A nurse has just received a unit of packed red blood cells from the blood bank to transfuse into a client as ordered. Before, preparing the blood for transfusion the nurse noticed the presence of bubbles in the bag. The nurse should take which of the following actions?
a. The nurse must look for another registered nurse to double check the bag
b. The nurse must add 10ml of normal saline to the bag to remove the bubbles
c. The nurse must return the bag to the blood bank for replacement
d. The nurse must add 100 units of Heparin to the bag
RATIONALE: The nurse should immediately return the unit of blood to the blood bank. The presence of gas bubbles in the bag indicates possible bacterial growth and unit is considered contaminated.
A nurse is assisting the physician in inserting a chest tube to the client. The nurse selects which of the following materials to be used as the first layer of the dressing at the chest tube insertion site?
a. The nurse must prepare a 4×4 sterile gauze
b. The nurse must put absorbent kelix dressing
c. Petrolatum jelly gauze
d. Gauze with betadine
RATIONALE: The first layer of the chest tube dressing is petrolatum gauze which allowed for an occlusive seal at the chest tube insertion site. Additional layers of gauze cover this layer, and the dressing is secured with a strong adhesive tape or Elastoplast tape.
A physician orders 1L of ½ normal saline to infuse over 8hours. The drop factors is 15 drops per 1ml. A nurse prepares to set the flow rate at how many drops per minute?
a. 20 gtts/minute
b. 28 drops per minute
c. 31 gtts/minute
d. 22 drops per minute
DROP/MIN = total volume in cc x drop factor/no. of hours x 60 minutes
= 1000 ml x 15gtts/8 hours (60 minutes)
= 31.2 or 31gtts/minute
A nurse enters a client’s room to perform physical assessment. The nurse wants to test the reflexes of the client. The nurse does which of the following as the most appropriate nursing action?
a. Use a penlight to shine a light towards the bridge of the nose
b. Stimulate the back of the throat using a tongue depressor
c. Pull down the client’s lower eyelids
d. Ask the client to swallow
RATIONALE: Pharyngeal reflex (gag reflex) is tested by touching the back of the throat with an object, such as a tongue depressor. It is considered normal if there is a positive response to these reflexes.
Mr. Cruz, 40 year old client was diagnosed with chronic pancreatitis. The nurse checks the laboratory results, anticipating a laboratory report that indicates a serum amylase level of _____.
a. 100 units/L
b. 500 units/L
c. 45 units/L
d. 300 units/L
RATIONALE: The normal serum amylase is 25 to 151 IU/L. In client with chronic pancreatitis, the increase in serum amylase does not exceed 3 times the normal value.
At 8:00 AM a nurse is preparing to change the Total Parenteral Nutrition (TPN) solution bag and tubing. The client’s central venous line is located in the right subclavian vein. The nurse would instruct the client to do which of the following most essential items during the tubing change?
a. instruct the client to breathe normally
b. the nurse must turn the head of the client to the right
c. ask the client to take a deep breath, hold it, bear down
d. tell the client to exhale slowly and evenly until tubing change is done
RATIONALE: The nurse should ask the client to perform Valsalva’s maneuver during tubing change this maneuver would help the client to avoid air embolism during the procedure.
A client begins to exhibit atrial fibrillation and has a ventricular rate at 150 beats per minute. The nurse assess the client for _____.
a. nausea and vomiting
b. flat neck veins
c. hypotension and dizziness
d. hypertension and headache
RATIONALE: If client developed uncontrolled atrial fibrillation with a ventricular rate over 100 beats per minute, the client may experience low cardiac output caused by loss of atrial kick. The nurse assesses the client for palpitation, chest pain, or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, shortness of breath and distended neck veins.
A nurse is making initial rounds at the beginning of the shift. She enters the room of a client receiving total parenteral nutrition (TPN) and discovers that the bag is empty. Which of the following solutions readily available on the nursing unit should the nurse hang until another TPN solution is mixed and delivered to the nursing unit?
a. 10% dextrose in water
b. 5% dextrose in water
c. 5% dextrose in 0.9% sodium chloride
RATIONALE: The solution containing the highest amount of glucose should be hung until the new TPN becomes available. The 10% water solution is the best because it minimizes the risk of hypoglycemia
A physician tells a nurse that the client’s intravenous line will be discontinued. A nurse obtains which of the following supplies from the unit supply area for use in applying pressure to the site after removing the intravenous (IV) catheter?
a. Sterile gauze
b. Adhesive bandage
c. Betadine swab
d. Alcohol swab
RATIONALE: A dry sterile dressing such as 2×2 gauze is used to apply pressure to the discontinued IV site. This material is absorbent, sterile and non-irritating.
A physician’s order reads Potassium chloride 30mEq to be added to 1L ml normal saline and to be given over 10-hour period. The available potassium chloride is 40mEq per 20ml. A nurse prepares how many milliliters of Potassium Chloride to administer the correct dose of medication?
Desire available x ml = 30 mEq/40 mEq x 20 ml = 15 ml