A patient is scheduled for a transfusion of red blood Cells, before sending for the blood, the nurse ensures the patient is ready by completing which of the following actions?
Checking that IV access is ready and patent
Verifying that the patient has signed a consent for the blood transfusion
Checking that the physician has written an order for the transfusion
All of the above.
An IV solution which is isotonic means*
Fluid shifts from ECF into ICF
There is no shift in body fluids
Fluid shifts from ICF to ECF
Osmolality is less than body fluids
Which of the following fluids is used to prime the line when preparing a blood Transfusion?
2.2% dextrose and 0.3% saline
5% dextrose and Water
0.9% Sodium chloride
Which of the following would the nurse draw up pior to flushing the saline lock? *
The volume specified by policy of 0.9% sodium chloride into a 3mL syringe
The volume specified by policy of heparin into a 10mL syringe
The volume specified by policy of 0.9% saline into a 10mL syringe
The Volume specified by policy of heparin into a 3mL syringe
Where can red blood cells be stored? *
Blood transfusion laboratory Fridge
Medication fridge if only for a short time
None of the above
Which of the following would pose a risk to a patient with a central line?
The process for changing an IV bag includes which of the following *
Opening the roller clamp completely to allow fluid through
Checking the IV bag with the physician’s order
Ensuring a pressure dressing is in close proximity
Grasping the IV port firmly with the dominant hand
Which of the following can cause hemolysis of transfused blood?
None of the above
All of the above
Using an IV access Y’ed with an incompatible solution
Transfusion incompatible blood
Using an IV access that is too small when transfusing rapidly
The Nurse begins transfusing a patient at 0900. It is now 1300 and only ½ of the blood is transfused. What should the nurse do?
Stop the transfusion and document that the patient only receives a partial unit.
Continue the transfusion cautiously with more frequent assessments
Elevate the IV pole to increase the flow
Dilute the unit with saline to decrease the viscosity so that the blood will flow more easily.
The following are all symptoms of septicemia expect which?
Distended neck veins
The universal blood recipient has the blood type
AB – correct.
A patient has called complaining of burning and tenderness at the IV site. Upon assessment of the site, the nurse notes redness, swelling and a thin red line as the inflammation follows the path of the vein. What would the nurse suspect?
A medication is prescribed for the client, and it is to be administered by IV. The patient has a continuous intravenous (IV) running. Which of the following Is a priority for the nurse before administering the medication via this route? *
Set the rate of the IV infusion
Determine the amount of IV fluid to be administered
Check the client’s mental alertness.
Confirm patency and assessment of the IV site.
A 17-year-old female is admitted to Emergency after being hit by a car. She requires an immediate red blood cell transfusion for active bleeding before her blood group can be determined. Which blood group is appropriate for this patient?
Group AB negative
Any blood group is appropriate in this urgent situation
Group O negative
Group O positive
A client complains of a headache, nausea and vomits during a blood transfusion. Which of the following actions should the nurse take immediately?
Check the client’s vital signs
Stop the blood transfusion
Slow down the rate of the blood flow
Notify the physician and blood bank personnel.
The nurse needs to replace the almost empty bag of DSW IV solution. Which bag should she pick? *
3.3% Dextrose & 0.3% saline
0.9% Sodium Chloride
5% Dextrose & Water
Shortly after hanging a premixed IV mini bag of Cipro, a patient informs the nurse that she has noticed red spots all over her abdomen. What should the nurse do?
Change both line sets (possible contamination)
Stop the infusion and notify the physician
Decrease the IV rate and continue to monitor
Inform the patient that a rash could be expected but you are only concerned the rash gets itchy.
The doctor has ordered morphine sulfate 2-4mg IV q3h. Which site should be used?
Your patient’s platelets transfusion has just finished. Suddenly he says he can’t breathe and collapses in his chair. Which type of acute transfusion reaction can present with dyspnea?
Febrile non- hemolytic
Transfusion related acute lung injury.
The client’s hemoglobin is low after surgery. Which of the following blood products the physician would most likely order? *
Packed red blood cells
What is the correct angle to inject into the skin when using an insulin pen?
It doesn’t matter.
Your patient requires 0.8mL solution for an IM injection. Which of the following is an accurate statement? *
Z-track technique is not required for small-volume IM injections
A 3mL syringe would be the most appropriate choice
Dorsogluteal is the preferred site for the IM injections
This volume of medication is appropriate for the IM injection.
The nurse is evaluating the integrity of the ventrogluteal injection site. The nurse finds the site by locating which anatomical landmarks?
Anterior aspect of the upper thigh
Middle third of the lateral thigh
Acromion process and axilla
Greater trochanter, anterior iliac spine, and iliac crest.
The client is to receive a Mantoax test for tuberculosis. The test is administered via an intradermal injection. Which of the following is the correct angle of the injection?
The nurse is preparing to administer a subcutaneous injection. Which of the following technique is correct?
Administer in the deltoid muscle. 3 fingers below the acromion process.
Administer in subcutaneous abdominal tissue, ensuring to aspirate prior to injection
Administer at a 90-degree angle in most adults
Administer in tissue with edema or nodules, provided there is no bruising.
Which statement is correct regarding a subcutaneous lock? *
Subcutaneous lock may be used for intermittent medication administration
Subcutaneous lock is ideal for clients with edema, coagulation disorders/ pod peripheral circulation.
Subcutaneous lock is inserted directly into a vein
Subcutaneous lock must be flushed q shift
What is the most common cause of medication error?
Insufficient drug knowledge
Failure to follow the rights of medication administration
An error in the transcription of the doctor’s order
A dispensing error in pharmacy.
The nurse administers IM ceftriaxone using the Z track Method. Why was this method used?
To provide a more even absorption of the drug
To reduce discomfort from the needle
To prevent the drug from irritating sensitive tissue
To provide faster absorption of the medication.
In order to safely administer enteral medications, the nurse would do which of the following? *
Hold all medications if the residual was less than 150mL
Flush the tube after each medication administered
Check for the tube placement only if the client has a history of placement problems
Mix the medications with the clients prescribed feeding formula.
The nurse is administering a metered – dose inhaler to a patient using a spacer. The nurse instructs the patients to exhale completely and then depresses the medication chamber. How long does the nurse instructs the patient to inhale deeply and slowly through the mouth before holding the breath for the 10 second? *
The patient has a prescription for a medication that is administered via an inhaler. Which of the following will allow the nurse to determine whether the patient requires a spacer for the inhaler?
The coordination of the patient
The dosage of the medication required
The schedule of administration
The use of a dry powder inhaler
Which of the following is not an advantage of using a spacer device such as an “Aerochamber” when administering inhaled medications via an MDI? *
Spacers allow patients to administer partial doses of inhaled medication
Spacers improve the drug’s absorption in the patient’s airway
Spacers allow medication particles to slowly reach the patients and break down into smaller pieces.
Spacers provide benefit to patients who have difficulty coordinating the stem involved in administering inhaled medications.
How long is it recommended to depress the dose button on as insulin pen after the insulin is injected into the skin? *
The student realizes this may lead to which of the following complications? *
Pain at the site
Mrs James Case study
The client is on continuous IV therapy and has a 1000mL bag of 2/3 and 1/3 infusing at the rate of 125mL/hr as per report received at 0700hrs. the student nurses assesses the IV q1 hour. When he assesses the IV at 1100hr, he is shocked to discover the IV and empty and it should have 600mL left in it.
The first action the student should take is
Go find the practicum teacher
Let the co-assigned nurse know
Increase the rate of the IV
Assess the client.
Which of the following is an important nursing assessment in this situation?
Level of mobility
Change in speech
Mr Bubbles case study
My bubble has a continuous IV in his right forearm with 1000mL of Ringers’ Lactate running at 125mL/hr
The Iv bag is reading 350mL TBA at 0700 hr. when would be the best time to hang a new bag? *
The client is on restricted fluids because of a kidney problem. The client needs analgesic for his medications. The physician has ordered the IV to be TKVO. Which of the following would be an appropriate specific rate for TKVO?
Surrounding the IV site, the skin is edematous, cold, and pale. Which nursing action would reduce his discomfort and edema?
Slow the rate of infusion, raise the head of the bed.
Apply ice packaged in a disposable glove to the affected area
Elevate his arm and wrap it in a warm towel for 20 min
Slow IV and apply a pressure dressing
When administering a transfusion, why should the blood be initially started slowly?
To allow the patient time to become less anxious
To prevent pain at the IV site
To prevent fluid overload
To detect transfusion reactions and intervene early before too much blood is transfused.
please I would like to know the answers for these questions thank you 🙂
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