IV Therapy Blood
A nurse suspects that an air embolism has occurred when the client's central venous catheter disconnects from the IV tubing. The nurse immediately places the client in which position? a) trendelenburg's on the left side b) trendelenberg's on the right side c) reverse trendelenberg's on the left side d) reverse trendelenberg's on the right side
. A - If the client develops an air embolism, the immediate action is to place the client in Trendelenburg's position on the left side. This position raises the client's feet higher than the head and traps any air in the right atrium. If necessary, the air can then be directly removed by intracardiac aspiration. Options B, C, and D are incorrect positions because reverse Trendelenburg's elevates the head, puts the air in a dependent position, and increases the risk of a cerebral embolism; lying on the right side places the air in a dependent position, rendering it more likely to migrate.
The nurse assesses a client with a triple-lumen catheter. Which is the nurse most likely to observe in a client with an air embolism? a) bilateral basilar crackles b) diminished breath sounds c) systolic click at right sternal border d) churning sound over right ventricle
. D - Clients with triple-lumen catheters are at risk for air embolism. Because an air embolism can be fatal, the nurse monitors for chest pain, coughing, hypotension, cyanosis, and hypoxia. In addition, if the client does have an air embolism, auscultation over the right ventricle may reveal a "churning" sound indicating the location of the embolism. Options A, B, and C are uncharacteristic of an air embolism.
A nurse evaluates the patency of a peripheral intravenous (IV) site and suspects an infiltration. Which does the nurse implement to determine if the IV has infiltrated? a) strips the tubing and assessments for a blood return b) checks the regional tissue of redness and warmth c) increases the infusion rate and observes for swelling d) gently palpates regional tissue for edema and coolness
. D - When assessing an IV for clinical indicators of infiltration, it is important to assess the site for edema and coolness, signifying leakage of the IV fluid into the surrounding tissues. Stripping the tubing will not cause a blood return but will force IV fluid into the vein or surrounding tissues that can increase the risk of tissue damage. Increasing the IV flow rate can further damage the tissues if the IV has infiltrated. Redness and warmth are more likely to indicate infection or phlebitis.
1.Which of the following nursing interventions is correct for clients receiving I.V. therapy? a Change the tubing every 8 hours. b . Monitor the flow rate at least every hour. c . Change the I.V. catheter and entry site daily. d . Increase the rate to catch up if the correct amount hasn't been infused at the end of the shift.
1. b Closely observing the rate of infusion prevents underhydration and overhydration. The I.V. catheter and entry site should be changed every 48-72 hours in most situations. Tubing is changed according to agency policy but not at the frequency of every 8 hrs. Increasing rate may lead to fluid overload.
A client receives a prescription for 1000 ml of intravenous (IV) 0.9% normal saline solution. Which statement guides the nurse during the administration of this solution? The solution: a) affects the plasma osmolarity b) is the same solution as sodium chloride 0.45% c) is isotonic with the plasma and other body fluids d) is hypertonic with the plasma and other body fluids
12. C - Sodium chloride 0.9% (not sodium chloride 0.45%) is the same solution as normal saline 0.9%. This solution is isotonic (not hypertonic), and isotonic solutions are frequently used for IV infusion because they do not affect the plasma osmolarity.
The nurse prepares to access an implanted vascular port. Which should the nurse implement first? a) apply a cool compress b) palpate the vascular port c) anchor the vascular port d) cleanse the site with alcohol
13. B - Before accessing an implanted vascular port, the nurse must palpate the port to locate the center of the septum because the nurse needs to know where to insert the needle to avoid more than one needle stick for the client. The nurse then applies the cool compress to the insertion site to provide mild pain relief for the needle stick, cleanses the site with alcohol, anchors the port with the nondominant hand, and avoids contamination of the septum.
A nurse should remain with a client during the first 15 min of a blood transfusion to a. verify the blood is being transfused. b. assess for an adverse reaction. c explain the procedure to the client. d obtain blood specimens.
19 b a. INCORRECT: Verifying the blood being transfused occurs prior to blood administration. b. CORRECT: Assessment of the client during the first 15 min of the transfusion is important because this is when most blood reactions occur. c. INCORRECT: Explanation of the procedure should be done prior to blood administration. d. INCORRECT: Blood specimens are obtained only in the event of a blood reaction.
2.A nursing home client is transferred to the hospital with dehyrdration and pnuemonia. After receiving the client from the emergency department, the nurse notices that his I.V. infusion has infiltrated. Which of the following is the best initial response by the nurse? a . Stop the infusion, remove the I.V. b . Remove the I.V. catheter and apply a cool compress to the site. c . Apply moist heat to the site. d . Gently massage the site.
2. c . Multiply the number of ml to be infused (125) by the drop factor (10); 125 x 10 = 1,250. Then divide the answer by the number of minutes to run the infusion (60); 1,250 divided by 60 = 20.83 or 20 to 21 gtt/minute
A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take when there is a transfusion reaction? (Select all that apply.) a. Stop the transfusion. b Send the blood bag and IV tubing to the blood bank. c Maintain an IV infusion with 0.9% sodium chloride. d Elevate the client's feet e Obtain blood cultures
20 a, b, & c a. CORRECT: The first action is to stop the infusion. b. CORRECT: The blood bag and administration tubing are sent to the laboratory for analysis. c. CORRECT: 0.9% sodium chloride solution should be administered through new IV tubing. d. INCORRECT: The client's feet are elevated if sepsis or septic shock is suspected following a transfusion. e. INCORRECT: Blood specimens are not routinely obtained unless sepsis is suspected.
A nurse is monitoring a client who began receiving a unit of blood 10 min ago. Which of the following should pose an immediate concern for the nurse? (Select all that apply.) a. Temperature change from 37° C (98.6° F) pretransfusion to 37.2° C (99.0° F) posttransfusion b. Dyspnea c Heart rate increase from 74/min pretransfusion to 81/min posttransfusion d Client report of itching e Client appears flushed
21 a, b, d & e a. CORRECT: A slight increase in temperature is an expected finding. b. CORRECT: Dyspnea may indicate a transfusion reaction. c. INCORRECT: A slight increase in heart rate is an expected finding. d. CORRECT: A client's report of itching may indicate a transfusion reaction. e. CORRECT: A flushed appearance of the client may indicate a transfusion reaction.
A nurse is completing preoperative teaching with a client who will undergo an elective surgical procedure that will include a blood transfusion. Which of the following statements by the nurse should be included in the teaching? a. "You should make an appointment to donate blood 8 weeks prior to the surgery." b. "If you need an autologous transfusion, the blood your brother donates can be used." c. "We will have you come in to donate your blood the day before surgery." d. "You will receive the blood you donated 4 weeks prior to the surgery."
22 d a. INCORRECT: The client should donate blood for an autologous transfusion no sooner than 5 weeks in advance, up to 72 hr prior to surgery. b. INCORRECT: A homologous transfusion involves receiving a transfusion of blood from donors other than the recipient. c. INCORRECT: The client should donate blood for an autologous transfusion no sooner than 5 weeks in advance, up to 72 hr prior to surgery. d. CORRECT: An autologous transfusion involves collecting a client's blood no sooner than 5 weeks in advance, up to 72 hr prior to surgery so it can be transfused during an elective surgery.
7. An elderly patient was hydrated with lactated Ringer's solution in the emergency room for the last hour. During the most recent evaluation of the patient by the nurse, a finding of a rapid bounding pulse and shortness of breath were noted. Reporting this episode to the physician, the nurse suspects that the patient now shows signs of: a. Hypovolemia, and needs more fluids b. Hypervolemia, and needs the fluids adjusted c. An acid-base disturbance d. Needing no adjustment in fluid administration
7. b Isotonic solutions has the same osmolality as body fluids. Isotonic solutions, such as Normal Saline and Ringer's Lactate, initially remain in the vascular compartment, expanding vascular volume. Isotonic imbalances occur when water and electrolytes are lost or gained in equal proportions, and serum osmolality remains constant.
5.An elderly patient was hydrated with lactated Ringer's solution in the emergency room for the last hour. During the most recent evaluation of the patient by the nurse, a finding of a rapid bounding pulse and shortness of breath were noted. Reporting this episode to the physician, the nurse suspects that the patient now shows signs of: a Hypovolemia, and needs more fluids b Hypervolemia, and needs the fluids adjusted c An acid-base disturbance d Needing no adjustment in fluid administration
5. b The proportion of body water decreases with aging. Tissue trauma, such as burns, causes fluids and electrolytes to be lost from the damaged cells, and the breakdown in the continuity of the tissue. In Type I Decubitus, the skin remains intact, and any shifting of fluids is due to the inflammatory process and internally maintained within the body. Vomiting and diarrhea can cause significant fluid loses. Age, sex, and body fat affect total body water. Infants have the delete spaces highest proportion of water; it accounts for 70--80% of their body weight. Decreased blood flow to the kidneys as caused by impaired cardiac function stimulates the rennin-angiotensin-aldosterone system, causing sodium and water retention. Clients who are confused or unable to communicate are at risk for inadequate fluid intake. Age does not play a significant factor here.
6.Following surgery, the client requires a blood transfusion. The main reason the nurse wants to complete the unit transfusion within a four-hour period that blood: a. Hanging for a longer four hours creates an increased risk of sepsis b. May clot in the bag c. May evaporate d. May not clot in the recipient after this time period
6. a Hanging for a longer four hours creates an increased risk of sepsis, which is why the nurse wants to complete the unit transfusion in less than four hours. The remaining items are not likely to happen.
8.Measurements related to fluid balance of clients that a nurse can initiate without a physician's order include: a. Daily weights, vital signs, and fluid intake and output b. Daily weights, diuretics, and waist measurement c. Monitoring temperature, fluid intake and output, and calorie count d. Auscultating lung sounds, monitoring color of urine, and placing a Foley catheter into the client
8. a Daily weights, checking vital signs, and monitoring fluid I&O all fall within the realm of nursing interventions. The remaining interventions either have the nurse perform a task requiring an MD order, such as giving diuretics or placing a Foley catheter, or have an action unrelated to this problem, such as the calorie count.
4.Calculate the hours that I.V. will run: Order: Ringer's lactate 500 ml IV; run 60 ml/hr
8.3 hours approximately
9.A malnourished elderly client requires long-term IV therapy care. It has been decided to use a PICC line to administer the fluids to this client. Site care to be performed for this client after insertion includes: a. Dressing changes every four hours, whether the dressing is soiled or not b. Use of aseptic technique when caring for the long term venous access device is expected. c. Isopropyl alcohol is the only cleansing solution used with these devices for cleaning. d. Securing catheter and covering entry site with gauze
9. b The skin is the first line of defense in the body. Using strict aseptic technique is most advocated. Frequency of varies from three to seven days, depending on the site. In some institutions, this may the agent for cleaning of the site, but providone iodine is also commonly used. After securing the catheter, an occlusive dressing is placed over the site. Follow agency protocol for frequency of dressing changes, and change when they are loose or soiled.
A client receiving parenteral nutrition (PN) through a subclavian catheter suddenly develops dyspnea, tachycardia, cyanosis, and decreased level of consciousness. Which is the best intervention for the nurse to implement for the client? a) turn to left side in trendelenburg's position b) obtain a start oxygen saturation level c) examine the insertion site for redness d) perform a start fingerstick glucose level
A - Clinical indicators of air embolism include chest pain, tachycardia, dyspnea, anxiety, feelings of impending doom, cyanosis, and hypotension. Positioning the client in Trendelenburg's and on the left side helps to isolate the air embolism in the right atrium and prevent a thromboembolic event in a vital organ. Monitoring the oxygen saturation is a reasonable nursing response to the client's condition; however, acting to prevent a deterioration in the client's condition is more important than obtaining additional client data. Options 3 and 4 are unrelated to the symptoms identified in the question.
A client receiving parenteral nutrition (PN) via a central venous catheter (CVC) is scheduled to receive an intravenous (IV) antibiotic. Which should the nurse implement before administering the antibiotic? a) turn off the PN for 30 minutes b) check for compatibility with PN c) ensure a separate IV access route d) flush the CVC with normal saline
C - The PN line is used only for the administration of the PN solution to prevent crystallization in the CVC tubing and disruption of the PN infusion. Any other IV medication must be administered through a separate IV access site including a separate infusion port of the CVC catheter. Therefore, options A, B, and D are incorrect actions.
The nurse notes redness, warmth, and purulent drainage at he insertion site of a central venous catheter (CVC) in a client receiving parenteral nutrition (PN). The nurse collaborates with the provider about this finding because: a) the client is not tolerating the PN solution b) the CVC is infiltrated and should be stopped c) the client is allergic to the dressing material d) infections of a CVC site can lead to septicemia
D - Redness, warmth, and purulent drainage are signs of an infection, not an indication of intolerance to the solution or an allergic reaction. All clients who have an infected IV insertion site are at risk of septicemia because the potential source of the infection is already in a vessel. Additionally, clients with a CVC are at high risk for septicemia because the CVC is very close to the heart. Infiltration of a CVC is unlikely because the catheters are usually threaded into the vena cava or right atrium; besides, the surrounding tissue is more likely to become cool and pale with infiltration.
The nurse prepares to administer an intravenous (IV) medication when the nurse notes that the medication is incompatible with the IV solution. Which is the best intervention for the nurse to implement for safe medication administration? a) ask the provider to prescribe a compatible IV solution b) start a new IV catheter for the incompatible medication c) collaborate with provider for a new administration route d) flush tubing before and after the medication with normal saline
D - When giving a medication intravenously, if the medication is incompatible with the IV solution, the tubing is flushed before and after the medication with infusions of normal saline to prevent in-line precipitation of the incompatible agents. Starting a new IV, changing the solution, or changing the administration route are unnecessary because a simpler, less risky, viable option exists.
A nurse is observing a newly hired nurse on the unit who is preparing to administer a blood transfusion. Which of the following actions by the newly hired nurse requires intervention by the nurse? a. Inserts a large-bore IV catheter in the client b Verifies blood compatibility and expiration date of the blood with an assistive personnel (AP) c Administers 0.9% sodium chloride IV d Assesses for a history of blood-transfusion reactions
b a. INCORRECT: A large-bore IV catheter is used for administering blood products. b. CORRECT: Verification of the client's identify, blood compatibility, and expiration date of the blood is done with another nurse. Assistive personnel cannot be asked to perform this task. c. INCORRECT: Blood and blood products are infused with 0.9% sodium chloride. IV solutions containing dextrose cannot be used. d. INCORRECT: The nurse should assess for a client history of blood-transfusion reactions to identify any potential risks for future reactions.
3.The physician has ordered an I.V. of 5% dextrose in lactated Ringer's solution at 125ml/hr. The I.V. tubing delivers 10 drops per ml. How many drops per minute should fall into the drip chamber? a . 10 to 11 b . 12 to 13 c 20 to 21 d . 22 to 24
c Multiply the number of ml to be infused (125) by the drop factor (10); 125 x 10 = 1,250. Then divide the answer by the number of minutes to run the infusion (60); 1,250 divided by 60 = 20.83 or 20 to 21 gtt/minute
