Critical Care Nursing NCLEX
F (TPN lines should only be used for the administration of TPN solution to prevent crystalization of the
CVC tubing and disruption of the TPN infusion. Any other IV med must be administered via different IV
access site) - T/F A client receiving TPN via a CVC is scheduled to receive an IV antibiotic. The nurse
should check for compatibility, turn off the TPN for 30 min, & flush the line w/ NS.
blood glucose (Clients receiving TPN are at risk for hyperglycemia related to the high concentration of
dextrose in the solution - usually composed of 10% or more dextrose in water!) - A client receiving TPN
complains of N, excessive thirst, and increased frequency of voiding. The nurse should initially assess
which client data?
D5W - lidocaine IV (a concentrated sln) must be diluted with:
immerse the chest tube in a bottle of sterile water (to reestablish an underwater seal to prevent tension
pneumo and mediastinal shift.) - If a chest tube accidentally disconnects from the tubing of the drainage
apparatus, the nurse should first
tension pneumo - Clamping the chest tube could cause ____
clamp the catheter (to prevent further air entry) & place the client in lateral Trendelenburg (to trap air
in the RA), then notify HCP - A client with a CVC who is receiving TPN suddenly becomes SOB; c/o CP;
and is tachycardic, pale, and anxious. The nurse, suspecting an air embolism, what do you do next?
obtain v/s (determine whether client is in hypovolemic shock from blood loss & to obtain baseline by
which to monitor progress of tx) - A client arrives at the ED with upper GI bleeding. What is the
*priority* action?
Serum carboxyhemoglobin levels (most direct measure of CO poisoning); hyperbaric O2 @ 100% -
What should the RN monitor to check for the presence of carbon monoxide poisoning? What type of O2
do we administer?
, place client on continuous cardiac monitoring - The nurse admits a client with MI to the CCU. What
should the RN plan to do in delivering care to this client?
return bag to blood bank (gas bubbles could indicate possible contamination) - The nurse checks a unit
of blood received from the blood bank and notes the presence of gas bubbles in the bag. What should
the RN do?
20-gauge (or larger to prevent addt'l hemolysis of RBC & prevent occlusion) - What is the smallest
gauge the nurse can administer blood through?
serum electrolyte levels (used to determine effectiveness of sln, make changes as necessary, and
decrease client's risk of fluid & electrolyte imbalances) - Which is the most important lab result for the
RN to present to the HCP for a pt receiving TPN?
10% dextrose (minimizes chance of client becoming hypoglycemic) - If a TPN sln bag becomes empty,
the RN should hang an infusion of _____ until another bag of TPN is available.
T (abrupt d/c can result in hypoglycemia**) - T/F The flow rate of a TPN infusion should be decreased
gradually when d/c the solution.
BG q 4-6 h - A client has TPN initiated per HCP's prescription at 75 mL/hour. What should the RN caring
for the client plan to monitor?
evening (to allow client maximal daytime freedom) - An ambulatory client will be receiving a 16-hour
cyclical TPN infusion at home. When is the best time for the nurse to initiate the infusion?
air or thromboembolism, clamp the infusion - Complication associated with subclavian central lines;
s/sx- sudden onset of CP shortly after initiation of TPN; first action?
1.2 micron (blue, for lipids) - When administering TPN containing fat emulsion, the RN must ensure that
_______ is being used during administration.
perform the Valsalva maneuver - The client should be asked to _______ during tube changes.
F (TPN lines should only be used for the administration of TPN solution to prevent crystalization of the
CVC tubing and disruption of the TPN infusion. Any other IV med must be administered via different IV
access site) - T/F A client receiving TPN via a CVC is scheduled to receive an IV antibiotic. The nurse
should check for compatibility, turn off the TPN for 30 min, & flush the line w/ NS.
blood glucose (Clients receiving TPN are at risk for hyperglycemia related to the high concentration of
dextrose in the solution - usually composed of 10% or more dextrose in water!) - A client receiving TPN
complains of N, excessive thirst, and increased frequency of voiding. The nurse should initially assess
which client data?
D5W - lidocaine IV (a concentrated sln) must be diluted with:
immerse the chest tube in a bottle of sterile water (to reestablish an underwater seal to prevent tension
pneumo and mediastinal shift.) - If a chest tube accidentally disconnects from the tubing of the drainage
apparatus, the nurse should first
tension pneumo - Clamping the chest tube could cause ____
clamp the catheter (to prevent further air entry) & place the client in lateral Trendelenburg (to trap air
in the RA), then notify HCP - A client with a CVC who is receiving TPN suddenly becomes SOB; c/o CP;
and is tachycardic, pale, and anxious. The nurse, suspecting an air embolism, what do you do next?
obtain v/s (determine whether client is in hypovolemic shock from blood loss & to obtain baseline by
which to monitor progress of tx) - A client arrives at the ED with upper GI bleeding. What is the
*priority* action?
Serum carboxyhemoglobin levels (most direct measure of CO poisoning); hyperbaric O2 @ 100% -
What should the RN monitor to check for the presence of carbon monoxide poisoning? What type of O2
do we administer?
, place client on continuous cardiac monitoring - The nurse admits a client with MI to the CCU. What
should the RN plan to do in delivering care to this client?
return bag to blood bank (gas bubbles could indicate possible contamination) - The nurse checks a unit
of blood received from the blood bank and notes the presence of gas bubbles in the bag. What should
the RN do?
20-gauge (or larger to prevent addt'l hemolysis of RBC & prevent occlusion) - What is the smallest
gauge the nurse can administer blood through?
serum electrolyte levels (used to determine effectiveness of sln, make changes as necessary, and
decrease client's risk of fluid & electrolyte imbalances) - Which is the most important lab result for the
RN to present to the HCP for a pt receiving TPN?
10% dextrose (minimizes chance of client becoming hypoglycemic) - If a TPN sln bag becomes empty,
the RN should hang an infusion of _____ until another bag of TPN is available.
T (abrupt d/c can result in hypoglycemia**) - T/F The flow rate of a TPN infusion should be decreased
gradually when d/c the solution.
BG q 4-6 h - A client has TPN initiated per HCP's prescription at 75 mL/hour. What should the RN caring
for the client plan to monitor?
evening (to allow client maximal daytime freedom) - An ambulatory client will be receiving a 16-hour
cyclical TPN infusion at home. When is the best time for the nurse to initiate the infusion?
air or thromboembolism, clamp the infusion - Complication associated with subclavian central lines;
s/sx- sudden onset of CP shortly after initiation of TPN; first action?
1.2 micron (blue, for lipids) - When administering TPN containing fat emulsion, the RN must ensure that
_______ is being used during administration.
perform the Valsalva maneuver - The client should be asked to _______ during tube changes.
