Module 3

Which clinical finding leads the nurse to conclude that an IV has infiltrated rather than caused inflammation? a. pain b. coolness c. localized swelling d. cessation in flow of solution

b. coolness

Which cause would a nurse suspect is responsible for warmth, redness and tenderness identified at a clients IV site? a. rapid fluid delivery b. phlebitis c. allergic response d. infiltration

b. phlebitis

A 2 year old child is admitted with gastroenteritis and dehydration. IV fluids are prescribed. Which is the most appropriate site for the first intravenous insertion? a. scalp vein near the fontanel b. venous arch on top of the foot c. dorsal metacarpals of the hand d. basilic vein at the antecubital fossa

c. dorsal metacarapals of the hand

Which possible legal complication might the nurse face in a situation in which IV therapy was administered to the wrong client? a. assault b. battery c. malpractice d. false imprisonment

c. malpractice

which action needs correction regarding insertion of an intravenous cannula for administration of fluids? a. washing hands with antibacterial soap before insertion of cannula\ b. using chlorohexidine at the selected site of insertion c. shaving the client's skin immediately around the insertion site d. applying skin protectant solutions at the site of insertion

c. shaving the client's skin immediately around the insertion site

Which nursing intervention would the nurse implement for client safety and quality of care when placing a short peripheral venous catheter? a. choose a distal site b. use the wrist of the client c. choose the dominant hand d. do not use the arm of the side of a masectomy e. choose a vein of appropriate length and width to fit the catheter's size

a. choose a distal site d. do not use the arm of the side of a masectomy e. choose a vein of appropriate length and width to fit the catheter's size

Which role would the UAP have when caring for a client receiving IV therapy? a. monitoring clinical manifestations b. collecting the data to be used in the assessment of the IV site c. administering IV fluids and medications d. evaluating the client for clinical manifestations

a. monitoring clinical manifestations

Which action would the nurse take when a client reports pain and burning at the peripheral IV site after the nurse has flushed the saline lock with normal saline? a. remove the IV catheter and restart the saline lock in another site b. document the findings per protocol and reassess the site in 8 hours c. flush the IV catheter and saline lock again vigorously with normal saline d. change the dressing and apply a new clean dressing per IV care protocol

a. remove the IV catheter and restart the saline lock in another site

Which factor would the nurse recognize as the cause when a client's IV infusion infiltrates? a. excessive height of IV bag b. failure to secure the catheter adequately c. contamination during catheter insertion d. infusion of a chemically irritating medication

b. failure to secure the catheter adequately

Which clinical indicator is most commonly used to determine whether the client has a fluid deficit when reporting vomiting and diarrhea for 3 days? a. presence of dry skin b. loss of body weight c. decrease in blood pressure d. altered general appearance

b. loss of body weight

Which clinical indicator would the nurse expect when an IV line has been infiltrated? SATA a. heat b. pallor c. edema d. decreased flow rate e. increased blood pressure

b. pallor c. edema d. decreased flow rate

During a 12 hour shift, a client has 6-oz (180 ml) cup of tea, and 360 ml of water. The client vomits 100 ml, and the instilled IV fluids equaled urinary output. Which fluid balance would the nurse record for the 12 hour period? a. 240 ml b. 340 ml c. 440 ml d. 540 ml

c. 440 mL

The nurse is preparing to insert an IV catheter in a thin emaciated client who is scheduled to begin IV fluid therapy. Which interventions would the nurse follow to provide high-quality care? SATA a. Insert an 18G catheter b. change the IV line every 7 days c. flush the IV with normal saline d. insert the catheter in the clients femur e. stop the insertion procedure when there is a break in technique

c. flush the IV with normal saline e. stop the insertion procedure when there is a break in technique

Twelve hours after sustaining full thickness burns to the chest and thighs, a client who is on NPO status is reporting severe thirst. The urinary output has been 60mL/h for the past 10 hours. No bowel sounds are heard. Which action would the nurse take? a. give the client orange juice by mouth b. increase the client's IV flow rate c. moisten the client's lips with wet 4 x 4 gauze d. offer the client 4 oz (120 mL) of water by mouth

c. moisten the client's lips with wet 4 x 4 gauze

aAn IV line is inserted in the scalp vein of an infant. The parent asks why the IV is not placed in the hand. Which response by the nurse is most appropriate? a. using a scalp vein improves the absorption rate b. inserting the IV in a scalp vein decreases the need for restraints c. usually veins in the arm or hand are used, but your baby's were too small d. IV solutions are too irritating for the line to be inserted into a vein in the arm or hand

c. usually veins in the arm or hand are used, but your baby's were too small