ADN 210 Exam 2
A client diagnosed with idiopathic thrombocytopenia purpura needs a peripherally inserted central catheter (PICC) placed. When explaining the catheter to the client, the nurse explains that one advantage of a catheter is that it can be used
to provide long-term access to central veins.
The nurse is preparing to perform venipuncture. Which items will the nurse plan to gather? Select all that apply.
tourniquet adhesive tape transparent dressing clean gloves antiseptic swabs
A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?
"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."
The nurse has finished teaching a client about medications that have been ordered for administration. Which client statement reflects that teaching about a piggyback infusion has been successful?
"You will give me that medication in tandem with my other IV solution."
Which is considered an isotonic solution?
0.9% normal saline
How long can an implanted port stay in for?
2-3 years
How long do you keep in a PICC line?
6 weeks - 6 months
A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?
An implanted central venous access device (CVAD)
The nurse is preparing to administer an I.V. medication through a tunneled venous access device. Prior to administering an I.V. medication, the nurse meets resistance when attempting to flush the line with saline. What is the best action by the nurse?
Assess for external blockage and/or clamping of the line.
While receiving a medication IV piggyback, the client reports discomfort at the IV site. Upon assessment, the site is cool to the touch and slightly swollen. What is the best action by the nurse?
Discontinue the IV site and restart IV in a new location.
The nurse assesses that extravasation of a chemotherapy agent has occurred. What is the nurse's initial action?
Discontinue the infusion
A nurse demonstrates the need for using isotonic solutions based on the understanding that if a hypotonic solution was used, what would happen to the cells?
Grow
A nurse assessing the IV site of a patient observes swelling and pallor around the site and notes a significant decrease in the flow rate. The patient complains of coldness around the infusion site. What IV complication does this describe?
Infiltration
A nurse is preparing to insert a peripheral IV catheter. When performing the venipuncture, which action would be appropriate?
Insert the needle with the bevel facing up.
How long do you keep in a non-tunneled central line?
No longer than 2 weeks
Who is responsible for maintaining the proper flow rate of the IV solution?
Nurse.
A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible?
Phlebitis
The nurse is participating in the care of a client who had a peripherally inserted central catheter (PICC) placed in the right arm. After catheter placement, the nurse should complete which action?
Send the client for a chest x-ray.
A nurse demonstrates the need for using isotonic solutions based on the understanding that if a hypertonic solution was used, what would happen to the cells?
Shrink
What 2 non-tunneled central line locations put the patient at risk for a pneumothorax?
Subclavian and internal jugular
What are the locations for a non-tunneled central line?
Subclavian, femoral, and internal jugular
When positioned properly, the tip of a central venous catheter should lie in the
Superior vena cava.
The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy should the nurse do first?
Verify the orders for type of solution and amount of infusion.
Which factor is associated with rapid absorption of a drug?
intravenous route of administration.
Which type of catheter is inserted so that the tip sits in the upper arm at or below the axillary line but is not useful to the nurse for blood draws due to inconsistent blood return?
midline catheter
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?
placing the tourniquet on the upper arm for 2 minutes
