chronic conditions- week 2

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

1. check HCP's prescription 2. obtain vital signs & history of transfusions 3. ascertain that IV catheter size is 18 or 20 gauge 4. change main line solution to normal saline 5. check client identification before hanging unit of blood

the nurse received orders to initiate an IV antibiotic & obtain a blood specimen for culture & sensitivity from a client with an elevated temperature for the past 2 days. prioritize the nurse's actions.

1. explain the procedure 2. collect specimen 3. send specimen to lab 4. administer first dose of antibiotics

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; APTT should be 1.5-2 times the normal APTT of 40 seconds, or 60-80 seconds when receiving IV heparin

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 & difficulty breathing. the HR has increased, & BP is falling. which type of shock would the nurse suspect the client is experiencing?

anaphylactic shock

a client's IV 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 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 CHF is receiving furosemide 80 mg once daily. which data collection assessment would be performed to evaluate medication effectiveness?

daily weight, I&O, 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 HCP prescribes IV antibiotics. which action is the priority before administering antibiotics?

determine the client's allergies

a client experiences GI bleeding, and the HCP prescribes a blood transfusion. while receiving the blood, the client develops flank pain, chills, & fever. which type of transfusion reaction is most likely taking place?

hemolytic

a client is hospitalized for IV antibiotic therapy and an incision & drainage of an abscess that developed at the sire 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 come 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 & 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 & burning at a peripheral IV site after the nurse has flushed the saline lock with normal saline?

remove the IV catheter & restart the saline lock in another site

which action needs correction regarding insertion of an IV 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 transfusion and infuse saline