Unit 1 IV Therapy & Blood Administration NCLEX Questions

A nurse has just finished assisting the physician in placing a central IV line. Which of the following is a priority intervention after central line insertion? 1) prepare the client for a chest radiograph 2) assess the clients temperature to monitor for infection 3) label the dressing with the date and time of the catheter insertion 4) monitor the BP to asses for FVE

1) prepare the client for a chest radiograph for possible pneumothorax for accidental puncture of the lung.

What type of tubing is needed for a blood transfusion?

Infusion blood set, large drip chamber with filter

What would you do if your patient was B+ and the blood bank sent you O+ blood?

Go ahead with transfusion; O+ blood is universal.

What do you do if your pt adamantly refuse a blood transfusion and might no survive if he does not receive the other blood?

Have patient sign refusal form, document, try to educate and persuade them or give them other options

What are the 3 types of transfusion rxns?

Hemolytic Non-Hemolytic/Febrile Allergic

The nurse assesses a peripheral IV dressing and notes that it is damp and the tape is loose. The best nursing action is to: 1) stop the infusion immediately 2) apply a sterile, occlusive dressing 3) ensure tight IV tubing connections 4) remove the IV and insert and new IV

3) ensure tight IV tubing connections

The nurse checks the gauge of the clients IV catheter. Which is the smallest gauge catheter that the nurse can use to administer blood? 1) 14 2) 19 3) 22 4) 24

2) 19 gauge

How long can a blood bag be hung/infused?

4 hours (bacterial contamination)

Your pt needs a coronary artery bypass graft surgery. She cannot receive blood because of her religious beliefs. When preparing such a patient for surgery, what are some of the alternative therapies that can be considered?

-Autologous--maybe, but it is too little; -Bloodless surgery if there is a surgeon who will perform this

You are infusing a unit of PRBC's via a peripheral line. It is not on a pump and is infusing via gravity flow. It stops running. How would you troubleshoot?

-Check tubing for occlusion -Raise IV pole -Check clamps

Prior to admin a transfusion, what steps will you need to do first?

-informed consent -verify allergies -assess patient: VS (febrile), fluid balance, mental status, SOB -18 gauge IV -pump or gravity drip ok -pre-medicate (anti-inflammatories, antipyretic (Tylenol), antihistamines -Verify information from pt/blood bag with another licensed care giver -Visually inspect bag for clots/precipitate

What would you do if your patient was O+ and the blood bank sent you AB+ blood?

O+ is only compatible with O+

What are the benefits of autologous blood?

Patient's own blood, it is the safest and stored well ahead of planned surgery.

A nurse is checking the insertion site of a peripheral 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: 1. Phlebitis of the vein 2. Infiltration of the IV line 3. Hypersensitivity to the IV solution 4. An allergic reaction to the IV catheter material

1

A nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the IV of an assigned client who is receiving fluid replacement therapy at least every: 1. 1 hour 2. 2 hours 3. 3 hours 4. 4 hours

1

Before performing a venipuncture to initiate continuous IV therapy, a nurse should: 1) inspect the IV solution and exp date 2) apply a cool compress to the affected area 3) secure a padded arm board above the IV site 4) apply a tourniquet below the venipuncutre site

1) inspect the IV solution and exp date

A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client's hospital gown? 1. Using a hospital gown with snaps at the sleeves 2. Disconnecting the IV tubing from the catheter in the vein 3. Checking the IV flow rate immediately after changing the hospital gown 4. Putting the bag and tubing thru the sleeve, followed by the client's arm

2

A nurse is assisting with caring for a client who is receiving a unit of packed RBCs. The nurse tells the client that it is most important to report which of the following signs immediately? 1. Sore throat or earache 2. Chills, itching, or rash 3. Unusual sleepiness or fatigue 4. Mild discomfort at the catheter site

2

A client began receiving an IV infusion of packed red blood cells 30 minutes ago. The client turns on the nurse call light and describes difficulty breathing, itching, and a tight sensation in the chest. Which of the following is the first action of the nurse? 1) call the physician 2) stop the transfusion 3) check the client's temperature 4) recheck the unit of blood for compatibility

2) stop the transfusion (transfusion rxn....iv line is kept open with NS and physician is notified...check vital signs....monitor the client for any life threatening symptoms)

A client is going to be transfused with a unit of packed RBCs. The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started? 1. 5 minutes 2. 15 minutes 3. 30 minutes 4. 45 minutes

2.

How long can a blood bag wait from the time it leaves the lab to transfusion?

20 to 30 minutes after this, the bag must be discarded into biohaz bag

The nurse assesses the client's peripheral IV site and noes that it is cool, pale, swollen, and not infusing. The nurse should document in the client's record that which of the following has probably occurred? 1) Phlebitis 2) Infection 3) Infiltration 4) Thrombosis

3) Infiltration The infusion stops with the pressure in the tissue exceeds the pressure in the tubing. The pallor, coolness and swelling of the IV site are the result of IV fluid infusing into the subcu tissue.

The client is receiving IV antibiotic therapy at home for 1 week via heparin lock (intermittent IV catheter). Which does the nurse include in client teaching for the early detection of the complications of IV therapy? 1) Protect the heparin lock continually 2) keep the heparin lock clean and dry 3) report local pain, drainage, or edema 4) apply pressure to the IV site if it dislodges

3) report local pain, drainage, or edema

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which of the following areas? 1. The pharmacy 2. The laboratory 3. The blood bank 4. The risk-management department

3.

A client who is receiving a blood transfusion rings the call bell for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. The nurse interprets that the client is experiencing: 1. Bacteremia 2. Fluid overload 3. Hypovolemic shock 4. A transfusion reaction

4

What does crossmatch and typing do?

Crossmatch: Cross-matches pt's blood and donor's blood Typing: Verifies Rh factor and ABO types/screens for presence of antibodies.

What is a hemolytic rxn?

Dire! Cell rupture/lysis; anaphylaxis; histamine release; circulatory collapse! the pt can die Sudden, usually within first 5 minutes. Start blood slowly at first, then do rate faster after 15 minutes. usually from errors on blood band

Your patient has a unit of blood infusing. It probably will be completed within 5 mins. The phlebotomist comes to you and asks if it is OK to draw the pt's CBC. How will you respond?

No, come back in 1 hour. Blood circulates and calibrates in 1 hour.

A physician writes an order to give Albumin 25% x 1. Do you need to get a type and crossmatch for this?

No. Albumin is a protein product (colloid).

What is the type of bag solution used with blood transfusions?

Normal saline only! D5W would clot or agglutinate

Your patient needs a unit of blood. His pre-transfusion temp is 100.5. What do you do?

Notify the provider.

What would you do if your patient was O- and the blood bank sent you O+ blood?

Send back to blood bank due to mismatched Rh factors.

What is an allergic transfusion rxn?

Sensitive to something in the blood, usually plasma. Anaphylaxis: itching, hives. But if bronchospasms, can be fatal, but not common. D/C like hemolytic if anaphylaxis

Your blood has arrived from the blood bank, but your pt's IV just infiltrated. What do you do?

Stop the IV, try to get IV re-done, but only before 30 minutes are up, or the blood goes bad after 30 mins.

You are transfusing PRBC's. You suspect the IV has infiltrated. What does that look like?

Swelling, purplish like a bruise

An order for type and crossmatch is not an order to transfuse. T or F

T

You observe a nurse priming tubing for a blood transfusion with D5W. What would you do?

Tell her to stop as D5W can cause clotting along with the transfusion. Normal saline is the only standard.

Your patient has a unit of PRBC's infusing. The physician comes to you and wants a unit of platelets transfused as well. He tells you that it has to be now while the blood is infusing since the platelet count is 25,000. The unit of blood just went up and needs to go over 2 hours. The pt has a second IV access. What would you do?

Tell the doctor we have to do this one at a time.

You are obtaining written consent for a blood transfusion. The patient states, "I am concerned about getting AIDS!" How do you respond?

The blood supply now a days is screened and is very safe.

A nurse is preparing an IV solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to do which of the following? 1. Change the IV tubing 2. Wipe the tubing with Betadine 3. Scrub the tubing with an alcohol swab 4. Scrub the tubing before attaching it to the IV bag

1

After reviewing a client's serum electrolyte levels, the provider prescribes an isotonic IV infusion. Which IV solution should the nurse plan to administer? 1) 5% dextrose in water 2) 10% dextrose in water 3) 3% sodium chloride solution 4) 0.45% sodium chloride solution

1) 5% dextrose in water 10% dextrose in water = hypertonic 3% sodium chloride solution = hypertonic 0.45% sodium chloride solution = hypotonic

A provider prescribes lipids (fat emulsion) IV for a client receing parenteral nutrition. Before initiating the intralipds, which should the nurse assess that is related to the infusion? 1) allergies 2) VS 3) history of seizures 4) serum glucose level

1) allergies Fat emulsions contain and emulsifying agent made from egg yolks (hypersensitivity to eggs)

The nurse prepares to access an implanted vascular access port. Which should the nurse implement first? 1) palpate the vascular port 2) anchor the vascular port 3) cleanse the site with alcohol 4) apply a cool compress to the site

1) palpate the vascular port

Before inserting a perpheral IV catheter, the nurse notes that the female client's muscles are tense and she is fidgeting with the bed sheet. Which statement should the nurse verbalize to the client? 1) This will be finished before you know it 2) inserting the IV does not hurt very much 3) The IV adds fluid into your blood stream 4) The IV catheter is an 18-gauge angiocatheter

3) The IV adds fluid into your blood stream

A client receiving PN via a central venous catheter (CVC) is scheduled to receive an IV antibiotic. Which should the nurse implement before administering the antibiotic? 1) Turn off the PN for 30 minutes 2) check for compatibility with PN 3) ensure a separate IV access route 4) flush the cvc with normal saline

3) ensure a separate IV access route

IV human albumin is prescribed for a client with burns. The nurse review the client's medical record for contraindications. The nurse contacts the physician before admin the human albumin if which of the following is noted in the client's record? 1) diabetes mellitus 2) multiple myeloma 3) renal insufficiency 4) lymphocytic leukemia

3) renal insufficiency Contraindicated due to blood derivative (also anemia, cardiac failure, allergies)

A nurse has been instructed to discontinue an IV line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with a(n): 1.Band-Aid 2. Alcohol swab 3. Betadine swab 4. Sterile 2x2 gauze

4

A nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which of the following? 1. An increased Hct level 2. An increased Hgb level 3. A decline of the temperature to normal 4. A decrease in oozing from puncture sites and gums

4

The nurse prepares a client for discharge who needs intermittent antibiotic infusions through a peripherally inserted central catheter (PICC) line. Which should the nurse include in client teaching about daily infusion care in the home? 1) keep the affected arm immobilized 2) aspirate 3 mL of blood from the PICC line 3) maintain a continuous IV infusion 4) check the insertion site for redness and swelling

4) check the insertion site for redness and swelling

What is auto transfusion?

Blood collected during and after surgery using an intraoperative blood salvage device. The autotransfusion is utilized in surgeries where there is expected a large volume blood loss - e.g. aneurysm, total joint replacement, and spinal surgeries. (**only collected above the diaphragm**)

What is CMV negative patients?

Pts who have not been exposed as adults to the cytomeglia virus (chemo pts/neonates at risk as they are immunocompromised)

The nurse is monitoring a client who is receiving a blood transfusion when the client complains of diaphoresis, warmth, and a backache. The nurse suspects a transfusion retain and should take which actions? select all that apply 1) contact the physician 2) remove the IV catheter 3) document the occurrence 4) stop the blood transfusion 5) hang 0.9% NaCl solution

1, 3, 4, 5

A nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to assess the client's: 1. Vital signs 2. Skin color 3. Oxygen saturation 4. Latest Hct level

1.

How long do you stay to monitor pt after transfusion starts?

15 minutes to verify no rxn to blood transfusion; document vital signs and pt tolerance to blood Per hospital policy on how often after this; some places are every 15 minutes. Some are before, 15 minutes after start, and 15 minutes after stopping transfusion minimum.

The nurse understands that which of the following are clinical indicators for IV fluids? Select all that apply. 1) syncope episodes 2) bounding pulse rate 3) chronic renal failure 4) rapid, weak and thready pulse 5) serum electrolyte abnormalities 6) abnormal serum and urine osmolality levels

4, 5, 6

What will you do during a hemolytic rxn?

Close clamp/disconnect tubing Saline flush Monitor pt Take vital signs Notify blood bank and provider -send blood bag to blood bank and send a urine collection for hematuria and proteins

Is it ok to give blood thru PICC or a central line?

Yes

Can a pt get circulatory overload from a blood transfusion?

Yes, due to volume. osmotic effect and colloids

Is a non-hemolytic/febrile transfusion reaction ok?

Yes. Common rxn.

You are caring for a pt who is requiring frequent transfusions for continued bleeding. The MD writes orders: Keep 2 units ahead at all times and check a serum Ca level. What is the rationale for both of these orders?

You should always keep 2 units in blood bank ready to go. Ca level is checked for hypocalcemia (anemic pts can get hypocalcemia due to citrate binding in the transfusion).

What is graft vs host disease?

blood transfusion attacks the body graft=blood host=body

one of the pts on your team needs a blood transfusion. There is a LVN working with you. What can be delegated to the LVN?

-transfusing if IV certified (spiking bag, regulate, transfuse, etc) -co-signer

one of the pts on your team needs a blood transfusion. There is a NA working with you. What can be delegated to the NA?

-vital signs -notify RN -sometimes fetch blood from bank

A nurse checks a unit of blood received from the blood bank and notes the presence of gas bubbles in the bag. Which should the nurse implement? 1) return the bag to the blood bank 2) infuse the blood using filter tubing 3) add 10 mL normal saline to the bag 4) agitate the bag to mix contents gently

1) return the bag to the blood bank

The nurse administers diphenhydramine (Benadryl) before a blood transfusion to: 1) prevent uticaria 2) avoid fever and chills 3) enhance clotting factors 4) expand the blood volume

1) prevent uticaria

A nurse is caring for a client who is reducing blood transfusion therapy. Which clinical manifestations would alert he burst to a hemolytic transfusion rxn? 1) headache 2) tachycardia 3) hypertension 4) apprehension 5) distended neck veins 6) a sense of impending doom

1, 2, 3, 4, 6

The nurse caring for a client receiving IV therapy monitors for which signs of infiltration at the catheter site of an IV infusion? select all that apply: 1) slowing of the IV rate 2) tenderness at the insertion site 3) edema around the insertion site 4) skin tightness at the insertion site 5) warmth of skin at the insertion site 6) fluid leaking from the insertion site

1, 2, 3, 4, 6

A nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 degrees F orally. The nurse reports the finding to the RN and anticipates that which of the following actions will take place? 1. The transfusion will begin as prescribed 2. The blood will be held and the physician will be notified 3. The transfusion will begin after the administration of an antihistamine 4. The transfusion will begin after the administration of 600 mg of acetaminophen

2

A nurse evaluates the latency of a peripheral IV site and suspects and infiltration. Which does the nurse implement to determine if the IV has infiltrated? 1) strips the tubing and assesses for blood return 2) checks the regional tissue for redness and warmth 3) increases the infusion rate and observes for swelling 4) gently palpates regional tissue for edema and coolness

4) gently palpates regional tissue for edema and coolness

The nurse prepares to administer an IV medication when the nurse notes that the med is incompatible with the IV solution. Which is the best intervention for the nurse to implement for safe medication administration? 1) ask the provider to prescribe a compatible IV solution 2) start a new IV cath for the incompatible medication 3) collaborate with the provider for a new admin route 4) flush tubing before and after admin the meds with NS

4) flush tubing before and after admin the meds with NS

A client has an order to receive 1000 mL of 5% dextrose in 0.45% NaCl. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing? 1. Uncaps the distal end of the tubing 2. Uncaps the spike portion of the tubing 3. Opens the roller clamp on the IV tubing 4. Closes the roller clamp on the IV tubing

4.

Which of the following clients are most likely to develop circulatory overload? (select all that apply) 1. A premature infant 2. A 101-year-old man 3. The client on renal dialysis 4. The client with diabetes mellitus 5. A 29-year-old woman with pneumonia 6. The client with CHF

1, 2, 3, 6

A nurse is doing a routine assessment of a client's peripheral 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 of the following has probably occurred? 1. Phlebitis 2. Infection 3. Infiltration 4. Thrombosis

3.