NCLEX Free Quiz

Answer & Rationale:

Option 4 is Correct

Rationale: The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV catheter. The vein should have been distended by the tourniquet before the vein was cannulated. Client discomfort varies with the client, the site, and the nurse’s insertion technique and is not a reliable measure of catheter placement. The nurse should not advance the catheter until placement in the vein is verified by blood return.

Answer & Rationale:

Option 4 is Correct

Rationale: A dry sterile dressing such as a sterile 2  2 is used to apply pressure to the discontinued IV site. This material is absorbent, sterile, and nonirritating. A Betadine swab would irritate the opened puncture site and would not stop the blood flow. An adhesive bandage or elastic wrap may be used to cover the site once hemostasis has occurred.

Answer & Rationale:

Option 3 is correct answer

Rationale: If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-veinopen rate pending further physician prescriptions. This maintains a patent IV access line and aids inmaintaining the client’s intravascular volume. The nurse would not remove the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be removed. Second, cultures are performed when infection, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.

Answer & Rationale:

Option 4 is correct answer

Rationale: Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. An elevated temperature would decline to normal after infusion of granulocytes if those cells were instrumental in fighting infection in the body.

Answer & Rationale:

Option 4 is correct answer

Rationale: In a child between the ages of 1 and 8 years, 12 to 20 breaths per minute are delivered.Options 1, 2, and 3 are incorrect.

Test-Taking Strategy: Use the process of elimination and note the age of the child. Recalling the normal respiratory rate in a child at this age will assist in directing you to option 4. If you had difficulty with this question, review CPR guidelines for a child.

Answer & Rationale:

Option 3 is correct answer

Rationale: In an infant, the rate of chest compressions is at least 100 times per minute. Options 1 and 2 identify rates that are too low, and option 4 identifies a rate that is too high.

Test-Taking Strategy: Use the process of elimination, considering the normal heart rate of an infant. Eliminate options 1 and 2 because of the low rates identified in the options. Eliminate option 4 because this ratewould bemuch too rapid for an infant. If you had difficulty with this question, reviewCPR for an infant.