Unit 1 IV Therapy & Blood Administration NCLEX Questions

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

1

A nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the IV of an assigned client who is receiving fluid replacement therapy at least every: 1. 1 hour 2. 2 hours 3. 3 hours 4. 4 hours

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

1

After reviewing a client's serum electrolyte levels, the provider prescribes an isotonic IV infusion. Which IV solution should the nurse plan to administer? 1) 5% dextrose in water 2) 10% dextrose in water 3) 3% sodium chloride solution 4) 0.45% sodium chloride solution

1) 5% dextrose in water 10% dextrose in water = hypertonic 3% sodium chloride solution = hypertonic 0.45% sodium chloride solution = hypotonic

A provider prescribes lipids (fat emulsion) IV for a client receing parenteral nutrition. Before initiating the intralipds, which should the nurse assess that is related to the infusion? 1) allergies 2) VS 3) history of seizures 4) serum glucose level

1) allergies Fat emulsions contain and emulsifying agent made from egg yolks (hypersensitivity to eggs)

Before performing a venipuncture to initiate continuous IV therapy, a nurse should: 1) inspect the IV solution and exp date 2) apply a cool compress to the affected area 3) secure a padded arm board above the IV site 4) apply a tourniquet below the venipuncutre site

1) inspect the IV solution and exp date

The nurse administers diphenhydramine (Benadryl) before a blood transfusion to: 1) prevent uticaria 2) avoid fever and chills 3) enhance clotting factors 4) expand the blood volume

1) prevent uticaria

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

2

The nurse checks the gauge of the clients IV catheter. Which is the smallest gauge catheter that the nurse can use to administer blood? 1) 14 2) 19 3) 22 4) 24

2) 19 gauge

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

4

A 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

4

A nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which of the following? 1. An increased Hct level 2. An increased Hgb level 3. A decline of the temperature to normal 4. A decrease in oozing from puncture sites and gums

4

An order for type and crossmatch is not an order to transfuse. T or F

T

The nurse prepares to access an implanted vascular access port. Which should the nurse implement first? 1) palpate the vascular port 2) anchor the vascular port 3) cleanse the site with alcohol 4) apply a cool compress to the site

1) palpate the vascular port

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. 30 minutes 4. 45 minutes

2.

The nurse prepares a client for discharge who needs intermittent antibiotic infusions through a peripherally inserted central catheter (PICC) line. Which should the nurse include in client teaching about daily infusion care in the home? 1) keep the affected arm immobilized 2) aspirate 3 mL of blood from the PICC line 3) maintain a continuous IV infusion 4) check the insertion site for redness and swelling

4) check the insertion site for redness and swelling

A nurse has just finished assisting the physician in placing a central IV line. Which of the following is a priority intervention after central line insertion? 1) prepare the client for a chest radiograph 2) assess the clients temperature to monitor for infection 3) label the dressing with the date and time of the catheter insertion 4) monitor the BP to asses for FVE

1) prepare the client for a chest radiograph for possible pneumothorax for accidental puncture of the lung.

A nurse checks a unit of blood received from the blood bank and notes the presence of gas bubbles in the bag. Which should the nurse implement? 1) return the bag to the blood bank 2) infuse the blood using filter tubing 3) add 10 mL normal saline to the bag 4) agitate the bag to mix contents gently

1) return the bag to the blood bank

A nurse is caring for a client who is reducing blood transfusion therapy. Which clinical manifestations would alert he burst to a hemolytic transfusion rxn? SELECT ALL 1) headache 2) tachycardia 3) hypertension 4) apprehension 5) distended neck veins 6) a sense of impending doom

1, 2, 3, 4, 6

The nurse caring for a client receiving IV therapy monitors for which signs of infiltration at the catheter site of an IV infusion? select all that apply: 1) slowing of the IV rate 2) tenderness at the insertion site 3) edema around the insertion site 4) skin tightness at the insertion site 5) warmth of skin at the insertion site 6) fluid leaking from the insertion site

1, 2, 3, 4, 6

Which of the following clients are most likely to develop circulatory overload? (select all that apply) 1. A premature infant 2. A 101-year-old man 3. The client on renal dialysis 4. The client with diabetes mellitus 5. A 29-year-old woman with pneumonia 6. The client with CHF

1, 2, 3, 6

The nurse assesses the client's peripheral IV site and noes that it is cool, pale, swollen, and not infusing. The nurse should document in the client's record that which of the following has probably occurred? 1) Phlebitis 2) Infection 3) Infiltration 4) Thrombosis

3) Infiltration The infusion stops with the pressure in the tissue exceeds the pressure in the tubing. The pallor, coolness and swelling of the IV site are the result of IV fluid infusing into the subcu tissue.

Before inserting a perpheral IV catheter, the nurse notes that the female client's muscles are tense and she is fidgeting with the bed sheet. Which statement should the nurse verbalize to the client? 1) This will be finished before you know it 2) inserting the IV does not hurt very much 3) The IV adds fluid into your blood stream 4) The IV catheter is an 18-gauge angiocatheter

3) The IV adds fluid into your blood stream

A client receiving PN via a central venous catheter (CVC) is scheduled to receive an IV antibiotic. Which should the nurse implement before administering the antibiotic? 1) Turn off the PN for 30 minutes 2) check for compatibility with PN 3) ensure a separate IV access route 4) flush the cvc with normal saline

3) ensure a separate IV access route

The nurse assesses a peripheral IV dressing and notes that it is damp and the tape is loose. The best nursing action is to: 1) stop the infusion immediately 2) apply a sterile, occlusive dressing 3) ensure tight IV tubing connections 4) remove the IV and insert and new IV

3) ensure tight IV tubing connections

IV human albumin is prescribed for a client with burns. The nurse review the client's medical record for contraindications. The nurse contacts the physician before admin the human albumin if which of the following is noted in the client's record? 1) diabetes mellitus 2) multiple myeloma 3) renal insufficiency 4) lymphocytic leukemia

3) renal insufficiency Contraindicated due to blood derivative (also anemia, cardiac failure, allergies)

The client is receiving IV antibiotic therapy at home for 1 week via heparin lock (intermittent IV catheter). Which does the nurse include in client teaching for the early detection of the complications of IV therapy? 1) Protect the heparin lock continually 2) keep the heparin lock clean and dry 3) report local pain, drainage, or edema 4) apply pressure to the IV site if it dislodges

3) report local pain, drainage, or edema

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which of the following areas? 1. The pharmacy 2. The laboratory 3. The blood bank 4. The risk-management department

3.

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

3.

The nurse prepares to administer an IV medication when the nurse notes that the med is incompatible with the IV solution. Which is the best intervention for the nurse to implement for safe medication administration? 1) ask the provider to prescribe a compatible IV solution 2) start a new IV cath for the incompatible medication 3) collaborate with the provider for a new admin route 4) flush tubing before and after admin the meds with NS

4) flush tubing before and after admin the meds with NS

A nurse evaluates the latency of a peripheral IV site and suspects and infiltration. Which does the nurse implement to determine if the IV has infiltrated? 1) strips the tubing and assesses for blood return 2) checks the regional tissue for redness and warmth 3) increases the infusion rate and observes for swelling 4) gently palpates regional tissue for edema and coolness

4) gently palpates regional tissue for edema and coolness

The nurse understands that which of the following are clinical indicators for IV fluids? Select all that apply. 1) syncope episodes 2) bounding pulse rate 3) chronic renal failure 4) rapid, weak and thready pulse 5) serum electrolyte abnormalities 6) abnormal serum and urine osmolality levels

4, 5, 6

A client has an order to receive 1000 mL of 5% dextrose in 0.45% NaCl. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing? 1. Uncaps the distal end of the tubing 2. Uncaps the spike portion of the tubing 3. Opens the roller clamp on the IV tubing 4. Closes the roller clamp on the IV tubing

4.

The nurse is monitoring a client who is receiving a blood transfusion when the client complains of diaphoresis, warmth, and a backache. The nurse suspects a transfusion retain and should take which actions? select all that apply 1) contact the physician 2) remove the IV catheter 3) document the occurrence 4) stop the blood transfusion 5) hang 0.9% NaCl solution

1, 3, 4, 5

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: 1. Vital signs 2. Skin color 3. Oxygen saturation 4. Latest Hct level

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

2

A nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 degrees F orally. The nurse reports the finding to the RN and anticipates that which of the following actions will take place? 1. The transfusion will begin as prescribed 2. The blood will be held and the physician will be notified 3. The transfusion will begin after the administration of an antihistamine 4. The transfusion will begin after the administration of 600 mg of acetaminophen

2

A client began receiving an IV infusion of packed red blood cells 30 minutes ago. The client turns on the nurse call light and describes difficulty breathing, itching, and a tight sensation in the chest. Which of the following is the first action of the nurse? 1) call the physician 2) stop the transfusion 3) check the client's temperature 4) recheck the unit of blood for compatibility

2) stop the transfusion (transfusion rxn....iv line is kept open with NS and physician is notified...check vital signs....monitor the client for any life threatening symptoms)