Chapter 13: Intravenous Therapy (Prep U)

A nurse needs to perform venipuncture on a client who has poor skin turgor. To prevent skin trauma at the venipuncture site, the nurse should:

place a soft cloth between the tourniquet and the skin.

A client receiving IV fluid therapy suddenly becomes anxious and exhibits an elevated blood pressure, a bounding pulse, and shortness of breath. Which nursing action(s) would be most appropriate to assist this client? Select all that apply.

-Slow the IV rate. -Contact the physician. -Provide oxygen to the client.

A client is prescribed to receive an intravenous infusion of 5% dextrose and 0.45% normal saline to be infused over 12 hours. Which action will the nurse take to prepare the client for this infusion? Select all that apply.

-Validate the client's identity. -Explain the purpose of the infusion. -Review how long the infusion will take. -Discuss the location of the insertion needle.

The nurse is caring for a client receiving intravenous fluids through a peripheral venipuncture catheter. Which finding indicates to the nurse that the client's IV site has infiltrated? Select all that apply.

-slowing of the infusion rate -swelling at the catheter site -skin cool at the catheter site

The nurse is caring for a client who has experienced an isotonic fluid deficit caused by vomiting and expects the healthcare provider to order which intravenous fluid?

0.9% saline

A client is prescribed 1 liter of 5% dextrose and 0.9% normal saline to be infused over 12 hours. The fluid will be infused by gravity, using tubing with a drop factor of 12 gtts/ml. How many drops per minute will the nurse set the solution to infuse? (Calculate to the nearest whole number.)

17

A client is receiving IV fluid administration and consuming a rather large amount of fluids orally. In calculating the client's fluid intake for the past 24 hours, the nurse notes the amount and immediately notifies the physician of this finding. Notification of a physician regarding fluid intake should occur after exceeding how many milliliters in 24 hours?

3000

The nurse is caring for a client in an urgent care center. The health care provider has ordered that the client is to receive 1 liter of fluid over 4 hours and then may be released. The fluids will be infused by gravity and the tubing has a drop factor of 10 gtts/mL. The nurse will need to set the fluids at how many drops per minute to ensure the fluids are infused as ordered? Your answer should be in whole number(s).

42

A nurse is preparing a dose of furosemide for an older adult with heart failure. The health care provider orders furosemide 1 mg/kg to be given intravenously. The client weighs 50 kg. The concentration of the drug is 40 mg/4mL (10 mg/mL). How many milliliters would the nurse administer? Record your answer using a whole number.

5

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?

50

A nurse is preparing to use microdrip tubing. What is the standard volume that this device delivers?

60

A client suffers from infectious diarrhea. Based on her loss of fluid, her protein level is below normal. What blood product will the physician order to restore intravascular volume?

Albumin

The nurse is caring for a client who has been NPO since admission two days ago and was admitted with vomiting as a primary symptom. The client has been receiving intravenous therapy at 100 mL/hr. since admission with Lactated Ringers (LR) as the intravenous solution. What nursing diagnosis is most appropriate for this client?

Altered Nutrition: Less than body requirements R/T lack of adequate caloric intake

An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction?

Be vigilant in identifying the client and the blood component.

A central venous catheter has been inserted in the right subclavian vein of the client. Which of the following would be the priority nursing action before total parenteral nutrition (TPN) can be started?

Call for a portable chest x-ray.

A client with aplastic anemia is going to receive a blood transfusion. In addition to taking vital signs and verifying that the unit of blood cells is matched to the client, what other assessments/actions would you take?

Check the client regarding chills, low back pain, dyspnea, and skin itching during the transfusion.

A nurse needs to administer a prescribed dosage of antineoplastic drugs to a client with cancer. Which of the following pieces of medical equipment is used to administer antineoplastic drugs?

Central venous catheter

When you complete the initial postoperative assessment for a client aged 55 years, you note that his IV is on time and infusing at 33 gtts/min (administration set - 10 gtts/ml). You check the order, which reads: "IV of 1000 cc D5S to infuse over 8 hours." What actions would you take?

Change the rate to 21 gtts/min and observe for fluid overload.

The IV solution for a client has infused, and the physician's order indicates that no more fluid is required. To discontinue IV therapy for this client, which nursing action would the nurse complete first?

Don clean gloves.

The nurse has received a health care provider's order to initiate intravenous therapy and will check the client's medical record for what prior client condition that would impact placement of the client's intravenous site?

History of a mastectomy for breast cancer

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

Which of the following solutions is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?

Isotonic

A client with type O blood and a history of anemia is scheduled for a blood transfusion. To avoid a transfusion reaction, this client must receive which blood type?

O

A nurse is assigned to care for a client who is bleeding severely following an accident and has been ordered transfusion of blood components. Which of the following should the nurse do to reduce the risk of septic reactions?

Refrigerate red blood cells and thawed fresh frozen plasma until use.

A client has a physician's order for NPO (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy to

Replace fluid and electrolytes

Assessing a client at 4:00 PM, a nurse notes that 800 ml of normal saline solution has been infusing since it was hung at 4:00PM yesterday. What would be the nurse's next action?

Replace the IV solution.

A 58-year-old woman is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires

Replacement of fluids for those lost from vomiting and diarrhea

Fresh-frozen plasma (FFP) has been prescribed for a hospital client. Prior to administration of this blood product, the nurse should prioritize which client education?

Signs and symptoms of a transfusion reaction

A nurse is assessing a client's peripheral intravenous access site and suspects infiltration. Which of the following would support the nurse's suspicion?

Swelling Coolness

The nurse is observing a UAP provide basic comfort measures to a client who has recently returned from surgery. The client's IV is currently being infused by gravity because the electronic infusion device is not yet available. The UAP will correct the UAP's actions if which is noted by the nurse?

The UAP elevates the client's arm where the intravenous site is located on two pillows.

A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction?

The donor blood was incompatible with that of the client.

The nurse is supervising a new graduate nurse who is caring for a client receiving total parenteral nutrition for the last two weeks. The health care provider has just written an order to discontinue this therapy according to policy. What action by the new nurse would cause the supervising nurse to intervene in relation to intravenous therapy?

The new graduate replaces the total parenteral nutrition intravenous solution with 0.9% saline.

The nurse is preparing to administer a unit of blood to a client and should know that which is the FIRST action of the nurse prior to the administration?

The nurse will check that the numbers of the client's wrist band and the unit of blood match and that this information is confirmed by another nurse.

A client receiving intravenous therapy shows signs of swelling at the infusion site and says it is uncomfortable. The infusion is also slowing. Which of the following complications would the nurse most likely prepare to assist in managing?

Thrombus formation

A nurse is caring for a client undergoing IV therapy. The nurse knows that intravenous administration of medication is appropriate in which of the following situations?

When the client has disorders that affect the absorption of medications

A client requires a blood transfusion, and the nurse is preparing the blood transfusion equipment. Which item will the nurse need?

Y-administration tubing

A client with ascites is receiving TPN until the condition clears. IV lipid emulsions would be contraindicated in a client with which condition?

egg allergy

The nurse is preparing to administer the solution in the attached image to a client. Which of the following types of solution is the nurse going to administer?

isotonic