Question

Which resource utilization habit should nurses use to support the business of healthcare and promote successful client outcomes?

Answer 1

Correct Answers:

Take only what is needed for that client to avoid waste

Rationale :

⭐ Nurses support the business of healthcare by using resources efficiently, preventing unnecessary costs.

⭐ Avoiding waste ensures supplies remain available for other patients who may need them.

⭐ This practice promotes equitable resource allocation across units and improves workflow.

⭐ Conserving supplies aligns with hospital financial sustainability and budget goals.

⭐ It also contributes to better client outcomes since essential resources are preserved and used appropriately.

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Answer 2

Correct Answers:

The blood is donated by the client and then is reinfused if needed

Rationale :

🌟 Autologous transfusion means the client’s own blood is collected in advance and given back if needed.

🌟 This reduces the risk of transfusion reactions since the blood is self-donated.

🌟 It also minimizes exposure to bloodborne pathogens from donor blood.

🌟 Clients from Jehovah’s Witness faith may still decline, but this is the accurate teaching explanation.

🌟 The nurse’s role is to provide factual, unbiased education while respecting beliefs.

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Answer 3

Correct Answers:

Evaluation

Rationale :

💎 In the nursing process, evaluation occurs after interventions to determine effectiveness.

💎 Asking the client “how they feel” and auscultating lung sounds checks the outcome of treatment.

💎 This step ensures the care plan is working or identifies the need for adjustments.

💎 Evaluation is essential to achieve continuous quality improvement in nursing care.

💎 It links directly to client-centered care, focusing on symptom relief and improvement.

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Answer 4

Correct Answers:

A client who has hemiparesis following a stroke three days ago

Rationale :

🔶 Hemiparesis after a stroke requires multiple disciplines: physical therapy, occupational therapy, speech therapy, and nursing.

🔶 An interdisciplinary conference ensures collaboration to maximize recovery and prevent complications.

🔶 Early intervention improves rehabilitation outcomes and quality of life.

🔶 Stroke recovery is complex, requiring coordination beyond routine nursing care.

🔶 This client benefits most from a team-based plan of care for mobility, ADLs, and communication.

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Answer 5

Correct Answers:

A client with chest pain and indigestion

Rationale :

♦ Chest pain is a potential sign of myocardial infarction, which is life-threatening.

♦ Even when described as “indigestion,” cardiac pain can mimic GI symptoms.

♦ Early assessment prevents delays in life-saving interventions such as ECG and cardiac enzymes.

♦ This is an ABC priority (Airway, Breathing, Circulation) requiring urgent attention.

♦ Other clients are stable and can safely wait while chest pain is addressed.

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Answer 6

Correct Answers:

A client experiencing cardiac dysrhymias and requiring IV potassium replacement

Rationale :

💎 Potassium chloride must always be given via an IV pump because rapid infusion can cause fatal cardiac arrhythmias.

💎 An IV pump ensures precise control of the infusion rate, reducing overdose risk.

💎 Clients with dysrhythmias are especially vulnerable to electrolyte changes, requiring strict monitoring.

💎 Infusing potassium too quickly can result in cardiac arrest.

💎 IV pumps are the standard of safety for all high-alert medications like potassium.

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Answer 7

Correct Answers:

Y intravenous tubing set with a clot filter
Thermometer
0.9% sodium chloride

Rationale :

🔷 Y intravenous tubing set with a clot filter

🔷 Blood must run through dedicated **Y-tubing with a 170–260-micron filter to trap fibrin, clots, and debris, reducing the risk of embolization and reaction.

🔷 The Y-set provides a second port for compatible 0.9% sodium chloride to prime the line, flush between units, and keep the vein open if a reaction occurs.

🔷 Using a blood-approved set supports proper flow rates and minimizes hemolysis; avoid mixing meds or incompatible fluids in this line.

🔷 Change the set per policy (e.g., after one or two units or within 4 hours) to limit bacterial contamination.

🔷 Prime and connect using aseptic technique, label start time, and maintain a dedicated lumen during transfusion.

🔷 Thermometer

🔷 Establishing a baseline temperature is essential because a rise of ≥1 °C (≥1.8 °F) may indicate a febrile non-hemolytic transfusion reaction.

🔷 Re-check vital signs (including temperature) at 15 minutes, then at policy intervals (e.g., q30–60 min), and at completion to detect early changes.

🔷 Document trends and correlate with other symptoms (chills, rigors, back/flank pain, dyspnea, rash) to differentiate reaction types.

🔷 Prompt detection via temperature monitoring enables rapid intervention and prevents progression to severe reactions.

🔷 A ready thermometer is therefore critical safety equipment whenever blood is administered.

🔷0.9% sodium chloride

🔷 Only isotonic 0.9% sodium chloride is compatible with PRBCs; hypotonic saline, dextrose solutions, and LR (calcium) can cause hemolysis or clotting with citrate-anticoagulated blood.

🔷 Use NS to prime the Y-tubing, maintain IV patency, and as the fluid to run if a reaction is suspected (after stopping the blood).

🔷 Keeping a bag of NS at the Y-port allows immediate switch-over without losing access for meds or further evaluation.

🔷 NS supports hemodynamic stability during workup of reactions while preventing further exposure to blood product.

🔷 This compatibility rule is a foundational transfusion safety principle.

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Answer 8

Correct Answers:

Update the plan and reprioritize needs as changes occur

Rationale :

⭐ Nursing care is dynamic, requiring frequent reassessment as client needs and conditions change.

⭐ Unexpected interruptions are common; reprioritization maintains safety and efficiency.

⭐ This approach reflects the nursing process step of evaluation and modification.

⭐ Flexibility allows the nurse to focus on urgent needs first without neglecting long-term goals.

⭐ A rigid plan without adjustment may compromise client safety and care quality.

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Answer 9

Correct Answers:

The insertion site is warm and tender to the touch
The IV fluid will not infuse without resistance
The client reports burning and pain during infusion.

Rationale :

🔶 Warm and tender insertion site

🔶 Warmth, tenderness, and possible erythema localize phlebitis (mechanical, chemical, or infectious), not a healthy site.

🔶 Untreated phlebitis can progress to thrombophlebitis, loss of access, and even bloodstream infection if microbial.

🔶 Actions: Stop the infusion, remove the catheter, apply warm compresses, elevate the limb, and restart IV access in a new site proximal/contralateral to the old one.

🔶 If purulence, fever, or streaking are present, obtain cultures per policy and notify the provider for possible antimicrobials.

🔶 Use proper catheter gauge/size, securement, and dilution/rate strategies to reduce endothelial irritation in the future.

🔶IV fluid will not infuse without resistance

🔶 Resistance suggests occlusion (kink, clamp, precipitate, thrombus) or infiltration/extravasation if the catheter tip has left the vein.

🔶 Do not force a flush—this risks catheter rupture, embolization, or tissue injury if extravasated.

🔶 Actions: Stop infusion; assess for positional change, check clamps/loops, attempt gentle repositioning; if still resistant or infiltration suspected, remove and restart elsewhere.

🔶 Consider line patency confirmation and compatibility (avoid precipitates) when administering antibiotics/IV additives.

🔶 Escalate to vascular access or provider if repeated occlusions occur or a vesicant is involved.

🔶Burning and pain during infusion

🔶 Burning/pain indicates chemical phlebitis, vein irritation, or infiltration/extravasation, especially with irritants/vesicants (some antibiotics, potassium).

🔶 Actions: Stop the infusion immediately; inspect for swelling, blanching, temperature change, slowed rate, and lack of blood return.

🔶 Manage based on type: infiltration—remove catheter, elevate, warm or cold compress per drug; extravasation—follow antidote protocol (drug-specific) and notify provider promptly.

🔶 Reassess dilution and infusion rate, ensure proper vein/needle gauge selection, and consider a central line for vesicants or repeated irritation.

🔶 Thorough documentation (drug, rate, site findings, interventions) supports safe continuity and quality review.

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Answer 10

Correct Answers:

Stop the blood transfusion

Rationale :

🌟 Flank pain during a transfusion is a classic sign of an acute hemolytic transfusion reaction, often caused by ABO incompatibility.

🌟 The first priority is to stop the transfusion immediately to prevent more incompatible blood from entering the client’s circulation.

🌟 If continued, the reaction can rapidly progress to shock, acute renal failure, disseminated intravascular coagulation (DIC), or death.

🌟 After stopping the blood, the nurse should maintain the IV line with 0.9% sodium chloride using new tubing, monitor vital signs, and prepare to send the blood bag and tubing to the lab for investigation.

🌟 Only after stopping the transfusion should the nurse notify the provider and continue further supportive interventions (oxygen, medications, labs).

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Examplify PN W4 NR226 Exam 1

No.

1 :
Which resource utilization habit should nurses use to support the business of healthcare and promote successful client outcomes?

2 :
The nurse is teaching a client who follows Jehovah's Witness practices about autologous blood transfusions in preparation for an upcoming surgery. What should the nurse include in the teaching?

3 :
A nurse is caring for a client who is receiving treatment for an acute asthma attack. Following treatment, the nurse auscultates the client's lungs and asks the client how they feel. Which step of the nursing process does this reflect?

4 :
A nurse is caring for four clients. Which client should the nurse request an interdisciplinary conference to plan and manage care?

5 :
A nurse is prioritizing care for four clients. Which client should the nurse assess first?

6 :
A nurse is planning care for a group of clients who each have an order for an intravenous infusion. For which client should the nurse use an IV pump to administer the ordered infusion?

7 :
Which equipment should the nurse gather to administer 1 unit of packed red blood cells to a client? Select all that apply.

8 :
A nurse starts planning out their shift at 0700. What should the nurse incorporate into their plan to overcome unexpected interruptions?

9 :
A nurse evaluates a peripheral intravenous (IV) site on a client receiving intravenous antibiotics. Which finding(s) indicate the IV site has developed complications? Select all that apply.

10 :
A nurse cares for a client who reports flank pain after starting an intravenous (IV) infusion of packed red blood cells (RBCs). What action should the nurse take first?

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Examplify PN W4 NR226 Exam 1

No.

1 : Which resource utilization habit should nurses use to support the business of healthcare and promote successful client outcomes?

2 : The nurse is teaching a client who follows Jehovah's Witness practices about autologous blood transfusions in preparation for an upcoming surgery. What should the nurse include in the teaching?

3 : A nurse is caring for a client who is receiving treatment for an acute asthma attack. Following treatment, the nurse auscultates the client's lungs and asks the client how they feel. Which step of the nursing process does this reflect?

4 : A nurse is caring for four clients. Which client should the nurse request an interdisciplinary conference to plan and manage care?

5 : A nurse is prioritizing care for four clients. Which client should the nurse assess first?

6 : ​A nurse is planning care for a group of clients who each have an order for an intravenous infusion. For which client should the nurse use an IV pump to administer the ordered infusion?

7 : Which equipment should the nurse gather to administer 1 unit of packed red blood cells to a client? Select all that apply.

8 : ​A nurse starts planning out their shift at 0700. What should the nurse incorporate into their plan to overcome unexpected interruptions?

9 : ​A nurse evaluates a peripheral intravenous (IV) site on a client receiving intravenous antibiotics. Which finding(s) indicate the IV site has developed complications? Select all that apply.

10 : A nurse cares for a client who reports flank pain after starting an intravenous (IV) infusion of packed red blood cells (RBCs). What action should the nurse take first?

1 :
Which resource utilization habit should nurses use to support the business of healthcare and promote successful client outcomes?

2 :
The nurse is teaching a client who follows Jehovah's Witness practices about autologous blood transfusions in preparation for an upcoming surgery. What should the nurse include in the teaching?

3 :
A nurse is caring for a client who is receiving treatment for an acute asthma attack. Following treatment, the nurse auscultates the client's lungs and asks the client how they feel. Which step of the nursing process does this reflect?

4 :
A nurse is caring for four clients. Which client should the nurse request an interdisciplinary conference to plan and manage care?

5 :
A nurse is prioritizing care for four clients. Which client should the nurse assess first?

6 :
A nurse is planning care for a group of clients who each have an order for an intravenous infusion. For which client should the nurse use an IV pump to administer the ordered infusion?

7 :
Which equipment should the nurse gather to administer 1 unit of packed red blood cells to a client? Select all that apply.

8 :
A nurse starts planning out their shift at 0700. What should the nurse incorporate into their plan to overcome unexpected interruptions?

9 :
A nurse evaluates a peripheral intravenous (IV) site on a client receiving intravenous antibiotics. Which finding(s) indicate the IV site has developed complications? Select all that apply.

10 :
A nurse cares for a client who reports flank pain after starting an intravenous (IV) infusion of packed red blood cells (RBCs). What action should the nurse take first?