Unit 2 review Flashcards
The client is diagnosed with dehydration the nurse knows the client will need restoration of
electrolytes
a severely malnourished client has been admitted to health care facility, the nurse is preparing to administer a total TPN solution into
superior/inferior vena cava
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
to prevent compromising circulation
a client who was involved in an accident is bleeding very heavily what would be required to replace the circulating blood
colloid solution
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
hypotonic solution
A nurse needs to give an accurate fluid output assessment on a client with sever diarrhea
which action should the nurse preform?
Weight client’s wet linen or dressing
A nurse is required to initiate IV therapy for a client which should the nurse consider
before starting the IV?
That the medication is clean and transparent, not expired
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?
60gtt/min
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?
Phlebitis
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?
Stop infusion
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?
Overcome pressure within the client’s veins
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?
A 55-yr old on
furosemide(diuretic)
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?
Weigh wet
undergarment subtract weight of similar dry item and fluid loses based on
1LB=1pint=475ml
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?
Hypertonic
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?
B negative and O negative
(universal donor)
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?
Stop the infusion first then notify pcp
A client is diagnosed with hypovolemia after a significant blood loss which action will
the nurse take?
Start IV normal saline as prescribed.
The nurse is performing an assessment for an older adult client admitted with dehydration
where would you assess skin turgur on this patient?
Sternum
The nurse is caring for a client undergoing IV the nurse knows that IBM administration
of medication is appropriate in which solution?
When a client has disorders that affect
the absorption of the medication.
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?
Bolus
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?
Helps stabilizes and reduces risk of infection
An Iv push and which way is this medication being administered?
Bolus
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?
Flush them with
saline to make sure they still work
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?
Uses gravity to infuses secondary
infusion
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?
The older adult is more susceptible to the drug than the younger adult
When instilling Iv medications you?
Flush before the meds and after
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?
A seven French triple lumen catheter
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?
The risk are the same for
both
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?
At home care/home health
the nurse has inserted a peripheral IV catheter into a client what is the appropriate action
when blood return is not obtained?
Change site of insertion
Fluid output as the sum of liquid eliminated from the body of this total amount such as
including urine, emesis(vomitus), blood loss, diarrhea, would or tube drainage and aspirated irrigations
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?
the clients BP becomes low
When preparing IV solutions always make sure the solution is
transparent and clear of
particles and not expired inspect
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?
Risk of injury
What characteristics should a nurse take into consideration when selecting a venipuncture
site?
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
Know when to remove a secondary solution from refrigeration:
at least 30 minutes before
instilling, to warm up medication to room temperature
A volume-control set
is used to administer IV medication in a small volume of solution at
intermittent intervals and to avoid accidentally overloading the circulatory system.
The choice depends on the type of container in which the solution is packaged.
Vented
tubing is necessary for administering solutions packaged in rigid glass containers.
define phlebitis
inflammation of the vein
define thrombus formation
a stationary blood clot
define pulmonary embolus
a blood clot that travels to the lung
define air embolism
a bubble of air traveling within the vascular system
explain the nurses action when performing a piggyback infusion
uses gravity to infuse the secondary medication/infusion
