Chapter 1: Professional Practice Concepts for Infusion Therapy
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A nurse is attempting to initiate I.V. therapy for a client diagnosed with gastroenteritis. The client is combative and resists the nurse’s efforts to start the I.V. Which action by the nurse would result in an intentional tort?
| a. | Failure to document the client’s combativeness |
| b. | Refusing to wear gloves while starting the I.V. |
| c. | Failure to report the client’s combativeness to a physician |
| d. | Starting an I.V. on a coherent client against the client’s wishes |
____ 2. A nurse who is caring for clients understands that he or she should provide care that meets at least the minimum standards of practice for nursing. Which phrase regarding standards of practice is most accurate?
| a. | Standards of practice focus on the care provider and define needed activities and behaviors. |
| b. | Standards of practice focus on the recipient of care and describe the outcomes of care. |
| c. | Standards of practice are written laws enacted by the legislature. |
| d. | Standards of practice are the result of the performance of a function or process. |
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 1. A nurse is caring for multiple clients in a rehabilitation facility. During the shift, the nurse notes that several medical devices are not functioning properly. According to the Safe Medical Devices Act, which problems should be reported to the U.S. Food and Drug Administration (FDA)? SELECT ALL THAT APPLY.
| a. | Outdated medication |
| b. | Misleading packaging |
| c. | Cracked or leaking I.V. solution bag |
| d. | Defective infusion pump tubing |
____ 2. A new infusion clinic is being started. The nursing supervisor of the new clinic must conform to specific standards of practice when developing nursing policies and procedures for the new program. To which organizational standards of practice must the nurse manager adhere? SELECT ALL THAT APPLY.
| a. | Centers for Disease Control and Prevention (CDC) guidelines |
| b. | Infusion Nurses Society (INS) standards |
| c. | American Medical Association (AMA) standards |
| d. | Oncology Nursing Society (ONS) standards |
____ 3. A staff nurse is serving on a hospital’s quality-assurance task force. On which quality-assurance models is the task force most likely to focus? SELECT ALL THAT APPLY.
| a. | Standards of care |
| b. | Standards of practice |
| c. | Performance improvement |
| d. | Continuous quality improvement |
____ 4. A nurse is planning for the discharge of a hospitalized client. The nurse reviews the client’s plan of care to determine whether all client outcomes were achieved. Which methods should the nurse use to evaluate the client’s outcomes? SELECT ALL THAT APPLY.
| a. | Collect data to determine whether standards were met. |
| b. | Identify controllable or uncontrollable variables. |
| c. | Determine the cause of the problem by comparing actual care with established standards. |
| d. | Re-evaluate to determine whether corrective action is effective and improvement in service is obtained. |
| e. | Contact The Joint Commission (JCAHO) Web site for standards. |
____ 5. While caring for a client, a nurse administers an incorrect dose of medication, causing the client to become ill. The nurse reports the incident to the nurse manager on the unit. The nurse manager then notifies risk management. Which risk-management strategies should be used by the nurse in this situation? SELECT ALL THAT APPLY.
| a. | Documentation |
| b. | Physical assessment |
| c. | Unusual occurrence reports |
| d. | Professional liability insurance |
____ 6. When nurses provide care to clients, nursing actions are governed by established standards of nursing care, as well as both state and federal laws. Which are sources of law? SELECT ALL THAT APPLY.
| a. | Constitution |
| b. | Statutes |
| c. | State Nurse Practice Acts |
| d. | Joint Commission standards |
____ 7. A new infusion clinic is being started. The nursing supervisor of the new clinic must conform to specific standards of practice when developing nursing policies and procedures for the new program. To which organizational standards of practice must the nurse manager adhere? SELECT ALL THAT APPLY.
| a. | Centers for Disease Control and Prevention (CDC) guidelines |
| b. | Infusion Nurses Society (INS) standards |
| c. | American Medical Association (AMA) standards |
| d. | Oncology Nursing Society (ONS) standards |
Chapter 3: Fundamentals of Fluid and Electrolyte Balance
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A nurse is assessing an older adult client who is disoriented to time and place. The nurse notes that the client’s eyes are sunken, the mouth is coated, the tongue has an extra longitudinal furrow, and the client’s lips are cracked. The client’s hand vein filling takes more than 5 seconds; tenting is apparent over the sternum; and the vital signs are BP 110/60 mm Hg, pulse 62, and respiratory rate of 12. Based on these assessment findings, which fluid or electrolyte imbalance should the nurse suspect?
| a. | Sodium excess |
| b. | Magnesium deficit |
| c. | Fluid volume deficit |
| d. | Fluid volume excess |
____ 2. A nurse prepares to assess a client who has been vomiting for several days. For which signs of fluid volume deficit (FVD) should the nurse assess?
| a. | Bounding pulse, decreased blood pressure, and moist crackles |
| b. | Dyspnea, jugular vein distention, and sternum fingerprinting |
| c. | Increased pulse rate, decreased blood pressure, and poor skin turgor |
| d. | Increased respiratory rate; warm, moist skin; and decreased body temperature |
____ 3. A nurse assesses a client who has moist crackles (rales) in the lung bases, an increased respiratory rate, dyspnea, and 3+ edema of the ankles. Which is the most accurate nursing diagnosis for this client?
| a. | Fluid volume deficit |
| b. | Fluid volume excess |
| c. | Impaired tissue integrity |
| d. | Altered tissue perfusion, renal |
____ 4. A nurse analyzes a client’s laboratory report that shows a serum potassium level of 5.7 mEq/L. Which client’s laboratory report is the nurse most likely reviewing?
| a. | The client with ulcerative colitis |
| b. | The client with Cushing’s syndrome |
| c. | The client who has overused laxatives |
| d. | The client who has sustained a traumatic burn |
____ 5. A nurse notes that a client admitted with renal failure has a serum phosphorus level of 7.0 mg/dL. Which medication should a nurse expect to be prescribed for this client?
| a. | Calcium gluconate |
| b. | Calcium chloride |
| c. | Calcitonin (Calcimar) |
| d. | Aluminum hydroxide gel (Amphojel) |
____ 6. A nurse is caring for a client with an ileostomy. Which acid-base imbalance will this client most likely experience?
| a. | Metabolic alkalosis |
| b. | Metabolic acidosis |
| c. | Respiratory acidosis |
| d. | Respiratory alkalosis |
____ 7. A nurse assesses a newly admitted client and notes fatigued muscles, reports of nausea and anorexia, irritability, and diminished deep tendon reflexes. The nurse reviews the client’s laboratory reports that reveal a serum chloride level of 92 mEq/L, a serum potassium level of 3.1 mEq/L, and a serum sodium level of 135 mEq/L. Which treatment should the nurse anticipate for this electrolyte imbalance?
| a. | Treatment with sodium bicarbonate |
| b. | Change of infusion to 5% dextrose in water |
| c. | Replacement therapy with potassium chloride |
| d. | Replacement therapy with sodium and chloride |
____ 8. A pediatric nurse is thinking critically to determine the best methods for assessing an infant’s 24-hour fluid needs. Which three methods for assessment of 24-hour fluid needs in an infant should the nurse consider?
| a. | Meter square, diaper weight, and urinary output |
| b. | Meter square, body weight, and caloric methods |
| c. | Meter square, specific gravity of urine, and urinary output |
| d. | Diaper weight, urinary output, and caloric needs |
____ 9. A nurse is administering I.V. potassium at a rate of 15 mEq/hr via a peripheral vein. When infusing potassium at this rate via this route, for which imbalance should the nurse monitor?
| a. | Hypernatremia |
| b. | Hypercalcemia |
| c. | Hyperkalemia |
| d. | Hyperglycemia |
____ 10. A client in a critical-care unit is experiencing drastic fluctuations in serum potassium. Which sentinel event can occur if the client’s serum potassium level is less than 2.5 mEq/L or greater than 7.0 mEq/L?
| a. | Embolic stroke |
| b. | Cardiac arrest |
| c. | Atrial fibrillation |
| d. | Intracranial hemorrhage |
____ 11. A nursing instructor is teaching a group of nursing students about the intracellular and extracellular fluid compartments of the cell. Which is the major electrolyte in the intracellular compartment?
| a. | Calcium |
| b. | Sodium |
| c. | Potassium |
| d. | Bicarbonate |
____ 12. A nursing instructor is teaching a group of nursing students about the intracellular and extracellular fluid compartments of the cell. Which electrolyte is the second most plentiful cation in the intracellular fluid compartment?
| a. | Calcium |
| b. | Sodium |
| c. | Chloride |
| d. | Magnesium |
____ 13. A nurse educator is conducting an in-service presentation on electrolytes. Which group of electrolytes should the educator refer to as being “positively charged”?
| a. | Potassium, sodium, calcium |
| b. | Potassium, sodium, bicarbonate |
| c. | Bicarbonate, phosphate, chloride |
| d. | Chloride, magnesium, bicarbonate |
____ 14. A nurse is caring for a client who has been experiencing prolonged vomiting prior to being admitted to a hospital. The client has experienced development of metabolic alkalosis. Which of the following are manifestations of alkalosis (bicarbonate excess)?
| a. | Tetany, soft tissue calcification |
| b. | Dizziness, tingling of fingers and toes, carpopedal spasm |
| c. | Kussmaul respirations, confusion, increased respiratory rate |
| d. | Impaired mentation, tingling of fingers and toes, depressed respirations |
____ 15. A nurse assesses a newly admitted client and notes fatigued muscles, reports of nausea and anorexia, irritability, and diminished deep tendon reflexes. The nurse reviews the client’s laboratory reports, which reveal a serum chloride level of 92 mEq/L, a serum potassium level of 3.1 mEq/L, and a serum sodium level of 135 mEq/L. Which electrolyte imbalance should the nurse suspect?
| a. | Hyponatremia |
| b. | Hypokalemia |
| c. | Hyperchloremia |
| d. | Hypernatremia |
____ 16. A client presents to an emergency department with confusion, a respiratory rate of 30 breaths per minute, blood pressure 100/70 mm Hg, and a previous admission for renal failure. The client’s arterial blood gases reveal a pH of 7.32, an HCO3 of 20 mEq/L, and a PaCO2 of 34 mm Hg. Which acid-base imbalance should a nurse suspect?
| a. | Metabolic acidosis |
| b. | Metabolic alkalosis |
| c. | Respiratory acidosis |
| d. | Respiratory alkalosis |
____ 17. An intensive care nurse is implementing orders for an elderly client diagnosed with hypermagnesemia. What is the most likely cause of hypermagnesemia in this client?
| a. | Renal failure |
| b. | Nasogastric tubes to suction |
| c. | Use of mechanical ventilators |
| d. | Overzealous administration of I.V. potassium chloride |
____ 18. A nurse is caring for an elderly, hospitalized client diagnosed with emphysema. The client’s arterial blood gases reveal that the blood chemistry is slightly alkaline but is considered physiologically neutral. To be considered physiologically neutral, or normal, what is the client’s serum pH?
____ 19. Which nursing action would be most important after adding 20 mEq potassium chloride to an I.V. bag of 1000 mL of 5% dextrose in water?
| a. | Rotate the bag gently. |
| b. | Attach the tubing to the client. |
| c. | Check the solution for particles. |
| d. | Place the time-tape on the I.V. bag. |
____ 20. A 3-year-old child is hospitalized because of persistent vomiting. For which condition should a nurse carefully monitor the child?
| a. | Diarrhea |
| b. | Metabolic acidosis |
| c. | Metabolic alkalosis |
| d. | Hyperactive bowel |
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 1. A nurse is caring for multiple clients on a medical-surgical unit. Which clients should a nurse identify as being at risk for developing “third spacing?” SELECT ALL THAT APPLY.
| a. | Client with cirrhosis |
| b. | Client with diabetes mellitus |
| c. | Client with sepsis |
| d. | Client with renal failure |
____ 2. The nurse understands that insensible fluid loss occurs through which routes? SELECT ALL THAT APPLY.
| a. | Skin |
| b. | Lungs |
| c. | Urinary output |
| d. | Gastrointestinal tract |
____ 3. A physician orders that a client receives 0.9% sodium chloride intravenously at 150 mL/hr. Which are characteristics of this I.V. solution? SELECT ALL THAT APPLY.
| a. | The solution is isotonic with the plasma. |
| b. | The solution is hypotonic with the plasma. |
| c. | The solution does not affect the plasma’s osmolarity. |
| d. | The solution contains only sodium and chloride ions. |
____ 4. A client, who has been experiencing vomiting and diarrhea for several days, is admitted to a hospital with a fluid volume deficit and numerous electrolyte imbalances. Which organs are involved in the regulation of fluid and electrolyte balance in the client’s body? SELECT ALL THAT APPLY.
| a. | Kidney |
| b. | Lung |
| c. | Pancreas |
| d. | Thyroid gland |
____ 5. A nurse analyzes a client’s laboratory data and notes an increase in serum sodium, a decrease in potassium, an elevated hematocrit, and an increase in blood urea nitrogen. Based on this information, which condition should the nurse anticipate in this client? SELECT ALL THAT APPLY.
| a. | Fluid volume excess |
| b. | Fluid volume deficit |
| c. | Decreased urinary output |
| d. | Increased urinary output |
____ 6. A client is admitted with a diagnosis of hypocalcemia. Which clinical manifestations are indicative of this diagnosis? SELECT ALL THAT APPLY.
| a. | Tingling sensations |
| b. | Hyperactive reflexes |
| c. | Hypotonicity of the muscles |
| d. | Positive Trousseau’s sign |
____ 7. A multidisciplinary health-care team is caring for a client diagnosed with hypercalcemia. Which treatments would be appropriate when treating this imbalance? SELECT ALL THAT APPLY.
| a. | Calcitonin |
| b. | Inorganic phosphates |
| c. | Calcium gluconate I.V. |
| d. | Infusion of 0.45% or 0.9% sodium chloride |
____ 8. A client presents to an emergency department and is diagnosed with respiratory acidosis. A nurse caring for the client knows that respiratory acidosis may be caused by which conditions? SELECT ALL THAT APPLY.
| a. | Asthma |
| b. | Diabetes |
| c. | Pneumonia |
| d. | Emphysema |
____ 9. A nurse in a long-term care facility is assessing the fluid volume status of clients. Which are acceptable methods of assessing fluid volume status in an elderly adult client? SELECT ALL THAT APPLY.
| a. | Skin turgor |
| b. | Presence of bowel sounds |
| c. | Blood pressure |
| d. | Rate and filling of veins of the hand |
Chapter 5: Infusion Equipment
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A nurse is preparing to administer a preoperative antibiotic I.V. piggyback. Which connection should be used to secure a piggyback administration set to the primary administration set?
| a. | Slide clamp |
| b. | Luer lock |
| c. | Slip lock |
| d. | Taping with paper tape |
____ 2. The product evaluation committee at a local hospital has decided to purchase a needleless I.V. system to be used throughout the organization. For which reason did the team most likely make this decision?
| a. | To protect the I.V. line’s integrity |
| b. | To decrease tubing changes |
| c. | To enable quicker blood draws |
| d. | To decrease the risk for needlestick injuries |
____ 3. A nurse is inspecting a container of infusate before client administration. To ensure integrity of a flexible plastic infusate solution container, the nurse should check for:
| a. | solution clarity, expiration date, and air vents. |
| b. | solution clarity, expiration date, and punctures. |
| c. | punctures, cracks, presence of ports, and clarity. |
| d. | punctures, expiration date, and presence of ports. |
____ 4. The nurse wants to maintain the integrity of a peripheral venous catheter. According to Infusion Nurses Society Standards of Practice (2011), peripheral intermittent locking devices must be kept patent following each catheter use with:
| a. | heparin. |
| b. | medication. |
| c. | 0.9% bacteriostatic sodium chloride. |
| d. | combination of sodium chloride followed by heparin flush. |
____ 5. A nurse is preparing an I.V. infusion using a Y-type infusate administration set. The nurse is most likely using this administration set to administer:
| a. | total parenteral nutrition. |
| b. | fat emulsion. |
| c. | primary I.V. solution. |
| d. | packed red cells. |
____ 6. A nurse is preparing to administer I.V. cyclosporine. To prevent leaching of diethylhexyl phthalate (DEHP) by this medication, the nurse should ensure that:
| a. | the pharmacy provides the cyclosporine in a polyvinyl chloride (PVC) bag. |
| b. | cyclosporine is compatible with the client’s other medications. |
| c. | the cyclosporine is administered through non-PVC I.V. tubing. |
| d. | cyclosporine is administered by a physician. |
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 1. A critical-care nurse is using a 0.22-mm filter for the delivery of infusion therapy. According to the Infusion Nurses Society Standards of Practice (2011), for nonlipid-containing solutions that require filtration, a 0.2-mm filter should be
| a. | air eliminating. |
| b. | particulate retentive. |
| c. | fat emboli reducing. |
| d. | bacterial retentive. |
____ 2. A client with osteomyelitis is admitted to the acute-care hospital to begin infusion therapy. The client needs infusion therapy for 3 weeks and has poor venous access. The I.V. team registered nurses are competent to insert peripherally inserted central catheters, as well as midline catheters. Which should be taken into consideration when selecting the most appropriate venous access device? SELECT ALL THAT APPLY.
| a. | The pH and osmolarity of prescribed therapy |
| b. | The interventional radiology support |
| c. | The time it takes to insert the venous access device |
| d. | The patient’s understanding and caregiver support for managing catheter upon discharge |
Chapter 7: Phlebotomy Techniques
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A nurse is preparing to draw blood from an older adult client using a butterfly safety needle. Which is the best angle for needle insertion during venipuncture?
| a. | 15 degrees |
| b. | 30 degrees |
| c. | 45 degrees |
| d. | 90 degrees |
____ 2. A physician orders multiple blood tests for a client. A nurse preparing to collect blood samples knows that most diagnostic blood tests require:
| a. | serum. |
| b. | plasma. |
| c. | whole blood. |
| d. | red blood cells. |
____ 3. A quality-control nurse reviews procedures to decrease the incidence of errors in a hospital laboratory. Which type of test requisition has been shown to decrease laboratory errors?
| a. | Bar coded |
| b. | Computer |
| c. | Manual triplicate forms |
| d. | Verbal requests |
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 1. A clinic nurse is performing venipuncture on multiple clients. Which complications of venipuncture (for venous sampling) should the nurse anticipate? SELECT ALL THAT APPLY.
| a. | Syncope |
| b. | Continued bleeding |
| c. | Thrombosis |
| d. | Septic shock |
____ 2. A nurse is preparing to obtain a blood sample from an infant. Which precautions should the nurse take when obtaining blood from a capillary puncture in an infant? SELECT ALL THAT APPLY.
| a. | Do not puncture deeper than 2.0 mm. |
| b. | Do not puncture over bruised areas. |
| c. | Obtain puncture over plantar surface of heel. |
| d. | Obtain puncture over back of heel. |
Chapter 9: Complications of Infusion Therapy: Peripheral and Central Vascular Access Devices
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A nurse is assisting in the placement of a client’s central venous catheter. The nurse is aware that the major complication that can occur during placement of a central venous access device is:
| a. | phlebitis. |
| b. | infiltration. |
| c. | fibrin sheath formation. |
| d. | intravascular and extravascular malpositioning. |
____ 2. A nurse is caring for a client who has a newly implanted port. For which complication, specifically associated with implanted ports, should the nurse observe?
| a. | Air embolus |
| b. | Occlusion |
| c. | External catheter breakage |
| d. | Displacement of the septum |
____ 3. A nurse is caring for a client who has lipid deposits occluding his or her central line. Which declotting agent should the nurse use to clear lipid deposits from a central line?
| a. | 70% ethanol |
| b. | Hydrochloric acid |
| c. | Sodium bicarbonate |
| d. | Alteplase (Activase) |
____ 4. A client complains to a nurse that his or her I.V. site is “sore.” The nurse notes that the site is red and edematous, but there is no palpable cord or streak. Using the criteria for infusion phlebitis, what should the nurse document as the severity of this phlebitis?
____ 5. A nurse in an intensive care unit is caring for a client who has lipid deposits in her central line. Which agent should the nurse select to instill into the catheter in an attempt to dissolve the lipid deposits?
| a. | Alteplase |
| b. | 70% ethanol |
| c. | Sodium bicarbonate |
| d. | 0.1% hydrochloric acid |
____ 6. A nurse in an intensive care unit is caring for a client who has an intraluminal obstruction of central line due to a thrombotic occlusion. Which declotting agent should the nurse select to remove the blood clots from a central line?
| a. | Alteplase |
| b. | 70% ethanol |
| c. | Sodium chloride |
| d. | Sodium bicarbonate |
____ 7. A nurse assesses that a client has developed 2+ phlebitis at the site of a current peripheral I.V. infusion. Which action should be the nurse’s first priority?
| a. | Notify the physician. |
| b. | Start a new line proximal to the old site. |
| c. | Discontinue the I.V. catheter at that site. |
| d. | Apply warm moist packs to the existing I.V. site. |
____ 8. A nurse priming an I.V. administration set uncaps the distal end to attach a needleless device. Before attachment, the administration set falls and hits the countertop. Which action should be taken by the nurse?
| a. | Attach a new needleless device. |
| b. | Change the administration set. |
| c. | Wipe the tubing port with povidone-iodine. |
| d. | Scrub the needleless device with an alcohol swab. |
____ 9. A nurse assesses the insertion site of a peripheral I.V. catheter and notes that the site is red, warm to touch, and slightly edematous proximal to the I.V. cannula. The client reports discomfort when the site is touched. The nurse should interpret that these signs are most likely due to:
| a. | phlebitis. |
| b. | a venous spasm. |
| c. | hypersensitivity to the I.V. solution. |
| d. | infiltration of the solution into the surrounding tissues. |
____ 10. A client who has a central venous tunneled catheter for administration of chemotherapy presents to a hospital with a fluctuating fever, hypotension, profuse sweating, nausea, and explosive diarrhea. Based on this information, which condition should a nurse suspect?
| a. | Local infection |
| b. | Septicemia |
| c. | Phlebitis at the infusion site |
| d. | Superior vena cava syndrome |
____ 11. A nurse assesses a client who is receiving an intermittent I.V. infusion of vancomycin hydrochloride. The nurse notes that the I.V. site is warm, edematous, and indurated. The nurse also observes red streaking of the skin, peau d’orange skin, and vesicles. Based on this information, which condition should the nurse suspect?
| a. | Occlusion |
| b. | Septicemia |
| c. | Extravasation |
| d. | Thrombophlebitis |
____ 12. A client who has been discharged from a hospital for 48 hours reports pain at a previous infusion site. On inspection of the site, a nurse finds redness and tenderness along the vein. Which condition should the nurse suspect?
| a. | Extravasation |
| b. | Speed shock |
| c. | Bacterial phlebitis |
| d. | Postinfusion phlebitis |
____ 13. A nurse is caring for multiple clients with I.V. access devices. The nurse carefully assesses each client for signs of local complications. For which systemic complication should the nurse observe?
| a. | Phlebitis |
| b. | Hematoma |
| c. | Speed shock |
| d. | Extravasation |
____ 14. A nurse suspects that a client with a peripheral access device is experiencing a venous spasm. Which report by the client should prompt the nurse to suspect this condition?
| a. | Redness along the vein |
| b. | Cold feeling in the extremity |
| c. | Sharp pain extending from the site of infusion |
| d. | Increased temperature at the peripheral infusion site |
____ 15. Which complication of I.V. therapy should a nurse suspect if a client has a fluctuating fever, chills, malaise, tachycardia, tachypnea, hypotension, and altered mental status?
| a. | Septicemia |
| b. | Local infection |
| c. | Thrombophlebitis |
| d. | Inflammatory response syndrome |
____ 16. Upon inspection of a client’s peripheral I.V. site, a nurse notes 2+ phlebitis of the client’s vein. Which action by the nurse is most appropriate?
| a. | Watch the site and document observations. |
| b. | Flush the cannula with 0.9% sodium chloride. |
| c. | Discontinue the cannula and apply heat to site. |
| d. | Leave the cannula in place and apply heat to the site. |
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 1. Upon inspection of a client’s peripheral I.V. site, a nurse notes 3+ phlebitis of the client’s vein. Which action by the nurse is most appropriate? SELECT ALL THAT APPLY.
| a. | Watch the site and document observations. |
| b. | Discontinue the cannula and apply cold to the site initially for approximately 30 to 45 minutes. |
| c. | Elevate extremity slightly. |
| d. | Apply warm compresses after 30 to 45 minutes. |
____ 2. A nurse on a medical-surgical unit is caring for multiple clients. Which clients should the nurse monitor closely for signs of phlebitis because they are at increased risk? SELECT ALL THAT APPLY.
| a. | Client with burns |
| b. | Client who is immunosuppressed |
| c. | Clients receiving total parenteral nutrition (TPN) |
| d. | Client who had multiple I.V. manipulations |
____ 3. A nurse attempts to withdraw a blood sample for laboratory analysis from a central venous catheter (CVC) and is unsuccessful due to an aspiration occlusion. What could potentially be causes of an aspiration occlusion? SELECT ALL THAT APPLY.
| a. | Catheter migration |
| b. | A fibrin tail extending from the catheter tip |
| c. | The catheter tip being pressed up against the vein wall |
| d. | Chylothorax |
Chapter 11: Transfusion Therapy
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. A nurse has transfused a unit of packed RBCs, which has a 250-mL bag of 0.9% sodium chloride attached. The follow-up I.V. order is to hang a 1000-mL bag of 5% dextrose in water. Which steps should be taken by the nurse after completing the transfusion and initiating the next I.V. order?
| a. | Aspirate the I.V. line before connecting the I.V. solution tubing. |
| b. | Infuse the remaining sodium chloride before attaching the new primary I.V. administration set. |
| c. | Flush the blood tubing with sodium chloride before changing to the primary I.V. administration set. |
| d. | Disconnect the tubing while there is blood in the line and attach the primary I.V. administration set. |
____ 2. A nurse obtains a blood specimen for type and cross match for a client suspected of having type A-positive blood. The nurse understands that A-positive blood contains which antibody in the plasma?
| a. | Anti-A |
| b. | Anti-O |
| c. | Anti-B |
| d. | Anti-A and anti-B |
____ 3. A maternal-child nurse is caring for a client who has type A-negative blood, received no prenatal care, and delivered a type A-positive fetus. The nurse is concerned for the client because previous exposure to an antigen through pregnancy or transfusion may cause the client to develop:
| a. | more antigens. |
| b. | an antibody to an antigen. |
| c. | tolerance to a transfusion. |
| d. | alloimmunization to the antibody. |
____ 4. A nurse is caring for a client diagnosed with thrombocytopenia. Thrombocytopenia is an abnormally low number of:
| a. | platelets in the blood. |
| b. | antibodies in the blood. |
| c. | RBCs in the blood. |
| d. | white blood cells in the blood. |
____ 5. A client presents to a hospital laboratory wishing to make an autologous donation. An autologous donation is defined as the donation of:
| a. | bone marrow to be used for transplant. |
| b. | blood by a donor to be used only by the donor. |
| c. | blood directly from one donor to a specified recipient. |
| d. | blood in a similar structure from a volunteer donor to a compatible recipient. |
____ 6. A unit of packed red blood cells (PRBCs) is ordered for a client with anemia. The physician does not specify a rate for the infusion, according to standards of practice. Thus, the nurse should set the transfusion drip rate so that the PRBCs will be infused within:
| a. | 1/2 hour. |
| b. | 1 hour. |
| c. | 2 hours. |
| d. | 4 hours. |
____ 7. A 25-year-old client who is a Jehovah’s Witness was recently diagnosed with multiple myeloma. The client presents with a hemoglobin (Hgb) level of 6 g/dL. The client’s physician orders a transfusion of 4 units of red blood cells, but the client refuses. Which is the most appropriate action by a nurse?
| a. | Do nothing. |
| b. | Administer the transfusion as ordered. |
| c. | Notify the physician of the client’s refusal. |
| d. | Convince the client to accept the transfusion. |
____ 8. A 90-year-old client is receiving 2 units of packed red blood cells. Furosemide (Lasix) 80 mg I.V. pyelography has been ordered after the first unit of blood has infused. The client asks a nurse why she is getting Lasix. The nurse’s response should be based on the understanding that furosemide:
| a. | prevents pulmonary emboli. |
| b. | prevents circulatory overload. |
| c. | lowers the blood pressure. |
| d. | counteracts the transfusion-induced hypercalcemia. |
____ 9. A nurse is caring for a client diagnosed with post-transfusion hepatitis after a blood transfusion. Which virus is the primary cause of post-transfusion hepatitis?
| a. | Hepatitis A virus |
| b. | Hepatitis B virus |
| c. | Cytomegalovirus |
| d. | HIV |
____ 10. A physician orders 1 unit of packed red blood cells for a client diagnosed with anemia. A nurse correctly infuses the blood cells over a period of:
| a. | 1 hour. |
| b. | 2 hours. |
| c. | 4 hours. |
| d. | 6 hours. |
____ 11. A nurse is preparing to administer a unit of packed red blood cells to a client. Which type of I.V. fluid should be used to facilitate the infusion of blood for this client?
| a. | Lactated Ringer’s |
| b. | Normal saline |
| c. | 5% dextrose in water |
| d. | 5% dextrose and normal saline |
____ 12. A nurse is caring for a client who is experiencing thrombocytopenia secondary to chemotherapy. Which laboratory test result would be consistent with thrombocytopenia from chemotherapy?
| a. | Low white blood cell count |
| b. | Low platelet count |
| c. | Low red blood cell count |
| d. | High platelet count |
____ 13. A physician instructs a nurse to obtain a fluid warmer before implementing written orders for a client. The nurse obtains the fluid warmer knowing that it is used primarily for the administration of:
| a. | parenteral nutrition (PN). |
| b. | solutions for the pediatric client. |
| c. | blood. |
| d. | solutions for the geriatric client. |
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 1. A client is concerned about receiving donated blood for fear of contracting AIDS. A nurse reassures the client knowing that all transfusions are screened for which antibodies? SELECT ALL THAT APPLY.
| a. | Syphilis |
| b. | HIV |
| c. | Surface hepatitis B |
| d. | Mononucleosis |
| e. | T-lymphotrophic virus |
____ 2. A nurse sends a client’s blood specimen to the laboratory for a type and crossmatch. For which antigens in the blood system should the laboratory check? SELECT ALL THAT APPLY.
| a. | ABO blood groups |
| b. | Rh factor |
| c. | Immunoglobulin M (IgM) |
| d. | Human leukocyte antigen (HLA) |
____ 3. A nurse is ordered to perform a type and cross match on a client scheduled for surgery. During the “type and cross,” the laboratory technician tests the client’s blood for the presence of which antigens? SELECT ALL THAT APPLY.
____ 4. A nurse is preparing to administer blood to a client. Before hanging a unit of blood, which information is a nurse responsible for verifying with another nurse? SELECT ALL THAT APPLY.
| a. | ABO and Rh |
| b. | Client identification with two independent identifiers |
| c. | Donor unit number |
| d. | Expiration date |
| e. | Client room number |
____ 5. A physician orders an infusion of fresh frozen plasma (FFP) for a client. A nurse administers the infusion knowing that FFP is used for which purposes? SELECT ALL THAT APPLY.
| a. | Platelet deficiencies |
| b. | Demonstrated factor deficiencies |
| c. | Warfarin sodium (Coumadin) drug reversal |
| d. | Antithrombin III deficiency |
Completion
Complete each statement.
1. A client who is to receive 4 units of whole blood has a hemoglobin (Hgb) level of 5 g/dL. A nurse should anticipate that the complete blood count after transfusion will reflect an Hgb of ____ g/dL. Fill in the blank.
