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A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?
- A. The catheter has been in place for 20 hours.
- B. The client has poor vascular access in the upper extremities.
- C. The catheter is placed in the proximal tibia.
- D. The client's left lower extremity is cool to the touch.
Correct Answer: D
Rationale: A cool extremity suggests decreased blood flow, potentially indicating compartment syndrome, a critical condition that could lead to limb loss if not addressed immediately. The other findings are less urgent.
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A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multi-dose vial of heparin with a concentration of 100 units/ml. Which of the syringe shown below should the nurse use to draw up and administer the heparin?
- A. 1-ml syringe
- B. 3-ml syringe
- C. 5-ml syringe
- D. 10-ml syringe
Correct Answer: D
Rationale: A 10-ml syringe is required for flushing PICC lines to avoid high pressure that could rupture the catheter. Smaller syringes generate higher pressure, increasing the risk of damage.
A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the bloodstream infection?
- A. Initiate a dedicated team to insert access devices.
- B. Require additional education for all nurses.
- C. Limit the use of peripheral venous access devices.
- D. Perform quality control testing on skin preparation products.
Correct Answer: A
Rationale: A dedicated IV team reduces complications, including bloodstream infections, improving outcomes. Education is helpful but less impactful, and limiting peripheral devices or testing products is less effective.
A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain?
- A. Administer topical lidocaine to the site.
- B. Place warm compresses on the site.
- C. Administer prescribed oral pain medication.
- D. Massage the site with scented oils.
Correct Answer: B
Rationale: Warm compresses help relieve pain from phlebitis after catheter removal. Lidocaine, oral medication, and massage are not standard treatments for this condition.
A nurse is calculating the infusion rate for a medication to be delivered. (Record your answer using a whole number.) drops/min
- A. 10 drops/min
- B. 12 drops/min
- C. 14 drops/min
- D. 16 drops/min
Correct Answer: D
Rationale: The correct infusion rate is 16 drops/min, as specified in the document.
A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) Patient Blood coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.)
- A. Unique facility identifier
- B. Lot number related to the donor
- C. Name of the client receiving blood
- D. ABO group and Rh type of the donor
- E. Blood type of the client receiving blood
Correct Answer: A,B,D
Rationale: The ISBT system requires a unique facility identifier, lot number, product code, and ABO/Rh type of the donor. Client-specific information is not included on the blood label.