Infection & IV therapy (2 of 2)

Which of the following provides the best practice for the graduate nurse in the administration and regulation of intravenous fluids to clients?

state licensing board

A client is ordered an intravenous (IV) solution of Ringer's lactate 1000 mL to infuse at 40 mL/hr. What is the maximum amount of time the nurse should allow this IV to hang?

24 hours

The major advantage for giving a client medication via intravenous (IV) route is which of the following?

Rapid distribution of the drug to all target tissues

The client asks the nurse why it is necessary to prime the intravenous tubing. What is the best response by the nurse?

"It eliminates air and potential of complications."

The nurse is caring for a client who has an order to receive Hespan IV. The client asks the nurse what this solution is for. What would be the nurse's response? Select all that apply.

"This solution pulls fluid into the vascular space." "This is a colloid solution used to replace blood." "Hespan is a solution used instead of a transfusion." "Hespan can be used to treat hypovolemic shock."

A nurse is training other nurses at the hospital to insert midline catheters. What would the nurse teach the other nurses about how many inches of the catheter should be inserted into the required site and for how long can it be used?

3 to 6 inches, used for up to 4 weeks

A central venous catheter has been inserted in the right subclavian vein of the client. Which of the following would be the priority nursing action before total parenteral nutrition (TPN) can be started?

Call for portable chest X-ray.

The nurse is caring for an older adult client with an IV infusing at 100 mL/hr. What should the nurse monitor this client for?

Circulatory overload

A client is brought to the emergency department with a diagnosis of possible cerebral vascular accident (CVA) and is being typed and crossmatched for fresh frozen plasma (FFP). Which is the best nursing understanding for this action?

Client is experiencing a hemorrhagic stroke.

The nursing instructor is discussing about the different types of IV fluids with the nursing students. What type of fluid would the instructor tell the students to be used to replace circulating blood?

Colloid solutions

The emergency department nurse is caring for a client who has just been admitted by ambulance for a suspected myocardial infarction. The physician orders IV fluids of normal saline to be hung at 100 mL/hr. The nurse knows that this is what type of IV solution?

Crystalloid

The nurse caring for a client with an intravenous infusion is looking up her institution's policy on changing IV equipment used in a venipuncture. When is most IV tubing changed?

Every 72 hours

The client has been receiving intravenous (IV) fluids for the last 6 hours and now is demonstrating bounding pulse, crackles in the lungs, leg swelling, and a blood pressure more than 15 mm Hg higher than baseline. Which is the most likely nursing diagnosis for this client?

Excess Fluid Volume

The client is going out on pass for the afternoon with his family. The physician has ordered that his venipuncture device needs to be temporarily capped. How will the nurse ensure that the vein remains patent?

Flush the lock with saline or heparinized saline.

The client is receiving total parenteral nutrition (TPN), and the solution bag is almost empty. The nurse discovers there are no containers prepared for use. The nurse contacts the health care provider. What order would the nurse expect from the health care provider?

Hang dextrose 10% in water (D10W) until new container is ready.

Thirty minutes after hanging a glass intravenous bottle of total parenteral nutrition (TPN), the nurse notices the solution has stopped dripping. Which is the best troubleshooting action of the nurse?

Hang vented tubing

The nurse would expect to hang which of the following intravenous (IV) solution to a client with cerebral edema?

Hypertonic solution

The nurse receives an order for a client to be given a colloid solution. Which is the likely reason for the use of this type of solution?

Increased blood loss

Which is the best option for raising the white blood cell count in a cancer client who is at risk for congestive failure?

Injection of filgrastim (Neupogen)

In providing nursing care to a client, which actions should the nurse take to reduce the risk of administering a contaminated intravenous (IV) solution? Select all that apply.

Inspect IV solutions for transparency prior to administration. Do not use any solution that is expired. Do not use any solution that is leaking.

The nurse is preparing an intravenous partial bottle (IVPB) of anti-infective as ordered. Which is the best method of delivery for a client with a history of congestive failure?

Intermittent infusion via medication lock

A client is scheduled for a test that requires an NPO status and has been ordered 5% dextrose in water (D5W). The nurse understands which of the following to be the best rationale for this action?

Isotonic solutions maintain body fluid balance.

Which isotonic solution is often used in providing a source of energy to clients receiving total parenteral nutrition (TPN)?

Lipid emulsions

A client is brought to the emergency department with full-thickness burns to 27% of the body. The nurse knows to prepare intravenous (IV) fluid administration from which solution group?

Lower osmolarity solution

To avoid complications of blood transfusion reaction, which nursing action is most important?

Matching numbers on blood bag to client bracelet

When flushing an intravenous (IV) lock with saline, the nurse avoids forcing the injection into the client. What is the best rationale for this action?

Minimizes potential for clot release

A client with severe malnutrition is ordered intravenous (IV) albumin. Which is the primary assessment in providing nursing care for this client?

Monitor for fluid overload.

There are limited infusion pumps available on the nursing unit. Which client has the greatest need for accurate fluid monitoring? Select all that apply.

Older adult receiving potassium chloride in the solution Middle-aged adult receiving medication for congestive failure

The nursing instructor is teaching student nurses about venipuncture techniques and possible complications from the procedure. What can happen if the venipuncture device is left in the clients' vein too long?

Phlebitis can develop.

Before instilling any additives to a client's medication lock, normal saline is used to flush the device. Which of the following provides the best rationale for this action?

Prevents drug/solution incompatibilities

The client complains that the intravenous (IV) site is stinging. No signs of infiltration or inflammation are assessed, but the nurse notices the rate is running faster than ordered. Which action should the nurse take first?

Reset the drip rate.

A postoperative total hip replacement client is to receive salvaged blood through the cell saver system. The nurse is most concerned about which possible transfusion reaction?

Septic reaction

The nurse is caring for a client who has just had total parenteral nutrition (TPN) ordered. The nurse is correct when informing the client that TPN is used for what?

To meet the client's caloric and nutritional needs

The client has just had a transfusion ordered for severe anemia. The nurse is gathering the supplies that are needed in order to transfuse the client. What kind of tubing does the nurse know is needed to infuse blood or blood products?

Y-administration tubing