Adult Nursing 2 - Quiz 1

A client verbalizes fear of infection from a blood transfusion. What is the nurse's best response? - "Every unit of donated blood is typed and tested for antibodies to infections." - "There is no need for testing unless you have a history of a transfusion reaction." - "The risk of transmission of HIV is so low, there's no need to worry." - "Blood typing is more important than testing for infection."

- "Every unit of donated blood is typed and tested for antibodies to infections."

A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition? - hyperkalemia - hypervolemia - hypercalcemia - dehydration

- dehydration

What does the nurse understand is the primary method by which fluid volume is regulated? - Urine excretion - Breathing - Bowel elimination - Perspiration

- Urine excretion

A client is experiencing edema in the tissue. What type of intravenous fluid would the nurse expect to be prescribed? - no intravenous solution - isotonic fluid - hypertonic solution - hypotonic solution

- hypertonic solution

The client is to receive a unit of packed red blood cells. What is the nurse's first action? - Verify that the client has signed a written consent form. - Observe for gas bubbles in the unit of packed red blood cells. - Ensure that the intravenous site has a 20-gauge or larger needle. - Check the label on the unit of blood with another registered nurse.

- Verify that the client has signed a written consent form.

A client diagnosed with hypernatremia needs fluid volume replacement. What intravenous solution would be the safest for the nurse to administer? - 5% dextrose in water - 0.45% sodium chloride - 5% dextrose in normal saline solution - 0.9% sodium chloride

- 0.45% sodium chloride

The nurse begins a routine blood transfusion of packed red blood cells (PRBCs) at 1100. To ensure client safety, the unit of blood should be completely transfused by what time? - 1500 - 1530 - 1115 - 1600

- 1500

The physician has prescribed a peripheral IV to be inserted before the client goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter? - Choose a hairless site if available. - Leave the tourniquet on for at least 3 minutes. - Have the client briefly hold his arm over his head before insertion. - Consider potential effects on the client's mobility when selecting a site.

- Consider potential effects on the client's mobility when selecting a site.

The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration? - Dark, concentrated urine - Cool and pale skin - Crackles in the lung fields - Distended jugular veins

- Dark, concentrated urine

A client on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurse's most appropriate action? - Administer the remaining PRBCs by the IV direct (IV push) route. - Discontinue the remainder of the PRBC transfusion and inform the health care provider. - Disconnect the bag of PRBCs, cool for 30 minutes and then administer. - Apply an icepack to the blood that remains to be infused.

- Discontinue the remainder of the PRBC transfusion and inform the health care provider.

You are caring for a new client on your unit who has third-spacing fluid. You know to assess for what type of edema? - Generalized - Dependent - Brassy - Pitting

- Generalized

The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which? - Cardiovascular compromise - Summer allergies - Insensible fluid loss - Lung function

- Insensible fluid loss

A client in acute renal failure has been prescribed 2 units of packed red blood cells (PRBCs). The nurse explains to the client that the blood transfusion is most likely needed for which reason? - Preparation for likely nephrectomy - Increases the effectiveness of dialysis - Lack of erythropoietin - Hypervolemia

- Lack of erythropoietin

A 64-year-old client is brought in to the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client? - No, start with the sodium chloride IV. - Yes, along with the hypotonic IV. - Yes, this will correct the sodium deficit. - No, sodium intake should be restricted.

- No, sodium intake should be restricted.

The nurse is assessing a client for local complications of intravenous therapy. Which are local complications? Select all that apply. - Phlebitis - Air embolism - Infection - Extravasation - Hematoma

- Phlebitis - Extravasation - Hematoma

A 54-year-old male patient is admitted to the hospital with a case of severe dehydration. The nurse reviews the patient's laboratory results. Which of the following results are consistent with the diagnosis? Select all that apply. - Serum osmolality of 310 mOsm/kg - Blood urea nitrogen (BUN) of 23 mg/dL - Serum sodium of 148 mEq/L - Serum glucose of 90 mg/dL - Hematocrit level of 48% - Urine specific gravity of 1.03

- Serum osmolality of 310 mOsm/kg - Blood urea nitrogen (BUN) of 23 mg/dL - Serum sodium of 148 mEq/L - Urine specific gravity of 1.03

Fresh-frozen plasma (FFP) has been prescribed for a hospital client. Prior to administration of this blood product, the nurse should prioritize what client education? - Infection risks associated with FFP administration - Strategies for managing transfusion-associated anxiety - Physiologic functions of plasma - Signs and symptoms of a transfusion reaction

- Signs and symptoms of a transfusion reaction

The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take? - Notify the client's health care provider - Remove the client's IV access. - Stop the transfusion immediately. - Assess the client's chest sounds and vital signs.

- Stop the transfusion immediately.

A client with an intravenous infusion is rubbing his arm. The nurse assesses the site and decides to discontinue the current infusion because of concern that the client has developed phlebitis. Which of the following clinical manifestations would the nurse assess with phlebitis? Select all that apply. - Tender area around the insertion site - Reddened area along the path of the vein - Ecchymosis at the insertion site - Cool area around the insertion site - Rapid, shallow respirations

- Tender area around the insertion site - Reddened area along the path of the vein

A 18-year-old client presents to the emergency department with a severe open fracture of the lower extremity. The health care provider tells the client that the client will need a blood transfusion. The client refuses, despite the advise of the health care provider. What does the nurse understand is the legal implication of the scenario? - The health care provider may first call the client's parents if the client refuses. - The client can only refuse the transfusion if the consent form has not been signed. - The client has a right to refuse the transfusion. - The health care provider may ask for a court order if the client refuses.

- The client has a right to refuse the transfusion.