Pharmacological Aspects of Nursing Care 8Th Edition By Broyles Reiss Evans – Test Bank
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CHAPTER 3: NURSING CLIENTS RECEIVING DRUGS INTRAVENOUSLY
TRUE/FALSE
1. The
primary reason for using an IV infusion pump is to save the nurse time.
ANS: F
|
|
Feedback |
|
Correct |
Electronic infusion pumps
are used 1) to maintain the patency of the vascular access by maintaining
constant pressure and 2) to provide more accurate IV flow rates than the
conventional gravity method of administration. |
|
Incorrect |
|
PTS:
1
REF: p.
86
OBJ: Cognitive Level: Comprehension
2. The
purpose of an IV filter is to remove particulate matter.
ANS:
T
PTS: 1
REF: p.
86
OBJ: Cognitive Level: Knowledge
3. IV
infusion devices may continue to function properly, even though the site is
infiltrated.
ANS:
T
PTS:
1
REF: p.
87
OBJ: Cognitive Level: Knowledge
4. An IV
that infuses too rapidly may cause circulatory overload.
ANS:
T
PTS:
1
REF: p.
89
OBJ: Cognitive Level: Knowledge
5. Clients
receiving home IV therapy are instructed to change the dressing on central
venous catheters using clean technique.
ANS: F
|
|
Feedback |
|
Correct |
Dressings on central venous
catheters should be changed using sterile technique. |
|
Incorrect |
|
PTS: 1
REF: p.
89
OBJ: Cognitive Level: Comprehension
6. When
referring to IV administration tubing, drop factor represents the number of
drops in each milliliter of IV fluid.
ANS:
T
PTS: 1
REF: p. 90
OBJ: Cognitive Level: Comprehension
MULTIPLE CHOICE
1. Which
of the following interventions is essential for the nurse to perform when
caring for a client receiving an intravenous drug infusion?
|
a. |
Employ clean technique when
handling the intravenous equipment. |
|
b. |
Monitor the client during
the infusion. |
|
c. |
Prime the tubing once the
infusion has started. |
|
d. |
Use the largest gauge
intravenous needle available. |
ANS: B
|
|
Feedback |
|
A |
Incorrect: Sterile technique
must be used. |
|
B |
Correct: The should be monitored at least hourly during intravenous
infusion |
|
C |
Incorrect: Fluid must be
primed through the tubing to remove air before the infusion is initiated. |
|
D |
Incorrect: The gauge choice
is based on many factors, including the size of the vein where the
venipuncture is to be done. |
PTS:
1
REF: p. 88 Safe Nursing Practice 3-1
OBJ: Cognitive Level: Comprehension
2. The
venipuncture site for an intravenous infusion in a 12-year-old is most often
located in the:
|
a. |
scalp. |
c. |
foot. |
|
b. |
hand. |
d. |
upper arm. |
ANS: B
|
|
Feedback |
|
A |
Incorrect: This is a site
for neonates and infants. |
|
B |
Correct: This is an appropriate site for older children and adults. |
|
C |
Incorrect: This is a site
for toddlers. |
|
D |
Incorrect: This is a site
for adults. |
PTS:
1
REF: p.
80
OBJ: Cognitive Level: Comprehension
3. What
is the first action the nurse should perform when administering a drug
intravenously through a special administration chamber?
|
a. |
Inject the medication to be
administered into the chamber. |
|
b. |
Set the intravenous flow
rate. |
|
c. |
Prime the infusion
equipment. |
|
d. |
Initiate the infusion at
the prescribed rate. |
ANS: C
|
|
Feedback |
|
A |
Incorrect: This is done
after the tubing has been primed. |
|
B |
Incorrect: This is done
after the tubing has been primed and the medication administered into the
chamber. |
|
C |
Correct: The nurse should prime the tubing first to remove air that
could result in an air embolism. |
|
D |
Incorrect: This is
performed after the tubing has been primed. |
PTS:
1
REF: p.
80
OBJ: Cognitive Level: Application
4. Which
rate, in general, is a safe dose when administering a medication via an
intravenous bolus injection?
|
a. |
0.5 mL per minute |
c. |
2 mL per minute |
|
b. |
1 mL per minute |
d. |
3 mL per minute |
ANS: B
|
|
Feedback |
|
A |
Incorrect: This rate is too
slow and will provide a slower onset of action. |
|
B |
Correct: As a general rule, IV boluses should be given at a rate of 1
mL per minute for providing appropriate onset of action and protecting the
vein. |
|
C |
Incorrect: This rate is too
fast for an IV bolus. |
|
D |
Incorrect: This rate is
much too fast for an IV bolus. |
PTS:
1
REF: p.
85
OBJ: Cognitive Level: Comprehension
5. Which
sequence of nursing actions is correct for administering a drug by intravenous
push through a saline lock?
|
a. |
Flush the setup with
prescribed fluid, disinfect the injection port, aspirate, administer the
medication, chart. |
|
b. |
Disinfect the injection
port, administer the medication, flush the setup with the prescribed fluid,
chart. |
|
c. |
Disinfect the injection
port, flush the setup with the prescribed fluid, aspirate, administer the
medication, flush again, chart. |
|
d. |
Wash hands, flush the setup
with the prescribed fluid, aspirate, administer the medication, chart. |
ANS: C
|
|
Feedback |
|
A |
Incorrect: The vascular assess
should be flushed before and after the medication. |
|
B |
Incorrect: The vascular
assess should be flushed before and after the medication. |
|
C |
Correct: This is the appropriate sequence of nursing actions. |
|
D |
Incorrect: The vascular
assess should be flushed before and after the medication. |
PTS:
1
REF: p. 85, Figure 3-11
OBJ: Cognitive Level: Application
6. The
nurse is caring for a client receiving an intravenous infusion via an
electronic infusion device. The device begins to alarm and the nurse addresses
this problem as soon as possible because the alarm:
|
a. |
is annoying to the client. |
|
b. |
indicates an increase in
the rate of the infusion. |
|
c. |
denotes the presence of
pain at the infusion site. |
|
d. |
indicates that the infusion
is not flowing properly. |
ANS: D
|
|
Feedback |
|
A |
Incorrect: This is not the
rationale for the nurse’s action. |
|
B |
Incorrect: This is not the
rationale for the nurse’s action and is a false statement. |
|
C |
Incorrect: This is not a function
of an electronic infusion device. |
|
D |
Correct: When an electronic infusion device alarm sounds, it indicates
the infusion is not flowing properly. |
PTS:
1
REF: p.
87
OBJ: Cognitive Level: Comprehension
7. A
client receiving intravenous medication who develops fever, chills, and nausea
is likely to have developed:
|
a. |
extravasation of fluid. |
c. |
a pyrogenic reaction. |
|
b. |
tissue necrosis. |
d. |
pulmonary edema. |
ANS: C
|
|
Feedback |
|
A |
Incorrect: This will cause
severe pain. |
|
B |
Incorrect: This will cause
severe pain. |
|
C |
Correct: These are manifestations of infection. |
|
D |
Incorrect: This will cause
shortness of breath. |
PTS:
1
REF: p.
89
OBJ: Cognitive Level: Comprehension
8. The
primary purpose of priming all IV tubing before connecting it to the client is
to:
|
a. |
prevent air embolism. |
|
b. |
ensure that an accurate
dose of medication is delivered. |
|
c. |
aid in the solution flow
through an infusion device. |
|
d. |
establish flow rate. |
ANS: A
|
|
Feedback |
|
A |
Correct: The purpose of priming IV tubing is to displace (remove) the
air that fills the tubing during manufacturing. |
|
B |
Incorrect: This is not the
purpose of priming IV tubing. |
|
C |
Incorrect: This is not the
purpose of priming IV tubing. |
|
D |
Incorrect: This is not the
purpose of priming IV tubing. |
PTS:
1
REF: p. 82 | p. 87 OBJ: Cognitive Level:
Comprehension
9. The
health care provider prescribes the client to receive 1000 mL of IV fluid every
eight hours. At what rate should the nurse program the electronic infusion pump
to infuse?
|
a. |
100 mL |
c. |
150 mL |
|
b. |
125 mL |
d. |
200 mL |
ANS: B
|
|
Feedback |
|
A |
Incorrect: The client
should receive 125 mL per hour. |
|
B |
Correct: Divide 1000 mL by eight hours = 125 mL/hr. |
|
C |
Incorrect: The client
should receive 125 mL per hour. |
|
D |
Incorrect: The client
should receive 125 mL per hour. |
PTS:
1
REF: p.
90
OBJ: Cognitive Level: Application
10. The
health care provider prescribes the client to receive 60 mL of IV fluid every
hour. If the tubing has a drop factor of 60, how many drops per minute should
the nurse set the tubing to infuse?
|
a. |
10 gtt |
c. |
60 gtt |
|
b. |
12.5 gtt |
d. |
125 gtt |
ANS: C
|
|
Feedback |
|
A |
Incorrect: The client
should receive 60 gtt/min. |
|
B |
Incorrect: The client
should receive 60 gtt/min. |
|
C |
Correct: When using a microdripper, the hourly rate is equal to the
number of drops per minute, because there are 60 gtt/mL in a microdripper. |
|
D |
Incorrect: The client
should receive 60 gtt/min. |
PTS:
1
REF: p.
90
OBJ: Cognitive Level: Application
11. The
health care provider prescribes the client to receive 2000 mL of IV fluid per
24 hours. If the tubing has a drop factor of 10, how many drops per minute
should the nurse set the IV to infuse?
|
a. |
10 gtt |
c. |
14 gtt |
|
b. |
12 gtt |
d. |
none of the above |
ANS: C
|
|
Feedback |
|
A |
Incorrect: The fluids
should infuse at 14 gtt/min. |
|
B |
Incorrect: The fluids
should infuse at 14 gtt/min. |
|
C |
Correct: Divide 2000 mL by 24 hours = 83.33 mL per hour; then divide
83.33 mL by 60 (minutes in an hour) = 1.39; then multiply 1.39 by 10 and
round to a whole number. |
|
D |
Incorrect: The fluids
should infuse at 14 gtt/min. |
PTS:
1
REF: p.
90
OBJ: Cognitive Level: Application
12. When
preparing to administer an intravenous push medication via a primary infusion,
the nurse must first:
|
a. |
be certain to use a filter
needle. |
|
b. |
check compatibility of the
medication with the infusion fluid. |
|
c. |
cleanse the infusion port
following medication administration. |
|
d. |
disconnect the primary
tubing during administration of the bolus. |
ANS: B
|
|
Feedback |
|
A |
Incorrect: Filter needles
are used when withdrawing medication from an ampule. |
|
B |
Correct: Before administering any IV medication, its compatibility with
the infusion fluid should be checked. |
|
C |
Incorrect: This is
performed immediately prior to checking for IV patency before administering
an IV bolus. |
|
D |
Incorrect: IV bolus
medications are administered into an infusion port on the IV tubing. |
PTS:
1
REF: p.
83
OBJ: Cognitive Level: Application
13. When
swelling occurs in the tissues surrounding the IV site, the nurse should first:
|
a. |
check for venous backflow. |
c. |
restart the infusion in a
different site. |
|
b. |
discontinue the infusion. |
d. |
apply warm, moist packs to
the skin. |
ANS: A
|
|
Feedback |
|
A |
Correct: Although infiltration should be suspected, checking for venous
flowback is the accepted method of confirming infiltration. |
|
B |
Incorrect: After
infiltration is confirmed, the IV should be discontinued. |
|
C |
Incorrect: This is
performed after the IV is discontinued. |
|
D |
Incorrect: This is
performed after the IV is discontinued. |
PTS:
1
REF: p. 81 | p. 88 OBJ: Cognitive Level:
Application
14. The
health care provider has prescribed the client to receive 500 mL fluid over
four hours. If the drop factor is 15, the nurse will set the infusion to infuse
at:
|
a. |
10 gtt/min |
c. |
31 gtt/min |
|
b. |
21 gtt/min |
d. |
45 gtt/min |
ANS: C
|
|
Feedback |
|
A |
Incorrect: This is not the appropriate
flow rate. |
|
B |
Incorrect: This is not the
appropriate flow rate. |
|
C |
Correct: Divide 500 mL by four hours = 125 mL/hr; divide 125 mL/hr by
60 minutes = 2.08 mL/min; multiply 2.08 by 15 = 31 gtt/min |
|
D |
Incorrect: This is not the
appropriate flow rate. |
PTS:
1
REF: p.
90
OBJ: Cognitive Level: Application
15. The
health care provider has prescribed the client to receive 250 mL fluid over two
hours. At what rate will the nurse set the electronic infusion device?
|
a. |
12.5mL/hr |
c. |
50 gtt/min |
|
b. |
125 gtt/min |
d. |
125 mL/hr |
ANS: D
|
|
Feedback |
|
A |
Incomplete: This is not the
correct rate. |
|
B |
Incomplete: This is not the
correct rate. |
|
C |
Incomplete: This is not the
correct rate. |
|
D |
Correct: Electronic infusion sets infuse based on mL/hr. Divide 250 mL
by two hours = 125 mL/hr. |
PTS:
1
REF: p. 86-87 | p. 90
OBJ: Cognitive Level: Application
16. The
nurse is initiating an intravenous access. After the vein has been pierced by
the IV needle the nurse would expect to see what to indicate that the needle is
in the vein?
|
a. |
little puffiness at the IV
site |
c. |
Slight bruising at the site |
|
b. |
backflow of blood into the
tubing |
d. |
all of the above |
ANS: B
|
|
Feedback |
|
A |
Incorrect: This would
indicate the possibility of piercing through the vein. |
|
B |
Correct: A backflow of blood in the tubing indicates that the needle is
located in the vein. |
|
C |
Incorrect: This would
indicate the possibility of piercing through the vein. |
|
D |
Incorrect: a and c are
incorrect. |
PTS:
1
REF: p.
81
OBJ: Cognitive Level: Evaluation
17. When
preparing an intravenous infusion the nursing action necessary to prevent air
embolism is:
|
a. |
maintain sterile technique
during setup. |
|
b. |
ensure that electronic
infusion pump is set for proper rate and volume. |
|
c. |
prime the tubing of the
intravenous administration set. |
|
d. |
ensure that the client has
a patent vascular access. |
ANS: C
|
|
Feedback |
|
A |
Incorrect: This action
prevents infection but does not prevent air embolism. |
|
B |
Incorrect: This action
ensures that the client receives the prescribed rate of infusion. |
|
C |
Correct: Priming the tubing prevents air embolism. |
|
D |
Incorrect: Although the
most significant factor for IV infusions, it does not prevent air embolism. |
PTS:
1
REF: p. 82 | p. 87 OBJ: Cognitive Level:
Application
18. The
client’s family has asked the nurse why they should not turn off the alarm on
the client’s IV infusion pump. The nurse’s best response is:
|
a. |
“It’s a nursing
responsibility.” |
|
b. |
“You have not been trained
in the use of the IV infusion device.” |
|
c. |
“You may accidentally
change the rate of infusion.” |
|
d. |
“If the alarm sounds, it
needs to be checked by a nurse.” |
ANS: D
|
|
Feedback |
|
A |
Incorrect: This does not
provide an adequate explanation. |
|
B |
Incorrect: This is an
inappropriate and unprofessional response. |
|
C |
Incorrect: Although it is
possible to accidentally change the rate, this is not the best answer. |
|
D |
Correct: If the pump alarm sounds, it means the fluids are not infusing
properly and a nurse needs to check the pump and fix the problem as soon as
possible. |
PTS:
1
REF: p.
87
OBJ: Cognitive Level: Application
19. The
nurse assesses the client’s IV site and determines that it has infiltrated. The
nurse’s best response is to:
|
a. |
call the health care
provider |
|
b. |
immediately stop the IV
infusion. |
|
c. |
apply a cold compress and
slow the rate of infusion. |
|
d. |
complete an incident
report. |
ANS: B
|
|
Feedback |
|
A |
Incorrect: This is not the
nurse’s first action. |
|
B |
Correct: The nurse should immediately stop the infusion, so that no
more fluid flows into the tissues surrounding the vein to prevent further
tissue trauma. |
|
C |
Incorrect: After stopping
the infusion, the nurse should follow the protocol of the institution
regarding how to treat the site. |
|
D |
Incorrect: An incident or
variance report generally is not initiated unless serious tissue damage has
occurred. |
PTS:
1
REF: p.
87
OBJ: Cognitive Level: Application
20. The
client complains of loss of motion in the arm with an IV infusing. The nurse assesses
the IV site and notes that the site is red, warm, and swollen. What is the most
likely cause and what action should be taken first?
|
a. |
tissue necrosis and the
nurse should monitor the site |
|
b. |
pyrogenic reaction and the
nurse should stop the infusion immediately. |
|
c. |
thrombophlebitis and the
nurse should stop the infusion immediately. |
|
d. |
fluid overload and the
nurse should decrease the flow rate and notify the health care provider. |
ANS: B
|
|
Feedback |
|
A |
Incorrect: These are not manifestations
of tissue necrosis. |
|
B |
Correct: A cardinal manifestation is the loss of motion in the limb
where the fluids are infusing. The nurse should stop the infusion immediately
and follow the facility protocol related to pyrogenic reactions. |
|
C |
Incorrect: Although redness
and warmth are manifestations of thrombophlebitis, the group of
manifestations indicate a pyrogenic reaction. |
|
D |
Incorrect: These are not
manifestations of fluid overload. |
PTS:
1
REF: p.
89
OBJ: Cognitive Level: Application
21. When
thrombophlebitis is suspected in a client receiving antimicrobial agents, the
nurse should:
|
a. |
check for venous backflow. |
c. |
restart the infusion in a
different site. |
|
b. |
discontinue the infusion. |
d. |
apply warm, moist packs to
the skin. |
ANS: B
|
|
Feedback |
|
A |
Incorrect: This is an
action related to infiltration. |
|
B |
Correct: If the client experiences manifestations of thrombophlebitis,
the infusion should be discontinued immediately. When antimicrobials infuse
too fast for the size of the vascular access vein, thrombophlebitis often
occurs. |
|
C |
Incorrect: Although
appropriate, the nurse’s first action is to stop the current infusion. |
|
D |
Incorrect: Although
appropriate, the nurse’s first action is to stop the current infusion. |
PTS:
1
REF: p.
88
OBJ: Cognitive Level: Application
22. When
setting up an intravenous infusion the nurse understands that he or she must:
|
a. |
use clean technique. |
|
b. |
confirm the prescription
for the IV infusion. |
|
c. |
explain the procedure to
the client. |
|
d. |
use aseptic technique. |
ANS: D
|
|
Feedback |
|
A |
Incorrect: Aseptic
technique must be used to prevent serious and sometimes fatal infections. |
|
B |
Incorrect: This should be
performed prior to setting up an intravenous infusion. |
|
C |
Incorrect: This is done
before setting up the intravenous infusion. |
|
D |
Correct: Aseptic technique must be used to prevent serious and
sometimes fatal infections. |
PTS:
1
REF: p.
82
OBJ: Cognitive Level: Application
23. A
nursing student is asked by her instructor what hydrostatic pressure is. Which
response by the student best defines hydrostatic pressure:
|
a. |
“It is the amount of pressure
necessary to move particles and fluids in and out of vascular volume.” |
|
b. |
“It is the force water
places against the vessel walls or capillary membranes.” |
|
c. |
“It is the measure of
solute particles in the vascular system.” |
|
d. |
“It is the amount of
pressure necessary to diffuse particles in the vascular volume.” |
ANS: B
|
|
Feedback |
|
A |
Incorrect: This is the
definition of osmotic pressure. |
|
B |
Correct: This is the definition of hydrostatic pressure. |
|
C |
Incorrect: This defines osmolality. |
|
D |
Incorrect: This is a
contrived definition. |
PTS:
1
REF: p.
74
OBJ: Cognitive Level: Application
24. A
client is prescribed lactated Ringer’s (LR) solution for a surgical procedure.
The nurse understands that the purpose for prescribing these IV fluids is:
|
a. |
LR is an isotonic solution
that will help maintain the client’s normal osmotic pressure. |
|
b. |
LR is the most commonly
prescribed IV fluids for clients during and following surgery. |
|
c. |
LR is a hypertonic solution
necessary to promote renal perfusion during surgery. |
|
d. |
LR is a hypotonic solution
necessary to promote renal perfusion following surgery. |
ANS: A
|
|
Feedback |
|
A |
Correct: This is the purpose for prescribing LR for surgical clients. |
|
B |
Incorrect: This is not a
valid reason. |
|
C |
Incorrect: LR is an
isotonic solution. |
|
D |
Incorrect: LR is an
isotonic solution. |
PTS:
1
REF: p.
76
OBJ: Cognitive Level: Comprehension
25. Dextrose
5% and 0.45% (1/2) normal saline is a commonly used IV solution in many acute
health care settings. The nurse understands that this solution is used because:
|
a. |
It is a hypertonic solution
used for hydration. |
|
b. |
It is a hypotonic solution used
to promote renal perfusion. |
|
c. |
It is an isotonic solution
used to maintain fluid and electrolyte homeostasis. |
|
d. |
It is preferred over other
hypotonic solutions. |
ANS: A
|
|
Feedback |
|
A |
Correct: This solution is hypertonic and is used for hydration and to
treat severe dehydration, sodium depletion, and other conditions requiring
increased fluid perfusion. |
|
B |
Incorrect: Dextrose 5% and
0.45% normal saline is a hypertonic solution. |
|
C |
Incorrect: Dextrose 5% and
0.45% normal saline is a hypertonic solution. |
|
D |
Incorrect: Dextrose 5% and
0.45% normal saline is a hypertonic solution. |
PTS:
1
REF: p.
76
OBJ: Cognitive Level: Knowledge
26. The
nurse is caring for a client receiving IV fluids via an electronic infusion
device when the alarm indicating “occlusion” rings on the pump. What should the
nurse do first?
|
a. |
Assess all tubings for
kinks. |
|
b. |
Assess the pump for the
proper rate. |
|
c. |
Assess the IV fluid bag to
be sure adequate volume is in the bag. |
|
d. |
Make sure that the pump is
plugged into the electrical outlet. |
ANS: A
|
|
Feedback |
|
A |
Correct: A common cause of IV occlusions is the presence of kinks in
the IV tubing, so these need to be checked and any found removed as soon as possible. |
|
B |
Incorrect: This action will
not address the occlusion alarm. |
|
C |
Incorrect: This action will
not address the occlusion alarm. |
|
D |
Incorrect: This action will
not address the occlusion alarm. |
PTS:
1
REF: p. 79
OBJ: Cognitive Level: Application
27. The
nurse is preparing to administer an IV bolus of pain medication to a surgical
client and realizes the first action is to:
|
a. |
don sterile gloves. |
|
b. |
cleanse the port with
alcohol. |
|
c. |
wash hands. |
|
d. |
draw back the plunger to
check for blood return. |
ANS: C
|
|
Feedback |
|
A |
Incorrect: Unless the
facility protocol states to use sterile gloves, clean gloves can be used, but
not until after the nurse’s hands are washed. |
|
B |
Incorrect: This is not the first
step. |
|
C |
Correct: The first action of the nurse is to wash the hands before
donning gloves. |
|
D |
Incorrect: This is not the
first step. |
PTS:
1
REF: p.
85
OBJ: Cognitive Level: Application
28. A
client receiving a vesicant medication is experiencing extravasation. The
nurse’s first action is to:
|
a. |
slow down the infusion. |
c. |
stop the infusion. |
|
b. |
recalibrate the infusion
rate. |
d. |
obtain an extravasation
kit. |
ANS: C
|
|
Feedback |
|
A |
Incorrect: The infusion
should be stopped immediately to prevent further tissue necrosis. |
|
B |
Incorrect: The infusion
should be stopped immediately to prevent further tissue necrosis. |
|
C |
Correct: The infusion should be stopped immediately to prevent further
tissue necrosis. |
|
D |
Incorrect: This should be
obtained after the infusion is stopped. |
PTS:
1
REF: p.
89
OBJ: Cognitive Level: Application
29. When
the client receiving IV fluids complains of pain from the infusion, the nurse
should:
|
a. |
increase the rate of
infusion to complete it sooner. |
|
b. |
gently move the hub of the
needle to see if the pain decreases. |
|
c. |
Stop the infusion
immediately and notify the health care provider. |
|
d. |
Document the client’s
response and monitor the site. |
ANS: B
|
|
Feedback |
|
A |
Incorrect: This will worsen
the pain regardless of the cause of the pain. |
|
B |
Correct: If tension is the cause of the pain, gently moving the hub of
the needle will decrease the pain. Always assess first. |
|
C |
Incorrect: Many times,
nursing assessment and interventions can eliminate the cause of the pain. |
|
D |
Incorrect: Although
appropriate, the nurse should assess for the cause of the pain and, if
possible, eliminate the cause of the pain. |
PTS: 1
REF: p.
89
OBJ: Cognitive Level: Application
30. A
client’s peripheral IV infusion set up was initiated three days ago. The nurse
realizes that there is a need to:
|
a. |
change the date on the IV
site dressing. |
|
b. |
check to see if the IV
prescription has changed. |
|
c. |
change the client’s IV
medications to an oral route. |
|
d. |
change (rotate) the IV
site. |
ANS: D
|
|
Feedback |
|
A |
Incorrect: The IV site and
dressing should be changed. A new date needs to be placed on the dressing and
the new IV tubing for the new infusion site. |
|
B |
Incorrect: Although
appropriate, this does not specifically address the information in the
question that the client’s IV was initiated three days (72 hours) ago. |
|
C |
Incorrect: This is not
within the nurse’s scope of practice. |
|
D |
Correct: The IV site and IV tubing should be changed every 48-72 hours
to prevent complications. |
PTS:
1
REF: p.
79
OBJ: Cognitive Level: Application
MULTIPLE RESPONSE
1. When
attempting venipuncture, if applying a tourniquet fails to raise an appropriate
vein, the nurse may try which of the following:
|
a. |
instruct client to open and
close a fist. |
|
b. |
tap the vein lightly. |
|
c. |
have the health care provider
do the venipuncture. |
|
d. |
apply an ice pack to the
site of the appropriate vein. |
ANS: A, B
|
|
Feedback |
|
Correct |
a & b are two
appropriate nursing actions. |
|
Incorrect |
c & d are not
appropriate. In most health care facilities, the health care provider does
not perform venipuncture. Applying an ice pack will constrict the vessel,
making it not only harder to see, but also too small in diameter to attempt a
venipuncture. |
PTS:
1
REF: p.
81
OBJ: Cognitive Level: Application
2. For
the client discharged receiving IV fluids, the nurse should instruct the client
to notify the nurse:
|
a. |
if redness, swelling, or
pain develops at the IV site. |
|
b. |
at the client’s next
appointment of any problems related to the infusion. |
|
c. |
if the client experiences
swelling of the legs or shortness of breath. |
|
d. |
if the client develops a
rash, itching, or hives. |
ANS: A, C, D
|
|
Feedback |
|
Correct |
a, c, & d represent
manifestations of complications associated with IV therapy, including
thrombophlebitis, infiltration, fluid overload, and allergic reaction,
respectively. |
|
Incorrect |
b. Manifestations of IV
therapy problems should be reported immediately to the nurse–not delayed
until the client’s next appointment. |
PTS:
1
REF: p.
90
OBJ: Cognitive Level: Application
3. When
caring for a client receiving peripheral intravenous fluid infusion in the
acute care setting, the nurse is responsible for routinely:
|
a. |
assessing for the 7 rights
of medication administration. |
|
b. |
evaluating effectiveness of
IV therapy. |
|
c. |
providing instructions for
central venous catheter care at home. |
|
d. |
assessing for complications
of infusion. |
ANS: A, B, D
|
|
Feedback |
|
Correct |
a, b, & d are necessary
nursing interventions. |
|
Incorrect |
c. These instructions are
given only the clients being discharged with a central venous catheter. This
client is receiving peripheral infusion. |
PTS:
1
REF: p.
79
OBJ: Cognitive Level: Application
4. The
nurse understands that besides extravasation, pain at the site of an IV
infusion can result from:
|
a. |
administering medication
that is not properly diluted. |
|
b. |
administering irritating
medications too rapidly. |
|
c. |
the IV catheter touching
the wall of the vein. |
|
d. |
an overload of the
circulatory system from hypertonic solutions. |
ANS: A, B, C
|
|
Feedback |
|
Correct |
a, b, and c are causes of
pain at the site of an IV infusion and should be addressed immediately. |
|
Incorrect |
d. Overload of the
circulatory system from hypertonic solutions is fluid overload. |
PTS:
1
REF: p.
89
OBJ: Cognitive Level: Comprehension
5. The
gauge of the IV needle is determined by which of the following factor(s)?
|
a. |
viscosity of the medication |
c. |
condition of the vein
selected |
|
b. |
size of the vein selected |
d. |
nature of the therapy |
ANS: A, B, C, D
|
|
Feedback |
|
Correct |
All of the responses are
factors for the nurse to consider when selecting a vein for IV injection. |
|
Incorrect |
|
PTS:
1
REF: p.
77
OBJ: Cognitive Level: Comprehension
CHAPTER 4: CALCULATING MEDICATION DOSAGES
TRUE/FALSE
1. Whenever
possible, use the metric system in medication prescriptions rather than the
apothecary system.
ANS:
T
PTS:
1
REF: p. 96
OBJ: Cognitive Level: Application
2. In
the metric system, the liter is the basic unit of weight.
ANS: F
|
|
Feedback |
|
Correct |
Liter is a measurement of
volume in the metric system. |
|
Incorrect |
|
PTS:
1
REF: p.
99
OBJ: Cognitive Level: Knowledge
3. One
milligram is equivalent to 1 milliliter.
ANS: F
|
|
Feedback |
|
Correct |
Milligram is a measurement
of weight and a milliliter is a measurement of volume. |
|
Incorrect |
|
PTS:
1
REF: p.
99
OBJ: Cognitive Level: Knowledge
MULTIPLE CHOICE
1. The
abbreviation “O.S.” in a prescription refers to:
|
a. |
right eye. |
c. |
left eye. |
|
b. |
left ear. |
d. |
right arm. |
ANS: C
|
|
Feedback |
|
A |
Incorrect: This
abbreviation for right eye is O.D. |
|
B |
Incorrect: There is no
abbreviation for left ear. |
|
C |
Correct: O.S. is the abbreviation for left eye. |
|
D |
Incorrect: There is not
abbreviation for right arm. |
PTS:
1
REF: p.
43
OBJ: Cognitive Level: Knowledge
2. The
abbreviation “gtt” in a prescription refers to a:
|
a. |
gallon. |
c. |
drop. |
|
b. |
gram. |
d. |
large vessel. |
ANS: C
|
|
Feedback |
|
A |
Incorrect: The abbreviation
for gallon is gal. |
|
B |
Incorrect: The abbreviation
for gram is g. |
|
C |
Correct: gtt is the abbreviation for drop. |
|
D |
Incorrect: There is no
abbreviation for large vessel. |
PTS:
1
REF: p.
42
OBJ: Cognitive Level: Knowledge
3. The
abbreviation “sol” in a prescription refers to:
|
a. |
suspension. |
c. |
solvent. |
|
b. |
solution. |
d. |
subcutaneous. |
ANS: B
|
|
Feedback |
|
A |
Incorrect: The abbreviation
for suspension is susp. |
|
B |
Correct: sol. is the abbreviation for solution. |
|
C |
Incorrect: Nursing does not
use an abbreviation for solvent. |
|
D |
Incorrect: The abbreviation
for subcutaneous is S.C., s.c., or sub. q. |
PTS:
1
REF: p.
42
OBJ: Cognitive Level: Knowledge
4. The
client is to receive medication “p.o.” The nurse knows to administer the
medication:
|
a. |
in the eye. |
c. |
put on. |
|
b. |
after midnight. |
d. |
by mouth. |
ANS: D
|
|
Feedback |
|
A |
Incorrect: p.o. is not the
abbreviation for in the eye. |
|
B |
Incorrect: p.o. is not the
abbreviation for after midnight. |
|
C |
Incorrect: p.o. is not the
abbreviation for put on. |
|
D |
Correct: The abbreviation for by mouth is p.o., meaning per os. |
PTS:
1
REF: p.
42
OBJ: Cognitive Level: Application
5. A
nurse is asked to administer one antibiotic tablet t.i.d. for seven days. The
total number of tablets required is:
|
a. |
30. |
c. |
21. |
|
b. |
14. |
d. |
70. |
ANS: C
|
|
Feedback |
|
A |
Incorrect: The medication
is prescribed for three times a day for 7 days = 21 tablets. |
|
B |
Incorrect: The medication
is prescribed for three times a day for 7 days = 21 tablets. |
|
C |
Correct: The medication is prescribed for three times a day for 7 days
= 21 tablets |
|
D |
Incorrect: The medication
is prescribed for three times a day for 7 days = 21 tablets |
PTS:
1
REF: p.
43
OBJ: Cognitive Level: Application
6. A
health care provider prescribes 50 mg of a drug. The drug is only available in
a 20 mL vial that contains 20 mg/mL of the drug. How much solution must the
nurse administer for each dose?
|
a. |
2.5 mL |
c. |
5 mL |
|
b. |
25 mL |
d. |
0.25 mL |
ANS: A
|
|
Feedback |
|
A |
Correct: 50 (prescribed dose) is divided by 20 (on-hand dose) and
multiplied by 1 mL = 2.5 mL. |
|
B |
Incorrect: This would yield
10 times the prescribed dose. |
|
C |
Incorrect: This would yield
twice the prescribed dose. |
|
D |
Incorrect: This would yield
a 5 mg dose. |
PTS:
1
REF: p.
102
OBJ: Cognitive Level: Application
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