Part 1: Medications/Blood IV therapy PN NCLEX Oct

18. The medication prescribed is heparin sodium 650 units subcutaneously every 12 hours. The medication vial reads heparin sodium (Liquaemin), 1000 units/mL. The nurse prepares how many milliliters to administer one dose?

0.65 mL

What should the nurse not solely depend on?

blood return for assurance that the cannula is in the vein. The blood return may occur, even if the cannula is only partially in the vein

A nurse is preparing an IV solution and tubing for a client who needs IV fluids. When prepping to prime the tubing, the tubing drops. The nurse should do what?

change the IV tubing

14. A nurse is caring for a client who is receiving a unit of packed red blood cells. The nurse tells the client to report what sign immediately?

chills, itching or rash

What are signs and symptoms of air embolus?

confusion, pallor, lightheadedness, tachycardia, tachypnea, hypotension, anxiety (hypotension, rapid heart rate, rapid breathing, confused, pale,)

What if the IV tubing is not changed?

could cause systemic infectino

5. nurse is helping a client who has received a transfusion of platelets. The nurse determines the client is benefiting most from the therapy if the client exhibits?

decrease in oozing from gums and puncture sites

Phlebitis at IV site determined by?

discomfort of client, redness, warmth, swelling

8. Nurse is caring for patient with peripheral IV infusion. The nurse is providing hygiene care, and would avoid which of the following when changing gown?

disconnecting IV tubing from catheter

16. Medication prescribed is hydropmorphone (Dilaudid) 3 mg intramuscular every 4 hours. THe med reads hydromorphone hydrochloride (Dilaudid), 4 mg/1 mL. The nurse administers how many mL to the client?

formula which can be used: desired (3)/available (4) * mL

With air embolism, what would the nurse hear over the pericardium upon auscultation?

loud churning sound

Hypotonic solution compared to isotonic solution?

lower concentration of salt or more water than an isotonic solution

What does fluid overload cause?

neck vein distention, and fluid shifting in alveoli (lung crackles)

Safe nursing practice, monitoring an IV at least?

once per hour for an adult client (problems can occur quickly); best to select most frequently occuring time-frame

Nurse is checking insertion site of a peripheral IV. the nurse notes the site to be red, warm, edematous inthe area of the vein to the IV catheter. The nurse interprets this as?

phlebitis of the vein

What problems would cause warmth of the site?

phlebitis, infection, thrombosis

What are manifestations of hyperglycemia?

polyuria, polydipsia, polyphage

15. Which of the clients are most likely to develop fluid overload? A premature infant A 101-year-old man A client on renal dialysis A client with diabetes mellitus A 29-year-old woman with pneumonia A client with congestive heart failure

premature infant, 101-year old man, client on renal dialysis, client with congestive heart failure

Why is it important the nurse closes the roller clamp prior to spiking?

prevent the solution from running freely through the tubing. then the nurse should uncap the proximal (spike) portion of the tubing, and attach it. The roller clamp is then opened slowly, and fluid flows through the tubing in a controlled fashion so air is not in the tubing!

What does phelebitis result in?

redness, warmth, swelling proximal to the IV catheter (and discomfort)

What should occur with phlebitis?

remove IV catheter and insert at new location

71. A nurse notes blanching, coolness, edema at the peripheral intravenous site. Which is the most appropriate action?

remove the IV

80. A nurse notes the client's peripheral IV catheter is red, warm, painful, slightly edematous proximal to insertion point of IV catheter. Based on these findings, initial nursing action?

remove the IV

Remember to eliminat?

similar options (in practice question hypersensitivity/ and allergic reaction were elimnated)

Nurse has been told to discontinue an IV line. The nurse removes the catheter by withdrawing the catheter while applying pressure to a site with?

sterile 2X2 gauze

What does the increased intravascular volume increase?

the blood pressure

7. A nurse is assessing client's peripheral site. The nurse finds the site is pale, swollen, cool, IV has stopped running. What has probably occured?

infiltration

Why is the appropirate action to remove the IV for infiltration?

infiltration is damagint to the surrounding tissue, most appropriate to remove IV to prevent further damage

What is phlebitis?

inflammation of the vein due to medication/chemical trauma, mechanical trauma from IV going in, or a local infection

3 mL syringe is used to administer?

intramuscular or subcutaneous injections

How to change celcius to farenhei, 38 degrees C to F?

(38*9)= 342/5= 68.4 + 32= 100.4

47. A health care provider prescribes one unit of packed red blood cells to infuse over 4 hours. One unit of blood containts 250 mL and the drop factor is 10 gtt/1 mL. The RN asks the LPN to assist with monitoring the flow rate during infusion. The LPN monitors the flow rate, knowing how many gtt/min should infuse?

*note infusion over 4 hours use all the data given 250 mL/4 hours * 1 hour/60 minutes * 10 gtt/1 mL

55. A registered nurse tells a licensed pn, the hcp has prescribed hypotonic IV solution for a client. Which IV solution should the LPN obtain for administration to client?

0.45 % saline

9. Nurse is listing tasks to be performed. The nurse plans to check the IV of assigned patient receiving fluid replacement therapy at least every?

1 hour

30. The IV prescription is 3000 mL of 5% dextrose to run over 24-hour period. The drop factor is 10 gtt/1mL. The nurse plans to adjust the flow rate to how many gtt/minute (round to whole number)?

1) Method: use units 10 gtt/1 mL * 3000 mL * 1/24hour * 1 hr/60 minutes = 21 gtt/min 2) Total volume/Time in minutes * drop factor 3000 mL/1440 minutes *10 gtt

41. A postoperative client has a prescription to receive an IV infusion of 1000 mL normal saline solution over 10 hours. THe drop (gtt) factor for the IV infusion set is 15 gtt/mL. The nurse sets the flow rate at how many drops per minute?

25 gtt/minute 15 gtt/mL * 1000 mL/10 hours * 1 hour/60 minutes

61. Morphine sulfate, 2.5 mg subcutaneously, is prescribed for a client postoperatively. The medication label reads "1/15 grains/mL". How many milliliters should the nurse administer?

1/15 grain * 54.8 mg/grain in 1 mL 2.5 mg in x mL 0.6 mL

38. A nurse is asked to regulate the flow rate of an IV solution being administered. The IV bag contains 50 mL of solution, and the solution is to be administered over 30 minutes. The administration set has a drop factor of 10 drops (gtt)/mL. The nurse should regulate the roller clamp on the infusion set to deliver how many drops per minute?

10 gtt/mL * 50 mL/30

58. A nurse is checking the remaining volume in a 1000-mL IV bag that is schedules to infuse over 8 hours. The nurse had just noted that at 11:00 AM the remaining IV fluid is at the 500-mL level. When she returns at noon, which value (mL) should the IV fluid be?

1000 mL/ 8 hour = 125 mL/hour 500-125 = 375

75. A nurse is preparing to hang an intravenous solution of 1000 mL 5% dextrose in lactated Ringer's to flow at 80 mL/hour. The nurse time-tapes the bag with a start time of 07:00. After making horuly marks on the time-tape, the nurse notes that the completion time for the bag is?

1000 mL/x hours = 80 mL/ 1 hour Take 12.5 hours 07:00 + 12.5 = 19:30 (not .5)

79. Health care provider's prescription reads: cyanobalamin (vitamin B12) 100 mcg intramuscular. THe medication label reads "cyanocobalamin (vit B12), 0.5 mg/mL. The nurse administers how many mL to the client

1000 mcg = 1 mg 0.5 mg/1 mL = 0.1/ x = 0.2 mL

46. Health care provider prescribes 1000 mL of 5% dextrose to run at 125 mL/hour. THe nurse calculates the infusion rate, knowing it will take how many hours for 1 L to infuse?

125x = 1000 x= 8 hours or total volume in mL (1000) ------- mL/hour (125 mL/hour) = 8 hours

29. The medication is an IM dose of 400,000 units of penicillin G. The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine (Bicillin) 300,000 units/mL. The nurse prepares how much medication to administer the correct dosage?

4/3= 1.3 remember that the vial is 10 mL 3,000,000/10 = 400,000/x

48. Diphenhydramine hydrochloride (benadryl), 25 mg orally every 6 hours, is prescribed for a child who weighs 25 kg. The safe pediatric dosage is 5 mg/kg/day. Is the dosage safe?

5 mg/kg/day *25 kg = 125 mg/day (safe dosage) given: 25 mg/ 6 hr * 24 hr/1 day = 100

What are other examples of isotonic solution, besides lactated ringer's?

5% dextrose in water, 0.9% normal saline, 5% dextrose in 0.225% normal saline

Use process of eliminate and notice that?

5% dextrose in water, 10 % dextrose in water, 5% dextrose in 0.9% saline are comparable or alike. All contain dextrose, and the 0.45% saline is the only different one

1 grain, how many mg?

64.8 mg (NCLEX says 1 gr = 60 mg)

When are warm compresses applied?

after IV is removed, and only if infiltrated solution is not damaging to surrounding tissue

31. Nurse is preparing to administer medication through an NG tube connected to suction. What indicates the accurate procedure for medication administration?

Clamp the NG tube for 30 minutes after medication administration

40. The nurse notes the appearance of skin breakdown on a client's hand at the site of intravenous catheter that had medication infusing. The nurse determines that which adverse effect occured? Figure shows open region, top few layers of skin gone/down to adipose, circular, swollen edges, red

Extravasation (vesicant substance ate through the skin)

What is infiltration?

IV fluid goes out of vein, and into the interstitial space, it is tissue injury but not as extreme as extravasation

Measuring infiltration should be done after?

IV has been removed

56. IV lactated Ringer's solution is prescribed for a postoperative client. A nursing student is caring for the client, and the nursing instructor asks the student about the tonicity of the prescribed solution. The student responds by telling the instructor the solution is?

Isotonic solution

Why is it important for the nurse to check the client's vital signs PRIOR to the infusion?

It's important to have a baseline value, otherwise it will be harder to see if a transfusion reaction ocur

What are the s/s of air embolism?

chest pain, dyspnea, hypoxia, anxiety, tachycardia, hypotension

76. A normal saline 0.9% IV solution is prescribed. The IV is to run at 100 mL/hour. The nurse prepares the solution, understanding which of the following is characteristic of the solution?

is the same solution as sodium chloride 0.9%

What type of solution is 5% dextrose in water?

isotonic solution

Normal saline 0.9% is?

isotonic, and are used for IV infusions because they do not influence the plasma osmolarity

Why eliminate phlebitis and thrombosis first from the question?

comparable, or alike, and r/t vein injury

When would levels of hemoglobin and hematocrit increase?

client has received transfusion of RBC

What clients cannot tolerate excessive fluid volume, and are therefore most likely to develop fluid overload?

client with respiratory, renal , cardiac, liver disease, older/very young

Fluid overload?

crackles and dyspnea

When would a fever be present?

sepsis

13. Client going to be transfused with a unit of packed red blood cells. The nurse understands it is necessary to remain with the client for what time period after transfusion has started?

15 minutes

17. Medication prescribed is digoxin (Lanoxin), 0.25 orally daily. Med lable 0.125 mg/tablet. THe nurse prepares how many tablets to administer the dose?

2

32. Morphine sulfate, 2.5 mg, is prescribed for a child. The safe pediatric dosage is 0.05 to 0.1 mg/kg/dose. The child weights 50 kg. Which statement describe the prescribed dosage?

2.5 mg/50 kg= 0.05 mg/kg This dosage is safe or 0.05 mg/kg/dose *50 kg = 2.5 mg/dose (safe 0.1 mg/kg/dose *50 kg = 5 mg/dose

6. Client has prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering appropriate equipment, the nurse takes which action prior to spiking the IV bag with tubing?

closes the roller clamp on the IV tubing

Why is 15 minutes, the time for the nurse to wait?

this is the most likely time a transfusion reaction will occur

What can phlebitis result in?

thrombophlebitis, clot development

What syringe is best to give an infant medication?

tuberculin syringe

How long should the nurse wait before reconnecting the tube to the suction?

up to 30 minutes, medication needs time for absorption

1. A nurse is helping a client who will receive a unit of blood. Prior to the infusion, it is MOST important for the nurse to check the client's?

vital signs

What is extravasation?

when tissue is damaged due to medication leakage through the surrounding skin and subcutaneous tissue/ can cause necrosis of tissue

Administering granulocytes (important to infection)?

would result in decreased temperature

52. A client receiving IV fluid therapy complains of burning and feeling of tightness at the IV insertion site. On assessment, the nurse detects coolness and swelling, and notes the IV flow rate has slowed. What has occured?

infiltration

10% dextrose in water?

hypertonic solution

10% dextrose in water, 5% dextrose in 0.9% normal saline, 5% dextrose in 0.45% normal saline are?

hypertonic solutions

5% dextrose in 0.9% saline?

hypertonic solutions

What is 0.45% normal saline?

hypotonic

Distilled water is an example of a?

hypotonic solution

57. A nurse is checking the IV dressing of a client with a peripheral intravenous solution infusing. The date on the dressing is 2/9 (Feb 9). The nurse calculates that the dressing should be changed on which of the following dates?

2/12

What will not be affected by transfusion of platelets?

increase in hematocrit, increase in hemoglobin, decline in temperature to normal

2. Client receiving a blood transfusion, rings for the nurse. The client is flushed, itching, and dyspenic. The nurse believes the client is experiencing?

a transfusion reaction

51. Client who has been receiving parenteral nutrition by way of central venous access device complains of chest pain and dyspnea. The nurse quickyl assesses the client's vital signs and notes the pulse rate has increased, and the blood pressure has dropped. The nurse determines the client is experiencing?

air embolism

Eliminate slow rate of infusion and check for loose catheter connections because?

alike in that they continue the IV therapy

Describe the tuberculin syringe?

long, thin barrel, calibrated in sixteenths of a minim and hundredths of a milliliter with a capacity of 1 mL. It is used to prepare small amounts of medication such as precise doses for infants or young children

26. The med prseecription states to administer Tylenol 650 mg orally for temp of more than 38 degrees (100.4 F). The med bottle states Tylenol is 325 mg tablets. The nurse takes the client's temp and notes that it is 101. The nurse does what?

temperature of client is over 100.4, administer 2 tylenol tablets

3. A client is experiencing a transfusion reaction. The nurse sends the blood bag that was used for the client to which area?

the blood bank

4. Nurse takes client's temp prior to blood transfusion, and the temperature is 100 degrees F orally. The nurse anticipates which action?

the blood will be held, and the health care provider will be notified

What are alike options to eliminate?

aspirate the NG tube after med administration, change the suction setting to low intermittent suction

Why are clients on renal dialysis likely to have fluid overload?

anuria sometimes occurs, when urine is not excreted or the low output of urine (oliguric)

Why return the blood to the blood bank?

any follow-up testing procedures that are needed after a transfusion reaction have been documented

What does infiltration mean, and why does it cause a pale/swollen/cool site?

dislodged from the vein, in the subcutaneous tissue. The coolness, pallor, and swelling is due to the IV fluid being deposited in subcutaneous tissue. The stopping of flowage is due to an increase in pressure in the tissues, which is greater than the pressure in the tubing

Changing the dressing on a daily basis is not necessary unles/

dressing becomes wet

When are the vital signs assessed when beginning the transfusion?

every 15 minutes for the first half hour after beginning the transfusion, and every half hour thereafter (not important to check skin color, O2 saturation, or latest hematocrit level)

When should the IV site dressing be changed?

every 48-72 hours, which is every 2 to 3 days. For the question 2/11-2/12 would be acceptable

If a client has bacteremia, what are signs?

fever

What are the signs of sepsis?

fever, malaise, chills

42. Client who is receiving PN complains of a headache. THe nurse notes that the client has increased blood pressure and a bounding pulse. The nurse reports the findings, knowing that these signs are indicative of which complicatio nof therapy?

fluid overload

Why does the pulse rate increase in fluid overload?

heart tries to pump the extra fluid volume