22: Intravenous Therapy
A client is newly prescribed a medication that must be taken on an empty stomach. Which statement by the nurse best describes why some medications should be taken before meals?
"This is because food and some drinks can affect the way your medicine works." Some medicines need to be taken "before food" or "on an empty stomach." This is because food and some drinks can affect the way these medicines work. For example, taking some medicines at the same time as eating may prevent the stomach and intestines from absorbing the medicine, making it less effective. Blood flow to the stomach increases after eating a meal. Gastric acid increases after a meal to help digestive food eaten. Nausea does not affect the absorption of a medication.
A group of nursing students is reviewing information about intravenous solutions. The students demonstrate understanding of the information when they identify which solution as hypotonic?
0.45 NaCl A 0.45 NaCl solution is a hypotonic solution. 0.9% NaCl and lactated Ringer's are examples of isotonic solutions. A 3% NaCl solution is an example of a hypertonic solution.
A nurse is performing care for a PICC site. After cleaning the site and applying a new dressing and new injection caps, the nurse prepares to flush the catheter according to agency policy. Which size syringe would the nurse use?
10-cc When flushing a PICC catheter, a large 10-cc syringe is used to avoid very high pressures that could cause catheter rupture.
A nurse is preparing to administer IV therapy to a client and selects a catheter with a large lumen. Which catheter would have the largest lumen
18 gauge IV catheters are available in various sizes. The lumen size is measured in gauges; odd numbers designate winged infusion needles (19, 21, 23), whereas even numbers designate catheter sizes. The most common adult catheter sizes are 22, 20, and 18. As the numbers increase, the lumen size decreases; thus, a 22-gauge needle is smaller in diameter than an 18-gauge needle. Of the catheter gauges listed, 18 would be the largest.
A client requires intravenous therapy for fluid replacement. The nurse assesses the client's upper extremities for a suitable insertion site. Assessment reveals that the client has small veins. Which catheter size would be most appropriate for the nurse to use?
22 gauge When evaluating IV catheter size, as the gauge number increases, the size of the lumen decreases. Therefore, for a client with small veins, a 22 gauge catheter would be most appropriate.
A client is to receive an intravenous infusion of isotonic solution. The nurse identifies a solution of which osmolarity as being appropriate?
325 mOsm/liter Isotonic fluids have an osmolarity of 250 to 375 mOsm/liter. A hypotonic solution has an osmolarity of less than 250 mOsm/liter. Hypertonic solutions have an osmolarity of 375 mOsm or greater.
The nurse is infusing ampicillin IV for Mr. B. The medication is diluted in 100 mL of NS and is to infuse over 1 hour. The nurse has tubing with a drop factor of 20 drops/ml. What is the drip rate of this infusion?
33 drops/minute Use formula : Drops per min = (volume/time in min) x drop factor drop factor represents the size of the drop that the administration set creates.
A nurse is administering total parenteral nutrition (TPN) solution to a severely dehydrated client at the health care facility. Which nutrient would the nurse identify as a carbohydrate source?
50% dextrose solution The carbohydrate source is often a 50% dextrose solution. The proportion of each ingredient is individualized based on the client's clinical condition. Protein is provided as synthetic crystalline amino acids, not as carbohydrates. The client's caloric need is assessed carefully to provide the number of calories required to maintain an anabolic state. Electrolytes such as sodium and potassium, vitamins, and trace elements are added, based on laboratory assays. To supply all necessary nutrients, fat in the form of 10% or 20% lipid emulsion is often given with TPN.
The nurse is reviewing the plan of care for several clients who have prescriptions for intravenous medications. The nurse understands that which client is at the highest risk for greater effect of the IV medication?
73-year-old client diagnosed with liver disease Older adults have a decrease in plasma protein, which is needed to bind and inactivate the medication in the bloodstream. The decrease in plasma proteins can increase the amount of medication circulating, which increases the effects. Decreased liver and kidney function also increases the amount of medication in the blood. The other options can have a risk, but they are not the highest.
A physician orders 1000 mL of Dextrose 5% and 1/2 normal saline to infuse over 12 hours. The nurse determines that the client will receive how many milliliters per hour? Fill in the blank with a whole number.
83 To determine the number of milliliters per hour, the nurse would divide the total amount of the infusion (1000 mL) by the total time (12 hours). The client would receive 83 mL/hour.
The nurse is infusing 0.9% NS to a hypovolemic client s/p an MVA. The nurse is ordered to infuse 1,000 mL of fluid over 1 hour. The tube has a drop factor of 5 drops/ml. What is the drip rate of the infusion?
83 drops/minute
A nurse is administering a piggyback infusion to a client with partial-thickness or second-degree burns. Which describes the most important feature of a piggyback infusion?
A parenteral drug is given in tandem with an IV solution. In a piggyback infusion, a parenteral drug is administered in tandem with a primary IV solution. Medication locks are not changed during piggyback infusion specifically, but in general to maintain patency. IV medication or fluid is given all at one time as quickly as possible in a bolus administration, not in piggyback infusion. It is not the primary IV solution but the secondary infusions that are administered by gravity in tandem with the currently infused primary solution.
A nurse is performing a venipuncture on the forearm of a client. What would be most appropriate for the nurse to do?
Apply the tourniquet about 6 inches above the intended site. The nurse should apply the tourniquet about 6 inches above the intended site. The skin below the site should be stretched taut. The nurse should hold the needle to enter the skin at a 15- to 30-degree angle, not a 45-degree angle. As the skin is pierced, the angle of the needle should be decreased so that it is almost parallel to the skin.
The nurse observes a prescription written for a client for a medication that does not correlate with the client's diagnosis or comorbid factors. What is the best action for the nurse to take?
Call the provider to obtain a rationale for the use of the medication for the client If the nurse is unsure of the medication or the reason for administration, it is best to ask to avoid improper medication administration. Human error is not unusual, and it would be in the best interest of the client and nurse to clarify any prescriptions that are unclear.
The nurse has inserted a peripheral intravenous catheter into a client. What is the appropriate action when a blood return is not obtained?
Change the site of catheter insertion. If a blood return is not obtained, the IV catheter is not appropriately placed. The nurse will remove the IV catheter and change the site. It is not appropriate to insert the catheter further, begin infusion, or pinch the IV tubing.
The nurse is preparing to administer two IV medications. What is the appropriate nursing action?
Consult a current drug reference book for IV compatibility. The nurse should consult a current drug reference book for compatibility before administering two IV medications. Other answers are incorrect.
A nurse is caring for a client who has a PICC line. Which nursing action is recommended?
Flush using normal saline and/or heparin solution according to facility policy. PICC lines are flushed with normal saline and/or heparin in order to maintain patency by preventing clot formation in the line. Sterile technique should be used for dressing changes for at least 24 hours after insertion and 3 to 7 days thereafter. The external part of the catheter should be kept under the dressing to prevent the introduction of microorganisms, leading to infection. Catheter caps should be changed every 3 to 7 days.
A client recently received 2 units of packed red blood cells. Which laboratory result below demonstrates that the blood transfusion was successful?
Hemoglobin level 15 g/dL (150 g/L) Hemoglobin levels are used to assess the effectiveness of a blood transfusion. A normal Hgb level for a male is 14 to 18 g/dL (140 to 180 g/L) and for a female, the level is 12 to 16 g/dL (120 to 160 g/L). Platelet count and prothrombin time are related to the clotting of blood.
The nurse is caring for a client who just returned from the postanesthesia care unit (PACU) and rates current pain as 9 out of 10. Which is the most appropriate postoperative prescription for this client?
IV morphine sulfate The intravenous route has the most rapid onset and is considered the best for a client, especially with a pain rating of 9 out of 10. Oral routes of medications start to work in 45 minutes. Intramuscular medications start to work within 30 minutes.
The nurse is providing care to a client who has a central venous access device that has been surgically implanted and sutured into a subcutaneous pocket. The nurse correctly identifies this as which type of device?
Implanted vascular access device An implanted vascular access device is surgically implanted and sutured into a subcutaneous pocket. A tunneled central venous catheter is implanted during a surgical procedure in which an incision is made in the deltopectoral groove and the subclavian vein is isolated. Then a subcutaneous pathway or tunnel is gently formed with long forceps to a point between the nipple and sternum. The catheter is threaded into the lower part of the vena cava at the entrance to the right atrium. An intraosseous device is most often inserted into the proximal tibia. A peripherally inserted central catheter is a long-line catheter that is placed peripherally but delivers medications and solution centrally, usually via the basilic vein with the tip terminating in either the axillary or subclavian vein or the superior vena cava.
A client is receiving IV therapy with an isotonic solution. The nurse notes swelling and coolness at the site along with an absent blood return. Which of the following would the nurse suspect?
Infiltration When IV solutions, such as isotonic solutions, inadvertently leak into the subcutaneous tissues, it is called infiltration. If the solution or medication is a vesicant or highly irritating, then it is called extravasation. Phlebitis is an inflammation of the vascular endothelium characterized by pain, warmth, and redness at the site. An air embolism involves the entry of air into the client's circulatory system manifested by pain in the chest, shoulder, or back; dyspnea; hypotension; thready pulse; cyanosis; and eventually loss of consciousness.
The nurse is preparing to administer prescribed intravenous antibiotics to a client. While assessing the medication lock, the nurse notes that there is resistance when administering the saline flush solution. What would be the best action by the nurse?
Insert a new IV medication lock and remove the old one. The nurse is to flush the medication IV lock every 8 to 12 hours, or depending on the facility policy. When flushing the IV lock, the nurse verifies the patency of the lock by aspirating blood return and the lock should flush without resistance. If the nurse is unable to flush without resistance, if there is leaking from the site during flushing, or if patency cannot be verified, the nurse should remove the IV lock and insert a new IV lock. If the nurse has resistance with flushing with saline, flushing with heparin would not be an appropriate option. The nurse should not administer the antibiotic if the IV lock is resistant during flushing. Calling the physician to change the order is not appropriate.
A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. What is an accurate guideline for IV management that the nurse should consider?
It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order. The nurse's ongoing verification of the IV solution and the infusion rate with the physician's order is essential. If more than one IV solution or medication is ordered, the nurse should make sure the additional IV solution can be attached to the existing tubing. As one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 50 mL of fluid remains in the original container. Every 72 hours is recommended for changing the administration sets of simple IV solutions.
The nurse is providing care to a client who has a Groshong catheter inserted. When irrigating the catheter, the nurse would use which solution?
Normal saline Catheter patency is usually maintained by periodically flushing the catheter with diluted heparin. However, because of its unique design, the Groshong catheter requires irrigation with normal saline rather than heparin.
A nurse is preparing to administer a transfusion of packed red blood cells to a client. Which solution would the nurse expect to use to administer the transfusion?
Normal saline When administering a blood transfusion, normal saline should be used to prevent cell hemolysis. Solutions containing dextrose cause hemolysis. Lactated Ringer's is not recommended.
A nurse is assigned to care for a client who is bleeding severely following an accident and has been ordered transfusion of blood components. What should the nurse do to reduce the risk of septic reactions?
Refrigerate red blood cells and thawed fresh frozen plasma until use. To minimize time for bacterial growth within the blood component and subsequent the risk for septic reactions, the nurse should refrigerate red blood cells and thawed fresh frozen plasma until use. Blood components should be infused within four hours of removal from the refrigerator. The nurse should not keep the frozen blood components at room temperature for an extended period of time because the longer they remain at room temperature, the more likely bacteria will grow and multiply. The nurse should use a blood warmer if necessary to warm blood and not immerse refrigerated blood components in warm water before use.
A client is to receive intravenous (IV) fluid therapy and the nurse is preparing the solution for use. Place the following steps in the order in which the nurse would perform them. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left.
Remove the IV solution bag from the outer plastic covering. Close the flow clamp on the IV administration set. Remove the protective cap from the tubing insertion port, and remove the protective covering from the spike on administration tubing. Insert the spike of the administration set into the port on the IV solution bag. Invert the IV solution bag and hang it on the IV pole. Compress the drip chamber until it is approximately one-half full. When preparing the solution for IV administration, the nurse would remove the solution bag from the outer plastic covering, grasp the IV administration set and close the flow clamp on the tubing, remove the protective cap from the tubing insertion port and from the spike on the administration tubing, quickly insert the spike into the port, invert the solution container and hang it on the IV pole, and finally compress the drip chamber until it is approximately one-half full.
A nurse is preparing to insert an intravenous infusion device in a toddler. Which site would the nurse be least likely to choose?
Scalp vein Intravenous insertion into a scalp vein is appropriate for an infant younger than 6 months but not for a toddler. The metacarpal, cephalic, dorsalis pedis, and great saphenous veins would be appropriate insertion sites for a toddler.
A nurse is assessing a client's lower arm for insertion of an IV catheter. The nurse palpates the vein and notes that it feels hard. Which action by the nurse would be most appropriate?
Select another site. If a vein appears hard or ropelike, the nurse should select another spot for the venipuncture. Applying a warm compress would be used to help dilate the vein. Loosening the tourniquet would have no effect on the "hardness" of the vein. The vein should not be used. Applying a topical anesthetic is appropriate to reduce the pain associated with insertion. However, a vein that feels hard should not be used.
A client who has been receiving a secondary infusion of a new antibiotic for several minutes reports itching and a sensation of throat tightness. What is the priority nursing intervention?
Stop the infusion of the antibiotic. The client may be experiencing a reaction to the antibiotic. Because intravenous administration occurs quickly, life-threatening reactions can also occur quickly. The first nursing action is to stop the infusion. The nurse will proceed to assure that there is an open airway, assess the skin for rash, and activate the Rapid Response Team if needed.
A client is receiving a secondary infusion of a new antibiotic. After 5 minutes of administration, the client reports itching and appears flushed. What is the first nursing intervention?
Stop the infusion. The client may be experiencing a reaction to the antibiotic. Because intravenous administration occurs quickly, life-threatening reactions can also occur quickly. The first nursing action is to stop the infusion. Slowing the rate is inappropriate, as this will not solve the problem if the client is having a reaction. Assessing the itching and contacting the health care provider can occur after the infusion is stopped.
A postoperative client's medication administration record (MAR) provides for PRN administration of a number of analgesics by various routes. Which action should the nurse take to assess the client's pain to determine the appropriate analgesic to administer?
The nurse will have the client rate pain on the pain scale of 1 to 10 and proceed accordingly. By assessing the client's pain using the pain scale the nurse can determine how severe the pain is and act accordingly. Intravenous drugs, because they are introduced directly into the circulatory system, have an onset that is faster than that of intramuscular (IM), subcutaneous (SC), or by mouth (PO) routes. IM and SC injections have to penetrate the muscles and tissues to be circulated in the body, which takes about 30 to 45 minutes. PO takes about 45 to 60 minutes for onset of action, as the drug needs to be digested in the stomach and then get into the circulation via the portal or hepatic vein.
The client states "I think my IV dressing needs to be changed." In which instance should the nurse change the dressing?
When the dressing is loose, bloody or wet. The nurse should regularly assess the integrity of the dressing to determine if it needs to be changed. Peripheral IV dressings are not routinely changed unless they are loose, bloody, or wet because changing dressings increases the risk of site contamination or dislodging the catheter. While changing the dressing can dislodge the catheter, the dressing should still be changed if wet.
A client diagnosed with cancer is receiving chemotherapy. Laboratory testing reveals deficiencies of certain blood cells. Based on the nurse's understanding about chemotherapy and its effect on blood cells, the nurse would expect to administer which blood component? Select all that apply.
White blood cells Platelets Chemotherapy often leads to a decreased level of white blood cells and platelets, necessitating the need for transfusion of these blood components. Albumin would be used to restore intravascular volume and maintain cardiac output in clients with hypoproteinemia. Fresh frozen plasma would be indicated to provide clotting factors to clients with coagulation deficiencies who are bleeding or about to undergo an invasive procedure. Cryoprecipitate is used for clients with fibrinogen deficiencies who are predisposed to bleeding problems due to a genetic lack of factor VIII.
Which client would most likely require placement of an implantable port?
a 58-year-old woman with stage 3 breast cancer requiring weekly chemotherapy This client needs frequent IV access. A central port is easily accessed for chemotherapy sessions, then the access is discontinued even though the port remains in place subcutaneously. A central port also allows for the infusion of chemotherapy into a central vessel; this is important because chemotherapy is caustic and severely damages peripheral vessels.
The nurse is preparing to administer a bolus of an intravenous medication. How should the medication be administered?
all at once Bolus administration is given into a vein all at one time. All other answers are incorrect.
A client diagnosed with anemia is receiving a blood transfusion. The client develops urticaria accompanied by wheezing and dyspnea not long after the transfusion starts. The nurse interprets this as indicative of:
allergic reaction. In a client with urticaria, the symptoms of severe allergic reaction are hives, wheezing, and dyspnea, which is due to an anaphylactic reaction. Minor adverse effects are called side effects. Many side effects are essentially harmless and can be ignored. Toxicity results from overdosage or buildup of medication in the blood due to impaired metabolism and excretion. Antagonism is a drug interaction by which drug effects decrease.
A client has an intermittent infusion device inserted for the administration of antibiotic therapy every 6 hours. The nurse would expect to flush the device at which frequency?
before and after each medication administration Peripheral intermittent lines are usually flushed with preservative-free 0.9% NaCl before and after each medication administration and every 8 hours when medications are not being given. Most agencies recommend changing intermittent devices every 72 hours to ensure patency and prevent common complications of IV therapy.
A nurse needs to administer a prescribed medication to a client using IV push. In which way is the medication being administered to the client?
bolus administration A bolus is a relatively large amount of medication given all at once; bolus administration sometimes is described as a drug given by IV push, or rapid intravenous administration. A continuous infusion, also called continuous drip, is instillation of a parenteral drug over several hours. It involves adding medication to a large volume of IV solution. After the medication is added, the solution is administered by gravity infusion or, more commonly, with an electronic infusion device such as a controller or pump.
A nurse is using an IV port when administering medication to a client. Which IV administration has the greatest potential to cause life-threatening changes?
bolus administration Because the entire dose is administered quickly, bolus administration has the greatest potential to cause life-threatening changes should a drug reaction occur. An electronic infusion device, continuous administration, and secondary administration do have the potential to cause life-threatening changes, but not to the same degree as a bolus administration, since the rate at which medication is administered is not as fast as during a bolus.
A nurse needs to administer a prescribed dosage of antineoplastic drugs to a client with cancer. Which piece of medical equipment is used to administer antineoplastic drugs?
central venous catheter Central venous catheters (CVCs) are often used to administer antineoplastic drugs to clients with cancer. CVCs provide a means of administering parenteral medication in a large volume of blood. A tuberculin injection is used when administering intradermal injections of small volumes to a client, whereas a wider-gauge syringe is used to administer medication into the tissue of the client. They do not provide a means of administering parenteral medication in a large volume of blood. Conventional syringes may not be suitable for administering antineoplastic drugs to clients with cancer.
Which client does the nurse recognize will require an intramuscular administration of the medication instead of an intravenous administration?
client who is low risk for hemorrhage and prescribed the Hepatitis B vaccination The hepatitis B vaccine is administered intramuscularly. Recombivax HB, a form of the hepatitis B vaccine, may be administered subcutaneously to clients who are at high risk for hemorrhage. This client is low risk. Medications for the clients experiencing the situations listed would be administered intravenously.
The nurse is providing discharge teaching for an older adult with arthritis who also has an implanted catheter. Which care does the nurse anticipate the client will need to provide catheter care?
home care The nurse anticipates the client will need home care to maintain and care for the implanted catheter, something that may be difficult to do with arthritis. The scenario presented does not indicate that the client needs long-term care or assisted living. An inpatient admission is not anticipated to be needed for the sole purpose of catheter care.
A nurse caring for a client with diarrhea needs to establish an intravenous (IV) access to administer fluids and medication. When explaining intravenous access to the client, what would the nurse most likely incorporate into the description?
insertion of a catheter into a peripheral vein The most common method of accessing the venous system is through percutaneous insertion of a needle or flexible catheter into a peripheral vein. Thus the nurse would include this in the description. The peripheral veins usually provide the quickest and easiest approach to establishing IV access for administration of solutions and medications. This process differs from central venous therapy, which involves placement of a flexible catheter into one of the client's large veins, with the catheter tip placed in either the superior vena cava or the right atrium.
A nurse is preparing a client for insertion of an intravenous device and is inspecting the client's extremities for a suitable site. Which of the following would be least appropriate for the nurse to do?
placing a tourniquet directly over the intended insertion site When locating and visualizing an appropriate site, the nurse would place a tourniquet on the extremity 4 to 6 inches (10 to 15 cm) above the intended site to distend the vein. The nurse also could lower the extremity below the level of the heart, ask the client to open and close the fist several times, or apply warm soaks for 5 minutes (300 seconds) before the venipuncture to vasodilate the selected vessel.
The nurse is caring for a client who has normal saline infusing through a peripheral intravenous catheter with a prescription for a secondary infusion of antibiotic. Which technique would be most appropriate for the nurse to administer the secondary infusion by gravity?
placing the secondary infusion higher than the primary solution The nurse should place the secondary infusion higher than the primary infusion. This will allow the secondary infusion to infuse first. When completed, the primary infusion will continue to infuse. The other options are not correct.
A nurse is preparing to convert a client's IV to an intermittent infusion device. The IV is connected to extension tubing. Before disconnecting the IV tubing from the extension tubing, the nurse clamps the extension tubing for which reason?
prevent air from entering the line When converting to an intermittent infusion device, the nurse clamps the extension tubing to prevent air from entering the line. The primary IV tubing is clamped to prevent blood loss when the IV and tubing are disconnected. Flushing maintains IV line patency. Taping the adapter device and extension tubing secures the device in the proper position.
What would be considered a "right" of drug administration? Select all that apply.
right drug right documentation right dose right client Clients have the right to expect safe and appropriate drug administration. Nurses must observe each of these rights to ensure that the administration is done accurately.
A nurse is preparing an intravenous infusion. Which part of the administration set would the nurse use to manually regulate the infusion rate?
roller clamp When regulating the flow rate manually, the nurse would use the roller clamp on the administration set. The spike is used to access the solution container. The drip chamber is compressed to be filled halfway to initiate and maintain the flow through the tubing. The roller clamp can be used to stop the flow through the tubing.
The nurse is reviewing the plan of care for a client who has a newly placed implanted catheter and is to be discharged home. What is a priority for the nurse to include in the plan of care?
signs of infection The priority for the nurse to teach the client would be the signs of infection. The other options would be done by the nurse.
A nurse flushes an intravenous lock before and after administering a medication. What is the rationale for this step?
to clear medication and prevent clot formation The intravenous lock is flushed before and after the infusion is completed to clear the vein of any medication and to prevent clot formation in the needle.
