Q1 - IV Therapy

A nurse has been instructed to discontinue an IV line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with a(n): 1.Band-Aid 2. Alcohol swab 3. Betadine swab 4. Sterile 2x2 gauze

4

An older adult patient receiving intravenous steroid therapy reports swelling, pain, and tenderness at the insertion site. Which immediate complication may the patient develop? A. Phlebitis B. Infiltration C. Ecchymosis D. Thrombosis

Ecchymosis

Which complication may happen if the tourniquet applied during the intravenous (IV) catheter insertion is left on an older patient's arm? A. Phlebitis B. Hematoma C. Thrombosis D. Ecchymosis

Ecchymosis - a tourniquet is used to distend the vein during venipuncture. In older adults, the skin is extremely fragile. So, if a tourniquet is not released immediately after insertion, release of vein pressure form puncture may cause ecchymosis

The primary health care provider instructs the nurse to change the dressing of a patient's catheter insertion site. Which action made by the nurse would lead to the dislodgement of the catheter?

Removing the dressing by pulling it away from the insertion site

A patient receiving intravenous therapy has developed a swollen extremity and engorged peripheral veins of the ipsilateral chest. Which complication should the nurse suspect? A. Phlebitis B. Thrombosis C. Nerve damage D. Extravasation

Thrombosis

A nurse finds a patient's IV insertion site red, warm, and slightly edematous. Which of the following actions should the nurse perform first? a. Check for a blood return b. Elevate the extremity c. Discontinue the IV line d. Apply warm, moist heat

c

How often should IV fluids be changed when the order is to keep the vein open? a) Every 24 hours b) Every 48 hours c) Every 72 hours d) When there is approximately 50 mL left in the container

c

The nurse is preparing an IV infusion prior to initiating an IV. The nurse removes the protective sheath covering the tubing insertion spike and accidentally touches the spike. What is the nurse's best action at this time? a) Wipe the insertion spike with an alcohol swab, allow the insertion spike to dry, and insert it into opening of the IV bag. b) Insert the spike into the opening of the IV bag, compress the drip chamber and release, thereby allowing it to fill to one half full. c) Discard IV tubing and obtain a new one. d) Discard IV tubing and fluids and obtain new supplies.

d

The nurse is teaching a hospitalized client who is being discharged about how to care for a peripherally inserted central catheter (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."

"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).

The nurse is inserting a peripheral intravenous (IV) catheter. Which patient statement is of greatest concern during this procedure? 1. "I hate having IVs started." 2. "It hurts when you are inserting the line." 3. "My hand tingles when you poke me." 4. "My IV lines never last very long."

"My hand tingles when you poke me." The patient'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 patient 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.

After reviewing a client's serum electrolyte levels, the provider prescribes an isotonic IV infusion. Which IV solution should the nurse plan to administer? 1) 5% dextrose in water 2) 10% dextrose in water 3) 3% sodium chloride solution 4) 0.45% sodium chloride solution

1) 5% dextrose in water 10% dextrose in water = hypertonic 3% sodium chloride solution = hypertonic 0.45% sodium chloride solution = hypotonic

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. 5% dextrose in lactated ringer's

The nurse has a prescription to hang an IV bag of 1000 mL 5% dextrose in water with 20 mEq potassium chloride. The nurse should plan to do which of the following immediately after injecting the potassium chloride in to 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

Before inserting a perpheral IV catheter, the nurse notes that the female client's muscles are tense and she is fidgeting with the bed sheet. Which statement should the nurse verbalize to the client? 1) This will be finished before you know it 2) inserting the IV does not hurt very much 3) The IV adds fluid into your blood stream 4) The IV catheter is an 18-gauge angiocatheter

3) The IV adds fluid into your blood stream

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

3. Portable chest x-ray film

A client is receiving parenteral nutrition (PN). The nurse monitors the client for complications of the therapy and should assess the client for which manifestations of hyperglycemia? 1. Fever, weak pulse, and thirst 2. Nausea, vomiting, and oliguria 3. Sweating, chills, and abdominal pain 4. Weakness, thirst, and increased urine output

4. Weakness, thirst, and increased urine output Rationale: The high glucose concentration in PN places client as risk for hyperglycemia. Signs exclude: excessive thirst, fatigue, restlessness, confusion, weakness. Kussmaul's respirations , diuresis, and coma when hyperglycemia is severe. If the client has these symptoms the blood glucose level should be checked immediately. The remaining options do not identify signs specific to hyperglycemia.

the nurse is assigned to assist in caring for a client who is receiving parenteral nutrition with fat emulsion.the nurse is instructed to monitor the client for signs of fat overload.the nurse monitors for which signs and symptoms of this complication? A) fever and pruritic urticaria B) bradycardia and chest pain C) hypothermia and muscle weakness D) hypertension and decreased urine output

A)fever and pruritic urticaria rationale signs and symptoms of fat overload include, fever, leukocytosis, hyperlipidemia, pruritic urticaria, and possibly focal seizures. hepatosplenomegaly may also be present.the other options are not signs of this complication.

Established standards for routine replacement of peripheral IV catheters and intravenous administration sets have recommended a maximum of _____ hours to reduce IV fluid contamination and prevent catheter site complications. a. 24 b. 48 c. 72 d. 96

ANS: D

A patient has been on prolonged steroid therapy. In assessing the patient for IV insertion, what finding does the nurse expect to see? A. Ecchymosis and possibly a hematoma B. Skin that is thick, tough, dry, and difficult to puncture C. Edema or puffiness, making visualization of veins difficult D. Rash with excoriation from scratching, which limits site selection

A. Ecchymosis and possibly a hematoma

The nurse is preparing to give a patient IV drug therapy. What information does the nurse need before administering the drug? A. Indications, contraindications, and precautions for IV therapy. B. Appropriate dilution, pH, and osmolarity of solution C. Rate of infusion and dosage of drugs D. Compatibility with other IV medications E. Percentage of adverse events for the drug F. Specifics of monitoring because of immediate effect

A. Indications, contraindications, and precautions for IV therapy. B. Appropriate dilution, pH, and osmolarity of solution C. Rate of infusion and dosage of drugs D. Compatibility with other IV medications F. Specifics of monitoring because of immediate effect

The nurse is preparing to start an infusion of 10% dextrose. Why would the nurse infuse the solution through a central line? A. Osmolartiy of the solution could cause phlebitis or thrombosis. B. The patient could be at risk for fluid overload. C. Viscosity of the solution would slow the infusion. D. The solution should not be mixed with other drugs or solutions.

A. Osmolartiy of the solution could cause phlebitis or thrombosis.

The charge nurse is reviewing IV therapy orders. What information must be included in each order? A. Specific type of solution B. Rate of administration C. Specific drug dose to be added to the solution D. Method for diluting drugs for the solution E. Specific type of administration equipment

A. Specific type of solution B. Rate of administration C. Specific drug dose to be added to the solution

A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC).Which statement should the nurse include in this clients teaching? a. Avoid carrying your grandchild with the arm that has the central catheter. b. Be sure to place the arm with the central catheter in a sling during the day. c. Flush the peripherally inserted central catheter line with normal saline daily. d. You can use the arm with the central catheter for most activities of daily living.

ANS: A 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.

While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding? a. Grade 3 phlebitis at IV site b. Infection at IV site c. Thrombosed area at IVsite d. Infiltration at IV site

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

A nurse is caring for a client who has just had a central venous access line inserted. Which action should thenurse take next? a. Begin the prescribed infusion via the new access. b. Ensure an x-ray is completed to confirm placement.c. Check medication calculations with a second RN.d. Make sure the solution is appropriate for a centralline.

ANS: B 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.

A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next? a. Administer a sublingual nitroglycerin tablet.b. Prepare to assist with chest tube insertion.c. Place a sterile dressing over the IV site.d. Re-position the client into the Trendelenburg position.

ANS: B 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 nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? a. Redness at the catheter insertion site b. Report of headache and stiff neck c. Temperature of 100.1 F (37.8 C) d. Pain rating of 8 on a scale of 0 to 10

ANS: B Complications of epidural therapy include infection, bleeding, leakage of cerebrospinal fluid, occlusion of the catheter lumen, and catheter migration. Headache, neck stiffness, and a temperature higher than 101 F are signs of meningitis and should be reported to the provider immediately. The other findings are important but do not require immediate intervention.

A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients teaching? a. You will need to wear a sling on your arm while the device is in place. b. There is no risk of infection because sterile technique will be used during insertion. c. Ask all providers to vigorously clean the connections prior to accessing the device. d. You will not be able to take a bath with this vascular access device.

ANS: C Clients should be actively engaged in the prevention of catheter-related bloodstream infections and taught to remind all providers to perform hand hygiene and vigorously clean connections prior to accessing the device. The other statements are incorrect.

A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first? a. Amount of pressure in fluid container b. Date of catheter tubing change c. Percent of heparin in infusion container d. Presence of an ulnar pulse

ANS: D An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of an ulnar pulse is one way to assess circulation to the arm in which the catheter is located. The nurse would note that there is enough pressure in the fluid container to keep the system flushed, and would check to see whether the catheter tubing needs to be changed. However, these are not assessments of greatest concern. Because of heparin-induced thrombocytopenia, heparin is not used in most institutions foran arterial catheter.

The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter? A) Choose a hairless site if available. B) Consider potential effects on the patients mobility when selecting a site. C) Have the patient briefly hold his arm over his head before insertion. D) Leave the tourniquet on for at least 3 minutes.

Ans: B Feedback: Ideally, both arms and hands are carefully inspected before choosing a specific venipuncture site that does not interfere with mobility. Instruct the patient to hold his arm in a dependent position to increase blood flow. Never leave a tourniquet in place

The nurse who is starting the shift finds a patient with an IV that is leaking all over the bed linens. What does the nurse do initially? 1. Assess the insertion site. 2. Check connections. 3. Check the infusion rate. 4. Discontinue the IV and start another.

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.

Which of the following patients would the nurse anticipate requiring the placement of a central venous catheter? a. A patient in same-day surgery who might require blood transfusions b, A patient in the intensive care unit requiring multiple simultaneous intravenous medications c. A patient in the cardiac care unit diagnosed with possible myocardial infarction d. A patient on the surgical unit recovering from hernia repair

B (The most likely candidate for a central venous catheter is the patient in intensive care requiring the administration of multiple medications. The central venous catheter will simplify the administration of multiple medications to this critically ill patient. Because same-day surgery patients are expected to go home at the end of the day, it would be unlikely this patient would need a central catheter. A patient diagnosed with myocardial infarction would be unlikely to need a central line unless his condition deteriorated. A patient post hernia repair would be unlikely to require a central venous line unless complications arose, which is not indicated in this scenario.)

The nurse needs to specifically prevent air emboli that may result from IV therapy. What should the nurse make sure to do to prevent air emboli? a. Use a needleless system b. Prime the tubing completely c. Check for medication compatibility d. Select a larger-gauge needle or catheter

B (Prime infusion tubing by filling with IV solution. Be certain tubing is clear of air and air bubbles. Large air bubbles can act as emboli. A needleless system does not specifically prevent introduction of air emboli. Medication incompatibility may lead to crystallization of the medication and my cause emboli to form from precipitate. It will not lead, however, to air embolism. Catheter size does not contribute to emboli formation.)

What should the nurse do upon noting bleeding around a dressing at an IV insertion site? a. Discontinue the IV b. Assess the insertion site c. Leave the dressing intact, but reinforce it d. Elevate and apply warm compresses to the extremity

B (When blood appears on the dressing, verify that the system is intact, and change the dressing. The IV should be discontinued in the event of infiltration or phlebitis. When blood appears on the dressing, verify that the system is intact, and change the dressing. If bleeding occurs around the venipuncture site and the catheter is within the vein, gauze dressing may be applied over the site. Be aware that if gauze dressing is used, it must be removed to accurately assess insertion site. Elevation is used in case of infiltration to reduce edema. Warm compresses are used in the case of phlebitis)

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.

Select all the statement that apply to the proper administration of total parenteral nutrition. a. can only be administered in a central line b. can hang for only 24 hours c. required glucose monitoring every six hours and PRN d. appropriate to use line to piggyback antibiotics e. label should contain all nutrients as well as date, time and expiration date.

BCE

The nurse is caring for a patient who will be on long-term antibiotic therapy. The patient has had numerous intravenous (IV) catheters in the past, but because the upcoming therapy will be given on a long-term basis, the nurse suggests that a _________________ be inserted.

CVAD (central venous access device CVAD CVADs, which include nontunneled and tunneled catheters, PICCs, and implanted ports, are designed for long-term use.)

What should the nurse do when discontinuing a peripheral IV? a. Withdraw the catheter quickly b. Keep the hub perpendicular to the skin c. Apply pressure to the site for 1 minute d. Inspect the catheter for intactness after removal

D (Inspect catheter for intactness after removal, noting tip integrity and length. Place clean sterile gauze above site, and withdraw catheter, using a slow, steady motion. Keep the hub parallel to the skin. Do not raise or lift catheter before it is completely out of the vein, to avoid trauma or hematoma formation. Apply pressure to the site for 2 to 3 minutes, using a dry, sterile gauze pad. Secure with tape. Note: Apply pressure for 5 to 10 minutes if patient is on anticoagulants.)

The nurse is assessing a patient's IV site and identifies signs and symptoms of infiltration. What is the first action that the nurse implements for this patient? A. Elevates the extremity. B. Applies a sterile dressing if weeping from the tissue has occurred. C. Removes the IV access. D. Stops the infusion

D. Stops the infusion

The nurse is supervising a student nurse who is preparing an IV bag with IV administration tubing. For which action by the student nurse must the nurse intervene? A. The student touches the drip chamber. B. The sterile cap from the distal end of the set is removed. C. The distal end is attached to a needless connector. D. The student touches the tubing spike.

D. The student touches the tubing spike.

A patient with a central venous catheter reports back pain between the shoulder blades. What should be the immediate nursing intervention in this situation? a. Changing the entire infusion administration system b. Obtaining a chest X-ray to assess the catheter tip location c. Discontinuing all infusions and flushing the central venous line d. Informing the primary health care provider of the assessment findings

Discontinuing all infusions and flushing the central venous line Back pain between the shoulder blades is a sign of catheter migration. The nurse should immediately stop the infusion and flush the catheter. Repositioning the catheter tip is a better intervention than changing the entire infusion system in this situation. A chest X-ray is always needed to assess the catheter tip; this action can be performed when the symptoms have subsided. The nurse should inform the primary health care provider after discontinuing the infusion.

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

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.

The nurse is reviewing assessment data of a patient and observes a hard, cordlike vein. Which complication of the intravenous (IV) therapy does the patient manifest?

Phlebitis

When flushing a patient'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 & reattempt flushing the line C. Stop flushing & try to aspirate blood from the line D. Use "Push-pull" pressure applied to the syringe while flushing the line

Stop flushing and try to aspirate blood from the line.

Which nursing intervention is the most appropriate when meeting resistance during the flushing of a peripheral catheter? 1. Stop flushing the catheter. 2. Assess the IV line for kinks. 3. Assess the catheter for blood return. 4. Reposition the extremity where the catheter is.

Stop flushing the catheter. When meeting resistance while flushing a catheter, the procedure should be stopped immediately. Continuing to apply pressure while flushing a catheter with resistance can result in a ruptured catheter or forcing a blood clot into the circulation. Assessing the IV line for kinks, assessing for blood return, and repositioning the extremity the catheter where the catheter is will not alter the patency of the catheter.

A 70-year-old patient 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 patient has crackles throughout all lung fields. Which action does the nurse take first? 1. Assess the midline IV insertion site. 2. Have the patient cough and deep-breathe. 3. Notify the health care provider about the crackles. 4. Slow the rate of the IV infusion.

Slow the rate of the IV infusion. The presence of crackles throughout the lungs is a sign of possible fluid overload [1] [2]. 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 patient cough and deep-breathe, and notifying the provider may be appropriate, but are not the initial actions for this patient.

A patient has received 1000 mL of IV fluid in 2 hours. The patient has dyspnea, tachycardia, crackles in the lungs, and peripheral edema. What is the nurse's best action at this time? a) Discontinue the present IV. b) Slow the infusion to KVO and notify the physician. c) Check for positional changes that affects the rate, the height of IV container, and kinking of tubing or obstruction d) Assess the patient for symptoms of fluid volume overload

a

A patient has been receiving IV antibiotics and, as a result, has had several IV site locations. What action can the nurse take to promote venous distention in the patient? (Select all that apply.) a) Apply a warm pack to the arm for several minutes. b) Elevate the arm 10 to 30 degrees. c) Teach the patient relaxation techniques. d) Use the side of paralysis to avoid a vasoconstriction response to catheter insertion. e) Choose a site distal to the previous IV site. f) Rub or stroke the patient's arm. g) Tap the patient's veins multiple times.

a, f, g

The nurse is preparing to start an IV on a 92-year-old patient. The nurse realizes that she may need to take which of the following actions? (Select all that apply.) a. Avoid using veins in the hand b. Avoid using veins in the dominant arm c. Use the largest-gauge catheter possible for maximum flow d. Avoid using a tourniquet

a.b.d (In older patients, use the smallest gauge possible. For example, a 22-gauge needle is adequate for fluid and medication therapy; use a 24-gauge in frail, older adults. Smaller gauge catheters are less traumatizing to the vein but still allow blood flow to provide increased hemodilution of IV fluids or medications. If possible, avoid the back of the older adult's hand or the dominant arm for venipuncture because they interfere with the older adult's independence. Minimize pressure from tourniquets, or avoid them if possible. Apply an upside down blood pressure cuff for effective compression.)

a nurse is removing an IV catheter from a patient whose IV infusion has been discontinued. which of the following actions is appropriate? a. apply firm pressure over the vein b. leave the roller clamp slightly open c. pull the catheter straight back from the insertion site d. lift the hub slightly upward away from the skin

c

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

-Client's response to the insertion -Date and time inserted -Type and size of device -Type of dressing applied -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.

A nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the IV of an assigned client who is receiving fluid replacement therapy at least every: 1. 1 hour 2. 2 hours 3. 3 hours 4. 4 hours

1

A nurse is preparing an IV solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to do which of the following? 1. Change the IV tubing 2. Wipe the tubing with Betadine 3. Scrub the tubing with an alcohol swab 4. Scrub the tubing before attaching it to the IV bag

1

The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which INITIAL question? 1) "Have you ever had a transfusion before?" 2) "Why do you think that you need the transfusion?" 3) "Have you ever gone into shock for any reason in the past?" 4) "Do you know the complications and risks of a transfusion?"

1) "Have you ever had a transfusion before?" Rationale: Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. Questioning about previous history of shock and knowledge of complications and risks of transfusion are not helpful because they may elicit a fearful response from the client. Although determining whether the client knows the reason for the transfusion is important, it is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion.

A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which action(s) to reduce the risk of possible transfusion complications? SELECT ALL THAT APPLY. 1) Ask a family member to donate blood ahead of time. 2) Give an autologous blood donation before the surgery. 3) Take iron supplements before surgery to boost hemoglobin levels. 4) Request that any donated blood be screened twice by the blood bank. 5) Take adequate amounts of vitamin C several days prior to the surgery date.

1) Ask a family member to donate blood ahead of time. 2) Give an autologous blood donation before the surgery. Rationale: A donation of the client's own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in replacing blood lost during the surgery. Vitamin C enhances iron absorption, but also is not helpful in replacing blood lost during surgery.

The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun? 1) Expiration date 2) Presence of clots 3) Blood group and type 4) Blood identification number

1) Expiration date Rationale: The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage is usually limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. The nurse also notes the blood identification (unit) number, blood group and type, and client's name. The nurse also inspects the unit of blood for leaks, abnormal color, clots, and bubbles and returns the unit to the blood bank if clots are noted.

A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 from a baseline of 125/78. The client's temperature is 100.8F orally from a baseline of 99.2F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? 1) Septicemia 2) Hyperkalemia 3) Circulatory overload 4) Delayed transfusion reaction

1) Septicemia Rationale: Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include CHILLS, FEVER, VOMITING, DIARRHEA, HYPOTENSION, and the development of SHOCK. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level.

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which PRIORITY item? 1) Vital signs 2) Skin color 3) Urine output 4) Latest hematocrit level

1) Vital signs Rationale: A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs BEFORE the procedure and again after the first 15 minutes. The other options do not identify assessments that are a priority just before beginning a transfusion.

A provider prescribes lipids (fat emulsion) IV for a client receing parenteral nutrition. Before initiating the intralipds, which should the nurse assess that is related to the infusion? 1) allergies 2) VS 3) history of seizures 4) serum glucose level

1) allergies Fat emulsions contain and emulsifying agent made from egg yolks (hypersensitivity to eggs)

Before performing a venipuncture to initiate continuous IV therapy, a nurse should: 1) inspect the IV solution and exp date 2) apply a cool compress to the affected area 3) secure a padded arm board above the IV site 4) apply a tourniquet below the venipuncutre site

1) inspect the IV solution and exp date

The nurse prepares to access an implanted vascular access port. Which should the nurse implement first? 1) palpate the vascular port 2) anchor the vascular port 3) cleanse the site with alcohol 4) apply a cool compress to the site

1) palpate the vascular port

A nurse has just finished assisting the physician in placing a central IV line. Which of the following is a priority intervention after central line insertion? 1) prepare the client for a chest radiograph 2) assess the clients temperature to monitor for infection 3) label the dressing with the date and time of the catheter insertion 4) monitor the BP to asses for FVE

1) prepare the client for a chest radiograph for possible pneumothorax for accidental puncture of the lung.

The nurse administers diphenhydramine (Benadryl) before a blood transfusion to: 1) prevent uticaria 2) avoid fever and chills 3) enhance clotting factors 4) expand the blood volume

1) prevent uticaria

A nurse checks a unit of blood received from the blood bank and notes the presence of gas bubbles in the bag. Which should the nurse implement? 1) return the bag to the blood bank 2) infuse the blood using filter tubing 3) add 10 mL normal saline to the bag 4) agitate the bag to mix contents gently

1) return the bag to the blood bank

A nurse is caring for a client who is reducing blood transfusion therapy. Which clinical manifestations would alert he burst to a hemolytic transfusion rxn? 1) headache 2) tachycardia 3) hypertension 4) apprehension 5) distended neck veins 6) a sense of impending doom

1, 2, 3, 4, 6

The nurse caring for a client receiving IV therapy monitors for which signs of infiltration at the catheter site of an IV infusion? select all that apply: 1) slowing of the IV rate 2) tenderness at the insertion site 3) edema around the insertion site 4) skin tightness at the insertion site 5) warmth of skin at the insertion site 6) fluid leaking from the insertion site

1, 2, 3, 4, 6

The nurse is monitoring a client who is receiving a blood transfusion when the client complains of diaphoresis, warmth, and a backache. The nurse suspects a transfusion retain and should take which actions? select all that apply 1) contact the physician 2) remove the IV catheter 3) document the occurrence 4) stop the blood transfusion 5) hang 0.9% NaCl solution

1, 3, 4, 5

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

A client with parenteral nutrition (PN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position? 1. On the left side, with the head lower than the feet 2. On the left side, with the head higher than the feet 3. On the right side, with the head lower than the feet 4. On the right side, with the head higher than the feet

1. On the left side, with the head lower than the feet (Trendelenburg) Rationale- Air embolism occurs when air enters the catheter system, such as when the system is opened for intravenous (IV) tubing changes or when the IV tubing disconnects. Air embolism is a critical situation; if it is suspected, the client should be placed in a left side-lying position. The head should be lower than the feet. This position is used to minimize the effect of the air traveling as a bolus to the lungs by trapping it in the right side of the heart. The positions in the remaining options are inappropriate if an air embolism is suspected.

A 22-year-old client is seen in the emergency department (ED) 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

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 nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client's hospital gown? 1. Using a hospital gown with snaps at the sleeves 2. Disconnecting the IV tubing from the catheter in the vein 3. Checking the IV flow rate immediately after changing the hospital gown 4. Putting the bag and tubing thru the sleeve, followed by the client's arm

2

A nurse is assisting with caring for a client who is receiving a unit of packed RBCs. The nurse tells the client that it is most important to report which of the following signs immediately? 1. Sore throat or earache 2. Chills, itching, or rash 3. Unusual sleepiness or fatigue 4. Mild discomfort at the catheter site

2

A nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 degrees F orally. The nurse reports the finding to the RN and anticipates that which of the following actions will take place? 1. The transfusion will begin as prescribed 2. The blood will be held and the physician will be notified 3. The transfusion will begin after the administration of an antihistamine 4. The transfusion will begin after the administration of 600 mg of acetaminophen

2

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client's bedside? 1) Lactated Ringer's 2) 0.9% sodium chloride 3) 5% dextrose in 0.9% sodium chloride 4) 5% dextrose in 0.45% sodium chloride

2) 0.9% sodium chloride Rationale: Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells. Lactated Ringer's is not the solution of choice with this procedure.

The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring? 1) 5 minutes 2) 15 mintues 3) 30 minutes 4) 45 mintues

2) 15 mintues Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is usually when a transfusion reaction may occur. This enables the nurse to detect a reaction and intervene quickly.

The nurse checks the gauge of the clients IV catheter. Which is the smallest gauge catheter that the nurse can use to administer blood? 1) 14 2) 19 3) 22 4) 24

2) 19 gauge

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement FIRST? 1) Maintain bed rest with legs elevated 2) Place the client in high-Fowler's position 3) Increase the rate of infusion of intravenous fluids 4) Consult with the HCP regarding initiation of oxygen therapy.

2) Place the client in high-Fowler's position Rationale: New onset of tachycardia, bounding pulses, crackles and wheezes post-transfusion are evidence of fluid overload, a complication associated with blood transfusions. Placing the client in a high-Fowler's (upright) position will facilitate breathing. Measures that increase blood return to the heart, such as leg elevation and administration of intravenous fluids, should be avoided at this time. In addition, administration of fluids cannot be initiated without a prescription. Consulting with the HCP regarding administration of oxygen may be necessary, but positional changes take a short amount of time to do and should be initiated first.

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Fresh-frozen plasma is prescribed and transfused to replace fluid and blood loss. The nurse understands that which is the rationale for transfusing fresh-frozen plasma to this client? 1) To treat the loss of platelets 2) To promote rapid volume expansion 3) Because a transfusion must be done slowly 4) Because it will increase the hemoglobin and hematocrit levels

2) To promote rapid volume expansion Rationale: Fresh-frozen plasma is often used for volume expansion as a results of fluid and blood loss. It does not contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in clotting factors and can be thawed quickly and transfused quickly. It will not specifically increase the hemoglobin and hematocrit level.

A client began receiving an IV infusion of packed red blood cells 30 minutes ago. The client turns on the nurse call light and describes difficulty breathing, itching, and a tight sensation in the chest. Which of the following is the first action of the nurse? 1) call the physician 2) stop the transfusion 3) check the client's temperature 4) recheck the unit of blood for compatibility

2) stop the transfusion (transfusion rxn....iv line is kept open with NS and physician is notified...check vital signs....monitor the client for any life threatening symptoms)

A client had a 1000 mL 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 400 mL remaining. The nurse should take which action first? 1. Call the physician 2. Slow the IV infusion 3. Sit the client up in bed 4. Remove the IV catheter

2. Slow the IV infusion

The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with which item? 1) An air vent 2) Tinted tubing 3) An in-line filter 4) A microdrip chamber

3) An in-line filter Rationale: The tubing used for blood administration has an in-line filter. The filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client. Tinted tubing is incorrect because blood does not need to be protected from light. The tubing should be macrodrip, not microdrip, to allow blood to flow freely through the drip chamber. An air vent is unnecessary because the blood bag is not made of glass.

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 F orally. Which action should the nurse take? 1) Begin the transfusion as prescribed. 2) Administer an antihistamine and begin the transfusion. 3) Delay hanging the blood and notify the health care provider. 4) Administer two tablets of acetaminophen (Tylenol) and begin the transfusion.

3) Delay hanging the blood and notify the health care provider. Rationale: If the client has a temperature higher than 100 F, the unit of blood should not be hung until the HCP is notified and has the opportunity to give further prescriptions. The HCP likely will prescribe that the blood be administered regardless of the temperature, but the decision is not within the nurse's scope of practice to make. The nurse needs an HCP's prescription to administer medications to the client.

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken NEXT? 1) Remove the intravenous (IV) line. 2) Run a solution of 5% dextrose in water. 3) Run normal saline at a keep-vein-open rate. 4) Obtain a culture of the tip of the catheter device removed from the client.

3) Run normal saline at a keep-vein-open rate. Rationale: If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further health care provider prescriptions. This maintains a patent IV access line and aids in maintaining the client's intravascular volume. The nurse would NOT remove the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should NOT be removed. Second, cultures are performed when infection, NOT transfusion reactions, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.

A client receiving PN via a central venous catheter (CVC) is scheduled to receive an IV antibiotic. Which should the nurse implement before administering the antibiotic? 1) Turn off the PN for 30 minutes 2) check for compatibility with PN 3) ensure a separate IV access route 4) flush the cvc with normal saline

3) ensure a separate IV access route

The nurse assesses a peripheral IV dressing and notes that it is damp and the tape is loose. The best nursing action is to: 1) stop the infusion immediately 2) apply a sterile, occlusive dressing 3) ensure tight IV tubing connections 4) remove the IV and insert and new IV

3) ensure tight IV tubing connections

IV human albumin is prescribed for a client with burns. The nurse review the client's medical record for contraindications. The nurse contacts the physician before admin the human albumin if which of the following is noted in the client's record? 1) diabetes mellitus 2) multiple myeloma 3) renal insufficiency 4) lymphocytic leukemia

3) renal insufficiency Contraindicated due to blood derivative (also anemia, cardiac failure, allergies)

The client is receiving IV antibiotic therapy at home for 1 week via heparin lock (intermittent IV catheter). Which does the nurse include in client teaching for the early detection of the complications of IV therapy? 1) Protect the heparin lock continually 2) keep the heparin lock clean and dry 3) report local pain, drainage, or edema 4) apply pressure to the IV site if it dislodges

3) report local pain, drainage, or edema

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which of the following areas? 1. The pharmacy 2. The laboratory 3. The blood bank 4. The risk-management department

3.

A client who is receiving a blood transfusion rings the call bell for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. The nurse interprets that the client is experiencing: 1. Bacteremia 2. Fluid overload 3. Hypovolemic shock 4. A transfusion reaction

4

A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias? 1) Infusion pump 2) Pulse oximeter 3) Cardiac monitor 4) Blood-warming device

4) Blood-warming device Rationale: If several units of blood are to be administered, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To prevent this, the nurse warms the blood with a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infusion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products.

The client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding? 1) Increased hematocrit level 2) Increased hemoglobin level 3) Decline of elevated temperature to normal 4) Decreased oozing of blood from puncture sites and gums

4) Decreased oozing of blood from puncture sites and gums Rationale: Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. An elevated temperature would decline to normal after infusion of granulocytes if those cells were instrumental in fighting infection in the body.

The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion? 1) Hematocrit level 2) Erythrocyte count 3) Hemoglobin level 4) White blood cell count

4) White blood cell count Rationale: The client who has neutropenia may receive a transfusion of granulocytes, or white blood cells. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up white blood cell counts and differential to evaluate the effectiveness of the therapy. The nurse also continues to monitor the client for signs and symptoms of infection. Erythrocyte count and hemoglobin and hematocrit levels are determined after transfusion of packed red blood cells.

The nurse prepares a client for discharge who needs intermittent antibiotic infusions through a peripherally inserted central catheter (PICC) line. Which should the nurse include in client teaching about daily infusion care in the home? 1) keep the affected arm immobilized 2) aspirate 3 mL of blood from the PICC line 3) maintain a continuous IV infusion 4) check the insertion site for redness and swelling

4) check the insertion site for redness and swelling

The nurse prepares to administer an IV medication when the nurse notes that the med is incompatible with the IV solution. Which is the best intervention for the nurse to implement for safe medication administration? 1) ask the provider to prescribe a compatible IV solution 2) start a new IV cath for the incompatible medication 3) collaborate with the provider for a new admin route 4) flush tubing before and after admin the meds with NS

4) flush tubing before and after admin the meds with NS

A nurse evaluates the latency of a peripheral IV site and suspects and infiltration. Which does the nurse implement to determine if the IV has infiltrated? 1) strips the tubing and assesses for blood return 2) checks the regional tissue for redness and warmth 3) increases the infusion rate and observes for swelling 4) gently palpates regional tissue for edema and coolness

4) gently palpates regional tissue for edema and coolness

The nurse understands that which of the following are clinical indicators for IV fluids? Select all that apply. 1) syncope episodes 2) bounding pulse rate 3) chronic renal failure 4) rapid, weak and thready pulse 5) serum electrolyte abnormalities 6) abnormal serum and urine osmolality levels

4, 5, 6

A client has an order to receive 1000 mL of 5% dextrose in 0.45% NaCl. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing? 1. Uncaps the distal end of the tubing 2. Uncaps the spike portion of the tubing 3. Opens the roller clamp on the IV tubing 4. Closes the roller clamp on the IV tubing

4.

The nurse is inserting an IV line into a client's vein. After the initial stick, the nurse continues to advance the catheter if: 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 back flash chamber of the catheter.

4. Blood return shows in the back flash chamber of the catheter.

A client with the recent diagnosis of MI and impaired renal function is recuperating on the step-down cardiac unit. The client's blood pressure has been borderline low and IV fluids have been infusing at 100 mL /hr via a central line catheter in the right internal jugular for approx 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

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. I need to keep my activity level to a minimum while this catheter is in place.

The nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change? 1. Breathe normally 2. Turn the head to the right 3. Exhale slowly and evenly 4. Take a deep breath, hold it, and bear down

4. Take a deep breath, hold it, and bear down Rationale: Client should be asked to perform the Valsalva maneuver during tubing changes--helps avoid air embolism during tubing changes. Nurse asks client to take a deep breath, hold it, and bear down. If the IV line is on the right, the client turns their head to the left. This position increases intrathoracic pressure. Breathing normally and exhaling slowly and evenly are inappropriate and could enhance the potential for an air embolism during the tubing change.

The nurse is assisting the physician during the insertion of a central line into the subclavian vein. How should the nurse cleanse the area? a. With chlorhexidine in a back and fourth scrubbing motion. b. Chlorhexidine usually precedes alcohol c. The physician scrubs an area using back and forth strokes d. The antimicrobial solution must be dabbed dry with a sterile towel

A

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.

When using an intermittent administration set to deliver medications, how often does the Infusion Nurses Society recommend that the set be changed? A. Every 24 hours B. Every shift C. Every morning D. After every dose

A. Every 24 hours

What should the nurse do upon noting that the patient's IV site is pale, cool, and edematous? (Select all that apply.) a. Stop the infusion b. Elevate the extremity c. Start a new IV d. Flush the IV site

A.B.C (Infiltration is indicated by swelling and possible pitting edema, pallor, coolness, pain at insertion site, and possible decrease in flow rate. The nurse should stop infusion and should discontinue IV, elevate affected extremity, restart new IV if continued therapy is necessary, and document degree of infiltration and nursing intervention. Flushing the IV site is not recommended.)

A nurse responds to an IV pump alarm related to increased pressure. Which action should 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.

ANS: A 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. Removal of the IV catheter and placement of a new IV catheter should be completed when no other option has resolved the problem

A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications? a. Initiate a dedicated team to insert access devices. b. Require additional education for all nurses. c. Limit the use of peripheral venous access devices. d. Perform quality control testing on skin preparation products.

ANS: A The Centers for Disease Control and Prevention 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. REF: 199

A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.) a. Unique facility identifier b. Lot number related to the donor c. Name of the client receiving blood d. ABO group and Rh type of the donor e. Blood ty

ANS: A, B, D The ISBT universal bar-coding system includes four components: (1) the unique facility identifier, (2) the lot number relating to the donor, (3) the product code, and (4) the ABO group and Rh type of the donor. REF: 200

A nurse assists with the insertion of a central vascular access device. Which actions should the nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.) a. Include a review for the need of the device each day in the clients plan of care. b. Remind the provider to perform hand hygiene prior to starting the procedure. c. Cleanse the preferred site with alcohol/chlorhexidine and let it dry completely before insertion. d. Ask everyone in the room to wear a surgical mask during the procedure. e. Plan to complete a sterile dressing change on the device every day.

ANS: A, B, D The central vascular access device bundle to prevent catheter-related bloodstream infections includes using a checklist during insertion, performing hand hygiene before inserting the catheter and anytime someone touches the catheter, using chlorhexidine to disinfect the skin at the site of insertion, using preferred sites, and reviewing the need for the catheter every day. The practitioner who inserts the device should wear sterile gloves, gown and mask, and anyone in the room should wear a mask. A sterile dressing change should be completed per organizational policy, usually every 7 days and as needed. REF: 216

nurse assesses a client who has a peripherally inserted central catheter (PICC). For which complications should the nurse assess? (Select all that apply.) a. Phlebitis b. Pneumothorax c. Thrombophlebitis d. Excessive bleeding e. Extravasation

ANS: A, C Although the complication rate with PICCs is fairly low, the most common complications are phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Pneumothorax, excessive bleeding, and extravasation are not common complications. REF: 206

A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain? a. Administer topical lidocaine to the site. b. Place warm compresses on the site. c. Administer prescribed oral pain medication. d. Massage the site with scented oils

ANS: B At the first sign of phlebitis, the catheter should be removed and warm compresses used to relieve pain. The other options are not appropriate for this type of pain.

Several types of long-term central venous access devices are used. A benefit of using an implanted port (e.g., Port-a-cath) is that it: a. is easy to use for self-administered infusions. b. does not need to pierce the skin for access. c. does not need to limit regular physical activity, including swimming. d. cannot dislodge from the port, even if child plays with port site.

ANS: B The exit site must be dry to decrease infection. Needs daily heparin flush. water sport are restricted

The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate? a. Avoid using friction when cleaning around the CVAD insertion site. b. Use the push-pause method to flush the CVAD after giving medications. c. Obtain an order from the health care provider to change CVAD dressing. d. Position the patient's face toward the CVAD during injection cap changes.

ANS: B The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled. The patient should turn away from the CVAD during cap changes.

Which of the following steps is necessary when a patient is prepared for IV insertion? a. Shaving the hair from the site b. Selecting a proximal site in an extremity c. Applying a tourniquet 4 to 6 inches above the selected site d. Vigorously taping and massaging the selected vein

ANS: C Apply a flat tourniquet around the arm, above the antecubital fossa or 4 to 6 inches (10 to 15 cm) above proposed insertion site. Do not shave the area. Shaving may cause microabrasions and may predispose to infection. Use the most distal site in the nondominant arm, if possible. Vigorous friction and multiple tapping of the veins, especially in older adults, may cause hematoma and/or venous constriction.

What should the nurse do once she/he recognizes that the patient has phlebitis at his IV site? a. Reduce the IV flow rate b. Elevate the affected extremity c. Place a moist warm compress over the site d. Adjust the additive in the current IV

ANS: C Phlebitis is indicated by pain, increased skin temperature, and erythema along the path of the vein. Stop infusion, and discontinue IV. Restart new IV if continued therapy is necessary. Place moist warm compress over area of phlebitis. Document the degree of phlebitis and nursing interventions per agency policy and procedure. Elevating the extremity is what is done for an infiltration to reduce edema.

After placement of a centrally inserted IV catheter, a patient reports acute chest pain and dyspnea. Which action should the nurse take first? a. Notify the health care provider. b. Offer reassurance to the patient. c. Auscultate the patient's breath sounds. d. Give prescribed PRN morphine sulfate IV.

ANS: C The initial action should be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax. The other actions may be appropriate, but further assessment of the patient is needed before notifying the health care provider, offering reassurance, or administration of morphine

The nurses assigns NAP to care for several patients with continuous IV infusions. Which of the following can NAP assist with? a. Changing empty IV solution containers b. Confirming the correct IV drip rate c. Assessing the patient for response to IV therapy d. Informing the nurse if they notice anything abnormal

ANS: D

A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client? a. Allergic reaction b. Bowel obstruction c. Catheter lumen occlusion d. Infection

ANS: D 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.

A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next? a. Apply cold compresses to the IV site. b. Elevate the extremity on a pillow. c. Flush the catheter with normal saline. d. Stop the infusion of intravenous fluids.

ANS: D 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 per institutional policy and may help speed circulation to the area.

A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene for a client who has a vascular access device? a. Provide a bed bath instead of letting the client take a shower. b. Use sterile technique when changing the dressing. c. Disconnect the intravenous fluid tubing prior to the clients bath. d. Use a plastic bag to cover the extremity with the device.

ANS: D The nurse should ask the UAP to cover the extremity with the vascular access device with a plastic bag or wrap to keep the dressing and site dry. The client may take a shower with a vascular device. The nurse should disconnect IV fluid tubing prior to the bath and change the dressing using sterile technique if necessary. These options are not appropriate to delegate to the UAP.

A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the clients skin during this procedure? a. Lower the extremity below the level of the heart. b. Apply warm compresses to the extremity. c. Tap the skin lightly and avoid slapping. d. Place a washcloth between the skin and tourniquet.

ANS: D To protect the clients skin, the nurse should place a washcloth or the clients gown between the skin and tourniquet. The other interventions are methods to distend the vein but will not protect the clients skin.

A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention? a. The initial site dressing is 3 days old. b. The PICC was inserted 4 weeks ago. c. A securement device is absent. d. Upper extremity swelling is noted.

ANS: D Upper extremity swelling could indicate infiltration, and the PICC 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. The dwell time for PICCs can be months or even years. Securement devices are being used more often now to secure the catheter in place and prevent complications such as phlebitis and infiltration. TheIV should have one, but this does not take priority over the client whose arm is swollen.

While assessing the patient's IV infusion, the nurse notes that it is infusing slower than it should be. What should the nurse do first? a. Discontinue the IV b. Increase the rate of the infusion c. Observe for fluid overload d. Check the position of the IV fluid and extremity

ANS: D Check patient for positional change that might affect rate, height of IV container, and tubing obstruction. Check condition of site. The most likely cause of a slow-running IV is positioning. An infiltrated or clotted IV line probably will not be running at all. Discontinue the IV if determined it is infiltrated or clotted off. Position will affect flow even if rate is increased. Fluid overload is not associated with slowing of the infusing rate. Often it is caused when an IV is running too fast.

You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration? A) Extravasation of the medication B) Discomfort to the patient C) Blanching at the site D) Hypersensitivity reaction to the medication

Ans: A Irritating medications, such as chemotherapeutic agents, can cause pain, burning, and redness at the site. Blistering, inflammation, and necrosis of tissues can occur. The extent of tissue damage is determined by the medication concentration, the quantity that extravasated, infusion site location, the tissue response, and the extravasation duration. Extravasation is the priority over the other listed consequences.

You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy? A) Air emboli B) Phlebitis C) Infiltration D) Fluid overload

Ans: C Feedback: Infiltration is the administration of nonvesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli, phlebitis, and fluid overload are not indications of infiltration.

The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion? A) Leave one hand ungloved to assess the site. B) Cleanse the skin with normal saline. C) Ask the patient about allergies to latex or iodine. D) Remove excessive hair from the selected site.

Ans: C Feedback: Before preparing the skin, the nurse should ask the patient if he or she is allergic to latex or iodine, which are products commonly used in preparing for IV therapy. A local reaction could result in irritation to the IV site, or, in the extreme, it could result in anaphylaxis, which can be life threatening. Both hands should always be gloved when preparing for IV insertion, and latex-free gloves must be used or the patient must report not having latex allergies. The skin is not usually cleansed with normal saline prior to insertion. Removing excessive hair at the selected site is always secondary to allergy inquiry.

What should be the next action by the nurse, once the over-the-needle catheter (ONC) has been inserted through the skin and into the vein? a. Loosen the stylet for removal b. Check for blood return in the flashback chamber c. Stabilize the catheter and release the tourniquet d. Advance the catheter until the hub rests at the insertion site

B (Observe for blood return through flashback chamber of catheter or tubing of winged cannula, indicating that bevel of needle has entered the vein. Lower needle until almost flush with skin. Advance catheter another 1/8 to ¼ inch into the vein and then loosen stylet site on ONC. Only after the catheter is advanced and is in its final position is the catheter stabilized with one hand while the tourniquet is released. Only after the blood and the needle are observed to advance another 1/8 to ¼ inch into the vein is the stylet loosened. At that point, continue to hold skin taut, and advance catheter into vein until hub rests at venipuncture site.)

The nurse is attempting to insert a peripheral IV when the patient reports tingling and a feeling like "pins and needles." What does the nurse do next? A. Change to a short-winged butterfly needle. B. Stop immediately, remove the catheter, and choose a new site. C. Ask the patient to wiggle the fingers to stimulate circulation. D. Pause the procedure and gently massage the fingers.

B. Stop immediately, remove the catheter, and choose a new site.

The nurse must insert a short peripheral IV catheter. In order to decrease the risk of deep vein thrombosis or phlebitis, which vein does the nurse choose for the infusion site? A. Wrist B. Foot C. Forearm D. Antecubital

C. Forearm

A client who is receiving intravenous 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.

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.

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 caring for a patient receiving intravenous therapy. The nurse should report which of the following to the primary care provider? a. Completion of each liter of fluid b. Initiation of IV fluids c. Small infiltration d. Extravasation

D

The nurse is selecting a site for peripheral IV insertion. Which patient condition influences the choice of left versus right upper extremity? A. Pneumothorax with a chest tube on the right side. B. Myocardial infarction with pain radiating down the left arm. C. Right hip fracture with immobilization and traction in place. D. Regular renal dialysis with a shunt in the left upper forearm.

D. Regular renal dialysis with a shunt in the left upper forearm.

What should the nurse document after inserting a venous catheter? 1. Patient's birth date 2. Name of the patient 3. Diagnosis of the patient 4. Date and time of the insertion

Date and time of the insertion Because intravenous (IV) therapy is risk prone, the nurse should document the date and time of the insertion after insertion. This will let other nurses know when the IV site needs to be rotated. The patient's birth date, name, and diagnosis are more important to note when infusing fluids and medication.

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

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.

Which is the least preferred site for peripherally inserted central catheters (PICC)? 1. Basilic vein 2. Femoral vein 3. Subclavian vein 4. Internal jugular vein

Femoral vein Because there is a higher risk for infection, the femoral vein is the least preferred site for a PICC line insertion. The basilic vein is preferred because it offers the largest diameter of the blood vessels. The subclavian vein is also preferred because it is easy to access using bony landmarks, followed by an internal jugular vein. The basilic, subclavian, and internal jugular veins have a lower risk for infection than the femoral vein. What action should the nurse take if the patient reports unusual pain during catheter use at the caval-atrial junction (CAJ)?1Reassure the patient.2Reinsert the catheter.3Repeat the chest x-ray.4Check for infection at the injection site.

A client admitted to the intensive care unit 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

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.

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

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

RN with certified registered nurse infusion (CRNI) certification who is assigned to the ED 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 nurse has just inserted a peripheral IV catheter for a continuous infusion. To secure the catheter, the nurse should: a. leave the connection between the hub & the tubing uncovered b. wrap tape around the circumference of the patient's arm c. tape the IV catheter's hub securely to the patient's skin d. place a piece of paper tape over the insertion site

a

a nurse is discontinuing an IV infusion. for which of the following reasons is it important to verify and document the integrity & condition of the IV catheter? a. a broken-off catheter tip indicates the risk for an embolus b. catheter erosion indicates that it was left in place too long c. blood within the catheter could indicate clot formation d. discoloration of the catheter could be a sign of phlebitis

a

The nurse is aware there are certain precautions to take when administering potassium chloride (KCl) intravenously. Which of the following would place the patient at risk for injury? a) Before administering an IV solution containing potassium, the nurse verifies the patient has adequate urine output. b) After determining the IV site is patent and without signs of complication, the nurse administers the potassium chloride by IV push. c) The nurse obtains a physician's order for the required additives of the IV solution. d) The nurse notifies the physician if the patient's serum potassium level is above normal limits.

b

a nurse is initiating a peripheral IV infusion punctures the skin & selected vein and observes blood return in the flashback chamber of the IV catheter. which of the following actions should the nurse perform next? a. secure the catheter to the skin with a transparent dressing b. lower the catheter until it is almost flush with the skin c. advance the catheter about 1/4 inch into the vein d. remove the stylet slowly from the lumen of the catheter

b

a patient in early stage renal failure is prescribed an infusion of 0.45% sodium chloride. this type of solution is appropriate because it a. pulls fluid from the cells and increases vascular volume b. dilutes extracellular fluid and rehydrates the cells c. replaces extracellular volume and maintains intravascular volume d. draws fluid into blood vessels and reduces interstitial compartments

b

The nursing assistive personnel turned and repositioned the patient as requested; however, now the alarm on the IV infusion pump is sounding. Which of the following situations is most likely to have set off the alarm? (Select all that apply.) a) The patient is probably developing phlebitis. b) There is now air in the tubing. c) The rate of infusion has increased. d) The patient is lying on the tubing.

b, d

Which of the following would be consistent with infiltration? (Select all that apply.) a) Redness b) Cool to touch c) Warm to touch d) Swelling around the insertion site e) With or without pain

b, d

The nurse is changing IV fluids. She has performed hand hygiene and applied clean gloves. The nurse hung the new bag of fluids on the IV pole, removed the protective cover of the tubing port, removed the spike from the old bag, and accidentally touched the spike with her hand. Which action should be taken at this time? a) Wipe the spike off with an alcohol swab, allow it to dry completely, and insert it into the bag of fluids. b) Continue inserting the spike into the new bag of IV fluids since she was wearing gloves at the time. c) Obtain a new IV tubing set and a new bag of IV fluids; discard the bag of fluids that she just hung, and remove the protective covering of the tubing port. d) Obtain a new IV tubing set, remove the protective cover of the spike, and insert the spike into the tubing port of the IV bag that she just hung. Prime the tubing.

c

The nursing staff attended an in-service on IV fluid management with discussion on patient safety. Which of the following statements, if made by one of the staff, indicates further instruction is needed? a) "Calculation and regulation of IV flow rates is inappropriate for nursing assistive personnel to perform." b) "Most electronic infusion pumps use microdrip tubing, and therefore, the setting on the infusion pump in milliliters per hour is the same as the calculated gtt per minute." c) "It is unnecessary to monitor infusion rates when an infusion pump is being used." d) "An electronic infusion device may continue to infuse IV fluids after an infiltration has begun."

c

A nurse who has just initiated an IV infusion explains to the patient that complications are possible and that she will monitor the infusion regularly. The nurse should teach the patient that which of the following findings is an indication of early infiltration? a. moisture b. bruising c. tingling d. coolness

d

a nurse has just initiated a new peripheral IV infusion with 5% dextrose in water for continuous infusion. how often should the nurse plan to replace the primary infusion tubing? a. every 24 hours b. every 48 hours c. every 72 hours d. every 96 hours

d

which of the following is an important nursing action when converting an IV infusion to a saline lock? a. open the roller clamp of the primary infusion to prime the saline lock b. apply pressure with a syringe to clear resistance in the IV catheter c. attach secondary tubing to allow mobility d. flush the IV catheter to confirm patency

d

A patient is prescribed intravenous antibiotics for 4 weeks. How often should the nurse change the gauze dressing? A. 24 hours B. 48 hours C. 36 hours D. 72 hours

48 hours

Which statement made by a student nurse regarding the guidelines published by the Occupational Safety and Health Administration (OSHA) on needleless connection devices indicates a need for further education? 1. "The guidelines necessitate the use of devices developed with safety mechanisms." 2. "The goal of the guidelines is to limit the transmission and spread of airborne pathogens." 3. "This regulation requires each employer to maintain a log regarding sharps injury along with the incident details." 4. "The Occupational Exposure to Bloodborne Pathogens, Final Rule has been revised as per the Needlestick Safety and Prevention Act."

"The goal of the guidelines is to limit the transmission and spread of airborne pathogens." The OSHA guidelines have the goal of limiting the spread of bloodborne, not airborne, pathogens. The Occupational Exposure to Bloodborne Pathogens, Final Rule necessitates the use of devices developed with safety mechanisms. It also requires each employer to maintain a log regarding sharps injury along with the incident details. The Occupational Exposure to Bloodborne Pathogens, Final Rule was revised in 2001 as per the Needlestick Safety and Prevention Act.

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."

"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.

Which of the following are CVADs? (Select all that apply.) a. Implanted subcutaneous ports b. Peripherally Inserted Central Catheters (PICC) lines c. Saline locks d. Heparin locks

ANS: A, B Four types of CVAD are available: nontunneled percutaneous central venous catheters, tunneled central venous catheters, PICCs, and implanted subcutaneous ports.

A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site? A) Leave the hair intact. B) Shave the area. C) Clip the hair in the area. D) Remove the hair with a depilatory.

Ans: C Feedback: Hair can be a source of infection and should be removed by clipping; it should not be left at the site. Shaving the area can cause skin abrasions, and depilatories can irritate the skin.

The nurse is caring for a patient diagnosed with pneumonia who receives IV antibiotics every 8 hours. How often should the nurse change the primary intermittent IV sets? a. No more often than every 72 hours b. At least every 72 hours c. With each IV bag change d. Every 24 hours

D (every 24 hours)

A client receiving parenteral nutrition (PN) complains of a headache. The nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse determines that the client is experiencing which complications of PN therapy? 1. Sepsis 2. Air embolism 3. Hypervolemia 4. Hyperglycemia

3. Hypervolemia Rationale- Hypervolemia is a critical situation and occurs from excessive fluid administration or administration of fluid too rapidly. Clients with cardiac, renal, or hepatic dysfunction are also at increased risk. The client's signs and symptoms presented in the question are consistent with hypervolemia. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. The increased volume also causes neck vein distention and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms presented in the question do not indicate sepsis, air embolism, or hyperglycemia.

The nurse is caring for a restless client who is beginning nutritional therapy with parenteral nutrition (PN). The nurse should plan to ensure that which action is taken to prevent the client from sustaining injury? 1. Calculate daily intake and output 2. Monitor the temperature once daily 3. Secure all connections in the PN system 4. Monitor blood glucose levels every 12 hours.

3. Secure all connections in the PN system Rationale: Nurse should plan to secure all connections in the tubing. This helps prevent the restless client from pulling the connections apart accidentally. Nurse should also monitor I&O, but this does not relate specifically to a risk for injury as presented in the question. Monitoring the temperature and blood glucose level does not relate to a risk for injury as presented in the question. Clients temp and blood glucose levels are monitored more frequently than the time frames identified in the options to detect signs of infection and hyperglycemia.

A client receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the HCP, and they initially prescribes that the solution and tubing be changed. What should the nurse do with the discontinued materials? 1. Discard them in the unit trash 2. Return them to the hospital pharmacy 3. Send them to the laboratory for culture 4. Save them for return to the manufacturer

3. Send them to the laboratory for culture Rationale: When client is receiving PN develops a fever, a catheter related infection should be suspected. The solution and tubing should be changed, and the discontinued materials should be cultured for infections organisms. The other options are incorrect. Because culture for infectious organisms is necessary, the dc'd materials are not discarded or returned to the pharmacy or manufacturer.

Central venous access devices (CVADs) can be used in the home, hospital, and long-term care facilities for patients who require which of the following? (Select all that apply.) a. Supplemental nutrition b. Blood and blood products c. Hemodynamic monitoring d. Blood sampling

A.B.C.D (CVADs can be used in the home, in the hospital, and in long-term care facilities for patients who require supplemental nutrition, blood and blood products, continuous fluids, medications, hemodynamic monitoring, and blood sampling.)

For which patients are electronic infusion devices (EID) used? (Select all that apply.) a. Those who require low hourly rates b. Those who are at risk for volume overload c. Those who have impaired renal clearance d. Those who are receiving fluids that require a specific hourly volume

A.B.C.D (Infusion pumps are necessary for patients requiring low hourly rates, at risk for volume overload, with impaired renal clearance, or receiving medications or fluids that require a specific hourly volume.)

The nurse is preparing to administer a blood transfusion to a patient. Which vein is selected for a midline catheter? 1. Cephalic 2. Subclavian 3. Internal jugular 4. Median antecubital

Median antecubital The median antecubital vein is the preferred site for the administration of a midline catheter because it does not require vein transillumination for visualization. The basilic vein, which is the second choice for midline catheter administration, requires ultrasound visualization. The cephalic, subclavian, and internal jugular veins are not used for midline catheter placement. The cephalic vein is the site of placement for short peripheral catheters. The subclavian and internal jugular veins are used for placement of nontunneled percutaneous central venous catheters

While the nurse is attempting to remove a midline catheter from a patient, the patient develops venospasms. Which technique does the nurse use to facilitate the removal of the catheter in this patient? 1. Medication administration 2. Forceful removal 3. Clipping of sutures 4. Breaking the catheter

Medication administration Veins can develop venospasms when rapid or forceful catheter removal techniques are used. Use of medications to relax the vein wall may be required if the catheter cannot be removed. Imaging studies can confirm whether the cause of removal failure is a thrombosis instead of venospasm. Extreme traction or forceful removal of a catheter could cause the catheter to break and embolize to the heart or pulmonary circulation. Clipping of sutures is used for the removal of non-tunneled percutaneous central catheters. Breaking the catheter is never an option.

A patient receiving intravenous therapy reports tingling and numbness at the insertion site. What could be the possible complication? 1. Ecchymosis 2. Thrombosis 3. Venous spasm 4. Nerve damage

Nerve damage

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

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.

An intravenous catheter that is inserted through a large arm vein and is advanced until the tip enters the central venous system is known as a __________________.

PICC (peripherally inserted central catheter PICC)

Which catheter types are more likely to cause venospasms when removed forcefully? Select all that apply. A - Midline B - Tunneled C - Short peripheral D - Peripherally inserted central E - Non-tunneled percutaneous central

Peripherally inserted central Midline Removal of midline and peripherally inserted central catheters (PICCs) must be performed with the same slow and gentle techniques used to insert them. Sudden or forced removal of the catheter results in the development of venospasms or breakage of the catheter and entry into pulmonary circulation. Short peripheral catheters do not cause venospasms due to their thin gauge size. Tunneled and non-tunneled percutaneous central catheters do not cause venospasms when they are removed because the vein diameter is large.

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.

Skin integrity can be compromised easily by the application of tape or dressings.

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.

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.

Which principles from the catheter-related bloodstream infection prevention bundle (CRBSI) are important to remember when assisting with the placement of a central line? Select all that apply. 1. Disinfect the site with alcohol. 2. Perform hand hygiene before touching the line. 3. Use a checklist during the insertion of the central line. 4. Drape the patient head to toe with a sterile barrier prior to line insertion. 5. Everyone in the room during the insertion procedure should wear a mask.

- Perform hand hygiene before touching the line. - Use a checklist during the insertion of the central line. - Drape the patient head to toe with a sterile barrier prior to line insertion. - Everyone in the room during the insertion procedure should wear a mask.

The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item? 1. Client's temperature 2. Expiration of the bag 3. Time of last dressing change 4. Tightness of tubing connections

1. Client's temperature Rationale- Redness at the catheter insertion site is a possible indication of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. The tightness of tubing connection should be assessed each time the PN is checked; loose connections would result in leakage, not skin redness. The expiration date on the bag is a viable option, but this also should be checked at the time the solution is hung and with each shift change. The time of the last dressing change should be checked with each shift change.

The nurse is transfusing blood to a patient. Which components should the nurse be sure to check on the blood label? Select all that apply. A. Dosage B. Tonicity C. Lot # D. Product code E. ABO group & Rh factor

ABO group and Rh factor Product code Lot number

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/VN)? a. Titrate vasoactive IV medications. b. Flush a saline lock with normal saline. c. Remove the patient's central venous catheter. d. Verify blood products prior to administration.

ANS: B A LPN/VN has the education, experience, and scope of practice to flush a saline lock with normal saline. Administration of blood products, adjustment of vasoactive infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice.

A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is accurate? a. "The prescribed infusion can be given more rapidly when the patient has a central line." b. "The hypertonic solution will be more rapidly diluted when given through a central line." c. "There is a decreased risk for infection when 25% dextrose is infused through a central line." d. "The required blood glucose monitoring is based on samples obtained from a central line."

ANS: B The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.

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.

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.

While assessing the patient, the nurse recognizes that special caution should be taken with the IV infusion because of fluid volume excess when the nurse notes the presence of: a. Poor skin turgor b. Crackles in the lungs c. Decreased blood pressure d. Dry skin and mucous membranes

B (Auscultation of crackles or rhonchi in lungs may signal fluid buildup in the lungs caused by fluid volume excess. Poor skin turgor is common with fluid volume deficit. The pinched skin stays elevated for several seconds (tenting). This may be an indication of the need for IV therapy. Decreased blood pressure may indicate fluid volume deficit caused by a decrease in stroke volume. This may indicate a need for IV therapy. Dry skin and mucous membranes may indicate dehydration.)

What is an appropriate technique for the nurse to implement when changing the dressing of a peripheral IV site? a. Wear sterile gloves to remove the old dressing b. Keep one finger over the IV catheter until the tape is replaced c. Cleanse with an antiseptic solution in a circular manner toward the site d. Tape the connection between the IV catheter port and the tubing

B (Keep one finger over the catheter at all times until tape or dressing secures placement. If patient is restless or uncooperative, it is helpful to have another staff member assist with the procedure. Perform hand hygiene. Apply disposable gloves. Apply the final swab in a circular pattern, moving outward from the insertion site. Do not tape over connection of access tubing or port to IV catheter.)

A patient has a peripherally inserted central catheter (PICC) placed and is ordered to receive IV cisplatin (Plantinol). The drug has infiltrated into the tissue and redness is observed in the right lower side of the neck. What is the nurse's first action? A. Apply cold compresses to the site of swelling B. Stop the infusion and disconnect the IV line from the administration set. C. Aspirate the drus from the IV access device D. Monitor the patient and document.

B. Stop the infusion and disconnect the IV line from the administration set.

A patient is prescribed intravenous antibiotics for four weeks. What is the most important assessment the nurse should perform after the peripherally inserted central catheter (PICC) is inserted in the brachial vein to prevent complications?

Check for signs of phlebitis in the patient's upper chest

The patient is on daily weights and is receiving intravenous therapy. The nurse notices that the patient has gained 2 kg since the previous morning. What else would the nurse expect to observe? (Select all that apply.) a. Dry skin and mucous membranes b. Distended neck veins c. Tenting of the skin d. Crackles or rhonchi in the lungs

B.D (A change in body weight of 1 kg corresponds to 1 L of fluid retention or loss. Dry skin and mucous membranes suggest fluid volume deficit (FVD). Distended neck veins suggest fluid volume excess (FVE). Poor skin turgor is seen when after pinching, skin fails to return to normal position within 3 seconds. With FVD, the pinched skin stays elevated for several seconds. This is called "tenting." Auscultation of crackles or rhonchi in lungs may signal fluid buildup in the lungs caused by FVE.)

The nurse caring for a patient receiving IV fluids knows that the current recommendation for changing the tubing on continuously running IV is: a. At least every 72 hours b. Every 24 hours c. No more often than every 96 hours d. With each IV solution bag change

C

The patient is expected to require intravenous therapy for several years as treatment for a chronic disease process. Which of the following would be the best choice for venous access in this patient? a. Peripherally inserted central catheter (PICC) b. Nontunneled percutaneous central venous catheter c. Subcutaneous implanted port d. Peripheral IV

C (Implanted infusion ports are used for long-term and complex IV therapy. When not in use, no external catheter is present, and port manufacturers recommend that the port be heparinized every 4 weeks to maintain patency. No other care is required for an unused port. PICCs provide alternative IV access when the patient requires intermediate-length venous access (>7 days to several months). These catheters are used for shorter placements (e.g., 5 to 10 days). Use of peripheral IV therapy increases the risk for patients to develop infection, vein sclerosis, phlebitis, and infiltration.)

What should the nurse do to decrease the potential for infection related to IV therapy? a. Use clean technique for dressing changes b. Change the IV tubing every 12 hours c. Palpate the insertion site daily through the intact dressing d. After cleansing the skin, dab dry with a sterile gauze pad

C (Palpate catheter insertion site for tenderness daily through the intact dressing. Perform hand hygiene before and after palpating, inserting, replacing, or dressing any intravascular device. Maintain use of sterile dressings. Replace IV tubing no more frequently than at 72 hour intervals unless clinically indicated. Allow site to air-dry before proceeding with procedure.)

The nurse is caring for a patient with a continuous intravenous infusion of 0.9% normal saline with 40 mEq of potassium chloride added to each liter. During a routine hourly check of the infusion, the nurse discovers that 4 hours of fluid has been infused in the past hour. The nurse's first action should be to: a. notify the primary care provider b. assess the patient c. reduce the infusion rate d. notify the charge nurse

C If the intravenous fluid is infusing 4 times faster than ordered, the first intervention should be to reduce the infusion rate. Notification of the primary care provider and the charge nurse would occur after the flow rate is reduced and an assessment of the patient is performed. Although assessing the patient is vitally important, you do not want to allow the fluid to continue infusing at a rapid rate while you are performing the assessment. )

Which patient would a nurse anticipate would be a candidate for a peripherally inserted central catheter (PICC)? a. An older adult who is having cataracts removed b. A perinatal patient who is having a prolonged labor c. A neonate who is requiring extended antibiotic therapy d. An adolescent who is having surgery for the reduction of a fracture

C (When a child is critically ill or long-term IV access is anticipated, a PICC catheter, a Broviac catheter, or an implanted port may be used to access a larger vein. PICCs can be used to infuse IV fluids, parenteral nutrition, blood and blood products, and medications such as antibiotics. Gerontological veins are very fragile; there is less subcutaneous support tissue, and there is thinning of the skin. In older patients, use the smallest gauge possible. For example, a 22-gauge needle is adequate for fluid and medication therapy. PICC lines are not inserted routinely. PICCs are used for long-term IV need.)

the nurse is asked to assist with preparing a client who will be receiving a total parenteral nutrition (TPN) solution via a central line.The nurse plans to obtain which essential piece of equipment for this procedure? A) urine test strips B) blood glucose meter C) electronic infusion pump D) noninvasive blood pressure monitor

C)electronic infusion pumprationale the nurse obtains an electronic infusion pump in preparation for the administration of TPN.it is necessary to use an infusion pump to ensure that the solution does not infuse too rapidly or fall too far behind.Because the client's blood glucose level is monitored every 6 to 8 hours during the administration of TPN, a blood glucose meter will also be needed, bu this is not the most essential item.Use of urine test strips to measure spilled glucose is not necessary and is not an accurate measure of a complication.A noninvasive blood pressure cuff is unnecessary for this procedure.

A client is admitted to the cardiothoracic surgical intensive care unit 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

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.

Which type of intravenous therapy-acquired infection is most responsible for increased death rates? 1. Peritoneal 2. Meningeal 3. Joint 4. Catheter-related bloodstream

Catheter-related bloodstream The Institute for Health Care Development identified catheter-related bloodstream infections (CR-BSI) as a severe hospital-acquired infection responsible for about 28,000 deaths per year. Hand hygiene of hospital staff and selection of the appropriate infusion site can reduce the risk of CR-BSI to a greater extent. Peritonitis is the inflammation and infection of the peritoneum, usually acquired in the hospital by peritoneal administration of medications. Meningitis is the inflammation of the meninges and can be caused in the hospital by the intraspinal administration of medications. Joint infection can be caused when medications are administered into a joint cavity.

Which veins are most appropriate for common peripheral catheter placement? Select all that apply. 1. Median 2. Jugular 3. Cephalic 4. Basilic 5. Vena cava

Cephalic Basilic Median The veins that are most appropriate for common peripheral catheter placement include the median, cephalic, and basilic vein. The jugular vein and vena cava are not typically used for peripheral catheter placement.

Which veins may lead to nerve damage if used for intravenous therapy? Select all that apply.

Cephalic vein near the wrist Veins on the palmar side of the wrist

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

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.

The nurse is preparing to draw blood from a central venous access device for blood cultures. Which of the following steps is part of that process? a. Apply sterile gloves b. Flush the port with 5 to 10 mL of 0.9% sodium chloride c. Slowly aspirate 5 mL of blood and discard the syringe d. Use the *distal lumen* to draw blood

D (Use the distal (red or brown) lumen to draw blood if the device has more than one lumen. The distal (red or brown) lumen typically is the largest-gauge lumen. Apply clean gloves to prevent transfer of body fluids. Do not flush before drawing blood for blood cultures. If blood cultures have been ordered, do not discard any blood. Use the initial specimen for blood cultures.)

A patient is seen in the emergency department (ED) with pain, redness, and warmth of the right lower arm. The patient was in the ED last week after an accident at work. On the day of the injury, the patient was in the ED 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 patient's phlebitis? 1. Grade 1 2. Grade 2 3. Grade 3 4. Grade 4

Grade 3 Grade 3 indicates pain at the access site with erythema and/or edema and streak formation with a palpable cord. Grade 1 indicates only erythema with or without pain; the patient has additional symptoms. Grade 2 indicates only pain at the access site with erythema and/or edema; the patient has additional symptoms. Grade 4 indicates pain at the access site with erythema and/or edema, streak formation, a palpable venous cord longer than 1 inch, and purulent drainage. No purulent drainage is present in this patient, and the palpable cord is 1 inch in length

The nurse is caring for a patient with a peripherally inserted central catheter (PICC). What could cause this catheter to become dislodged? 1. Phlebitis 2. Thrombophlebitis 3. Excessive physical activity 4. Catheter-related bloodstream infections

Excessive physical activity Patients with PICCs should be instructed to avoid excessive physical activity because it may result in the dislodgement of the catheter and the development of lumen occlusion. Phlebitis, thrombophlebitis, and catheter-related bloodstream infections do not cause dislodgement of the catheter, but they are possible complications during infusion therapy

Which complication is common in both thrombophlebitis and phlebitis? 1. Infiltration 2. Contraction 3.Extravasation 4. Inflammation

Inflammation Inflammation is a common complication seen in both thrombophlebitis and phlebitis. Infiltration, contraction (venous spasm), and extravasation are complications of infusion therapy.

How will the nurse document the intravenous (IV) therapy complication of a blood clot inside the vein? 1. Phlebitis 2. Thrombosis 3. Extravasation 4. Thrombophlebitis

Thrombosis A thrombosis is a blood clot inside the vein, a potential complication of IV therapy. Phlebitis is inflammation of the vein. Extravasation is the leakage of the IV fluid into extravascular tissue. Thrombophlebitis is inflammation and a blood clot in the vein.