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
anything 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 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
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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
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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: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: 2lanning
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
"amont# ,iedringhous# Comprehensive Nursing Care 'nd -dition .pdate Test /ank
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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:
Cogniti+e e+e(: Analy*ing
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: 2lanning
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
&uantities of fluid than are other methods
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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
&uantities of fluid than are other methods
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:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
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
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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:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
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
hour times the drip rate: =0 @0 B 10 1# or 1# since it is impossible to count 1D of a drop
Rationa(e ": 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 #: 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:
Cogniti+e e+e(: Analy*ing
"amont# ,iedringhous# Comprehensive Nursing Care 'nd -dition .pdate Test /ank
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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:
Cogniti+e e+e(: Analy*ing
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 8
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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
it 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
it is the most distal The digital# antecubital cephalic# and great saphenous veins are choices of last resort
)(o*a( Rationa(e:
Cogniti+e e+e(: Applying
C(ient Need: Safe -ffective Care -nvironment
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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!
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"! 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:
Cogniti+e e+e(: Analy*ing
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: 2lanning
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:
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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
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 #: 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
)(o*a( Rationa(e:
Cogniti+e e+e(: Applying
C(ient Need: Safe -ffective Care -nvironment
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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
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", 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:
Cogniti+e e+e(: Analy*ing
C(ient Need: Safe -ffective Care -nvironment
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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
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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
categori*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
categori*ed as a 'F on the phlebitis scale
)(o*a( Rationa(e:
Cogniti+e e+e(: Analy*ing
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Assessment
earning /ut%ome: Identify complications associated %ith infusion therapy
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
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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:
Cogniti+e e+e(: Applying
C(ient Need: Safe -ffective Care -nvironment
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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
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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:
Cogniti+e e+e(: Analy*ing
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Assessment
earning /ut%ome: Identify complications associated %ith infusion therapy
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
doing anything else# is to make sure that the client does not receive any more blood After the infusion is stopped
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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
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
)(o*a( Rationa(e:
Cogniti+e e+e(: Analy*ing
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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!
Standard Tet: 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
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Rationa(e $: If stuck %ith a needle# the nurse should immediately flood the e5posed area %ith %ater and clean the%ound %ith soap and %ater or skin disinfectant if availableG report it immediately to the employerG seek
immediate medical attention
)(o*a( Rationa(e:
Cogniti+e e+e(: Applying
C(ient Need:C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
earning /ut%ome:
Question 1
Type: MCSA
The nurse %ill use %hich of the follo%ing safety devices %hen using needles in client care e5cept:
1! ,eedleless systems
2! "etracting catheters
"! Cardboard contaminated sharps containers
#! Eloves
Corre%t &ns'er:
Rationa(e 1: ,eedleless systems and needle safety devices are used to protect the safety of healthcare personnel
Rationa(e 2: "etracting or shielded catheters are used to minimi*e the possibility of needle stick in$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:
Cogniti+e e+e(: Applying
C(ient Need:C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
earning /ut%ome:
Question 18
Type: MCMA
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The nurse considers %hich of the follo%ing classifications of la% %hen administering IV therapy3(Select all that
apply!
Standard Tet: 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
imprisonment or fines# such as assault and battery
Rationa(e $: Criminal la% is a %rong against the public for %hich government can prosecute and impose
imprisonment or fines# such as assault and battery
)(o*a( Rationa(e:
Cogniti+e e+e(: .nderstanding
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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
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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*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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!
Standard Tet: Select all that apply
1! Abrasions
2! Chemical e5posure
"! >ate5 allergy
#! ,eedle stick
$! /urns
Corre%t &ns'er: 1#'##4
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Rationa(e 1: Abrasions from e&uipment packaging offer potential portals for microorganisms
Rationa(e 2: 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:
Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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!
Standard Tet: 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 2: IV therapy# %hether
Rationa(e ": IV therapy# %hether
Rationa(e #: IV therapy# %hether
Rationa(e $: IV therapy# %hether
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)(o*a( Rationa(e:
Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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 2: 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:
Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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!
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Standard Tet: 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 $: 2lastic containers are made up of plastici*ers and are not completely inertG markers should never be
used to %rite on the bag because the ink could be absorbed into the plastic
)(o*a( Rationa(e:
Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
earning /ut%ome:
Question 2#
Type: JI/
The nurse differentiates the microdrip IV administration set as providing @0 gttDml
Standard Tet:
Corre%t &ns'er: 10 gttDml D 1) gttDml D '0 gttDml
Rationa(e : A microdrip IV administration set delivers fluids %ith a drop factor of @0 gttDmlMacrodrip IV
administration sets deliver fluids %ith a drop factor ranging from 107'0 gttDml
)(o*a( Rationa(e:
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Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
earning /ut%ome:
Question 2$
Type: MCMA
The nurse is selecting a peripheral infusion device for insertion The scalp vein needle is most appropriate for:
(Select all that apply!
Standard Tet: Select all that apply
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:
Cogniti+e e+e(: Applying
C(ient Need:C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
earning /ut%ome:
Question 20
Type: MCMA
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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!
Standard Tet: 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
action# %hich can in$ure red blood cells
Rationa(e $: 2eristaltic regulators are not appropriate for administration of blood because of their s&uee*ing
action# %hich can in$ure red blood cells
)(o*a( Rationa(e:
Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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:
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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:
Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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:
Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
earning /ut%ome:
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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!
Standard Tet: Select all that 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 2: 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:
Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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
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"! 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:
Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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!
Standard Tet: Select all that apply
1! 2regnancy
2! Jluid overload
"! CVA
#! +rthopedic surgery
$! 9ialysis shunt
Corre%t &ns'er: #4#)
Rationa(e 1: ,+ J--9/AC
Rationa(e 2: ,+ J--9/AC
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Rationa(e ": ,+ J--9/AC
Rationa(e #: ,+ J--9/AC
Rationa(e $: ,+ J--9/AC
)(o*a( Rationa(e:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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
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Rationa(e $: After successful insertion of the cannula# the catheter is stabili*ed by the . method# ? method orChevron method
)(o*a( Rationa(e:
Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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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 complications:(Select all that apply!
Standard Tet: 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:
Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
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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!
Standard Tet: 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 2: 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 $: An appropriate nursing intervention at this time is to remove the cannula
)(o*a( Rationa(e:
Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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Question "$
Type: MCSA
Appropriate preventive measures for the nurse to take to prevent circulatory overload include:(Select all that
apply!
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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:
Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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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
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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:
Cogniti+e e+e(: .nderstanding
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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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!
Standard Tet: 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
administered# 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
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Rationa(e $: In the event a client sho%s signs of an allergic reaction soon after a medication has beenadministered# appropriate nursing interventions include stopping the infusion immediately
)(o*a( Rationa(e:
Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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Question "8
Type: MCMA
The nurse is revie%ing a clientLs history %ith the client prior to initiating a blood transfusion The nurse e5plains
the ob$ectives for administering blood transfusions as including:(Select all that apply!
Standard Tet: 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:
Cogniti+e e+e(: Applying
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C(ient Need:
C(ient Need Su*:
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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:
Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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Question #3
Type: MCMA
The nurse is caring for a client %ith hypovolemic shock from trauma Administration of albumin is indicated for:
(Select all that apply!
Standard Tet: Select all that apply
1! Supporting the clientLs blood pressure
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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:
Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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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 2: The signs and symptoms of an anaphylactic transfusion reaction include an5iety#
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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:
Cogniti+e e+e(: .nderstanding
C(ient Need:
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Assessment
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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!
Standard Tet: 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:
Cogniti+e e+e(: Applying
C(ient Need:
C(ient Need Su*:
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Question #"
Type: MCMA
,ursing responsibilities for the >2,D>V, %ho provides IV therapy include:
Standard Tet: 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 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 $: If stuck %ith a needle# the nurse should immediately flood the e5posed area %ith %ater and clean the
%ound %ith soap and %ater or skin disinfectant# if availableG report it immediately to the employerG and seek
immediate medical attention
)(o*a( Rationa(e:
Cogniti+e e+e(: ApplyingC(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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Question ##
Type: MCSA
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The nurse %ill use all of the follo%ing safety devices %hen using needles in client care e5cept:
1! ,eedleless systems
2! "etracting catheters
"! Cardboard contaminated sharps containers
#! Eloves
Corre%t &ns'er:
Rationa(e 1: ,eedleless systems and needle safety devices are used to protect the safety of healthcare personnel
Rationa(e 2: "etracting or shielded catheters are used to minimi*e the possibility of needle stick in$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:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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Question #$
Type: MCMA
The nurse considers %hich of the follo%ing classifications of la% %hen administering IV therapy3
Standard Tet: Select all that apply
1! Criminal la%
2! Common la%
"! Civil la%
#! ,egligence
$! Jederal la%
Corre%t &ns'er: 1#'#
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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 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 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 impose
imprisonment or fines# such as assault and battery
)(o*a( Rationa(e:
Cogniti+e e+e(: .nderstanding
C(ient Need: 2hysiological IntegrityC(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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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
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)(o*a( Rationa(e:
Cogniti+e e+e(: no%ing
C(ient Need: Safe -ffective Care -nvironment
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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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:
Standard Tet: 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 2: 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:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological IntegrityC(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
earning /ut%ome:
Question #8
Type: MCMA
The nurse e5plains to the clientLs family the purposes of IV therapy# %hich include:
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Standard Tet: 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 2: IV therapy# %hether
Rationa(e ": IV therapy# %hether
Rationa(e #: IV therapy# %hether
Rationa(e $: IV therapy# %hether
)(o*a( Rationa(e:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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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:
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Rationa(e 1: A hypertonic solution such as 9)604)6 ,S %ill e5pand the
Rationa(e 2: 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:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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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:
Standard Tet: 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 %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
)(o*a( Rationa(e:
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Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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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:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
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:
Standard Tet: Select all that apply
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
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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:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
earning /ut%ome:
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:
Standard Tet: 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
$! 2lace a piggyback administration set above the air detector device
Corre%t &ns'er: #4#)
Rationa(e 1: 2eristaltic regulators are not appropriate for administration of blood# because of their s&uee*ing
action# %hich can in$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
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
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)(o*a( Rationa(e:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
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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:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
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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
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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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C(ient Need: 2sychosocial Integrity
C(ient Need Su*:
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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:
Standard Tet: Select all that 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 2: 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:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
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C(ient Need Su*:
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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:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
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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
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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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C(ient Need: 2hysiological Integrity
C(ient Need Su*:
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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 complications3
Standard Tet: Select all that apply
1! Skin integrity
2! Site of infusion
"! 9uration of infusion
#! ClientLs medical condition
$! Client activity
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Corre%t &ns'er: 1#'##)
Rationa(e 1: The lack of skin integrity of the client can contribute to in$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:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
earning /ut%ome:
Question 03
Type: MCMA
The nurse notes redness at the tip of an intravenous catheter and along the vein Appropriate nursing intervention
include:
Standard Tet: 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 2: 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
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Rationa(e $: An appropriate nursing intervention at this time is to remove the cannula
)(o*a( Rationa(e:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
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Question 01
Type: MCMA
Appropriate preventive measures for the nurse to take to prevent circulatory overload include:
Standard Tet: Select all that apply
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 $: 2reventing circulatory overload involves making accurate fluid calculations
)(o*a( Rationa(e:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
earning /ut%ome:
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Question 02
Type: MCSA
The nurse understands that the primary cause of septicemia from IV therapy is:
1! The client %ith a renal or cardiac condition
2! ?ealth careOac&uired infection
"! Air in the IV tubing
#! Infusing medications too &uickly
Corre%t &ns'er: '
Rationa(e 1: The client %ith a renal or cardiac condition is at risk for circulatory overload
Rationa(e 2: The client %ith a health careOac&uired infection (or nosocomial infection! is at risk for septicemia o
bacteremia
Rationa(e ": The client %hose IV tubing gets air in it is at risk for an air embolism
Rationa(e #: The client %ho has medications or fluids infused at a rapid rate is at risk for speed shock# %hich is areaction to rapid induction of foreign substance
)(o*a( Rationa(e:
Cogniti+e e+e(: .nderstanding
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
earning /ut%ome:
Question 0"
Type: MCMA
A client complains of itching# runny nose# and %hee*ing after the first dose of an antibiotic The appropriate
nursing actions include:
Standard Tet: Select all that apply
1! Stop the infusion immediately
2! -nsure a patent air%ay
"! Check vital signs
#! Monitor condition changes
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$! 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 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
administered# appropriate nursing interventions include stopping the infusion immediately
Rationa(e $: In the event a client sho%s signs of an allergic reaction soon after a medication has beenadministered# appropriate nursing interventions include stopping the infusion immediately
)(o*a( Rationa(e:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
earning /ut%ome:
Question 0#
Type: MCMAThe nurse is revie%ing a clientLs history %ith the client prior to initiating a blood transfusion The nurse lists theob$ectives for administering blood transfusions# including:
Standard Tet: Select all that apply
1! "estoring and maintaining blood volume
2! Improving the o5ygen7carrying capacity of the circulatory system
"! "estoring and maintaining acidObase balance
#! 2ermitting neonatal blood e5change
$! Treating blood deficiencies such as anemia
Corre%t &ns'er: 1#'#4#)
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Rationa(e 1: "estoring and maintaining blood volume# as in the case of hemorrhage# is an ob$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 $: Anemia and other hematologic disorders are treated %ith blood transfusions
)(o*a( Rationa(e:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
earning /ut%ome:
Question 0$
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:
Cogniti+e e+e(: Applying
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C(ient Need: 2hysiological Integrity
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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:
Standard Tet: Select all that apply
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:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
earning /ut%ome:
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
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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 2: 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:
Cogniti+e e+e(: .nderstanding
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Assessment
earning /ut%ome:
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:
Standard Tet: 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 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
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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:
Cogniti+e e+e(: Applying
C(ient Need: 2hysiological Integrity
C(ient Need Su*:
Nursing-.ntegrated Con%epts: ,ursing 2rocess: Implementation
earning /ut%ome: