Purple book Ch. 14

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client's intravenous (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. Infiltration

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 (IV) solution at 100 mL/hour? 1. Serum osmolality 2. Serum electrolyte levels 3. Portable chest x-ray film 4. Intake and output record

3. Portable chest x-ray film

The nurse is completing a time tape for a 1000-mL IV bag that is scheduled to infuse over 8 hours. The nurse has just placed the 11:00 am marking at the 500-mL level. The nurse would place the mark for noon at which numerical level (mL) on the time tape?

375 mL

A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed to increase intravascular volume, replace immediate blood loss volume, and increase blood pressure? 1. 5% dextrose in lactated Ringer's 2. 0.33% sodium chloride (⅓ normal saline) 3. 0.225% sodium chloride (¼ normal saline) 4. 0.45% sodium chloride (½ normal saline)

1. 5% dextrose in lactated Ringer's

A client rings the call bell and complains of pain at the site of an intravenous (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?Select all that apply. 1. Notify the health care provider (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. Notify the health care provider (HCP). 2. Remove the IV catheter at that site. 3. Apply warm moist packs to the site. 5. Document the occurrence, actions taken, and the client's response.

The nurse notes that the site of a client's peripheral intravenous (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 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 of the vein

The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to take which action immediately after injecting the potassium chloride into the port 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. Rotate the bag gently.

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 3 pm. 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 intravenous (IV) bag has 400 mL remaining. The nurse should take which action first? 1. Slow the IV infusion. 2. Sit the client up in bed. 3. Remove the IV catheter. 4. Call the health care provider (HCP).

1. Slow the IV infusion.

The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if 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. "I need to restrict my activity while this catheter is in place."

The nurse is preparing a continuous intravenous (IV) 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. Obtain new IV tubing.

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. Blood return shows in the backflash chamber of the catheter.

A client with the recent diagnosis of myocardial infarction and impaired renal function is recuperating on the step-down cardiac unit. The client's blood pressure has been borderline low and intravenous (IV) fluids have been infusing at 100 mL/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

A health care provider has written a prescription to discontinue an intravenous (IV) 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 × 2 gauze

4. Sterile 2 × 2 gauze