Ch. 12 Intravenous Therapy and Blood Administration

What is Thrombosis?

Local coagulation or clotting of the clot in a part of the circulatory system.

Which of these clients is/are most likely to develop fluid circulatory overload?

A premature infant 101 year old man Client with heart failure A client receiving renal dialysis Clients with cardiac, respiratory, renal, or liver diseases and older and younger clients cannot tolerate an excessive fluid volume.

The 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 intravenous IV site of an assigned client who is receiving fluid replacement therapy how frequently?

Every hour. for questions like this it is best to answer the most frequent occurring time.

What signs are associated with Bacteremia?

Fever

A client is going to be transfused with a unit of packed PRBCS packed red blood cells. The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started?

15 minutes. The first 15 minutes of a transfusion, which is the most likely time that a transfusion reaction will occur. This enables the nurse to detect a reaction and intervene quickly.

Signs of fluid overload

Dyspnea(labored breathing) and crackles

Increased hemoglobin and hematocrit levels would be seen when the client has received a transfusion of?

Red blood cells.

The nurse is preparing an intravenous 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 would plan to take which action?

Changing the tubing because it has been contaminated

The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells. the nurse would tell the client that it is most important to report which signs immediately.

Chills, itching and rash. because these could be signs of a possible transfusion reaction.

A client has a prescription to receive 1000mL of 5% dextrose in .45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing?

Infiltration

The nurse is checking the insertion site of a peripheral intravenous 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 most likely the result of which complication?

Phlebitis, at an IV site results in discomfort at the site and redness, warmth, and swelling proximal to the IV catheter. The IV catheter would be removed, and a new IV line would be inserted at a different site.

The 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 findings?

Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. remember that bleeding is a concern when platelets are low.

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 area.

The Blood bank

The nurse takes a client's temperature before giving blood transfusion. The temperature is 100*F 37.7*C orally. The nurse reports the finding to the RN and anticipates that which action will take place?

The blood will be held, and the primary health care provider will be notified

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

The nurse would clamp the tubing to prevent the solution form running freely through the tubing after it is attached to the intravenous bag. The nurse would next uncap the proximal spike portion of the tubing and attach it to the IV bag. The IV bag is elevated, the roller clamp is then opened slowly, and the fluid is allowed to flow through the tubing in a controlled fashion to prevent air from remaining in parts of the tubing.

A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic and complaining of generalized itching. How would the nurse correctly interpret these findings.

Transfusion reaction

The nurse is assigned to care for a client with a peripheral intravenous infusion. the nurse is providing hygiene care to the client and would take action while changing the clients hospital gown?

Using a gown with snaps and inserting the IV bag and tubing through the sleeve of the gown first are appropriate. The flow rate must be checked immediately after changing the gown because the roller clamp may have been affected during the change.

The 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 check which item?

Vital signs A change in vital signs may indicate that a transfusion reaction is occurring. The nurse assesses the client's vital signs before the procedure to obtain a baseline every 15 minutes for the first half hour after beginning the transfusion and every hour thereafter.

What is Phlebitis?

inflammation of a vein

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

2 x 2 gauze This material is absorbent, sterile and nonirritating to the site.