Chapter 36. Administering Intravenous Solutions and Medications

1. The primary care provider orders an IV of 5% dextrose in normal saline (0.45% sodium chloride) to infuse over a 10-hour period. Which of the following actions should the nurse take? (Select all that apply.) a. Monitor intake and output (I&O) every shift. b. Monitor weight daily. c. Flush with heparin solution intermittently. d. Monitor lung sounds every 4 hours. e. Monitor IV site for infiltration. f. Monitor blood sugar levels. ANS: A, D, E To monitor fluid overload, it is important to assess lung sounds and I&O. Monitoring the IV site for infiltration or phlebitis is also critical. DIF: Cognitive Level: Application REF: p. 700 OBJ: Theory #3 TOP: IV Nursing Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 2. The nurse is aware that the disadvantages of infusion pumps include: (Select all that apply.) a. a saline lock is required. b. infusion pump change out every shift. c. the initial expense of machines. d. an alarm that can be deactivated by family. e. the need for special administration sets. ANS: C, D, E Infusion pumps have some disadvantages such as their initial expense, the need for special administration sets, and the fact that the alarm button sounds when the IV container is empty, when there is air in the line, and when there is an occlusion. DIF: Cognitive Level: Comprehension REF: p. 706 OBJ: Theory #3 TOP: Infusion Pumps KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk S - The Marketplace to Buy and Sell your Study Material 3. Signs that would cause the nurse to discontinue a blood transfusion would include: (Select all that apply.) a. hives. b. facial flushing. c. nosebleed. d. back pain. e. bloody colored urine. ANS: A, B, D Symptoms such as hives, facial flushing, back pain, itching, chills, apprehension, and fever are the most common reactions. Many times the primary care provider will order Benadryl for the itching or hives and allow the blood to run. DIF: Cognitive Level: Comprehension REF: p. 713 OBJ: Theory #6 TOP: Blood Reaction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk