NUR 113 Test 1
The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement?
"I need to restrict my activity while this catheter is in place."
A client is scheduled for placement of a peripherally inserted central catheter (PICC). The nurse has explained the advantages of this catheter to the client. Which statement made by the client indicates a need for further explanation?
"It is specifically designed for short-term use."
The nurse cares for a client prior to surgery. The client asks the nurse, "What is the advantage of spinal anesthesia over general anesthesia for controlling my pain?" Which is the best response by the nurse?
"Your pain can be managed without making you as sleepy."
A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client's bedside?
0.9% sodium chloride
The nurse is caring for an abdominal surgical client who has a Jackson-Pratt drain in place. Which interventions should the nurse include in the plan of care for this drain?
1.Make sure suction is maintained. 2.Check that the drains are sutured in place. 3.Compress the reservoir to restore suction after emptying. 4.Record the amount and color of drainage according to agency protocol or health care provider's orders.
The nurse is picking up a unit of packed red blood cells at the hospital blood bank. After putting the pen down, the nurse glances at the clock, which reads 1300. The nurse calculates that the transfusion must be started by which time?
1330
The nurse has a prescription to administer whole blood to a client who does not currently have an intravenous (IV) line inserted. When obtaining supplies to start the blood infusion, the nurse should select a catheter of at least which size?
18-20 gauge
What size needle and syringe is used to irrigate a wound?
19 gauge and 35ML
The nurse is assisting in the care of a client who is being seen in the clinic with a suspected acetaminophen overdose. What is the nurse's priority of care?
Administer acetylcysteine
The nurse provides instructions to a preoperative client about the use of an incentive spirometer. The nurse determines that the client needs further instruction if the client indicates that he or she will take which action?
After maximal inspiration, hold the breath for 10 seconds and then exhale.
The nurse enters the room of a client who began receiving a blood transfusion 45 minutes earlier to check on the client. The client is complaining of "itching all over" and has a generalized rash. The client's temperature has not changed from baseline and the lungs are clear to auscultation. Which complication of blood transfusion therapy should the nurse determine that this client is most likely experiencing?
Allergic transfusion reaction
A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry for a preoperative client. The nurse should perform which best action to ensure accurate readings on the oximeter?
Ask the client to limit motion in the hand attached to the pulse oximeter.
The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation?
Blood return shows in the backflash chamber of the catheter.
How does sanguineous drainage appear?
Bright red: indicated active bleeding
A client has just undergone insertion of a central venous catheter at the bedside under ultrasound. The nurse would be sure to check which results before initiating the flow rate of the client's intravenous (IV) solution at 100 mL/hour?
Chest radiology results
The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that this client mostlikely is experiencing which complication of blood transfusion therapy?
Circulatory overload
How does serous drainage appear?
Clear, watery, plasma
One unit of packed red blood cells has been prescribed for a client with severe anemia. The client has received multiple transfusions in the past, and it is documented that the client has experienced urticaria-type reactions (pruritus) from the transfusions. The nurse anticipates that which medication will be prescribed before administration of the red blood cells to prevent this type of reaction?
Diphenhydramine (antihistamine)
The nurse notes that the client's intravenous (IV) site is cool, pale, and swollen and that the solution is not infusing. What is the nurse's priority action?
Discontinue IV
The nurse is monitoring a client who is receiving a blood transfusion. After 30 minutes of the infusion, the client begins to have chills and back pain. His temperature is 100.1°F (37.8°C). What action should the nurse take first?
Discontinue the infusion and start an infusion of normal saline using new tubing.
The nurse plans to administer a medication by intravenous (IV) bolus through the primary IV line. The nurse notes that the medication is incompatible with the primary IV solution. Which is the appropriate nursing action to safely administer the medication?
Flush the tubing before and after the medication with normal saline.
A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias?
blood warming device
A postpartum client who received an epidural analgesic after giving birth by cesarean section is lethargic and has a respiratory rate of 8 breaths per minute. The nurse should obtain which medication from the emergency cart after notifying the health care provider?
Naloxone
If IV is placed in emergency situation how long can it stay In before is has to be changed?
No longer than 48 hours
The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action?
Obtain new IV tubing
When a client is transferred from the postanesthesia care unit and arrives on the surgical unit, which should be the first action taken by the nurse?
Obtain the clients vital signs
The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse should document in the medical record that the client experienced which condition?
Phlebitis to vein
The nurse cares for a client who is at risk for wound dehiscence after abdominal surgery. Which action is the priority to minimize this risk?
Place a pillow over the incision site during deep breathing and coughing.
Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first?
Place the client in high Fowler's position.
The nurse has just obtained a unit of blood from the blood bank to transfuse into a client as prescribed. Before preparing the blood for transfusion, the nurse looks for which member of the health care team to assist in checking the unit of blood?
RN/ Licensed individual
The nurse is caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are blood pressure (BP), 118/70 mm Hg; pulse, 91 beats/minute; and respirations, 16 breaths/minute. Preoperative vital signs were BP, 132/88 mm Hg; pulse, 74 beats/minute; and respirations, 20 breaths/minute. Which action should the nurse plan to take first?
Recheck the vital signs in 15 minutes
The nurse is assessing a client's peripheral intravenous (IV) site after completion of a vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best?
Remove the IV site and restart at another site.
The nurse determines that a client is having a transfusion reaction to blood. After the nurse stops the transfusion, which action should be taken next?
Run normal saline at a keep-vein-open rate.
A client has an epidural catheter in place after colon surgery and is receiving pain medication through the catheter. During the night the client calls the nurse and says, "I have a terrible headache that just started now." The nurse checks the epidural catheter insertion site and notes a small amount of clear drainage leaking from the bandage. What is the first action the nurse should take?
Stop the infusion
The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item?
Vital signs
How often is TPN tubing changed?
every 24 hours
How often should blood tubings be changes?
every 4 hours (after every infusion)
How often is IV tubing changed?
every 96 hours
If fever is present after 48 hours what is this a sign of?
infection
How does purulent drainage appear?
thick, yellow, green, tan, brown (INFECTION)