Kilgore College NURSING 1429041 MODULE 8 EXAM QUESTIONS AND ANSWERS

Module 8: Exam 1. A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. On the basis of this assessment, the nurse should take which action first? o Remove the IV catheter o Slow the rate of infusion o Notify the health care provider o Check for loose catheter connections 2. A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned client. One hour later the client complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse. The IV bag has 100 mL remaining. Which action should the nurse take first? o Remove the IV o Sit the client up in bed o Shut off the IV infusion o Slow the rate of infusion 3. A nurse discontinues an infusion of a unit of packed red blood cells (RBCs) because the client is experiencing a transfusion reaction. After discontinuing the transfusion, which action should the nurse take next? o Remove the IV catheter o Contact the health care provider o Change the solution to 5% dextrose in water o Obtain a culture of the tip of the catheter device removed from the client 4. The nurse determines that the client is exhibiting signs of a hemolytic transfusion reaction while receiving a blood transfusion. The nurse should perform these actions in which priority order? Arrange the actions in the order that they should be performed. All options must be used. Correct o Stopping the infusion of blood o Hanging an IV bag of normal saline solution (NS) at a keep-vein-open (KVO) rate o Notifying the health care provider o Obtaining vital signs/oxygen saturation o Documenting the findings 5. A client with heart failure is being given furosemide and digoxin. The client calls the nurse and complains of anorexia and nausea. Which action should the nurse take first? o Administer an antiemetic o Administer the daily dose of digoxin o Discontinue the morning dose of furosemide o Check the result of laboratory testing for potassium on the sample drawn 3 hours ago 6. The health care provider (HCP)prescribes the administration of total parenteral nutrition (TPN), to be started at a rate of 50 mL/hr by way of infusion pump through an established subclavian central line. After the first 2 hours of the TPN infusion, the client suddenly complains of difficulty breathing and chest pain. The nurse should take which immediate action? o Obtain blood for culture o Clamp the TPN infusion line o Obtain an electrocardiogram (ECG) o Obtain a sample for blood glucose testing 7. The health care provider prescribes 2000 mL of 5% dextrose and normal saline 0.45% for infusion over 24 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number). o 21 8. A nurse is assessing a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the insertion site. What should the nurse do first? o Remove the IV o Apply a warm compress o Check for blood return o Measure the area of infiltration 9. A home care nurse has been assigned a client who has been discharged home with a prescription for total parenteral nutrition (TPN). Which parameters does the nurse plan to check at each visit as a means of identifying complications of the TPN therapy? Select all that apply. o Weight o Glucose test o Temperature o Peripheral pulses o Hemoglobin and hematocrit 10. A nurse is caring for a group of adult clients on an acute care nursing unit. Which clients does the nurse recognize as the most likely candidates for total parenteral nutrition (TPN)? Select all that apply. o A client with pancreatitis o A client with severe sepsis o A client with renal calculi o A client who has undergone repair of a hiatal hernia o A client with a severe exacerbation of ulcerative colitis Rationale: TPN is indicated in the client whose gastrointestinal tract is not functional or who cannot tolerate an enteral diet for extended periods. The client with sepsis is very ill and may require TPN. Other candidates include clients who have undergone extensive surgery, sustained multiple fractures, or have advanced cancer or AIDS. The client who has undergone hiatal hernia repair is not a candidate, because this client would resume a normal diet within a relatively short period after the hernia repair. The client with renal calculi also is not a candidate because the client would be able to eat. 11. A client with a peripheral intravenous (IV) line in place has a new prescription for infusion of total parenteral nutrition (TPN), a solution containing 25% glucose. Which action should be taken by the nurse? o Hanging the IV solution as prescribed o Questioning the health care provider about the prescription o Diluting the solution with sterile water to half-strength o Hanging the IV solution but setting the infusion at just half the prescribed rate Rationale: TPN solutions containing as much as 10% glucose can be infused through peripheral vessels. A TPN solution containing 25% glucose is hypertonic. The nurse should question the prescription in the absence of a central venous catheter or a peripherally inserted central catheter. Diluting the solution with sterile water to half-strength and hanging the IV solution as prescribed are both inappropriate. The nurse must not alter a prescribed solution independently. 12. The first bag of total parenteral nutrition (TPN) solution has arrived on the clinical unit for a client beginning this nutritional therapy. The solution is to be infused by way of a central line. Which essential piece of equipment should the nurse obtain before hanging the solution? o Pulse oximeter o Blood glucose meter o Electronic infusion device o Noninvasive blood pressure monitor 13. A nurse is monitoring a client who is receiving total parenteral nutrition (TPN). Which t signs and symptoms causes the nurse to suspect that the client is experiencing hyperglycemia as a complication? o Pallor, weak pulse, and anuria o Nausea, vomiting, and oliguria o Nausea, thirst, and increased urine output o Sweating, chills, and decreased urine output 14. At 1600 the nurse checks a client’s total parenteral nutrition (TPN) infusion bag and notes that the solution is running at a rate of 100 mL/hr. The bag was hung the previous day at 1800. The nurse plans to change the infusion bag and tubing this evening at what time? o 1700 o 1800 o 2000