PrepU Med Surg Assignment 2

A nurse needs to administer a prescribed dosage of antineoplastic drugs to a client with cancer. Which of the following pieces of medical equipment is used to administer antineoplastic drugs?

Central venous catheter

Which of the following solutions is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?

Isotonic

Assessing your client at 1600, you note that 800 ml or normal saline solution has been infusing since you hung the bag at 1600 yesterday. What would you expect your next action to be?

Replace the IV solution

A nurse needs to perform veni puncture on a 74-year-old client who has poor skin turgor. Which nursing intervention does the nurse use to prevent skin trauma at the veni puncture site?

The nurse places a soft cloth between the tourniquet and the skin.

A 36-year-old client with type O blood and a history of anemia is scheduled for a blood transfusion. To avoid a transfusion reaction, this client must receive which blood type?

Type O

A nurse is discontinuing an intravenous infusion. After washing the hands, the nurse clamps the tubing, removes the tape holding the dressing and venipuncture device in place, and dons clean gloves. Place in order the remaining steps of the procedure that the nurse would follow.

-Gently press a dry, sterile gauze square over the site. -Remove the venipuncture device by pulling it out without hesitation, following the course of the vein. -Cover the site with a dressing or bandage. -Continue to apply pressure to the site for 30 to 45 seconds while elevating the forearm to control bleeding. -Remove gloves and wash your hands. -Record the time the IV infusion was discontinued, the amount of fluid infused, and the appearance of the venipuncture site.

A client receiving IV fluid therapy suddenly becomes anxious and exhibits an elevated blood pressure, a bounding pulse, and shortness of breath. Which nursing action(s) would be most appropriate to assist this client? Select all that apply.

-Slow the IV rate. -Contact the physician. - Provide oxygen to the client.

A client receiving intravenous therapy is experiencing circulatory overload. Which of the following nursing actions is correct? Select all that apply.

-Slow the infusion rate. -Elevate the client's head. -Contact the physician.

The physician's order of IV therapy for a client includes the use of a medication lock. Why would this device be ordered? Select all that apply.

-The client needs intermittent IV medication. -The client will eventually transition from continuous infusion. -The client may require emergency IV fluids.

Which of the following statements about hypotonic solutions are true? Select all that apply.

-They are often indicated for clients with diarrhea. -They initiate cellular swelling that can increase blood pressure.

A 64-year-old male client needs an IV started. Which of the following nursing interventions would the nurse follow to prepare this client? Select all that apply.

-Verify the identity of the client using multiple methods. -Explain how long the procedure is expected to take. -Give the client an idea of how much discomfort the procedure will cause.

The physician has ordered an IV of 3000 mLs of 0.9% sodium chloride to be infused over the next 24 hours. The nurse uses IV tubing that has a drip factor of 10. How many drops per minute will deliver the correct amount of IV fluid?

21 gtt/min

Your client is receiving IV fluid administration and consuming a rather large amount of fluids orally. In calculating the client's fluid intake for the past 24 hours, you note the amount and immediately notify the physician of your findings. Notification of a physician regarding fluid intake should occur after exceeding how many milliliter in 24 hours?

3000

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?

50

A nurse is preparing to use microdrip tubing. What is the standard volume that this device delivers?

60

Which of the following clients would be a candidate for total parenteral nutrition?

A client with colitis and bloody diarrhea

Willis Beacon is receiving TPN until his ascites clears. In which of the following allergies would you expect IV lipid emulsions to be contraindicated?

A client with egg allergy

Leaving your surgical suite post-op, Martin Franks has hypertonic solution running, via gravity, at 100 ml/hour to decrease his post-op edema. Before transporting to his room, the IV pole is set at the proper height to overcome the pressure within Martin's veins. What is that height?

At least 18 - 24 inches above infusion site

Loretta Sweeney, a 92-year-old female client, has IV solution ordered by her physician to treat her dehydration. You notice the order was written to administer the fluid at a slower rate than what you expected. Why would the physician designate the slower infusion rate for Mrs. Sweeney?

Because Mrs. Sweeney may have cardiac or renal disorders

During rounds, you check the initial date on the IV fluid container and tubing for a client on continuous fluid infusion. The date indicates the client has been on therapy for 2 full days. Based on this information, you should perform which of the following nursing interventions?

Change the IV solution container.

A client with aplastic anemia is going to receive a blood transfusion. In addition to taking vital signs and verifying that the unit of blood cells is matched to the client, what other assessments/actions would you take?

Check the client regarding chills, low back pain, dyspnea, and skin itching during the transfusion.

Lucy Spencer, a 69-year-old client who ihas just completed hip fracture surgical repair, has IV fluid running upon return to her hospital room. Understanding the osmotic principles of IV therapy, which fluid would you expect to see administered to decrease post-op edema?

Hypertonic solution

Your 87-year-old client who is status-post stomach removal from cancer is receiving nutrition via total parenteral nutrition. The physician's order includes lipid emulsion administration (contained in glass bottles) on Monday, Wednesday, and Friday. What type of IV fluid administration device would you use for TPN administration?

In-line filter

A nurse assessing the IV site of a patient observes swelling and pallor around the site and notes a significant decrease in the flow rate. The patient complains of coldness around the infusion site. What IV complication does this describe?

Infiltration

A post-surgical patient's MAR provides for PRN administration of a number of analgesics by various routes. Which of the following routes will likely provide the most rapid pain relief for the patient?

Intravenous

Your 84-year-old male client is in full-blown pulmonary edema. Your intent is to get the appropriate medication to be effective as quickly as possible. Which medication route will be the quickest to give your client a fighting chance?

Intravenous

The nurse is preparing to administer the solution in the attached image to a client. Which of the following types of solution is the nurse going to administer?

Isotonic

The RN is processing the physician's orders and recognizes that Mr. Chorn is to receive normal saline to keep vein open. The nurse is aware that normal saline solution is categorized as one of the following?

Isotonic solution.

A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider?

It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order.

A client with renal disease requires IV fluids. It is important for the nurse to

Place the fluids on an electronic device

Assessing your client at 4 <sc>PM, you note that 800 ml of normal saline solution has been infusing since you hung the bag at 4 <sc>PM yesterday. What would you expect your next action to be?

Replace the IV solution.

A 58-year-old woman is suffering from food poisoning after eating a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires

Replacement of fluids for those lost from vomiting and diarrhea

When capping a primary line for intermittent use, a nurse notices local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. What is the most likely complication that has occurred?

Thrombus

A client receiving intravenous therapy shows signs of swelling at the infusion site and says it is uncomfortable. The infusion is also slowing. Which of the following complications would the nurse most likely prepare to assist in managing?

Thrombus formation

A client comes to the emergency department and is bleeding profusely. Blood transufion is ordered and the client is being typed and cross-matched. While awaiting the results, the physician orders a unit of packed red blood cells to administered stat. Which blood type would the nurse expect to be used?

Type O

A nurse is caring for a client undergoing IV therapy. The nurse knows that intravenous administration of medication is appropriate in which of the following situations?

When the client has disorders that affect the absorption of medications

A client involved in a motor vehicle collision requires a blood transfusion, and you are preparing the blood transfusion equipment. Which of the following items will you need?

Y-administration tubing