Adv Skills IV start/push
After flushing a client's left forearm saline lock (SL) with normal saline, the client begins to report a painful and burning sensation at the insertion site. Which is the most appropriate action for the nurse to take? A remove the angiocatheter & saline lock and restart the SL in another site B Document the findings per protocol & reassess the site in 8 hours C Flush the angiocatheter & saline lock again with sterile water D Change the dressing & apply a new clean drsessing
A The angiocatheter has slipped out of the vein and infiltrated into the tissue and needs to be removed and restarted in another site. The nurse then needs to document the actions and follow protocol for reassessment. Flushing the angiocatheter with sterile water would only increase the pain and aggravate the infiltration site. Changing the dressing will not help infiltration.
A client receiving morphine is being monitored by the nurse for adverse effects of the drug. Which clinical findings warrant immediate follow up by the nurse? Select all that apply. A Polyuria B Sedation C Bradycardia D Dilated pupils E Slow respirations
B,C, E The central nervous system (CNS) depressant effect of morphine causes sedation. The CNS depressant effect of morphine causes bradycardia and bradypnea. Morphine does not increase urine output. Morphine causes constriction of pupils.
What are the clinical indicators that a nurse expects when an IV line has infiltrated? Select ALL that apply: A Heat B Pallor C Edema D Decreased flow rate E Increased blood pressure
B,C,D-Accumulation of fluid in the tissues between the surface of the skin & the blood vessels makes the skin appear pale. Accum. of fluid in the interstitial compartment causes swelling. As the needle is dislodged from the vein, the drip rate of the IV slows or ceases.
A nurse is caring for a severely dehydrated infant. After adequate kidney function is confirmed, potassium is added to the intravenous rehydration solution. The prescribed infusion rate is 15 mL/kg body weight every 24 hours. The infant weighs 13 lb (5.9 kg). What does the nurse calculate as the infant's intravenous fluid intake per 24-hour period? in ml
88.5 mL
2 yo toddler receiving IV antibiotics. What is the nurse to do to prevent child from pulling the IV A. Keeps arms restrained B. Tell child not to touch the IV site C. Cover the IV with protective device D. Have the parent hold the child continuously
C
A nurse is evaluating a client who received intravenous morphine. Which life-threatening response indicates the potential need for naloxone administration? A blurred vision B urinary retention C mental confusion D respiratory depression
D Because morphine is a central nervous system depressant, it affects the medulla, the respiratory center in the brain. Respiratory depression may progress to respiratory arrest and death.
What is the priority nursing intervention for a young infant who has an intravenous (IV) line in place after undergoing abdominal surgery? A administering oral fluids B limiting handling by parents C weighing diapers after each voiding D maintaining patency of the intravenous catheter and tubing
D It is imperative that the nurse monitor the IV site and tubing for patency. Signs of obstruction or infiltration must be detected and, if needed, a new means of circulatory access must be obtained quickly. Although an accurate output record is important, maintenance of the iv infusion is the priority.
Client with severe diarrhea admitted for severe dehydration. The nurse anticipates which IV will be prescribed initially. A. 3% sodium chloride B. 0.9% sodium chloride C. 5 % dextrose and 0.9 % NaCL D. 5 % dextrose and lactated Ringer solution
B - isotonic solution - volume expander to replace volume loss and promote physiological stabilization. Not 3% NaCL to high of concentration (hypertonic) used only for hyponatremia. C,D may be appropriate after this initial IV
The healthcare provider has prescribed 700 mL of intravenous fluid to be infused over 24 hours. At what rate should the nurse set the volume-control device? mL/hr
29 mL/hr
A client with stage 4 ovarian cancer is admitted for dehydration. The client is to receive an intravenous (IV) bolus of 500 mL D 5W for 1 hour, after which the rate is to be changed to 150 mL/hr. The drop factor is 15 gtt/mL. At what rate, in drops per minute, should the nurse regulate the IV after delivery of the 500-mL bolus? A 15 B 25 C 38 D 42
C
The nurse inspects a 2 day old IV site and identifies erythema warmth and mild edema. Client reports tenderness when the area palpated. What should the nurse do first? A. Irrigate the IV tubing B. DC the infusion C. Slow the rate of the infusion D. Obtain a prescription for analgesic
DC the infusion
Client admitted for dehydration with NS at 125 m/hr started. One hour after IV started the client begins screaming, I cant breath! What is the nurses priority action A. elevate the head of the bed and get vitals B. DC the IV site and contact the PCP C. Change the IV to an intermittent infusion device D. Contact the PCP to obtain a prescription for a sedative
A - take pressure off the diaphram
A client is to receive 125 mL of intravenous (IV) fluid every hour. The drop factor of the IV tubing is 10 gtt/mL. How many drops per minute should the nurse administer? gtts/min
21 gtts/min
The health care provider prescribes 1000 mL of total parenteral nutrition to be administered in 12 hours. Based on this prescription, how many milliliters of solution should be administered per hour?
83 mL/hr
IV catheter to be inserted into a toddlers peripheral vein. As local anesthetic is applied the toddler starts to cry and asks if the insertion is going to hurt. How should the nurse respond. A. Yes, it will hurt but not for very long B. Maybe it will hurt, big kids don't cry C. Yes is may hurt but if you hold still it may not hurt too much D. It will hurt a little, but I'm good at getting the needle in your arm.
A
6 yo child is getting a catheter inserted and is starting to cry. Nurses best response when child starts to cry? A. Do you want the IV in the R or L arm? B. Do you want me to come back in a little while C. The needle will only hurt for a second. Don't be afraid D. The med in the IV will make you feel better
A - child given sense of control
A nurse is administering intravenous (IV) fluids to a dehydrated infant. What intervention is most important at this time? A Calculating the total caloric intake B Continuing the prescribed flow rate C Making hourly temperature assessments D Maintaining the fluid at body temperature
B An infant's intravascular compartment is limited and cannot accommodate a large volume of fluid administered in a short time. Equipment such as an infusion pump with a volume-control chamber should be used because it controls the prescribed amount of fluid to be infused. IV fluids are administered at room temperature.
A client is scheduled to receive intravenous (IV) fluids to be delivered at 80 mL/hr. To adjust the drip rate when administering the IV via gravity, what must the nurse determine? A Total volume of fluid in the IV bag B Size of the needle or catheter in the vein C Drops per milliliter delivered by the infusion set D Diameter of the tubing being used to instill the fluid
C
After surgery client develops DVT and pulmonary embolus. Heparin continuous drip prescribed. Several hours later vancomycin IV every 12 is prescribed. Client has 1 IV site: peripheral line in left forearm. What action should nurse take? A. Stop the heparin, flush the line, give vanco B. Use piggyback set up to give vanc into hep C. Start another IV for the vanc and continue the hep as prescribed D. Hold vanc tell provider they are not compatible.
C - vanc and hep incompatible in the same IV need to be admin separately
A nurse is monitoring a client who is receiving an intravenous (IV) infusion of normal saline. What is a serious complication of IV therapy? A Bleeding at the infusion site B Shortness of breath with crackles C Feeling of warmth throughout the body D Infiltration at the catheter insertion site
B Hypervolemia may precipitate pulmonary edema, which produces shortness of breath, crackles, cough, apprehension, and frothy sputum. Although bleeding at the infusion site may occur, it is not the most serious complication; an altered respiratory status is the priority.
A client is to receive an intravenous (IV) antibiotic in 50 mL of 0.9% sodium chloride to be administered over 20 minutes. At what rate should the nurse set the infusion pump? mL/hr
150 mL/hr
A client, admitted to the cardiac care unit with a myocardial infarction, complains of chest pain. What intervention will be most effective in relieving the client's pain? A Nitroglycerin sublingually B Oxygen per nasal cannula C Lidocaine hydrochloride 50 mg IV bolus D Morphine sulfate 2 mg IV
D Morphine is an opioid analgesic that acts on the central nervous system by a sympathetic mechanism. Morphine decreases systemic vascular resistance, which decreases left ventricular afterload, thus decreasing myocardial oxygen consumption. Nitroglycerin sublingually relieves anginal pain, not myocardial infarction pain.
An infant is undergoing parenteral therapy. The healthcare provider has instructed that 400 mL of D5W 0.45% sodium chloride be infused over 8 hours. At how many milliliters per hour should the nurse maintain the hourly rate?
50 mL/hr
In the postanesthesia care unit a client received intrathecal morphine intraoperatively to control pain. Considering the administration of this medication, what should the nurse include as part of the client's initial 24-hour postoperative care? A monitoring of respiratory rate hourly B assessing the client for tachycardia C administering naloxone every 3-4 hours D observing the client for signs of CNS excitement
A
A client with dehydration is prescribed an intravenous (IV) fluid infusion. Which healthcare professional would the nurse expect to be delegated this task? A Registered nurse B LPN C licensed vocational nurse D UAP
A -tasks such as IV administration of fluids should be carried out by the RN because they are associated with risks. The LPN and LVN may provide oral medications and treatments under the supervision of an RN
A client is admitted to the coronary care unit complaining of "viselike" chest pain radiating to the neck. Assessment reveals a blood pressure of 124/64 mm Hg, an irregular apical pulse of 64 beats per minute, and diaphoresis. Cardiac monitoring is instituted, and morphine sulfate 4 mg intravenous (IV) push stat is prescribed. What is the priority nursing care for this client? A relief of pain B Client teaching C Cardiac monitoring D Maintenance of bed rest
A Unrelieved chest pain increases anxiety, fatigue, and myocardial oxygen consumption, with the possibility of extending the infarction. The client will not be ready for teaching until the chest pain is relieved.
A client is admitted to the emergency department with a possible myocardial infarction. Three hours after admission, the client experiences a new onset of severe chest pain. The client is diaphoretic with a pulse rate of 110 beats per minute. Which action should the nurse take immediately? A Decrease the oxygen amount B Obtain an ECG C Administer the prescribed morphine D Off acetaminophen until the pain subsides
C The client requires immediate relief of pain by administering morphine. The client needs increased oxygen, not less. ECG monitoring is continuous in the ED, so the nurse does not need to obtain an ECG. Acetaminophen does not relieve the pain associated with a myocardial infarction.
A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the drug, the client complains of feeling dizzy. What action should the nurse take? A Determine if this is an allergic reaction B Elevate the client's head and keep the extremities warm C Place the client in the supine position and take the vital signs D Tell the client that this is not a typical sensation after receiving morphine sulfate.
C Vertigo is a symptom of hypotension, a side effect of morphine sulfate. The supine position increases venous return, increases cardiac output, and increases blood flow to the brain. Dizziness is a symptom of hypotension that is a side effect, not an allergic response, to morphine sulfate. Raising the client's head may aggravate dizziness. Dizziness is a typical side effect of morphine sulfate.
After thoracic surgery for removal of a cancerous lesion in the lung, the client is drowsy, complains of pain when awakened, and then falls asleep. The client has a prescription for morphine sulfate via IV every 3 hours as needed for pain. The clients preoperative BP was 128/76 mm HG . Postop assessments reveal that the clients BP ranges between 90/60 & 100/70. What is the nurse's best initial action? A administer morphine as prescribed B obtain a prescription for vasoconstrictor C Give half the prescribed amount of morphine D Withhold the morphine until the BP stabilizes
D Morphine is an opioid analgesic that may decrease the BP further. It should be withheld and not administered at this time.
A nurse is preparing to administer an intravenous piggyback medication to a client who is receiving a continuous infusion of IV fluids. What is the priority nursing intervention? A Get an additional IV infusion pump for the medication B Check the compatibility of the medication and the continuous IV solution C Disconnect the continuous IV solution while administering the piggyback medication D Flush the client's venous access device to ensure patency
B Compatibility of the ordered IV medication and infusing IV solution needs to be verified to prevent harm to the client because incompatible solutions may increase, decrease, or neutralize effects of the medication.. An additional IV infusion pump is not necessary because IV medication will be administered through a piggyback infusion. The nurse needs to stop IV fluids & disconnect the tubing only if the ordered IV med is not compatible with IV fluids and there is an order to hold the continuous infusion. The client has a continuous infusion of IV; therefore patency of the IV access device is already determined
A healthcare provider prescribes morphine for a client being treated for myocardial infarction. What physiologic response will occur if the client experiences the intended therapeutic effect of morphine? A Increased respiratory rate B Decreased workload of the heart C Reduced size of the clot blocking the coronary artery D Diminished metabolites within the ischemic heart muscle
B Morphine reduces pain and anxiety. This limits the response of the sympathetic nervous system, ultimately decreasing cardiac preload and the workload of the heart. Reduced respiratory rate is a side effect of morphine;
A client is scheduled to receive an intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours. Before administering this IV medication, it is a priority for the nurse to assess which of the following? Select all that apply. A Urinary output B Deep tendon reflexes C Last bowel movement D Arterial blood gas results E Last serum potassium level F Patency of the intravenous access
A,E,F- Urinary output must be normal before giving IV potassium. If the urine output is low, a potassium infusion may damage renal cells. A patent IV access is essential because potassium is very irritating and painful to subcut tissue. The infusion of KCL 40 mEq in 100 mL of 5% dextrose & water has not direct effect on deep tendon reflexes, bowel patterns, or ABG's.
A nurse reviews a list of medications that have been prescribed for a client. The nurse is aware that it is unsafe to administer which medication as an intravenous (IV) bolus? A saline flush B potassium chloride C naloxone D adenosine
B Potassium chloride given as an IV bolus can cause cardiac arrest. It should NEVER be administered intravenously without being diluted and infused slowly through an IV infusion pump. A, C, and D are appropriate to be given as an IV bolus undiluted.
Pregnant woman admitted with tentative placenta Previn. The nurse implements prescriptions to start an IV infusion, administer O2 and draw labs. The clients apprehension in increasing and she asks nurse what is happening. The nurse tells her not to worry that she is going to be alright and that everything is under control. What is the best interpretation of the nurses statement? A. Adequate - preparations are routine and need no explanation B. Effective - clients anxieties would increase if she knew the danger involved C. Questionable because client has the right to know the treatment and why D. Incorrect because the PCP should offer assurances with management of care
C.
Which nursing action is necessary if nerve damage is suspected during an intravenous catheter insertion? A The nurse should clean the exit site with alcohol B The nurse should temporarily slow the infusion rate C The nurse should immediately stop the drug infusion & hang isotonic solution D The nurse should immediately stop the insertion if the client reports extreme pain
D The nurse should immediately stop the insertion if the client reports extreme pain in case of nerve damage.
An intravenous infusion of 800 mL/24 hr is prescribed for a 2½-year-old child. At how many milliliters per hour will the nurse set the volume control device? A 38 mL B 33 mL C 28 mL D 23 mL
33 mL/hr
There are 200 ml in clients IV bag. The nurse took the bag down when there were 50 ml still in the bag and hung a new 1000 ml bag. The client received two IV piggybacks (IVPBs) during the shift each contained 100 ml. When calculating the I and O at the end of shift the nurse looks at the IV bag. How many ml of IV fluid did the client receive during the shift? The pic shows 400 left in the bag.
950 ml
A client with a thromboembolic disorder is receiving a continuous intravenous infusion of heparin at a rate of 1000 units per hour. There are 25,000 units of heparin in 500 mL of 5% dextrose solution. At how many milliliters per hour should the nurse set the rate on the electronic infusion control device?
20 mL/hr
A 7-year-old child with cystic fibrosis is receiving an intravenous antibiotic. The medication is supplied in a 125-mL bag of 0.45% sodium chloride. It is to be infused over 30 minutes. At what rate should the infusion pump be set to deliver the medication in the prescribed time? Express your answer as a whole number.
250 mL
A healthcare provider prescribes 2 liters of intravenous (IV) fluid to be administered over 12 hours to a client who sustained a burn injury. The drop factor of the tubing is 10 gtts/mL. The nurse should set the flow rate at how many drops per minute? gtts/min
28 gtts/min
The healthcare provider's prescription for intravenous fluid states that the client is to receive 1 L of fluid every 8 hours. If the equipment delivers 15 drops/mL, at what rate should the nurse regulate the flow? drops/min
31 drops/min
Ceftriaxone 2.5 grams intravenous piggyback (IVPB) every 8 hours is prescribed for a client with a severe infection. The pharmacy sends a vial labeled 5 grams per 10 mL. What volume of ceftriaxone should the nurse add to the IVPB solution? mL
5 mL
A client's intravenous (IV) infusion infiltrates. The nurse concludes that what is most likely the cause of the infiltration? A Excessive height of the iv bag B Failure to secure the catheter adequately C Contamination during the catheter insertion D Infusion of a chemically irritation medication
B
A nurse is caring for a client who is receiving an intravenous (IV) infusion. What should the nurse do first if the IV infusion infiltrates? A Elevate the IV site B Discontinue the infusion C Attempt to flush the tubing D Apply a warm, moist compress
B
The nurse finds the respiratory rate is 8 breaths per minute in a client who is on intravenous morphine sulfate. What should the nurse do immediately in this situation? A measure other vital sign B stop administering the medication C Elevate the head of the client's bed D report to the primary HCP
B A respiratory rate of 8 breaths per minute indicates respiratory depression, and the nurse should stop the medication immediately. The nurse can measure the other vital signs after discontinuing the medication administration. Elevating the head of the client's bed ensures proper breathing. Therefore the nurse should elevate the client's bed after discontinuing the medication.
5 month old infant experiencing severe diarrhea and is given IV fluids. What is the most important reason for the nurse to closely monitor the flow rate? A. Limitation of output B. Replacement of lost fluids C. Avoidance of IV infiltration D. Prevention of cardiac overload
D. If circulation is overloaded or rate to rapid, stress on the heart becomes too great - cardiac overload can occur
Corrective surgery for hypertrophic pyloric stenosis is completed, and the infant is returned to the pediatric unit with an intravenous (IV) infusion in progress. What is the priority nursing action? A Applying adequate restraints B Administering a mild sedative C Removing the nasogastric tube D Assessing the IV site for infiltration
D
When the nurse arrives at 8:00 am, a client has a 1000 mL bag of D5W hanging, with 450 mL infused during the prior shift. The IV infusion is to deliver 100 mL per hour. At 11:00 am the healthcare provider changes the prescription for the intravenous solution to 1000 mL 0.9% sodium chloride to be administered at 75 mL per hour and changes the dietary order from nothing by mouth to clear liquids. From 1:00 pm to the end of the 12-hour shift at 8:00 pm, the client has 4 oz (120 mL) of apple juice, a half cup of tea, a half cup of gelatin, and 6 oz (180 mL) of water. How many milliliters should the nurse document as the client's total fluid intake for the 12-hour shift?
1515mL . Between 8:00 am and 11:00 am, 100 mL per hour were infused. Between 11:00 am and 8:00 pm, 75 mL per hour were infused. A half cup is 4 oz, and each ounce is equivalent to 30 mL, so the juice, tea, and gelatin each provided 120 mL. Water intake was 180 mL. The 450 mL infused during the prior shift should not be included.
A client is to receive 2000 mL of intravenous (IV) fluid in 12 hours. At what rate should the nurse set the electronic infusion control device? Record your answer using a whole number. mL/hr
167 mL/hr
Ampicillin 160 mg IV every 4 hours is prescribed. A vial containing 250 mg per 5 mL is available. How many milliliters should the nurse administer?
3.2mL
An intravenous (IV) solution of 1000 mL 5% dextrose in water is to be infused at 125 mL/hr to correct a client's fluid imbalance. The infusion set delivers 15 drops/mL. To ensure that the solution will infuse over an 8-hour period, at how many drops per minute should the nurse set the rate of flow? Record your answer using a whole number. gtts/mn
31 gtts/min
The healthcare provider orders 1000 mL normal saline to be infused over 8 hours for a client with a diagnosis of dehydration. The intravenous (IV) tubing delivers 15 drops per milliliter (drop factor). The nurse should administer the IV infusion at what rate?
31 gtts/min
A client, receiving a potassium infusion via a peripheral intravenous (IV) site, reports a burning sensation above the IV site. What should the nurse do first? A Check the IV access for a blood return B Apply warm compresses to affected extremity C Slow the IV infusion until until the burning sensation is gone D Request an oral supplement from the PHCP
A Because potassium infusions can be caustic to the vein, a nurse should check for continued blood return. That finding determines the nurse's next intervention(s). If blood return is present, then it is appropriate to apply warm compresses. If there is not a blood return, the infusion needs to be stopped via that IV site, not slowed. If the potassium infusion cannot be administered, the primary healthcare provider must be notified so that other means of potassium replacement can be instituted.
What is a nurse's responsibility when administering prescribed opioid analgesics? Select all that apply. A Count the client's respirations B Document the intensity of the client's pain C Withhold the med if the client reports pruritus D Verify the number of doses in the locked cabinet before administering the prescribed dose E Discard the med in the client's toilet before leaving the room if the med is refused
A,B,D Pruritus is a common side effect that can be managed with antihistamines. It is not an allergic response, so it does not preclude administration.
The nurse assesses a client receiving intravenous (IV) fluids. Which assessment finding should warrant the nurse calling the primary healthcare provider? A crackles in lungs B Supple skin turgor C Urine output of 240 mL over 8 hours D Increase in BP from 110/76 to 124/68 mm HG
A-Crackles in the lungs indicate the client is overloaded with fluids. Nurse should notify the PHCP to slow or discontinue the IV fluid. Supple skin turgor is a normal finding. A urine output of 240 mL in 8 hr is adequate. (30 mL per hour is ok) An increase in bp is to be expected with fluid administration.
A client is receiving morphine sulfate for severe metastatic bone pain. What will the nurse do to assess for complications from a common serious side effect of morphine? A Monitor for diarrhea B Observe for an opioid addiction C Assess for altered breathing patterns D Check for a decreased urinary output
C Morphine sulfate is a central nervous system depressant that commonly decreases the respiratory rate, which can lead to respiratory arrest.
After surgery, a client received a prescription for 8 mg of morphine sulfate to be given by injection. The vial on hand is labeled 1 mL = 10 mg. How much solution should the nurse administer? Record your answer using one decimal place and include a leading zero if applicable.
0.8mL
How should a nurse prepare an intravenous piggyback (IVPB) medication for administration to a client receiving an IV infusion? Select ALL that apply. A Wear clean gloves to check the IV site B Rotate the bag after adding the medication to mix C Use 100 mL of fluid to mix the medication D Flush the IV insertion site with 2 mL saline E Place the IVPB at a lower level than the existing IV F Use a sterile technique when preparing the medication
A,B,F Clean gloves should be worn to check the IV since there is a risk of coming into contact with blood. Ensuring the med is mixed is important-rotating is one way, although there are others. Because IV solutions enter the body's internal environment, all solutions and meds must be sterile to prevent introduction of microbes. The amount and type of solution depend on the med. The insertion site doesn't have to be flushed with an infusing IV. The IVPB should be hung higher, not lower, than the existing bag.
In order to minimize the likelihood for error during intravenous administration of antibiotics, the legal authority advised the delegatee to wear a colored vest that says, "Do not disturb! Medication administration in process." Which delegatee is appropriate to follow the advice of legal authority? A Nursing aide B Registered nurse C Patient care associate D Licensed vocational nurse
B Administration of intravenous (IV) medications is under the scope of practice of the registered nurse.A licensed vocational nurse can only administer intramuscular medication and oral medications for the client.
A 2½-year-old child is receiving intravenous (IV) fluid. A 500-mL bag of D5 in ½NS is hung at 1 am and is to infuse at 45 mL/hr. At 6 am the nurse notes that there is 125 mL left in the bag. What does the nurse conclude about the fluid that has infused? A should be recalculated in an hour B Is more than the child should have received C Is less than the amount prescribed for the child D Remained at the prescribed rate through the night
B An excessive amount of fluid has infused. The IV should be delivered at 45 mL/hr and should be checked on a regular schedule. If the IV had infused at the prescribed rate of 45 mL/hr for 5 hours, 225 mL should have infused, leaving 275 mL in the bottle. An excessive, not less-than-prescribed, amount of fluid has infused.
A 9-year-old child is returned to the postanesthesia care unit after surgery to correct a compound fracture of the humerus. An intravenous (IV) infusion pump is in place, delivering D5% 0.45% NS at a rate of 70 mL/hr. What action will the postanesthesia care nurse implement? A Question the prescription B Continue the current solution and flow rate C change the IV bag to one containing D5% 0.9% NS D Offer oral fluid when the child awakens and slow down the IV rate
B Because it is the correct solution ( hypertonic) and flow rate for a healthy 9-year-old child, the infusion should be continued. There is no reason to question the prescription. Changing the IV bag cannot be done without a prescription; also, there is no indication that the child needs a hypotonic solution D5% and 0.9% NS which is isotonic. Offering fluids and slowing the IV rate are not necessary. The client's gag reflex and the presence of bowel sounds must first be assessed before the administration of oral fluids.
A primary nurse is leaving the unit for lunch and gives a verbal report to another nurse on the unit. The primary nurse states that a client has a prescription for morphine 2 mg intravenously (IV) every 3 hours for abdominal pain because the client had major abdominal surgery that morning. While the primary nurse is still at lunch, the client complains of pain on a level 8 on a pain scale of 0 to 10. What is the first thing the covering nurse should do? A determine the documented time when the pain med was last given B verify that the written prescription matches the administration record C Encourage nonpharm. measures initially to relieve the pain D Explain that the primary nurse will be back from lunc ub a few minutes
B Before administering any medication for the first time, the nurse must verify the accuracy of the prescription. Checking when the pain medication was last given is done after the prescription is verified.
A nurse identifies that a client's IV site is warm, red, and tender. What does the nurse conclude is the most likely cause of this finding? A Rapid delivery of the infusion B CHemical irritation to the tissues C Allergic response to the infusion D Catheter infiltration into the tissues
B Chemical irritation to the tissues is a sign of phlebitis that can be caused by irritating medications. Rapid infusion causes fluid overload, not phlebitis. A local allergic reaction is associated with hives or a pruritic rash. Infiltration causes a pale, cool insertion site because of fluid accumulation in the tissue.
A nurse assesses a client's intravenous site. What clinical finding, unique to infiltration, leads the nurse to conclude that the IV site has infiltrated, rather than become inflamed? A Pain B Coolness C Localized swelling D Cessation in flow of solution
B When an IV infiltrates, the solution entering the interstitial space is at room temp(approx 75 degrees F, body temp is 98.6 degree F); therefore the skin will feel cool to the touch at the site of an IV infiltration. The site of an inflammation will feel warm to the touch due to vasodilation and hyperemia. Pain may occur with both an inflammation and an infiltration. A cessation of flow occurs with both an inflammation and an infiltration . An inflammation in the vein at the insertion site may close the lumen of the vessel, interfering with the flow of solution. An infiltration will cause excess fluid in the interstitial compartment to the extent that it will not accommodate more solution, interfering with the flow of the solution.
What is the priority nursing action when a 3-month-old infant is receiving intravenous (IV) fluids by way of an antecubital vein? A Monitoring for infiltration behind the infant's elbow B Applying arm boards to prevent bending at the elbows C Checking both of the infant's pupils for dilation every hour D Telling the parent why they cannot hold the infant during IV therapy
B-the arm board should be used so the child will not bend the elbow and restrict the flow of IV fluids. First the flow of fluid must be ensured; then inspection for signs of infiltration at IV insertion site, not the elbow. Pupil responses are unrelated to dehydration and fluid replacement.
Which action should the nurse take first when a client's gravity flow IV rate is too slow? A Reposition the client's arm B Adjust the flow clamp to deliver the correct rate C Evaluate the appearance of the catheter insertion site D Determine the amount of fluid that should've been absorbed
C If infiltration or phlebitis is responsible for the decreased flow rate, the IV catheter must be removed and restarted in a new site.
A client who is hospitalized after a myocardial infarction asks the nurse why morphine was prescribed. What will the nurse include in the reply A Decreases anxiety and promotes sleep B Helps prevent development of atrial fibrillation C Relieves pain and reduces cardiac oxygen demand D Dilates coronary blood vessels to increase oxygen supply
C Morphine is a specific central nervous system depressant used to relieve the pain associated with myocardial infarction; it also decreases apprehension and reduces cardiac oxygen demand by decreasing cardiac workload.
The nurse is preparing to insert an intravenous catheter in a thin, emaciated client who is scheduled to begin intravenous fluid therapy. Which interventions should the nurse follow to provide high-quality care? Select all that apply. A Insert an 18 G IV catheter B Change the intravenous line every 7 days C Flush the intravenous line every 7 days D Insert the intravenous catheter in the client's femur E stop the insertion procedure when there is a break in technique
C,E The nurse should flush the IV line with normal saline to maintain patency. The nurse should stop the insertion procedure when there is a break in technique. This intervention helps prevent catheter-related bloodstream infections and provides high-quality care to the client. The nurse should change the intravenous line every 72 to 96 hours to prevent the risk of infection. The nurse should avoid inserting the catheter in the client's femur because it increases the risk of bloodborne infections.
The nurse administers an intravenous (IV) solution that is piggybacked into a primary IV line using gravity flow tubing; the nurse hangs the secondary infusion bag higher than the primary infusion bag. After completion of the infusion, the client expresses concern about air in the piggyback tubing. The client asks if that means an air embolism is probable. What is the nurse's best response? A "air in the tubing, even if it got into the vein, will not be fatal unless it is a large amount." B "The antibiotic and now the air are flowing into the primary IV bag, not into the venous system directly." C "the solution from the large IV bag begins to flow when the solution from the smaller bag ceases to flow." D "The clamps on the tubing leading from both bags will be closed for a few minutes to prevent air from entering the vein."
C-The secondary bag, containing the med, is hung higher than the level of fluid in primary IV so gravity forces it to empty first. Air in the secondary line will not enter the vein. Closing the clamps on the tubing leading from both bags for a few minutes is contraindicated because it stops the infusion, which can clog the lumen of the catheter that is inserted into the vein.
A school nurse is asked to develop a program for teachers about infection control, especially focusing on hand washing technique. What is the most effective way for the nurse to evaluate what the teachers have learned? A Observe the teachers lecture the children about hand hygiene B Give an objective written final exam to the teachers C Schedule a seminar for the teachers to share their knowledge D Watch the teachers demonstrate infection control techniques
D
