NNN

Fundamentals of Nursing

Oct 03, 20246 min read

Practice Questions

Helena is a post-surgical patient with a hemoglobin level of 7.6 g/dL and hematocrit of 25%. Today, she was prescribed with pRBC transfusion. You took the client’s temperature and it was at 38.2°C orally. Which of the following is a correct intervention?

  • Proceed with the transfusion. This is a normal finding post-surgery.
  • Administer an anti-histamine before proceeding.
  • Administer two tablets of Acetaminophen before proceeding.
  • Notify the physician and defer the transfusion.

Prior to explaining the procedure to the client, which of the following responses is the most important cue prior to the health teaching?

  • “I have had a transfusion before.”
  • “I am allergic to eggs.”
  • “I think I know why I need to be transfused with blood.”
  • None of the above

You are currently monitoring a client who is undergoing blood transfusion when suddenly he experienced chills, urticaria, hypotension, and respiratory distress. Which action should be taken?

  • Remove the intravenous (IV) line.
  • Run a solution of 5% dextrose in water.
  • Run normal saline at a keep-vein-open rate.
  • Obtain a culture of the tip of the catheter device removed from the client.

You have read from the chart that a blood transfusion was prescribed to Gella, a patient with aplastic anemia. Which of the following actions should you do FIRST?

  • Check patient VS.
  • Order the blood from blood bank
  • Obtain Y site blood administration tubing
  • Look for signed informed consent.

After the blood transfusion, you assessed the client for blood transfusion reactions. The following assessments were noted: HR: 120 bpm, Pulse: +4 in quality, presence of fine, short, high pitched crackling at base. Which of the following is your FIRST action?

  • Maintain bed rest with legs elevated.
  • Place the client in high-Fowler’s position.
  • Increase the rate of infusion of intravenous fluids.
  • Consult with the primary health care provider (PHCP) regarding initiation of oxygen therapy.

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first?

  • Slow the IV infusion.
  • Sit the client up in bed.
  • Remove the IV catheter.
  • Call the primary health care provider (PHCP).

You need to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride. However, since the patient also has infection, she is also prescribed with piperacillin/tazobactam and it also needs to be administered now. The client has one IV site. Which action should you do first?

  • Start a second IV site.
  • Check compatibility of the medication and IV fluids.
  • Mix the prepackaged piperacillin/tazobactam per agency policy.
  • Prime the tubing with the IV solution and back-prime the medication.

You are currently inserting an IV line into a client. While you were inserting it, which of the following signs should you stop advancing the catheter?

  • The catheter advances easily.
  • The vein is distended under the needle.
  • The client does not complain of discomfort.
  • Blood return shows in the backflash chamber of the catheter.

Nurse Jasmine provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement?

  • “I need to wear a MedicAlert tag or bracelet.”
  • “I need to restrict my activity while this catheter is in place.”
  • “I need to keep the insertion site protected when in the shower or bath.”
  • “I need to check the markings on the catheter each time the dressing is changed.”

Raymond is a 5 year old with chronic disease. He had just undergone insertion of central venous catheter via ultrasound. Which of the assessment data should you look first prior to administration of IV fluids?

  • Serum osmolality
  • Serum electrolyte levels
  • Intake and output record
  • Chest radiology results
  • [ ]9 normal saline solution had been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 12 hours to increase urine output and maintain the client’s blood pressure. Upon entering the Justine’s room, the you noted that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previously known data?
  • Excessive bleeding
  • Crackles in the lungs
  • Incompatibility of the infusion
  • Chest pain radiating to the left arm

Terlipressin was prescribed to Erlita due to bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which essential item is needed during the administration of this medication?

  • An airway
  • A suction setup
  • A cardiac monitor
  • A tracheotomy set

Elise is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription?

  • Discontinue the PN.
  • Decrease PN rate to 50 mL/hour.
  • Start 0.9% normal saline at 25 mL/hour.
  • Continue current infusion rate prescriptions for PN.

Nurse Fely is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. Which of the following assessment findings is the MOST ALARMING?

  • Temperature: 38.1 C
  • Expiration date is next month
  • Dressing change due today
  • Tight tubing connections

You are preparing to hang fat emulsion and observes that fat globules are visible at the top of the solution. Which of the following actions should you take?

  • Roll the bottle of solution gently.
  • Obtain a different bottle of solution.
  • Shake the bottle of solution vigorously.
  • Run the bottle of solution under warm water.

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