Chapter 13 Intravenous Therapy
Fresh-frozen plasma (FFP) has been prescribed for a hospital client. Prior to administration of this blood product, the nurse should prioritize what client education?
Signs and symptoms of a transfusion reaction
A client is receiving IV fluid administration and consuming a rather large amount of fluids orally. In calculating the client's fluid intake for the past 24 hours, the nurse notes the amount and immediately notifies the physician of this finding. Notification of a physician regarding fluid intake should occur after exceeding how many milliliters in 24 hours?
3000
A nurse is administering total parenteral nutrition (TPN) solution to a severely dehydrated client at the healthcare facility. Which of the following nutrients should the nurse add to the TPN solution as a carbohydrate source?
5% dextrose solution
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?
50
A nurse is preparing a dose of furosemide for an older adult with heart failure. The health care provider orders furosemide 1 mg/kg to be given intravenously. The client weighs 50 kg. The concentration of the drug is 40 mg/4mL (10 mg/mL). How many milliliters would the nurse administer? Record your answer using a whole number.
5ml
A nurse is preparing to use microdrip tubing. What is the standard volume that this device delivers?
60
A client has been a client in the ICU for 17 days, seriously ill. A multitude of medications are ordered for the client's treatment regimen, most of which are administered intravenously. What is an indication for the use of IV medications? Select all that apply
All options are correct.
The nurse is caring for a client who has been NPO since admission two days ago and was admitted with vomiting as a primary symptom. The client has been receiving intravenous therapy at 100 mL/hr. since admission with Lactated Ringers (LR) as the intravenous solution. What nursing diagnosis is most appropriate for this client
Altered Nutrition: Less than body requirements R/T lack of adequate caloric intake
An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction
Be vigilant in identifying the client and the blood component.
An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction?
Be vigilant in identifying the client and the blood component.
A nurse needs to administer a prescribed dosage of antineoplastic drugs to a client with cancer. Which of the following pieces of medical equipment is used to administer antineoplastic drugs?
Central venous catheter
The nurse is preparing to begin an intravenous infusion and is aware that which are the responsibilities of the nurse in initiating this therapy? Select all that apply.
Choose the type of intravenous tubing to be used in the administration. Choose the site for the intravenous therapy. Choose the infusion device to administer the intravenous fluid.
A client is receiving the first of two prescribed units of PRBCs. Shortly after the initiation of the transfusion, the client reports chills and experiences a sharp increase in temperature. What is the nurse's priority action?
Discontinue the transfusion.
A nurse assessing the IV site of a patient observes swelling and pallor around the site and notes a significant decrease in the flow rate. The patient complains of coldness around the infusion site. What IV complication does this describe?
Infiltration
The nurse is caring for a client who has been receiving intravenous therapy via a central venous catheter inserted through the subclavian vein. Suddenly after the tubing to the intravenous solution is changed, the client develops shortness of breath, chest pain, and tachycardia. What should be the PRIORITY action of the nurse at this time?
Place the bed in Trendelenburg position with the client on the left side.
A client with renal disease requires IV fluids. It is important for the nurse to
Place the fluids on an electronic device
Assessing a client at 4:00 PM, a nurse notes that 800 ml of normal saline solution has been infusing since it was hung at 4:00PM yesterday. What would be the nurse's next action?
Replace the IV solution.
A client is receiving a blood transfusion and reports a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action?
Slow the infusion rate and monitor the client closely.
The nurse is caring for an older adult client who is receiving intravenous therapy (IV). Which assessment data would indicate that the client is experiencing a complication of IV therapy?
The client's jugular veins are distended.
A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction?
The donor blood was incompatible with that of the client.
The nurse is caring for a client who has experienced an isotonic fluid deficit caused by vomiting and expects the healthcare provider to order which intravenous fluid?
0.9% saline
The nurse is caring for a client in an urgent care center. The health care provider has ordered that the client is to receive 1 liter of fluid over 4 hours and then may be released. The fluids will be infused by gravity and the tubing has a drop factor of 10 gtts/mL. The nurse will need to set the fluids at how many drops per minute to ensure the fluids are infused as ordered? Your answer should be in whole number(s).
42
A client with aplastic anemia is going to receive a blood transfusion. In addition to taking vital signs and verifying that the unit of blood cells is matched to the client, what other assessments/actions would you take?
Check the client regarding chills, low back pain, dyspnea, and skin itching during the
The nurse is preparing to administer the solution in the attached image to a client. Which of the following types of solution is the nurse going to administer?
Isotonic
A client with type O blood and a history of anemia is scheduled for a blood transfusion. To avoid a transfusion reaction, this client must receive which blood type
O
A 58-year-old woman is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires
Replacement of fluids for those lost from vomiting and diarrhea
A physician orders IV solution for a 92-year-old client to treat dehydration. The order was written to administer the fluid at a slower rate than what the nurse expected. Why would the physician designate the slower infusion rate for this client?
The client may have cardiac or renal disorders.
The nurse is supervising a new graduate nurse who is caring for a client receiving total parenteral nutrition for the last two weeks. The health care provider has just written an order to discontinue this therapy according to policy. What action by the new nurse would cause the supervising nurse to intervene in relation to intravenous therapy?
The new graduate replaces the total parenteral nutrition intravenous solution with 0.9%
The nurse is preparing to administer a unit of blood to a client and should know that which is the FIRST action of the nurse prior to the administration?
The nurse will check that the numbers of the client's wrist band and the unit of blood match and that this information is confirmed by another nurse.
A client comes to the emergency department and is bleeding profusely. Blood transfusion is ordered and the client is being typed and cross-matched. While awaiting the results, the physician orders a unit of packed red blood cells to administered stat. Which blood type would the nurse expect to be used?
Type O
A nurse needs to perform venipuncture on a client who has poor skin turgor. To prevent skin trauma at the venipuncture site, the nurse should:
place a soft cloth between the tourniquet and the skin.
A client is receiving total parenteral nutrition. The physician order includes lipid emulsion administration (contained in glass bottles) on Monday, Wednesday, and Friday. What type of IV tubing would the nurse select for the lipid administration?
vented tubing