Unit 2 review

Question 1

The client is diagnosed with dehydration the nurse knows the client will need restoration of

Answer 1

electrolytes

Question 2

a severely malnourished client has been admitted to health care facility, the nurse is preparing to administer a total TPN solution into

Answer 2

superior/inferior vena cava

Question 3

a nurse needs to select a vena puncture site to administer a prescribed amount of iv fluid to a client the nurse looks for a large vein while using a needle with a large gauge what explains the nurses action

Answer 3

to prevent compromising circulation

Question 4

a client who was involved in an accident is bleeding very heavily what would be required to replace the circulating blood

Answer 4

colloid solution

Question 5

a client has been brought to health care facility c/o diarrhea and vomiting the nurse caring for the client knows the client should be administered

Answer 5

hypotonic solution

Question 6

A nurse needs to give an accurate fluid output assessment on a client with sever diarrhea
which action should the nurse preform?

Answer 6

Weight client’s wet linen or dressing

Question 7

A nurse is required to initiate IV therapy for a client which should the nurse consider
before starting the IV?

Answer 7

That the medication is clean and transparent, not expired

Question 8

The physician has asked the nurse to use a micro drip tubing to administer a prescribed
dosage of IV solution to a client what is the standard drop factor of micro drip tubing?

Answer 8

60gtt/min

Question 9

a client with dehydration is being administered IV fluids during rounds the nurse notices
the skin around the iv site was reddish and inflamed the nurse recognizes that what phenomime is likely responsible?

Answer 9

Phlebitis

Question 10

a nurse is caring for a client with Phlebitis the nurse notices the client’s forearm which
has the tubing has become red and slightly warm which action should the nurse preform
to prevent further complications?

Answer 10

Stop infusion

Question 11

When administering IV solution the nurse ensures the solution is placed at least those 18
to 24 inches above the side of infusion for which reason should the nurse maintain this
position for the IV solution?

Answer 11

Overcome pressure within the client’s veins

Question 12

the nurse works at an agency that automatically places certain clients on an intake and output for which client will the nurse document all I&O?

Answer 12

A 55-yr old on
furosemide(diuretic)

Question 13

the nurse is teaching a nursing student how to record strict IO for a client who wears
adult absorbent undergarments which nursing teaching is appropriate?

Answer 13

Weigh wet
undergarment subtract weight of similar dry item and fluid loses based on
1LB=1pint=475ml

Question 14

the nurse is caring for a client who is in a motor vehicle accident and has had several
severe cerebral edema which fluids does the nurse anticipate infusing?

Answer 14

Hypertonic

Question 15

The nurse is caring for a client whose blood type is B negative which blood donor type
does the nurse confirm his compatible for this client?

Answer 15

B negative and O negative
(universal donor)

Question 16

the nurse is monitoring a blood transfusion for a client with anemia so 5 minutes after the transfusion begins the client reports feeling short of breath and itchy which action should the nurse take?

Answer 16

Stop the infusion first then notify pcp

Question 17

A client is diagnosed with hypovolemia after a significant blood loss which action will
the nurse take?

Answer 17

Start IV normal saline as prescribed.

Question 18

The nurse is performing an assessment for an older adult client admitted with dehydration
where would you assess skin turgur on this patient?

Answer 18

Sternum

Question 19

The nurse is caring for a client undergoing IV the nurse knows that IBM administration
of medication is appropriate in which solution?

Answer 19

When a client has disorders that affect
the absorption of the medication.

Question 20

The nurse is using an Iv port when administering medication to the client which Iv administration has the greatest potential to cause life threatening changes?

Answer 20

Bolus

Question 21

A nurse is accessing a clients Hickman catheter in order to administer prescribed IV medication the nurse knows that these tunneled catheters help the client which of the following ways?

Answer 21

Helps stabilizes and reduces risk of infection

Question 22

An Iv push and which way is this medication being administered?

Answer 22

Bolus

Question 23

if a pt has a triple lumen central venous catheter and action that a nurse should perform to
maintain patency of all the unused lumens, what should she or he do?

Answer 23

Flush them with
saline to make sure they still work

Question 24

When performing a piggyback infusion, the nurse lowers the container of the primary solution approximately 10 inches or 25 centimeters below the height of the secondary solution which reason explains the nurse’s action?

Answer 24

Uses gravity to infuses secondary
infusion

Question 25

So, a nurse is providing care for an elderly client whose analgesia has been ordered by an IV route while reviewing the client’s medication ministration record the nurse observes that the dosage change differs from those of most younger adult clients what is most likely the rationale for the difference between the older adult and the younger adults dosage?

Answer 25

The older adult is more susceptible to the drug than the younger adult

Question 26

When instilling Iv medications you?

Answer 26

Flush before the meds and after

Question 27

The client is receiving three different IV medications 2 of the medications are not compatible with each other which type of access is most appropriate for this client?

Answer 27

A seven French triple lumen catheter

Question 28

A nursing student is teaching the client regarding insertion of a central line catheter which statement by the student would cause the nurse to intervene?

Answer 28

The risk are the same for both

Question 29

The nurse is providing discharge teaching for an older adult with arthritis who has also has an implanted catheter which care does the nurse anticipate the client will need to provide catheter care?

Answer 29

At home care/home health

Question 30

the nurse has inserted a peripheral IV catheter into a client what is the appropriate action when blood return is not obtained?

Answer 30

Change site of insertion

Question 31

Fluid output as the sum of liquid eliminated from the body of this total amount such as

Answer 31

including urine, emesis(vomitus), blood loss, diarrhea, would or tube drainage and aspirated irrigations

Question 32

When a nurse monitors a client receiving a blood transfusion which is the most indicative that the client is experiencing a transfusion reaction during the 1st 15 minutes of the infusion?

Answer 32

the clients BP becomes low

Question 33

When preparing IV solutions always make sure the solution is

Answer 33

transparent and clear of particles and not expired inspect

Question 34

a recent nursing graduate who now works on acute medicine unit administers many Iv medication to clients on the unit the nurse is vigilant when checking the five rights of safe medication administration because any medications carry a higher possibility of what nursing diagnosis?

Answer 34

Risk of injury

Question 35

What characteristics should a nurse take into consideration when selecting a venipuncture site?

Answer 35

to prevent compromising circulation. any scars, lesions, inflammation, edema, or hematomas (blood that has seeped within tissue) in either arm, has had a previous mastectomy, or has a fistula for kidney dialysis. Puncturing a vein with an injury or a vascular purpose creates a potential for infection, further compromises circulation

Question 36

Know when to remove a secondary solution from refrigeration:

Answer 36

at least 30 minutes before instilling, to warm up medication to room temperature

Question 37

A volume-control set

Answer 37

is used to administer IV medication in a small volume of solution at intermittent intervals and to avoid accidentally overloading the circulatory system.

Question 38

The choice depends on the type of container in which the solution is packaged.

Answer 38

Vented tubing is necessary for administering solutions packaged in rigid glass containers.

Question 39

define phlebitis

Answer 39

inflammation of the vein

Question 40

define thrombus formation

Answer 40

a stationary blood clot

Question 41

define pulmonary embolus

Answer 41

a blood clot that travels to the lung

Question 42

define air embolism

Answer 42

a bubble of air traveling within the vascular system

Question 43

explain the nurses action when performing a piggyback infusion

Answer 43

uses gravity to infuse the secondary medication/infusion