ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 13 : Intravenous Therapy Questions
Question 1 of 5
To avoid complications of blood transfusion reaction, which nursing action is most important?
Correct Answer: A
Rationale: When the laboratory draws a sample of blood for typing and crossmatching, an identification bracelet is attached to the client and must match to confirm the correct blood at time of administration. A 20-gauge needle or greater is preferred for administration of blood but not a priority for avoiding transfusion reaction. Normal saline is the isotonic solution used with transfusions but not indicated for prevention of reactions. If the patient verbalized of feeling unusual, immediate assessment would be completed by the nurse and the infusion would be stopped, not decreased by half.
Question 2 of 5
The major advantage for giving a client medication via intravenous (IV) route is which of the following?
Correct Answer: C
Rationale: The IV route produces a rapid drug effect throughout the body. IV administration of drugs can be more costly than the oral route. Adverse reaction toward the medication is not effected by the route. The easiest route for drug therapy in the home is usually oral route.
Question 3 of 5
The client asks the nurse why it is necessary to prime the intravenous tubing. Which is the best response by the nurse?
Correct Answer: A
Rationale: A bolus of air that is forced into the venous system can result in pulmonary emboli, shock, or death. Priming the tubing does not keep the catheter open and flowing and is not indicated for infection control purposes. An air lock used in intramuscular injections is not indicated for IV administration.
Question 4 of 5
The client has been receiving intravenous (IV) fluids for the last 6 hours and now is demonstrating bounding pulse, crackles in the lungs, leg swelling, and a blood pressure more than $15 \mathrm{~mm} \mathrm{Hg}$ higher than baseline. Which is the most likely nursing problem statement for this client?
Correct Answer: C
Rationale: The symptoms the client is experiencing indicate excess fluid volume. If the edema continues in the lower extremities, peripheral tissue perfusion and skin integrity can become impaired. Ineffective airway associated with the crackles is directly related to the fluid volume overload.
Question 5 of 5
The client is receiving total parenteral nutrition (TPN), and the solution bag is almost empty. The nurse discovers there are no containers prepared for use. The nurse contacts the healthcare provider. Which order would the nurse expect from the healthcare provider?
Correct Answer: A
Rationale: Abruptly stopping the administration of hypertonic, high-glucose solutions will result in a rebound hypoglycemic effect and can be avoided if the approximate glucose concentration can be assessed and added to D10W solution. NSS does not contain glucose. Slowing or stopping the rate of infusion will not prevent rebound hypoglycemia.