IV therapy NCLEX questions

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2. Slow the IV infusion
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A client had a 1000 mL bag of 5% dextrose in 0.9% sodium chloride hung at 3pm. The nurse making rounds at 3:45 pm finds that the client is complaining of a pounding headache and is dyspneic, is experiencing chills, and is apprehensive, with an increased pulse rate. The IV bag has 400 mL remaining. The nurse should take which action first? 1. Call the physician 2. Slow the IV infusion 3. Sit the client up in bed 4. Remove the IV catheter
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1.Rotate the bag gently
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The nurse has a prescription to hang an IV bag of 1000 mL 5% dextrose in water with 20 mEq potassium chloride. The nurse should plan to do which of the following immediately after injecting the potassium chloride in to the port of the IV bag? 1. Rotate the bag gently. 2. Attach the tubing to the client 3. Prime the tubing with the IV solution Check the solution for yellowish discoloration
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4. Circulatory overload
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A client with the recent diagnosis of MI and impaired renal function is recuperating on the step-down cardiac unit. The client’s blood pressure has been borderline low and IV fluids have been infusing at 100 mL /hr via a central line catheter in the right internal jugular for approx 24 hours to increase renal output and maintain the blood pressure. Upon entering the client’s room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that the client is most likely experiencing which complication of IV therapy. 1. Hematoma 2. Air embolism 3. Systemic infection 4. Circulatory overload
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3. Infiltration
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The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client’s IV site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which of the following complications has occurred. 1. Infection 2. Phlebitis 3. Infiltration 4. Thrombosis
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4. Blood return shows in the backflash chamber of the catheter.
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The nurse is inserting an IV line into a client’s vein. After the initial stick, the nurse continues to advance the catheter if: 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.
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1. Phlebitis of the vein
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The nurse nostes that the site of a client’s peripheral IV catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client experienced: 1. Phlebitis of the vein 2. Infiltration of the IV line 3. Hypersensitivity to the IV solution 4. Allergic reaction to the IV catheter material
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11. Obtain new IV tubing
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The nurse is preparing a continuous IV infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device,the exposed tubing drops and hits the top of the medication cart. Which of the following is the appropriate action by the nurse? 1. Obtain new IV tubing 2. Attach a new needleless device. 3. Wipe the distal end of the tubing with Betadine 4. Scrub the needleless device with an alcohol swab
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4. Sterile 2×2 gauze
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A physician has written a prescription to discontinue an IV line. The nurse obtains which of the following supplies from the unit supply area for applying pressure to the site after removing the IV catheter? 1. Elastic wrap 2. Betadine swab 3. Adhesive bandage 4. Sterile 2×2 gauze
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3. Portable chest x-ray film
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A client has just undergone insertion of a central venous catheter at the bedside. The nurse would be sure to check the results of which of the following before initiating the flow rate of the client’s IV solution at 100 mL/hr? 1. Serum osmolality 2. Serum electrolyte levels 3. Portable chest x-ray film 4. Intake and output record
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1. 5% dextrose in lactated ringer’s
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A client involved in a motor vehicle crash presents to the ER with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which IV solution will most likely be prescribe to increase intravascular volume, replace immediate blood loss volume, and increase blood pressure? 1. 5% dextrose in lactated ringers 2. 0.33% sodium chloride (1/3 normal saline) 3. 0.225% sodium chloride (1/4 normal saline) 4. 0.45% sodium chloride (1/2 normal saline)
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4. I need to keep my activity level to a minimum while this catheter is in place.
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The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter. The nurse determines that the client needs further instructions if the client made which statement? 1. I need to wear a medic-alter tag or bracelet 2. I need to have a repair kit available in the home for use if needed. 3. I need to keep the insertion site protected when in the shower or bath. 4. I need to keep my activity level to a minimum while this catheter is in place.
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1,2,3,5
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A client rings the call bell and complains of pain at the site of an IV infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? SATA 1. Notifies the physician 2. Removes the IV catheter at that site 3. Applies warm moist packs to the site 4. Starts a new IV line in a proximal portion of the same vein 5. Documents the occurence, actions taken, and the client’s response
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375
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The nurse is completing a time tape for a 1000 mL IV bag that is scheduled to infuse over 8 hours. The nurse has just placed the 11am marking at the 500 mL level. The nurse would place the mark for noon at which numerical level on the time tape? ____ mL

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