IV Therapy & Blood Admin (saunders NCLEX book)

Question 1

A nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. The nurse planning the work assignment for the shift makes a notation to check the IV sites of these clients every:

1. 1 hour
2. 2 hours
3. 3 hours
4. 4 hours

Answer 1

1 hour
**Rationale: Safe nursing practice includes monitoring an IV infusion at least once per hour in an adult client. The IV may be checked even more frequently, depending on whether medication also is being infused. Therefore, options 2, 3, and 4 are incorrect.
Test-Taking Strategy: Focus on the subject, the time frequency for checking an IV site. Select the option that identifies the most frequent time frame. If this question was difficult, review the nursing care related to safe IV administration.

Question 2

A licensed practical nurse (LPN) is asked to prepare an intravenous (IV) infusion of 1000 mL 5% dextrose in lactated Ringer’s at 80 mL/hour to be administered to an assigned client. The LPN time-tapes the bag with a start time of 09:00. After making hourly marks on the time-tape, the LPN notes that the completion time for the bag is:

1. 15:30
2. 17:30
3. 19:30
4. 21:30

Answer 2

21:30
**Rationale: At a rate of 80 mL per hour, the 1000-mL bag will be finished infusing in 12.5 hours. This brings the end time to 21:30, using military time.
Test-Taking Strategy: To answer this question accurately you must be familiar with military time and with the procedure for time-taping an IV. Focus on the data in the question and note that at a rate of 80 mL per hour, the 1000-mL bag will be finished infusing in 12.5 hours. This will assist in answering correctly. Review military time and IV administration if you had difficulty with this question.

Question 3

A client is scheduled for insertion of a peripherally inserted central catheter (PICC), and the nurse explains the advantages of this catheter. Which statement by the client indicates a lack of understanding about this type of catheter?

1. There is less pain and discomfort.
2. This type of catheter is very reliable.
3. It is reasonable in cost.
4. It is specifically designed for short-term use.

Answer 3

It is specifically designed for short-term use.
**Rationale: PICC catheters are intended to be used for clients who need long-term catheter placement. It is reasonable in cost because the catheter does not need routine replacement, as do traditional peripheral IV catheters. The catheter is more comfortable for the client because there is no repeated venipuncture with catheter change. The catheter is also very reliable. It is less likely to infiltrate and can be used for administration of a number of different types of medications.
Test-Taking Strategy: Note the strategic words “indicates a lack of understanding.” These words indicate a negative event query and the need to select an incorrect client statement. The words “short-term” in option 4 will direct you to this option. Review the characteristics of a PICC catheter if you had difficulty with this question.

Question 4

A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The licensed practical nurse (LPN) inspects the site and determines that the client has developed phlebitis. The LPN would plan to avoid which of the following actions in the care of this client?

1. Prepare to apply warm moist packs to the site.
2. Prepare to start a new line in a proximal portion of the same vein.
3. Prepare to discontinue the IV catheter at that site.
4. Notify the registered nurse (RN).

Answer 4

Prepare to start a new line in a proximal portion of the same vein.
**Rationale: As directed, the LPN should discontinue the IV at the phlebitic site and apply warm moist compresses to the area to speed resolution of the inflammation. Because phlebitis has occurred, the LPN also notifies the RN, who will contact the physician about the IV complication. The LPN should prepare for restarting the IV in a vein other than the one that has developed phlebitis.
Test-Taking Strategy: The strategic word in this question is “avoid.” This tells you that the correct option is an incorrect nursing action. Noting that the client has phlebitis and recalling the pathophysiology associated with phlebitis will direct you to option 2. Review nursing interventions related to phlebitis if you had difficulty with this question.

Question 5

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 15:00. The nurse, making rounds at 15:45, finds that the client is complaining of a pounding headache, is dyspneic with chills, is apprehensive, and has an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which of the following actions first?

1. Sit the client up in bed.
2. Place the client in Trendelenburg’s position.
3. Shut off the infusion.
4. Discontinue the angiocatheter and IV.

Answer 5

Shut off the infusion.
**Rationale: The client’s symptoms are compatible with speed shock. This may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action of the nurse from the options presented is to shut off the infusion. The nurse may elevate the head of the bed to aid the client’s breathing. Placing the client in Trendelenburg’s position is not an appropriate action. The registered nurse is notified immediately, who then contacts the physician. The angiocatheter does not need to be removed. It may be needed to treat this complication.
Test-Taking Strategy: To answer this question accurately you must be able to recognize signs of speed shock and recall the appropriate interventions. Also note the strategic word “first.” This tells you that more than one or all of the options are likely to be correct actions, and you must prioritize them according to a time sequence. Focusing on the data and recognizing that the client is experiencing speed shock will direct you to option 3. Review the immediate nursing actions related to speed shock if you had difficulty with this question.

Question 6

A nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which of the following is the appropriate action by the nurse?

1. Wipe the tubing port with povidone-iodine.
2. Scrub the needleless device with an alcohol swab.
3. Attach a new needleless device.
4. Change the IV tubing.

Answer 6

Change the IV tubing.
**Rationale: The nurse should change the IV tubing because it has become contaminated and could cause systemic infection to the client. Wiping the port with povidone-iodine is insufficient and would be contraindicated regardless, because the catheter will be attached directly to an angiocatheter in the client’s vein. The needleless device has not been contaminated and does not need replacement or cleansing.
Test-Taking Strategy: Use knowledge of basic infection control measures and intravenous therapy concepts to answer this question. Noting that the nurse has contaminated the IV tubing will direct you to option 4. Review aseptic technique if you had difficulty with this question.

Question 7

A nurse enters a client’s room to check the client who began receiving a blood transfusion 45 minutes earlier. The client is flushed and dyspneic. The nurse listens to the client’s lung sounds and notes the presence of crackles in the lung bases. The client states that she was just going to ring the call bell for the nurse. The nurse determines that this client is most likely experiencing which of the following complications of blood transfusion therapy?

1. Hypovolemic shock
2. Transfusion reaction
3. Fluid overload
4. Bacteremia

Answer 7

Fluid overload
**Rationale: An allergic reaction, which is one type of blood transfusion reaction, would produce symptoms such as flushing, dyspnea, itching, and a generalized rash. With fluid overload, the client has the presence of crackles in the lungs in addition to dyspnea. With bacteremia, the client would have a fever, which is not part of the clinical picture presented. Hypovolemic shock (restlessness, increased pulse, decreased blood pressure) is not likely to occur in a client receiving fluids.
Test-Taking Strategy: Focus on the data in the question and the fact that the client is receiving a blood transfusion. This will assist in directing you to option 3. Review the complications of blood transfusion therapy if you had difficulty with this question.

Question 8

A nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells. Before leaving the room, the nurse tells the client that it is most important to immediately report which of the following signs if they occur?

1. Fatigue
2. Nausea
3. Headache
4. Backache

.

Answer 8

Backache
**Rationale: The nurse should instruct the client to immediately report signs of a transfusion reaction, which can include a backache among other signs such as chills, itching, or rash. These signs of transfusion reaction would require the nurse to stop the transfusion. Fatigue, headache, and nausea are not specifically related to transfusion reaction; however, if these occur, the nurse should investigate their cause.
Test-Taking Strategy: Note that the strategic words in the question are “most important” and “immediately.” This tells you that more than one or all of the options may be partially or totally correct. Knowing that a transfusion reaction is a concern when a client receives a blood transfusion and recalling the manifestations of a reaction will direct you to option 4. Review the signs of a transfusion reaction if you had difficulty with this question