NURS 618 Disease Management I,saunders medication and IV therapy questions and answers with Rationale 2022

NURS 618 Disease Management I,saunders medication
and IV therapy questions and answers with Rationale
2022

1. A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse

making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic,

experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400

mL remaining. The nurse should take which action first?

1. Slow the IV infusion.

2. Sit the client up in bed.

3. Remove the IV catheter.

4. Call the health care provider (HCP).




Answer:

1. Slow the IV infusion.




Rationale:

The client's symptoms are compatible with circulatory overload. This may be verified by noting that 600

mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other

actions may follow in rapid sequence. The nurse may elevate the head of the bed to aid the client's

breathing, if necessary. The nurse also notifies the HCP. The IV catheter is not removed; it may be

needed for the administration of medications to resolve the complication.




2. The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with

NURS 618 Disease Management I,saunders medication
and IV therapy questions and answers with Rationale
2022

,NURS 618 Disease Management I,saunders medication
and IV therapy questions and answers with Rationale
2022
20 mEq of potassium chloride. The nurse also needs to hang an IV infusion of piperacillin/tazobactam.

The client has one IV site. The nurse should plan to take which action first?

1. Start a second IV site.

2. Check compatibility of the medication and IV fluids.

3. Mix the prepackaged piperacillin/tazobactam per agency policy.

4. Prime the tubing with the IV solution, and back-prime the medication.




Answer:

2. Check compatibility of the medication and IV fluids.




Rationale:

When hanging an IV antibiotic, the nurse should first check compatibility of the medication and the IV

fluids currently prescribed. If the fluids and medication are incompatible, it would then be appropriate

to start a second IV site. If they are compatible, the nurse should hang them together so as to avoid

having to start another IV site. After this, the nurse should prepare the prepackaged

piperacillin/tazobactam per agency policy, then prime the tubing with the IV solution, and then back-

prime the medication. Back- priming prevents any medication from being lost during the priming

process.




3. The nurse is making initial rounds on the nursing unit to assess the condition of assigned

clients. Which assessment findings are consistent with infiltration? Select all that apply.


NURS 618 Disease Management I,saunders medication
and IV therapy questions and answers with Rationale
2022

,NURS 618 Disease Management I,saunders medication
and IV therapy questions and answers with Rationale
2022
1. Pain and erythema

2. Pallor and coolness

3. Numbness and pain

4. Edema and blanched skin

5. Formation of a red streak and purulent drainage




Answers:

2. Pallor and coolness

3. Numbness and pain

4. Edema and blanched skin




Rationale:

An infiltrated intravenous (IV) line is one that has dislodged from the vein and is lying in subcutaneous

tissue. Pallor, coolness, edema, pain, numbness, and blanched skin are the results of IV fluid being

deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the

tubing, the flow of the IV solution will stop, and if an electronic pump is being used, it will alarm.

Erythema can be associated with infection, phlebitis, or thrombosis. Formation of a red streak and

purulent drainage is associated with phlebitis and infection.




4. The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick, the nurse would

continue to advance the catheter in which situation?

NURS 618 Disease Management I,saunders medication
and IV therapy questions and answers with Rationale
2022

, NURS 618 Disease Management I,saunders medication
and IV therapy questions and answers with Rationale
2022
1. The catheter advances easily.

2. The vein is distended under the needle.

3. The client does not complain of discomfort.

4. Blood return shows in the backflash chamber of the catheter.




Answer:

4. Blood return shows in the backflash chamber of the catheter.




Rationale:

The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV

catheter. The vein should have been distended by the tourniquet before the vein was cannulated, and

if further distention occurs after venipuncture, this could mean the needle went through the vein and

into the tissue; therefore, the catheter should not be advanced. Client discomfort varies with the client,

the site, and the nurse's insertion technique and is not a reliable measure of catheter placement. The

nurse should not advance the catheter until placement in the vein is verified by blood return.




5. The nurse is assessing a client's peripheral intravenous (IV) site after completion of a vancomycin

infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to

the insertion point of the IV catheter. At this time, which action by the nurse is best?

1. Check for the presence of blood return.

2. Remove the IV site and restart at another site.


NURS 618 Disease Management I,saunders medication
and IV therapy questions and answers with Rationale
2022