IV scebario oractice

A client rings the call bell and complaints of pain at the site of an intravenous infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which action in the care of this client? Select all that apply. 1. Notify the HCP 2. Remove the IV catheter at that site 3. Apply warm moist packs to the site 4. Start a new IV line in a proximal portion of the same vein 5. Document the occurrence, actions taken, and the client's response

1, 2, 3, 5 The nurse should remove the IV at the phlebitic site and apply warm moist compresses to the area to speed resolution of the inflammation. Because phlebitis occurred, the nurse also notifies the HCP about the IV complication. The nurse should restart the IV in a vein other than the one that has developed phlebitis, Finally, the nurse documents the occurrence, actions taken, and the client's response.

The nurse notes that the site of a client's peripheral intravenous catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse should document in the medical record that the client experienced which condition? 1. Phlebitis of the vein 2. Infiltration of the IV line 3. Hypersensitivity to the IV solution 4. Allergic reaction to the IV catheter material

1. Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and swelling proximal to the catheter. If phlebitis occurs, the nurse should discontinue the IV line and insert a new IV line at a different site.

A client involved in a motor vehicle crash presents to the ED with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous solution will most likely be prescribed to increase intravascular volume, replace immediate blood loss volume, and increase blood pressure? 1. 5% dextrose in lactated Ringers 2. 0.33% sodium chloride 3. 0.225% sodium chloride 4. 0.45 % sodium chloride

1. The goal with this pt is to expand intravascular volume as fast as possible. The 5% dextrose in lactated ringers (hypertonic solution) would increase intravascular volume and immediately replace lost fluid volume until a blood transfusion could be administered, resulting in an increase in pts BP.

The nurse has a prescription to hang a 1000mL IV bag of 5% dextrose in water with 20mEq of potassium chloride and needs to add the medicatio to the IV bag. The nurse should plan to take which action immediately after injecting the potassium chloride into the prot of the IV bag? 1. Rotate the bag gently 2. Attach the tubing to the client 3. Prime the tubing with the IV solution 4. Check the solution for yellowish discoloration

1. The nurse should agitate or rotate the bag gently to mix the medication evenly in the solution. The nurse should then attach a completed medication label. The nurse can then prime the tubing. The IV solution should have been checked for discoloration before the medication was added to the solution. The tubing is attached to the client last.

A client had a 1000mL bag of 5% dextrose in 0.9% sodium chloride hung at 3PM. The nurse making rounds at 3:45 PM finds that the client is complaining of a pounding headache and is dyspneic, is experiencing chills, and is apprehensive with an increased pulse rate. The IV bag has 400mL remaining. The nurse should take which action first? 1. Slow the IV infusion 2. Sit the client up in the bed 3. Remove the IV catheter 4. Call the HCP

1. The client's symptoms are compatible with circulatory overload. This may be verified by nothing that 600mL has infused in 45 minutes. The first action of the nurse is to slow the infusion. The IV catheter is not removed, it may be needed for the administration of medications to resolve the complication.

The nurse provides a list of instructions to a client being discharged to a home with a peripheral inserted central catheter. The nurse determines that the client needs further instructions when the client made which statement? 1. "I need to wear a Medic-Alert tag or bracelet" 2. I need to restrict my activity while this catheter is in place". 3. "I need to have a repair kit available in the home for use if needed" 4. I need to keep the insertion site protected when in the shower or bath".

2. The client should be taught thtat only minor activity restrictions apply with this type of catheter. The client should protect the site during bathing and should carry or wear a medic-alert ID. The client should have a repair kit in the home for use as needed because the catheter is for long-term use.

The nurse is preparing a continuous intravenous infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action? 1. Obtain a new IV bag 2. Obtain new IV tubing 3. Wipe the spike end of the tubing with Betadine 4. Scrub the spike end of the tubing with an alcohol swab

2. The nurse should obtain new IV tubing because contamination has occurred and could cause systemic infection to the client.

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client's IV site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which complication has occurred? 1. Infection 2. Phlebitis 3. Infiltration 4. Thrombosis

3. An infiltrated IV has pallor, coolness and swelling resulting from the IV fluid being deposited into the subcutaneous tissue.

A client has just undergone insertion of a central venous catheter at the bedside. the nurse would be sure to check which results before initiating the flow rate of the client's intravenous solution 100mL/hour? 1. Serum osmolality 2. Serum electrolyte levels 3. Portatable chest x-ray film 4. Intake and output record

3. Before beginning administration of IV solution, the nurse should assess whether the chest radiograph reveals that the central catheter is in the proper place. This is necessary to prevent infusion of IV fluid into pulmonary or subcutaneous tissues.

The nurse is completing a time tape for a 1000mL IV bag that is scheduled to infuse over 8 hours. The nurse has just placed the 1100Am marking at the 500mL level. The nurse would place the mark for noon at which numerical mL on the time tape? Fill in the blank

375; The IV is scheduled to run over 8 hours, then the hourly rate is 125/mL hour. Using 500mL as the reference point, the next hourly marking would be at 375mL, which is 125mL less than 500.

A health care provider has written a prescription to discontinue an intravenous line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter? 1. Elastic wrap 2. Betadine swab 3. Adhesive bandage 4. Sterile 2 x 2 gauze

4. A dry, sterile dressing such as a sterile 2x2 is used to apply pressure to the discontinued IV site. This material is absorbent, sterile and nonirritating.

A client with the recent diagnosis of myocardial infarction and impaired renal function is recuperating on the step-down cardiac unit. The clients BP has been borderline low and IV fluids have been infusing at 100mL/hour via a central line catheter in the right internal jugular for approximately 24 hours to increase renal output and maintain the blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that the client is most likely experiencing which complication of IV therapy? 1. Hematoma 2. Air embolism 3. Systemic infection 4. Circulatory overload

4. Circulatory overload is a complication of IV therapy Signs includ rapid breathing, dyspnea, a moist cough and crackles.

The nurse is inserting an intravenous line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation? 1. The catheter advances easily 2. The vein is distended under the needle 3. The client does not complain of discomfort 4. Blood return shows in the backflash chamber of the catheter.

4. The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV catheter. The vein should have been distended by the tourniquet before the vein was cannulated. The nurse should not advance the catheter until placement in the vein is verified by blood return