Module 07: Exam

After receiving report, which of the following patients should the nurse see first? A patient: A. who is receiving an IV piggyback antibiotic and is complaining of shortness of breath and itching B. who is unable to explain the purpose and side effects of the medication. C. who complained of "stinging" at the IV site when the previous nurse administered an IV push medication. D. with IV fluids infusing without difficulty but who was reported to have no blood return upon aspiration.

A

Which of the following are disadvantages of an IV bolus? (Select all that apply.) A. Absence of time to correct errors. Correct B. Can cause direct irritation to lining of the blood vessels. Correct C. IV primary infusion unable to infuse at same time.

A, B

Which of the following are assessment measures the nurse should make before administering an IV medication? (Select all that apply.) A. Patency and appearance of IV site. B. Length of time patient has been hospitalized. C. History of medication allergies. D. Patient's understanding of medication therapy. E. Assistive personnel's ability to monitor infusion. F. Drug information and compatibility. G. Rate of infusion.

A, C, D, F, G

The nurse is to administer 5 mg of morphine sulfate (morphine) IV push. The medication is available as 10 mg/mL. What is the nurse's best action? A. Assess the patient's IV site for patency, and administer 2 mL of morphine sulfate. B. Dilute the amount of morphine sulfate to be given in 5 to 10 mL of 0.9% sodium chloride and administer at the correct rate C. Administer 0.5 mL of morphine sulfate at the correct rate by IV push without further dilution. D. Administer 5 mL of morphine sulfate, followed by a flush of 2 to 3 mL normal saline.

B

The nurse is planning to administer medication by IV bolus through a saline lock. After the medication is delivered, why is it necessary to flush the port with 2 to 3 mL of normal saline at the same rate as the medication was delivered? A. In order to ensure patency of the IV site while observing for puffiness. B. To prevent dislodging a blood clot into the bloodstream. C. To ensure that any medication remaining within the IV is delivered at the correct rate D. To avoid causing circulatory compromise from fluid volume excess.

C

The nursing instructor is reviewing IV medication administration with the nursing students. Which of the following statements, if made by a student, indicates further instruction is needed? A. "The nurse should never administer IV medications through tubing that is infusing blood, blood products, or parenteral nutrition solutions." B. "The six rights of medication administration include the right medication, the right dose, the right patient, the right route, the right time, and the right documentation." C. "If the IV bolus medication is incompatible with the IV fluids, another IV site will have to be started." D. "The administration of hyperosmolar drugs by the intravenous route increases the risk of phlebitis."

C

Which is a disadvantage of a piggyback infusion? (Select all that apply.) A. Absence of time to correct errors. B. Can cause direct irritation to lining of the blood vessels. C. IV primary infusion unable to infuse at same time.

C

Which of the following is a correct sequence for administering an IV piggyback through an existing IV infusion that uses a needleless system? A. Connect infusion tubing to medication bag and prime tubing, hang piggyback medication bag at same level as primary fluid bag, wipe off lower Y-port of primary infusion line with an alcohol swab, and insert tip of piggyback infusion tubing, then regulate flow rate of IV piggyback. B. Cleanse the port with alcohol and assess the patency of the IV line by flushing it with 2 to 3 mL of sterile normal saline. Attach appropriate IV tubing to the saline lock, and administer the medication via piggyback. When the infusion is completed, disconnect the tubing, cleanse the port with alcohol, and flush the IV line with 2 to 3 mL sterile normal saline. C. Connect infusion tubing to medication bag and prime tubing, hang piggyback medication bag above level of primary fluid bag, wipe off upper Y-port of primary infusion line with an alcohol swab and insert tip of piggyback infusion tubing, and regulate flow rate of IV piggyback.

C

The nurse needs to administer an IV push medication for a patient who is complaining of pain. The medication is incompatible with the IV fluid that is infusing. What is the nurse's best initial action? A. Initiate a saline lock in a different location (proximal to the present IV site) to be used for IV push medications. B. Wait until the infusion is complete and then administer the pain medication. C. Contact the health care provider and request the pain medication be given by a different route, or request a different pain medication that would be compatible with the IV fluids. D. Stop the infusion, flush with 10 mL of 0.9% sodium chloride, give the IV pain medication over the appropriate amount of time, flush with another 10 mL of 0.9% sodium chloride at the same rate as the medication was administered, and restart the IV fluids.

D

The nurse wants to take appropriate precautions when administering IV medications in order to provide safe and effective nursing care. Which of the following may prevent the nurse from reaching the goal of safe, effective care? A. The nurse is aware the presence of liver or kidney diseases may increase the risk of an adverse drug reaction. B. Clean gloves are worn during administration of an IV bolus. C. The nurse uses commercially prepared solutions and medications when available. D. The nurse labels the IV medication with the drug name and patient's name

D