Fund. Ch 36

16. A patient has an order for an infusion of 5% dextrose in 0.45% sodium chloride at a rate of 100 mL/hr IV. The IV tubing has a drop factor of 15 gtt/mL. At how many drops per minute should the nurse regulate the infusion?

25

14. The nurse takes into consideration that according to The Joint Commission, the first IV antibiotics order for a community acquired pneumonia must be administered within:

4 hours

21. A patient who requires an immediate transfusion of blood has previously signed a consent form to receive it. The nurse confirms that the consent was signed within the last:

48 to 72 hours.

20. A nurse is aware that for a patient with a continuous IV infusion running, the IV bag should be changed when only ______ mL of solution remains in the bag.

50 mL

3. The nurse is aware that as a safety precaution against over hydration, the tubing drip factor set appropriate for a 6-month-old infant is:

60 gtt/mL

1. The nurse anticipates that the malnourished postoperative 70-year-old patient will receive an intravenous (IV) infusion of 5% dextrose in 0.45% saline, because it is: .

Hypertonic

12. A patient rings the call bell and states that the IV insertion site is painful. The site is reddened, warm, and swollen. The nurse assesses that the patient is most likely experiencing:

Phlebitis

4. The nurse evaluating a piggyback IV setup finds an error in the construction of the fluids. Which situation would the nurse correct?

Primary line clamp is closed.

9. A patient is admitted with a peripherally inserted central catheter (PICC). As part of standard care for this patient, the nurse should:

avoid taking blood pressures on the arm with the PICC line.

15. A nurse is monitoring the status of an older adult patient who is receiving IV therapy. Indicator of fluid volume overload is suspected when the nurse assesses:

crackles in the lung fields

24. The nurse caring for a patient with an intermittent IV device should:

infuse saline or heparin solution to maintain patency.

13. A patient receiving TPN fluid therapy experiences an air embolus in the central line. The nurse should immediately turn the patient onto the:

left side and lower the head of the bed.

11. The nurse observes that the insertion site of an IV catheter looks pale and puffy and the area feels cool to the touch. The initial action for the nurse should be to:

discontinue the infusion and start a new IV site.

17. A nurse accessing the injection port of the IV tubing will "scrub the hub" for: .

15 seconds

5. The nurse assisting in the initiation of a blood transfusion is aware that the only appropriate solution to infuse through a parallel infusion set before and after the transfusion is:

Normal Saline

7. A patient is receiving IV fluids through an infusion pump. How often should the nurse check the functioning of the pump?

Q 1 to 2 Hrs

18. A patient is to have an IV insertion site changed. The current line is in the lower right forearm. Which location is contraindicated for the new site?

Right hand

8. When a patient receiving IV medication exhibits light headedness, tightness in the chest, flushed face, and irregular pulse, the nurse suspects:

Speed Shock

2. The nurse is planning for the initiation of a blood transfusion. The type of tubing the nurse will prepare is a:

Y administration set

23. The LVN/LPN is told by the RN to discontinue an IV line to the patient. The best nursing action is to:

stop the IV flow by clamping the tubing securely.

A patient complains of chills, back pain, and shortness of breath a few minutes after the blood infusion is started. The first thing the nurse should do is:

stop the blood infusion and start the saline.

19. The nurse would plan to get another nurse to try to obtain a successful venipuncture if the first nurse was not successful in:

two attempts.

10. A patient has just undergone placement of a central venous catheter through the subclavian vein. When the placement is complete, the nurse should:

wait for the results of the chest radiograph before beginning fluids