IV) infusion of 1000 mL of normal saline with 20 mEq of potassium chloride added. A prescription is written to administer sodium nitroprusside by continuous IV infusion. The nurse should plan to do which to administer this medication? 1. Monitor the blood pressure every 15 minutes during administration. 2. Protect the sodium nitroprusside from light with an opaque material. 3. Check the solution for a faint brown coloration and discard it if this is noticed. 4. Piggyback the sodium nitroprusside into the IV line containing the potassium chloride.

Answer: 2 Rationale: Sodium nitroprusside can be degraded by light and should be protected with an opaque material. It is dispensed in powdered form and must be dissolved and diluted for the IV solution. A fresh solution may have a faint brown coloration, but solutions that are deeply colored, such as blue-green or dark red, should be discarded. No other medication should be mixed with the infusion solution. During the infusion, the blood pressure should be monitored continuously either through an arterial line or with an electronic monitoring device.

The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement? 1. "I need to wear a MedicAlert tag or bracelet." 2. "I need to restrict my activity while this catheter is in place." 3. "I need to keep the insertion site protected when in the shower or bath." 4. "I need to check the markings on the catheter each time the dressing is changed."

Answer: 2 Rationale: The client should be taught that only minor activity restrictions apply with this type of catheter. The client should carry or wear a MedicAlert identification and should protect the site during bathing to prevent infection. The client should check the markings on the catheter during each dressing change to assess for catheter migration or dislodgement.

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action? 1. Obtain a new IV bag. 2. Obtain new IV tubing. 3. Wipe the spike end of the tubing with povidone iodine. 4. Scrub the spike end of the tubing with an alcohol swab.

Answer: 2 Rationale: The nurse should obtain new IV tubing because contamination has occurred and could cause systemic infection to the client. There is no need to obtain a new IV bag because the bag was not contaminated. Wiping with povidone iodine or alcohol is insufficient and is contraindicated because the spike will be inserted into the IV bag.

The nurse has a new prescription to administer verapamil by the intravenous (IV) route. In administering this medication, the most important nursing action should be to use what item to monitor the client's response to the medication? 1. A pulse oximeter 2. A cardiac monitor 3. Supplemental oxygen 4.A noninvasive blood pressure monitor

Answer: 2 Rationale: Verapamil is a calcium channel blocker that may be used to treat rapid-rate supraventricular tachydysrhythmias such as atrial flutter or atrial fibrillation. A cardiac monitor is used to determine the client's response to the medication. A pulse oximeter and oxygen are related to respiratory care and may be other useful adjuncts to care, but they are not directly related to the use of this medication. A noninvasive blood pressure monitor also is helpful but is not as essential or critical as the cardiac monitor.

The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride. The nurse also needs to hang an IV infusion of piperacillin/tazobactam. The client has one IV site. The nurse should plan to take which action first? 1. Start a second IV site. 2. Check compatibility of the medication and IV fluids. 3. Mix the prepackaged piperacillin/tazobactam per agency policy. 4. Prime the tubing with the IV solution, and back-prime the medication.

Answer: 2 Rationale: When hanging an IV antibiotic, the nurse should first check compatibility of the medication and the IV fluids currently prescribed. If the fluids and medication are incompatible, it would then be appropriate to start a second IV site. If they are compatible, the nurse should hang them together so as to avoid having to start another IV site. After this, the nurse should prepare the prepackaged piperacillin/tazobactam per agency policy, then prime the tubing with the IV solution, and then back-prime the medication. Back-priming prevents any medication from being lost during the priming process.

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? Select all that apply. 1. Pain and erythema 2. Pallor and coolness 3. Numbness and pain 4. Edema and blanched skin 5. Formation of a red streak and purulent drainage

Answer: 2,3,4 Rationale: An infiltrated intravenous (IV) line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, edema, pain, numbness, and blanched skin are the results of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop, and if an electronic pump is being used, it will alarm. Erythema can be associated with infection, phlebitis, or thrombosis. Formation of a red streak and purulent drainage is associated with phlebitis and infection.

A client develops atrial fibrillation with a ventricular rate of 140 beats/minute and signs of decreased cardiac output. Which medication should the nurse anticipate administering first? 1. Warfarin 2. Lidocaine 3. Metoprolol 4.Atropine sulfate

Answer: 3 Rationale: Beta blockers such as metoprolol slow conduction of impulses through the atrioventricular node and decrease the heart rate. In rapid atrial fibrillation, the goal first is to slow the ventricular rate and improve the cardiac output and then attempt to restore normal sinus rhythm. Atropine sulfate will further increase the heart rate and will further decrease the cardiac output. Although warfarin is administered to clients with atrial fibrillation to prevent clots from forming in the atria, it will have no effect in decreasing the ventricular rate or restoring normal sinus rhythm. Lidocaine is useful only in suppressing ventricular dysrhythmias.

A client who is receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On assessment, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which complication has occurred? 1. Infection 2. Phlebitis 3. Infiltration 4.Thrombosis

Answer: 3 Rationale: An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling at the IV site result when IV fluid is deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of IV solution will slow down or stop. The corrective action is to remove the catheter and start a new IV line at another site. The conditions identified in the remaining options are likely to be accompanied by warmth at the site, not coolness.

A client has just undergone insertion of a central venous catheter at the bedside. The nurse would be sure to check which results before initiating the flow rate of the client's intravenous (IV) solution at 100 mL/hour? 1. Serum osmolality 2. Serum electrolyte levels 3. Portable chest x-ray film 4. Intake and output record

Answer: 3 Rationale: Before beginning administration of IV solution, the nurse should assess whether the chest radiograph reveals that the central catheter 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, but they do not relate to this procedure.

The nurse is preparing to infuse (piggyback) a 50-mL dose of a compatible medication through the primary intravenous (IV) line. How should the nurse correctly attach the medication bag? 1. Hanging the medication bag level with the primary IV bag 2. Hanging the medication bag lower than the primary IV bag 3. Hanging the medication bag higher than the primary IV bag 4.Disconnecting the primary IV solution and plugging in the medication

Answer: 3 Rationale: For an intermittent IV infusion that is piggybacked to the primary IV line, the bag for the intermittent infusion is placed higher than the primary solution bag. This allows gravity to assist in infusing the medication. Once the intermittent infusion is complete, the primary IV infusion will resume at the drip rate set for the intermittent infusion. For this reason, it also is important to remember to check the infusion frequently and reset the primary IV drip rate correctly once the intermittent infusion is complete.

Vasopressin is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse should prepare to administer this medication by which route? 1. Orally 2. By inhalation 3. By intravenous infusion 4.Through a Sengstaken-Blakemore tube

Answer: 3 Rationale: If bleeding occurs, the health team intervenes quickly to control it by combining vasoactive medications with endoscopic therapies. Vasoactive medications reduce portal pressure. Vasopressin is a synthetic antidiuretic hormone. Administration of this hormone reduces bleeding. It acts directly on gastrointestinal smooth muscle as a vasoconstrictor. To take advantage of these effects, it should be administered via continuous intravenous infusion. It can also be administered via the subcutaneous route. Therefore, the remaining options are incorrect.

A client is admitted to the hospital with a diagnosis of myocardial infarction (MI) and is going to have an intravenous (IV) nitroglycerin infusion started. Noting that the client does not have an intra-arterial monitoring line in place, what piece of equipment should the nurse obtain for use at the bedside? 1. Defibrillator 2. Pulse oximeter 3. Noninvasive blood pressure monitor 4.Central venous pressure (CVP) insertion tray

Answer: 3 Rationale: Nitroglycerin dilates both arteries and veins, causing peripheral blood pooling, thereby reducing preload, afterload, and myocardial work. This also accounts for the primary side effect of nitroglycerin, which is hypotension. In the absence of continuous direct arterial pressure (intra-arterial) monitoring, the nurse should use an automatic noninvasive blood pressure monitor. The remaining options are not specifically associated with the administration of IV nitroglycerin.

A client is scheduled for insertion of a peripherally inserted central catheter, and the nurse explains the advantages of this catheter. Which statement by the client indicates a need for follow-up? 1. "It is reasonable in cost." 2. "This type of catheter is very reliable." 3. "It is specifically designed for short-term use." 4."I should not have pain or discomfort with this catheter."

Answer: 3 Rationale: Peripherally inserted central catheters are intended to be used for clients who need long-term catheter placement. They can be left in place for several months. It is reasonable in cost because the catheter does not need routine replacement, as do traditional peripheral intravenous catheters. The catheter is more comfortable for the client because there is no repeated venipuncture with catheter change. The catheter is also very reliable. It is less likely to infiltrate and can be used for administration of a number of types of medications.

The nurse plans to administer a medication by intravenous (IV) bolus through the primary IV line. The nurse notes that the medication is incompatible with the primary IV solution. Which is the appropriate nursing action to safely administer the medication? 1.Start a new IV line for the medication. 2.Flush the tubing after the medication with sterile water. 3.Flush the tubing before and after the medication with normal saline. 4.Call the health care provider for a prescription to change the route of the medication. {ask about Phenytoin IV}

Answer: 3 Rationale: When giving a medication by IV bolus, if the medication is incompatible with the IV solution, the tubing is flushed before and after the medication with infusions of normal saline. Option 1 is premature and not necessary. Sterile water is not used for an IV flush. Option 4 is inappropriate.

The nurse is obtaining blood from a client's double-lumen central venous catheter for blood cultures. Which actions are correct for performing this procedure? Select all that apply. 1. Use the distal port of the catheter for obtaining the blood specimen. 2. Flush with 5 to 10 mL of normal saline before obtaining the specimen. 3. Turn the infusion off for at least 1 minute before obtaining the specimen. 4. Use the initial specimen of blood obtained from the catheter for the blood cultures. 5. Discard the first syringe of blood and use the second syringe for the blood cultures.

Answer: 3,4 Rationale: When drawing blood from a double-lumen central venous catheter, the proximal port is used because it is usually the port with the largest lumen. For blood cultures, the initial specimen is used for the sample, and the line is not flushed beforehand. Turning off the infusion for 1 minute prevents contaminating the sample with intravenous solution.

A client is scheduled for placement of a peripherally inserted central catheter (PICC). The nurse has explained the advantages of this catheter to the client. Which statement made by the client indicates a need for further explanation? 1. "It is reasonable in cost." 2. "There is less pain and discomfort." 3. "This type of catheter is very reliable." 4."It is specifically designed for short-term use."

Answer: 4 Rationale: A PICC is a central line that is inserted in the upper arm. It is a flexible catheter that terminates in the superior vena cava of the heart. Placement is verified by x-ray or other methods prior to use. PICCs are intended to be used for clients needing long-term intravenous catheter placement. They are reasonable in cost because they do not need routine replacement, as do traditional peripheral intravenous catheters. The catheter also is reliable. The catheter is less likely to result in infiltration and can be used for administration of a number of different types of medications without extravasation.

A health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter? 1. Elastic wrap 2. Povidone iodine swab 3. Adhesive bandage 4.Sterile 2 × 2 gauze

Answer: 4 Rationale: A dry sterile dressing such as a sterile 2 × 2 gauze is used to apply pressure to the discontinued IV site. This material is absorbent, sterile, and nonirritating. A povidone iodine swab would irritate the opened puncture site and would not stop the blood flow. An adhesive bandage or elastic wrap may be used to cover the site once hemostasis has occurred.

The nurse is making a note in the care plan for a client who has a multilumen central venous catheter. The nurse should write to change the injection caps on the lumens at which times? 1. Once a week 2. At the change of each shift 3. After administration of each medication 4.Whenever blood is drawn from the lumen

Answer: 4 Rationale: Changing the injection caps is done to reduce systemic infection, which can be caused by contaminated caps. The injection cap should be discarded and a new one applied once it has been removed from the actual lumen. It is removed whenever blood work is drawn from the lumen. Once a week is too infrequent. At the change of shift is too frequent. It is not necessary to change the injection caps after administration of each medication because it is unnecessary to remove the cap to administer medication. In addition, agencies have policies that guide the frequency of routine injection cap changes (often every 48 hours). Agency policies should always be followed.

A client with the recent diagnosis of myocardial infarction and impaired renal function is recuperating on the cardiac step-down unit. The client's blood pressure has been borderline low, and intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular vein for approximately 24 hours to increase renal output and maintain the blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that the client is most likely experiencing which complication of IV therapy? 1. Hematoma 2. Air embolism 3. Systemic infection 4.Circulatory overload

Answer: 4 Rationale: Circulatory (fluid) overload is a complication of IV therapy. Signs include rapid breathing, dyspnea, a moist cough, and crackles. When circulatory overload is present, the client's blood pressure also increases. Hematoma is characterized by ecchymosis, swelling, and leakage at the IV insertion site, as well as hard and painful lumps at the site. Air embolism is characterized by tachycardia, dyspnea, hypotension, cyanosis, and decreased level of consciousness. Systemic infection is characterized by chills, fever, malaise, headache, nausea, vomiting, backache, and tachycardia.

A client has frequent runs of ventricular tachycardia. The health care provider has prescribed flecainide. What is the best nursing action related to the effects of this medication while the client is hospitalized? 1. Monitor the client's urinary output. 2. Assess the client for neurological changes. 3. Keep the call bell within the client's reach. 4.Monitor vital signs and cardiac rhythm frequently.

Answer: 4 Rationale: Flecainide is an antidysrhythmic medication that slows conduction and decreases excitability, conduction velocity, and automaticity. The nurse needs to monitor the client's vital signs for changes and cardiac rhythm for the development of a new or a worsening dysrhythmia. The remaining options are components of standard care.

The emergency department nurse is preparing to administer fomepizole to a client suspected of ingesting antifreeze solution during a suicidal attempt. The nurse should prepare to administer this medication by which method? 1. Direct intravenous (IV) bolus 2. Diluting the medication and administering it rapidly by the IV route 3. Administering the medication through a nasogastric tube, followed by activated charcoal 4. Diluting the medication in 100 mL of 0.9% normal saline and administering it over 30 minutes

Answer: 4 Rationale: Fomepizole is used for the treatment of known or suspected ethylene glycol (antifreeze) intoxication. It is administered via the IV route, is not administered undiluted, and is not administered by rapid IV infusion. It is diluted in at least 100 mL of 0.9% normal saline or 5% dextrose in water and administered over a 30-minute period.

A client being admitted to the coronary care unit from the emergency department has a stat prescription to receive a dose of intravenous procainamide followed by a continuous infusion. Based on this prescription, the nurse should assess for which condition? 1. Dyspnea 2. Bradycardia 3. Hypertension 4. Ventricular ectopy

Answer: 4 Rationale: Procainamide is an antidysrhythmic medication used to treat ventricular dysrhythmias unresponsive to lidocaine. The other options are not indications for giving this medication.

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first? 1. Slow the IV infusion. 2. Sit the client up in bed. 3. Remove the IV catheter. 4. Call the health care provider (HCP).

Answer: 1 Rationale: The client's symptoms are compatible with circulatory overload. This may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may follow in rapid sequence. The nurse may elevate the head of the bed to aid the client's breathing, if necessary. The nurse also notifies the HCP. The IV catheter is not removed; it may be needed for the administration of medications to resolve the complication.

A client with heart failure and hypotension has been started on intravenous medication therapy with inamrinone. The nurse determines which finding, if noted in the client, is an adverse effect of the medication? 1. Decreased weight 2. Decreased blood pressure 3. Absence of lung crackles 4.Reduced peripheral edema

Answer: 2 Rationale: Inamrinone is an inotropic agent used to relieve the manifestations of heart failure. Therapeutic effects include a decrease in weight (fluid), lung crackles, dyspnea, and edema. Blood pressure should remain stable or increase (if the client is hypotensive). Hypotension is an adverse effect of the medication.

The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instruction if the client makes which statement? 1. "I need to wear a MedicAlert tag or bracelet." 2. "I need to restrict my activity while this catheter is in place." 3. "I need to have a repair kit available in the home for use if needed." 4. "I need to keep the insertion site protected when in the shower or bath."

Answer: 2 Rationale: The client should be taught that only minor activity restrictions apply with this type of catheter. The client should protect the site during bathing and should carry or wear a MedicAlert identification. The client should have a repair kit in the home for use as needed because the catheter is for long-term use.

The nurse prepares to administer acetylcysteine to the client with an overdose of acetaminophen. What is the appropriate action when administering this antidote? 1.Administer the medication subcutaneously in the deltoid muscle. 2.Administer the medication by intramuscular (IM) injection in the gluteal muscle. 3.Mix the medication in a flavored ice drink, and allow the client to drink the medication. 4.Administer the medication mixed in 50 mL of normal saline and piggybacked through the main intravenous (IV) line.

Answer: 3

The nurse in the hospital emergency department is preparing to administer fomepizole to a client with ethylene glycol (antifreeze) intoxication. The nurse should plan to administer this medication by which route? 1. Oral route 2. Intramuscular route 3. Intravenous (IV) route 4. Through a nasogastric tube

Answer: 3 Rationale: Fomepizole is a medication that is used to treat known or suspected ethylene glycol (antifreeze) intoxication. It is administered via the IV route. The routes in the remaining options are incorrect.

Vasopressin therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which essential item is needed during the administration of this medication? 1. An airway 2. A suction setup 3. A cardiac monitor 4. A tracheotomy set

Answer: 3 Rationale: The major action of vasopressin is constriction of the splanchnic blood flow. Continuous electrocardiogram and blood pressure monitoring are essential because of the constrictive effects of the medication on the coronary arteries. The remaining options are not essential items required during the administration of this medication. However, these items may be needed if a complication arises.

he nurse has a prescription to administer phenytoin by intravenous (IV) push through an IV line infusing 1000 mL of 0.9% sodium chloride. Arrange the actions in the order that they should be performed. All options must be used. 1.Inject the medication. 2.Draw up the medication in a 3-mL syringe. 3.Check the client's identification (ID) bracelet. 4.Pinch off the IV tubing above the injection port. 5.Check the compatibility of phenytoin with the IV solution. 6.Document that the medication was administered.

Correct Order: 5,2,3,4,1,6 Rationale: The nurse should first check the compatibility of the medication with the ingredients in the IV solution. The nurse then draws up the medication, checks the ID bracelet to verify client identity, pinches off the tubing above the injection port, and injects the medication at the recommended rate through the port nearest to the IV insertion site. The nurse then documents that the medication was administered.

A client returning to the nursing unit after a cardiac catheterization procedure has a stat prescription to receive a dose of intravenous procainamide. Which piece of equipment would be most appropriate for the nurse to use in determining the client's response to this medication? 1. Glucometer 2. Pulse oximeter 3. Cardiac monitor 4.Noninvasive blood pressure cuff

Answer: 3 Rationale: Procainamide is an antiarrhythmic medication often used to treat ventricular arrhythmias that do not respond adequately to lidocaine. The effectiveness of this medication is best determined by evaluating the client's cardiac rhythm. Therefore, a cardiac monitor would be the most appropriate device for determining the client's response, although the blood pressure cuff and the pulse oximeter would provide general information about the client's cardiovascular status. A glucometer is not needed for this client with the information presented.

The nurse is administering lidocaine hydrochloride by the intravenous route. Which finding(s) should the nurse report to the health care provider immediately? 1. Urine output of 275 mL over the past 8 hours 2. Client complaints of blurred vision and nausea 3. Heart rate of 70 beats/min, blood pressure of 130/72 mm Hg 4.Client complaints of a headache and a temperature of 100°F (37.8°C) orally

Answer: 2 Rationale: Blurred vision and nausea are common indicators of lidocaine toxicity. Urine output is greater than the minimum amount of 30 mL/hr, and therefore is adequate. The heart rate of 70 beats/min and the blood pressure of 130/72 mm Hg are normal. A headache and elevated temperature are important to note but are not related to the lidocaine.

A client has just undergone insertion of a central venous catheter at the bedside under ultrasound. The nurse would be sure to check which results before initiating the flow rate of the client's intravenous (IV) solution at 100 mL/hour? 1. Serum osmolality 2. Serum electrolyte levels 3. Intake and output record 4.Chest radiology results

Answer: 4 Rationale: Before beginning administration of IV solution, the nurse should assess whether the chest radiology results reveal that the central catheter 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, but they do not relate to this procedure.

The nurse has a prescription to give amiodarone intravenously to a client. What is the priority assessment during administration of this medication? 1. Blood pressure 2. Cardiac rhythm 3. Skin color and dryness 4.Oxygen saturation level

Answer: 2 Rationale: Amiodarone is an antidysrhythmic used to treat life-threatening ventricular dysrhythmias. The client requires continuous cardiac monitoring, with infusion of the medication by an intravenous pump. Although the other assessments are not incorrect, monitoring of cardiac rhythm is the priority nursing action.

The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to take which action immediately after injecting the potassium chloride into the port of the IV bag? 1. Rotate the bag gently. 2. Attach the tubing to the client. 3. Prime the tubing with the IV solution. 4.Check the solution for yellowish discoloration.

Answer: 1 Rationale: After adding a medication to a bag of IV solution, the nurse should agitate or rotate the bag gently to mix the medication evenly in the solution. The nurse should then attach a completed medication label. The nurse can then prime the tubing. The IV solution should have been checked for discoloration before the medication was added to the solution. The tubing is attached to the client last.

A client hospitalized with a diagnosis of myocardial infarction calls for the unit nurse because the client is experiencing chest pain. The nurse administers a sublingual nitroglycerin tablet as prescribed. The client, who is receiving oxygen by nasal cannula, reports that her chest pain is unrelieved by the nitroglycerin. Which is the next nursing action for this client? 1. Call the client's family. 2. Increase the flow rate of oxygen. 3. Contact the health care provider (HCP). 4.Administer another nitroglycerin tablet.

Answer: 4 Rationale: For the hospitalized client, nitroglycerin tablets are administered 1 tablet every 5 minutes, for a total of 3 tablets per episode of chest pain, as long as the client maintains a systolic blood pressure of 100 mm Hg or higher. Increasing the flow rate of oxygen may be prescribed by the HCP but would not be the next nursing action. If 3 nitroglycerin tablets do not relieve the client's chest pain, the HCP needs to be notified. It is premature to call the client's family.

The nurse is caring for a client with acute pulmonary edema. The health care provider (HCP) tells the nurse that medication will be prescribed to help reduce preload and afterload. Based on the HCP's statement, what medication should the nurse anticipate administering? 1. Digoxin 2. Prednisone 3. Furosemide 4.Nitroprusside sodium

Answer: 4 Rationale: Intravenous nitroprusside is a potent vasodilator that reduces preload and afterload. It is a medication used to treat the client with pulmonary edema. Prednisone is a steroidal antiinflammatory medication that is not usually prescribed for acute pulmonary edema and could aggravate the symptoms due to sodium and retention effects of this medication. Digoxin is a cardiac glycoside that increases cardiac contractility. Furosemide is a loop diuretic and can reduce preload by enhancing the renal excretion of sodium and water, which reduces circulating blood volume. Furosemide is often prescribed for acute pulmonary edema, but the action of the medication is not to decrease both preload and afterload.

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? 1. 5% dextrose in lactated Ringer's solution 2. 0.33% sodium chloride (⅓ normal saline) 3. 0.45% sodium chloride (½ normal saline) 4.0.225% sodium chloride (¼ normal saline)

Answer: 1 Rationale: For this client, the goal of therapy is to expand intravascular volume as quickly as possible. In this situation, the client will likely experience a decrease in intravascular volume from blood loss, resulting in decreased blood pressure. Therefore, a solution that increases intravascular volume, replaces immediate blood loss volume, and increases blood pressure is needed. The 5% dextrose in lactated Ringer's (hypertonic) solution would increase intravascular volume and immediately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client's blood pressure. The solutions in the remaining options would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, the solutions would move into the cells via osmosis.

The nurse in the hospital emergency department is caring for a client with suspected opioid overdose and is preparing to administer the reversal agent via the intravenous route. Which statement is correct about the administration of this medication? 1. Prepare only 1 dose of the reversal agent. 2. Administer the entire dose by slow intravenous push. 3. Administer the medication rapidly by the intravenous route. 4.After the initial dose, prepare to administer additional intravenous doses if needed.

Answer: 4 Rationale: The reversal agent for opioids is naloxone hydrochloride, which should be titrated every 2 to 5 minutes according to client response. Therefore, the remaining options are incorrect.

A client has an epidural catheter in place after colon surgery and is receiving pain medication through the catheter. During the night the client calls the nurse and says, "I have a terrible headache that just started now." The nurse checks the epidural catheter insertion site and notes a small amount of clear drainage leaking from the bandage. What is the first action the nurse should take? 1. Stop the infusion. 2. Change the dressing bandage. 3. Remove the epidural catheter. 4.Notify the health care provider (HCP).

Answer: 1 Rationale: If a client complains of a sudden headache and clear drainage is present near the epidural insertion site, it is possible that the catheter has migrated. The immediate actions by the nurse are to stop the infusion and then to notify the HCP. The HCP needs to be notified, but the nurse can delegate that task to a colleague while caring for the client. It is not appropriate for the nurse to remove the epidural catheter without a prescription. Simply changing the bandage does not address the critical problem.

The nurse is caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The nurse administers morphine sulfate to the client as prescribed by the health care provider. After administration of the morphine sulfate, what is the priority assessment? 1. Respirations 2. Mental status 3. Urinary output 4. Blood pressure

Answer: 1 Rationale: Morphine sulfate is an opioid analgesic that may be administered to relieve pain in a client with MI. The nurse would monitor the client's respirations and blood pressure. Signs of morphine toxicity include respiratory depression and hypotension. Respiratory depression is the priority concern using the ABCs-Airway, Breathing, and Circulation-assessment. Although monitoring mental status is a component of the nurse's assessment, it is not the priority after administration of morphine sulfate. Urinary output is unrelated to the administration of this medication. Monitoring the temperature also is not associated with the use of this medication.

A postpartum client who received an epidural analgesic after giving birth by cesarean section is lethargic and has a respiratory rate of 8 breaths per minute. The nurse should obtain which medication from the emergency cart after notifying the health care provider? 1. Naloxone 2. Betamethasone 3. Morphine sulfate 4.Meperidine hydrochloride

Answer: 1 Rationale: Opioids are used for epidural analgesia, which can lead to delayed respiratory depression. For this reason, respirations are monitored for 24 hours after administration of epidural analgesia. Naloxone is an opioid antagonist, which reverses the effects of opioids and is given if the respiratory rate falls below 8 breaths per minute. Betamethasone is a corticosteroid administered to enhance fetal lung maturity. Morphine sulfate and meperidine hydrochloride are opioids and would further compromise the respiratory rate.

A client in shock is receiving dopamine hydrochloride by intravenous (IV) infusion. The nurse should have which medication available for local injection if IV infiltration and medication extravasation occur? 1. Vitamin K 2. Phentolamine 3. Atropine sulfate 4.Protamine sulfate

Answer: 2 Rationale: Phentolamine is an alpha-adrenergic blocking agent that prevents dermal necrosis and sloughing after infiltration of norepinephrine or dopamine. Vitamin K is the antidote for warfarin. Atropine sulfate is the antidote for cholinergic crisis. Protamine sulfate is the antidote for heparin.

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. After taking appropriate steps to care for the client, the nurse should document in the medical record that which occurred? 1. Phlebitis of the vein 2. Infiltration of the IV line 3. Hypersensitivity to the IV solution 4.Allergic reaction to the IV catheter

Answer: 1 Rationale: Phlebitis at an IV site can be distinguished by client discomfort at the site, as well as redness, warmth, and swelling proximal to the catheter. The IV line should be discontinued, and a new line should be inserted at a different site. The remaining options are incorrect occurrences.

The nurse is assisting in the care of a client who is being seen in the clinic with a suspected acetaminophen overdose. What is the nurse's priority of care? 1. Administer acetylcysteine. 2. Obtain a 12-lead electrocardiogram. 3. Ask the client about other medication use. 4.Ask the client why so many acetaminophen were taken.

Answer: 1 Rationale: The antidote for acetaminophen is acetylcysteine, which works by preventing the hepatotoxic metabolites of acetaminophen from forming, so early administration is essential. Although the other options may be part of the client's assessment, they do not need to be carried out immediately.

The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation? 1. The catheter advances easily. 2. The vein is distended under the needle. 3. The client does not complain of discomfort. 4. Blood return shows in the backflash chamber of the catheter.

Answer: 4 Rationale: The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV catheter. The vein should have been distended by the tourniquet before the vein was cannulated, and if further distention occurs after venipuncture, this could mean the needle went through the vein and into the tissue; therefore, the catheter should not be advanced. Client 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 catheter until placement in the vein is verified by blood return.