Med Surg IV
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction? A.) Bilateral flank pain B.) Distended juglar veins C.) Blood pressure 184/92 mm Hg D.) Itching
D
A nurse is planning care for a client who is to receive a blood transfusion. The nurse knows the total infusion time for a unit of packed red blood cells should not exceed which of the following? A.) 2 hours B.) 6 hours C.) 8 hours D.) 4 hours
D
A client who is postoperative is receiving IV fluids and a unit of whole blood. The nurse should observe the client for which of the following as an early sign of circulatory overload? A.) Flushing B.) Dyspnea C.) Bradycardia D.) Vomiting
B
A nurse is administering platelets to a client who reports feeling chilled and is itching. Which of the following is a priority nursing action? A.) Notify the provider B.) Stop the infusion C.) Maintain IV line with 0.9% sodium chloride D.) Return the platelet bag and tubing to the blood bank
B
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction? A.) Generalized urticaria B.) Blood pressure 184/92 mm Hg C.) Distended juglar veins D.) Bilateral flank pain
A
A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following should be the first nursing action? A.) Stop the transfusion immediately B.) Cover the client with a blanket C.) Notify the provider D.) Assess the client's skin for a rash
A
A nurse is preparing to administer blood to a client. As the nurse begins to check the 1st unit with another nurse, she notices that the unit of blood is type B and the client's blood type is AB. Which of the following actions should the nurse take? A.) Administer the blood as ordered B.) Contact the provider for IV orders C.) Notify the blood bank D.) Notify the blood bank supervisor
A
A provider prescribes a transfusion of one unit of packed RBC for a client who has a low hemoglobin level. The provider also prescribes diphenhydramine (Benadryl) for administration before the transfusion to prevent__________________. A.) urticaria B.) fever C.) fluid overload D.) hemolysis
A
A nurse is caring for a client receiving total parenteral nutrition (TPN) therapy via an infusion pump. When assessing the client receiving this therapy, which of the following observations by the nurse is of least importance? A.) IV site B.) Height of IV pole C.) Date of tubing D.) Contents of solution bag
B
A nurse is caring for a client treated with intermittent IV vancomycin (Vancocin). The client reports pain at the IV site when the nurse starts the infusion. Which of the following nursing actions is appropriate at this time? A.) Notify the provider and have the medication changed B.) Assess the patency of the IV site C.) Turn down the infusion rate on the IV D.) Apply cold compresses to the site after the medication has infused
B
A nurse is monitoring a client who is receiving packed RBCs. Which of the following findings is expected during blood administration? A.) The drip chamber with filter is filled completely with blood B.) The packed RBCs are connected by Y tubing to normal saline C.) The blood has been infusing steadily for 5 hr with no client symptoms D.) A medication is being administered IV through the Y site closest to the client
B
A nurse is monitoring a client's IV site. Which of the following findings are NOT associated with phlebitis? A.) Erythemia B.) Damp dressing C.) Throbbing D.) Warm at insertion site
B
A nurse is planning possible interventions in the care of a client who may have a need for total parental nutrition (TPN). Which of the following clients should benefit from TPN? A.) A client who has acute gastritis B.) A client who has a complete bowel obstruction C.) A client who has been vomiting for the past 4 hours D.) A client who has undergone a cholecystectomy
B
A nurse is caring for a client who is prescribed an infusion of 5% dextrose in water. Which of the following is the amount of dextrose in this solution? A.) 5 g/L B.) 500 g/L C.) 5 g/100 mL D.) 50 g/100 mL
C
A nurse is monitoring a client's IV site. Which of the following findings are NOT associated with infiltration? A.) Decreased skin temperature B.) Pallor C.) Throbbing D.) Local swelling
C
A nurse is monitoring a client's transfusion of packed red blood cells and suspects that a hemolytic reaction is occuring. Which of the following is the priority intervention? A.) Assess the client's respiratory rate B.) Administer 0.9% sodium chloride through the IV line C.) Stop the transfusion D.) Notify the blood bank
C
A nurse is planning care for a client who is dizzy and lightheaded from severe dehydration over the past 72 hours. Which of the following is an appropriate nursing action? A.) Monitor output every 6 hours B.) Offer 6 oz of oral fluids every hour C.) Assess pulse rate and quality D.) Infuse hypotonic IV fluids
C
A nurse is caring for a group of clients who require parenteral therapy via a central access catheter. Which of the following clients is not a candidate for placement of a peripherally inserted central catheter (PICC)? A.) A client requiring routine blood samplings B.) A client who has anemia and is receiving blood transfusions C.) A client who has cancer and is receiving chemotherapy D.) A client who has paraplegia and requires antibiotic therapy
D
A client is to receive a unit of packed red blood cells. The nurse should prime the blood administration tubing using which of the following IV solutions? A.) Lactated Ringer's solution B.) 0.9% sodium chloride C.) Dextrose 5% in water D.) Dextrose 5% in 0.45% sodium chloride
B
A nurse is discussing with a newly licensed nurse the information that should match on the requisition and the blood product prior to administration. Which of the following statements by the newly licensed nurse necessities interventions? "Both the requisition and the blood product should identify the _____________________. A.) client's identification number." B.) blood group and type." C.) blood unit number." D.) blood bank of origin."
D
A nurse is providing education to a client who is being discharged home with total parental nutrition (TPN). Which of the following statements by the nurse is NOT appropriate? A.) "Keep the TPN refrigerated when not in use." B.) "Warm the TPN bag in the microwave before hanging." C.) "Shake the TPN bag before administering." D.) "Maintain TPN infusion rate when behind schedule."
D
