Ramont2e Rev TIF Ch28

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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank

Chapter 28Question 1

Type: MCMA

The nurse takes responsibilities for administering IV medications very seriously because: (Select all that apply!

Standard Tet: Select all that apply

1! "emoving medications# once in$ected# can be very difficult

2! If pathogens enter the intravenous line# it can result in septicemia

"! Medications in$ected intravenously enter the bloodstream immediately

#! The client must be carefully taught ho% to regulate the IV flo%

$! "apid interventions are re&uired if complications arise

Corre%t &ns'er: '##)

Rationa(e 1: The intravenous line provides direct access to the bloodstream# and if pathogens are introduced# the

risk of septicemia is very high IV complications must be carefully monitored# and re&uire a &uick response tominimi*e damage +nce a medication is in$ected# it cannot be removed# because it begins circulating in the

bloodstream The client does not regulate the IV# and must be taught ho% to protect the IV and avoid touching

anything that %ould change the flo% rate of the fluid

Rationa(e 2: The intravenous line provides direct access to the bloodstream# and if pathogens are introduced# therisk of septicemia is very high IV complications must be carefully monitored# and re&uire a &uick response to

minimi*e damage +nce a medication is in$ected# it cannot be removed# because it begins circulating in the

bloodstream The client does not regulate the IV# and must be taught ho% to protect the IV and avoid touchinganything that %ould change the flo% rate of the fluid

Rationa(e ": The intravenous line provides direct access to the bloodstream# and if pathogens are introduced# the

risk of septicemia is very high IV complications must be carefully monitored# and re&uire a &uick response to

minimi*e damage +nce a medication is in$ected# it cannot be removed# because it begins circulating in the bloodstream The client does not regulate the IV# and must be taught ho% to protect the IV and avoid touching


Rationa(e #: The intravenous line provides direct access to the bloodstream# and if pathogens are introduced# the

risk of septicemia is very high IV complications must be carefully monitored# and re&uire a &uick response tominimi*e damage +nce a medication is in$ected# it cannot be removed# because it begins circulating in the

bloodstream The client does not regulate the IV# and must be taught ho% to protect the IV and avoid touching


"amont# ,iedringhous# Comprehensive Nursing Care 'nd -dition .pdate Test /ank

Copyright '01' by 2earson -ducation# Inc



Rationa(e $: The intravenous line provides direct access to the bloodstream# and if pathogens are introduced# therisk of septicemia is very high IV complications must be carefully monitored# and re&uire a &uick response to

minimi*e damage +nce a medication is in$ected# it cannot be removed# because it begins circulating in the

bloodstream The client does not regulate the IV# and must be taught ho% to protect the IV and avoid touchinganything that %ould change the flo% rate of the fluid

)(o*a( Rationa(e:

Cogniti+e e+e(: Applying

C(ient Need: 2hysiological Integrity

C(ient Need Su*:

Nursing-.ntegrated Con%epts: ,ursing 2rocess: 2lanning

earning /ut%ome: Identify nursing responsibilities and concerns in IV therapy

Question 2

Type: MCSA

The nurse %ould anticipate the use of hypertonic IV solutions for %hich of the follo%ing clients3

1! The client in diabetic ketoacidosis

2! The client %ith chronic renal failure

"! The client %ith congestive heart failure

#! The client %ith hypotension

Corre%t &ns'er: 4

Rationa(e 1: The use of hypertonic solutions in the hypotensive client %orks by pulling fluid out of theintracellular space and e5panding the circulating blood volume# thereby causing a rise in blood pressure The use

of hypertonic solutions %ould be contraindicated in clients %ith diabetic ketoacidosis# chronic renal failure# and

congestive heart failure because these clients %ould not be able to tolerate the increased fluid volume that %ouldresult in the intravascular space

Rationa(e 2: The use of hypertonic solutions in the hypotensive client %orks by pulling fluid out of the

intracellular space and e5panding the circulating blood volume# thereby causing a rise in blood pressure The use

of hypertonic solutions %ould be contraindicated in clients %ith diabetic ketoacidosis# chronic renal failure# andcongestive heart failure because these clients %ould not be able to tolerate the increased fluid volume that %ould

result in the intravascular space

Rationa(e ": The use of hypertonic solutions in the hypotensive client %orks by pulling fluid out of the

intracellular space and e5panding the circulating blood volume# thereby causing a rise in blood pressure The useof hypertonic solutions %ould be contraindicated in clients %ith diabetic ketoacidosis# chronic renal failure# and

congestive heart failure because these clients %ould not be able to tolerate the increased fluid volume that %ould

result in the intravascular space





Rationa(e #: The use of hypertonic solutions in the hypotensive client %orks by pulling fluid out of theintracellular space and e5panding the circulating blood volume# thereby causing a rise in blood pressure The use

of hypertonic solutions %ould be contraindicated in clients %ith diabetic ketoacidosis# chronic renal failure# and

congestive heart failure because these clients %ould not be able to tolerate the increased fluid volume that %ouldresult in the intravascular space

)(o*a( Rationa(e:

Cogniti+e e+e(: Analy*ing


C(ient Need Su*:


earning /ut%ome:

Question "

Type: MCSA

The nurse %ould anticipate the use of a )6 de5trose7containing IV solution for %hich of the follo%ing clients3

1! The malnourished client

2! The diabetic client

"! The client %ho %ill be npo for 1'7'4 hours

#! The client %ho %ill be npo for )78 days

Corre%t &ns'er:

Rationa(e 1: 9e5trose7containing IV solutions provide enough glucose to prevent ketosis in the client %ho %ill bnpo for 1'7'4 hours# but do not provide enough sugar to maintain the malnourished client or the client %ho %il

have nothing by mouth for as long as a %eek These clients %ould re&uire a higher de5trose concentration# as

found in T2, The diabetic client should receive de5trose7containing solutions %ith care# and the clients overallcondition and blood sugar %ould determine %hether an isotonic solution %ould be given (if blood sugar levels are

high! or a de5trose solution used (if blood sugar levels are lo% and %ell controlled!

Rationa(e 2: 9e5trose7containing IV solutions provide enough glucose to prevent ketosis in the client %ho %ill b

npo for 1'7'4 hours# but do not provide enough sugar to maintain the malnourished client or the client %ho %ilhave nothing by mouth for as long as a %eek These clients %ould re&uire a higher de5trose concentration# as

found in T2, The diabetic client should receive de5trose7containing solutions %ith care# and the clients overallcondition and blood sugar %ould determine %hether an isotonic solution %ould be given (if blood sugar levels arehigh! or a de5trose solution used (if blood sugar levels are lo% and %ell controlled!

Rationa(e ": 9e5trose7containing IV solutions provide enough glucose to prevent ketosis in the client %ho %ill b

npo for 1'7'4 hours# but do not provide enough sugar to maintain the malnourished client or the client %ho %il

have nothing by mouth for as long as a %eek These clients %ould re&uire a higher de5trose concentration# asfound in T2, The diabetic client should receive de5trose7containing solutions %ith care# and the clients overall





condition and blood sugar %ould determine %hether an isotonic solution %ould be given (if blood sugar levels arehigh! or a de5trose solution used (if blood sugar levels are lo% and %ell controlled!

Rationa(e #: 9e5trose7containing IV solutions provide enough glucose to prevent ketosis in the client %ho %ill b

npo for 1'7'4 hours# but do not provide enough sugar to maintain the malnourished client or the client %ho %il

have nothing by mouth for as long as a %eek These clients %ould re&uire a higher de5trose concentration# asfound in T2, The diabetic client should receive de5trose7containing solutions %ith care# and the clients overall

condition and blood sugar %ould determine %hether an isotonic solution %ould be given (if blood sugar levels arehigh! or a de5trose solution used (if blood sugar levels are lo% and %ell controlled!

)(o*a( Rationa(e:



C(ient Need Su*:


earning /ut%ome:

Question #

Type: MCSA

The nurse caring for a client %ith an IV infusing via an infusion pump monitors the intravenous site more

carefully for %hich type of complication associated %ith this type of electronic infusion device3

1! Inaccurate fluid administration

2! Severe fluid e5travasation if the IV site infiltrates

"! Air emboli

#! 2hlebitis

Corre%t &ns'er: '

Rationa(e 1: The infusion pump is set to deliver fluid at a specific pressure# and %ill continue to infuse fluid into

an infiltrated site until enough fluid builds to increase pressure and set off the pressure alarm on the pump As a

result# the nurse must monitor the IV site very carefully because an IV infiltrate can continue to e5pand# %hereas controller flo%s by gravity# and %ill reduce flo% much faster# reducing the risk of a severe acute IV infiltrate Air

emboli and phlebitis can occur %ith any IV infusion Infusion pumps are more accurate in delivering preset

&uantities of fluid than are other methods

Rationa(e 2: The infusion pump is set to deliver fluid at a specific pressure# and %ill continue to infuse fluid intoan infiltrated site until enough fluid builds to increase pressure and set off the pressure alarm on the pump As a

result# the nurse must monitor the IV site very carefully because an IV infiltrate can continue to e5pand# %hereas

controller flo%s by gravity# and %ill reduce flo% much faster# reducing the risk of a severe acute IV infiltrate Airemboli and phlebitis can occur %ith any IV infusion Infusion pumps are more accurate in delivering preset






Rationa(e ": The infusion pump is set to deliver fluid at a specific pressure# and %ill continue to infuse fluid intoan infiltrated site until enough fluid builds to increase pressure and set off the pressure alarm on the pump As a

result# the nurse must monitor the IV site very carefully because an IV infiltrate can continue to e5pand# %hereas

controller flo%s by gravity# and %ill reduce flo% much faster# reducing the risk of a severe acute IV infiltrate Airemboli and phlebitis can occur %ith any IV infusion Infusion pumps are more accurate in delivering preset


Rationa(e #: The infusion pump is set to deliver fluid at a specific pressure# and %ill continue to infuse fluid intoan infiltrated site until enough fluid builds to increase pressure and set off the pressure alarm on the pump As aresult# the nurse must monitor the IV site very carefully because an IV infiltrate can continue to e5pand# %hereas

controller flo%s by gravity# and %ill reduce flo% much faster# reducing the risk of a severe acute IV infiltrate Air

emboli and phlebitis can occur %ith any IV infusion Infusion pumps are more accurate in delivering preset&uantities of fluid than are other methods

)(o*a( Rationa(e:



C(ient Need Su*:

Nursing-.ntegrated Con%epts: ,ursing 2rocess: Assessment

earning /ut%ome: Identify the e&uipment involved in providing parenteral therapy

Question $

Type: MCSA

The nurse is caring for a client %ho is receiving blood# and recogni*es that the proper administration e&uipment i

in use %hen %hich of the follo%ing is found3

1! Infusion pump

2! -lectronic controller device

"! Syringe pump

#! ; tubing infusing by gravity

Corre%t &ns'er: 4

Rationa(e 1: /lood should infuse by gravity using a ;7tube setup that allo%s blood to infuse via one line and

normal saline to infuse via the other line /lood should never be administered on an infusion device# because the pressure from the device %ill damage the red blood cells and the controller pump %ill not function properly

Rationa(e 2: /lood should infuse by gravity using a ;7tube setup that allo%s blood to infuse via one line and

normal saline to infuse via the other line /lood should never be administered on an infusion device# because the

pressure from the device %ill damage the red blood cells and the controller pump %ill not function properly





Rationa(e ": /lood should infuse by gravity using a ;7tube setup that allo%s blood to infuse via one line andnormal saline to infuse via the other line /lood should never be administered on an infusion device# because the

pressure from the device %ill damage the red blood cells and the controller pump %ill not function properly

Rationa(e #: /lood should infuse by gravity using a ;7tube setup that allo%s blood to infuse via one line and

normal saline to infuse via the other line /lood should never be administered on an infusion device# because the pressure from the device %ill damage the red blood cells and the controller pump %ill not function properly

)(o*a( Rationa(e:



C(ient Need Su*:

Nursing-.ntegrated Con%epts: ,ursing 2rocess: -valuation

earning /ut%ome: Identify the e&uipment involved in providing parenteral therapy

Question 0

Type: MCSA

The provider has ordered 9)< to infuse at =0 m> per hour The nurse prepares the solution using a 10 drop7per7

milliliter infusion set ?o% many drops per minute %ill the nurse set the infusion to deliver3

1! =00

2! 1

"! 1

#! =

Corre%t &ns'er:

Rationa(e 1: The nurse calculates drip rate by dividing the amount to be delivered per hour by @0 minutes in an

hour times the drip rate: =0 @0 B 10 1# or 1# since it is impossible to count 1D of a drop

Rationa(e 2: The nurse calculates drip rate by dividing the amount to be delivered per hour by @0 minutes in an


Rationa(e ": The nurse calculates drip rate by dividing the amount to be delivered per hour by @0 minutes in an


Rationa(e #: The nurse calculates drip rate by dividing the amount to be delivered per hour by @0 minutes in anhour times the drip rate: =0 @0 B 10 1# or 1# since it is impossible to count 1D of a drop

)(o*a( Rationa(e:






C(ient Need: Safe -ffective Care -nvironment

C(ient Need Su*:

Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation

earning /ut%ome: 9escribe ho% to calculate IV rates accurately

Question

Type: MCSA

The physician orders 4#000 m> of IV solution to infuse over the ne5t '4 hours The nurse prepares the infusion

using a 1) drop7per7milliliter solution set ?o% many drops per minute %ill the nurse count to deliver the proper

amount of IV solution by gravity flo%3

1! 41

2! ')

"! 4'

#! '@

Corre%t &ns'er: 4

Rationa(e 1: Calculate the IV drip rate by taking the amount to be infused (4#000! and dividing it by the time it isto infuse ('4 hours!# then divide by @0 to get m> per minute# then multiply by 1) to get the drip rate: 4#000 '4

1@@@@ @0 '88 B 1) 41@@# %hich rounds to 4'

Rationa(e 2: Calculate the IV drip rate by taking the amount to be infused (4#000! and dividing it by the time it isto infuse ('4 hours!# then divide by @0 to get m> per minute# then multiply by 1) to get the drip rate: 4#000 '4

1@@@@ @0 '88 B 1) 41@@# %hich rounds to 4'

Rationa(e ": Calculate the IV drip rate by taking the amount to be infused (4#000! and dividing it by the time it is

to infuse ('4 hours!# then divide by @0 to get m> per minute# then multiply by 1) to get the drip rate: 4#000 '4 1@@@@ @0 '88 B 1) 41@@# %hich rounds to 4'

Rationa(e #: Calculate the IV drip rate by taking the amount to be infused (4#000! and dividing it by the time it is

to infuse ('4 hours!# then divide by @0 to get m> per minute# then multiply by 1) to get the drip rate: 4#000 '4

1@@@@ @0 '88 B 1) 41@@# %hich rounds to 4'

)(o*a( Rationa(e:



C(ient Need Su*:


earning /ut%ome: 9escribe ho% to calculate IV rates accurately

Question 8





Type: MCSA

The nurse is initiating an IV of )6 9e5trose and 04) ,S to infuse at @0 m>Dhour for '4 hours on a client %ho ha

never had an IV before <hich of the follo%ing sites %ould be the nurses first choice3

1! 9igital vein

2! Metacarpal vein

"! Antecubital cephalic vein

#! Ereat saphenous vein

Corre%t &ns'er: '

Rationa(e 1: <hen choosing a vein for short7term therapy# the metacarpal vein %ould be the best choice because

it is the most distal The digital# antecubital cephalic# and great saphenous veins are choices of last resort

Rationa(e 2: <hen choosing a vein for short7term therapy# the metacarpal vein %ould be the best choice becauseit is the most distal The digital# antecubital cephalic# and great saphenous veins are choices of last resort

Rationa(e ": <hen choosing a vein for short7term therapy# the metacarpal vein %ould be the best choice because


Rationa(e #: <hen choosing a vein for short7term therapy# the metacarpal vein %ould be the best choice because


)(o*a( Rationa(e:



C(ient Need Su*:


earning /ut%ome: Identify peripheral veins appropriate for use in IV therapy

Question

Type: MCSA

The nurse %orking in the -mergency 9epartment is preparing to initiate an IV on a client %ho lost several liters

of blood in a trauma The nurse anticipates that the client %ill be receiving many liters of fluid and blood over the

ne5t '4 hours and %ill re&uire IV access for at least a %eek The client is a previously healthy '07year7old male

<hat si*e and type of infusion device %ill the nurse use for this IV3

1! 1@7gauge scalp needle (butterfly!

2! ''7gauge scalp needle (butterfly!





"! 147gauge over7the7needle catheter

#! 1=7gauge over7the7needle catheter

Corre%t &ns'er: 4

Rationa(e 1: The client %ho is anticipated to need blood and large volumes of fluids re&uires a large7bore over7

the7needle catheter 147gauges %ould be too large for insertion into a peripheral vein# so the best choice is an 1=7gauge Scalp needles %ould not be chosen for large &uantities of fluid and blood

Rationa(e 2: The client %ho is anticipated to need blood and large volumes of fluids re&uires a large7bore over7the7needle catheter 147gauges %ould be too large for insertion into a peripheral vein# so the best choice is an 1=7

gauge Scalp needles %ould not be chosen for large &uantities of fluid and blood

Rationa(e ": The client %ho is anticipated to need blood and large volumes of fluids re&uires a large7bore over7

the7needle catheter 147gauges %ould be too large for insertion into a peripheral vein# so the best choice is an 1=7gauge Scalp needles %ould not be chosen for large &uantities of fluid and blood

Rationa(e #: The client %ho is anticipated to need blood and large volumes of fluids re&uires a large7bore over7the7needle catheter 147gauges %ould be too large for insertion into a peripheral vein# so the best choice is an 1=7

gauge Scalp needles %ould not be chosen for large &uantities of fluid and blood

)(o*a( Rationa(e:



C(ient Need Su*:


earning /ut%ome: 9escribe factors that influence IV site and needle selection

Question 13

Type: MCSA

The nurse is initiating an IV# and has introduced the catheter into the skin# and is not immediately successful

<hat %ill the nurse do ne5t3

1! "emove the catheter and ask another nurse to initiate the IV

2! 2robe around %ith the catheter until the vein is found

"! Eently feel the tip of the cannula

#! Insert the needle further

Corre%t &ns'er:





Rationa(e 1: The nurse %ill gently feel the tip of the cannula to determine its location in relationship to the vein+nly if the nurse is unsuccessful in cannulating the vein after determining location %ould the catheter be

removed 2robing around %ith the catheter can cause tissue trauma# and should not be practiced Inserting the

needle further %ithout locating the tip %ill be unlikely to improve success

Rationa(e 2: The nurse %ill gently feel the tip of the cannula to determine its location in relationship to the vein+nly if the nurse is unsuccessful in cannulating the vein after determining location %ould the catheter be

removed 2robing around %ith the catheter can cause tissue trauma# and should not be practiced Inserting theneedle further %ithout locating the tip %ill be unlikely to improve success

Rationa(e ": The nurse %ill gently feel the tip of the cannula to determine its location in relationship to the vein

+nly if the nurse is unsuccessful in cannulating the vein after determining location %ould the catheter be



Rationa(e #: The nurse %ill gently feel the tip of the cannula to determine its location in relationship to the vein

+nly if the nurse is unsuccessful in cannulating the vein after determining location %ould the catheter be



)(o*a( Rationa(e:



C(ient Need Su*:


earning /ut%ome: -5plain venipuncture techni&ues and >2,D>V, responsibilities in monitoring IV drip rate

Question 11

Type: MCSA

The client reports that the IV site hurts The nurse assesses the site# and it appears normal# %ithout redness#

edema# drainage# or any indication of complications <hat is the nurses priority intervention3

1! 9iscontinue the infusion

2! ,otify the physician

"! Slo% the rate of infusion

#! ,otify the ",

Corre%t &ns'er: 4

Rationa(e 1: The nurse should notify the ",# %ho %ill assess the client further The infusion should not be

discontinued because the discomfort could be caused by caustic solution that might re&uire further dilution The





", can determine if the physician must be notified# but the rate of infusion should not be decreased until furtherevaluation of the discomfort can be made

Rationa(e 2: The nurse should notify the ",# %ho %ill assess the client further The infusion should not be

discontinued because the discomfort could be caused by caustic solution that might re&uire further dilution The

", can determine if the physician must be notified# but the rate of infusion should not be decreased until furtherevaluation of the discomfort can be made

Rationa(e ": The nurse should notify the ",# %ho %ill assess the client further The infusion should not be

discontinued because the discomfort could be caused by caustic solution that might re&uire further dilution The", can determine if the physician must be notified# but the rate of infusion should not be decreased until further

evaluation of the discomfort can be made

Rationa(e #: The nurse should notify the ",# %ho %ill assess the client further The infusion should not be

discontinued because the discomfort could be caused by caustic solution that might re&uire further dilution The", can determine if the physician must be notified# but the rate of infusion should not be decreased until further

evaluation of the discomfort can be made

)(o*a( Rationa(e:



C(ient Need Su*:


earning /ut%ome: Identify complications associated %ith infusion therapy

Question 12

Type: MCSA

The nurse caring for a client %ith phlebitis at the old IV site assesses the site and finds that the site is painful and

edematous# %ith no palpable cord e5tending one inch above the site The nurse categori*es the site as %hich of th

follo%ing on the phlebitis scale3

1! 1F

2! 'F

"! F

#! 4F

Corre%t &ns'er: '

Rationa(e 1: -dema places this site above a 1F# and the lack of palpable cord indicates it is not a F# so the site is

categori*ed as a 'F on the phlebitis scale





Rationa(e 2: -dema places this site above a 1F# and the lack of palpable cord indicates it is not a F# so the site iscategori*ed as a 'F on the phlebitis scale

Rationa(e ": -dema places this site above a 1F# and the lack of palpable cord indicates it is not a F# so the site is


Rationa(e #: -dema places this site above a 1F# and the lack of palpable cord indicates it is not a F# so the site is


)(o*a( Rationa(e:



C(ient Need Su*:



Question 1"

Type: MCSA

The nurse is asked to retrieve blood from the blood bank to administer to another nurses assigned client <hat

does the nurse take to the blood bank3

1! ,ursing license

2! "e&uisition stamped %ith clients information

"! Cooler in %hich to place the blood

#! Another nurse for identification of blood

Corre%t &ns'er: '

Rationa(e 1: <hen the nurse gets to the blood bank# both the technician and the nurse %ill confirm that the blood

received is the right blood for the right client# so the nurse must have something stamped %ith the clientsinformation# such as the re&uisition for the blood The nurse does not need her license# as that is verified %ith

employmentG a cooler is not needed# because blood should not be stored longer than four hours after receiptG and

another nurse %ill not be needed until the nurse returns to the unit# %hen the blood %ill be double7checked before

administration

Rationa(e 2: <hen the nurse gets to the blood bank# both the technician and the nurse %ill confirm that the blood

received is the right blood for the right client# so the nurse must have something stamped %ith the clients

information# such as the re&uisition for the blood The nurse does not need her license# as that is verified %ithemploymentG a cooler is not needed# because blood should not be stored longer than four hours after receiptG and

another nurse %ill not be needed until the nurse returns to the unit# %hen the blood %ill be double7checked before

administration





Rationa(e ": <hen the nurse gets to the blood bank# both the technician and the nurse %ill confirm that the bloodreceived is the right blood for the right client# so the nurse must have something stamped %ith the clients

information# such as the re&uisition for the blood The nurse does not need her license# as that is verified %ith

employmentG a cooler is not needed# because blood should not be stored longer than four hours after receiptG andanother nurse %ill not be needed until the nurse returns to the unit# %hen the blood %ill be double7checked before

administration

Rationa(e #: <hen the nurse gets to the blood bank# both the technician and the nurse %ill confirm that the bloodreceived is the right blood for the right client# so the nurse must have something stamped %ith the clientsinformation# such as the re&uisition for the blood The nurse does not need her license# as that is verified %ith

employmentG a cooler is not needed# because blood should not be stored longer than four hours after receiptG and

another nurse %ill not be needed until the nurse returns to the unit# %hen the blood %ill be double7checked beforeadministration

)(o*a( Rationa(e:



C(ient Need Su*:


earning /ut%ome: 9iscuss the procedure for administering blood products and nursing measures for potential

complications

Question 1#

Type: MCSA

The nurse is caring for a client %ith an infusing IV The client reports chills and has a temperature of H=C# and

this mornings %hite blood cell count %as elevated The nurse suspects:

1! >ocali*ed infection of IV site

2! Allergic reaction

"! Septicemia

#! Circulatory overload

Corre%t &ns'er:

Rationa(e 1: Jever and chills elevate the level of suspicion that the client has contracted septicemia A locali*edinfection %ould have symptoms at the site but %ould not be likely to have systemic symptoms The symptoms ar

not consistent %ith an allergic reaction or circulatory overload

Rationa(e 2: Jever and chills elevate the level of suspicion that the client has contracted septicemia A locali*ed

infection %ould have symptoms at the site but %ould not be likely to have systemic symptoms The symptoms arnot consistent %ith an allergic reaction or circulatory overload





Rationa(e ": Jever and chills elevate the level of suspicion that the client has contracted septicemia A locali*edinfection %ould have symptoms at the site but %ould not be likely to have systemic symptoms The symptoms ar

not consistent %ith an allergic reaction or circulatory overload

Rationa(e #: Jever and chills elevate the level of suspicion that the client has contracted septicemia A locali*ed

infection %ould have symptoms at the site but %ould not be likely to have systemic symptoms The symptoms arnot consistent %ith an allergic reaction or circulatory overload

)(o*a( Rationa(e:



C(ient Need Su*:



Question 1$

Type: MCSA

The nurse assisting %ith the care of a client receiving t%o units of blood is asked to record vital signs after the

second unit is initiated The nurse enters the room of the client# a '=7year7old female admitted follo%ing a

salpingectomy secondary to an ectopic pregnancy# and finds her unconscious %ith %eak pulse and shallo%

respirations The nurse notes a rash over the e5posed areas of her body <hat is the nurses priority action3

1! Attempt to revive the %oman and measure vital signs

2! Increase the rate of the blood infusion to raise her blood pressure &uickly

"! Stop the blood infusion

#! 2repare another IV %ith fresh tubing# and connect to the IV site %here the blood %as infusing

Corre%t &ns'er:

Rationa(e 1: The client is most likely having a blood transfusion reaction# and the priority intervention# before

doing anything else# is to make sure that the client does not receive any more blood After the infusion is stopped

the ", should be notified# vital signs should be recorded# and ne% IV solution should be hung using fresh tubing#

but the first and most important priority is to stop infusing the blood that is causing the reaction

Rationa(e 2: The client is most likely having a blood transfusion reaction# and the priority intervention# beforedoing anything else# is to make sure that the client does not receive any more blood After the infusion is stopped

the ", should be notified# vital signs should be recorded# and ne% IV solution should be hung using fresh tubing#

but the first and most important priority is to stop infusing the blood that is causing the reaction

Rationa(e ": The client is most likely having a blood transfusion reaction# and the priority intervention# before






the ", should be notified# vital signs should be recorded# and ne% IV solution should be hung using fresh tubing# but the first and most important priority is to stop infusing the blood that is causing the reaction

Rationa(e #: The client is most likely having a blood transfusion reaction# and the priority intervention# before


the ", should be notified# vital signs should be recorded# and ne% IV solution should be hung using fresh tubing# but the first and most important priority is to stop infusing the blood that is causing the reaction

)(o*a( Rationa(e:



C(ient Need Su*:


earning /ut%ome: 9iscuss the procedure for administering blood products and nursing measures for potential

complications

Question 10

Type: MCMA

,ursing responsibilities for the >2,D>V, %ho provides IV therapy include:(Select all that apply!


1! 2erforming %ithin the state nurse practice act

2! 2reparing and educating clients about IV therapy

"! Assigning .A2 to monitor the client

#! Maintaining droplet precautions for any client %ith an IV in place

$! "eporting needle stick in$uries to the C9C

Corre%t &ns'er: 1#'

Rationa(e 1: The >2,D>V, must kno% %hat is legal for them to do and must al%ays perform duties %ithin the

scope of practice

Rationa(e 2: The >2,sD>V,s %ho provide IV therapy prepare and educate clients about IV therapy to ensurecooperation and a therapeutic relationship

Rationa(e ": >2,sD>V,s observe clients closely for potential complications and provide early interventionG this

responsibility is not delegated to unlicensed assistive personnel

Rationa(e #: All nursing personnel must follo% Standard 2recautionsG all body fluids e5cept s%eat are treated asif kno%n to be infectious %ith ?IV# hepatitis / and C# and other blood borne pathogens





Rationa(e $: If stuck %ith a needle# the nurse should immediately flood the e5posed area %ith %ater and clean the%ound %ith soap and %ater or skin disinfectant if availableG report it immediately to the employerG seek

immediate medical attention

)(o*a( Rationa(e:


C(ient Need:C(ient Need Su*:


earning /ut%ome:

Question 1

Type: MCSA

The nurse %ill use %hich of the follo%ing safety devices %hen using needles in client care e5cept:

1! ,eedleless systems

2! "etracting catheters

"! Cardboard contaminated sharps containers

#! Eloves

Corre%t &ns'er:

Rationa(e 1: ,eedleless systems and needle safety devices are used to protect the safety of healthcare personnel

Rationa(e 2: "etracting or shielded catheters are used to minimi*e the possibility of needle stick in$uries

Rationa(e ": Contaminated sharps must be placed in a puncture resistant# leak7proof and labeled container

Rationa(e #: Eloves are one of the main barriers used to protect nursing personnel from body fluids that coulde5pose the nurse to ?IV# hepatitis / and C

)(o*a( Rationa(e:




earning /ut%ome:

Question 18

Type: MCMA





The nurse considers %hich of the follo%ing classifications of la% %hen administering IV therapy3(Select all that

apply!


1! Criminal la%

2! Common la%

"! Civil la%

#! ,egligence

$! Jederal la%

Corre%t &ns'er: 1#'#

Rationa(e 1: Criminal la% is a %rong against the public for %hich government can prosecute and imposeimprisonment or fines# such as assault and battery

Rationa(e 2: Criminal la% is a %rong against the public for %hich government can prosecute and impose

imprisonment or fines# such as assault and battery

Rationa(e ": Criminal la% is a %rong against the public for %hich government can prosecute and imposeimprisonment or fines# such as assault and battery

Rationa(e #: Criminal la% is a %rong against the public for %hich government can prosecute and impose


Rationa(e $: Criminal la% is a %rong against the public for %hich government can prosecute and impose


)(o*a( Rationa(e:

Cogniti+e e+e(: .nderstanding

C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question 1

Type: MCSA

The nurse is a%are that the Koint Commission has indicated that standards of care must be developed to measure

&uality based on e5pectations of service <hich of the follo%ing regulators enforce ?ealth Insurance 2ortability

and Accountability Act regulations3





1! +ccupational Safety and ?ealth Administrations

2! State departments of health and human services

"! The Koint Commission

#! The environmental 2rotection Agency

Corre%t &ns'er: '

Rationa(e 1: +S?A does not enforce ?I2AA regulations

Rationa(e 2: State departments of health and human services enforce ?I2AA regulations

Rationa(e ": The Koint Commission does not enforce ?I2AA regulations# rather it publishes professionalstandards of care

Rationa(e #: The -2A does not enforce ?I2AA regulations

)(o*a( Rationa(e:

Cogniti+e e+e(:

C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question 23

Type: MCMA

The nurse prepares the client care area to minimi*e physical ha*ards of administering IV therapy# %hich include:

(Select all that apply!


1! Abrasions

2! Chemical e5posure

"! >ate5 allergy

#! ,eedle stick

$! /urns

Corre%t &ns'er: 1#'##4





Rationa(e 1: Abrasions from e&uipment packaging offer potential portals for microorganisms


Rationa(e ": Abrasions from e&uipment packaging offer potential portals for microorganisms

Rationa(e #: Abrasions from e&uipment packaging offer potential portals for microorganisms

Rationa(e $: Abrasions from e&uipment packaging offer potential portals for microorganisms

)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question 21

Type: MCMA

The nurse e5plains to the clientLs family the purpose(s! of IV therapy# %hich include:(Select all that apply!


1! Maintaining blood volume

2! -nsuring slo% delivery of medications

"! 2roviding nutrition

#! Correcting electrolyte imbalances

$! "ehydration

Corre%t &ns'er: 1##4#)

Rationa(e 1: IV therapy# %hether


Rationa(e ": IV therapy# %hether

Rationa(e #: IV therapy# %hether

Rationa(e $: IV therapy# %hether





)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question 22

Type: MCSA

The nurse is caring for a client %ith burns <hich of the follo%ing IV solutions %ould not be appropriate for this

client3

1! 9)6 04)6 ,S

2! 9)6>"

"! 04)6,S

#! 0H6 ,S

Corre%t &ns'er:

Rationa(e 1: A hypertonic solution such as 9)604)6 ,S %ill e5pand the


Rationa(e ": A hypertonic solution such as 9)604)6 ,S %ill e5pand the

Rationa(e #: A hypertonic solution such as 9)604)6 ,S %ill e5pand the

)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question 2"

Type: MCMA

The nurse is caring for an elderly client %ho has not seen a plastic IV solution container before The nurse

e5plains the advantages of the plastic bag as including:(Select all that apply!






1! 2lastic containers are light%eight

2! 2lastic containers are rigid

"! 2lastic containers are vented systems

#! 2lastic containers are collapsible

$! 2lastic containers are inert

Corre%t &ns'er: 1#4

Rationa(e 1: 2lastic containers are light%eight %hen compared to glass containers

Rationa(e 2: 2lastic containers are fle5ible

Rationa(e ": 2lastic containers do not need to be vented

Rationa(e #: 2lastic containers are collapsible# not rigid

Rationa(e $: 2lastic containers are made up of plastici*ers and are not completely inertG markers should never be

used to %rite on the bag because the ink could be absorbed into the plastic

)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question 2#

Type: JI/

The nurse differentiates the microdrip IV administration set as providing @0 gttDml

Standard Tet:

Corre%t &ns'er: 10 gttDml D 1) gttDml D '0 gttDml

Rationa(e : A microdrip IV administration set delivers fluids %ith a drop factor of @0 gttDmlMacrodrip IV

administration sets deliver fluids %ith a drop factor ranging from 107'0 gttDml

)(o*a( Rationa(e:






C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question 2$

Type: MCMA

The nurse is selecting a peripheral infusion device for insertion The scalp vein needle is most appropriate for:



1! Single dose therapy

2! 9elivery of blood

"! >ong term peripheral IV therapy

#! Transplant clients

$! Clients allergic to nylon or Teflon

Corre%t &ns'er: 1#)

Rationa(e 1: Scalp vein needles are used for short term therapy# such as single dose therapy

Rationa(e 2: +ver the needle catheters are used for delivery of viscous fluids# such as blood and blood products

Rationa(e ": +ver the needle catheters are used for long term peripheral IV therapy

Rationa(e #: +ver the needle catheters are used for clients %ho %ill be undergoing transplant surgery

Rationa(e $: Scalp vein needles are used for client %ho are allergic to nylon

)(o*a( Rationa(e:




earning /ut%ome:

Question 20

Type: MCMA





The nurse is caring for a client %ith an IV# and %ill be administering a blood transfusion The follo%ing

considerations are appropriate %hen considering the infusion device:(Select all that apply!


1! 2eristaltic regulators are appropriate for administration of blood

2! The tubing cassette should be held upright %hen priming

"! Accurate function of the machine should be verified

#! Systematically check the IV if the deviceLs alarm is going off

$! 2lace a piggyback administration set above the air detector device

Corre%t &ns'er: #4#)

Rationa(e 1: 2eristaltic regulators are not appropriate for administration of blood because of their s&uee*ingaction# %hich can in$ure red blood cells

Rationa(e 2: 2eristaltic regulators are not appropriate for administration of blood because of their s&uee*ing

action# %hich can in$ure red blood cells

Rationa(e ": 2eristaltic regulators are not appropriate for administration of blood because of their s&uee*ingaction# %hich can in$ure red blood cells

Rationa(e #: 2eristaltic regulators are not appropriate for administration of blood because of their s&uee*ing


Rationa(e $: 2eristaltic regulators are not appropriate for administration of blood because of their s&uee*ing


)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question 2

Type: JI/

The nurse is calculating the flo% rate using the standard formula The order is as follo%s: Infuse 1000 m> of 9)<

over 10 hours %ith a drip factor of 10 <hat are the drops per minute3 18 gttDmin

Standard Tet:





Corre%t &ns'er: 18 gttDmin D '8 gttDmin D 1@ gttDmin

Rationa(e : The standard formula is:Amount of fluid (in m>! B 9rop factor 9rops per minute Time to infuse inminutes9etermine the fluid per our: 1000 m> divided by 10 hours 100 m>The time to infuse is no% @0 minutes

or 1 hourAmount of fluid (100 m>! B 9rop factor(10! 9rops per minute Time to infuse in minutes (@0!100 B

10 gttDmin @0100 B 1 1@@ gttDmin round up to nearest %hole number 18 gttDmin @

)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question 28

Type: MCSA

The nurse is preparing a preschooler for IV insertion Age appropriate considerations for the 7@ year old include

1! .sing distraction# such as shaking a rattle

2! ?aving the child push his or her hands together

"! -5plain procedure shortly beforehand

#! Consider appearance of IV infusion line

Corre%t &ns'er: '

Rationa(e 1: .sing a rattle# singing a song# or providing a toy are distractions appropriate for an infant

Rationa(e 2: ?aving the child push his or hands together has the child concentrating on the motion rather than the

IV in$ection

Rationa(e ": -5plaining the procedure shortly before it is performed is appropriate for the school age child

Rationa(e #: Considering the appearance of IV infusion lines# or infusion ports is appropriate for adolescents

)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:


earning /ut%ome:





Question 2

Type: MCMA

The nurse is preparing to insert an IV in a 1@7year7old client Appropriate IV insertion sites include:(Select all tha

apply!


1! Scalp veins

2! 9orsal hand veins

"! 9orsal foot veins

#! Jorearm veins

$! Cephalic vein

Corre%t &ns'er: '#4#)

Rationa(e 1: Scalp veins are appropriate sites for IV insertion in infants


Rationa(e ": Scalp veins are appropriate sites for IV insertion in infants

Rationa(e #: Scalp veins are appropriate sites for IV insertion in infants

Rationa(e $: Scalp veins are appropriate sites for IV insertion in infants

)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question "3

Type: MCSA

The nurse is preparing to insert an IV in a clientLs cephalic vein <hen the vein is access %ith a venous catheter#

the nurse can feel a pop upon penetrating the:

1! Tunica media

2! Tunica adventitia





"! Tunica intima

#! Valves

Corre%t &ns'er: '

Rationa(e 1: The tunica media is the middle layer of a veinG this layer is composed of the muscle and elastic

tissues that constrict and distend the vein

Rationa(e 2: The tunica adventitia is the outermost layer of the vein %allG it is made up of connective tissue

Rationa(e ": The innermost layer is the tunica intima# or endothelial liningG this layer is thin and supports thevalves pointing to%ard the heart

Rationa(e #: Valves are found %ithin the veinG and can be identified as visible bulges in the distended vein

)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question "1

Type: MCMA

<hen preparing to insert an IV# the nurse revie%s the client history to determine if there are sites that have been

affected by pree5isting conditions Conditions that may limit available veins include:(Select all that apply!


1! 2regnancy

2! Jluid overload

"! CVA

#! +rthopedic surgery

$! 9ialysis shunt


Rationa(e 1: ,+ J--9/AC

Rationa(e 2: ,+ J--9/AC





Rationa(e ": ,+ J--9/AC

Rationa(e #: ,+ J--9/AC

Rationa(e $: ,+ J--9/AC

)(o*a( Rationa(e:



C(ient Need Su*:


earning /ut%ome:

Question "2

Type: S-N

Successful IV insertions include the follo%ing steps 2lace the follo%ing in the correct order# from beginning ofthe procedure to the end

Standard Tet: Click and drag the options belo% to move them up or do%n

Choi%e 1! "emove e5cess hair

Choi%e 2! 2repare the area %ith the facility7specified agent

Choi%e "! Apply a tourni&uet

Choi%e #! Approach the vein %ith the bevel up

Choi%e $! Stabili*e the catheter

Corre%t &ns'er: 1#'##4#)

Rationa(e 1: "emove e5cess hair to facilitate catheter insertion# taping and dressing adherenceG use scissors rathethan shaving

Rationa(e 2: Skin cleansing is done %ith a facility7specified agent# using a circular motion from the inside out an

allo%ing the area to dry for 1 minute

Rationa(e ": Apply a tourni&uet# either a flat rubberi*ed band# a Velcro7closure band or a blood pressure cuff

inflated at 0 mm ?g

Rationa(e #: After applying gloves# the nurse approaches the vein %ith the bevel of the cannula up an to the side

of the vein





Rationa(e $: After successful insertion of the cannula# the catheter is stabili*ed by the . method# ? method orChevron method

)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question ""

Type: MCMA

The nurse is a%are of many contributing factors to complications of IV therapy <hich of the follo%ing factors

contribute to locali*ed complications:(Select all that apply!


1! Skin integrity

2! Site of infusion

"! 9uration of infusion

#! ClientLs medical condition

$! Client activity

Corre%t &ns'er: 1#'##)

Rationa(e 1: The lack of skin integrity of the client may contribute to in$ury of the vein

Rationa(e 2: The site of the infusion# if a%k%ard or precarious# can contribute to e5travasation of the infusion

Rationa(e ": The duration of the infusion can contribute to the possibility of phlebitis

Rationa(e #: The clientLs medical condition can contribute to systemic complications of IV therapy

Rationa(e $: A clientLs level of activity# as in that of an infant# can contribute to phlebitis# infiltration andhematoma

)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:






earning /ut%ome:

Question "#

Type: MCMA

The nurse notes redness at the tip of an intravenous catheter and along the vein Appropriate nursing intervention

include:(Select all that apply!


1! "emove the cannula

2! Tape the cannula securely

"! Apply a %arm compress to the site

#! Check for bleeding

$! Slo% the IV rate

Corre%t &ns'er: 1#

Rationa(e 1: An appropriate nursing intervention at this time is to remove the cannula


Rationa(e ": An appropriate nursing intervention at this time is to remove the cannula

Rationa(e #: An appropriate nursing intervention at this time is to remove the cannula

Rationa(e $: An appropriate nursing intervention at this time is to remove the cannula

)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question "$

Type: MCSA

Appropriate preventive measures for the nurse to take to prevent circulatory overload include:(Select all that

apply!





1! 2ractice consistent hand hygiene

2! Monitor infusions fre&uently

"! -nsure sterile dressing to insertion site

#! Monitor insertion site routinely

$! Make accurate fluid calculations

Corre%t &ns'er: )

Rationa(e 1: Consistent hand hygiene is appropriate prevention for septicemia# bacteremia

Rationa(e 2: Monitoring infusions fre&uently is appropriate prevention for circulatory overload

Rationa(e ": -nsuring sterile dressings are appropriate preventive measures for septicemia and bacteremia

Rationa(e #: The insertion site should be monitored routinely# but it is not a preventive measure for circulatoryoverload

Rationa(e $: 2reventing circulatory overload involves making accurate fluid calculations

)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question "0

Type: MCSA

The nurse understands the primary cause of septicemia from IV therapy is:

1! 9ue to the client %ith a renal or cardiac condition

2! ?ealthcare ac&uired infection

"! Air in the IV tubing

#! Infusing medications too &uickly

Corre%t &ns'er: '

Rationa(e 1: The client %ith a renal or cardiac condition is at risk for circulatory overload





Rationa(e 2: The client %ith a healthcare ac&uired infection (or nosocomial infection! is at risk for septicemia or bacteremia

Rationa(e ": The client %hose IV tubing gets air in it is at risk for an air embolism

Rationa(e #: The client %ho has medications or fluids infused at a rapid rate is at risk for speed shock# %hich is a

reaction to rapid induction of foreign substance

)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question "

Type: MCMA

A client complains of itching# runny nose# and %hee*ing after the first dose of an antibiotic The appropriate

nursing actions include:(Select all that apply!


1! Stop the infusion immediately

2! -nsure patent air%ay

"! Check vital signs

#! Monitor condition changes

$! Administer an antidote

Corre%t &ns'er: 1#'

Rationa(e 1: In the event a client sho%s signs of an allergic reaction soon after a medication has been

administered# appropriate nursing interventions include stopping the infusion immediately

Rationa(e 2: In the event a client sho%s signs of an allergic reaction soon after a medication has beenadministered# appropriate nursing interventions include stopping the infusion immediately

Rationa(e ": In the event a client sho%s signs of an allergic reaction soon after a medication has been


Rationa(e #: In the event a client sho%s signs of an allergic reaction soon after a medication has beenadministered# appropriate nursing interventions include stopping the infusion immediately





Rationa(e $: In the event a client sho%s signs of an allergic reaction soon after a medication has beenadministered# appropriate nursing interventions include stopping the infusion immediately

)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question "8

Type: MCMA

The nurse is revie%ing a clientLs history %ith the client prior to initiating a blood transfusion The nurse e5plains

the ob$ectives for administering blood transfusions as including:(Select all that apply!


1! "estoring and maintaining blood volume

2! Improving the o5ygen7carrying capacity of the circulatory system

"! "estoring and maintaining acid7base balance

#! 2ermitting neonatal blood e5change

$! Treating blood deficiencies such as anemia

Corre%t &ns'er: 1#'#4#)

Rationa(e 1: "estoring and maintaining blood volume# as in the case of hemorrhage# is an ob$ective foradministering a blood transfusion

Rationa(e 2: Improving the o5ygen carrying capacity of the circulatory system is an ob$ective for administering a

blood transfusion

Rationa(e ": "estoring and maintaining coagulation factors is an ob$ective for administering blood or bloodcomponents

Rationa(e #: /lood transfusions are indicated in the case of severe "h incompatibility in the neonate

Rationa(e $: Anemia and other hematologic disorders are treated %ith blood transfusions

)(o*a( Rationa(e:






C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question "

Type: MCSA

The nurse is preparing to infuse cryoprecipitate Important nursing interventions include:

1! Tha%ing product before infusion

2! Infuse each unit over ' hours

"! .se glass bottles

#! ,o filter is re&uired

Corre%t &ns'er: 1

Rationa(e 1: .nits of cryoprecipitate are kept fro*en# and must be tha%ed prior to infusion

Rationa(e 2: -ach unit of cryoprecipitate is infused at a rate of 17' m>Dmin# resulting in an infusion time of '710minutes per unit

Rationa(e ": Albumin is supplied in glass bottlesG other blood products are supplied in plastic bags

Rationa(e #: A 1807micron filter is re&uired %ith infusion of cryoprecipitate

)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question #3

Type: MCMA

The nurse is caring for a client %ith hypovolemic shock from trauma Administration of albumin is indicated for:



1! Supporting the clientLs blood pressure





2! Increasing plasma volume

"! Improving the o5ygen7carrying capacity

#! 2revent bleeding

$! 2reventing febrile transfusion reactions

Corre%t &ns'er: 1#'

Rationa(e 1: Albumin is a colloid volume e5pander and %ill support the clientLs blood pressure

Rationa(e 2: Albumin is a colloid volume e5pander and %ill support the clientLs blood pressure

Rationa(e ": Albumin is a colloid volume e5pander and %ill support the clientLs blood pressure

Rationa(e #: Albumin is a colloid volume e5pander and %ill support the clientLs blood pressure

Rationa(e $: Albumin is a colloid volume e5pander and %ill support the clientLs blood pressure

)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question #1Type: MCSA

A client %ho is receiving a transfusion of 2"/Cs complains of a headache# nausea# chest pain# and flu7like

symptoms The nurse reali*es this is most likely:

1! An anaphylactic transfusion reaction

2! Acute hemolytic transfusion reaction

"! An allergic reaction

#! A febrile nonhemolytic reaction

Corre%t &ns'er: 4

Rationa(e 1: The signs and symptoms of an anaphylactic transfusion reaction include an5iety#






Rationa(e ": The signs and symptoms of an anaphylactic transfusion reaction include an5iety#

Rationa(e #: The signs and symptoms of an anaphylactic transfusion reaction include an5iety#

)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:


earning /ut%ome:

Question #2

Type: MCMA

The nurse is revie%ing the potential complications of a transfusion %ith a client Infections that may be long term

in nature include:(Select all that apply!


1! ?epatitis /

2! Eraft7versus7host disease

"! ?yperkalemia

#! Sepsis

$! ?IV

Corre%t &ns'er: 1#)

Rationa(e 1: ?epatitis / is a viral infection that is spread by blood and serum# and may be life7long in nature

Rationa(e 2: ?epatitis / is a viral infection that is spread by blood and serum# and may be life7long in nature

Rationa(e ": ?epatitis / is a viral infection that is spread by blood and serum# and may be life7long in nature

Rationa(e #: ?epatitis / is a viral infection that is spread by blood and serum# and may be life7long in nature

Rationa(e $: ?epatitis / is a viral infection that is spread by blood and serum# and may be life7long in nature

)(o*a( Rationa(e:


C(ient Need:

C(ient Need Su*:






earning /ut%ome:

Question #"

Type: MCMA

,ursing responsibilities for the >2,D>V, %ho provides IV therapy include:


1! 2erforming %ithin the state nurse practice act

2! 2reparing and educating clients about IV therapy

"! Assigning .A2 to monitor the client

#! Maintaining droplet precautions for any client %ith an IV in place

$! "eporting needle stick in$uries to the C9C

Corre%t &ns'er: 1#'

Rationa(e 1: The >2,D>V, must kno% %hat is legal for her to do# and must al%ays perform duties %ithin the

scope of practice

Rationa(e 2: The >2,sD>V,s %ho provide IV therapy prepare and educate clients about IV therapy to ensurecooperation and a therapeutic relationship

Rationa(e ": >2,sD>V,s observe clients closely for potential complications and provide early interventionG this

responsibility is not delegated to unlicensed assistive personnel

Rationa(e #: All nursing personnel must follo% Standard 2recautionsG all body fluids e5cept s%eat are treated asif kno%n to be infectious %ith ?IV# hepatitis / and C# and other bloodborne pathogens

Rationa(e $: If stuck %ith a needle# the nurse should immediately flood the e5posed area %ith %ater and clean the

%ound %ith soap and %ater or skin disinfectant# if availableG report it immediately to the employerG and seek

immediate medical attention

)(o*a( Rationa(e:

Cogniti+e e+e(: ApplyingC(ient Need: 2hysiological Integrity

C(ient Need Su*:


earning /ut%ome:

Question ##

Type: MCSA





The nurse %ill use all of the follo%ing safety devices %hen using needles in client care e5cept:

1! ,eedleless systems

2! "etracting catheters

"! Cardboard contaminated sharps containers

#! Eloves

Corre%t &ns'er:

Rationa(e 1: ,eedleless systems and needle safety devices are used to protect the safety of healthcare personnel

Rationa(e 2: "etracting or shielded catheters are used to minimi*e the possibility of needle stick in$uries

Rationa(e ": Contaminated sharps must be placed in a puncture7resistant# leakproof# labeled container

Rationa(e #: Eloves are one of the main barriers used to protect nursing personnel from body fluids that coulde5pose them to ?IV or hepatitis / or C

)(o*a( Rationa(e:



C(ient Need Su*:


earning /ut%ome:

Question #$

Type: MCMA

The nurse considers %hich of the follo%ing classifications of la% %hen administering IV therapy3


1! Criminal la%

2! Common la%

"! Civil la%

#! ,egligence

$! Jederal la%

Corre%t &ns'er: 1#'#





Rationa(e 1: Criminal la% is a %rong against the public for %hich government can prosecute and imposeimprisonment or fines# such as assault and battery

Rationa(e 2: Criminal la% is a %rong against the public for %hich government can prosecute and impose


Rationa(e ": Criminal la% is a %rong against the public for %hich government can prosecute and impose


Rationa(e #: Criminal la% is a %rong against the public for %hich government can prosecute and impose


Rationa(e $: Criminal la% is a %rong against the public for %hich government can prosecute and impose


)(o*a( Rationa(e:


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Question #0

Type: MCSA

The nurse is a%are that the Koint Commission has indicated that standards of care must be developed to measure

&uality based on e5pectations of service <hich of the follo%ing regulators enforce(s! ?ealth Insurance

2ortability and Accountability Act regulations3

1! +ccupational Safety and ?ealth Administration

2! State departments of health and human services

"! The Koint Commission

#! The -nvironmental 2rotection Agency

Corre%t &ns'er: '

Rationa(e 1: +S?A does not enforce ?I2AA regulations

Rationa(e 2: State departments of health and human services enforce ?I2AA regulations

Rationa(e ": The Koint Commission does not enforce ?I2AA regulationsG rather# it publishes professional

standards of care

Rationa(e #: The -2A does not enforce ?I2AA regulations





)(o*a( Rationa(e:

Cogniti+e e+e(: no%ing


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Question #

Type: MCMA

The nurse prepares the client care area to minimi*e physical ha*ards of administering IV therapy# %hich include:


1! Abrasions

2! Chemical e5posure

"! >ate5 allergy

#! ,eedle stick

$! /urns

Corre%t &ns'er: 1#'##4



Rationa(e ": Abrasions from e&uipment packaging offer potential portals for microorganisms

Rationa(e #: Abrasions from e&uipment packaging offer potential portals for microorganisms

Rationa(e $: Abrasions from e&uipment packaging offer potential portals for microorganisms

)(o*a( Rationa(e:


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Question #8

Type: MCMA

The nurse e5plains to the clientLs family the purposes of IV therapy# %hich include:






1! Maintaining blood volume

2! -nsuring slo% delivery of medications

"! 2roviding nutrition

#! Correcting electrolyte imbalances

$! "ehydration

Corre%t &ns'er: 1##4#)



Rationa(e ": IV therapy# %hether

Rationa(e #: IV therapy# %hether

Rationa(e $: IV therapy# %hether

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Question #

Type: MCSA

The nurse is caring for a client %ith burns <hich of the follo%ing IV solutions %ould not be appropriate for this

client3

1! 9)6 04)6 ,S

2! 9)6>"

"! 04)6,S

#! 0H6 ,S

Corre%t &ns'er:







Rationa(e ": A hypertonic solution such as 9)604)6 ,S %ill e5pand the

Rationa(e #: A hypertonic solution such as 9)604)6 ,S %ill e5pand the

)(o*a( Rationa(e:



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Question $3

Type: MCMAThe nurse is caring for an elderly client %ho has not seen a plastic IV solution container before The nurse

e5plains that the advantages of the plastic bag include:


1! 2lastic containers are light%eight

2! 2lastic containers are rigid

"! 2lastic containers are vented systems

#! 2lastic containers are collapsible

$! 2lastic containers are inert

Corre%t &ns'er: 1#4

Rationa(e 1: 2lastic containers are light%eight %hen compared %ith glass containers

Rationa(e 2: 2lastic containers are fle5ible

Rationa(e ": 2lastic containers do not need to be vented

Rationa(e #: 2lastic containers are collapsible# not rigid

Rationa(e $: 2lastic containers are made up of plastici*ers and are not completely inertG markers should never beused to %rite on the bag# because the ink could be absorbed into the plastic

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Question $1

Type: JI/

The nurse differentiates the microdrip IV administration set as providing @0 gttDml

Standard Tet:

Corre%t &ns'er: 10 gttDml D 1) gttDml D '0 gttDml

Rationa(e : A microdrip IV administration set delivers fluids %ith a drop factor of @0 gttDml Macrodrip IVadministration sets deliver fluids %ith a drop factor ranging from 10 to '0 gttDml

)(o*a( Rationa(e:



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Question $2

Type: MCMA

The nurse is selecting a peripheral infusion device for insertion The scalp vein needle is most appropriate for:


1! Single7dose therapy

2! 9elivery of blood

"! >ong7term peripheral IV therapy

#! Transplant clients

$! Clients allergic to nylon or Teflon

Corre%t &ns'er: 1#)

Rationa(e 1: Scalp vein needles are used for short7term therapy# such as single7dose therapy

Rationa(e 2: +ver7the7needle catheters are used for delivery of viscous fluids# such as blood and blood products





Rationa(e ": +ver7the7needle catheters are used for long7term peripheral IV therapy

Rationa(e #: +ver7the7needle catheters are used for clients %ho %ill be undergoing transplant surgery

Rationa(e $: Scalp vein needles are used for client %ho are allergic to nylon

)(o*a( Rationa(e:



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Question $"

Type: MCMA

The nurse is caring for a client %ith an IV# and %ill be administering a blood transfusion The follo%ing

considerations are appropriate %hen considering the infusion device:


1! 2eristaltic regulators are appropriate for administration of blood

2! The tubing cassette should be held upright %hen priming

"! Accurate function of the machine should be verified

#! Systematically check the IV if the deviceLs alarm is going off

$! 2lace a piggyback administration set above the air detector device


Rationa(e 1: 2eristaltic regulators are not appropriate for administration of blood# because of their s&uee*ing


Rationa(e 2: 2eristaltic regulators are not appropriate for administration of blood# because of their s&uee*ing


Rationa(e ": 2eristaltic regulators are not appropriate for administration of blood# because of their s&uee*ingaction# %hich can in$ure red blood cells

Rationa(e #: 2eristaltic regulators are not appropriate for administration of blood# because of their s&uee*ing


Rationa(e $: 2eristaltic regulators are not appropriate for administration of blood# because of their s&uee*ingaction# %hich can in$ure red blood cells





)(o*a( Rationa(e:



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Question $#

Type: JI/

The nurse is calculating the flo% rate using the standard formula The order is as follo%s: Infuse 1000 m> of 9)<over 10 hours %ith a drip factor of 10 <hat are the drops per minute3

Standard Tet:

Corre%t &ns'er: 18 gttDmin D '8 gttDmin D 1@ gttDmin

Rationa(e : The standard formula is: Amount of fluid (in m>! B drop factor drops per minute 9etermine thefluid per hour: 1000 m> divided by 10 hours 100 m> The time to infuse is no% @0 minutes# or 1 hour Amount

of fluid (100 m>! B drop factor (10! drops per minute Time to infuse in minutes (@0!100 B 10 gttDmin @0#10B 1 1@@ gttDminG round up to nearest %hole number 18 gttDmin @

)(o*a( Rationa(e:



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Question $$

Type: MCSA

The nurse is preparing a preschooler for IV insertion Age7appropriate considerations for the O@7year7old include

1! .sing distraction# such as shaking a rattle

2! ?aving the child push his hands together

"! -5plaining the procedure shortly beforehand

#! Considering the appearance of the IV infusion line

Corre%t &ns'er: '

Rationa(e 1: .sing a rattle# singing a song# and providing a toy are distractions appropriate for an infant





Rationa(e 2: ?aving the child push his hands together has the child concentrating on the motion rather than theIV in$ection

Rationa(e ": -5plaining the procedure shortly before it is performed is appropriate for the school7age child

Rationa(e #: Considering the appearance of IV infusion lines or infusion ports is appropriate for adolescents

)(o*a( Rationa(e:


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Question $0

Type: MCMA

The nurse is preparing to insert an IV in a 1@7year7old client Appropriate IV insertion sites include:


1! Scalp veins

2! 9orsal hand veins

"! 9orsal foot veins

#! Jorearm veins

$! Cephalic vein

Corre%t &ns'er: '#4#)



Rationa(e ": Scalp veins are appropriate sites for IV insertion in infants

Rationa(e #: Scalp veins are appropriate sites for IV insertion in infants

Rationa(e $: Scalp veins are appropriate sites for IV insertion in infants

)(o*a( Rationa(e:







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Question $

Type: MCSA

The nurse is preparing to insert an IV in a clientLs cephalic vein <hen the vein is accessed %ith a venous cathete

the nurse can feel a pop upon penetrating the:

1! Tunica media

2! Tunica adventitia

"! Tunica intima

#! Valves

Corre%t &ns'er: '

Rationa(e 1: The tunica media is the middle layer of a veinG this layer is composed of the muscle and elastic

tissues that constrict and distend the vein

Rationa(e 2: The tunica adventitia is the outermost layer of the vein %allG it is made up of connective tissue

Rationa(e ": The innermost layer is the tunica intima# or endothelial liningG this layer is thin# and supports the

valves pointing to%ard the heart

Rationa(e #: Valves are found %ithin the veinG and can be identified as visible bulges in the distended vein

)(o*a( Rationa(e:



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Question $8

Type: S-N

Successful IV insertions include the follo%ing steps 2lace the follo%ing in the correct order# from beginning ofthe procedure to the end:

Standard Tet: Click and drag the options belo% to move them up or do%n

Choi%e 1! "emove e5cess hair

Choi%e 2! 2repare the area %ith the facility7specified agent





Choi%e "! Apply a tourni&uet

Choi%e #! Approach the vein %ith the bevel up

Choi%e $! Stabili*e the catheter

Corre%t &ns'er: 1#'##4#)

Rationa(e 1: "emove e5cess hair to facilitate catheter insertion# taping# and dressing adherenceG use scissors

rather than shaving

Rationa(e 2: Skin cleansing is done %ith a facility7specified agent# using a circular motion from the inside out anallo%ing the area to dry for 1 minute

Rationa(e ": Apply a tourni&uet# either a flat rubberi*ed band# a Velcro7closure band# or a blood pressure cuff

inflated at 0 mm ?g

Rationa(e #: After applying gloves# the nurse approaches the vein %ith the bevel of the cannula up and to the side

of the vein

Rationa(e $: After successful insertion of the cannula# the catheter is stabili*ed by the . method# ? method# or

Chevron method

)(o*a( Rationa(e:



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Question $

Type: MCMA

The nurse is a%are of many contributing factors to complications of IV therapy <hich of the follo%ing factors

contribute to locali*ed complications3


1! Skin integrity

2! Site of infusion

"! 9uration of infusion

#! ClientLs medical condition

$! Client activity





Corre%t &ns'er: 1#'##)

Rationa(e 1: The lack of skin integrity of the client can contribute to in$ury of the vein

Rationa(e 2: The site of the infusion# if a%k%ard or precarious# can contribute to e5travasation of the infusion

Rationa(e ": The duration of the infusion can contribute to the possibility of phlebitis

Rationa(e #: The clientLs medical condition can contribute to systemic complications of IV therapy

Rationa(e $: A clientLs level of activity# as in that of an infant# can contribute to phlebitis# infiltration# and

hematoma

)(o*a( Rationa(e:



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Question 03

Type: MCMA

The nurse notes redness at the tip of an intravenous catheter and along the vein Appropriate nursing intervention

include:


1! "emove the cannula

2! Tape the cannula securely

"! Apply a %arm compress to the site

#! Check for bleeding

$! Slo% the IV rate

Corre%t &ns'er: 1#



Rationa(e ": An appropriate nursing intervention at this time is to remove the cannula

Rationa(e #: An appropriate nursing intervention at this time is to remove the cannula





Rationa(e $: An appropriate nursing intervention at this time is to remove the cannula

)(o*a( Rationa(e:



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Question 01

Type: MCMA

Appropriate preventive measures for the nurse to take to prevent circulatory overload include:


1! 2ractice consistent hand hygiene

2! Monitor infusions fre&uently

"! -nsure sterile dressing to the insertion site

#! Monitor the insertion site routinely

$! Make accurate fluid calculations

Corre%t &ns'er: '#)

Rationa(e 1: Consistent hand hygiene is appropriate prevention for septicemia and bacteremia

Rationa(e 2: Monitoring infusions fre&uently is appropriate prevention for circulatory overload

Rationa(e ": -nsuring sterile dressings is an appropriate preventive measure for septicemia and bacteremia

Rationa(e #: The insertion site should be monitored routinely# but it is not a preventive measure for circulatory

overload

Rationa(e $: 2reventing circulatory overload involves making accurate fluid calculations

)(o*a( Rationa(e:



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Question 02

Type: MCSA

The nurse understands that the primary cause of septicemia from IV therapy is:

1! The client %ith a renal or cardiac condition

2! ?ealth careOac&uired infection

"! Air in the IV tubing

#! Infusing medications too &uickly

Corre%t &ns'er: '

Rationa(e 1: The client %ith a renal or cardiac condition is at risk for circulatory overload

Rationa(e 2: The client %ith a health careOac&uired infection (or nosocomial infection! is at risk for septicemia o

bacteremia

Rationa(e ": The client %hose IV tubing gets air in it is at risk for an air embolism

Rationa(e #: The client %ho has medications or fluids infused at a rapid rate is at risk for speed shock# %hich is areaction to rapid induction of foreign substance

)(o*a( Rationa(e:



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Question 0"

Type: MCMA

A client complains of itching# runny nose# and %hee*ing after the first dose of an antibiotic The appropriate

nursing actions include:


1! Stop the infusion immediately

2! -nsure a patent air%ay

"! Check vital signs

#! Monitor condition changes





$! Administer an antidote

Corre%t &ns'er: 1#'

Rationa(e 1: In the event a client sho%s signs of an allergic reaction soon after a medication has been


Rationa(e 2: In the event a client sho%s signs of an allergic reaction soon after a medication has beenadministered# appropriate nursing interventions include stopping the infusion immediately

Rationa(e ": In the event a client sho%s signs of an allergic reaction soon after a medication has beenadministered# appropriate nursing interventions include stopping the infusion immediately

Rationa(e #: In the event a client sho%s signs of an allergic reaction soon after a medication has been


Rationa(e $: In the event a client sho%s signs of an allergic reaction soon after a medication has beenadministered# appropriate nursing interventions include stopping the infusion immediately

)(o*a( Rationa(e:



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Question 0#

Type: MCMAThe nurse is revie%ing a clientLs history %ith the client prior to initiating a blood transfusion The nurse lists theob$ectives for administering blood transfusions# including:


1! "estoring and maintaining blood volume

2! Improving the o5ygen7carrying capacity of the circulatory system

"! "estoring and maintaining acidObase balance

#! 2ermitting neonatal blood e5change

$! Treating blood deficiencies such as anemia

Corre%t &ns'er: 1#'#4#)





Rationa(e 1: "estoring and maintaining blood volume# as in the case of hemorrhage# is an ob$ective foradministering a blood transfusion

Rationa(e 2: Improving the o5ygen7carrying capacity of the circulatory system is an ob$ective for administering a

blood transfusion

Rationa(e ": "estoring and maintaining coagulation factors is an ob$ective for administering blood or blood

components

Rationa(e #: /lood transfusions are indicated in the case of severe "h incompatibility in the neonate

Rationa(e $: Anemia and other hematologic disorders are treated %ith blood transfusions

)(o*a( Rationa(e:



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Question 0$

Type: MCSA

The nurse is preparing to infuse cryoprecipitate Important nursing interventions include:

1! Tha%ing product before infusion

2! Infusing each unit over ' hours

"! .sing glass bottles

#! ,o filter is re&uired

Corre%t &ns'er: 1

Rationa(e 1: .nits of cryoprecipitate are kept fro*en# and must be tha%ed prior to infusion

Rationa(e 2: -ach unit of cryoprecipitate is infused at a rate of 1O' m>Dmin# resulting in an infusion time of 'O1minutes per unit

Rationa(e ": Albumin is supplied in glass bottlesG other blood products are supplied in plastic bags

Rationa(e #: A 1807micron filter is re&uired %ith infusion of cryoprecipitate

)(o*a( Rationa(e:







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Question 00

Type: MCMA

The nurse is caring for a client %ith hypovolemic shock from trauma Administration of albumin is indicated for:


1! Supporting the clientLs blood pressure

2! Increasing plasma volume

"! Improving the o5ygen7carrying capacity

#! 2reventing bleeding

$! 2reventing febrile transfusion reactions

Corre%t &ns'er: 1#'

Rationa(e 1: Albumin is a colloid volume e5pander# and %ill support the clientLs blood pressure

Rationa(e 2: Albumin is a colloid volume e5pander# and %ill support the clientLs blood pressure

Rationa(e ": Albumin is a colloid volume e5pander# and %ill support the clientLs blood pressure

Rationa(e #: Albumin is a colloid volume e5pander# and %ill support the clientLs blood pressure

Rationa(e $: Albumin is a colloid volume e5pander# and %ill support the clientLs blood pressure

)(o*a( Rationa(e:



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Question 0

Type: MCSA

A client %ho is receiving a transfusion of 2"/Cs complains of a headache# nausea# chest pain# and flulike

symptoms The nurse reali*es this is most likely:

1! An anaphylactic transfusion reaction





2! Acute hemolytic transfusion reaction

"! An allergic reaction

#! A febrile nonhemolytic reaction

Corre%t &ns'er: 4



Rationa(e ": The signs and symptoms of an anaphylactic transfusion reaction include an5iety#

Rationa(e #: The signs and symptoms of an anaphylactic transfusion reaction include an5iety#

)(o*a( Rationa(e:



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Question 08

Type: MCMA

The nurse is revie%ing the potential complications of a transfusion %ith a client Infections that can be long7term

in nature include:


1! ?epatitis /

2! Eraft7versus7host disease

"! ?yperkalemia

#! Sepsis

$! ?IV

Corre%t &ns'er: 1#)

Rationa(e 1: ?epatitis / is a viral infection that is spread by blood and serum# and can be lifelong in nature

Rationa(e 2: ?epatitis / is a viral infection that is spread by blood and serum# and can be lifelong in nature





Rationa(e ": ?epatitis / is a viral infection that is spread by blood and serum# and can be lifelong in nature

Rationa(e #: ?epatitis / is a viral infection that is spread by blood and serum# and can be lifelong in nature

Rationa(e $: ?epatitis / is a viral infection that is spread by blood and serum# and can be lifelong in nature

)(o*a( Rationa(e:



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Documents

Ramont2e Rev TIF Ch28