Infusion Therapy

A client is being admitted to the burn unit from another hospital. The client has an intraosseous IV that was started 2 days ago, according to the client's medical record. What does the admitting nurse do first? A. Anticipate an order to discontinue the intraosseous IV and start an epidural IV. B. Call the previous hospital to verify the date. C. Immediately discontinue the intraosseous IV. D. Nothing; this is a long-term treatment.

A. Anticipate an order to discontinue the intraosseous IV and start an epidural IV. The intraosseous route should be used only during the immediate period of resuscitation and should not be used for longer than 24 hours. Alternative IV routes, such as epidural access, should then be considered for pain management. The nurse should know what to do in this client's situation without contacting the previous hospital. Other client data, such as the date and time that the burn occurred, should validate the date and time of insertion of the IV. Discontinuing the IV is not the priority in this situation—the client is in a precarious fluid balance situation. One IV access should not be stopped until another is established. This type of IV is not used for long-term therapy; an action must be taken.

The nurse is starting a peripheral IV catheter on a recently admitted client. What actions does the nurse perform before insertion of the line? (Select all that apply.) A. Apply povidone-iodine to clean skin, dry for 2 minutes. B. Clean the skin around the site. C. Prepare the skin with 70% alcohol or chlorhexidine. D. Shave the hair around the area of insertion. E. Wear clean gloves and touch the site only with fingertips after applying antiseptics.

A. Apply povidone-iodine to clean skin, dry for 2 minutes. B. Clean the skin around the site. C. Prepare the skin with 70% alcohol or chlorhexidine. Povidone-iodine (Betadine) is applied to the selected insertion site before insertion. The solution is allowed to dry, which takes about 2 minutes. The insertion site should be cleansed before the antiseptic skin preparations are completed. After soap and water cleansing, prepping with 70% alcohol or chlorhexidine is done. Clipping, rather than shaving, hair around the selected IV site is done; shaving is abrasive and makes the skin more vulnerable to infection (i.e., microbial invasion). The insertion site should not be palpated again after it has been prepped; this mistake is frequently made with IV starts.

The nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What does the nurse do initially? A. Assess the insertion site. B. Check connections. C. Check the infusion rate. D. Discontinue the IV and start another.

A. Assess the insertion site. Assessing the insertion site to check for patency is the priority. IV assessments typically begin at the insertion site and move "up" the line; that is, from the insertion site to the tubing, to the tubing's connection to the bag. Checking the IV connection is important, but is not the priority in this situation. Checking the infusion rate is not the priority. Discontinuing the IV to start another may be required, but it may be possible to "save" the IV, and the problem may be positional or involve a loose connection.

A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does the nurse teach the new graduate nurse to use for this client? A. Midline catheter B. Nontunneled percutaneous central catheter C. Peripherally inserted central catheter D. Short peripheral catheter

A. Midline catheter For a client with fragile veins (which occur with long-term corticosteroid use) and the need for a catheter for 5 days, the midline catheter is the best choice. Nontunneled central catheters usually are used for clients who require IV access for longer periods. Peripherally inserted central catheters usually are used for clients who require IV access for longer periods. A short peripheral catheter is likely to infiltrate before 5 days in a client with fragile veins, requiring reinsertion.

A client admitted to the ICU is expected to remain for 3 weeks. The nurse has orders to start an IV. Which vascular access device is best for this client? A. Midline catheter B. Peripherally inserted central catheter (PICC) C. Short peripheral catheter D. Tunneled central catheter

A. Midline catheter Midline catheters are used for therapies lasting from 1 to 4 weeks. PICCs are typically used when IV therapy is expected to last for months. Short peripheral catheters are allowed to dwell (stay in) for 72 to 96 hours, but they then require removal and insertion at another venous site. Tunneled central catheters must be inserted by a health care provider; the nurse typically is not qualified to start this type of IV.

The nurse is caring for an older adult client who has been admitted for dehydration and needs IV fluids. Which location does the nurse choose to place a peripheral IV on this client?

B [basilic vein] The most appropriate veins for peripheral IV therapy include the dorsal venous network and the basilic, cephalic, and median veins. However, an older client has poor skin turgor on the back of the hand, making this a poor selection. The palmar side of the wrist should be avoided because the median nerve is located there, causing increased pain and difficulty with stabilization. The cephalic vein, although large and prominent in most people, is not the best choice because the sensory branch of the median nerve intersects with it up to three times. The best choice is the basilic vein.

If a client is to receive an entire 250-mL bag of saline over the next 4 hours and the drop rate of the IV tubing chamber is 15 drops/mL, at what drop rate per minute will the nurse set this IV? ____________ drops/min

16 Drops per minute = volume × drop factor ÷ total minutes 250 × 15 = 15.625 4 (hours) × 60 (minutes/hour)

A severely dehydrated client requires a rapid infusion of normal saline and needs a midline IV placed. Which staff member does the ER charge nurse assign to complete this task? A. RN who is certified in the administration of oral and infused chemotherapy medications 2. RN with 2 years of experience in the ER who is skilled at insertion of short peripheral catheters 3. RN with 10 years of experience on a medical-surgical unit who has cared for many clients requiring IV infusions 4. RN with certified registered nurse infusion (CRNI) certification who is assigned to the ER for the day

4. RN with certified registered nurse infusion (CRNI) certification who is assigned to the ER for the day The nurse with CRNI certification is most likely to be able to quickly insert a midline catheter for a client who is dehydrated. The chemotherapy nurse and the ED nurse have the appropriate scope of practice, but will not be as skilled in inserting a midline IV catheter. The medical-surgical nurse may be skilled at inserting short peripheral catheters, but will not be skilled in inserting midline IV catheters.

A client is scheduled to receive 1000 mL of normal saline in 24 hours. The nurse should set the infusion pump to deliver how many milliliters per hour? _____________ mL/hr

42 1000 mL divided by 24 hours = 41.6 mL/hr

The nurse is teaching a hospitalized client who is being discharged about how to care for a PICC line. Which client statement indicates a need for further education? A. "I can continue my 20-mile running schedule as I have for the past 10 years." B, "I can still go about my normal activities of daily living." C. "I have less chance of getting an infection because the line is not in my hand." D. "The PICC line can stay in for months."

A. "I can continue my 20-mile running schedule as I have for the past 10 years." Excessive physical activity can dislodge the PICC and should be avoided. Clients with PICCs should be able to perform normal activities of daily living. PICCs have low complication rates because the insertion site is in the upper extremity. The dry skin of the arm has fewer types and numbers of microorganisms, leading to lower rates of infection. PICC lines can be used long term (months).

A client is admitted to the cardiothoracic surgical ICU after cardiac bypass surgery. The client is still sedated on a ventilator and has an arterial catheter in the right wrist. What assessment does the nurse make to determine patency of the client's arterial line? A. Blood pressure B. Capillary refill and pulse C. Neurologic function D. Questioning the client about the pain level at the site

B. Capillary refill and pulse Capillary refill and pulse should be assessed to ensure that the arterial line is not occluding the artery. Blood pressure and neurologic function are not pertinent to the client's arterial line. Although the client's comfort level is important with an arterial line, it is not a determinant of patency of the line.

The nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters does the nurse choose most often? A. Back of the hand for an older adult B. Cephalic vein of the forearm C. Lower arm on the side of a radical mastectomy D. Subclavian vein

B. Cephalic vein of the forearm For same-day surgery, the cephalic or basilic vein allows insertion of a larger IV catheter while allowing movement of the arm without impairing intravenous flow. Peripheral venous catheters should never be inserted into the back of the hand in an older adult because the veins are brittle. Peripheral venous catheters should never be inserted into the lower arm on the same side as a radical mastectomy because they interfere with limited circulation. Catheters are typically inserted into the subclavian vein by the health care provider, not by the nurse.

A client who is receiving IV antibiotic treatments every 6 hours has an intermittent IV set that was opened and begun 20 hours ago. What action does the nurse take? A. Change the set immediately. B. Change the set in about 4 hours. C. Change the set in the next 12 to 24 hours. D. Nothing; the set is for long-term use.

B. Change the set in about 4 hours. Because both ends of the set are being manipulated with each dose, standards of practice dictate that the set should be changed every 24 hours, so the set should be changed in about 4 hours. It is not necessary to change out the set immediately, but it must be changed before the next 12 to 24 hours.

The nurse is administering a drug to a client through an implanted port. Before giving the medication, what does the nurse do to ensure safety? A. Administer 5 mL of a heparinized solution. B. Check for blood return. C. Flush the port with 10 mL of normal saline. D. Palpate the port for stability.

B. Check for blood return. Before a drug is given through an implanted port, it is critical that the nurse check for blood return. If no blood return is observed, the drug should be held until patency is reestablished. Ports are flushed with heparin or saline after, rather than before, use. The port is palpated for stability, but this action alone does not ensure the client's safety.

The nurse is documenting peripheral venous catheter insertion for a client. What does the nurse include in the note? (Select all that apply.) A. Client's name and hospital number B. Client's response to the insertion C. Date and time inserted D. Type and size of device E. Type of dressing applied F. Vein used for insertion

B. Client's response to the insertion C. Date and time inserted D. Type and size of device E. Type of dressing applied F. Vein used for insertion The client's ability to adapt to interventions, such as IV insertion, should be noted when the intervention is performed. The date and time of the insertion are important data. IV sites need to be routinely monitored and changed at prescribed intervals per facility policy. It is important to note the device used (often the brand name is given), as well as all specifics such as needle or cannula length, gauge, and material (Teflon). It is necessary to describe the dressing applied, and the vein used should be noted. The client's name and hospital number should be on the medical record, but the nurse makes certain that the information is recorded in the correct medical record.

The nurse checking an IV fluid order questions its accuracy. What does the nurse do first? A. Asks the charge nurse about the order B. Contacts the health care provider who ordered it C. Contacts the pharmacy for clarification D. Starts the fluid as ordered, with plans to check it later

B. Contacts the health care provider who ordered it The nurse is responsible for accuracy and has the duty to verify the order with the health care provider who ordered it. Although the nurse can consult the charge nurse, this is not the definitive action that the nurse should take. Contacting the pharmacy is not the definitive action that the nurse should take. Giving (or starting) the fluid when the order is questionable is not appropriate.

The nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion? A. Asks the client to both say and spell his or her full name before starting the blood transfusion B. Ensures that another qualified health care professional checks the unit before administering C. Checks the blood identification numbers with the laboratory technician at the blood bank at the time it is dispensed D. Makes certain that an IV solution of 0.9% normal saline is infusing into the client before starting the unit

B. Ensures that another qualified health care professional checks the unit before administering To ensure safety, blood must be checked by two qualified health care professionals, usually two registered nurses. Administering an incorrectly matched unit of blood creates great consequences for the client and is considered to be a sentinel event. It requires a great amount of follow-up and often changing of policies to improve safety. The Joint Commission requires that the client provide two identifiers, but they are the name and date of birth or some other identifying data, depending on the facility; saying and spelling the name is only one identifier. Although a check is provided at the blood bank, this is not the one that is done before administration to the client. Clients do need to have normal saline running with blood, but this is not considered to be part of the safety check before administration of blood and blood products.

A 70-year-old client with severe dehydration is ordered an infusion of an isotonic solution at 250 mL/hr through a midline IV catheter. After 2 hours, the nurse notes that the client has crackles throughout all lung fields. Which action does the nurse take first? A. Assess the midline IV insertion site. B. Have the client cough and deep-breathe. C. Notify the health care provider about the crackles. D. Slow the rate of the IV infusion.

D. Slow the rate of the IV infusion. The presence of crackles throughout the lungs is a sign of possible fluid overload. The nurse should slow the rate of infusion and further assess for indicators of volume overload and/or respiratory distress. Assessing the site, having the client cough and deep-breathe, and notifying the provider may be appropriate, but are not the initial actions for this client.

The nurse is revising an agency's recommended central line catheter-related bloodstream infection prevention (CR-BSI) bundle. Which actions decrease the client's risk for this complication? (Select all that apply.) A. During insertion, draping the area around the site with a sterile barrier B. Immediately removing the client's venous access device (VAD) when it is no longer needed C. Making certain that observers of the insertion are instructed to look away during the procedure D. Thorough hand hygiene (i.e., no quick scrub) before insertion E. Using chlorhexidine for skin disinfection

B. Immediately removing the client's venous access device (VAD) when it is no longer needed D. Thorough hand hygiene (i.e., no quick scrub) before insertion E. Using chlorhexidine for skin disinfection As soon as the VAD is deemed unnecessary, it should be removed to reduce the risk for infection. Thorough handwashing is a key factor in insertion and maintenance of a central line device; quick handwashing is not sufficient. Chlorhexidine is recommended for skin disinfection because it has been shown to have the best outcomes in infection prevention. During the insertion, the whole body (head to toe) of the client is draped with a sterile barrier; draping only the area around the site will increase risk for infection. Looking away will not reduce the risk for infection. Reducing the number of people in the room and having everyone wear a mask will help reduce the risk for infection.

Which statement is true about the special needs of older adults receiving IV therapy? A. Placement of the catheter on the back of the client's dominant hand is preferred. B. Skin integrity can be compromised easily by the application of tape or dressings. C. To avoid rolling the veins, a greater angle of 25 degrees between the skin and the catheter will improve success with venipuncture. D. When the catheter is inserted into the forearm, excess hair should be shaved before insertion.

B. Skin integrity can be compromised easily by the application of tape or dressings. Skin in older adults tends to be thin. Tape or dressings used with IV therapy can compromise skin integrity. Placement on the back of the dominant hand is contraindicated because hand movement can increase the risk of catheter dislodgement. An angle smaller than 25 degrees is required for venipuncture success in older adults. This technique is less likely to puncture through the older adult client's vein. Clipping the hair around the insertion site typically is necessary only for younger men.

The nurse assessing a client's peripheral IV site obtains and documents information about it. Which assessment data indicate the need for immediate nursing intervention? A. Client states, "It really hurt when the nurse put the IV in." B. The vein feels hard and cordlike above the insertion site. C. Transparent dressing was changed 5 days ago. D. Tubing for the IV was last changed 72 hours ago.

B. The vein feels hard and cordlike above the insertion site. A hard, cordlike vein suggests phlebitis at the IV site. The IV should be discontinued and restarted at another site. It is common for IVs to cause pain during insertion. An intact transparent dressing requires changing only every 7 days. Tubing for peripheral IVs should be changed every 72 to 96 hours.

The nurse is inserting a peripheral IV catheter. Which client statement is of greatest concern during this procedure? A. "I hate having IVs started." B. "It hurts when you are inserting the line." C. "My hand tingles when you poke me." D. "My IV lines never last very long."

C. "My hand tingles when you poke me." The client's statement about a tingling feeling indicates possible nerve puncture. To avoid further nerve damage, the nurse should stop immediately, remove the IV catheter, and choose a new site. The other statements indicate a need for client teaching, but are not indicators of immediate complications of catheter insertion—pain at the insertion site is common, and IV sites that "never last very long" should be addressed with teaching about the importance of proper protection of the site.

A client who used to work as a nurse asks, "Why is the hospital using a 'fancy new IV' without a needle? That seems expensive." How does the nurse respond? A. "OSHA, a government agency, requires us to use this new type of IV." B. "These systems are designed to save time, not money." C. "They minimize health care workers' exposure to contaminated needles." D. "They minimize clients' exposure to contaminated needles."

C. "They minimize health care workers' exposure to contaminated needles." Needleless IVs were designed to protect health care personnel from exposure to contaminated needles. The Occupational Safety and Health Administration (OSHA) requires the use of devices with engineered safety mechanisms only. It does not mandate that they be needleless. Saving time and money is not the purpose of the needleless IV, and it was not designed to protect clients from exposure to contaminated needles.

A 22-year-old client is seen in the ER with acute right lower quadrant abdominal pain, nausea, and rebound tenderness. It appears that surgery is imminent. What gauge catheter does the ED nurse choose when starting this client's intravenous solution? A. 24 B. 22 C. 18 D. 14

C. 18 An 18-gauge catheter is the size of choice for clients who will undergo surgery. If they need to receive fluids rapidly, or if they need to receive more viscous fluids (such as blood or blood products), a lumen of this size would accommodate those needs. Neither a 24-gauge nor a 22-gauge catheter is an appropriate size (too small) for clients who will undergo surgery. If it becomes necessary to administer fluids to the client rapidly, another IV would be needed with a larger needle—18, for example. Administering through the smallest gauge necessary is usually best practice, unless the client may be going into hypovolemic status (shock). A 14-gauge catheter is an extremely large-gauge needle that is very damaging to the vein.

A client is seen in the ER with pain, redness, and warmth of the right lower arm. The client was in the ER last week after an accident at work. On the day of the injury, the client was in the ER for 12 hours receiving IV fluids. On close examination, the nurse notes the presence of a palpable cord 1 inch in length and streak formation. How does the nurse classify this client's phlebitis? A. Grade 1 B. Grade 2 C. Grade 3 D. Grade 4

C. Grade 3 Grade 1: only erythema with or without pain Grade 2: erythema WITH pain and/or edema Grade 3: erythema WITH pain and/or edema and streak formation with a palpable cord. Grade 4: erythema WITH pain and/or edema and streak formation with a palpable cord than 1 inch, and purulent drainage. No purulent drainage is present in this client, and the palpable cord is 1 inch in length.

A client is to receive an IV solution of 5% dextrose and 0.45% normal saline at 125 mL/hr. Which system provides the safest method for the nurse to accurately administer this solution? A. Controller B. Glass container C. Infusion pump D. Syringe pump

C. Infusion pump Infusion pumps are used for drugs or fluids under pressure. They accurately measure the volume of fluid being infused. A controller is a stationary, pole-mounted electronic device that uses a sensor to monitor fluid flow and detect when flow has been interrupted. Because controllers rely completely on gravity to create fluid flow and do not create pressure, they do not ensure infusion but only control the drip rate. A glass container is necessary to use only with IV solutions that may cling to the plastic bag; this is not an issue with this solution. A syringe pump does not hold sufficient volume to be practical in this situation.

Which client does the charge nurse on a medical-surgical unit assign to the LPN/LVN? A. Cardiac client who has a diltiazem (Cardizem) IV infusion being titrated to maintain a heart rate between 60 and 80 beats/min B. Diabetic client admitted for hyperglycemia who is on an IV insulin drip and needs frequent glucose checks C. Older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours D. Postoperative client receiving blood products after excessive blood loss during surgery

C. Older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours The older client admitted for confusion with a heparin lock is the most stable and requires basic monitoring of the IV site for common complications such as phlebitis and local infection, which would be familiar to an LPN/LVN. The cardiac client with a diltiazem (Cardizem) IV infusion, the diabetic client on an IV insulin drip, and the postoperative client receiving blood products all are not stable and will require ongoing assessments and adjustments in IV therapy that should be performed by an RN.

When flushing a client's central line with normal saline, the nurse feels resistance. Which action does the nurse take first? A. Decrease the pressure being used to flush the line. B. Obtain a 10-mL syringe and reattempt flushing the line. C. Stop flushing and try to aspirate blood from the line. D. Use "push-pull" pressure applied to the syringe while flushing the line.

C. Stop flushing and try to aspirate blood from the line. If resistance is felt when flushing any IV line, the nurse should stop and further assess the line. Aspiration of blood would indicate that the central line is intact and is not obstructed by thrombus. Continuing or reattempting to flush the line, or using a push-pull action on the syringe, might result in thrombus or injection of particulate matter into the client's circulation.

The nurse is preparing to flush a PICC line. The protocol specifies using 50 units of heparin. Available is a multidose vial containing heparin, 10 units/mL. Which syringe does the nurse use to draw up and administer the heparin? A. 1mL B. 3mL C. 5mL D. 10 ml

D [the 10-mL syringe] Always use a 10-mL syringe when flushing PICC lines because a smaller syringe creates higher pressure, which could rupture the lumen of the PICC line.

What information is most important to teach the client going home with a peripherally inserted central catheter (PICC) line? a. "Avoid carrying your grandchild with the arm that has the IV." b. "Be sure to place the arm with the IV in a sling during the day." c. "Flush the IV line with normal saline daily." d. "You can use the arm with the IV for most of the activities of daily living."

a. "Avoid carrying your grandchild with the arm that has the IV." Rational: A properly placed PICC (in the antecubital fossa or the basilic vein) allows the client considerable freedom of movement. Clients can participate in most activities of daily living; however, heavy lifting can dislodge the catheter or occlude the lumen. Although it is important to keep the insertion site and tubing dry, the client can shower. The device is flushed with heparin.

A nursing student asks why midline catheters need strict sterile dressing changes when short peripheral IVs do not. Which answer by the experienced nurse is most accurate? a. "Because of the length of time they stay inserted." b. "They really don't need strict sterile technique." c. "Because the tip is in the right atrium of the heart." d. "The tonicity of the fluids used promotes infection."

a. "Because of the length of time they stay inserted." Rational: Midline catheters can stay in place for as long as 4 weeks, so dressing changes must be done with strict sterile technique to reduce the incidence of infection. The tip does not lie in the right atrium; it resides no farther than the axillary vein. These catheters are used for a wide range of fluids and medications, so tonicity would not be a factor in infection risk.

A student nurse is preparing to take a blood pressure (BP) on a client who has a peripheral IV line in the left arm. What instruction by the faculty member is most important? a. "Use the arm that doesn't have the IV site in it." b. "Don't inflate the cuff too high if you use the left arm." c. "Make sure the IV line is secure before taking the BP." d. "While the BP is taken, a little backflow of the IV is okay."

a. "Use the arm that doesn't have the IV site in it." Rational: Nurses should not take blood pressure on arms that have IVs because increased pressure can cause infiltration and can cause fluid to leak from the insertion site. Because the affected arm should not be used for BP, none of the other options can be correct.

The nurse is preparing to administer a medication IV push. What information does the nurse need to know before beginning the infusion? (Select all that apply.) a. Any dilution required b. Rate of administration c. Compatibility with infusions d. Other routes of administration e. Specific monitoring needed

a. Any dilution required b. Rate of administration c. Compatibility with infusions e. Specific monitoring needed Rational: Giving IV push medications requires specific knowledge about each drug, including dilution, rate of administration, compatibility, and monitoring. pH and osmolarity and specific infusion sites appropriate for giving the specific drug are also important to know. When giving an IV push medication, it is not necessary to know whether other routes of administration are possible.

What action does the nurse take to prevent infection in the older adult receiving IV therapy? a. Applying skin protectant before applying the dressing b. Avoiding the use of alcohol pads when removing tape c. Shaving the skin before attempting the venipuncture d. Using maximum friction to cleanse the skin

a. Applying skin protectant before applying the dressing Rational: The skin of an older adult may be more delicate and compromised. Avoidance of a disruption in skin integrity lessens the chance of an infection occurring with an IV catheter. A barrier applied to the skin before the IV dressing is placed helps maintain skin integrity.

The nurse is caring for a client who is receiving an epidural infusion for pain management. Which action has the highest priority? a. Assessing the respiratory rate b. Changing the dressing over the site c. Using various pain management therapies d. Weaning the pain medication

a. Assessing the respiratory rate Rational: Complications from an epidural infusion can be caused by the type of medication being infused, or they can be related to the catheter. When used for pain management, the client needs to be assessed for level of alertness, respiratory status, and itching. Using other pain management therapies and weaning the pain medication are important, but monitoring respiratory status has the highest priority in the nursing care of this client.

To prevent infection when infusing an intermittent "piggyback" line, which intervention does the nurse implement? a. Backpriming the secondary container from the primary line b. Detaching and capping the secondary line after use c. Using a new secondary container with each drug infused d. Using sterile gloves when administering medication

a. Backpriming the secondary container from the primary line Rational: The backpriming method allows multiple drugs to be infused through the same secondary set. This method allows the primary and secondary sets to remain connected together as an infusion system and allows the nurse to adhere to the Infusion Nurses Society (INS) standards of practice. The client is at increased risk for infection whenever the catheter is disconnected from the tubing. Sterile gloves are not necessary for IV administration of medication.

Which infusion device does the nurse select for the older adult client with a medical diagnosis of "dehydration"? a. Cassette pump b. Elastomeric balloons c. Volumetric controller d. Syringe pump

a. Cassette pump Rational: An older adult client who has dehydration will require a large fluid volume that is accurately measured by using a cassette pump during the infusion. Volumetric controllers count drops for administered volume and are inherently inaccurate because of variation in drop size. A syringe pump is accurate but not appropriate for a large volume. Elastomeric balloons are used to deliver intermittent medications.

When an IV pump alarms because of pressure, what action does the nurse take first? a. Check for kinking of the catheter. b. Flush the catheter with a thrombolytic enzyme. c. Get a new infusion pump. d. Remove the IV catheter.

a. Check for kinking of the catheter. Rational: Fluid flow through the infusion system requires that pressure on the external side be greater than pressure at the catheter tip. Fluid flow can be slowed for many reasons. A common reason, and one that is easy to correct, is a kinked catheter. If this is not the cause of the pressure alarm, the nurse may have to ascertain whether a clot has formed inside the catheter lumen, or if the pump is no longer functional.

A nurse is preparing to administer two drugs at the same time to a client via a double-lumen midline catheter. Which action by the nurse is most important? a. Check the two drugs for compatibility. b. Compare the recommended infusion times. c. Schedule any post-infusion lab draws. d. Flush both lumens with saline before starting the infusion.

a. Check the two drugs for compatibility. Rational: Because midline catheters dwell in the peripheral, not central, circulation, incompatible drugs should not be given together via a double-lumen midline catheter because the flow rate of the blood is not high enough to dilute the drugs before they mix. The other options are valid interventions before starting the infusion, but they do not take precedence over determining whether the drugs may be infused at the same time.

The nurse is preparing to give a client an IV push medication through an intermittent IV set (saline lock) using a needleless system. Which actions by the nurse are most appropriate? (Select all that apply.) a. Cleanse the access port vigorously for at least 30 seconds. b. Use an antimicrobial agent when cleansing the port. c. Clean the ridges in the Luer-Lok connection well. d. Rinse the antimicrobial agent off with saline. e. Allow the antimicrobial agent to dry before using IV.

a. Cleanse the access port vigorously for at least 30 seconds. b. Use an antimicrobial agent when cleansing the port. c. Clean the ridges in the Luer-Lok connection well. Rational: Needleless systems need careful cleansing before use. Guidelines include scrubbing the connection vigorously with an antimicrobial agent for 30 seconds, and paying special attention to the ridges in the Luer-Lok device. Rinsing and drying are not necessary.

The nurse is assessing several clients receiving intravenous therapy. Which client situation requires immediate intervention? a. Completion of an intermittent medication into a Groshong catheter b. Physician's order to discontinue a peripheral intravenous catheter c. Nonaccessed implanted port placed 1 month ago without problem d. Peripheral IV catheter dated 5 days ago used for once-daily antibiotics

a. Completion of an intermittent medication into a Groshong catheter Rational: A Groshong catheter is a peripherally inserted catheter that needs to be flushed with saline after intermittent use. Peripheral IV catheters should be discontinued after 4 days, so this one should be changed; however, this is not the priority. An order to discontinue the peripheral catheter requires intervention, but flushing of the Groshong catheter is more of an immediate intervention to prevent clotting of the catheter. A nonaccessed implanted port site needs to be assessed, but this is not an immediate intervention.

A client is receiving an infusion of amiodarone (Cordarone), and the nurse notes that the client's arm has begun to blister around the IV site. This manifestation is consistent with which condition? a. Extravasation b. Infiltration c. Infection d. Phlebitis

a. Extravasation Rational: Certain medications, including amiodarone, vancomycin, and ciprofloxacin, are venous irritants that can cause tissue sloughing and necrosis if the IV infiltrates. The other three complications are possible with any infusion and are not specific to amiodarone.

When assessing the client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. What is the most accurate documentation of this finding? a. Grade 3 phlebitis at IV site b. Infection at IV site c. Thrombosed area at IV site d. Infiltration at IV site

a. Grade 3 phlebitis at IV site Rational: The presence of a red streak and palpable cord indicates grade 3 phlebitis. No information in the description indicates that infection, infiltration, or thrombosis is present.

A nurse is changing the administration set on a client's central venous catheter. Which intervention is most important for the nurse to complete? a. Have the client hold his breath during the set change. b. Keep the slide clamp on the catheter extension open. c. Position the client in a high Fowler's position. d. Position in the client in a semi-Fowler's position.

a. Have the client hold his breath during the set change. Rational: An air embolus is less likely to form if the exit site is lower than the level of the heart, and if pressure in the thoracic cavity is greater when the disconnection occurs. Having the client perform the Valsalva maneuver and maintain it during disconnection and reconnection helps maintain higher intrathoracic pressure. The slide clamp on the catheter extension should be kept clamped. The client should be placed in the flat position when administration sets are changed.

A nursing administrator is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which action by the administrator would have the biggest impact on decreasing complications? a. Investigate initiating a dedicated IV team. b. Require inservice education for all RNs. c. Limit IV starts to the most experienced nurses. d. Perform quality control testing on skin preparation products.

a. Investigate initiating a dedicated IV team. Rational: The Centers for Disease Control and Prevention (CDC) recommends having a dedicated IV team to reduce complications, save money, and improve client satisfaction and outcomes. In-service education would always be helpful, but it would not have the same outcomes as an IV team. Limiting IV starts to the most experienced nurses does not allow newer nurses to gain this expertise. The quality of skin preparation products is only one aspect of IV insertion that could contribute to infection.

The RN is working with an experienced LPN (licensed practical nurse) who has been assigned several clients receiving IV therapy. What actions guide the RN in delegating aspects of IV therapy to the LPN? (Select all that apply.) a. Look up and read the State Nurse Practice Act. b. Check facility policy regarding LPNs and IV therapy. c. Ask the LPN what he or she is comfortable performing. d. Supervise the LPN when performing IV therapy. e. Divide the clients up between the two of them.

a. Look up and read the State Nurse Practice Act. b. Check facility policy regarding LPNs and IV therapy. Rational: The State Nurse Practice Act will have the information the RN needs, and in some states, LPNs are able to perform specific aspects of IV therapy. However, in a client care situation, it may be difficult and time-consuming to find it and read what LPNs are permitted to do, so another good solution would be for the nurse to check facility policy and follow it.

A client has a peripherally inserted central catheter (PICC) line and the primary nurse is updating the care plan. For which common complications does the nurse assess? (Select all that apply.) a. Phlebitis b. Pneumothorax c. Thrombophlebitis d. Excessive bleeding e. Extravasation

a. Phlebitis c. Thrombophlebitis Rational: Although the complication rate with PICC lines is fairly low, the most common complications are phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Pneumothorax, excessive bleeding, and extravasation are not common complications.

The nurse preparing to insert an IV on an older adult client notices that the client's skin is extremely fragile. Which action by the nurse is best? a. Use a blood pressure cuff to cause the vein to distend. b. Slap the skin vigorously to cause the vein to rise. c. Place a gauze pad under the tourniquet before tightening. d. Avoid the use of a tourniquet if the vein is already hard.

a. Use a blood pressure cuff to cause the vein to distend. Rational: The skin of older adults is often fragile, and a tourniquet may leave an ecchymotic area after the IV insertion. One option for fragile skin is to inflate a blood pressure cuff to a reading just slightly less than the client's diastolic pressure. Tapping the skin lightly may help distend a vein, but avoid slapping vigorously. Gauze padding would not prevent bruising. Veins that are already distended may be cannulated without using a tourniquet, but they must be assessed first, and hard or cordlike veins need to be avoided.

A client is to receive a blood transfusion. Before the transfusion, what action by the nurse takes priority? a. Verifying the client's identity b. Ensuring that the blood bank has enough blood c. Establishing a peripheral IV site d. Feeding the client before starting the blood

a. Verifying the client's identity Rational: Blood transfusion reactions can be devastating and can be prevented in large measure by positive client identification. This is accomplished by two professionals using two different client identifiers. Ensuring that the blood bank has enough blood would not be a normal nursing action, and transfusions can be given without regard to food and drink.

The RN assigned a new nurse to a client who was receiving chemotherapy through an intravenous extension set attached to a Huber needle. Which information about disconnecting the Huber needle is most important for the RN to provide to the new nurse? a. "Apply topical anesthetic cream to the area after discontinuing the system." b. "Be aware of a rebound effect when discontinuing the system." c. "Be sure to flush the system with saline after removing the Huber needle." d. "Place pressure over the site to prevent bleeding."

b. "Be aware of a rebound effect when discontinuing the system." Rational: Huber needles are used to access implanted ports placed under the skin. Because the dense septum holds tightly to the needle, a rebound can occur when it is pulled from the septum, often resulting in needle stick injury to the nurse. Topical anesthetic cream can be used when accessing the system. Flushing is carried out when the system is accessed and once monthly. Because the implanted port is not being removed, there is no need for a pressure dressing.

The home care nurse is about to administer IV medication to the client and reads in the chart that the PICC line in the client's left arm has been in place for 4 weeks. The IV is patent, with a good blood return. The site is clean and free from manifestations of infiltration, irritation, and infection. Which action by the nurse is most appropriate? a. Notify the physician. b. Administer the prescribed medication. c. Discontinue the PICC line. d. Switch the medication to the oral route.

b. Administer the prescribed medication. Rational: A PICC line that is functioning well without inflammation or infection may remain in place for months or even years. Because the line shows no signs of complications, it is permissible to administer the IV antibiotic. The physician does not have to be called to have the IV route changed to an oral route.

A client has just had a central venous access line inserted. What is the nurse's next action? a. Beginning the prescribed infusion as soon as possible b. Confirming placement of the catheter by x-ray c. Having the infusion team start the IV therapy d. Confirming that solutions are appropriate for the central line

b. Confirming placement of the catheter by x-ray Rational: A central venous access device, once placed, needs an x-ray confirmation of proper placement before it is used. The bedside nurse would be responsible for beginning the infusion once placement has been verified. Any IV solution can be given through a central line.

The nurse finishes administering an intermittent medication through a Groshong catheter. What is the nurse's next action? a. Clamping the catheter b. Flushing the line with saline c. Flushing with heparin d. Removing the access needle

b. Flushing the line with saline Rational: The Groshong catheter is a type of midline catheter. After intermittent use, the catheter is to be flushed with saline. The manufacturer's instructions state that the catheter should not be clamped to maintain the integrity of the catheter valve. If a heparin flush is ordered, it is given after the catheter has been flushed with saline. The access needle is used for implanted ports.

The nurse is preparing to administer an infusion of dopamine (Intropin) using a smart pump. After programming the pump and attaching the IV to the client, what action by the nurse is most important? a. Start the infusion as ordered. b. Hand-calculate the infusion rate. c. Ensure that the pump is plugged in. d. Place a "time tape" on the IV bag.

b. Hand-calculate the infusion rate. Rational: Using a smart pump does not relieve the nurse of the responsibility of ensuring that the rate is correct. Pumps can malfunction or can be programmed incorrectly, and concentrations of solution can change and differ from the pump's drug library. The nurse must hand-calculate the rate before starting the infusion, then must ensure that the pump is plugged into an electrical source. "Time tapes" on the sides of IV bags are no longer used to show approximate volume infused.

The nurse wants to find written standards for IV therapy. The nursing manager suggests that the nurse investigate publications from which resource? a. IV Therapy Nursing Society b. Infusion Nurses Society c. Nurse's State Board of Nursing d. Hospital's IV solutions vendor

b. Infusion Nurses Society The Infusion Nurses Society publishes guidelines and standards related to IV therapy and offers a national certification examination. The State Board of Nursing publishes legal information related to nursing practice, and the solutions vendor would have written information pertaining only to specific products. The IV Therapy Nursing Society does not exist, and the other organizations listed do not provide standards and guidelines related to IV therapy.

After discontinuing a nontunneled, percutaneous central catheter, it is most important for the nurse to record which information? a. Application of a sterile dressing b. Length of the catheter c. Occurrence of venospasms d. Type of ointment used to seal the tract

b. Length of the catheter Rational: After removal of a catheter, measure the catheter length and compare it with the length documented on insertion. If the entire length has not been removed, the nurse should contact the physician immediately because some of the catheter may still be in the client's vein.

A client is to receive 10 days of antibiotic therapy for urosepsis. The nurse plans to insert which type of intravenous catheter? a. Hickman b. Midline c. Nontunneled central d. Short peripheral

b. Midline Rational: Midline catheters are used for therapies lasting from 1 to 4 weeks. Short peripheral catheters can be inserted by the nurse for use with antibiotic therapy, but they can stay in only for up to 96 hours. If the length of IV therapy is longer than 6 days, a midline catheter should be chosen. Nontunneled central catheters and Hickman catheters are inserted by a physician.

The nurse is caring for a client admitted yesterday with an intraosseous (IO) infusion after a car crash. Which action by the nurse takes priority? a. Ensure that the IV flow rate has been recalculated for an IO infusion. b. Plan to insert another kind of IV line during the shift. c. Determine which IV medications can be given safely via the IO. d. Monitor the site and dressings routinely for hemorrhage.

b. Plan to insert another kind of IV line during the shift. Rational: IO infusions, although valuable in an emergency, should be left in place for only 24 hours. The nurse should plan to insert a peripheral IV sometime during the shift. IV solutions, flow rates, and medications are given the same way that they are given IV. Hemorrhage is not a complication of IO infusion.

A client who is having a tunneled central venous catheter inserted begins to report chest pain and difficulty breathing. What action does the nurse take first? a. Administer the PRN pain medication. b. Prepare to assist with chest tube insertion. c. Place a sterile dressing over the IV site. d. Place the client in the Trendelenburg position.

b. Prepare to assist with chest tube insertion. Rational: An insertion-related complication of central venous catheters is a pneumothorax. Signs and symptoms of a pneumothorax include chest pain and dyspnea. Treatment includes removing the catheter, administering oxygen, and placing a chest tube. Pain is caused by the pneumothorax, which must be taken care of with a chest tube insertion. Use of a sterile dressing and placement of the client in a Trendelenburg position are not indicated for the primary problem of a pneumothorax.

A new nurse is securing the connections on a new IV administration set connected to a peripherally inserted central catheter (PICC) line with tape. Which action by the precepting nurse is most appropriate? a. Make sure the tape being used is from a sterile IV start kit. b. Stop the nurse and confirm that the Luer-Lok connections are tight. c. Help the new nurse document the set change appropriately. d. Show the new nurse how to turn back the corner of the tape for easy removal.

b. Stop the nurse and confirm that the Luer-Lok connections are tight. Rational: PICC line administration sets must be secured using the Luer-Lok to help prevent air emboli. When starting peripheral IVs, nurses must use the tape from the sterile IV start kit when possible, instead of using tape that might be dirty. Documentation is a critical function, but it does not take priority over doing a procedure correctly, nor does showing the new nurse time- and work-saving tips.

A client is admitted to the hospital for excessive nausea and vomiting, and a blood pressure of 90/50 mm Hg. A catheter of which gauge is most appropriate for the nurse to choose for this client's peripheral IV? a. 24 b. 22 c. 20 d. 18

c. 20 Rational: The nurse selects the access device most appropriate for the designated purpose. In this case, because a large amount of fluid will be needed as a result of excessive fluid loss, the appropriate needle is the 20-gauge catheter IV, because this is the most commonly used size in adults and it can be used for all fluids. The 22- and 24-gauge catheters will have a slower rate of flow, which may not be desirable with excessive fluid losses and low blood pressure. The 18-gauge catheter allows rapid flow of IV fluids. However, it requires a large vein and is more prone to irritation to the vein wall.

The nurse is caring for a client with an intraosseous catheter placed in the leg 20 hours ago. Which assessment is of greatest concern? a. Length of time catheter is in place b. Poor vascular access in upper extremities c. Affected leg cool to touch d. Site of intraosseous catheter placement

c. Affected leg cool to touch Rational: Compartment syndrome is a condition in which increased tissue perfusion in a confined anatomic space causes decreased blood flow to the area. A cool extremity can signal the possibility of this syndrome. All other distractors are important. However, the possible development of a compartment syndrome requires immediate intervention because the client could require amputation of the limb if the nurse does not pick up this perfusion problem.

A client who has just had an IV started in the right cephalic vein tells the nurse that the wrist and the hand below the IV site feel like "pins and needles." Which action by the nurse is best? a. Document the finding and continue to monitor the IV site. b. Check for the presence of a strong blood return. c. Discontinue the IV and restart it at another site. d. Elevate the extremity above the level of the heart.

c. Discontinue the IV and restart it at another site. Rational: The sensation that the client has described is related to the IV needle touching the nerve or possibly transecting the nerve. This can lead to loss of function and potential permanent disability in the distal extremity. It is considered an emergency and the IV must be discontinued.

The nurse has just performed an IV start on a client. After the catheter has been threaded its full length in the client's vein, which action does the nurse perform next? a. Secure the IV with a securement device or tape. b. Dispose of the IV needle in the sharps container. c. Engage the safety mechanism of the IV catheter d. Note the date and time of the dressing application over the insertion site.

c. Engage the safety mechanism of the IV catheter Rational: A federal law enacted in 2000 requires health care facilities to use IV catheters with an engineered safety mechanism to prevent needle sticks, which can be a source of contamination by bloodborne pathogens. This priority action would help keep the nurse safe. Securing the IV and dating/timing the dressing are also important actions, but engaging the safety mechanism comes first. After engaging the safety mechanism, safely dispose of the needle in the sharps container.

A new nurse is preparing to start an IV on a client who is dehydrated and needs significant fluid volume. The new nurse selects a butterfly needle for the infusion. What action by the supervising nurse is best? a. Help the new nurse with the procedure as needed. b. Make sure the new nurse has the correct dressing. c. Stop the new nurse and review the procedure in private. d. Get the ultrasonic vein finder to help illuminate veins.

c. Stop the new nurse and review the procedure in private. Rational: Winged (butterfly) needles generally are used for single doses of medications or for blood sampling. They would not be used for large volumes of fluid or kept in for any length of time. The other options do not acknowledge that the new nurse's actions are incorrect and should be stopped.

Which client is the best candidate to receive hypodermoclysis for IV therapy? a. Client requiring 4000 mL normal saline in 24 hours b. Client with an extensive burn injury c. Client with allergy to hyaluronidase d. Client receiving pain management

d. Client receiving pain management Rational: Subcutaneous therapy (hypodermoclysis) involves the slow infusion of isotonic fluids into the client's subcutaneous tissue. Most often, it is used in hospices for pain management. It should not be used if fluid replacement needs exceed 3000 mL/day. To be used, the client must have sufficient areas of intact skin. Hyaluronidase is frequently used to help absorb the fluid during therapy.

Five days after the start of intraperitoneal therapy, the client reports abdominal pain and "feeling warm." The nurse prepares to assess the client further for evidence of which condition? a. Allergic reaction b. Bowel obstruction c. Catheter lumen occlusion d. Infection

d. Infection Rational: Fever, abdominal pain, abdominal rigidity, and rebound tenderness may be present in the client who has peritonitis related to intraperitoneal therapy. Peritonitis is preventable by using strict aseptic technique in handling all equipment and infusion supplies. An allergic reaction would occur earlier in the course of treatment. Bowel obstruction and catheter lumen occlusion can occur but would present clinically in different ways.

Which IV order does the nurse question? a. Flush Groshong catheter with 10 mL normal saline every 8 hours. b. Infuse 20 mEq potassium chloride in 1000 mL D5W at 50 mL/hr. c. Infuse 500 mL normal saline over 1 hour. d. Infuse 0.9% normal saline at keep vein open (KVO) rate.

d. Infuse 0.9% normal saline at keep vein open (KVO) rate. Rational: To be complete, IV orders for infusion fluids should specify the rate of infusion. This order does not specify the rate of infusion and is not considered complete.

The nurse is caring for four clients receiving IV therapy. Which client does the nurse assess first? a. Client with a newly inserted peripherally inserted central catheter (PICC) line waiting for x-ray b. Client with a peripheral catheter for intermittent infusions c. Older adult client with a nonaccessed implanted port d. Older adult client with normal saline infusion

d. Older adult client with normal saline infusion Rational: Older adults are more prone to fluid overload and resulting congestive heart failure. Because this client is receiving continuous IV fluid, he or she is at risk for fluid overload and needs to be assessed. All other clients would need to be assessed for complications of IV catheters. However, they do not need immediate assessment.

The nurse is caring for a client with a radial arterial catheter. Which assessment takes priority? a. Amount of pressure in fluid container b. Date of catheter tubing change c. Checking for heparin in infusion container d. Presence of an ulnar pulse

d. Presence of an ulnar pulse Rational: An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of ulnar pulse is one way to assess circulation to the arm in which the catheter is located.

In examining a peripheral IV site, the nurse observes a red streak along the length of the vein, and the vein feels hard and cordlike. What action by the nurse takes priority? a. Applying continuous heat b. Continuing to monitor site c. Elevating the extremity d. Removing the catheter

d. Removing the catheter Rational: The clinical manifestations described are those associated with phlebitis. Phlebitis is an inflammation of the vein. Its presence in a vein being used for IV therapy may be caused by mechanical forces associated with the IV device, or by chemical factors related to the composition and osmolarity of the drug solution. The key manifestation is that symptoms are directly associated with the vein, and the catheter must be removed. Warm compresses can be applied for 20 minutes four times daily after the catheter is removed. The site needs to be monitored after the catheter is removed. The arm is not swollen. Therefore, elevation of the extremity is not a correct option.

Before the administration of intravenous fluid, it is most important for the nurse to obtain which information from the health care provider's orders? a. Intravenous catheter size b. Osmolarity of the solution c. Vein to be used for therapy d. Specific type of IV fluid

d. Specific type of IV fluid Rational: An order for infusion therapy must contain the following to be complete: specific type of fluid, rate of administration, and drugs added to the solution. Osmolarity of the solution is not necessary because it is incorporated into the specific type of fluid. It is the nurse's independent decision about the most appropriate vein to cannulate and the catheter size to use.

When assessing a client's peripheral IV site, the nurse notices edema and tenderness above the site. What action does the nurse take first? a. Apply cold compresses to the IV site. b. Elevate the extremity on a pillow. c. Flush the catheter. d. Stop the infusion of IV fluids.

d. Stop the infusion of IV fluids. Rational: Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of infiltration include edema and tenderness above the site. The nurse should stop the infusion and remove the catheter. Cold compresses and elevation of the extremity can be done after the catheter is discontinued to increase client comfort. Alternatively, warm compresses may be prescribed by institutional policy and may help speed circulation to the area.

Which assessment finding for a client with a peripherally inserted central catheter (PICC) line requires immediate attention? a. Initial dressing over site is 3 days old. b. Line has been in for 4 weeks. c. A securement device is absent. d. Upper extremity swelling is noted.

d. Upper extremity swelling is noted. Rational: Upper extremity swelling could indicate infiltration, and the PICC line will need to be removed. The initial dressing over the PICC site should be changed within 24 hours. This does not require immediate attention, but the swelling does.