Quiz 4 - Perfusion, Tissue Integrity & Safety
When administering an IV piggyback medication to infuse by gravity, how can the nurse ensure that the medication will infuse properly?
- Hang the piggyback medication higher than the primary fluid - When a medication or any fluid is infused by gravity a pump is not necessary to run the infusion. Placing the secondary bag higher than the primary fluid will allow for the fluid to infuse at a faster rate than the primary bag with the help of gravity.
The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question?
- "Have you ever had a transfusion before?" - Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. Questioning about previous history of shock and knowledge of complications and risks of transfusion are not helpful because they may elicit a fearful response from the client. Although determining whether the client knows the reason for the transfusion is important, it is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion.
A health care provider's prescription reads morphine sulfate, 8mg stat. The medication ampule reads morphine sulfate, 10mg/mL. The nurse prepares how many milliliters to administer the correct dose?
- 0.8 mL - Rationale: Desired x mL/ Available = Milliters 8mg x 1mL / 10mg = 0.8mL
A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain with intravenous (IV) solution from the IV storage area to hang with the blood products at the client's bedside?
- 0.9% sodium chloride - Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells. Lactated Ringer's is not the solution of choice with this procedure.
A health care provider's prescription reads to administer an IV dose of 400,000 units of penicillin G benzathine (Bicillin). The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine (Bicillin), 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Record your answer using one decimal place.
- 1.3 mL - Rationale: Desired x mL/ Available = Milliliters per dose 400,000 units x 1mL / 300,000 units = 1.33 = 1.3 mL
A healthcare provider's prescription reads levothyroxine (Synthroid), 150mcg orally daily. The medication label reads Synthroid, 0.1mg/tablet. The nurse administers how many tablet(s) to the client?
- 1.5 tablets - Rationale: First, convert 150mcg to milligrams. In the metric system, to convert smaller to larger, divide by 1000 or move the decimal three places to the left. Therefore, 150mcg = 0.15mg. Next, use the formula to calculate the correct dose: (Desired/Available) x Tablet = Tablets per dose (0.15mg/0.1mg) x 1 tablet = 1.5 tablets
The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring?
- 15 minutes - The nurse must remain with the client for the first 15 minutes of a transfusion, which is usually when a transfusion reaction may occur. This enables the nurse to detect a reaction and intervene quickly. The nurse engages in safe nursing practice by obtaining coverage for the other assigned clients during this time. Therefore, the remaining options re incorrect time frames.
A healthcare provider prescribes heparin sodium, 1300 units/hour by continuous IV infusion. The pharmacy prepares the medication and delivers an IV bag labeled heprain sodium 20,000 units/250mL D5W. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 1300 units/hour? Record the answer to the nearest whole number.
- 16 mL/hour - Rationale: First, you need to determine the amount of heparin sodium in 1mL. The next step is to determine the infusion rate, or milliliters per hour. Step 1: Known amount of medication in solution/ Total volume of diluent = Amount of medication per milliliter 20,000 units/250mL = 80 units/mL Step 2: Dose per hour desired/Concentration per milliliter = Infusion rate, or mL/hour 1300 units/(80units/mL) = 16.25 or 16 mL/hour
The same IV orders above (500 mL NS over 5 hours) will have how many mL left in the IV bag after 3 hours?
- 200mL - 500mL/5hr = 100 mL/hr x 3hr = 200mL
Cefuroxime sodium, 1g in 50mL normal saline, is to be administered over 30 minutes. The drop factor is 15gtt/mL. The nurse sets the flow rate at how many drops per minute?
- 25 gtt/minute - Rationale: Total volume x Drop factor/ Time in minutes = Drops per minute 50mL x 15gtt/ 30 minutes = 25 gtt/minute
Order for 500 mL of 0.45NS is to infuse over 8 hours. Calculate the flow rate
- 63mL/hr
A health care provider prescribes regular insulin, 8 units/hour by continuous IV infusion. The pharmacy prepares the medication and then delivers an IV bag labeled 100 units of regular insulin in 100mL normal saline. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 8 units/hour?
- 8 mL/hour - Rationale: First, you need to determine the amount of insulin in 1mL. The next step is to determine the infusion rate (mL/hr) Step 1: Known amount of medication in solution/Total volume of diluent = Amount of medication per milliliter 100 units/100mL = 1 unit/mL Step 2: Dose per hour desired/Concentration per milliliter = Infusion rate (mL/hour) 8 units / (1 unit/mL) = 8 mL/hour.
What is the correct order of the steps for starting an IV on a client? Place steps in the appropriate order. A. Perform hand hygiene, don gloves, open the IV extension set and prime the set with sterile saline. B. Apply the tourniquet above the site chosen and clean the site. C. Open the catheter and hold it securely while inserting the catheter into the chosen vein. D. When a flash of blood is observed, insert the catheter fully into the vein, and remove the cannula. E. Attach the IV extension set and assure placement by drawing blood into the IV extension set via the saline syringe, then flush. F. Continuing to hold the catheter in place, apply a clear transparent dressing so the site is visible. G. Place initials, date, and time on the IV transparent dressing
- A, B, C, D, E, F, G
After changing the intravenous tubing on a patient's primary infusion, the nurse notes air bubbles in the tubing. How should the nurse remove them?
- Close the clamp, stretch the tubing downward, and flick the tubing - Closing the clamp is a preventative action to keep the air bubbles from going into the patient's IV. Flicking the tubing will create small vibrations to remove the bubbles from the tubing.
Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.60 F orally. Which action should the nurse take?
- Delay hanging the blood and notify the health care provider (HCP) - If the client has a temperature higher than 1000 F, the unit of blood should not be hung until the HCP is notified and has the opportunity to give further prescriptions. The HCP likely will prescribe that the blood be administered regardless of teh temperature, but the decision is not within the nurse's scope of practice to make. The nurse needs an HCP's prescription to administer medication to the client.
How often should the IV tubing be changed on a primary IV line?
- Every 72 hours - This answer is correct because IV tubing change should be changed every 72 hours on a primary IV line. Also tubing should be replaced whenever the sterile pathway could be compromised. Primary IV fluids are utilized for clients with dehydration, electrolyte imbalances, severe burns, and to administer nutrients as well as medications
The nurse who is about to begin a blood transfusion knows the blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun?
- Expiration date - The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage usually is limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. The nurse also notes the blood identification (unit) number, blood group and type, and client's name. The nurse also inspects the unit of blood for leaks, abnormal color, clots, and bubbles and returns the unit to the blood bank if clots are noted.
The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client's intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which complication has occurred?
- Infiltration - An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling are the results of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line at another site. Infection, phlebitis, and thrombosis are likely to be accompanied by warmth at the site, not coolness.
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 - The nurse should obtain new IV tubing because contamination has occurred and could cause systemic infection to the client. There is no need to obtain a new IV bag because the bag was not contaminated. Wiping with Betadine or alcohol is insufficient and is contraindicated because the spike will be inserted into the IV bag.
The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to take which action immediately after injecting the potassium chloride into the port of the IV bag?
- Rotate the bag gently - After adding a medication to a bag of IV solution, the nurse should agitate or rotate the bag gently to mix the medication evenly in the solution. The nurse should then attach a completed medication label. The nurse can them prime the tubing. The IV solution should have been checked for discoloration before the medication was added to the solution. The tubing is attached to the client last.
The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next?
- Run normal saline at a keep-vein-open rate - If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further health care provider prescriptions. This maintains a patent IV access line and aids in maintaining the client's intravascular volume. The nurse would not remove the IV line because then there would be no IV access route Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be removed. Second, cultures are performed when infections, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.
The nurse is starting a client's 3rd unit of PRBCs. The client begins complaining of severe back pain, becomes apprehensive, and VS: T 100.9F, P 126, RR 28, BP 80/54. Which intervention should the nurse perform as priority?
- Stop the infusion - This answer is correct because the client is having a blood transfusion reaction and the nurse must stop the infusion immediately.
Which signs alert the nurse to a potential complication of an IV push? Select all that apply.
- The client presents with labored breathing after the push - The nurse assesses that the insertion catheter will not flush - The nurse observes clear liquid ooze from the IV insertion site - This answer is correct because clear fluid oozing around the IV catheter insertion site indicates something is wrong with the IV site. If the nurse assesses that the catheter will not flush, she should check for kinks in the catheter tubing and do not forcefully flush the IV catheter. Labored breathing after a push of med can mean an adverse reaction is occurring.
When choosing a site for the IV catheter, which statement(s) is/are true? Select all that apply.
- The nurse will choose a vein that is not visibly hard or scarred - The nurse and client will collaborate on choosing an appropriate site - The nurse will attempt to choose a site to maximize client mobility - This answer is correct because often the client knows which veins are easily accessible and can advise the nurse. The collaboration between the client and the nurse can increase access to a functional site. Many clients prefer the IV not be placed in the dominant hand, so they can continue to maximize mobility as much as possible while hospitalized. The nurse should choose a vein that is not visibly hard or scarred. Patients should not care for their own IV site.
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 - A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs before the procedure and again after the first 15 minutes. The other options do not identify assessments that are a priority just before beginning a transfusion.
List 4 complications that can arise from a peripheral IV:
- Your Answer: Four complications can arise from a peripheral IV are: Phlebitis Infiltration Infection Extravasation - Answer: Phlebitis Infiltration Air embolism Extravasation infection hypervolemia
