questions with multiple
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,A client has a continuously running peripheral infusion. Answer: 3,4, 5
The physician orders an antibiotic as a piggyback
infusion four times per day. In order to administer the
antibiotic, the nurse should do which of the following?
Select all that apply.
1. Avoid compatibility issues by starting an additional IV
access.
2. Start a new IV access to eliminate the problem of too
much volume for one site.
3. Flush the IV line before and after infusion of an
incompatible drug.
4. Check to see if the antibiotic is compatible with the
continuous infusion.
5. Change the flow rate to facilitate the administration of
the antibiotic.
The family of a home infusion client calls the home Answer 3, 5
health nurse one night to report that the electronic
infusion pump is alarming. What should the nurse
anticipate as the cause of the infusion pump alarming?
Select all that apply.
1. The client's pulse and blood pressure are falling.
2. The client is experiencing a reaction to the medication.
3. The prescribed infusion is complete.
4. There is an incompatibility with the medications.
5. An occlusion has interrupted the infusion.
The home health nurse is monitoring a client who Answer 1
performs self- care of a central line. The nurse observes
the client doing all of the following activities. Which
activity indicates the need for further education?
1. Flushing the central line with a 3 mL syringe
2. Cleaning the needleless injection cap with alcohol
before accessing
3. Using sterile gloves to change the central line dressing
4. Wearing a mask while changing the central line
dressing
The client has a tunneled Groshong catheter for Answer 3
intermittent medication administration. After
administering the medication, the nurse prepares to do
which of the following?
1. Clamp the catheter after medication administration.
2. Flush the catheter with heparin at scheduled times.
3. Flush the catheter with saline after medication
administration.
4. Initiate a Valsalva maneuver when disconnecting
medication tubing.
The client has a percutaneous jugular central venous line Answer 1
that is capped and used for intermittent infusions. After
administering the medication, the best method to
maintain patency is to do which of the following?
1. Flush the line first with 3- 5 mL of normal saline, then
with 1- 3 mL of heparinized normal saline.
2. Flush the line with 3- 5 mL of normal saline.
3. Flush the line with 3- 5 mL of heparinized normal
saline.
4. Flush the line first with 3- 5 mL of heparin, then with 1-
3 mL of normal saline.
The nurse is caring for a client with a Hickman central Answer 4
line. While changing the central line dressing, the nurse
notes that the injection cap ( e. g., heplock adapter) is of
the slip lock variety instead of a luer lock device. The
nurse recognizes that this adapter puts the client at risk
for which complication?
1. Sepsis
2. Occlusion
3. Phlebitis
4. Air embolism
,The client is to receive the intravenous medication Answer 3
vancomycin ( Vancocin). To prevent adverse reactions
from rapid infusion, by what method should the nurse
plan to administer this drug?
1. Using gravity
2. With a regulator
3. Electronic infusion pump
4. Elastomeric pump
The physician is going to order a hypotonic intravenous Answer 4
solution for a client with cellular dehydration. The nurse
would expect which fluid to be administered?
1. 0.9% normal saline
2. 5% dextrose in normal saline
3. Lactated Ringer's solution
4. 0.45% sodium chloride
The nurse is caring for several clients with central Answer 1
venous catheters. While changing the tubing on the
central lines, the nurse would not need to instruct the
client to perform Valsalva maneuver when the client has
which catheter?
1. Groshong
2. Single- lumen
3. Percutaneous
4. Accessed subcutaneous venous port
The client is receiving 5% dextrose in 0.45% sodium Answer 3
chloride. The physician has ordered the client receive
one unit of packed cells. Prior to hanging the blood, the
nurse will prime the blood tubing with which solution?
1. 5% dextrose
2. Lactated Ringer's
3. 0.9% sodium chloride
4. 5% dextrose in 0.45% sodium chloride
While assessing a client's intravenous ( IV) line, the Answer 1
nurse notes that the area is swollen, cool, pale, and
causes the client discomfort. What complication should
the nurse document?
1. Infiltration
2. Phlebitis
3. Infection
4. Air embolism
The client is receiving 5% dextrose and 0.45% sodium Answer 2,5
chloride intravenously and is complaining of pain at the
IV site. The nurse assesses the site and notes erythema
and edema. What is the appropriate action for the nurse
to take? Select all that apply.
1. Slow the infusion to a keep- open rate.
2. Discontinue the IV and apply a warm compress to the
IV site.
3. Apply antibiotic ointment to the IV site.
4. Gently pull back on the IV catheter to attempt
repositioning.
5. Relocate the IV site and document the event.
The nurse is preparing to start a peripheral intravenous ( Answer 2
IV) line in a client. The client's record indicates a latex
allergy. What action should be taken by the nurse?
1. Utilize a new tourniquet for this client.
2. Use a blood pressure cuff to distend the vein.
3. Avoid putting povidone iodine on the skin.
4. Initiate a latex- free alternative therapy.
The nurse is inserting an intravenous ( IV) line into a cli- Answer 2
ent. After piercing the skin and entering the vein, what
manifestation should cause the nurse to refrain from
advancing the catheter?
1. Blood backflow into the IV catheter
2. Mild resistance with advancement
3. No reports of client discomfort
4. IV catheter was inserted bevel side up
, The nurse is inserting a peripheral intravenous ( IV) line. Answer 5,3,1,2,4
Place the following steps in order to perform this
procedure correctly.
1. Apply a tourniquet above insertion site.
2. Insert catheter at 5- 15 degree angle through skin.
3. Select a vein and cleanse the skin.
4. Attach tubing primed with IV solution.
5. Gather the appropriate equipment.
The nurse would perform which action when washing Answer 4,5
hands as part of medical asepsis before caring for a
client in an outpatient clinic? Select all that apply.
1. Wash hands with the hands held higher than the
elbows.
2. Adjust temperature of water to the hottest possible.
3. Scrub hands and nails with a scrub brush for 5
minutes. 4. Use a clean paper towel to turn water off.
5. Rub vigorously using firm circular motions.
The nurse's forearm becomes splattered with blood while Answer 4
inserting an intravenous catheter. What action should the
nurse take?
1. Wash blood away with isopropyl alcohol.
2. Wipe blood away with a tissue.
3. Flush forearm with hot water, letting water flow from
elbow toward fingers.
4. Wash forearm with soap and water.
The nurse would take which action to protect the client Answer 2
from infection at the portal of entry?
1. Place sputum specimen in a biohazard bag for
transport to the lab.
2. Empty Jackson- Pratt drain using sterile technique.
3. Dispose of soiled gloves in waste container.
4. Wash hands after providing client care.
Which actions by the nurse comply with core principles Answer 2,4
of surgical asepsis? Select all that apply.
1. Wash hands before and after client care.
2. Keep sterile field in view at all times.
3. Wear personal protective equipment.
4. Add contents to sterile field holding package 6 inches
above field.
5. Consider outer 1.5 inches of sterile field as
contaminated.
Which precaution would the nurse implement when Answer 2
admitting a client with herpes zoster to the nursing unit?
1. Airborne precautions
2. Contact precautions
3. Droplet precautions
4. Neutropenic precautions
A client with tuberculosis asks the nurse if visitors will Answer 1
need to wear masks. What response by the nurse is
most accurate?
1. " Everyone who enters your room must wear a mask
to protect themselves from tuberculosis."
2. " Masks would not be necessary for visitors who have
had tuberculosis before."
3. " It is less important for your family to wear masks,
since they live in close contact with you."
4. " Only visitors who are at risk for tuberculosis need to
wear a mask."
The nurse is leaving the room of a client who has Answer 2, 3, 4, 1
methicillin- resistant Staphylococcus aureus ( MRSA)
microorganisms in a wound and the urine. Place the
following personal protective equipment in order of
removal.
1. Eye protection
2. Gloves
3. Mask
4. Gown