Clinical Key Questions
A nurse is gathering supplies to assess an implanted venous access device. Which syringe is the most appropriate to use for that assessment?
10-ml syringe
On first rounds, the nurse observes that the patient has an IV infusion of D5 normal saline running at 125 ml/hr. Later, at 0700, 500 ml remain in the bag. At what time should the IV bag empty?
1100 Rationale: 500 ml ÷ 125 ml/hr = 4 hr; 0700 + 4 hr = 1100.
The patient is to receive 500 ml over 4 hours. The IV tubing available is 10 gtt/ml. Which of the following is the appropriate drip per minute rate?
21 gtt/min Rationale: 500 ml ÷ 4 hr = 125 ml/hr; 125 ml/hr × 10 gtt/min = 1250 gtt/hr; 1250 gtt/hr ÷ 60 gtt/min = 20.833 gtt/min.
When hanging the first of two ordered IV antibiotics for a patient with one IV site, the nurse uses an intermittent administration set and notes that it will need to be changed in how many hours?
24 hours
The practitioner has ordered an IV infusion of 1000 ml over 10 hours. The macrodrip infusion set has a calibration of 15 gtt/ml. Which of the following rates should the nurse use to regulate the macrodrip infusion?
25 gtt/min Rationale: 1000ml ÷ 10 hours = 100 ml/hr; 100 ml/hr × 15 gtt/ml = 1500 gtt/hr; 1500 gtt/hr ÷ 60 min = 25 gtt/min.
When a patient undergoing a blood transfusion complains of flank pain and hematuria, which of the following adverse reactions should the nurse suspect?
A hemolytic transfusion reaction
A nursing student asks the preceptor about when to routinely change an IV solution. Which statement would be an appropriate response to the student?
"The IV solution should be changed when the tubing is changed."
Which of the following steps should the nurse include when inserting an ONC?
Advance the catheter until the hub rests at the venipuncture site.
Which of the following is an appropriate action for the nurse who is preparing to insert an IV catheter in a 9-year-old child?
Allowing the older child to select the IV site helps increase cooperation, letting the child feel some control in the procedure. Veins in the scalp or the foot should be considered with infants, but not older children. Family members should be allowed to stay with the child to help the child cope with the procedure. Venipuncture should be performed in a neutral space to allow the child's room to be a safe place.
Which of the following steps should the nurse include when preparing for IV catheter insertion?
Apply a tourniquet above the selected site.
The nurse is preparing to remove a short peripheral catheter from a patient who is taking an anticoagulant medication and is to be discharged home. Which of the following should the nurse plan to do?
Apply pressure to the site for a longer period of time.
An 80-year-old patient is receiving a maintenance IV infusion of normal saline solution at 100 ml/hr via a gravity IV flow-control device. When the nurse checked the patient an hour ago, 800 ml was left in the bag. The bag is now empty. Which of the following should the nurse do first?
Assess vital signs, lungs, and urine output and notify the practitioner.
Two days after receiving a blood transfusion, a patient begins to experience chills, fever, and signs of shock. The nurse should suspect which type of reaction?
Bacterial sepsis
When selecting a potential IV site on an older adult patient, the nurse should consider which of the following?
Dorsal veins in the hands should be avoided if possible.
A nurse caring for a patient who has been receiving CPN for several weeks notes that the patient has developed dry, flaky skin; hair loss; coarse hair; and impaired wound healing. The nurse suspects the patient has developed which condition?
EFAD Rationale: EFAD occurs when patients do not receive any or adequate amounts of ILE over an extended period of time. It is characterized by dry, scaly skin; sparse hair growth; and impaired wound healing.
Infiltration of a scalp PIV catheter may be indicated by edema at the catheter insertion site or by which of these signs?
Edema on the dependent side of the head and swelling of the eye
A patient had extensive abdominal surgery for colon cancer earlier in the day and is receiving PCA. The patient's wife has repeatedly asked if the nurse can alleviate discomfort. The patient reports that pain is at a level of 5 out of 10. Which of the following should the nurse instruct the patient's spouse to do?
Encourage the patient to depress the button when feeling discomfort.
The patient is experiencing wheezing and laryngeal edema during a blood transfusion. The nurse should anticipate an order from the practitioner for which medication?
Epinephrine
How often should a gauze dressing be changed on a peripheral catheter site?
Every 2 days
After removing a short peripheral catheter, the nurse should do which of the following?
Examine the integrity of the catheter.
Preferred dressings vary with a patient's specific circumstances. What is the best dressing for a patient who is diaphoretic or a patient with a bleeding or oozing site?
Gauze and tape dressing
A neonate needs a PIV catheter. To minimize complications and enhance patency, the nurse should prefer which site?
Hand
When preparing to run an IV piggyback infusion, the nurse should do which of the following?
Hang the piggyback medication bag above the level of the primary bag.
When caring for a patient who recently began CPN therapy, the nurse reviews the initial laboratory results, knowing that the most common metabolic complication associated with CPN is which condition?
Hyperglycemia
The nurse is making initial rounds. When assessing the patient, the nurse notices that the IV site is swollen and cool to the touch and that the flow rate is very slow. Which of the following is the most likely cause?
Infiltration
Which action should the nurse take when administering CPN with lipids?
Initiate and maintain the infusion at the prescribed rate.
The nurse is changing a dressing over the patient's IV catheter insertion site. When removing the tape and dressing, what should the nurse do?
Keep one gloved finger on the catheter
Which of the following techniques should the nurse use while removing a short peripheral IV catheter?
Keep the catheter hub parallel to the skin while withdrawing it.
A patient has redness, drainage, and pain at the CVC insertion site as well as a fever. Which of the following is the most appropriate nursing intervention?
Notify the practitioner and discuss further interventions to confirm CLABSI.
While changing a patient's IV solution, the nurse accidentally brushes the tubing spike against the outside of the solution container. What should the nurse do next?
Obtain a new IV tubing set.
What should the nurse consider doing when assessing a patient's implanted port?
Palpating the port device to identify the borders
Which of the following actions should the nurse take when changing a CVC dressing on a diaphoretic patient?
Place an occlusive gauze dressing over the catheter site
During a transfusion, a nurse sees that the patient's heart rate has increased and that the patient is complaining of chills and lower back pain. What is the next step the nurse should take after stopping the transfusion?
Remove blood product and tubing
A man is being treated for burns. The nurse anticipates administering albumin to achieve which of the following goals?
Replacing and maintaining intravascular volume
If a patient develops a skin rash, edema, and wheezing during a blood transfusion, what should the nurse do?
Stop the transfusion immediately
When looking for a well-dilated vein in which to insert an IV catheter, the nurse keeps the extremity in a dependent position and applies heat. What is another technique that the nurse might use?
Stroking the extremity from distal to proximal below the proposed venipuncture site promotes venous filling. Stroking the extremity from proximal to distal, elevating the arm, and applying a second tourniquet all have the reverse effect.
After spiking the blood bag and filling the drip chamber to cover the filter, the nurse observes air bubbles in the drip chamber. Which action should be taken next?
Tap the filter chamber lightly
When incorporating a patient's weight into an initial weight-based medication calculation, which parameter is the most appropriate to use to ensure consistency?
The admission weight
The charge nurse is evaluating a new nurse's ability to insert an IV catheter. Which of the following actions by the new nurse may indicate the need for more education?
The nurse should apply the tourniquet 10 to 15 cm (4 to 6 inches) above the anticipated insertion site and check the presence of the distal pulse. Diminished arterial flow prevents venous filling; the pressure of the tourniquet should be tight enough to cause the vein to dilate, but not so tight that it affects arterial flow. Using the most distal site in the nondominant arm; pressing down and noting a resilient, soft, bouncy feeling as pressure is released; and placing the extremity in a dependent position are all good techniques.
A nurse is initiating opioid PCA for a postoperative older adult. Which of the following should the nurse consider?
The older adult should be well hydrated.
Which of the following should the nurse know when caring for a patient who is receiving IV fluids via an IV volume controller?
The system should be checked at least every hour.
Which sign does NOT indicate infiltration of a PIV catheter?
Warmth
The nurse observes that a patient receiving CPN has fever, malaise, and chills. The nurse should suspect that the patient has developed which complication?
a systemic infection
How often should a gauze dressing be changed on a central-line site?
at least every 2 days
Which of the following statements about PCA for children is correct?
developmental level, cognitive level, and motor skills must be considered
A new graduate nurse hanging a 3-in-1 CPN admixture places a 1.2-micron filter inline and connects the infusion to the patient's CVC. The nurse observing the new graduate nurse should take which action?
have the graduate nurse start the infusion.
Soon after the initiation of PPN and 10% lipid emulsion therapy, a patient suddenly experiences fever, chills, muscle ache, back pain, nausea, and vomiting. Which of the following complications should the nurse suspect?
lipid emulsion intolerance
The practitioner orders an IV antibiotic for a patient with severe fluid overload from heart failure. Which administration device should the nurse prepare to use?
mini-infusion pump
When deaccessing an implanted port, what is the purpose of providing port stability?
minimizes the patient's discomfort and ensures that the withdrawal of the needle (a sharp object) is controlled
Proper care of CVCs includes which of the following nursing actions?
replacing the dressing when it is damp, loose, or soiled
When calculating the rate of infusion, which factors other than the flow rate should the nurse take into consideration?
the total volume (ml) and administration time (hr)
A patient with a right upper extremity CVC reports pain, swelling, and tenderness of the extremity. No fluids are infusing through the catheter. The nurse knows that these signs and symptoms may indicate which of the following CVC-associated complications?
thrombophlebitis or venous thrombosis
A patient was involved in a motor vehicle crash, and paramedics at the scene placed a short peripheral catheter in the left antecubital space. When should the nurse replace this catheter?
within 48 hours of insertion
The nurse is preparing to administer an antibiotic via IV piggyback to a patient with aspiration pneumonia. How should the nurse verify that the antibiotic is going to the correct patient?
Ask the patient his or her name and verify the name on the patient's armband.
A postoperative patient is receiving PCA. Important nursing considerations in caring for a patient receiving an opioid include assessing the sedation level. Which of the following describes an appropriate sedation level?
Awake and alert
During rapid resuscitation of a trauma patient, the blood filter has become clogged. What is the most appropriate nursing intervention?
Change the filter
The practitioner prescribes 20,000 units of heparin in 500 ml of D5W to infuse at 21 drops/min. The drop factor is 10 drops/ml. The patient's admission weight is 160 lb. Which calculations are needed to determine the ml/hr the patient will receive?
Conversions of drops/min to ml/min and ml/min to ml/hr
Which strategy does NOT minimize pain during PIV catheter insertion?
Inserting the IV when the neonate is sleeping Rationale: Administering sucrose before IV insertion, swaddling, and providing skin-to-skin care have all demonstrated an ability to blunt the pain response in neonates.
Before inserting a PIV catheter, the nurse must ensure that a vein, not an artery, has been identified for cannulation. How can the nurse be confident that a vessel is a vein?
It fills when occluded with a tourniquet.
The nurse needs to access a patient's implanted access device. Which of these needles is best for accessing the device?
Noncoring needle
When preparing to administer RBCs, the nurse notes that lactated Ringer solution is hanging on the IV pole. Which substance should the nurse use to flush the line before hanging the blood?
Normal saline
After a successful blood transfusion, the nurse expects to see which of the following signs or symptoms?
Urinary output of at least 0.5 to 1 ml/kg/hr
The nurse is caring for a patient who has a critical IV drip infusing. To make sure that the patient gets the right amount of medication, what should the nurse do?
Use an EID to control the rate.
During which time period should the nurse be most alert to life-threatening reactions from blood transfusions?
Within the first 15 minutes or 90 ml of the transfusion
Which equation would the nurse use to determine the concentration of a drug?
total amount of medication (mg) in the total volume of solution (ml)
The nurse is teaching a new graduate nurse about PPN for an adult patient. Which of the following questions from the new graduate nurse indicates the need for further education?
"I should make sure that the PPN solution is still cold when I hang it." Rationale: PPN should be at room temperature when it is hung. The nurse should explain to the new graduate nurse that the PPN should be removed from the refrigerator 1 hour before hanging it.
During the IV dressing change, the nurse completes a thorough assessment of the IV site and notices slight redness and edema at the insertion site. What is the appropriate nursing intervention?
Discontinue the IV.
A patient is admitted to the medical unit with dehydration. An order for normal saline IV solution at 200 ml/hr is initiated. A nurse new to the unit is caring for this patient. The nurse's preceptor explains that the potential for complications in administering IV fluids includes fluid overload. Which assessment would indicate a need to change the patient's IV fluid therapy?
Distended neck veins
After placing an IV catheter in a patient's forearm, the nurse should take which action to secure it in place?
If using a gauze dressing, the nurse should tape all edges to minimize IV site contamination. Tape should never be placed on the insertion site because it may introduce contaminants and prevents easy visualization of the site. Wrapping gauze around the arm may prevent visualization of the insertion site and cause constriction. Tape on top of a transparent dressing prevents moisture from being carried away from the skin.
An obese patient who had a right mastectomy several years ago has better veins in her right hand but is left handed. Where should the nurse place the IV catheter?
In her left lower arm
After running an FFP infusion slowly for the first 15 minutes to watch for any transfusion reactions, what should the nurse do next?
Increase the infusion rate as desired
Before removing a short peripheral catheter, the nurse should do which of the following?
Assess the site for redness, swelling, tenderness, and temperature.
A postoperative patient is receiving opioids via PCA. Which of the following adverse effects requires immediate intervention?
Respiratory rate of 8
The nurse is preparing for intermittent administration of a medication, using a tandem infusion set. After the medication is infused, the nurse should expect which of the following?
the IV solution from the primary line will back up into the tandem line
A patient is receiving a liter of D5 lactated Ringer's solution every 12 hours using an administration set with a drop factor of 15 gtt/ml. At which of the following rates should the nurse set this infusion?
21 gtt/min Rationale: 1000 ml ÷ 12 hours = 83.33ml/hr; 83.33ml/hr × 15 gtt/min = 1250 gtt/hr; 1250 gtt/hr ÷ 60 gtt/min = 20.833 gtt/min.
A patient has an IV infusion with a microdrip infusion set. The order is for 40 ml/hr. Which of the following rates should the nurse use to regulate the microdrip infusion?
40 gtt/min Rationale: 40 ml/hr × 60 gtt/ml = 2400 gtt; 2400 gtt ÷ 60 min = 40 gtt/min.
A 3-year-old child is admitted with a diagnosis of dehydration and is to receive IV fluids. The nurse should gather the necessary equipment, including a volume-control device with which of the following drip factors?
60 gtt/ml Rationale: Microdrip tubing, which has a drop factor of 60 gtt/ml, is recommended for children to minimize the risk of accidental fluid overload. IV tubing with drip factors of 10, 15, and 20 gtt/ml does not provide an adequate safety benefit.
Which of the following patients is the most likely candidate for PPN?
A patient with bilateral subclavian vein thromboses
Which type of filter can be used during transfusion of all blood products (RBCs, platelets, FFP, cryoprecipitate)?
A standard filter
After two unsuccessful attempts to insert an IV catheter in an older adult patient, the nurse should take which of the following actions?
Ask another nurse to attempt another insertion.
During the evening assessment, the nurse notices that the IV dressing is wet because the IV tubing to the IV cannula has a loose connection. What should the nurse do immediately after tightening the IV tubing and cannula connection?
Change the IV dressing.
After inserting an ONC through the skin and into the vein, the nurse's next action should be which of the following?
Check for blood return in the flashback chamber.
Which of the following actions should be performed to avoid the most common cause of fatal transfusion reactions?
Check the blood component information and patient identification with another nurse
After the PPN infusion has been started, the nurse should take which of the following actions?
Check the patient's vital signs and comfort level.
When preparing to administer blood products, what is the most appropriate action?
Completely prime the tubing and cover the filter with normal saline
A nurse taking over the care of a patient receiving PPN notes that the 20% lipid emulsion was hung 10 hours ago. Which of the following nursing actions is appropriate?
Continue the lipid emulsion infusion for 2 more hours.
After removing a short peripheral catheter, the nurse should do which of the following?
Control bleeding with gauze and pressure.
After the short peripheral catheter is removed, the nurse suspects that the tip broke off. What is the first thing the nurse should do?
Save the used catheter.
While assessing the integrity of the IV tubing, the nurse notes approximately 2 ml of air in the tubing. What should the nurse do next?
Scrub the access port below the air with disinfectant, insert a syringe into a port, and aspirate the air into the syringe.
In addition to assessing the patient's characteristics of pain and previously successful pain-management strategies, the nurse should assess which of the following before a patient uses PCA?
The patient's cognitive status
An unidentified male trauma patient requires an emergent transfusion. What is the correct transfusion option?
Type O-positive, uncrossmatched blood
The nurse is reviewing a patient's MAR and notes that an IV antibiotic is due to be hung in 15 minutes. Which of the following steps should the nurse take first?
verify the practitioner's order to ensure that the correct medication, dose, time, and route are correctly entered on the MAR.
