CHAPTER 21 - INTRAVENOUS THERAPY

The nurse is caring for a client with a peripherally inserted central catheter (PICC) in the right arm. Which assessment finding would require immediate follow up by the nurse? - soiled dressing - right arm is larger than left - slow blood return with aspiration - slight resistance when flushing the line

right arm is larger than left Rationale: A complication of a PICC line is venous thrombosis (clot formation). If a client develops a venous thrombosis, the affected arm can appear larger than the other arm. The other options are all normal findings.

The nurse is providing care to a client who has a Groshong catheter inserted. When irrigating the catheter, the nurse would use which solution? Sterile water 5% dextrose Normal saline Diluted heparin

Normal saline Rationale: 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

The nurse is teaching a nursing student regarding safety of chemotherapeutic medication. Which statement by the nurse is correct? - "Antineoplastic drugs only target cancer cells." - "Antineoplastic drugs can be absorbed through the skin." - "Once the drugs are packaged in pharmacy, there are no risks in handling the medication." - "Pharmacists usually administer chemo drugs."

"Antineoplastic drugs can be absorbed through the skin." Rationale: Antineoplastic drugs are absorbed through the skin and should always be handled with caution. All other options are incorrect.

The nurse has finished teaching a client about medications that have been ordered for administration. Which client statement reflects that teaching about a piggyback infusion has been successful? - "You will give me that medication in tandem with my other IV solution." - "This is the first medication I will receive." - "A piggyback is a type of chemotherapy that will treat my cancer." - "I could not receive this type of medication if I were under the age of 18."

"You will give me that medication in tandem with my other IV solution" p. 529-529 Rationale: A piggyback is a secondary infusion - the administration of a parenteral drug that has been diluted in a small volume of IV solution over 30-60 minutes. It is called a piggyback because it is given in tandem with primary IV solution; therefore, this client statement reflects that teaching has been successful. Other client statements are incorrect and require further teaching

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 mL/hour Rationale: 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 working on a medical unit when an unlicensed assistive personnel (UAP) approaches and states that Mrs. G.'s IV dressing is curling at the edges and appears wet. What is the nurse's best approach to this situation? - Assess the dressing and delegate the dressing change to the UAP if the dressing is not intact. - Leave the dressing change for the next shift. - Assess the dressing and redress it if the dressing is not intact. - Reinforce the dressing with a tegaderm.

Assess the dressing and redress it if the dressing is not intact Rationale: Under current regulations an IV dressing change is not a task that can be delegated.

What would be considered a "right" of drug administration. (Select all that apply.) Right class Right dose Right documentation Right drug Right client

Right dose Right documentation Right drug Right client p. 426 Rationale: 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

The National Formulary (NF) is a list of medications which are regulated by the U.S. government. It describes medications based on certain categories. Which category does the National Formulary not describe? - Source - Physical properties - Side effects - Purity

Side effects p. 411 Rationale: The National Formulary describes medication products according to their source, physical and chemical properties, tests for purity and identity, method of storage, category, and normal dosages

A client comes to the emergency department and is bleeding profusely. Blood transfusion is ordered and the client is being typed and cross-matched. While awaiting the results, the physician orders a unit of packed red blood cells to be administered STAT. Which blood type would the nurse expect to be used? Type A Type B Type O Type AB

Type O Rationale: People with group O negative blood are often referred to as universal donors for packed cells because type O blood has neither A nor B antigens, and people with other blood types can safely receive it.

The nurse is providing teaching to an older adult with arthritis and an implanted catheter. What living arrangements does the nurse anticipate in the discharge plan of care? - home nursing visits - continued inpatient admission - long-term care facility admission - assisted living arrangements

home nursing visits p. 428-431 Rationale: 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. Other answers are incorrect, as the client does not need assisted living, long-term care, or continued admission

The nurse is caring for a client who has normal saline infusing through a peripheral intravenous catheter with a prescription for an antibiotic secondary infusion. Which technique would be most appropriate for the nurse to administer the secondary infusion by gravity? - stopping the primary solution until the secondary infusion is completed - placing the primary solution higher than the secondary solution - placing the secondary infusion higher than the primary solution - placing the secondary and primary infusion at equal height

placing the secondary infusion higher than the primary solution Rationale: The nurse should place the secondary infusion higher than the primary infusion. This will allow the secondary infusion first and when completed, the primary infusion will continue to infuse. The other options are not correct.

The nurse is reviewing the plan of care for a client who 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? - how to access the port - to keep a dressing over the port - signs of infection - flushing the port with heparin

signs of infection p. 476 Rationale: 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 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: - antagonism. - side effect. - toxicity. - allergic reaction.

allergic reaction Rationale: 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 - at least every 8 hours - once daily - every 72 hours

before and after each medication administration p. 485 Rationale: 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 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? - placement of a flexible catheter into a large vein - placement of a flexible catheter in the right atrium - insertion of a catheter into a peripheral vein - insertion of a catheter tip into the superior vena cava

insertion of a catheter into a peripheral vein Rationale: 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 client has an order for an intermittent infusion of 250 mL of 0.9 normal saline. The nurse understands that this type of infusion is used for which situation? - medications that are given over 1 minute for rapid therapeutic effect - medications that can be given through a capped intravenous port - medications that need to be infused over 20 to 60 minutes - medications that are toxic if given over short periods

medications that need to be infused over 20 to 60 minutes Rationale: Intermittent infusions are used for medications that need to be administered for an intermediate length of time, usually 20 to 60 minutes. The intravenous push technique is used for medications that can be given over 1 minute for rapid therapeutic effect, and may be given into a continuously infusing IV set or into a capped IV port. The continuous infusion technique is used for medications that are toxic if given over short periods.

The nurse is caring for a client with endocarditis who will require 6 weeks of antibiotic therapy. The nurse should anticipate which type of access for this client? - percutaneous catheter inserted into the jugular vein - peripheral inserted central catheter (PICC) in the right axillary vein - 18 gauge peripheral intravenous port in the right forearm - implanted catheter under the right subclavian

peripheral inserted central catheter (PICC) in the right axillary vein Rationale: The PICC line would be appropriate for clients who are to receive short term fluid or medication therapy. The other options would not be appropriate for this client

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 blood loss during the disconnection - prevent air from entering the line - secure the device in the proper position - maintain IV line patency

prevent air from entering the line Rationale: 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

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 5-cc 20-cc 15-cc

10-cc p. 517, Procedure 21-4 Rationale: When flushing a PICC catheter, a large 10-cc syringe is used to avoid very high pressures that could cause catheter rupture

The nurse administers medications by various routes of delivery. The nurse would use which route for a client that needs immediate effect of the medication? - transdermal - oral - intravenous - rectal

intravenous p. 531 Rationale: Medication administered through IV route has an immediate effect. The medication is infused directly into the blood stream and circulates through the body. The other routes are not immediate in action

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? - Continuous administration - Bolus administration - Electronic infusion device - Secondary administration

Bolus administration Rationale: 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? - Tuberculin injection - Syringe with a large-bore needle - Conventional syringe - Central venous catheter

Central venous catheter p. Rationale: 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 since they cannot normally access a central vein

The nurse is administering a medication intravenously to a child. The nurse understands which is the most appropriate reason the child should be closely monitored for effects after receiving the medication? - The liver of a child metabolizes the drug quickly. - Children can have an increase in active drug circulation. - Children have less blood volume, so more medication is required. - A child's kidney excretes more of the medication.

Children can have an increase in active drug circulation Rationale: The nurse understands that children can have an increase in active drug circulation. Therefore, the child should be closely monitored for effects after receiving the medication. Other answer choices are incorrect.

The nurse is preparing to administer two IV medications. What is the appropriate nursing action? - Hold one medication for an hour and administer it after the first medication. - Prepare to administer through two separate tubes. - Administer the drugs through the same tubing. - Consult current drug reference book for IV compatibility.

Consult current drug reference book for IV compatibility Rationale: 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? - Change catheter caps every 10 days or as per facility policy. - Flush using normal saline and/or heparin solution according to facility policy. - Keep external portion of catheter coiled on top of dressing. - Use clean technique when changing dressing.

Flush using normal saline and/or heparin solution according to facility policy Rationale: 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 is being started on total parenteral nutrition (TPN). When initiating the therapy, the nurse gradually tapers up the infusion rate as ordered to prevent which potential complication? - Infection - Pneumothorax - Air embolism - Hyperglycemia

Hyperglycemia Rationale: Metabolic complications also may present a problem for the client receiving TPN. Most commonly, clients experience hyperglycemia if they are unable to tolerate the high glucose content of the TPN solution. When therapy is initiated, the infusion rate is usually tapered up over a period of a day or two. Using strict aseptic technique during catheter manipulations, dressing changes, and tubing and bottle changes helps to reduce the risk for infection. Air embolism and pneumothorax are potential complications that are associated with central line placement, not TPN administration.

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 Phlebitis Extravasation Air embolism

Infiltration p. 487 Rationale: 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.

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? - Dextrose 5% and water - Lactated Ringer's - Normal saline - Dextrose 50%

Normal saline Rationale: 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 preparing an intravenous infusion. Which part of the administration set would the nurse use to manually regulate the infusion rate? Slide clamp Drip chamber Spike Roller clamp

Roller clamp p. 479-480 Rationale: 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 half-way to initiate and maintain the flow through the tubing. The roller clamp can be used to stop the flow through the tubing

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? Slow the rate of infusion. Assess the characteristics of the itching. Stop the infusion. Contact the healthcare provider.

Stop the infusion p. 496-497 Rationale: 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 healthcare provider can occur after the infusion is stopped

A client who has been receiving a secondary infusion of a new antibiotic for several minutes reporting itching and a sensation of throat tightness. What is the priority nursing intervention? - Assess skin for rash. - Open the airway. - Activate the Rapid Response Team. - Stop the infusion of antibiotic.

Stop the infusion of antibiotic Rationale: 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 has a central venous catheter inserted. The nurse understands that the tip of the catheter would be found at which location? Select all that apply. Right atrium Median cubital vein Basilic vein Left ventricle Superior vena cava

Superior vena cava Right atrium Rationale: Central venous therapy involves placement of a flexible catheter into one of the client's large veins, with the tip of the catheter placed in either the superior vena cava or the right atrium. No IV catheter is placed in the left ventricle. The median cubital vein and basilic vein would be used for peripheral IV therapy or for the insertion of peripheral central venous catheters.

Which is not true regarding Nurse Practice Acts? - They describe what medications nurses can prescribe. - They were established to describe legitimate nursing function. - They define the boundaries of the functions of a nurse. - They vary among states.

They describe what medications nurses can prescribe p. 417 Rationale: Prescribing and dispensing medications are not legal practices for registered nurses, with the exception of nurses in advance practice roles

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? assisted living inpatient admission long-term care facility home care

home care Rationale: 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, nor assisted living. An inpatient admission is not anticipated to be needed for the sole purpose of catheter care

A client has had a peripherally inserted central catheter (PICC) inserted. The nurse reviews the client's medical record for what before using the catheter for infusion therapy? insertion of a self-sealing port removal of the introducer x-ray confirmation of catheter tip location use of a local anesthetic

x-ray confirmation of catheter tip location p. 477 Rationale: A radiograph (x-ray) confirms correct placement of the PICC tip, after which the catheter can be used for infusion therapy. An implanted vascular access device has a self-sealing port or septum. An introducer is used to insert multilumen central venous catheters. Local anesthetic may be used to insert any central venous access device.

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.

- 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.

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? Lactated Ringer's 3% NaCl 0.45 NaCL 0.9% NaCl

0.45 NaCL Rationale: 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 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? 20 gauge 18 gauge 19 gauge 22 gauge

22 gauge Rationale: 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 has had a central venous catheter inserted. To reduce the risk of catheter-related bloodstream infection (CRBSI), the nurse would change the dressing at which time after insertion? 24 hours 96 hours. 72 hours 48 hours

24 hours. Rationale: Applying evidence-based guidelines for the prevention of CRBSIs, the nurse would change the dressing 24 hours after insertion, and then every 7 days if the dressing is visibly soiled or bloody.

A nurse is preparing to insert an IV catheter into the skin. The nurse prepares to enter the skin at which angle? 10 degrees 55 degrees 40 degrees 25 degrees

25 degrees p. 484 Rationale: When inserting the IV catheter, the nurse enters the skin at a 21- to 30-degree angle and then as the skin is pierced, the nurse decreases the angle to 15 degrees. Doing so permits entry into the veins at an angle and decreases the risk of puncturing through a vein

A client has been prescribed three different intravenous medications. Two of the medications are not compatible with each other. Which type of IV access is appropriate? 22 gauge IV catheter with two lumens 20 gauge IV catheter with three lumens 18 gauge IV catheter port 7 French triple lumen central catheter

7 French triple lumen central catheter p. 475-476 Rationale: With a multiple lumen central line, incompatible medications can be administered simultaneously as each lumen is channeled so that it exits the catheter at a separate location near the heart. Other answers are incorrect

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 16-year-old client diagnosed with left radial fracture 35-year-old client diagnosed with migraines 45-year-old client diagnosed with lung cancer

73-year-old client diagnosed with liver disease p. 445 Rationale: Older adults have 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

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? - Call the physician to request oral antibiotics. - Insert a new IV medication lock and remove the old one. - Flush the lock with heparin solution. - Administer the prescribed antibiotics as prescribed.

Insert a new IV medication lock and remove the old one p. 534 Rationale: 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? - Generally, the nurse should change the administration sets of simple IV solutions every 24 hours. - As one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 10 mL of fluid remains in the original container. - 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 should use new tubing when attaching additional IV solutions.

It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order Rationale: 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.

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? - Avoid infusing blood components within four hours of refrigeration. - Keep the frozen blood components at room temperature for a longer duration. - Refrigerate red blood cells and thawed fresh frozen plasma until use. - Immerse the refrigerated blood components in warm water before use.

Refrigerate red blood cells and thawed fresh frozen plasma until use Rationale: 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