NUR 209 FINAL EXAM 1 QUESTIONS AND ANSWERS
The nurse is documenting peripheral venous catheter insertion for a client. What does
the nurse include in the note? Select all that apply
a) Client's name and hospital number
b) Client's response to the insertion
c) Date and time inserted
d) Type and size of device
e) Type of dressing applied
f) Vein used for insertion - Answers - b, c, d, e, f(The client's ability to adapt to
interventions, such as IV insertion, should be noted when the intervention is performed.
The date and time of the insertion are important data. IV sites need to be routinely
monitored and changed at prescribed intervals per facility policy. It is important to note
the device used (often the brand name is given), as well as all specifics such as needle
or cannula length, gauge, and material (Teflon). It is necessary to describe the dressing
applied, and the vein used should be noted.The client's name and hospital number
should be on the medical record, but the nurse makes certain that the information is
recorded in the correct medical record.)
Although a check is provided at the blood bank, this is not the one that is done before
administration to the client. Clients do need to have normal saline running with blood,
but this is not considered to be part of the safety check before administration of blood
and blood products.)
The new registered nurse is giving a blood transfusion to a patient. Which statement by
the new nurse indicates the need for action by the supervising nurse?
a. "I will complete red blood cell transfusion within 6 hours."
b. "I will check the patient verification with another registered nurse."
c. "I will use normal saline solution to dilute the blood."
d. "I will remain with the patient for the first 15 to 30 minutes of the infusion." - Answers -
A
The new registered nurse is identifying a patient for blood transfusion. Which action by
the new nurse warrants intervention by the supervising nurse?
a. Checks the health care provider's order before the blood transfusion
b. Compares the hospital identification band name and number to those on the blood
component tag
c. Uses the patient's room number as a form of identification
d. Examines blood bag tag and attached tag to ensure that the ABO and Rh types are
compatible - Answers - C
The nurse is inserting an intravenous needle into an older patient for the purpose of
administering a blood transfusion. Which size needle should the nurse select?
a. 22-gauge needle
b. 20-gauge needle
c. 19-gauge needle
, d. 23-gauge butterfly needle - Answers - B
A patient is receiving a blood transfusion. Which solution does the nurse administer with
the blood?
a. Ringer's lactate
b. Normal saline
c. Dextrose in water
d. Dextrose in saline . - Answers - B
A patient is receiving a blood transfusion through a single-lumen peripherally inserted
central catheter. The patient has two other peripheral IVs: one is capped and the other
has D5 /.45 NS running at a rate of 50 mL/hr. What can be given concurrently through
the line that is selected for the blood product?
a. Normal saline
b. Piggyback of 10 mEq potassium chloride
c. Total parenteral nutrition
d. Furosemide (Lasix) 5 mg IV push - Answers - A
The nurse assessing a client's peripheral IV site obtains and documents information
about it. Which assessment data indicate the need for immediate nursing intervention?
a) Client states, "It really hurt when the nurse put the IV in."
b) The vein feels hard and cordlike above the insertion site.
c) Transparent dressing was changed 5 days ago.
d) Tubing for the IV was last changed 72 hours ago. - Answers - B(A hard, cordlike vein
suggests phlebitis at the IV site and indicates an immediate need for nursing
intervention. The IV should be discontinued and restarted at another site.It is common
for IVs to cause pain during insertion. An intact transparent dressing requires changing
only every 7 days. Tubing for peripheral IVs should be changed every 72 to 96 hours.)
The nurse is to administer a unit of whole blood to a postoperative client. What does the
nurse do to ensure the safety of the blood transfusion?
a) Asks the client to both say and spell his or her full name before starting the blood
transfusion
b) Ensures that another qualified health care professional checks the unit before
administering
c) Checks the blood identification numbers with the laboratory technician at the blood
bank at the time it is dispensed
d) Makes certain that an IV solution of 0.9% normal saline is infusing into the client
before starting the unit - Answers - b (To ensure safety, blood must be checked by two
qualified health care professionals, usually two registered nurses.Administering an
incorrectly matched unit of blood creates great consequences for the client and is
considered to be a sentinel event. It requires a great amount of follow-up and often
changing of policies to improve safety. The Joint Commission requires that the client
provide two identifiers, but they are the name and date of birth or some other identifying
data, depending on the facility; saying and spelling the name is only one identifier.
The nurse is documenting peripheral venous catheter insertion for a client. What does
the nurse include in the note? Select all that apply
a) Client's name and hospital number
b) Client's response to the insertion
c) Date and time inserted
d) Type and size of device
e) Type of dressing applied
f) Vein used for insertion - Answers - b, c, d, e, f(The client's ability to adapt to
interventions, such as IV insertion, should be noted when the intervention is performed.
The date and time of the insertion are important data. IV sites need to be routinely
monitored and changed at prescribed intervals per facility policy. It is important to note
the device used (often the brand name is given), as well as all specifics such as needle
or cannula length, gauge, and material (Teflon). It is necessary to describe the dressing
applied, and the vein used should be noted.The client's name and hospital number
should be on the medical record, but the nurse makes certain that the information is
recorded in the correct medical record.)
Although a check is provided at the blood bank, this is not the one that is done before
administration to the client. Clients do need to have normal saline running with blood,
but this is not considered to be part of the safety check before administration of blood
and blood products.)
The new registered nurse is giving a blood transfusion to a patient. Which statement by
the new nurse indicates the need for action by the supervising nurse?
a. "I will complete red blood cell transfusion within 6 hours."
b. "I will check the patient verification with another registered nurse."
c. "I will use normal saline solution to dilute the blood."
d. "I will remain with the patient for the first 15 to 30 minutes of the infusion." - Answers -
A
The new registered nurse is identifying a patient for blood transfusion. Which action by
the new nurse warrants intervention by the supervising nurse?
a. Checks the health care provider's order before the blood transfusion
b. Compares the hospital identification band name and number to those on the blood
component tag
c. Uses the patient's room number as a form of identification
d. Examines blood bag tag and attached tag to ensure that the ABO and Rh types are
compatible - Answers - C
The nurse is inserting an intravenous needle into an older patient for the purpose of
administering a blood transfusion. Which size needle should the nurse select?
a. 22-gauge needle
b. 20-gauge needle
c. 19-gauge needle
, d. 23-gauge butterfly needle - Answers - B
A patient is receiving a blood transfusion. Which solution does the nurse administer with
the blood?
a. Ringer's lactate
b. Normal saline
c. Dextrose in water
d. Dextrose in saline . - Answers - B
A patient is receiving a blood transfusion through a single-lumen peripherally inserted
central catheter. The patient has two other peripheral IVs: one is capped and the other
has D5 /.45 NS running at a rate of 50 mL/hr. What can be given concurrently through
the line that is selected for the blood product?
a. Normal saline
b. Piggyback of 10 mEq potassium chloride
c. Total parenteral nutrition
d. Furosemide (Lasix) 5 mg IV push - Answers - A
The nurse assessing a client's peripheral IV site obtains and documents information
about it. Which assessment data indicate the need for immediate nursing intervention?
a) Client states, "It really hurt when the nurse put the IV in."
b) The vein feels hard and cordlike above the insertion site.
c) Transparent dressing was changed 5 days ago.
d) Tubing for the IV was last changed 72 hours ago. - Answers - B(A hard, cordlike vein
suggests phlebitis at the IV site and indicates an immediate need for nursing
intervention. The IV should be discontinued and restarted at another site.It is common
for IVs to cause pain during insertion. An intact transparent dressing requires changing
only every 7 days. Tubing for peripheral IVs should be changed every 72 to 96 hours.)
The nurse is to administer a unit of whole blood to a postoperative client. What does the
nurse do to ensure the safety of the blood transfusion?
a) Asks the client to both say and spell his or her full name before starting the blood
transfusion
b) Ensures that another qualified health care professional checks the unit before
administering
c) Checks the blood identification numbers with the laboratory technician at the blood
bank at the time it is dispensed
d) Makes certain that an IV solution of 0.9% normal saline is infusing into the client
before starting the unit - Answers - b (To ensure safety, blood must be checked by two
qualified health care professionals, usually two registered nurses.Administering an
incorrectly matched unit of blood creates great consequences for the client and is
considered to be a sentinel event. It requires a great amount of follow-up and often
changing of policies to improve safety. The Joint Commission requires that the client
provide two identifiers, but they are the name and date of birth or some other identifying
data, depending on the facility; saying and spelling the name is only one identifier.
