quiz 5- chapter 15
a client is being admitted to the burn unit from another hospital. according to the clients medical record, the client has an intraosseous IV that was started 2 days ago. which nursing action is most appropriate? A. anticipate an order to discontinue the intraosseous IV B. call the previous hospital to verify the date C. immediately discontinue the intraosseous IV D. start an epidural IV
A
a client who takes corticosteroids daily for RA requires insertion of an IV catheter to receive antibiotics for 5 days. which type of catheter does the charge nurse teach the new nurse to use? A. midline Cath B. tunneled percutaneous central Cath C. peripherally inserted central Cath D. short peripheral Cath
A
the nurse is teaching a client who is being discharged about care for a peripherally inserted central catheter (PICC) line. which client statement indicates a need for further teaching? A. I can continue my 30 mile running schedule as I have in the past B. I can still go about my normal activities of living C. I have less chance of infection because the line is not in my hand D. the PICC line can stay in for months
A
the nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. what will the nurse do first? A. assess the insertion site B. check connections C. check the infusion rate D. discontinue the IV and start another
A
the nurse is starting a peripheral IV catheter on a client who was recently admitted. What actions does the nurse perform before insertion of the line? (Select all that apply.) A. Apply povidone-iodine to clean skin, dry for 2 minutes. B. Clean the skin around the site. C. Prepare the skin with 70% alcohol or chlorhexidine. D. Shave the hair around the area of insertion. E. Wear clean gloves and touch the site only with fingertips after applying antiseptics.
A, B, C
a client that is receiving IV antibiotic therapy q 6 hours has an intermittent IV set that was opened 20 hours ago. what action will the nurse take? A. change the set immediately B. change the set in about 4 hour C. change the set in the next 12-24 hour D. nothing; the set is for long term use
B
the nurse is administering a drug to a client through an implanted port. before giving the medication, what will the nurse do to ensure safety? A. administer 5mL of heparinized solution B. check for blood return C. flush the port with 10mL of NS D. palpate the port for stability
B
the nurse is admitting patients to the same day surgery unit. which insertion site for routine peripheral venous catheters will the nurse choose most often? A. back of the hand B. cephalic vein on the forearm C. palmer side of the wrist D. subclavian vein
B
the nurse is checking an IV fluid order and questions the accuracy. what nursing action is appropriate? A. ask the charge nurse about the order B. contact the prescriber C. contact the pharmacy for clarification D. start the fluid as ordered
B
the nurse is teaching a course about special needs of older adults. receiving IV therapy. what teaching will the nurse include? A. placement of the catheter on the back of the clients dominant hand is preferred. B. skin integrity can be damaged easily by the application of tape or dressings. C. to avoid rolling the veins, a greater angle of 25 degrees between the catheter and the skin improves success with venipuncture. D. when the catheter is inserted in the forearm, excess hair should be shaved.
B
the nurse is too administer a unit of whole blood to a post op client. what will the nurse do to ensure safety of the blood transfusion? A. ask the client to both say and spell his or whole full name before starting B. ensure that another qualified health care professional check the unit before administering C. check the blood identification numbers with the lab tech at the blood bank at the time it is dispensed D. make sure that 0.9% NS is infusing into the client before starting
B
the primary healthcare provider has prescribed 1 liter of D5NS to infuse at a rate of 125 ml/hr. the nurse begins the infusion at 0700. when will the nurse anticipate the completion of the infusion? A. 1300 B. 1500 C. 1900 D. 2100
B
which nursing assessment data indicate the need for immediate nursing intervention? A. client states "it really hurt when the nurse put the IV in" B. the vein feels hard and cordlike above the insertion site C. transparent dressing was. changed 5 days ago D. tubing for the IV was changed 72 hours ago
B
the nurse is documenting peripheral venous catheter insertion for a client. what will the nurse include in the note? select all that apply. A. clients name and hospital number B. clients response to insertion C. date and time inserted D. type and size of device E. type of dressing applied F. vein used for insertion
B, C, D, E, F
The nurse is revising an agency's recommended central line-associated bloodstream infection (CLABSI) bundle. Which actions decrease the client's risk for this complication? (Select all that apply.) A. During insertion, draping just the area around the site with a sterile barrier B. Removing the client's venous access device (VAD) when it is no longer needed C. Making certain that observers of the insertion are instructed to look away during the procedure D. Thorough hand hygiene before insertion E. Using chlorhexidine for skin disinfection
B, D, E
A client had a 20-gauge short peripheral catheter (SPC) inserted for antibiotic administration 48 hours ago. Which nursing intervention is appropriate? A. discontinue the SPC B. relocate the SPC for infection control C. assess the SPC for redness, swelling, or pain D. change the occlusive dressing covering the SPC
C
a 22 yo client presents with appendicitis and is preparing for surgery. what gauge catheter will the ED nurse select for this client? A. 24 B. 22 C. 18 D. 14
C
a male client is seen in the ED with pain, redness, and warmth in the right lower arm. the client was in the ED last week after an accident at work where he received 12 hours of IV fluids. on assessment, the nurse notes a palpable cord 1 inch in length and a streak formation. how will the nurse document the assessment? A. grade 1 phlebitis B. grade 2 phlebitis C. grade 3 phlebitis D. grade 4 phlebitis
C
an older adult client receiving an infusion of 5% dextrose in 0.9% NS at 150 ml/hr has developed SOB with a decrease in oxygen saturation to 86%. what is the priority nursing intervention? A. notify the health care provider B. place the client on oxygen C. sit the client upright in bed D. assess the clients lung sounds
C
the nurse is inserting a peripheral IV catheter. which client statement is of the greatest concern? A. I hate having IVs started B. it hurts when you are inserting the line C. my hand tingles when you poke me D. my IV lines never last very long
C
the nurse is preparing to insert a peripheral venous catheter. what action will the nurse take? A. palpate for hardness of the vein B. use the clients dominant arm for insertion C. select the most distal site D. look near the elbow joint first
C
when flushing a clients central line with NS, the nurse feels resistance. which action will the nurse take first? A. decrease the pressure being used to flush the line B. obtain a 10mL syringe to reattempt flushing C. stop flushing and try to aspirate blood D. use push pull pressure applied to the syringe when flushing the line
C
which client on the unit does the charge nurse assign to the LPN? A. a client who has a diltiazem IV infusion being titrated to maintain a HR of 60-80 BPM. B. a client admitted for hyperglycemia who has an IV insulin drip and needs frequent glucose checks. C. an. older client admitted for confusion who has a heparin lock that needs flushed q 8 hours. D. a client receiving blood products after excessive blood loss during surgery
C
a client receiving gentamicin intravenously reports that the peripheral IV insertion site has become painful and reddened. what is the priority nursing action? A. contact the primary health care provider B. document the findings in the electronic health record C. change the IV site to a new location D. stop infusing the drug
D