Saunders NCLEX Review Ch 13 & 14

117. The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question: 1. Have you ever had a transfusion before? 2. Why do you think that you need the transfusion? 3. Have you ever gone into shock for any reason in the past? 4. do you know the complications and risks of a transfusion?

1

118. A client receiving a transfusion of packed red blood cells begins to vomit. The clients blood pressure is 90/50 from a baseline of 125/78. The clients temperature is 100.8F orally from a baseline of 99.2F. The nurse determines that the client may be experiencing which complication of a blood transfusion? 1. Septicemia 2. Hyperkalemia 3. Circulatory overload 4. Delayed transfusion reaction

1

122. The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item? 1. Vitals 2. skin color 3. urine output 4. latest hematocrit level

1

103. A client had a 1000mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive with an increased pulse rate. The IV bag has 400mL remaining. The nurse should take which action first? 1. Slow the IV infusion 2. Sit the client up in bed 3. Remove the IV catheter 4. Call the health care provider

1 Circulatory overload

112. A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which IV solution will most likely be prescribed for this client? 1. 5% dextrose in lactated ringers solution 2. 0.33% sodium chloride (1/3 NS) 3. 0.45% sodium chloride (1/2) NS 4. 0.225% sodium chloride (1/4 NS)

1 to expand volume quickly

128. A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which actions to reduce the risk of possible transfusion complications? Select all that apply: 1. Ask a family member to donate blood ahead of time 2. Give an autologous blood donation before the surgery 3. Take iron supplements before surgery to boost hemoglobin levels 4. Request that any donated blood be screened twice by the blood banks 5. Take adequate amounts of of vitamin C several days prior to surgery date

1, 2

111. A client rings the call light and complains of pain at the site of an IV infusion. The nurse assess the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? Select all that apply: 1. Remove the IV catheter at that site 2. Apply warm moist packs to the site 3. notify the health care provider 4. start a new iv line in a proximal portion of the same vein 5. document the occurrence, actions taken, and the clients response

1, 2, 3, 5

127. The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. The nurse takes which actions in order to prevent a complication of the blood transfusion as it relates to deterioration of blood cells? Select all that apply: 1. checks the expiration date 2. inspects for the presence of clots 3. checks the blood group and type 4. checks the blood identification number 5. hangs the blood within the specified time frame per agency policy

1, 5 check expiration date to ensure blood is fresh

104. The nurse has a prescription to hang a 1000mL intravenous IV bag of 5% dextrose in water with 20mEq of potassium chloride. The nurse also needs to hang an IV infusion of piperacillin/tazobactam. The client has one IV site. The nurse should plan to take which action first? 1. start a second line 2. check compatibility of the medication and iv fluids 3. mix the prepackaged piperacillin/taxobactam per agency policy 4. prime the tubing with the iv solution and back prime the medication

2

108. The nurse is assessing a clients peripheral intravenous site after completion of vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best? 1. Check for the presence of blood return 2. remove the iv site and restart at another site 3. document the findings and continue to monitor the iv site 4. call the health care provider and request that the vancomycin be given orally

2

109. The nurse is preparing a continuous intravenous infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action? 1. Obtain a new IV bag 2. Obtain new IV tubing 3. Wipe the spike end of the tubing with povidone iodine 4. scrub the spike end of the tubing with an alcohol swab

2

113. The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further teaching when the client makes which statement? 1. I need to wear a MedicAlert tag or bracelet 2. I need to restrict my activity while this catheter is in place 3. I need to keep the insertion site protected when in the shower and bath 4. I need to check the markings on the catheter each time the dressing is changed

2

115. IV fluids have been infusing at 100mL/hour via a central line catheter in the right internal jugular four approximately 24 hours to increase urine output and maintain the clients blood pressure. Upon entering the clients room the nurse notes that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previously known data? 1. Excessive bleeding 2. Crackles in the lungs 3. Incompatibility of the infusion 4. Chest pain radiating to the left arm

2

124. Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement FIRST? 1. maintain bedrest with legs elevated 2. place the client in high fowlers position 3. increase the rate of infusion of intravenous fluids 4. consult with the health care provider regarding initiation of oxygen therapy

2

130. A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which IV solution from the IV storage area to hang with the blood product at the clients bedside? 1. Lactated RIngers 2. 0.9% sodium chloride 3. 5% dextrose in 0.9% sodium chloride 4. 5% dextrose in 0.45% sodium chloride

2

106. The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? Select all that apply: 1. pain and erythema 2. pallor and coolness 3. numbness and pain 4. edema and blanched skin 5. formation of a red streak and purulent drainage

2, 3, 4 Infiltration = pallor, coolness, edema, pain, numbness, and blanched skin

116. Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6 g/dL and a hematocrit level of 30%. The nurse takes the clients temperature before hanging the blood transfusion and records 100.6F orally. Which action should the nurse take? 1. Begin the transfusion as prescribed 2. administer an antihistamine and begin the transfusion 3. delay hanging the blood and notify the health care provider 4. administer 2 tablets of acetaminophen and begin the transfusion

3

119. The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next? 1. remove the IV line 2. Run a solution of 5% detrose in water 3. Run normal saline at a keep-vein-open rate 4. obtain a culture of the tip of the catheter device removed from the client

3

131. The nurse caring for a client who is receiving a blood transfusion and is complaining of a cough. The nurse checks the clients vital signs which include temperature of 97.2F, pulse 108, BP 152/76, RR 24, 95% O2 on room air. The client denies pain at this time. Based on this information, what initial action should the nurse take? 1. Collect a urine sample for analysis 2. Place the client in an upright position 3. Compare current data to baseline data 4. Slow the rate of the blood transfusion

3

126. a client is brought to the emergency department having experienced blood loss related to an arterial laceration. Which blood component should the nurse expect the health care provider to prescribe? 1. platelets 2. granulocytes 3. fresh frozen plasma 4. packed red blood cells

3 FFP is often used for volume expansion as a result of fluid and blood loss

120. the nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with which item? 1. 2 3. PHOTOS - FILTER 4.

3, filter

105. The nurse is completing a time tape for a 1000mL IV bag that is scheduled to infuse over 8 hours. The nurse has just placed the 1100 marking at the 500mL level. The nurse would place the mark for 1200 at which numerical level (mL) on the time tape? Fill in the blank: ___mL

375

107. The nurse is inserting an IV line into a clients vein. After the initial stick, the nurse would continue to advance the catheter in which situation? 1. The catheter advances easily 2. The vein is distended under the needle 3. The client does not complain of discomfort 4. Blood return shows in the backflash chamber of the catheter

4

110. A health care provider has written a prescription to discontinue an IV line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter? 1. Elastic wrap 2. Povidone iodine swab 3. Adhesive bandage 4. Sterile 2x2 gauze

4

123. The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. What action should the nurse take next? 1. check a set of vital signs 2. order the blood from the blood bank 3. obtain Y site blood administration tubing 4. check to be sure that consent for the transfusion has been signed

4

125. the nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion? 1. Hematocrit level 2. Erythrocyte count 3. Hemoglobin level 4. White blood cell count

4

121. A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the clients exhibits which finding? 1. Increased hematocrit level 2. Increased hemoglobin level 3. decline of elevated temperature to normal 4. decreased oozing of blood from puncture sites and gums

4 platelets are needed for proper blood clotting

129. A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias? 1. Infusion pump 2. Pulse oximeter 3. Cardiac monitor 4. Blood warming device

4 Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias

114. A client has just undergone insertion of a central venous catheter at the bedside under the ultrasound. The nurse would be sure to check which results before initiating the flow rate of the clients intravenous solution at 100mL/hour? 1. Serum osmolality 2. Serum electrolyte levels 3. Intake and output record 4. Chest radiology results

4 check proper placement