med surg iv therapy practice

1. A client who is receiving a blood transfusion rings the call bell for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. The nurse interprets that the client is experiencing: 1. Bacteremia 2. Fluid overload 3. Hypovolemic shock 4. A transfusion reaction

A transfusion reaction

1. A nurse is preparing an IV solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to do which of the following? 1. Change the IV tubing 2. Wipe the tubing with Betadine 3. Scrub the tubing with an alcohol swab 4. Scrub the tubing before attaching it to the IV bag.

Change the IV tubing

1. A nurse is assisting with caring for a client who is receiving a unit of packed RBCs. The nurse tells the client that it is most important to report which of the following signs immediately? 1. Sore throat or earache 2. Chills, itching, or rash 3. Unusual sleepiness or fatigue 4. Mild discomfort at the catheter site.

Chills, itching, or rash

1. A client with the recent diagnosis of MI and impaired renal function is recuperating on the step-down cardiac unit. The client's blood pressure has been borderline low and IV fluids have been infusing at 100 mL /hr via a central line catheter in the right internal jugular for approx 24 hours to increase renal output and maintain the blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that the client is most likely experiencing which complication of IV therapy. 1. Hematoma 2. Air embolism 3. Systemic infection 4. Circulatory overload

Circulatory overload

1. A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client's hospital gown? 1. Using a hospital gown with snaps at the sleeves 2. Disconnecting the IV tubing from the catheter in the vein 3. Checking the IV flow rate immediately after changing the hospital gown 4. Putting the bag and tubing thru the sleeve, followed by the client's arm

Disconnecting the IV tubing from the catheter in the vein

1. A nurse is doing a routine assessment of a client's peripheral IV site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which of the following has probably occurred? 1. Phlebitis 2. Infection 3. Infiltration 4. Thrombosis

Infiltration

1. A nurse is checking the insertion site of a peripheral IV catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of: 1. Phlebitis of the vein 2. Infiltration of the IV line 3. Hypersensitivity to the IV solution 4. An allergic reaction to the IV catheter material.

Phlebitis of the vein

1. A client has just undergone insertion of a central venous catheter at the bedside. The nurse would be sure to check the results of which of the following before initiating the flow rate of the client's IV solution at 100 mL/hr? 1. Serum osmolality 2. Serum electrolyte levels 3. Portable chest x-ray film 4. Intake and output record

Portable chest x-ray film

nurse has been instructed to discontinue an IV line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with a(n): 1.Band-Aid 2. Alcohol swab 3. Betadine swab 4. Sterile 2x2 gauze

Sterile 2x2 gauze

1. The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client's IV site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which of the following complications has occurred. 1. Infection 2. Phlebitis 3. Infiltration 4. Thrombosis

infiltration

1. A client rings the call bell and complains of pain at the site of an IV infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? SATA 1. Notifies the physician 2. Removes the IV catheter at that site 3. Applies warm moist packs to the site 4. Starts a new IV line in a proximal portion of the same vein 5. Documents the occurrence, actions taken, and the client's response

1. Notifies the physician 2. Removes the IV catheter at that site 3. Applies warm moist packs to the site 5. Documents the occurrence, actions taken, and the client's response

1. A client is going to be transfused with a unit of packed RBCs. The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started? 1. 5 minutes 2. 15 minutes 3. 50 minutes 4. 45 minutes.

15 minutes

1. A nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to assess the client's: A. Vital signs B. Skin color C. Oxygen saturation D. Latest Hct level

Vital signs