Chapter 16 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 16

Question 1

Type: MCMA

A patients peripheral intravenous catheter has infiltrated several times during an 8-hour shift. The nurse realizes that the patient needs a central venous access device. Which intravascular devices could a properly trained nurse insert under the guidelines of the infusion nursing standards of practice?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A triple-lumen catheter

2. A peripherally inserted central catheter

3. A tunneled noncuffed catheter

4. An implanted port

5. A midline catheter

Correct Answer: 2,5

Rationale 1: A triple-lumen catheter is inserted by a physician.

Rationale 2: This catheter can be inserted by nurses educated and skilled in the procedure.

Rationale 3: A tunneled noncuffed catheter is used for long-term therapy and requires an operative procedure for insertion.

Rationale 4: An implanted port is used for long-term therapy and requires an operative procedure for insertion.

Rationale 5: A midline catheter can be inserted by nurses educated and skilled in the procedure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-1

Question 2

Type: MCSA

Which nursing diagnosis would explain the purpose of using a self-sheathing stylet catheter?

1. Risk for Fluid Volume Deficit

2. Risk for Injury

3. Risk for Altered Nutrition

4. Risk for Infection

Correct Answer: 2

Rationale 1: Using a self-sheathing stylet catheter does not improve therapy for fluid volume deficit.

Rationale 2: Risk for Injury is the nursing diagnosis that explains the purpose of the self-sheathing catheter. It is engineered with a safety mechanism that encases the needle in a protective chamber upon removal from the inserted catheter, thus preventing a needle-stick injury.

Rationale 3: The use of a self-sheathing stylet catheter is not related to nutritional status.

Rationale 4: The self-sheathing stylet catheter does not prevent infection.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-1

Question 3

Type: MCSA

The nurse is preparing to discharge a patient after infusing chemotherapy through an implanted port. What instructions for port care would the nurse provide?

1. Apply a nonadhering dressing weekly.

2. Apply a sterile dressing every 2 days.

3. Place a clean bandage daily.

4. No dressings are necessary.

Correct Answer: 4

Rationale 1: Use of a nonadhering dressing is not recommended.

Rationale 2: There is no need to use a sterile dressing.

Rationale 3: Bandaging is not necessary.

Rationale 4: No dressings are necessary because the port is completely under the skin.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-3

Question 4

Type: MCSA

A patient receiving peripheral intravenous therapy is mobile but having difficulty maneuvering the intravenous infusion pump. The nurse would choose which add-on device to allow greater mobility for the patient?

1. A multiflow adapter

2. An extension set

3. A stopcock

4. A filter device

Correct Answer: 2

Rationale 1: A multiflow adapter is used for the administration of two or more infusates simultaneously and does not increase tubing length.

Rationale 2: An extension set is a device that adds length to the existing administration set and allows the patient to move more freely without having to push the intravenous pump.

Rationale 3: A stopcock is used to direct flow of an infusate and would not increase tubing length.

Rationale 4: A filter device provides sterility to the infused parenteral medication or solution but does not increase the tubing length.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-3

Question 5

Type: MCMA

The alarm of a patients infusion delivery system is sounding. The nurse should assess for which conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Air in the line

2. Occlusion of the tubing

3. Infusion complete

4. Wrong fluid being infused

5. Free flow

Correct Answer: 1,2,3,5

Rationale 1: The infusion pump detects the presence of air in the fluid pathway of the set.

Rationale 2: Infusion pumps detect disruptions of flow above the catheter and resistance to flow below the device.

Rationale 3: The preset volume limit has been reached, which sounds the alarm.

Rationale 4: There is no alarm to indicate that the wrong intravenous fluid is infusing.

Rationale 5: The device detects rapid infusion of fluid and sounds the alarm.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-1

Question 6

Type: MCMA

Prior to initiating infusion therapy, which nursing diagnosis is the nurse most likely to incorporate into the patients plan of care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Risk for Infection

2. Alteration in Comfort

3. Impaired Gas Exchange

4. Fluid Volume Deficit

5. Ineffective Individual Coping

Correct Answer: 1,4

Rationale 1: There are inherent risks associated with the invasive nature of infusion therapy. Knowledge of infection control principles is essential for minimizing and preventing complications from infection.

Rationale 2: There is often minimal short-term discomfort to the patient during insertion of the device for infusion therapy.

Rationale 3: This diagnosis does not reflect the purpose of infusion therapy and reflects the respiratory status of the patient.

Rationale 4: Infusion therapy directly reflects the patients fluid volume and electrolyte status.

Rationale 5: The patients coping does not reflect the reason the patient needs infusion therapy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 16-2

Question 7

Type: MCSA

The nurse would initiate which method to facilitate drying of the antiseptic solution applied to the intravenous site?

1. Fan the area

2. Blot the area

3. Blow on the area

4. Allow the area to dry itself

Correct Answer: 4

Rationale 1: Fanning the area is contraindicated as it would increase the risk of infection.

Rationale 2: Blotting the prepped area is contraindicated, as it would increase the risk of infection to the site.

Rationale 3: Blowing on the prepped area is contraindicated, as it would increase the risk of infection to the site.

Rationale 4: Allowing the area to dry itself is the infusion therapy standard of practice.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-2

Question 8

Type: MCMA

The nurse has successfully completed insertion of a peripheral venous catheter. Documentation following the procedure includes which information?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Method of securing the catheter

2. Size, length, and type of catheter

3. Patient complaints of pain during the procedure

4. Patient participation in the procedure

5. Complications of the procedure

Correct Answer: 1,2,3,5

Rationale 1: Documentation of the method of securing the catheter objectively describes the care rendered during the procedure. It also allows for tracking patient outcomes and monitoring care.

Rationale 2: Documentation of the size, length, and type of catheter objectively describes the care rendered during the procedure. It also allows for tracking patient outcomes and monitoring care.

Rationale 3: Documentation of patient complaints of pain during the procedure objectively describes the care rendered during the procedure and the patients response to the procedure. It also allows for tracking patient outcomes and monitoring care.

Rationale 4: Patient participation in the procedure is not considered pertinent information that should be documented when an infusion-therapy-related procedure has been performed.

Rationale 5: Accurate documentation of complications objectively describes the care rendered during the procedure. It also allows for tracking patient outcomes and monitoring care.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-2

Question 9

Type: MCMA

The nurse inspects the intravenous catheter after removal. Documentation would include which information?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Length of catheter

2. Condition of access caps

3. Type of catheter

4. Condition of catheter

5. Size of catheter

Correct Answer: 1,3,4,5

Rationale 1: Documentation of the length of the catheter is necessary after discontinuation of an intravenous catheter to verify that the catheter did not get sheared or broken when entering the patients vascular system.

Rationale 2: This portion of intravenous catheter insertion does not enter the patients vascular system.

Rationale 3: Documentation of the type of catheter is necessary after discontinuation of an intravenous catheter.

Rationale 4: Documentation of the condition of the catheter is necessary after discontinuation of an intravenous catheter because this data will verify that the catheter was intact and was not sheared or broken when entering the patients vascular system.

Rationale 5: Documentation of the size of the catheter is necessary after discontinuation of an intravenous catheter to verify that the catheter did not get sheared or broken when entering the patients vascular system.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-2

Question 10

Type: MCSA

A patient complains of heaviness and swelling in the extremity of the intravenous infusion. The nurse assesses that the skin around the site is stretched, firm, and cool. What primary nursing intervention is indicated?

1. Flush the catheter.

2. Document the finding.

3. Notify the physician.

4. Discontinue the catheter.

Correct Answer: 4

Rationale 1: Flushing the catheter will cause further irritation of the surrounding tissue.

Rationale 2: Documenting the finding is necessary; however, it is not the initial intervention that should be implemented.

Rationale 3: Notifying the health care provider is necessary to obtain treatment of the infiltration, but this is not the initial intervention that would be performed.

Rationale 4: These findings indicate that the catheter is infiltrated. It should be discontinued.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-3

Question 11

Type: MCSA

Which nursing diagnosis would the nurse include in the plan of care for a patient with a catheter embolism?

1. Ineffective Coping

2. Fluid Volume Deficit

3. Impaired Skin Integrity

4. Alteration in Comfort

Correct Answer: 4

Rationale 1: The manner in which a patient copes does not impact this life-threatening emergency.

Rationale 2: A catheter embolism does not reflect signs of fluid loss but rather of decreased vascular perfusion.

Rationale 3: The catheter has broken inside the patients vasculature, and skin integrity will not be altered.

Rationale 4: The patient often experiences chest pain with a catheter embolism.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 16-3

Question 12

Type: MCSA

Following insertion of a peripheral vascular device, the patient immediately complains of shortness of breath, chest pain, and palpitations. What is the nurses initial intervention?

1. Obtain radiographic studies.

2. Notify the physician.

3. Place a tourniquet proximal to the site.

4. Obtain vital signs.

Correct Answer: 3

Rationale 1: Radiographic studies may be indicated, but this is not the initial intervention.

Rationale 2: The physician should be notified, but this is not the initial intervention.

Rationale 3: If a catheter embolism is suspected, immediate interventions must be initiated; the nurse would secure a tourniquet on the patients arm to minimize movement of the catheter.

Rationale 4: Vital signs should be obtained, but this is not the initial intervention.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-3

Question 13

Type: FIB

The flow rate for an IV line is ordered at 60 mL/hr via gravity. The nurse starts the infusion with an infusion set with a drip factor of 10 gtts/mL. The IV should run at _______ drops per minute.

Standard Text:

Correct Answer: 10

Rationale : 60 mL/hr x 10 gtts/mL = 600. 600/ 60(time in minutes) = 10 gtts/min

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-2

Question 14

Type: MCSA

The nurse is caring for a patient receiving medication directly into the cerebrospinal fluid. The nurse correctly describes this procedure as involving which type of catheter?

1. An intraspinal catheter

2. An intrathecal catheter

3. A subcutaneous infusion set

4. An intraosseous catheter

Correct Answer: 2

Rationale 1: An intraspinal catheter is used for procedures such as the delivery of anesthesia, diagnostic testing, and infusions that involve the spine.

Rationale 2: An intrathecal catheter allows for administration of medications directly into the cerebrospinal fluid.

Rationale 3: Subcutaneous infusion sets are designed to deliver medication into the subcutaneous tissues either intermittently or continuously.

Rationale 4: An intraosseous catheter is inserted into the bones of the long legs or iliac crest to treat thermal injuries, trauma, cardiac arrest, or other life-threatening illnesses until the traditional vascular access can be obtained.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-1

Question 15

Type: MCSA

Which intervention would the nurse perform to help prevent an air embolism in a patient receiving intravenous fluid therapy?

1. Open the clamps on administration sets as they are being changed.

2. Wait until solution containers are empty before changing.

3. Use irrigation-type connections on all tubing.

4. Purge air from the system before initiating the infusion.

Correct Answer: 4

Rationale 1: The clamps should be closed.

Rationale 2: Solution containers should be changed before they are totally empty.

Rationale 3: Luer-Lok connections should be used to prevent accidental disconnection of the tubing.

Rationale 4: Infusion systems must be purged of air before the infusion is initiated.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-3

Question 16

Type: MCSA

The patient asks why the physician ordered only red blood cells (packed RBCs) instead of the entire unit of whole blood. What rationale should the nurse provide?

1. RBCs are useful for patients who are experiencing a depletion of clotting factors.

2. It is the only blood that is left in the blood bank.

3. It is an optimal method of transfusing only the specific component needed by the patient.

4. RBCs are useful in preventing transfusion reactions.

Correct Answer: 3

Rationale 1: Cryoprecipitates, plasma, and platelets are used to replace clotting factors.

Rationale 2: Using the only blood left in the blood bank would never be the rationale for a blood transfusion.

Rationale 3: Using only the needed component is a safe and economical use of the blood supply.

Rationale 4: RBCs cannot prevent a transfusion reaction.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-4

Question 17

Type: MCSA

The nurse is caring for an 80-year-old patient who is receiving a unit of whole blood. During the transfusion the nurse prioritizes assessment for which possible complication?

1. Liver failure

2. Infection

3. Fluid overload

4. Thrombosis

Correct Answer: 3

Rationale 1: Liver failure is not associated with blood transfusions.

Rationale 2: The clinical manifestations of bacterial contamination may not occur until the transfusion is complete, or in some instances several hours later, depending on the virulence of the infecting organism. This is not the most critical assessment during the transfusion.

Rationale 3: Older patients are at high risk for fluid volume overload during blood transfusions. Whole blood has the most volume, so it also carries the highest risk of causing fluid overload.

Rationale 4: An increased risk for thrombosis is not common during blood transfusion.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-5

Question 18

Type: MCMA

A patient admitted 14 hours ago following a motorcycle accident has received 20 units of blood due to massive hemorrhage. Nursing assessment for which complications is essential?


Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Coagulation imbalances

2. Acid-base imbalance

3. Hypocalcemia

4. Elevated blood ammonia titers

5. Hypokalemia

Correct Answer: 1,2,3,4

Rationale 1: Patients who have repeated exposure to blood products and the preservatives used to store blood products have an increased risk of developing coagulation imbalances.

Rationale 2: Patients who have repeated exposure to blood products and the preservatives used to store blood products have an increased risk of developing acid-base imbalance.

Rationale 3: Patients who have repeated exposure to blood products and the preservatives used to store blood products have an increased risk of developing hypocalcemia.

Rationale 4: Patients who have repeated exposure to blood products and the preservatives used to store blood products have an

increased risk of developing elevated blood ammonia titers.

Rationale 5: Patients who have repeated exposure to blood products and the preservatives used to store blood products have an increased risk of developing hyperkalemia, not hypokalemia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-5

Question 19

Type: MCSA

The nurse understands that the osmotic makeup of the blood has an effect on the composition of interstitial spaces. Because of this factor, the nurse plans to assess the patient for which complication?

1. Transfusion reaction

2. Hypovolemia

3. Infection

4. Circulatory overload

Correct Answer: 4

Rationale 1: Transfusion reactions are not associated with the osmotic makeup of the blood.

Rationale 2: Hypovolemia is not a consideration because the volume is being increased, not decreased.

Rationale 3: Infections do not manifest themselves until after the completion of the transfusion and are not related to the osmolality of the blood.

Rationale 4: Circulatory overload can occur with transfusions because the increased osmotic makeup of the blood causes fluid to be mobilized from the interstitial space, thereby increasing intravascular volume well beyond that given during the transfusion. High-risk patients include the elderly and those individuals who already have increased circulatory volume or who have a history of heart failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-5

Question 20

Type: MCSA

The nurse is caring for a patient who suddenly developed severe respiratory distress after a blood transfusion. The health provider makes the diagnosis of transfusion-related acute lung injury (TRALI). The nurse explains which implication of this diagnosis?

1. The patient can never have another transfusion again from any donor.

2. If transfusions are necessary, it will be important to use specially screened blood from which white blood cells have been removed.

3. The patient can never have another transfusion from the same donor.

4. Close family members of the patient should never have a blood transfusion.

Correct Answer: 3

Rationale 1: It is acceptable for the patient to have another transfusion from another donor.

Rationale 2: There is no indication that specially screened blood or blood with no white blood cells is required.

Rationale 3: The exact cause of this complication is not fully understood. One prevailing theory is that TRALI is caused by the presence of granulocyte antibodies and biologically active lipids in the donor plasma that the recipient reacts to. If antibodies are present in the donors plasma, they stimulate the WBCs in the recipients blood. Once TRALI has occurred, the recipient should not receive any more transfusions from the same donor.

Rationale 4: Family members should be informed, but this is not an indication that they should not have transfusions.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-5

Question 21

Type: MCSA

The policy and procedure for blood administration call for giving no more than 30 mL in the first 15 minutes. To give that much through tubing with 10 gtts/mL, what would the drip rate be?

1. 60 gtts/min

2. 20 gtts/min

3. 12 gtts/min

4. 5 gtts/min

Correct Answer: 2

Rationale 1: This is an incorrect calculation of the drip rate.

Rationale 2: If the patient is to receive 30 mL in 15 minutes, that would be 2 mL per minute. At 10 gtts per mL, that would be 20 gtts per minute.

Rationale 3: This is an incorrect calculation of the drip rate.

Rationale 4: This is an incorrect calculation of the drip rate.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-2

Question 22

Type: MCSA

Which patient statement indicates the need for further teaching about blood transfusions?

1. There is no risk of a disease being transmitted through the transfusion of someone elses blood.

2. There is still some risk of contracting hepatitis B through a blood transfusion.

3. There is still some risk of contracting hepatitis C through a blood transfusion.

4. There is a period of time when HIV-contaminated blood will test negative.

Correct Answer: 1

Rationale 1: It is not true that there is no risk of disease transmission from a blood transfusion. The patient requires additional teaching.

Rationale 2: Some risk of hepatitis B transmission remains because of the window in which the patient has not produced antibodies.

Rationale 3: There is a slight risk for contracting hepatitis C from a transfusion.

Rationale 4: There is currently an 11-day window between infection and detecting the presence of antibodies.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-5

Question 23

Type: MCSA

A patient is in critical need of additional blood transfusions related to massive hemorrhage. The blood bank has no blood that matches

the patients type. The nurse would agree to administer non-type-specific blood if the patient has which blood type?

1. B

2. AB

3. A

4. O

Correct Answer: 2

Rationale 1: A patient with type B blood has A antibodies.

Rationale 2: Type AB blood has no antibodies. A person with type AB blood can receive any type of blood in an emergency situation and is referred to as a universal recipient.

Rationale 3: A person with blood type A has B antibodies.

Rationale 4: A person with type O blood has antibodies to both type A and type B.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-5

Question 24

Type: MCSA

A unit of packed red blood cells was ordered for a patient. Twenty minutes after the blood began infusing, the patient developed dyspnea, chest pain, bloody urine, and a decrease in blood pressure. The nurse would characterize this as which type of transfusion reaction?

1. Allergic

2. Febrile nonhemolytic

3. Delayed hemolytic

4. Acute hemolytic

Correct Answer: 4

Rationale 1: Allergic reactions are manifested by itching, hives, flushing, and chills.

Rationale 2: Febrile nonhemolytic reactions are manifested by increased pulse rate, temperature increase of 1C, chills, headache, nausea and vomiting, anxiety, flushing, back pain, and muscle aches.

Rationale 3: Delayed hemolytic reactions are manifested by fever, anemia, increased bilirubin level, decreased or absent haptoglobin, and jaundice.

Rationale 4: Bloody urine and decreased urine output, petechiae, jaundice, decreased blood pressure, chest tightness, low back pain, nausea, anxiety, dyspnea, hypotension, bronchospasm, hemoglobinemia, acute renal failure, shock, cardiac arrest, and death are symptoms that typically occur within the first 15 minutes of the transfusion with an acute hemolytic reaction.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-5

Question 25

Type: MCMA

A patient had an acute hemolytic transfusion reaction that resulted in death. When discussing this situation with nursing staff, the manager should consider which possible causes of this reaction?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Nurses error when checking the blood

2. WBC incompatibility

3. ABO incompatibility of the donor and recipient

4. Recipients sensitivity to foreign plasma proteins

5. Contaminated blood

Correct Answer: 1,3

Rationale 1: Acute hemolytic reactions may be due to a mistake in labeling by the laboratory or blood bank or a nursing error.

Rationale 2: WBC incompatibility causes febrile nonhemolytic reactions.

Rationale 3: This is the physiological reason for the transfusion reaction.

Rationale 4: Recipient sensitivity to foreign plasma proteins causes allergic reactions.

Rationale 5: Contaminated blood causes infections, not transfusion reactions.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-5

Question 26

Type: MCMA

The nurse has chosen the nursing diagnosis Risk of Injury for a patient who will likely need several blood transfusions to treat gastrointestinal bleeding. What rationale would the nurse provide for this choice?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. There is a risk of dehydration.

2. The patient has a risk of iron overload.

3. There is risk of hemolysis of red blood cells.

4. There is a risk for social isolation.

5. There is a risk for hearing loss.

Correct Answer: 2,3

Rationale 1: The patient receiving blood transfusions may experience fluid overload if fluid is given too quickly or from the physiologic action of the blood on interstitial fluids.

Rationale 2: Iron overload can occur if a patient chronically requires blood transfusions, as in the case of gastrointestinal bleeding, until the source of bleeding is identified and the bleeding is stopped.

Rationale 3: Transfusion reactions are a verified risk for this patient. Hemolytic transfusion reactions result in destruction of red blood cells.

Rationale 4: There is no reason a patient receiving blood transfusions should be isolated.

Rationale 5: Hearing loss is not a complication of blood transfusions.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16-5

Question 27

Type: MCSA

Which technique should the nurse use when infusing fresh frozen plasma?

1. Administer slowly.

2. Give through a filter.

3. Agitate the bag periodically.

4. Give IV push.

Correct Answer: 2

Rationale 1: Fresh frozen plasma is effective for rapid volume replacement.

Rationale 2: Fresh frozen plasma should be administered through a filter.

Rationale 3: There is no need to agitate the bag.

Rationale 4: Fresh frozen plasma is not given IV push.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-4

Question 28

Type: FIB

The nurse is planning to administer 10 units of platelets to a patient with thrombocytopenia. The nurse plans to have a platelet count drawn within _______ minutes of the end of the transfusion.

Standard Text:

Correct Answer: 60

Rationale : The best way to assess the therapeutic effect of platelet administration is to have a platelet count drawn within 1 hour following transfusion.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-4

Question 29

Type: MCSA

A patient is to receive Factor VIIa. How will the nurse plan to administer this factor?

1. By IV bolus

2. By slow IV infusion

3. Subcutaneously

4. Rapid IV drip

5.

Correct Answer: 1

Rationale 1: Factor VIIa is administered by IV bolus only.

Rationale 2: This is not the correct method of infusing Factor VIIa.

Rationale 3: This is not the correct method of infusing Factor VIIa.

Rationale 4: This is not the correct method of infusing Factor VIIa.

Rationale 5:

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16-4

Question 30

Type: MCMA

A patient has been prescribed 3 units of packed red blood cells. How should the nurse proceed?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Start an IV site with an 18-gauge catheter.

2. Obtain special Y-type tubing.

3. Attach D5NS to the selected tubing and prime the line.

4. Warm the blood for at least one hour before beginning the transfusion.

5. Stay with the patient for the first 15 minutes of the transfusion.

Correct Answer: 1,2,5

Rationale 1: A 16- to 20-gauge catheter is required for RBCs to pass through without being damaged.

Rationale 2: Y-type blood transfusion tubing is used for transfusions.

Rationale 3: Blood is always given with plain normal saline (NS).

Rationale 4: Blood transfusion should begin within 30 minutes of obtaining the blood from the blood bank.

Rationale 5: The nurse must be present with the patient to assess for clinical manifestations of transfusion reaction. The first 15 minutes are the most critical time for assessment, but the nurse must monitor the patient frequently.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16-5

Question 31

Type: FIB

A patient has received a unit of packed red blood cells. If the patient is not bleeding, the nurse would expect that the hematocrit would rise _____ %.

Standard Text:

Correct Answer: 3

Rationale : The nurse can anticipate that the hematocrit will rise 3% for each unit of packed RBCs if the patient is not bleeding.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 16-5

 

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