Health and Healing IV Nurs 4506 Test 2

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Sample questions from Health and Healing IV Nurs 4506 Test 2

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.At change of shift on a medical-surgical unit, the RN receives report on four clients. Which client should the RN assess first?

   • A.A 72-year-old with chronic heart failure who has unchanged bilateral ankle edema and an SpO2 of 94% on room air
   • B.A 68-year-old receiving IV antibiotics whose temperature is 38.1 C and who is waiting for a scheduled dose
   • C.A 45-year-old with a peripheral IV whose site is cool, pale, and swollen, with a slowed infusion
   • D.A 29-year-old requesting discharge instructions after an uncomplicated appendectomy, with BP 122/76 mm Hg and HR 82/min

   Rationale: The cool, pale, swollen IV site and slowed infusion suggest infiltration, so the RN should promptly assess the site and stop the infusion as indicated. The client with a fever needs timely evaluation, but the reported temperature and pending antibiotic do not outweigh a potentially worsening IV complication. The stable chronic edema and routine discharge teaching can be addressed after urgent needs. Prioritize an active change that may cause harm over stable findings or planned care.

2. 2.During an evening shift on a pediatric unit, a 6-year-old with a peripheral IV is receiving maintenance fluids at 60 mL/hr. The child is alert, has a temperature of 37.1 C, HR 104/min, RR 22/min, BP 98/60 mm Hg, and SpO2 99% on room air. Which actions may the RN delegate to an unlicensed assistive personnel (UAP) for this stable client? Select all that apply.

   • A.Teach the parent how to identify signs of IV infiltration
   • B.Obtain and report the child's routine vital signs
   • C.Notify the RN promptly if the child reports pain at the IV site
   • D.Adjust the IV pump rate to compensate for fluid that infused late
   • E.Measure and record oral intake and urine output
   • F.Assess the IV site for infiltration and decide whether the infusion should be stopped

   Rationale: A UAP may collect routine vital signs and measure and record intake and output for a stable client; the RN interprets the findings. Reporting a new complaint of IV-site pain is appropriate because the RN must assess for a complication. Assessing the site, teaching the parent, and changing a pump rate require nursing judgment or education and should not be delegated to a UAP.

3. 3.A provider prescribes an IV medication for a 34-year-old client in the outpatient infusion clinic. The order reads, "potassium chloride 10 mEq IV push now." The client is alert, with HR 88/min, BP 118/72 mm Hg, and a serum potassium of 2.9 mEq/L. What should the RN do?

   • A.Clarify the prescription with the provider before administering the medication
   • B.Ask a second RN to verify the dose and then administer it by IV push
   • C.Administer the medication slowly through the existing peripheral IV
   • D.Dilute the medication in a small amount of saline and administer it over 5 minutes

   Rationale: Potassium chloride must not be administered by IV push, so the RN should hold the medication and clarify the unsafe prescription. A second-nurse check does not make an unsafe route acceptable. Diluting it or giving it slowly by push still leaves the dangerous route unchanged. The exam takeaway is to question and clarify any medication order that presents an immediate safety risk.

4. 4.In a community clinic, a 16-year-old with type 1 diabetes is scheduled for an IV contrast study and tells the RN, "I took my usual insulin, but I have not eaten because I was told to fast." The client is diaphoretic and shaky; glucose is 54 mg/dL, HR 112/min, and BP 108/66 mm Hg. Which action should the RN take first?

   • A.Complete the contrast-study checklist before addressing the glucose result
   • B.Give the client the scheduled insulin dose to prevent hyperglycemia during the procedure
   • C.Ask the parent to drive the client home to eat a meal
   • D.Notify the radiology department that the procedure must be delayed and treat the hypoglycemia per protocol

   Answer and rationale are in the full material.

5. 5.In the emergency department, a 52-year-old with a central venous catheter develops shaking chills during an IV infusion. The temperature rises from 37.2 C to 39.0 C, HR is 124/min, RR is 24/min, BP is 88/54 mm Hg, and SpO2 is 95% on room air. Which action should the RN take first?

   • A.Administer an antipyretic and continue the infusion at the prescribed rate
   • B.Stop the infusion, maintain access as appropriate, and immediately notify the provider while initiating the sepsis response
   • C.Wait 30 minutes and repeat the temperature before taking action
   • D.Remove the central venous catheter and send the client home with oral fluids

   Answer and rationale are in the full material.