Nursing Acceleration Challenge Exam I PN-RN Pharmacological and Parenteral Therapies Questions and Answers 1 — Questions and Answers
Question 1: A nurse is monitoring a client receiving an IV infusion of 0.9% sodium chloride. The client complains of pain and swelling at the IV site, and the surrounding skin appears cool and blanched. Which action should the nurse take first?
- Stop the infusion and remove the IV catheter. (Correct answer)
- Slow the infusion rate and apply a warm compress.
- Check for blood return by lowering the IV bag.
- Administer the prescribed analgesic for the pain.
Correct answer: Stop the infusion and remove the IV catheter.
The client's signs and symptoms (pain, swelling, coolness, blanching) are classic indicators of IV infiltration, where the IV fluid leaks into the surrounding subcutaneous tissue. The immediate priority is to stop the infusion to prevent further fluid from entering the tissue and causing more damage. After stopping the infusion, the catheter should be removed.
Question 2: A nurse is preparing to administer a continuous intravenous infusion of heparin. Which of the following laboratory values is essential for the nurse to review immediately before initiating the infusion?
- Prothrombin Time (PT)
- International Normalized Ratio (INR)
- Activated Partial Thromboplastin Time (aPTT) (Correct answer)
- Hemoglobin and Hematocrit
Correct answer: Activated Partial Thromboplastin Time (aPTT)
The therapeutic effect of a continuous unfractionated heparin (UFH) infusion is monitored by the aPTT. The nurse must know the baseline aPTT and the desired therapeutic range before starting the infusion to ensure patient safety and effective anticoagulation. PT and INR are used to monitor warfarin therapy. While hemoglobin and hematocrit are important to monitor for bleeding, the aPTT is the primary lab value used for titrating the heparin infusion.
Question 3: A nurse is caring for a client receiving Total Parenteral Nutrition (TPN) via a central venous catheter. Which of the following is a priority nursing intervention to prevent a metabolic complication?
- Monitoring blood glucose levels every 4 to 6 hours. (Correct answer)
- Changing the central line dressing every 24 hours.
- Using the TPN line to administer IV push antibiotics.
- Infusing the TPN solution rapidly if it falls behind schedule.
Correct answer: Monitoring blood glucose levels every 4 to 6 hours.
TPN solutions have a high dextrose concentration, which places the client at high risk for hyperglycemia. Frequent blood glucose monitoring (typically every 4-6 hours) is essential to detect and manage this common and serious metabolic complication. Central line dressings are changed using sterile technique, but typically not every 24 hours (usually every 7 days or per protocol). The TPN line should be dedicated to the TPN infusion to prevent infection. TPN rates should never be increased to 'catch up' as this can cause severe metabolic disturbances like hyperglycemia and fluid overload.
Question 4: A nurse is initiating a transfusion of packed red blood cells (PRBCs). Fifteen minutes into the transfusion, the client develops shortness of breath, chills, and lower back pain. What is the nurse's priority action?
- Administer an antihistamine as ordered.
- Slow the rate of the transfusion.
- Stop the transfusion immediately. (Correct answer)
- Notify the healthcare provider.
Correct answer: Stop the transfusion immediately.
The client's symptoms of chills, shortness of breath, and lower back pain are classic signs of an acute hemolytic transfusion reaction, a life-threatening emergency. The absolute first and most critical action is to stop the transfusion immediately to prevent any more incompatible blood from entering the client's system. After stopping the transfusion, the nurse would then notify the provider and perform other supportive interventions, such as maintaining IV access with normal saline.
Question 5: A client is admitted with severe dehydration secondary to gastroenteritis. The healthcare provider orders an intravenous fluid to rapidly expand intravascular volume. Which type of IV solution would the nurse anticipate being ordered?
- 0.45% Sodium Chloride (1/2 NS)
- 0.9% Sodium Chloride (Normal Saline) (Correct answer)
- Dextrose 5% in water (D5W)
- 3% Sodium Chloride
Correct answer: 0.9% Sodium Chloride (Normal Saline)
0.9% Sodium Chloride (Normal Saline) is an isotonic solution, meaning it has a similar osmolarity to body fluids. It is the fluid of choice for rapid intravascular volume expansion in cases of dehydration or hypovolemia because it primarily stays within the vascular space. 0.45% NaCl is hypotonic and would shift fluid into cells. D5W is isotonic in the bag but becomes hypotonic in the body as dextrose is metabolized. 3% NaCl is a hypertonic solution used for specific electrolyte imbalances like severe hyponatremia, not for general volume expansion.
Question 6: When administering an intramuscular (IM) injection of an irritating medication to an average-sized adult, which of the following actions demonstrates the correct technique?
- Selecting the dorsogluteal site as the preferred location.
- Using a 25-gauge, 5/8-inch needle for the injection.
- Inserting the needle at a 45-degree angle to the skin.
- Utilizing the Z-track method during the injection. (Correct answer)
Correct answer: Utilizing the Z-track method during the injection.
The Z-track method is a technique used to prevent the leakage of irritating and discoloring medications into the subcutaneous tissue. This method involves displacing the skin and subcutaneous tissue laterally before injection, which creates a zigzag path that seals the medication in the muscle upon needle withdrawal. The dorsogluteal site is no longer recommended due to the risk of sciatic nerve injury. A 5/8-inch needle is too short for an adult IM injection (typically 1 to 1.5 inches is needed). IM injections are administered at a 90-degree angle.
Nursing Acceleration Challenge Exam I PN-RN Pharmacological and Parenteral Therapies Questions and Answers 1
A nurse is monitoring a client receiving an IV infusion of 0.9% sodium chloride.
The client complains of pain and swelling at the IV site, and the surrounding skin appears cool and blanched.
Which action should the nurse take first?