321 module 1 IV and Blood tranfusion

The nurse begins a routine blood transfusion of packed red blood cells (PRBCs) at 1100. To ensure client safety, the unit of blood should be completely transfused by what time?

Administration time for PRBCs should not exceed 4 hours because of the increased risk of bacterial proliferation. For the first 15 minutes, the transfusion should be run slowly- no faster than 5 mL/min.

The client is to receive a unit of packed red blood cells. The first intervention of the nurse is to You Selected: Verify that the client has signed a written consent form.

All the options are interventions the nurse will do to ensure the blood transfusion is safe. The question asks about the first action of the nurse. The first action would be verifying that the client has signed a written consent form. Then, the nurse would ensure the intravenous site has a 20-gauge or larger needle. The nurse would proceed to obtain the unit of blood, check the blood with another registered nurse, and observe for gas bubbles in the unit of blood.

Heparin infusions are titrated using which of the following lab values?

Anti-Xa and PTT

The nurse is collecting equipment to administer a unit of packed red blood cells. Which IV fluid should be used to initiate the IV for this transfusion? 1. 1,000 mL of lactated Ringer's solution 2. 250 mL of normal saline 3. 500 mL of 5% dextrose and water 4. 100 mL of 5% dextrose and 1/2 normal saline

Correct Answer: 2 Rationale: Blood and blood products should only be administered with normal saline. Other IV fluids may cause damage to the cells being administered.

The client is admitted to the acute care unit with a phosphorus level of 2.3 mg/dL. Which nursing intervention would support this client's homeostasis? 1. Encourage consumption of milk and yogurt. 2. Enforce strict isolation protocols. 3. Encourage consumption of a high-calorie carbohydrate diet. 4. Strain all urine.

Correct Answer: 1 Rationale 1: A phosphorus level of 2.3 is low and the client needs additional phosphorus. Provision of phosphorus-rich foods such as milk and yogurt is a good way to provide that additional phosphorus. Rationale 2: There is no indication of the need to place this client in strict isolation. Rationale 3: A high carbohydrate diet is not going to improve this client's phosphorus level. Rationale 4: Straining all urine is not going to improve this client's phosphorus level.

The nurse is preparing to start an IV in the hand of a client who has very small veins. Which actions would be useful in dilating the veins? (Select all that apply.) 1. Position the hand at heart level. 2. Stroke the vein. 3. Have the client clench and unclench the fist. 4. Slap the back of the client's hand. 5. Massage the vein.

Correct Answer: 2,3,5 Rationale 1: The hand should be lower than the heart to dilate the vein. Rationale 2: Stroking the vein is helpful to help dilate the vein. Rationale 3: Having the client clench and unclench the fist is a strategy used to help dilate a vein. Rationale 4: Slapping the vein is contraindicated and may actually reduce venous filling. Rationale 5: Massaging the vein helps with vein dilation.

A client on diuretic therapy has a serum potassium level of 3.4 mg/dL. Which food would the nurse encourage this client to choose from the dinner menu? 1. Baked chicken 2. Green beans 3. Cantaloupe 4. Iced tea

Correct Answer: 3 Rationale: A potassium level of 3.4 is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, the highest in potassium is cantaloupe.

A nurse needs to administer medications to a client through an intravenous port. Which of the following actions should the nurse perform to ascertain that the IV catheter is in the vein?

Observe the tubing near the insertion device

A client tells the nurse that he would like to donate blood before his abdominal surgery next week. What should be the nurse's first action?

Explain the time frame needed for autologous donation. Explanation: Preoperative autologous donations are ideally collected 4 to 6 weeks before surgery. The nurse should first explain that time frame to this client. Surgery is scheduled in one week which means that autologous blood donation may not be an option for this client. A list of donation centers can be provided to the client; and even though iron is recommended and 2 units of blood may be suggested, the first action is to tell the client about the needed time frame for donation.

A nurse is caring for a patient who has had a bone marrow aspiration with biopsy. What complication should the nurse be aware of and monitor the patient for?

Hemorrhage Explanation: Hazards of either bone marrow aspiration or biopsy include bleeding and infection. The risk of bleeding is somewhat increased if the patient's platelet count is low or if the patient has been taking a medication (e.g., aspirin) that alters platelet function.

A client involved in a motor vehicle accident arrives at the emergency department unconscious and severely hypotensive. The nurse suspects he has several fractures in the pelvis and legs. Which parenteral fluid is the best choice for the client's current condition?

Packed red blood cells (RBCs) Explanation: In a trauma situation, the first blood product given is unmatched (O negative) packed RBCs. Fresh frozen plasma is commonly used to replace clotting factors. Normal saline or lactated Ringer's solution is used to increase volume and blood pressure; however, too much colloid will hemodilute the blood and doesn't improve oxygen-carrying capacity as well as packed RBCs do.

A patient has been ordered to begin an insulin infusion. The initial blood glucose is 285. What is the correct bolus amount of insulin to give the patient and the correct rate to start the insulin infusion?

Bolus 4 units and begin infusion at 2 units/hr

Which of the following is MOST IMPORTANT when administering an IV Push medication in order to prevent crystallization in the IV tubing?

Y site compatabilty

A nurse is preparing an intravenous infusion. Which part of the administration set would the nurse use to manually regulate the infusion rate? Slide clamp Drip chamber Spike Roller clamp

Roller clamp p. 479-480 Rationale: When regulating the flow rate manually, the nurse would use the roller clamp on the administration set. The spike is used to access the solution container. The drip chamber is compressed to be filled half-way to initiate and maintain the flow through the tubing. The roller clamp can be used to stop the flow through the tubing

Which parenteral potassium order is safe for the nurse to implement? 1. Add 20 mEq of KCL to 1,000 mL of IV fluid 2. 10 mEq KCL IV over 1-2 minutes 3. Dilute 20 mEq KCL in 3 mL of NS and give IV push 4. 10 mEq KCL SQ

Correct Answer: 1 Rationale 1: Parenteral potassium should be well diluted and given IV. Rationale 2: If given in concentrated form, parenteral potassium is lethal to the client. Rationale 3: Parenteral potassium should be well diluted and given IV. It is not given SQ, by IV push, or in limited dilution (such as 20 mEq in 25 mL of fluid). Rationale 4: Parenteral potassium should be well diluted and given IV. It is not given SQ, by IV push, or in limited dilution (such as 20 mEq in 25 mL of fluid).

The 154-pound adult client has had vomiting and diarrhea for 4 days secondary to a viral infection. What hourly urine measurement would indicate that efforts to rehydrate this client have not yet been successful and should continue? 1. 35 mL per hour 2. 80 mL per hour 3. 50 mL per hour 4. 30 mL per hour

Correct Answer: 4 Rationale 1: This is the expected urine output and would be considered successful. Rationale 2: This volume of urine output means efforts to rehydrate the client have been successful. Rationale 3: This volume of urine output indicates efforts to rehydrate the client have been successful. Rationale 4: Normal urine output for adult clients is at least 0.5 mL/kg/hour. This client weighs 70 kg, so adequate urine output would be 35 mL/hour. The only option lower than 35 mL per hour is 30 mL per hour.

A patient is receiving IV therapy with an isotonic solution. The nurse notes swelling and coolness at the site along with an absent blood return. Which of the following would the nurse suspect?

Infiltration p. 487 Rationale: When IV solutions, such as isotonic solutions, inadvertently leak into the subcutaneous tissues, it is called infiltration. If the solution or medication is a vesicant or highly irritating, then it is called extravasation. Phlebitis is an inflammation of the vascular endothelium characterized by pain, warmth, and redness at the site. An air embolism involves the entry of air into the client's circulatory system manifested by pain in the chest, shoulder, or back; dyspnea; hypotension; thready pulse; cyanosis; and eventually loss of consciousness.

The nurse is working at a blood donation clinic. What teaching should the nurse provide to the donor immediately after blood donation?

Remain for observation after eating and drinking. Explanation: After blood donation, the donor receives food and fluids and is asked to remain for observation. After the needle is removed, donors are asked to hold the involved arm straight up, and firm pressure is applied with sterile gauze for 2 to 3 minutes. A firm bandage is then applied. The donor remains recumbent until he or she feels able to sit up, usually within a few minutes.

The nurse is reviewing laboratory data for a client who is receiving total parenteral nutrition. Which laboratory value should be immediately brought to the physician's attention?

serum glucose of 328 Serum glucose of 328 Potassium of 3.5 BUN of 60 Prealbumin of 15

A patient with a history of congestive heart failure has an order to receive one unit of packed red blood cells (RBCs). If the nurse hangs the blood at 12:00 pm, by what time must the infusion be completed?

4:00 pm

The mother of a 1-month-old infant is concerned because the infant has had vomiting and diarrhea for 2 days. What instruction should the nurse give this infant's mother? 1. Have the infant be seen by a physician 2. Give the infant at least 2 ounces of juice every 2 hours. 3. Measure the infant's urine output for 24 hours. 4. Provide the infant with 50 mL of glucose water.

Correct Answer: 1 Rationale 1: Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to health care providers for evaluation. Rationale 2: Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, nor is juice the best choice of fluid. Rationale 3: Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated. Rationale 4: Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, nor is glucose water the best choice of fluid.

The client has been placed on a 1,200 mL oral fluid restriction. How should the nurse plan for this restriction? 1. Allow 600 mL from 7-3, 400 mL from 3-11, and 200 mL from 11-7. 2. Instruct the client that the 1,200 mL of fluid placed in the bedside pitcher must last until tomorrow. 3. Offer the client softer, cold foods such as sherbet and custard. 4. Remove fluids from diet trays and offer them only between meals.

Correct Answer: 1 Rationale 1: The amount of fluid allowed should be divided between the three major times of the day (7-3, 3-11, 11-7). This helps by taking into consideration meals and medication administration. Rationale 2: The client should be given a choice regarding consumption of fluids at mealtime. Rationale 3: Sherbet and custard are counted as liquids and should be avoided. Rationale 4: The client should be given a choice regarding consumption of fluids at mealtime.

The nurse is caring for a client who is receiving intravenous fluids that are not regulated on an electronic controller. In order to calculate the rate of the IV flow in drops per minute, the nurse must know the number of drops per milliliter of fluid the tubing delivers. Where should the nurse look for this information? 1. On the packaging of the tubing 2. In the charting from the nurse who started the infusion 3. In the drug reference book 4. On the roller clamp of the tubing

Correct Answer: 1 Rationale 1: The drop factor (number of drops per milliliter of fluid) of tubing is located on the packaging. Rationale 2: The nurse would not document the drop factor of the intravenous tubing. Rationale 3: The drop factor would not be in a drug reference book. Rationale 4: The drop factor would not be on the roller clamp of the intravenous tubing.

After initiating a blood transfusion for a client, the nurse should now: 1. Stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion. 2. Assign the UAP to sit with the client for 15 minutes. 3. Advise the client to notify the nurse if he experiences any chilling, nausea, flushing, or rapid heart rate. 4. Return to the room and take a set of vital signs in 15 minutes.

Correct Answer: 1 Rationale 1: The nurse should stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion. Rationale 2: The nurse cannot delegate this assessment to the UAP. Rationale 3: The client should be advised of reactions to report, but this self-reporting is more indicated after the nurse is no longer in constant attendance. Rationale 4: The nurse should stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion. The nurse cannot delegate this assessment to the UAP.

A client tells the nurse about rarely feeling thirsty. The nurse realizes that further assessment is needed to evaluate: Standard Text: Select all that apply. 1. status of osmotic pressure. 2. vascular volume. 3. presence of angiotensin. 4. urine output. 5. body weight.

Correct Answer: 1,2,3 Rationale 1: A number of stimuli trigger the thirst center, including the osmotic pressure of body fluids. Rationale 2: A number of stimuli trigger the thirst center including vascular volume. Rationale 3: A number of stimuli trigger the thirst center including angiotensin. Rationale 4: Urine output does not trigger the thirst center. Rationale 5: Body weight does not trigger the thirst center.

A client sustained a significant loss of blood after a motor vehicle accident. The nurse notes that the client's urine output has decreased and suspects that which hormones have influenced this client's fluid balance? Standard Text: Select all that apply. 1. Aldosterone. 2. Angiotensin. 3. Antidiuretic hormone. 4. Estrogen. 5. Progesterone.

Correct Answer: 1,2,3 Rationale 1: Aldosterone promotes sodium retention in the distal nephron, reducing urine output. Rationale 2: Angiotensin acts directly on the nephrons to promote sodium and water retention. Rationale 3: When serum osmolality rises, antidiuretic hormone is produced, causing the collecting ducts to become more permeable to water. This increased permeability allows more water to be reabsorbed into the blood. As more water is reabsorbed, urine output falls and serum osmolality decreases, because the water dilutes body fluids. Rationale 4: Estrogen is not a hormone that participates in fluid balance in the body. Rationale 5: Progesterone is not a hormone that participates in fluid balance in the body.

A client has had a subclavian central venous catheter inserted. What should the nurse assess as a priority for this client's care? 1. Presence of bibasilar crackles 2. Tachycardia 3. Decreased pedal pulses 4. Headache

Correct Answer: 2 Rationale 1: Bibasilar crackles may develop secondary to fluid overload or to the disease process, but would not be particularly evident just after placement of the subclavian catheter. Rationale 2: Because insertion of a subclavian central venous catheter may result in hemothorax, pneumothorax, cardiac perforation, thrombosis, or infection, the priority finding for planning care is tachycardia. Rationale 3: Decrease in pedal pulses would not be associated with the placement of a subclavian catheter. Rationale 4: Headache would not be associated with the placement of a subclavian catheter.

The client's arterial blood gas report reveals a pH of 6.58. How does the nurse evaluate this value? 1. There is a slight elevation. 2. This value is incompatible with life. 3. This is a low normal value. 4. This value is extremely elevated.

Correct Answer: 2 Rationale 1: The body's pH range is normally 7.35 to 7.45. This is not an elevation. Rationale 2: The body's pH range is normally 7.35 to 7.45. Values lower than 6.8 or higher than 7.8 are generally considered incompatible with life. If the nurse assesses that this client is physiologically more stable than would be expected with this pH, the possibility of a lab error should be considered. Rationale 3: The body's pH range is normally 7.35 to 7.45. Values lower than 6.8 or higher than 7.8 are generally considered incompatible with life. Rationale 4: The body's pH range is normally 7.35 to 7.45. This value is not extremely elevated

An older client receiving intravenous fluids at 175 ml/hr is demonstrating crackles, shortness of breath, and distended neck veins. The nurse recognizes these findings as being which complication of intravenous fluid therapy? 1. An allergic reaction to the antibiotics in the fluid 2. Fluid volume excess 3. Pulmonary embolism 4. Speed shock

Correct Answer: 2 Rationale 1: The information provided does not support that the client is receiving an antibiotic. Rationale 2: Fluid volume excess may occur if clients, especially the very young or elderly, receive IV fluid rapidly. Rationale 3: The information provided does not support the development of a pulmonary embolism. Rationale 4: The client has been receiving fluids at the established rate and would not be experiencing symptoms of speed shock.

Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client complains of a headache. The nurse assesses that the client has slight shortness of breath and feels warm to the touch. What action by the nurse is priority? 1. Notify the client's physician. 2. Discontinue the transfusion. 3. Slow the rate of the transfusion. 4. Prepare to resuscitate the client.

Correct Answer: 2 Rationale 1: This would not be the nurse's first action. Rationale 2: The priority intervention is to discontinue the transfusion. If this client is having a transfusion reaction, it will be better to limit the amount of blood transfused. The nurse would also contact the physician to collaborate on further treatment, but this action should be after the transfusion is discontinued. Rationale 3: Slowing the rate of the transfusion allows additional blood to be infused. Rationale 4: At this point, there is no need to prepare for resuscitation.

The client who has an IV with an intermittent infusion lock in place wishes to shower. What action should be taken by the nurse? 1. Have the UAP discontinue the lock. 2. Cover the lock with an occlusive dressing. 3. Place a piece of cloth tape under the lock, wrapping the top in a U shape. 4. Tell the client that a bed bath is necessary until the IV is discontinued.

Correct Answer: 2 Rationale 1: UAP cannot discontinue the lock. Rationale 2: The client can shower if the lock is covered with an occlusive dressing. Rationale 3: Cloth tape will not protect the lock. Rationale 4: The client can shower if the lock is covered with an occlusive dressing.

After obtaining a unit of packed red blood cells for a client, the nurse learns the client needed to leave the care area for an emergency x-ray. What action should the nurse take? 1. Set up the blood with the IV fluid and y-tubing and place it on the IV standard in the client's room to initiate immediately after the client returns. 2. Place the blood in the unit refrigerator until the client returns. 3. Return the blood to the laboratory blood bank until the client returns. 4. Set up the blood with the IV fluid and y-tubing and place it in the unit medication room to initiate immediately after the client returns.

Correct Answer: 3 Rationale 1: Blood should not be held at room temperature for more than 30 minutes before the transfusion is initiated. Rationale 2: The unit refrigerator is not climate controlled for blood storage. Rationale 3: Blood should not be held at room temperature for more than 30 minutes before the transfusion is initiated. The unit must be returned to the laboratory blood bank until the client has returned from the CT. Rationale 4: Blood should not be held at room temperature for more than 30 minutes before the transfusion is initiated. After obtaining a unit of packed red blood cells for a client, the nurse learns the client needed to leave the care area for an emergency x-ray. What action should the nurse take? 1. Set up the blood with the IV fluid and y-tubing and place it on the IV standard in the client's room to initiate immediately after the client returns. 2. Place the blood in the unit refrigerator until the client returns. 3. Return the blood to the laboratory blood bank until the client returns. 4. Set up the blood with the IV fluid and y-tubing and place it in the unit medication room to initiate immediately after the client returns.

The nurse is caring for an 80-year-old client with the medical diagnosis of heart failure. The client has edema, orthopnea, and confusion. Which nursing diagnosis is most appropriate for this client? 1. Heart Failure related to edema, as evidenced by confusion 2. Fluid Volume Deficit related to loss of fluids as evidenced by edema 3. Excess Fluid Volume related to retention of fluids as evidenced by edema and orthopnea 4. Excess Fluid Volume related to congestive heart failure as evidenced by edema and confusion

Correct Answer: 3 Rationale 1: Heart failure is a medical diagnosis, not a nursing diagnosis. Rationale 2: This client does not exhibit fluid volume deficit. Rationale 3: Edema and orthopnea are assessment findings associated with excess fluid volume. Rationale 4: Congestive heart failure is a medical diagnosis and cannot be used as the "related to" factor in a nursing diagnosis.

The nurse is caring for a client who is 3-days postoperative. Which intervention should the nurse implement to decrease the client's possibility of developing hypercalcemia? 1. Measure vital signs every 4 hours. 2. Assist the client to turn, cough, and deep breathe every 2 hours. 3. Assist the client to ambulate around the room at least three times daily. 4. Irrigate the client's nasogastric tube every 2 hours.

Correct Answer: 3 Rationale 1: Measuring vital signs will not decrease the possibility of developing hypercalcemia. Rationale 2: Turning, coughing, and deep breathing every 2 hours will not prevent the development of hypercalcemia. Rationale 3: Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching of calcium from the bones into the serum. Rationale 4: Irrigating the nasogastric tube every 2 hours is not going to prevent the development of hypercalcemia.

The client complains of burning along the vein in which a medicated IV is infusing. Upon assessment, the nurse finds the IV site is slightly reddened, but not warmer than the surrounding skin, and without swelling. What action should be taken by the nurse? 1. Slow the IV infusion and reassess the area in 15 minutes. 2. Place a cool pack over the IV site and vein. 3. Discontinue the IV and place a warm pack on the area. 4. Call the physician for direction.

Correct Answer: 3 Rationale 1: Simply slowing the IV will not prevent further damage to the vein and will also alter the amount of IV fluid and medication the client is receiving. Rationale 2: A cool pack over the IV site will not prevent additional damage to the vein. Rationale 3: This assessment likely indicates the beginning of phlebitis. The nurse should discontinue the IV and place a warm pack on the area. Rationale 4: This assessment and evaluation are within the scope of nursing practice, so at this point, collaboration with the physician is not necessary.

The client has orders for the administration of IV fluid at a "keep vein open" rate in preparation for administration of IV antibiotics starting at noon. When the nurse goes to the room to start the IV, the UAP is preparing to bathe the client. What should the nurse do? 1. Instruct the UAP to wait until the IV is started to bathe the client. 2. Let the UAP start the bath on the opposite side of where the nurse will be starting the IV. 3. Tell the UAP to notify the nurse as soon as the bath is completed. 4. Give the UAP permission to skip the client's bath for today.

Correct Answer: 3 Rationale 1: Since this IV is being initiated to support the administration of IV antibiotic therapy that is not scheduled to start until noon, the nurse should let the UAP give the bath and then start the IV. Rationale 2: Having the UAP bathing one side of the client while the nurse starts the IV on the opposite side would be uncomfortable and stressful for the client and could potentially compromise client modesty. This action would also not protect the IV site from movement while the UAP completes the bath. Rationale 3: Since this IV is being initiated to support the administration of IV antibiotic therapy that is not scheduled to start until noon, the nurse should let the UAP give the bath and then start the IV. This will protect the IV site from movement during this bath. Rationale 4: There is no reason to skip the bath.

The nurse is providing discharge instructions to a client who has been started on furosemide (Lasix) once daily. What information is essential to include in this information? 1. Take the medication at bedtime. 2. Avoid high-potassium foods. 3. Stand up slowly from a sitting position. 4. Do not take this medication on the days you take digitalis (Lanoxin).

Correct Answer: 3 Rationale 1: The medication should be taken in the morning to prevent awakening at night to void. Rationale 2: The client should be encouraged to eat potassium-rich foods and will probably be prescribed a potassium supplement. Rationale 3: Clients who are taking diuretics must make position changes slowly in order to minimize dizziness from orthostatic hypotension. Rationale 4: While clients who take digitalis (Lanoxin) and furosemide (Lasix) are at higher risk for the development of digitalis toxicity, the medications are often taken concurrently. The client and health care provider must monitor these clients closely for the development of digitalis toxicity.

The nurse is caring for a client who is receiving IV therapy at a rate of 10 mL/hour. The 500-mL IV bottle was hung at 0900 Monday morning when the IV catheter was initiated. It is now 0900 on Tuesday morning. What nursing action should be taken? 1. Refigure the rate of the IV. 2. Infuse the remaining IV fluid before hanging a new bag. 3. Discard the remaining IV fluid and hang a new bag. 4. Discontinue the IV site and restart an IV in the opposite hand.

Correct Answer: 3 Rationale 1: There is no need to refigure the rate of the IV. Rationale 2: The nurse should not infuse the remaining IV fluid before hanging a new bag. Rationale 3: The remaining IV fluid should be discarded and a new bag hung. IV fluid should be changed every 24 hours, regardless of how much solution remains. This helps to minimize the risk of contamination. Rationale 4: There is no need to restart the IV in the opposite hand.

One hour after a transfusion of packed red cells is started; a patient develops redness on his trunk and complains of itching. The nurse stops the red blood cell (RBC) infusion and administers the ordered diphenhydramine (Benadryl) 25 mg po. Thirty minutes later, the redness and itching is gone. What is the next action the nurse should take?

Resume the transfusion Explanation: Some patients develop urticaria (hives) or generalized itching during a transfusion. The cause of these reactions is thought to be a sensitivity reaction to a plasma protein within the blood component being transfused. Symptoms of an allergic reaction are urticaria, itching, and flushing. The reactions are usually mild and respond to antihistamines. If the symptoms resolve after administration of an antihistamine (e.g., diphenhydramine [Benadryl]), the transfusion may be resumed.