Care of Chronic Conditions- Safety

The nurse received orders to initiate an intravenous antibiotic and obtain a blood specimen for culture and sensitivity from a client with an elevated temperature for the past 2 days. Prioritize the nurse's actions.

1. Explain the procedure to the client. 2. Collect the specimen according to protocol. 3. Send the specimen to the laboratory. 4. Administer the first dose of antibiotics.

In which order would the nurse complete these steps when administering a blood transfusion?

1.Check primary health care provider's prescription. 2.Obtain vital signs and history of transfusions. 3.Ascertain that intravenous catheter size is 18 or 20 gauge. 4. Change main line solution to normal saline. 5. Check client identification before hanging unit of blood.

Which laboratory value would the nurse use to determine whether a client is receiving a therapeutic dose of intravenous heparin?

Activated partial thromboplastin time (APTT) is 70 seconds

After insertion of a central venous catheter through the left subclavian vein, a client reports chest pain and dyspnea and has decreased breath sounds on the left side. Which action would the nurse take first?

Administer oxygen as prescribed.

A client receiving a blood transfusion reports itching and difficulty breathing. The heart rate has increased, and the blood pressure is falling. Which type of shock would the nurse suspect the client is experiencing?

Anaphylactic shock

A client's intravenous cannula insertion site has become red, swollen, and warm to the touch. Purulent drainage is also noted. Which intervention would the nurse implement?

Clean the site with alcohol, remove the cannula, and save for culture.

When assessing a client's forearm for a potential intravenous (IV) catheter insertion site, the nurse notes that the client has an excessive amount of hair. Which action would the nurse take to properly prepare the site for insertion?

Clip the hair.

The client with congestive heart failure is receiving furosemide 80 mg once daily. Which data collection assessment would be performed to evaluate medication effectiveness? Select all that apply. One, some, or all responses may be correct.

Daily weight Intake and output Monitor for edema Daily pulse oximetry Auscultate breath sounds

A client is admitted with cellulitis of the left leg and a temperature of 103°F (39.4°C). The primary health care provider prescribes intravenous (IV) antibiotics. Which action is the priority before administering the antibiotics?

Determine the client's allergies.

A client experiences gastrointestinal (GI) bleeding, and the health care provider prescribes a blood transfusion. While receiving the blood, the client develops flank pain, chills, and fever. Which type of transfusion reaction would the nurse conclude that the client probably is experiencing?

Hemolytic

A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When would the nurse begin to teach the client about how to care for the wound?

In the preoperative period

A client is scheduled to receive total parenteral nutrition (TPN). To administer TPN, which piece of equipment is important for the nurse to obtain?

Infusion pump

A client has a peripherally inserted central catheter (PICC) in place. The client notifies the nurse that the catheter got tangled up in bedclothes and came out. Which action would the nurse take to determine the likelihood of a catheter embolus?

Inspect the catheter.

Which personal protective equipment will the nurse plan to wear when providing central venous access device site care?

Mask and sterile gloves

A client begins to have difficulty breathing 30 minutes after the insertion of a subclavian central line. Which would the nurse do first?

Raise the head of the bed.

Which action would the nurse take when a client reports pain and burning at a peripheral intravenous (IV) site after the nurse has flushed the saline lock with normal saline?

Remove the IV catheter and restart the saline lock in another site.

Which action needs correction regarding insertion of an intravenous cannula for administration of fluids?

Shaving the client's skin immediately around the insertion site

Which action would the nurse take first when a client who is receiving a blood transfusion develops fever, chills, and low back pain?

Stop the blood transfusion and infuse saline.