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A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first?
- A. Amount of pressure in fluid container
- B. Date of catheter tubing change
- C. Percent of heparin in infusion container
- D. Presence of an ulnar pulse
Correct Answer: D
Rationale: An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of an ulnar pulse is one way to assess circulation to the arm in which the catheter is located. The other assessments are relevant but secondary to ensuring circulation.
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A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?
- A. Apply cold compresses to the IV site.
- B. Elevate the extremity on a pillow.
- C. Flush the catheter with normal saline.
- D. Stop the infusion of intravenous fluids.
Correct Answer: D
Rationale: Edema and tenderness suggest infiltration or phlebitis, requiring immediate cessation of the infusion to prevent further tissue damage. Flushing could worsen the issue, and cold compresses or elevation are secondary actions.
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.
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.
A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next?
- A. Begin the prescribed infusion via the new access.
- B. Ensure an x-ray is completed to confirm placement.
- C. Check medication calculations with a second RN.
- D. Make sure the solution is appropriate for a central line.
Correct Answer: B
Rationale: A central venous access device, once placed, needs an x-ray confirmation of proper placement before it is used. The bedside nurse would be responsible for beginning the infusion once placement has been verified. Any IV solution can be given through a central line.
A registered nurse (RN) delegates client care to an experienced licensed practical nurse (LPN). Which standards should guide the RN when delegating aspects of IV therapy to the LPN? (Select all that apply.)
- A. State Nurse Practice Act
- B. The facility's Policies and Procedures
- C. The LPN's level of education and experience
- D. The Joint Commission's goals and criterion
- E. Client needs and prescribed orders
Correct Answer: A,B
Rationale: The State Nurse Practice Act and facility policies guide delegation, as they outline LPN scope of practice. Other factors like experience and client needs are considered but are not primary standards.