Interventions Exam 2

What is the rate of administration for packed red blood cells?

1 unit over 2 to 3 hours, no longer than 4 hours Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours. Answer A describes platelets, answer C represents cryoprecipitate, and answer D describes fresh-frozen plasma.

When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document?

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The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. A. Rate of the IV solution B. Manufacturer of the IV catheter C. Location of the IV catheter access D. Client's reaction to the procedure E. Type of IV solution F. Gauge and length of the IV catheter

A. Rate of the IV solution C. Location of the IV catheter access D. Client's reaction to the procedure E. Type of IV solution F. Gauge and length of the IV catheter The nurse should document the location where the IV access was placed, as well as the size of the IV catheter or needle, the type of IV solution, the rate of the IV infusion, and the use of a securing or stabilization device. Additionally, document the condition of the site. Record the client's reaction to the procedure and pertinent client teaching, such as asking the client to alert the nurse if the client experiences any pain from the IV or notices any swelling at the site. Document the IV fluid solution on the intake and output record.

A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse? A. Stop the transfusion and infuse normal saline using a new administration set. B. Check the client's vital signs. C. Stop the transfusion and infuse normal saline using the blood tubing. D. Notify the health care provider of the client's response.

A. Stop the transfusion and infuse normal saline using a new administration set A client who reports difficulty breathing during a blood transfusion may be having a transfusion reaction. The first action is to stop the transfusion and infuse normal saline using a new administration set. Changing the administration set prevents the client from receiving more of the blood that is causing the reaction. After stopping the transfusion and infusing normal saline using a new administration set, the nurse should check the client's vital signs and notify the health care provider of the reaction.

The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action? A. Tighten the roller clamp to stop the infusion. B. Twist the tubing around a pencil. C. Tap the tubing below the air bubbles. D. Milk the air in the direction of the drip chamber.

A. Tighten the roller clamp to stop the infusion The priority nursing action is to tighten the roller clamp on the tubing as this action prevents forward movement of air. All other options are appropriate to remove the air once the tubing has been clamped.

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?

An implanted central venous access device (CVAD) Implanted CVADs are ideal for long-term uses such as chemotherapy. The short-term nature of peripheral IVs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of chemotherapy.

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? A. Elevate the client's head. B. Apply a warm compress. C. Position the client on the left side. D. Apply antiseptic and a dressing.

B. Apply a warm compress Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.

A client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action? A. Assess the area distal to the IV site for signs and symptoms of deep vein thrombosis. B. Flush the IV with 3 mL of normal saline. C. Change from infusion with an electronic pump to infusion by gravity. D. Flush the IV with 2 mL of 100 U/mL heparin.

B. Flush the IV with 3 mL of normal saline If fluid is slow to infuse, the nurse should reposition the client's arm and/or flush the IV. Changing to IV infusion will not resolve the problem and heparin is not used for clearing peripheral IVs. Deep vein thrombosis is unrelated to slow IV fluid infusion.

When the nurse is starting an intravenous infusion on a client who will be receiving multiple intravenous antibiotics, which guideline should the nurse follow? A. Use veins of the lower extremities. B. Use distal veins before proximal veins. C. Use small veins before larger veins. D. Use the brachial plexus vein.

B. use distal veins before proximal veins Use larger veins and the distal portion of the vein, leaving the more proximal sites for later venipunctures.

When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing: A. allergic reaction. B. pulmonary embolism. C. fluid overload. D. anaphylaxis.

C. Fluid overload Fluid overload can occur when blood components are infused too quickly or too voluminously. Symptoms include increased venous pressure, distended neck veins, dyspnea, coughing, and abnormal breath sounds.

During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect? A. allergic reaction: allergy to transfused blood B. febrile reaction: fever develops during infusion C. hemolytic transfusion reaction: incompatibility of blood product D. bacterial reaction: bacteria present in the blood

C. Hemolytic transfusion reaction: incompatibility of blood product The listed symptoms occur when a blood product is incompatible. Hives, itching, and anaphylaxis occur in allergic reactions; fever, chills, headache, and malaise occur in febrile reactions. In a bacterial reaction, fever; hypertension; dry, flushed skin; and abdominal pain occur.

The client is being discharged and has a prescription to have the PICC (peripherally inserted central catheter) discontinued prior to discharge. The nurse has checked the chart. The PICC has been inserted in the client's arm to the 30 cm mark. What interventions would the nurse include when discontinuing the PICC? Select all that apply. A. Elevate the client's head of the bed to 45°. B. Instruct the client to breath normally during the catheter removal. C. Remove the catheter slowly, keeping the catheter parallel to the client's skin. D. Measure the catheter and ensure 30 cm of the catheter has been removed. E. Apply pressure to the site with a clean gauze until hemostasis occurs.

C. Remove the catheter slowly, keeping the catheter parallel to the client's skin. D. Measure the catheter and ensure 30 cm of the catheter has been removed. When removing a PICC, the nurse would remove the catheter slowly and keep the catheter parallel to the client's skin. This is to prevent tearing of the catheter. The nurse would measure the catheter and ensure the catheter had been removed intact to the 30 cm mark. The nurse would lay the client flat or place the client in Trendelenburg position. This is to prevent the risk of an air embolism. The nurse would instruct the client to hold the breath and perform a Valsalva maneuver during the catheter removal. This action also reduces the risk for an air embolism. The nurse would apply sterile gauze, not clean gauze, to the insertion site. Sterile gauze is used to prevent an infection.

A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client? A. Transparent semipermeable membrane dressing B. Occlusive dressing C. Sealed IV dressing D. Gauze dressing

D. Gauze dressing A gauze dressing is recommended if the client is diaphoretic or if the site is bleeding or oozing. However, the gauze dressing should be replaced with a transparent semipermeable membrane once this is resolved. Transparent semipermeable membranes are a type of sealed IV dressing. Occlusive dressings would not be appropriate.

After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client? A. every 12 hours B. every 24 hours C. every 36 hours D. every 72 hours

D. every 72 hours IV tubings are generally changed every 72 hours or as per the facility's policy. Solutions are replaced when they finish infusing or every 24 hours, whichever occurs first. IV tubings are not replaced after every solution is over or after every 12, 24, or 36 hours.

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms?

Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately.

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?

Ensure that the prescribed solution is clear and transparent. Before preparing the solution, the nurse should inspect the container and determine that the solution is clear and transparent, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached. The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled.

When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document? 1 2 3 4

Grade 2 Grade 2 phlebitis presents with pain at access site with erythema and/or edema. Grade 1 presents as erythema at access site with or without pain. Grade 3 presents as grade 2 with a streak formation and palpable venous cord. Grade 4 presents as grade 3 with a palpable venous cord >1 inch and with purulent drainage.

A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation?

Remove the IV from the site and start at another location

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action?

Stop the transfusion. Life-threatening transfusion reactions generally occur within the first 5 to 15 minutes of the infusion, so the nurse or someone designated by the nurse usually remains with the client during this critical time. Whenever a transfusion reaction is suspected or identified, the nurse's first step is to stop the transfusion, thereby limiting the amount of blood to which the client is exposed. Reassuring the client will not help if the client is experiencing a blood reaction. Increasing the rate of the administration will make the potential reaction worse, if this is a transfusion reaction. Listening to the client's lungs is not the priority action.

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? a) Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. b) Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. c) Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. d) Discontinue the infusion immediately, apply warm, moist compresses to the site, and restart the IV at another site.

a) Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.

During a blood transfusion, a patient displays signs of immediate onset facial flushing, fever, chills, headache, low back pain, and shock. Which transfusion reaction should the nurse suspect? a) Hemolytic transfusion reaction: incompatibility of blood product b) Febrile reaction: fever develops during infusion c) Allergic reaction: allergy to transfused blood d) Bacterial reaction: bacteria present in the blood

a) Hemolytic transfusion reaction: incompatibility of blood product

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? a) Slow or stop the infusion; monitor vital signs, notify the physician, place the patient in upright position with feet dependent. b) Stop the transfusion immediately and keep the vein open with normal saline, notify the physician stat, administer antihistamine parenterally as needed. c) Stop the transfusion immediately and keep the vein open with normal saline, notify the physician, and treat symptoms. d) Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the physician, administer antibiotics stat.

a) Slow or stop the infusion; monitor vital signs, notify the physician, place the patient in upright position with feet dependent. The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.

An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use a(an) a) 18-gauge needle b) Winged infusion needle c) Central venous access d) Intermittent infusion device

b) Winged infusion needle Winged infusion needles are short, beveled needles with plastic flaps or wings. They may be used for short-term therapy or when therapy is given to a child or infant.

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs? a) A peripheral venous catheter inserted to the cephalic vein b) A midline peripheral catheter c) An implanted central venous access device (CVAD) d) A peripheral venous catheter inserted to the antecubital fossa

c) An implanted central venous access device (CVAD) Implanted CVADs are ideal for long-term uses such as chemotherapy. The short-term nature of peripheral IVs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of chemotherapy.

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which of the following interventions should the nurse perform for this complication? a) Position the client on the left side. b) Apply antiseptic and a dressing. c) Apply a warm compress. d) Elevate the client's head.

c) Apply a warm compress.

A nurse is flushing a patient's implanted port after administering medications. The nurse observes that the port flushes, but does not have a blood return. What would be the nurse's next action based on these findings? a) Gently push down on the needle and flush it a second time. b) Stop flushing and remove the needle; notify the primary care provider. c) Ask the patient to perform a Valsalva maneuver; change the patient position. d) Close the clamp; wait 3 minutes, try flushing the port again.

c) Ask the patient to perform a Valsalva maneuver; change the patient position. If a port flushes but does not have a blood return, the nurse should ask the patient to perform a Valsalva maneuver, have the patient change position or place the affected arm over the head, or raise or lower the head of the bed. If these measures do not work, the nurse should remove the needle and reaccess the device with a new needle.

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms indicative of what? a) A systemic blood infection b) Rapid fluid administration c) Phlebitis d) An infiltration

c) Phlebitis Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, pus, warmth, induration, and pain. A systemic infection includes manifestations such as chills, fever, tachycardia, and hypotension. An infiltration involves manifestations such as swelling, coolness, and pallor at the catheter insertion site. Rapid fluid administration can result in fluid overload, and manifestations may include an elevated blood pressure, edema in the tissues, and crackles in the lungs.

When providing chemotherapeutic agents, which catheter is accessed with a noncoring needle? a) Peripheral central catheter b) Hickman catheter c) Groshong catheter d) Implanted venous access

d) Implanted venous access

A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? a) Reposition the extremity and raise the height of the IV pole. b) Apply pressure to the dressing on the IV. c) Pull the catheter out slightly and reinsert it. d) Put on gloves; remove the catheter; apply pressure with a sterile pad.

d) Put on gloves; remove the catheter; apply pressure with a sterile pad. This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also apply pressure with a sterile gauze pad, secure the gauze with tape over the insertion site, and restart the IV in a new location.

A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess?

moist crackles heard upon auscultation

The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice?

ordering type of solution, additive, amount of infusion, and duration The nurse prepares the solution for administration, performs a venipuncture, regulates the rate of administration, monitors the infusion, and discontinues the administration when fluid balance is restored. The healthcare provider, not the nurse, specifies the type of solution, additional additives, the volume (in mL), and the duration of the infusion.

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms indicative of:

phlebitis. Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, pus, warmth, induration, and pain. A systemic infection includes manifestations such as chills, fever, tachycardia, and hypotension. An infiltration involves manifestations such as swelling, coolness, and pallor at the catheter insertion site. Rapid fluid administration can result in fluid overload, and manifestations may include an elevated blood pressure, edema in the tissues, and crackles in the lungs.

A nurse is initiating a peripheral venous access IV infusion for a pt. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool o the touch. What would be the nurses next action related to these findings

put on gloves; remove the catheter

A nurse is administering a blood transfusion for a pt displays signs of dyspnea, dry couch, and pulmonary edema. What would be the nurse's priority actions related to these symptoms?

slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent.

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 Phlebitis and thrombus present as local acute tenderness, redness, warmth, and slight edema of the vein above the site. Sepsis manifests as a red and tender insertion site with fever, malaise, and other vital sign changes. Infiltration or the escape of fluid into the subcutaneous tissue manifests as swelling, pallor, coldness, or pain around the infusion site and significant decrease in the flow rate. The signs of speed shock are pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, and dyspnea.