Blood Transfusions, CVAD, Enteral Tubes & Ostomy Care

A patient receiving tube feedings has prescriptions for several drugs. Which of the following drugs would the nurse expect to administer to the patient without any special preparation? Select all that apply.

-Liquid stool softener -Sublingual nitroglycerin

The nurse has presented an educational inservice about caring for patients who have newly created ostomies. The nurse asks participants, "How will you know when a patient begins to accept the altered body image?" Which of the following responses by participants indicate a correct understanding of the material? Select all that apply.

-The patient is willing to look at the stoma. -The patient makes neutral or positive statements about the ostomy. -The patient expresses interest in learning self-care.

A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use?

30-mL

A patient with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this patient's needs?

An implanted central venous access device (CVAD)

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

A patient's low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform?

Assess the patient's vital signs to establish baselines.

A patient is having a blood transfusion, but the fluid is dripping very slowly. The blood has been infusing for more than 4 hours. What should the nurse do next?

Discontinue the blood transfusion

During a blood transfusion with packed red blood cells (RBCs), a patient begins to complain of chills, low back pain, and nausea. What priority action should the nurse take?

Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing

During a blood transfusion, a patient displays signs of immediate onset facial flushing, fever, chills, headache, low back pain, and shock. Which transfusion reaction should the nurse suspect?

Hemolytic transfusion reaction: incompatibility of blood product

The nurse is completing a pretransfusion assessment to determine the history of previous transfusions as well as previous reactions to transfusions for a female patient. From the following list, what is the most important information to obtain from this patient prior to the transfusion?

Number of pregnancies

A client has a central venous catheter inserted into the subclavian vein. The nurse assesses the client immediately following the insertion of the catheter and notes a sudden onset of chest pain and shortness of breath. Which of the following complications should the nurse be prepared to treat?

Pneumothorax

Which of the following is caused by improper catheter placement and inadvertent puncture of the pleura?

Pneumothorax

When a central venous catheter dressing becomes moist or loose, what should a nurse do first?

Remove the dressing, clean the site, and apply a new dressing.

A charge nurse enters a client's room and observes a physician instructing another nurse on how to insert a central line into the client's neck. The nurse is holding the cannula and inserting the line. What would be the appropriate response by the charge nurse?

Stop the procedure and inform the nurse that he/she is practicing outside of a nurse's legal scope of practice.

A patient with a diagnosis of gastric cancer has been unable to tolerate oral food and fluid intake and her tumor location precludes the use of enteral feeding. What intervention should the nurse identify as best meeting this patient's nutritional needs?

TPN administered via a peripherally inserted central catheter

An adult patient in the ICU has a central venous catheter in place. Over the past 24 hours, the patient has developed signs and symptoms that are suggestive of a central line associated bloodstream infection (CLABSI). What aspect of the patient's care may have increased susceptibility to CLABSI?

The patient's central line was placed in the femoral vein.

A nurse assessing a patient with an ostomy appliance documents the condition "prolapse" in the patient chart and notifies the physician. Which of the following statements describes this condition?

The stoma is protruding into the bag and may become twisted.

When preparing to insert a nasogastric tube, the nurse determines the length of the tube to be inserted. The nurse nurse places the distal tip of the tube at which location?

Tip of the nose

What blood type might be used in an emergency situation when the patient's blood type is not available?

Type O

The physician orders a transfusion with packed red blood cells (RBCs) for a patient hospitalized with severe iron deficiency anemia. When blood is administered, what is the most important action the nurse can take to prevent a transfusion reaction?

Verify the patient identification according to hospital policy

A graduate nurse is cleaning a central venous access device (CVAD) and is being evaluated by the preceptor nurse. The preceptor nurse makes a recommendation for relearning the skill when she notes the graduate nurse does the following action:

Wipes catheter ports from distal end to insertion site

A nurse must provide total parenteral nutrition (TPN) to a client through a triple-lumen central line. To prevent complications of TPN, the nurse should:

cover the catheter insertion site with an occlusive dressing.

A nurse is assisting with the removal a of central venous access device (CVAD). The nurse should:

instruct the client to take a deep breath and hold it.

The nurse obtains a unit of blood for the client, Donald D. Smith. The name on the label on the unit of blood reads Donald A. Smith. All the other identifiers are correct. The nurse

refuses to administer the blood.

The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be

solid.