Question

Which type of intravenous (IV) tubing is used to administer blood?

Answer 1

Correct Answers:

Y tubing

Rationale :

🩸Y tubing is specifically used for blood administration because it includes a built-in filter that helps trap clots and debris.

💧The Y configuration allows one arm for normal saline priming/flush and the other for blood product infusion using compatible solution.

🧪Using the correct blood administration set reduces the risk of hemolysis and infusion complications related to inappropriate tubing.

✅This tubing supports safe transfusion practice by maintaining patency, enabling saline flush, and meeting blood product administration standards.

📌Core message

Y tubing is the standard blood administration tubing because it supports filtered transfusion and saline compatibility.

Answer 2

Correct Answers:

0.9% sodium chloride

Rationale :

💧0.9% sodium chloride is an isotonic fluid that expands intravascular volume without causing major fluid shifts into or out of cells.

🩸It is the preferred compatible solution when managing IV access around blood transfusions, because it does not cause red cell damage.

📉Hypotonic fluids like 0.45% sodium chloride can shift water into cells and are not the typical first choice for stabilizing circulating volume.

🧫Dextrose-containing solutions may be inappropriate in some acute situations and are not used to prime blood tubing, making normal saline the safest anticipated order.

📌Core message

0.9% sodium chloride is the preferred isotonic IV fluid for volume support and blood compatibility.

Answer 3

Correct Answers

Blank 1 Correct Option: Consent
Blank 2 Correct Option: blood type

Rationale :

📝Before transfusion begins, confirming informed consent ensures the client has agreed to the procedure after understanding benefits and risks.

🩸Verifying blood type is essential to prevent ABO incompatibility, one of the most dangerous transfusion errors.

🔍This verification step supports correct matching of the client to the correct blood product, reducing the risk of acute hemolytic reactions.

✅Although baseline vital signs are important, transfusion safety starts with confirming authorization (consent) and compatibility (blood type) before blood is infused.

📌Core message

Safe transfusion begins by verifying consent and confirming blood type compatibility.

Answer 4

Correct Answers:

Hematocrit
Urine specific gravity
Sodium
Magnesium

Rationale :

💧Fluid imbalance changes blood concentration, so hematocrit may rise with dehydration and fall with fluid overload due to hemodilution.

🚽Urine specific gravity reflects hydration status because concentrated urine increases with dehydration while dilute urine occurs with excess free water.

🧂Sodium is sensitive to water shifts, and its level changes with hypervolemia, dehydration, and free-water imbalance.

⚡Magnesium can shift with renal handling and dilution/concentration effects, especially when fluid status changes affect electrolyte balance.

🧫White blood cells are not primarily altered by hydration status in the same predictable way as concentration-based and electrolyte labs.

📌Core message

Fluid imbalance most clearly affects hematocrit, urine specific gravity, and electrolytes like sodium and magnesium.

Answer 5

Correct Answers:

2.5

Rationale :

🧮The concentration is 650 mg in 5 mL, which equals 130 mg per 1 mL when divided evenly.

📏To give 325 mg, the nurse calculates volume using dose ÷ concentration: 325 ÷ 130 = 2.5 mL.

💊This ensures the client receives the correct therapeutic dose while preventing under-dosing or overdosing.

✅Accurate liquid medication calculation supports safe administration, especially when high-concentration pediatric-style liquids are used in adults.

📌Core message

Use dose ÷ concentration to calculate oral liquid volumes accurately (here, 2.5 mL).

Answer 6

Correct Answers:

Nonmaleficence

Rationale :

🧠A bone marrow biopsy is an invasive procedure that carries risks like pain, bleeding, and infection, making harm prevention a major ethical focus.

⚕️Nonmaleficence guides nurses to reduce avoidable injury by ensuring proper technique, monitoring, and timely response to complications.

💉This includes actions such as supporting aseptic practice, observing for bleeding, and managing discomfort appropriately.

📋While informed decision-making relates to consent processes, the principle most directly highlighted by performing and monitoring an invasive test is preventing unnecessary harm.

📌Core message

In invasive procedures like bone marrow biopsy, nonmaleficence emphasizes minimizing harm and complications.

Answer 7

Correct Answers:

Explain the need for a trained person to monitor PICC care

Rationale :

🧑‍⚕️A PICC line requires sterile technique, dressing changes, flushing, and assessment for infection or occlusion, so competent follow-up is essential.

📚Explaining the need for a trained person supports client safety while respecting family concerns through clear education and collaboration.

🧫Without proper monitoring, the client is at risk for serious complications such as CLABSI, thrombosis, and catheter malfunction.

🤝This response promotes shared decision-making by offering rationale and reinforcing that safe home care depends on appropriate support, rather than automatically canceling needed services.

📌Core message

PICC care needs trained monitoring to prevent serious complications like infection and occlusion.

Answer 8

Correct Answers:

Assessment

Rationale :

🔎Assessment is the first nursing process phase and focuses on gathering subjective and objective information about the client.

📋This includes observing, interviewing, reviewing records, and obtaining baseline measurements to identify what is happening clinically.

🧠Accurate assessment supports all later steps because diagnoses, interventions, and evaluation depend on the quality of collected data.

✅When a scenario describes identifying findings or collecting information, it aligns best with the assessment phase rather than planning or evaluation.

📌Core message

Assessment means collecting and validating data before making nursing decisions.

Answer 9

Correct Answers:

Stop the transfusion and call the healthcare provider

Rationale :

🚨When a transfusion reaction is suspected, the immediate priority is to stop the transfusion to prevent further exposure to the blood product.

📞Notifying the healthcare provider ensures rapid medical management and supports facility protocol for transfusion reaction workup.

🧪Follow-up steps commonly include monitoring vital signs, maintaining IV access with compatible solution per protocol, and coordinating required specimens and notifications.

✅Rechecking types and notifying the blood bank are important, but they come after the first lifesaving action of stopping the transfusion and escalating care.

📌Core message

Suspected transfusion reaction → stop the transfusion immediately and notify the provider.

Answer 10

Correct Answers

Blank 1 Correct Option: falls
Blank 2 Correct Option: confusion

Rationale :

🚶Confusion increases fall risk because clients may misjudge their environment, forget limitations, or attempt to ambulate unsafely.

🧠Altered cognition reduces attention and coordination, making it harder to follow safety instructions and use call lights appropriately.

🏥Hospital settings add hazards like unfamiliar layouts, tubing, and urgency to reach the bathroom, which combine with confusion to raise risk.

✅Although vomiting and diarrhea can contribute to weakness, confusion most directly predicts unsafe decision-making and accidental falls.

📌Core message

Confusion is a major predictor of falls, so safety precautions must be prioritized.

1 :
Which type of intravenous (IV) tubing is used to administer blood?

2 :
Which type of intravenous (IV) fluid should the nurse anticipate the healthcare provider will order?

3 :
Study the question below.

Correct Answers

4 :
Which laboratory test(s) should the nurse anticipate will be affected by the client's fluid imbalance? Select all that apply.

5 :
The client has an order for acetaminophen 325mg PO.The pharmacy provides acetaminophen 650mg/5ml. How many mL per dose should the nurse administer?

6 :
Which ethical principle does the bone marrow biopsy present?

7 :
Which action should the nurse take?

8 :
Which step of the nursing process does this reflect?

9 :
What priority action should the nurse take?

10 :
A Nurse is attending to a client.

Correct Answers

1 : Which type of intravenous (IV) tubing is used to administer blood?

2 : Which type of intravenous (IV) fluid should the nurse anticipate the healthcare provider will order?

3 : Study the question below.

Correct Answers

4 : Which laboratory test(s) should the nurse anticipate will be affected by the client's fluid imbalance? Select all that apply.

5 : The client has an order for acetaminophen 325mg PO.The pharmacy provides acetaminophen 650mg/5ml. How many mL per dose should the nurse administer?

6 : Which ethical principle does the bone marrow biopsy present?

7 : Which action should the nurse take?

8 : Which step of the nursing process does this reflect?

9 : What priority action should the nurse take?

10 : A Nurse is attending to a client.

Correct Answers

1 :
Which type of intravenous (IV) tubing is used to administer blood?

2 :
Which type of intravenous (IV) fluid should the nurse anticipate the healthcare provider will order?

3 :
Study the question below.

4 :
Which laboratory test(s) should the nurse anticipate will be affected by the client's fluid imbalance? Select all that apply.

5 :
The client has an order for acetaminophen 325mg PO.The pharmacy provides acetaminophen 650mg/5ml. How many mL per dose should the nurse administer?

6 :
Which ethical principle does the bone marrow biopsy present?

7 :
Which action should the nurse take?

8 :
Which step of the nursing process does this reflect?

9 :
What priority action should the nurse take?

10 :
A Nurse is attending to a client.