Nursing science pt 3

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

*A premature infant *A 101 year-old man *A client with heart failure *A client receiving renal dialysis

The nurse is assigned to care for a client with a peripheral intravenous (IV) infusion .The nurse is providing hygiene care to the client and would take which actions while changing the client's hospital gown? SATA

*Using a hospital gown with snaps at the sleeves *Checking the IV flow rate immediately after changing the hospital gown *Putting the bag and the tubing through the sleeve, followed by the client's arm

A client is going to be transfused with a unit of 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 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 is exhibiting which findings?

A decrease in oozing from puncture sites, and gums

The 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 would plan to take which action?

Change the IV tubing

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, or rash

A client has a prescription to receive 1000ml of 5% dextrose in 0.45% sodium chloride .After gathering the appropiate equipment,the nurse takes which action first before spiking the intravenous (IV) BAG with the tubing?

Closes the roller clamp on the IV tubing

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 (IV) site of an assigned client who is receiving fluid replacement therapy how frequently?

Every hour

The 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 complication has probably occurred?

Infiltration

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

Phlebitis of the vein

The nurse has been instructed to remove an (IV) line. The nurse removes the catheter while applying pressure to the site with which item?

Sterile 2 by 2 gauze

A client who was receiving a blood transfusion has expericed 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 a blood transfusion. the temperature is 100 orally. the nurse reports the findings to the registered nurse (RN) and anticipates that which action will take place?

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

A client who is receiving a blood transfusion pushes the call button for 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 assisting with caring for a client who will receive a unit of blood .just before the infusion ,it is important for the nurse to check which item?

Vital Signs