Funds Quiz 2- IV, Blood transfusion

A client 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 client's needs?

An implanted central venous access device (CVAD)

A nurse at the health care facility needs to administer an otic application for a client with an earache. What should the nurse do after instilling the prescribed eardrops in the client's ear?

Ask the client to maintain the position for some time.

The nurse is preparing to administer oral medication to a client. Which is the first action the nurse will take?

Compare the medication administration record (MAR) with the written medical order.

A nurse is caring for four different pediatric clients, all of whom require insertion of an intravenous (IV) catheter. For which client would it be appropriate to insert the IV into the foot?

Infant

Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?

acute confusion related to cerebral edema

eye drop administration

apply in conjunctival sac. do not allow to fall in the cornea. Apply gentle pressure with your gloved finger over the inner canthus to prevent the eye drops from flowing into the tear duct.

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?

decreased blood volume and intracellular dehydration

how to figure out infusion rate ex: mL/hr

divide the mL by hours: 1000mL/12hrs

A client is hypotensive secondary to hypovolemia resulting from dehydration. Based on the nurse's knowledge about intravenous solutions, the nurse would expect the physician to prescribe which type of solution?

isotonic

what are the two lines in blood transfusion

one for blood and one for normal saline

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?

potassium

ear drop-infants

pull down and back

ear drops- adults

pull up and back

A nurse is administering an adult client's ordered antipsychotic drug intramuscularly. What would be the most appropriate site for administration?

Deltoid

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)?

metabolic alkalosis

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

remove the IV

A decrease in arterial blood pressure will result in the release of

renin

A nurse is assessing a client's lower arm for insertion of an IV catheter. The nurse palpates the vein and notes that it feels hard. Which action by the nurse would be most appropriate?

select another site

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?

1 unit over 2 to 3 hours, no longer than 4 hours

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation?

Discontinue the IV and relocate it to another site.

What is the lab test commonly used in the assessment and treatment of acid-base balance?

arterial blood gas

A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What is the nurse's most appropriate action?

discontinue the IV

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?

placing the tourniquet on the upper arm for 2 minutes

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation?

Notify the primary care provider immediately for possible fluid overload.

Which finding best indicates to the nurse that the client has a therapeutic outcome from a blood transfusion?

The client has a steady gait while ambulating to void.

A medication order has ac written after the medication dosage. What does ac stand for?

before meals

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

cardiac irregularities

After teaching a group of nursing students about pharmacokinetics, the instructor determines that the education was successful when the students identify what process by which the medication is delivered to the target cells and tissues?

distribution

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of:

phlebitis

A nurse is administering a prescribed intramuscular injection to a client by the Z-track method. Which action ensures that the medicine remains sealed?

pulling the tissue laterally until the tissue is taut

A woman aged 58 years 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

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action?

stop the infusion

A client with an infection is receiving intravenous antibiotic therapy. The client has an intermittent infusion device in place. The nurse flushes the device with normal saline solution before administering the antibiotic based on which rationale?

to prevent blood clot formation

when does a chest x ray need to be done?

when a central line is given because the lungs sit under the central vein

When administering a subcutaneous injection to a client, the needle pulls out of the skin when the skin fold is released. What would be the appropriate next action of the nurse in this situation?

Engage safety shield on needle guard and discard needle appropriately.

What type of tubing is used for blood transfusions?

y tubing