IV therapy NCLEX questions

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

4

A hematoma is caused by

infiltration of blood into the tissues at the puncture site

Hematoma is prevented by

pressure until bleeding stops and not

The nurse notes that the site of a client's peripheral IV 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 documents in the medical record that the client experienced: 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

A client rings the call bell and complains of pain at the site of an IV infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? SATA 1. Notifies the physician 2. Removes the IV catheter at that site 3. Applies warm moist packs to the site 4. Starts a new IV line in a proximal portion of the same vein 5. Documents the occurence, actions taken, and the client's response

1 2 3 5

The nurse is preparing a continuous IV infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device,the exposed tubing drops and hits the top of the medication cart. Which of the following is the appropriate action by the nurse? 1. Obtain new IV tubing 2. Attach a new needleless device. 3. Wipe the distal end of the tubing with Betadine 4. Scrub the needleless device with an alcohol swab

1

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

1

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 of the following complications has occurred. 1. Infection 2. Phlebitis 3. Infiltration 4. Thrombosis

3

A patient in shock is receiving an infusion of dopamine when it is discovered that an extravasation has occurred. What drug should be on standby for this occurrence?

Phentolamine Maintain phentolamine on standby in case extravasation occurs; infiltration of the site with 10 mL of saline containing 5 to 10 mg of phentolamine is usually effective in saving the area