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NCLEX: IV therapy and Blood Transfusions Exam Questions & Answers

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NCLEX: IV therapy and Blood Transfusions Exam Questions & Answers -A client with a peripherally inserted central venous catheter (PICC) in the right upper extremity suddenly exhibits chest pain, dyspnea, hypotension, and tachycardia. The nurse suspects an embolism related to the PICC line. What sho...

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  • December 29, 2022
  • September 27, 2024
  • 25
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • nclex iv therapy and blood transfusions exam questions amp answers
  • nclex iv therapy and blood transfusions
  • iv therapy and blood transfusions
  • a client with a peripherally inserted central venous ca

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NCLEX: IV therapy and Blood Transfusions
Exam Questions & Answers
A client with a peripherally inserted central venous catheter (PICC) in the right upper extremity
suddenly exhibits chest pain, dyspnea, hypotension, and tachycardia. The nurse suspects an embolism
related to the PICC line. What should the nurse do?
- When a client has any type of central catheter, there is a risk for breaking of the catheter,
dislodgement of a thrombus, or entry of air into the circulation, all of which can lead to an embolism.
Signs and symptoms that this complication is occurring include sudden chest pain, dyspnea,
tachypnea, hypoxia, cyanosis, hypotension, and tachycardia. If this occurs, the nurse should CLAMP
THE CATHETER, PLACE THE CLIENT ON THE LEFT SIDE WITH THE HEAD LOWER
THAN THE FEET (TO TRAP THE EMBOLISM IN THE RIGHT ATRIUM OF THE HEART),
ADMINISTER OXYGEN, AND NOTIFY THE HCP.

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 intravenous (IV) bag has
400 mL remaining. The nurse should take which action first?
1. Slow the IV infusion
2. Sit the client up in the bed
3. Remove the IV catheter
4. Call the health care provider – 1

The client's symptoms are compatible with circulatory overload. This may be verified by noting that
600 mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion.
Other actions may follow in rapid sequence. The nurse must elevate the head of the bed to aid the
client's breathing, if necessary. The nurse also notifies the HCP. The IV catheter is not removed, it
may be needed for the administration of medications to resolve the complication

The nurse has a prescription to hang at 1000 mL intravenous (IV) bag of 5% dextrose in water with
20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan
to take which action immediately after injecting the potassium chloride into 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
4. Check the solution for yellowish discoloration - 1
After adding a medication to a bag of IV solution, the nurse should agitate or rotate the bag gently to
mix the medication evenly in the solution. The nurse should then attach a completed medication label.
The nurse can then prime the tubing. The IV solution should have been checked for discoloration
before the medication was added to the solution. The tubing is attached to the client last.

,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 should place the mark
for noon at which numerical level (mL) on the time tape? _____ mL
- 375 mL

If the IV is scheduled to run over 8 hours, then the hourly rate is 125 mL/hr. Using 500 mL as the
reference point, the next hourly marking would be at 375 mL, which is 125 mL less than 500.

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The
nurse notes that a client's intravenous (IV) site is cool, pale, and swollen, and the solution is not
infusing. The nurse concludes that which complication has occured?
1. Infection
2. Phlebitis
3. Infiltration
4. Thrombosis – 3

An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor,
coolness, and swelling are the results of IV fluid being deposited in the subcutaneous tissue. When
the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop.
The corrective action is to remove the catheter and start a new IV line at another site. Infection,
phlebitis, and thrombophlebitis are likely to be accompanied by warmth at the site, not coolness.

The nurse is inserting an intravenous line into a client's vein. After the initial stick, the nurse would
continue to advance the catheter in which situation?
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 – 4

The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV
catheter. The vein should have be distended by the tourniquet before the vein was cannulated. Client
discomfort varies with the client, the site, and the nurse's insertion technique and is not a reliable
measure of cathater placement. The nurse should not advance the catheter until the placement in the
vein is verified by blood return.

The nurse notes that the site of a client's peripheral intravenous (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 should document in the medical record that the client
experienced which condition?
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 – 1

Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth,
and swelling proximal to the catheter. If phlebitis occurs, the nurse should discontinue the IV line and
insert a new IV line at a different site. Coolness at the site would be noted if the IV catheter was
infiltrated. An allergic reaction produces a rash, redness, and itching. A mahor reaction, such as
hypersensitivity, can cause dyspnea, a swollen tongue, and cyanosis.

The nurse is preparing a continous intravenous (IV) infusion at the medication cart. As the nurse goes
to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top
of the medication cart. The nurse should take which action?
1. Obtain a new IV bag
2. Obtain new IV tubing
3. Wipe the spike end of the tubing with betadine
4. Scrub the spike end of the tubing with an alcohol swab – 2

The nurse should obtain new IV tubing because contamination has occurred and could cause systemic
infection to the client. There is no need to obtain a new IV bag because the bag was not contaminated.
Wiping with Betadine or alcohol is insufficient and is contraindicated because the spike will be
inserted into the IV bag.

A health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse
should obtain which item 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 2x2 gauze – 4

A dry sterile dressing such as a sterile 2x2 is used to apply pressure to the discontinued IV site. This
material is absorbent, sterile, and nonirritating. A Betadine swab would irritate the opened puncture
site and would not stop the blood flow. An adhesive bandage or elastic wrap may be used to cover the
site once hemostasis has occurred.

A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The nurse
assesses the site and determines that phlebitis has developed. The nurse should take which action(s)
in the care of this client? Select all that apply.
1. Notify the health care provider
2. Remove the IV catheter at the site
3. Apply warm moist packs to the site
4. Start a new IV line in a proximal portion of the same vein
5. Document the occurrence, actions taken, and the client's response - 1, 2, 3, 5

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