6573736 Silvestri Chapter 13 Ed549

Silvestri, 3/e, ISBN 1-1460-0052-6Chapter 006 (edited file)—"Cultural Diversity"10/14/08, Page 1 of 9, 4 Figure(s), 2 Table(s), 1 Box(es)

13: Intravenous Therapy and Blood Administration

PRACTICE QUESTIONS

1. A client has an order to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which of the following actions first before spiking the IV bag with the tubing? 1. Uncaps the spike portion of the tubing 2. Uncaps the distal end of the tubing 3. Closes the roller clamp on the IV tubing 4. Opens the roller clamp on the IV tubing Answer: 3 Rationale: The nurse should first clamp the tubing to prevent the solution from running freely through the tubing once it is attached to the IV bag. The nurse should next uncap the proximal (spike) portion of the tubing and attach it to the IV bag. Then, the roller clamp is opened slowly and the fluid is allowed to flow through the tubing in a controlled fashion to prevent air from remaining in parts of the tubing. Test-Taking Strategy: Use the process of elimination and note the key word, first. This question tests a specific procedure related to intravenous therapy. Visualize this procedure to answer the question correctly. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1184.

2. A nurse is checking the IV dressing of a client with a peripheral intravenous solution infusing. The date on the dressing is 2/9 (February 9). The nurse calculates that the dressing should be changed on which of the following dates? 1. 2/10 2. 2/12 3. 2/14 4. 2/16 Answer: 2 Rationale: The IV site dressing should be changed every 48 to 72 hours, which is every 2 to 3 days. With an insertion date of 2/9, the due date for change, depending on agency policy, would be either 2/11 or 2/12. Changing the dressing every 5 to 7 days (options 3 and 4) would place the client at risk for infection. Changing the dressing on a daily basis is not necessary, unless the dressing becomes wet. Test-Taking Strategy: Use the process of elimination. Recalling that the IV site dressing should be changed every 48 to 72 hours will direct you to option 2. Review the standard accepted


guidelines for intravenous site maintenance if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 244.Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 1181, 1187.

3. A nurse is doing a routine assessment of a client’s peripheral IV site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which of the following has probably occurred? 1. Infiltration 2. Phlebitis 3. Thrombosis 4. Infection Answer: 1 Rationale: An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited into the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The other three options identify complications that are likely to be accompanied by warmth at the site, not coolness. Test-Taking Strategy: Focus on the data in the question and note the key word, cool. Recalling that coolness occurs at the site of IV infiltration will direct you to option 1. Review the signs of infiltration if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 246.Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1189.

4. A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client’s hospital gown? 1. Use a hospital gown with snaps at the sleeves. 2. Put the bag and tubing through the sleeve, followed by the client’s arm. 3. Disconnect the IV tubing from the catheter in the vein. 4. Check the IV flow rate immediately after changing the hospital gown.Answer: 3 Rationale: The tubing should not be removed from the IV catheter. With each break in the system, there is an increased chance of introducing bacteria into the system, leading to infection. Options 1 and 2 are appropriate. The flow rate should be checked immediately after changing


the hospital gown because the position of the roller clamp may have been affected during the change. Test-Taking Strategy: Use the process of elimination and note the key word avoid. This word indicates a false response question and that you need to select the incorrect action. Visualize this procedure and use knowledge of the basic principles related to intravenous therapy and asepsis to direct you to option 3. Review these principles if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1181.

5. A nurse is making a worksheet and is listing the tasks that need to be done on assigned adult clients during the shift. The nurse writes on the plan to check the IV of an assigned client receiving fluid replacement therapy every: 1. 4 hours 2. 3 hours 3. 2 hours 4. 1 hour Answer: 4 Rationale: Safe nursing practice includes monitoring an IV infusion at least once per hour in an adult client. Options 1, 2, and 3 do not provide time frames that are safe or acceptable. Test-Taking Strategy: Use the process of elimination. To answer this question accurately, it is necessary to be familiar with the specific time frames indicated in this nursing procedure. In questions similar to this one, it is best to select the most frequent time frame. Review the precautions related to administering IV fluid if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Communication and Documentation Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 242.

6. A nurse is checking the insertion site of a peripheral intravenous catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is most likely due to: 1. Infiltration of the IV line 2. Phlebitis of the vein 3. Hypersensitivity to the IV solution 4. Allergic reaction to the IV catheter material Answer: 2 Rationale: Phlebitis at an IV site can be distinguished by client discomfort at the site, as well as by redness, warmth, and swelling proximal to the IV catheter. The IV catheter should be removed, and a new IV should be inserted at a different site. The remaining options are


incorrect. Test-Taking Strategy: Use the process of elimination. Remember that similar options are not likely to be correct. In this case, options 3 and 4 are similar and are therefore eliminated. Recalling that warmth occurs at the site of phlebitis will direct you to option 2. Review the signs of phlebitis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 246.

7. A nurse has been instructed to discontinue an intravenous line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with a(n): 1. Alcohol swab 2. Betadine swab 3. Band-Aid 4. Sterile 2 × 2 gauze Answer: 4 Rationale: A dry sterile dressing, such as a sterile 2 × 2 gauze, is used to apply pressure to the site while the catheter is discontinued and removed. This material is absorbent, sterile, and nonirritating to the site. A Betadine or alcohol swab would irritate the opened puncture site and would not stop the blood flow. A Band-Aid may be used to cover the site once hemostasis has occurred. Test-Taking Strategy: Use the process of elimination. Visualize this procedure and think about each of the items identified in the options to answer the question. Noting the word “sterile” in option 4 will assist in directing you to this option. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed) St. Louis: Mosby, p. 450.Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1190.

8. A nurse is preparing an IV solution and tubing for a client requiring IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to do which of the following? 1. Scrub the tubing before attaching it to the IV bag. 2. Change the IV tubing. 3. Wipe the tubing with Betadine. 4. Scrub the tubing with an alcohol swab. Answer: 2 Rationale: The nurse should change the IV tubing. The tubing has become contaminated and, if


used, could result in systemic infection to the client. Wiping or scrubbing the tubing is insufficient to prevent systemic infection. Test-Taking Strategy: Use knowledge of basic infection control measures and intravenous therapy concepts to answer this question. Note the similarity of options 1, 3, and 4 and eliminate these options. Review aseptic technique and IV therapy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1180.

9. A client is going to be transfused with a unit of packed red blood cells. The nurse understands that it is necessary to remain with the client for what time period, once the transfusion is started?1. 5 minutes2. 15 minutes3. 30 minutes4. 45 minutesAnswer: 2Rationale: 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 clients during this time. Options 1, 3, and 4 are incorrect.Test-Taking Strategy: Use the process of elimination and knowledge regarding blood transfusion procedures to answer this question. Remember, the client must be directly monitored for the first 15 minutes of the transfusion. Review the nursing responsibilities involved in beginning a blood transfusion if you had difficulty with this question.Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/PlanningContent Area: Fundamental SkillsReference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1191.

10. A nurse is assisting in caring for a client receiving a unit of packed red blood cells. The nurse tells the client that it is most important to report which of the following signs immediately? 1. Mild discomfort at the catheter site 2. Chills, itching, or rash 3. Unusual sleepiness or fatigue 4. Headache, nausea, or vomiting Answer: 2 Rationale: The client is told to report chills, itching, or rash immediately. These could possibly be signs of a transfusion reaction. Mild discomfort at the catheter site may be indicative of a problem, or could result from the size of the IV catheter required to infuse the blood product. Sleepiness, fatigue, headache, nausea, and vomiting are unrelated to a transfusion reaction.


Test-Taking Strategy: Note the key words, most important and immediately. This tells you that more than one or all the options may be partially or totally correct. Knowing that a transfusion reaction is of greatest concern to the nurse, prioritize and select the option that characterizes this problem. Review the signs of a transfusion reaction if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 1190-1192.

11. A nurse is assisting in caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to assess the client’s: 1. Skin color 2. Oxygen saturation 3. Vital signs 4. Latest hematocrit levelAnswer: 3 Rationale: A change in vital signs may indicate that a transfusion reaction is occurring. The nurse assesses the client’s vital signs before the procedure to obtain a baseline, every 15 minutes for the first half-hour after beginning the transfusion, and every half-hour thereafter. Test-Taking Strategy: Note the key words, just before and most important. This tells you that more than one option may be partially or totally correct. Recalling the signs of a blood transfusion reaction will direct you to option 3. Additionally, vital signs is the umbrella (global) option. Review these signs if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1191.

12. A client receiving a blood transfusion rings the call bell for the nurse. On entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. The nurse interprets that the client is experiencing: 1. Fluid overload 2. Bacteremia 3. Hypovolemic shock 4. Transfusion reaction Answer: 4 Rationale: The signs and symptoms exhibited by the client are consistent with a transfusion reaction. With fluid overload, the client would have crackles in addition to dyspnea. With bacteremia, the client would have a fever, which is not part of the clinical picture presented. There is no correlation between the signs mentioned in the question and hypovolemic shock. The signs identified in the question are indicative of an allergic reaction, which is one type of


blood transfusion reaction. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Recalling the signs of a transfusion reaction will direct you to option 4. Review the complications of blood administration and the signs of a transfusion reaction if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1192.

13. A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag used for the client to which of the following areas? 1. Risk management department 2. Laboratory 3. Pharmacy 4. Blood bank Answer: 4 Rationale: The nurse prepares to return the blood transfusion bag containing any remaining blood to the blood bank. This allows the blood bank to complete any follow-up testing procedures needed once a transfusion reaction has been documented. Options 1, 2, and 3 are incorrect.Test-Taking Strategy: Use the process of elimination. Recalling that blood is obtained from the blood bank will help you to eliminate each of the incorrect options. Review the procedures to follow when a blood transfusion reaction occurs if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1193.Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed) St. Louis: Mosby, p 450.

14. A nurse takes a client’s temperature before giving a blood transfusion. The temperature is 100° F orally. The nurse reports the finding to the registered nurse and anticipates that which of the following actions will take place? 1. The transfusion will begin as prescribed. 2. The blood will be held and the physician will be notified. 3. The transfusion will begin after administering an antihistamine. 4. The transfusion will begin after administration of 600 mg of acetaminophen (Tylenol). Answer: 2 Rationale: If the client has a temperature equal to or higher than 100° F, the unit of blood should be held until the physician is notified and has the opportunity to give further orders. The other options are incorrect.


Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 3, and 4 because they are similar. Remember that, if the temperature is elevated, the physician needs to be notified before initiating a blood transfusion. Review the procedures related to administering a blood transfusion if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed) St. Louis: Mosby, p. 450.

15. A nurse is assisting in caring for a client who has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which of the following? 1. Decline of temperature to normal 2. Decrease in oozing from puncture sites and gums 3. Increased hemoglobin level 4. Increased hematocrit level Answer: 2 Rationale: Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. A temperature would decline to normal after infusion of granulocytes if those transfused cells were then instrumental in fighting infection in the body. Increased hemoglobin and hematocrit levels would be seen when the client has received a transfusion of red blood cells. Test-Taking Strategy: Use the process of elimination. Recalling that bleeding is a concern when the platelets are low will easily direct you to option 2. Review the action of platelets if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 680.

<AQ>16. A nurse is completing a time tape for a 1000-mL IV bag that is scheduled to infuse over 8 hours. The nurse has just placed the 11:00 AM marking at the 500-mL level. The nurse would place the mark for 12:00 noon at which numerical level (mL) on the time tape?Answer: 375 Rationale: If the IV is scheduled to run over 8 hours, then the hourly rate is 125 mL/hour. Using 500 mL as the reference point, the next hourly marking would be at 375 mL, which is 125 mL less than 500.Test-Taking Strategy: Use basic principles related to pharmacology math and IV administration to answer this question. If this question was difficult, review the concepts related to marking an IV solution by using a time tape.Level of Cognitive Ability: Application


Client Needs: Physiological Integrity Integrated Process: Nursing Process/ImplementationContent Area: Fundamental SkillsReference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1176.

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6573736 Silvestri Chapter 13 Ed549