1. 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
dyspnic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous
(IV) bag has 400 mL remaining. The nurse should take which action first?

a) Slow the IV infusion

b) . 2. Sit the client up in bed.
c) Remove the IV catheter.
d) Call the health care provider (HCP).

2. The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water
with 20 mEq of potassium chloride. The nurse also needs to hang an IV infusion of piperacillin
tazobactam. The client has one IV site. The nurse should plan to take which action first?

a) Start a second IV site.

b) Check compatibility of the medication and IV fluids.
c) Mix the prepackaged piperacillin/tazobactam per agency policy.
d) Prime the tubing with the IV solution, and back prime the medication.

105. The nurse is completing a time tape for a 1000-mL intravenous (IV) bag that is scheduled to
infuse over 8 hours. The nurse has just placed the 1100 marking at the 500-mL level. The nurse
would place the mark for 1200 at which numerical level (mL) on the time tape? Fill in the blank.
Answer: ______ mL

106. The nurse is making initial rounds on the nursing unit to assess the condition of assigned
clients. Which assessment findings are consistent with infiltration? Select all that apply.

a) Pain and erythema

b) Pallor and coolness
c) Numbness and pain
d) Edema and blanched skin
e) Formation of a red streak and purulent drainage

107. The nurse is inserting an intravenous (IV) line into a client’s vein. After the initial stick, the
nurse would continue to advance the catheter in which situation?
 a) The catheter advances easily.
b) The vein is distended under the needle.
c) The client does not complain of discomfort.
d) Blood return shows in the back-flash chamber of the catheter.

108. The nurse is assessing a client’s peripheral intravenous (IV) site after completion of a
vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous
proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best?

a) Check for the presence of blood return.

b) Remove the IV site and restart at another site.
c) Document the findings and continue to monitor the IV site.
d) Call the health care provider (HCP) and request that the vancomycin be given orally.

109. The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the
nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike
end hits the top of the medication cart. The nurse should take which action?

a) Obtain a new IV bag.

b) Obtain new IV tubing.
c) Wipe the spike end of the tubing with povidone iodine.
d) Scrub the spike end of the tubing with an alcohol swab.

110. A health care provider has written a prescription to discontinue an intravenous (IV) line.
The nurse should obtain which item from the unit supply area for applying pressure to the site
after removing the IV catheter?

a) Elastic wrap
b) Povidone iodine swab
c) Adhesive bandage
d) Sterile 2Â2 gauze

111. A client rings the call light and complains of pain at the site of an intravenous (IV) infusion.
The nurse assesses the site and determines that phlebitis has developed. The nurse should take
which actions in the care of this client? Select all that apply.
 a) Remove the IV catheter at that site.
b) Apply warm moist packs to the site.
c) Notify the health care provider (HCP).
d) Start a new IV line in a proximal portion of the same vein.
e) Document the occurrence, actions taken, and the client’s response.

112. A client involved in a motor vehicle crash presents to the emergency department with
severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse
anticipates that which intravenous (IV) solution will most likely be prescribed for this client?

a) 5% dextrose in lactated Ringer’s solution

b) 0.33% sodium chloride (1/3 normal saline)
c) 0.45% sodium chloride (1/2 normal saline)
d) 0.225% sodium chloride (1/4 normal saline)

113. The nurse 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?

a) “I need to wear a MedicAlert tag or bracelet.”

b) “I need to restrict my activity while this catheter is in place.”
c) “Ineedtokeeptheinsertionsiteprotectedwhen in the shower or bath.”
d) “I need to check the markings on the catheter each time the dressing is changed.”

114. A client has just undergone insertion of a central venous catheter at the bedside under
ultrasound. The nurse would be sure to check which results before initiating the flow rate of the
client’s intravenous (IV) solution at 100 mL/hour?

a) Serum osmolality
b) Serum electrolyte levels
c) Intake and output record
d) Chest radiology results
115. Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the
right internal jugular for approximately 24 hours to increase urine output and maintain the
client’s

blood pressure. Upon entering the client’s room, the nurse notes 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?

a) Excessive bleeding
b) Crackles in the lungs
c) Incompatibility of the infusion
d) Chest pain radiating to the left arm

3. Packed red blood cells have been prescribed for a female client with a hemoglobin level of
7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client’s
temperature before hanging the blood transfusion and records 100.6 °F (38.1 °C) orally. Which
action should the nurse take?

a) Begin the transfusion as prescribed

b) . 2. Administer an antihistamine and begin the transfusion.
c) Delay hanging the blood and notify the health care provider (HCP).
d) Administer 2 tablets of acetaminophen and begin the transfusion.

5. The nurse has received a prescription to transfuse a client with a unit of packed red blood
cells. Before explaining the procedure to the client, the nurse should ask which initial question?

a) “Have you ever had a transfusion before?”

b) “Why do you think that you need the transfusion?”
c) “Have you ever gone into shock for any reason in the past?”
d) “Do you know the complications and risks of a transfusion?”

6. A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The
client’s blood pressure is 90/50 mm Hg from a baseline of 125/ 78 mm Hg. The client’s
temperature is 100.8 °F
(38.2 °C) orally from a baseline of 99.2 °F (37.3 °C) orally. The nurse determines that the client
may be experiencing which complication of a blood transfusion?

a) Septicemia
b) Hyperkalemia
c) Circulatory overload
d) Delayed transfusion reaction

7. The nurse determines that a client is having a transfusion reaction. After the nurse stops the
transfusion, which action should be taken next?

a) Remove the intravenous (IV) line.

b) Run a solution of 5% dextrose in water.
c) Run normal saline at a keep-vein-open rate.
d) Obtain a culture of the tip of the catheter device removed from the client.

8. The nurse has just received a unit of packed red blood cells from the blood bank for
transfusion to an assigned client. The nurse is careful to select tubing especially made for blood
products, knowing that this tubing is manufactured with which item?

a) 1.
b) 2.
c) 3.
d) 4.

9. A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting
most from this therapy if the client exhibits which finding?

a) Increased hematocrit level

b) Increased hemoglobin level
c) Decline of elevated temperature to normal
d) Decreased oozing of blood from puncture sites and gums

10. The nurse has obtained a unit of blood from the blood bank and has checked the blood bag
properly with another nurse. Just before beginning the transfusion, the nurse should assess which
priority item?
 a) Vital signs
b) Skin color
c) Urine output
d) Latest hematocrit level

11. The nurse has just received a prescription to transfuseaunitofpacked red blood cellsforan
assigned client. What action should the nurse take next?

a) Check a set of vital signs.

b) Order the blood from the blood bank.
c) Obtain Y-site blood administration tubing
d) . 4. Check to be sure that consent for the transfusion has been signed.

12. Following infusion of a unit of packed red blood cells, the client has developed new onset of
tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement
first?

a) Maintain bed rest with legs elevated.

b) Place the client in high-Fowler’s position.
c) Increase the rate of infusion of intravenous fluids.
d) Consult with the health care provider (HCP) regarding initiation of oxygen therapy.

13. The nurse, listening to the morning report, learns that an assigned client received a unit of
granulocytes the previous evening. The nurse makes a note to assess the results of which daily
serum laboratory studies to assess the effectiveness of the transfusion?

a) Hematocrit level
b) Erythrocyte count
c) Hemoglobin level
d) White blood cell count

14. A client is brought to the emergency department having experienced blood loss related to an
arterial laceration. Which blood component should the nurse expect the health care provider to
prescribe?

a) Platelets
 b) Granulocytes
c) Fresh-frozen plasma
d) Packed red blood cells

15. The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate
after a certain period of time. The nurse takes which actions in order to prevent a complication of
the blood transfusion as it relates to deterioration of blood cells? Select all that apply.

a) Checks the expiration date

b) Inspects for the presence of clots
c) Checks the blood group and type
d) Checks the blood identification number
e) Hangs the blood within the specified time frame per agency policy

16. A client requiring surgery is anxious about the possible need for a blood transfusion during
or after the procedure. The nurse suggests to the client to take which actions to reduce the risk of
possible transfusion complications? Select all that apply.

a) Ask a family member to donate blood ahead of time.

b) Give an autologous blood donation before the surgery.
c) Take iron supplements before surgery to boost hemoglobin levels.
d) Request that any donated blood be screened twice by the blood bank.
e) Take adequate amounts of vitamin C several days prior to the surgery date.

17. A client with severe blood loss resulting from multiple trauma requires rapid transfusion of
several units of blood. The nurseasks another health team member to obtain which device for use
during the

transfusion procedure to help reduce the risk of cardiac dysrhythmias?

a) Infusion pump
b) Pulse oximeter
c) Cardiac monitor
d) Blood-warming device
18. A client has a prescription to receive a unit of packed red blood cells. The nurse should
obtain which intravenous (IV) solution from the IV storage area to hang with the blood product
at the client’s bedside?

a) Lactated Ringer’s
b) 0.9% sodium chloride
c) 5% dextrose in 0.9% sodium chloride
d) 5% dextrose in 0.45% sodium chloride

19. The nurse is caring for a client who is receiving a blood transfusion and is complaining of a
cough. The nurse checks the client’s vital signs, which include temperature of 97.2 °F (36.2 °C),
pulse of 108 beats per minute, blood pressure of 152/ 76 mm Hg, respiratory rate of 24 breaths
per minute, and an oxygen saturation level of 95% on room air. The client denies pain at this
time. Based on this information, what initial action should the nurse take?

a) Collect a urine sample for analysis.

b) Place the client in an upright position.
c) Compare current data to baseline data

20. The nurse is teaching a client who has iron deficiency anemia about foods she should include
in the diet. The nurse determines that the client understands the dietary modifications if which
items are selected from the menu?

a) Nuts and milk

b) Coffee and tea
c) Cooked rolled oats and fish
d) Oranges and dark green leafy vegetables

21. The nurse is planning to teach a client with malabsorption syndrome about the necessity of
following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include
which food items on the list? Select all that apply.

a) Oranges
b) Broccoli
 c) Margarine
d) Cream cheese
e) Luncheon meats
f) . Broiled haddock

22. The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about
dietary modifications. The nurse determines that the client understands these dietary
modifications if the client selects which items from the dietary menu?

a) Cream of wheat, blueberries, coffee

b) Sausage and eggs, banana, orange juice
c) Bacon, cantaloupe melon, tomato juice
d) Cured pork, grits, strawberries, orange juice

23. The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse
provides dietary teaching and should focus on foods high in which vitamin that may be lacking
in a vegan diet?

a) Vitamin A
b) Vitamin B12
c) Vitamin C
d) Vitamin E

24. A client with hypertension has been told to maintain a diet low in sodium.The nurse who is
teaching this client about foods that are allowed should include which food item in a list
provided to the client?

a) Tomato soup
b) Boiled shrimp
c) Instant oatmeal
d) Summer squash

25. A post operative client has been placed on a clear liquid diet. The nurse should provide the
client with which items that are allowed to be consumed on this diet? Select all that apply.

a) Broth
 b) Coffee
c) Gelatin
d) Pudding
e) Vegetable juice
f) Pureed vegetables

26. The nurse is instructing a client with hypertension on the importance of choosing foods low
in sodium. The nurse should teach the client to limit intake of which food?

a) Apples
b) Bananas
c) Smoked sausage
d) Steamed vegetables

27. A client who is recovering from surgery has been advanced from aclearliquid dietto a full
liquid diet. The client is looking forward to the diet change because he has been “bored” with the
clear liquid diet. The nurse should offer which full liquid item to the client?

a) Tea
b) Gelatin
c) Custard
d) Ice pop

28. Aclientisrecoveringfromabdominalsurgeryandhas a large abdominal wound. The nurse

should encourage the client to eat which food item that is naturally high in vitamin C to promote
wound healing?

a) Milk
b) Oranges
c) Bananas
d) Chicken

29. The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the
disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines
that the client has the best understanding of the dietary measures to follow if the client states an
intention to increase the intake of which food?

a) Milk
b) Chicken
c) Broccoli
d) Legumes

30. A client 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?

a) Discontinue the PN.

b) Decrease PN rate to 50 mL/hour.
c) Start 0.9% normal saline at 25 mL/hour
d) . 4. Continue current infusion rate prescriptions for PN.

31. The nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The
client’s central venous line is located in the right subclavian vein. The nurse asks the client to
take which essential action during the tubing change?

a) Breathe normally.
b) Turn the head to the right.
c) Exhale slowly and evenly.
d) Take a deep breath, hold it, and bear down.

32. A client with parenteral nutrition (PN) infusing has disconnected the tubing from the central
line catheter. The nurse assesses the client and suspects an air embolism. The nurse should
immediately place the client in which position?

a) On the left side, with the head lower than the feet
b) On the left side, with the head higher than the feet
c) On the right side, with the head lower than the feet
d) On the rightside,with the head higher than the feet
33. Which nursing action is essential prior to initiating a new prescription for 500 mL of fat
emulsion (lipids) to infuse at 50 mL/hour?

a) Ensure that the client does not have diabetes.

b) Determine whether the client has an allergy to eggs.
c) Add regular insulin to the fat emulsion, using aseptic technique.
d) Contact the health care provider (HCP) to have a central line inserted for fat emulsion
infusion.

34. The nurse monitors the client receiving parenteral nutrition (PN) for complications of the
therapy and should assess the client for which manifestations of hyperglycemia?

a) Fever, weak pulse, and thirst

b) Nausea, vomiting, and oliguria
c) Sweating, chills, and abdominal pain
d) Weakness, thirst, and increased urine output

35. The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN)
and notes that the catheter insertion site appears reddened. The nurse should next assess which
item?

a) Client’s temperature
b) Expiration date on the bag
c) Time of last dressing change
d) Tightness of tubing connections

36. The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at
the top of the solution. The nurse should take which action?

a) Roll the bottle of solution gently.

b) Obtain a different bottle of solution.
c) Shake the bottle of solution vigorously.
d) Run the bottle of solution under warm water.
37. A client receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the
health care provider (HCP),and the HCP initially prescribes that the solution and tubing be
changed.What should the nurse do with the discontinued materials?

a) Discard them in the unit trash.

b) Return them to the hospital pharmacy.
c) Save them for return to the manufacturer.
d) Prepare to send them to the laboratory for culture.

38. A client has been discharged to home on parenteral nutrition (PN). With each visit, the home
care nurse should assess which parameter most closely in monitoring this therapy?

a) Pulse and weight

b) Temperature and weight
c) Pulse and blood pressure
d) Temperature and blood pressure

39. The nurse, caring for a group of adult clients on an acute care medical-surgical nursing unit,
determines thatwhichclientswouldbethemostlikelycandidates for parenteral nutrition (PN)? Select
all that apply.

1. A client with extensive burns

2. A client with cancer who is septic

3. Aclientwhohashadanopencholecystectomy

4. A client with severe exacerbation of Crohn’s disease

5. A client with persistent nausea and vomiting from chemotherapy

40. The nurse is preparing to hang the first bag of parenteral nutrition (PN) solution via the
central line of an assigned client. The nurse should obtain which most essential piece of
equipment before hanging the solution?

a) Urine test strips

b) Blood glucose meter
c) Electronic infusion pump
 d) Noninvasive blood pressure monitor

41. The nurse is making initial rounds at the beginning of the shift and notes that the parenteral
nutrition (PN)bagofanassignedclientisempty.Whichsolution should the nurse hang until another
PN solution is mixed and delivered to the nursing unit?

a) 5% dextrose in water
b) 10% dextrose in water
c) 5% dextrose in Ringer’s lactate
d) 5% dextrose in 0.9% sodium chloride

42. The nurse is monitoring the status of a client’s fat emulsion (lipid) infusion and
notesthattheinfusion is1hourbehind.Whichactionshouldthenursetake?

a) Adjust the infusion rate to catch up over the next hour.

b) Increase the infusion rate to catch up over the next 2 hours.
c) Ensurethatthefatemulsioninfusionrateisinfusing at the prescribed rate.
d) Adjust the infusion rate to run wide open until the solution is back on time.

43. A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1
week. The nurse should next assess the client for the presence of which condition?

a) Thirst
b) Polyuria
c) Decreased blood pressure
d) Crackles on auscultation of the lungs

44. The nurse is caring for a restless client who is beginning nutritional therapy with parenteral
nutrition (PN). The nurse should plan to ensure that which action is taken to prevent the client
rom sustaining injury?

a) Calculate daily intake and output.

b) Monitor the temperature once daily.
c) Secure all connections in the PN system.
d) Monitor blood glucose levels every 12 hours.
45. A client receiving parenteral nutrition (PN) complains of a headache. The nurse notes that the
client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles
bilaterally. The nurse determines that the client is experiencing which complication of PN
therapy?

a) Sepsis
b) Air embolism
c) Hypervolemia
d) Hyperglycemia.