Chapter 15 Infusion therapy study guide
Which teaching would the nurse provide for the client and family on prevention of catheter-related bloodstream infection (CRBSI) before the IV catheter was inserted? Select all that apply. A. The type of catheter to be inserted B. Hand hygiene C. Aseptic technique for care of the catheter D. Activity limitations E. Signs and symptoms of complications F. Alternatives to catheter and therapy
A, B, C, D, E, F All options are correct responses to essential teaching that the nurse should provide for the client and family before an IV catheter is inserted for therapy.
Which nursing actions are implemented when caring for a client with an implanted port? Select all that apply. A. Before giving a drug through the port, always check for a blood return. B. De-access the port using a 5-mL syringe and 5 mL of heparin 5 units/mL. C. Before puncturing a port, palpate the port and locate the septum. D. Use a non-coring needle to access the implanted port. E. Flush the implanted port at least once monthly between courses of therapy. F. Use a topical anesthetic cream to decrease the pain of accessing the port.
A, C, D, E, F All options are appropriate for the care of an implanted port except option B. The INS recommendation for locking or de-accessing a port is the use of a 10-mL syringe with either heparin 10 units/mL or preservative-free 0.9% normal saline.
At what rate would the nurse set the infusion when a client is to receive 0.45% normal saline, 1000 mL over 15 hours? A. 50 mL/hr B. 67 mL/hr C. 75 mL/hr D. 83 mL/hr
B 1000mL / 15 hr 5 66.6 rounded up to 67 mL/hr
What is the minimum gauge of short peripheral catheter (SPC) through which a nurse can infuse a unit of packed RBCs for a client? A. 18 gauge B. 20 gauge C. 22 gauge D. 24 gauge
C Using a 22-gauge SPC is adequate for most therapies and blood can infuse without damage. Needles with a smaller gauge can damage blood cell membranes, making them useless in transfusion therapy.
Which criteria must the nurse follow before using a newly established peripherally inserted central catheter (PICC) to start IV therapy for a client? A. Wait for the results of a chest x-ray indicating that the tip resides in the lower superior vena cava (SVC). B. Check the client's chart to ensure that sterile technique is used for insertion to reduce the risk for catheter-related blood-stream infection (CRBSI). C. Review the purpose of the PICC line and check the pH or osmolality of fluids to be infused through the line. D. Check patency of the PICC line by flushing with 20 mL of sterile normal saline.
A Before the PICC line can be used for infusion, a chest x-ray indicating that the tip resides in the lower SVC is required when the catheter is not placed under fluoroscopy or with the use of the electrocardiogram tip-locator technique. Sterile technique is used with all IV insertions. The PICC line is placed in a vein with high flow that can handle hyperosmolar fluids and those in various pH ranges. Flushing the catheter should be done before each use to assess pa-tency of the catheter and after each use to en-sure that occlusion from blood that backflows into the lumen does not occur.
What is the nurse's best action when a client receiving IP therapy reports nausea and vomiting? A. Reduce the IP flow rate and administer antiemetics. B. Help the client move from side to side to distribute the fluid evenly. C. Flush the catheter with normal saline after the fluid has drained. D. Notify the health care provider and obtain a prescription for abdominal x-ray.
A Reducing the flow rate and treatment with anti-emetic drugs can reduce symptoms of nausea and vomiting. Option B will evenly distribute the IP fluid but will not relieve nausea and vomiting. Option C ensures patency of the catheter but does not relieve nausea and vomiting. With option D, the nurse would notify the health care provider for something to relieve nausea and vomiting, but the abdominal x-ray would not do this.
Which instruction will the nurse be sure to give the assistive personnel (AP) when checking the blood pressure of a client receiving IV therapy? A. "Avoid taking blood pressure in an extremity with any type of IV catheter in place." B. "Put the pump on hold while you take the client's blood pressure, then restart it." C. "Remind the phlebotomist to draw blood from the extremity without an IV catheter." D. "You can check blood pressure with a short peripheral catheter, but not with a midline catheter."
A Remind assistive personnel (AP) to avoid taking blood pressures in an extremity with any type of catheter in place. If a short peripheral catheter is being used for continuous infusion, the compression while taking the blood pressure can increase venous pressure, causing fluid to overflow from the puncture site and infiltration. When a midline catheter or PICC is being used, compression from the blood pressure cuff could increase vein irritation and lead to phlebitis.
What is the nurse's first action(s) when a client who is receiving IV chemotherapy through a PICC line develops infiltration into the tissue and redness is observed? A. Stop the infusion and disconnect the IV line from the administration set. B. Apply pressure and elevate the site of swelling and redness. C. Aspirate the drug from the intravenous access device. D. Check vital signs, monitor the client, and document the incident.
A The IV insertion site should be assessed carefully for early signs of infiltration, including swelling, coolness, tingling, or redness. If any of these symptoms are present, discontinue the drug immediately and notify the infusion therapy team and/or primary health care provider per agency policy when complications like this occur.
What would the nurse do when caring for an older adult client receiving IV fluids through a central line at 150 mL/hr, who becomes short of breath, develops puffiness around the eyes, and now has a cough? A. Place the client in an upright position, administer oxygen, slow the IV fluids, and notify the health care provider. B. Notify the health care provider, place the client in Trendelenburg position, and ad-minister urokinase to unclot the catheter. C. Assess for patency of the central line catheter, change the tubing, and resume the IV fluids. D. Remove the central line, apply pressure, notify the health care provider, and place the client in a semi-Fowler's position.
A The client's symptoms point to circulatory over-load, not a clot or other obstruction within the catheter. Key interventions at this time would include: slow the IV rate and notify the health care provider; raise client to an upright position; monitor vital signs and administer oxygen as prescribed; administer diuretics as pre-scribed. When breathing difficulties are present, lying flat or in Trendelenburg position makes breathing harder.
Which priority concept concerns the nurse when performing infusion therapy for any client? A. Fluid and electrolyte balance B. Tissue integrity C. Acid-base imbalance D. Perfusion
A The priority concept for when a nurse is providing infusion therapy for any client is fluid and electrolyte balance. The interrelated concept for infusion therapy is tissue integrity.
What is the best place for the nurse to add a filter to a client's IV administration set? A. As close as possible to the catheter hub B. Immediately below the infusion pump C. As close to the solution container as possible D. At any convenient connection point unlikely to be disconnected
A The purpose of filters is to remove particulate matter, microorganisms, and air from the infusion system. Filters should be placed as close to the catheter hub as possible to prevent particulate matter (e.g., rubber pieces, glass particles, cotton fibers, drug particles, paper, and metal fibers) from becoming trapped in the small circulation of the lungs. A red blood cell is about 5 microns in diameter and is the largest size that can pass through the pulmonary capillary bed; IV fluids may contain particles larger than 5 microns. For patients receiving infusion therapy for long periods, a significant number of particles could block the blood flow through the pulmonary circulation. Microcirculation in the spleen, kidneys, and liver could also be affected.
What is the priority nursing responsibility when a client is receiving IV therapy through an infusion pump? A. Monitor the client's infusion site and rate. B. Program the correct amount of fluid into the pump. C. Position the container for gravity flow. D. Check the equipment at the end of the infusion.
A The use of pumps does not decrease the nurse's responsibility to carefully monitor the client's infusion site and the infusion rate. Smart pumps (infusion pumps with dosage calculation soft-ware) have been promoted to reduce adverse drug events (ADEs). Incorrect programming of pumps without this feature is one of the most common types of drug errors, especially in hospitals.
Which client is the nurse most likely to teach about placement of a tunneled central venous catheter? A. Client in wheelchair to receive IV antibiotics for 16 weeks B. Client with trauma from a motor vehicle crash C. Client in need of fluid replacement for dehydration D. Client with acute renal failure and decreased urine output
A Tunneled catheters are used primarily when the need for infusion therapy is frequent and long term. Tunneled catheters are chosen when several weeks or months of infusion therapy are needed and a PICC is not a good choice (e.g., wheelchair bound, paraplegic).
Which type of intravenous (IV) access would the nurse use to administer a client's chemotherapy treatment? Select all that apply. A. Intra-arterial catheter B. Peripherally inserted central catheter (PICC) C. Implanted port D. Short peripheral catheter E. Dialysis catheter F. Midline catheter
A, B, C Use of an intra-arterial catheter for infusion therapy is not common and is generally used for direct treatment of tumor sites. Chemotherapy agents administered arterially allow infusion of a high concentration of drug directly to the tumor site. With a PICC line, there are no limitations on the pH or osmolality of fluids that can be infused. Clients requiring lengthy courses (more than 14 days) of antibiotics, chemotherapy agents, parenteral nutrition formulas, and vasopressor agents can benefit from a PICC. Implanted ports are used most often for clients receiving chemotherapy.
Which activities would be performed by infusion nurses for clients requiring infusion therapy? Select all that apply. A. Provide education about infusion therapy for staff, families, and clients. B. Monitor client outcomes with infusion therapy. C. Develop evidence-based policies and procedures. D. Consult on product selection and purchasing decisions. E. Develop new products for more effective infusion therapy. F. Insert and maintain peripheral, midline, and central venous catheters.
A, B, C, D, F Infusion nurses may perform any or all of these activities: develop evidence-based policies and procedures; insert and maintain various types of peripheral, midline, and central venous catheters and subcutaneous and intraosseous accesses; monitor client outcomes of infusion therapy; educate staff, clients, and families regarding infusion therapy; consult on product selection and purchasing decisions; provide therapies such as blood withdrawal, therapeutic phlebotomy, hypodermoclysis, intraosseous infusions, and administration of medications.
When the nurse is providing care for a client with a midline catheter, which key points are true? Select all that apply. A. Midline catheters are inserted in the upper arm, most commonly in the median antecubital vein. B. Midline catheters are used for hydration and for IV drug therapy up to 14 days. C. Strict sterile techniques are used for insertion and for dressing changes for mid-line catheters. D. Midline catheters can be used for the infusion of vesicant medications. E. All parenteral nutrition formulas may be infused through a midline catheter. F. When using a double-lumen midline catheter, do not administer incompatible drugs.
A, B, C, F Options A, B, C, and F are correct statements about midline catheters. Midline catheters should not be used to infuse vesicant solutions. Vesicant solutions can cause severe tissue damage if they escape into the subcutaneous tissue (extravasation). When using a double-lumen midline catheter, do not administer incompatible drugs simultaneously through both lumens because the blood flow rate in the axillary vein is not high enough to ensure adequate hemodilution and prevention of drug interaction in the vein.
Which key points would the nurse teach a client about intraosseous (IO) therapy? Select all that apply. A. The only absolute contraindication is a fracture in the bone to be used as a site. B. The IO route is for short term use and should not be used for more than 24 hours. C. The most common site accessed for IO therapy is the distal femur. D. The same fluids and drugs given IV can be given IO. E. During the IO procedure, most clients rate the pain as a 2 or 3 on a scale of 0 to 10. F. For access, 12-or 14-gauge needles specifically designed for IO therapy are preferred.
A, B, D, E Options A, B, D, and E are appropriate for the nurse to teach a client about IO therapy. The most commonly used site is the proximal tibia (not the distal femur). The preferred access needles are 15-or 16-gauge needles specifically designed for IO therapy.
Which specific actions will the nurse take when assessing a client's IV site? Select all that apply. A. Look for redness, swelling, hardness, or drainage. B. Check integrity of the dressing to make sure it is clean, dry, and adherent to the skin on all sides. C. Ensure that all connections are taped to prevent disconnection and leaking of fluids. D. Check the rate and amount of fluid that has infused. E. Be sure that the correct type of fluid is being infused. F. Check the skin around the dressing for medical adhesive-related skin injury (MARSI).
A, B, D, E Options A, B, D, and E are appropriate to assessing a client's IV site. Connections should not be taped. The skin under the dressing (not around) should be checked for medical adhesive-related skin injury (MARSI).
What information must the nurse know before giving any IV drug to a client? Select all that apply. A. Indications and proper dosage B. Contraindications and precautions C. Percentage of adverse events for the drug D. Compatibility with other IV medications E. Rate of infusion and osmolarity F. Potential for irritant and vesicant effects
A, B, D, E, F For all drug administration, nurses must be knowledgeable about drug indications, proper dosage, contraindications, and precautions. IV administration also requires knowledge of appropriate dilution, rate of infusion, pH and osmolarity, compatibility with other IV medications, appropriate infusion site (peripheral versus central circulation), potential for vesicant/ irritant effects, and specific aspects of client monitoring because of its immediate effect.
Which substances does the nurse understand are not compatible with plastic containers when administering IV therapy to clients? Select all that apply. A. Insulin B. Nitroglycerin C. Propranolol D. Lorazepam E. Furosemide F. Fat emulsion
A, B, D, F A problem with using some plastic containers is that they are not compatible with substances such as insulin, nitroglycerin, lorazepam, fat emulsions, and lipid-based drugs. Nitroglycerin and insulin adhere to the walls of the polyvinyl chloride (PVC) container, making it impossible to know exactly how much medication the client is receiving.
Which statements does the nurse recognize as true when providing care for a client receiving intraperitoneal (IP) infusions? Select all that apply. A. IP infusion therapy involves the administration of chemotherapy agents into the peritoneal cavity. B. An IP catheter has large internal lumens with multiple side-holes along the catheter length to allow for delivery of large quantities of fluid. C. Clean techniques are used when handling IP access and supplies. D. IP therapy is used for clients who are receiving medications for diagnostic tests. E. IP therapy includes three phases: the instillation phase; the dwell phase, usually 1 to 4 hours; and the drain phase. F. Strict aseptic techniques are used when handling the IP access and supplies.
A, B, E, F Options A, B, E, and F are correct statements about IP therapy. Microbial peritonitis and inflammation of the peritoneal membranes from the invasion of microorganisms is a complication of IP therapy, so it is essential to use aseptic technique (not clean) to decrease the risk of this occurrence. IP therapy is used for administration of chemotherapy agents into the peritoneal cavity and to treat intra-abdominal malignancies such as ovarian and GI tumors, not for diagnostic purposes.
Which major components and precautions of the catheter-related bloodstream infection (CRBSI) prevention bundle must the specially trained nurse follow when inserting a PICC line into a client? Select all that apply. A. Measuring upper arm circumference as a baseline before insertion B. Betadine skin antisepsis C. Proper aseptic hand hygiene D. Maximal barrier precautions on insertion E. Optimal catheter site selection F. Daily review of line necessity with prompt removal of unnecessary lines
A, C, D, E, F All options are appropriate and part of the catheter-related bloodstream infection (CRBSI) prevention bundle, except option B which should be chlorhexidine skin antisepsis (not betadine).
For which conditions does the nurse consider intrathecal infusion appropriate for a client? Select all that apply. A. Traumatic brain injury B. Leukemia C. Multiple sclerosis D. Cancer of the central nervous system E. Cerebral palsy F. Chronic pain
A, C, D, E, F Intrathecal infusion of chemotherapy is used for treating central nervous system (CNS) cancers and postoperative pain. It can also be used to manage chronic pain and treat spasticity of neurologic diseases such as cerebral palsy, multiple sclerosis, reflex sympathetic dystrophy, and traumatic brain injuries. It is not an appropriate therapy for the treatment of leukemia in adults.
What information must be included with each prescription for IV therapy for the nurse to administer it safely to a client? Select all that apply. A. Frequency of drug administration B. Specific type of administration equipment C. Rate of administration D. Specific type of solution E. Method for diluting drugs for the solution F. Specific drug to be added to the solution
A, C, D, F A drug prescription should include: drug name, preferably by generic name; specific dose and route; frequency of administration; time(s) of administration; length of time for infusion (number of doses/days); purpose (required in some health care agencies, especially nursing homes). The specific type of equipment to be used is not a requirement for a valid prescription. The pharmacy determines the correct diluent based on manufacturer's recommendations or requirements.
Which techniques will the nurse use to prevent air emboli when changing the IV administration set or connectors for a client with a central venous catheter? Select all that apply. A. Placing the client flat or in Trendelenburg so that the catheter site is below the heart B. Using sterile technique when handling the IV set and connectors C. Asking the client to perform the Valsalva maneuver by holding his or her breath and bearing down D. Timing the IV set change to the expiratory cycle if the client is spontaneously breathing E. Having an assistive personnel (AP) apply pressure at the insertion site F. Timing the IV set change to the inspiratory cycle when the client is receiving positive-pressure mechanical ventilation
A, C, D, F Techniques used to increase the intrathoracic pressure and prevent air embolism during IV set change include: placing the client in a flat or Trendelenburg position to ensure that the catheter exit site is at or below the level of the heart; asking the client to perform a Valsalva maneuver by holding his or her breath and bearing down; timing the IV set change to the expiratory cycle when the client is spontaneously breathing; and timing the IV set change to the inspiratory cycle when the client is receiving positive-pressure mechanical ventilation. Intravenous sets and connectors are not sterile except for where they connect together. The AP would not be asked to apply pressure at the insertion site during an IV set change.
Which intravenous (IV) fluid would the nurse infuse for a client when the health care provider prescribes a hypotonic solution? A. 0.9% NaCl B. 0.45% NaCl C. Lactated Ringer's solution D. 5% dextrose with 0.9% saline
B A hypotonic solution has a lower than normal blood plasma osmolarity (fluids less than 270 mOsm/L). An example of a hypotonic solution is half-strength saline (0.45% NaCl).
Which factor increases the likelihood that a client who comes into the emergency department (ED) after a serious motor crash is a candidate for intraosseous (IO) therapy? A. Endotracheal intubation is difficult to accomplish. B. IV access cannot be established within a few minutes. C. Client is an older adult and very thin. D. Client has a history of chronic renal failure.
B Adult victims of trauma benefit from IO therapy because health care providers often cannot access these clients' vascular systems for traditional IV therapy.
Which intervention would the nurse use to reduce the risk of infection when a client is receiving IV drugs by way of a needleless system? A. Always use a hand scrub when entering a client's room. B. Clean all needleless system connections with an antimicrobial agent for 10-15 seconds before connecting infusion sets. C. Use tape to assure that secondary IV sets remain attached to primary IV sets. D. Disconnect secondary IV sets after each dose of IV drug is completed.
B Clean all needleless system connections vigorously with an antimicrobial agent (usually 70% alcohol or alcohol and 2% chlorhexidine swabs) for 10-15 seconds before connecting infusion sets or syringes, paying special attention to the small ridges in the Luer-Lok device. The "scrub the hub" technique suggests generating friction by scrubbing the connection hubs in a twisting motion.
Which statement by a client to a nurse indicates the need for additional teaching regarding care of a PICC line? A. "My PICC line has a lumen size 4 French so blood samples can be drawn from it." B. "I will be able to rejoin my soccer team as long as I protect the PICC with padding." C. "My PICC line will work for IV antibiotics even up to 14 days." D. "I will be careful to use sterile technique when I change the dressing."
B Option B indicates that the client needs additional teaching about the PICC line. While clients will be able to perform their usual activities of daily living (ADLs), they should avoid excessive physical activity (e.g., playing soccer) because of the increased risk for catheter dislodgment and possible lumen occlusion. Options A, C, and D indicate understanding of care for PICC lines.
What is the nurse's priority action when attempting to insert a short peripheral catheter (SPC) and the client reports a feeling of "pins and needles"? A. Ask the client to wiggle the fingers to stimulate circulation. B. Stop immediately, remove the catheter, and choose a new site. C. Change to a short-winged butterfly needle. D. Pause the procedure and gently massage the fingers.
B Reports of tingling, feeling "pins and needles" in the extremity, or numbness during the venipuncture procedure can indicate nerve puncture. If any of these symptoms occur, stop the IV insertion procedure immediately, remove the catheter, and choose a new site.
Which nursing action is essential when a client is receiving infusion therapy through an intra-arterial catheter placed in the carotid artery? A. Monitor respirations for rate and regularity. B. Perform frequent neurologic and cognitive status assessments. C. Assess the extremities for sensation and peripheral pulses. D. Place antiembolic stockings on client's lower extremities.
B When the carotid artery is used for intra-arterial infusion, perform neurologic and cognitive assessments to determine adequate blood flow to the brain. When a femoral catheter is used, the client will have very limited movement so apply antiembolic stockings or other measures to prevent deep vein thrombosis.
Which are among the most common reasons for a nurse to administer infusion therapy to a client? Select all that apply. A. Keep a line open for surgery B. Administer medications C. Maintain electrolyte or acid-base balance D. Maintain fluid balance or correct fluid imbalance E. Chemotherapy for cancer clients F. Correct electrolyte or acid-base imbalance
B, C, D, F The most common reasons for using infusion therapy with clients are to: maintain fluid balance or correct fluid imbalance; maintain electrolyte or acid-base balance or correct electrolyte or acid-base imbalance; administer medications; and replace blood or blood products.
Which actions must the nurse follow to remove a short peripheral catheter (SPC) when a client is ready for discharge to home? Select all that apply. A. Flush the SPC before removal. B. Remove the SPC dressing. C. Explain the procedure to the client. D. Rapidly withdraw the catheter from the skin. E. Immediately cover the puncture site with dry gauze. F. Hold pressure until hemostasis is achieved. G. Assess the catheter tip to ensure it is intact and completely removed. H. Document catheter removal and appearance of the site.
B, C, E, F, G, H All options are appropriate actions for removal of an SPC, except A and D. It is not necessary to flush the catheter before removing it. The catheter should be slowly (not rapidly) with-drawn from the skin.
Which type of equipment decreases the risk of disconnection or leakage when a nurse attaches an administration set to a client's central venous catheter? A. Slip lock connector B. Extension set C. Luer-Lok connector D. Needleless connector
C A Luer-Lok connection has an end with a threaded collar that requires twisting onto the corresponding threads of the catheter hub. All connections, including extension sets, should have a Luer-Lok design to ensure that the set remains firmly connected. A slip lock has a male end that slips into the female catheter hub but does not have the threaded collar. An extension set lengthens the tubing but does not protect against disconnection or leakage. A needleless connection protects against needlesticks but does not stop disconnection or leakage.
Which grade of infiltration (based on Infusion Nurses Society [INS] criteria) would the nurse document after observing a client's IV site to have skin that is blanched and translucent, gross edema more than 6 inches in any direction, area cool to touch, moderate pain, and site numbness? A. Grade 1 B. Grade 2 C. Grade 3 D. Grade 4
C According to INS criteria, Grade 3 infiltration includes the following symptoms: skin blanched, translucent, gross edema more than 6 inches in any direction, cool to touch, mild-to-moderate pain, and possible numbness.
What would the nurse's first action(s) be when a client's IV site demonstrates slowed flow rate, skin tightness, discomfort at the site (e.g., burning, tenderness), and leakage around the site? A. Apply a cold pack and elevate the extremity. B. Place a sterile dressing over the site if weeping from the tissue occurs. C. Stop the solution and remove the intravenous access. D. Insert a new IV catheter above the site of the old one.
C First, stop infusion and remove short peripheral catheter immediately. After this, a sterile dressing can be applied if there is weeping from the tissue. Next, the extremity can be elevated and cold or warm compresses applied. A new catheter should be inserted in the opposite (not the same) extremity. Finally, the nurse would rate the infiltration using the INS Infiltration Scale and document the event.
What solution and volume does the nurse typically use to flush a client's short peripheral catheter IV saline lock? A. 3 mL heparinized saline B. 5 mL bacteriostatic saline C. 3 mL normal saline D. 5 mL heparin solution
C For short peripheral catheters, usually 3 mL nor-mal saline is adequate to flush the catheter. For all other catheters, 5 to 10 mL of preservative-free normal saline is needed. Flush catheters immediately after each use. A saline lock should be flushed at least once each shift. Research has shown that for SPCs, 3 mL of saline is just as effective at maintaining patency of the catheter without the risks associated with the use of heparin flushes.
Which client condition influences the nurse's choice of right versus left forearm placement when a short peripheral catheter (SPC) needs placement? A. Myocardial infarction with pain radiating down the left arm B. Pneumothorax with a chest tube on the right side C. Regular renal dialysis with a shunt on the left forearm D. Right hip fracture with immobilization and traction in place
C Mastectomy, axillary lymph node dissection, lymphedema, paralysis of the upper extremity, and the presence of dialysis grafts or fistulas alter the normal pattern of blood flow through the arm. Using veins in the extremity affected by one of these conditions requires a primary health care provider's order.
Which technique will the nurse use to access a client's implanted port for chemotherapy? A. Palpate the port, scrub the skin, and access port with a butterfly needle. B. Scrub the port with alcohol and access the port with a needleless device. C. Palpate the port, scrub the skin, and access the port with a noncoring needle. D. Scrub the port with betadine and flush using saline in a 10-mL syringe.
C Port access should be done only by formally trained health care professionals using a mask and aseptic technique. Before puncture, palpate the port to locate the septum. Carefully palpate to feel the shape and depth of the port body to ensure puncture of the septum. Scrub the skin over the port with alcohol. Implanted ports are accessed by using a non-coring needle (a common brand name is Huber) that is specially designed with a deflected tip. This design slices through the dense septum without coring out a small piece of it, thus preserving the integrity of the septum.
For which potential problem does the nurse assess the client after receiving epidural therapy when symptoms of headache, stiff neck, or temperature higher than 101°F (38.3°C) develop? A. Allergic reaction B. Leakage of cerebrospinal fluid C. Meningitis D. Catheter migration
C The client may also exhibit neurologic and systemic signs of infection (e.g., meningitis) such as headache, stiff neck, or temperature higher than 101°F (38.3°C). Report any neurologic change to the primary health care provider immediately!
What is the RN generalist's role for a client in need of infusion therapy? A. Placement of a peripherally inserted central catheters (PICC) B. Changing dressing on all intravenous sites every 48 hours C. Insertion of short peripheral catheters (SPC) D. Providing services such as hypodermoclysis and intraosseous infusions
C The registered nurse (RN) generalist is taught to insert peripheral IV lines; most institutions have a process for demonstrating competency for this skill (e.g., demonstrate successful placement a specified number of times on clients with a preceptor watching). Options A and D are specialty actions not usually performed by a generalist nurse. Option B is wrong because of the time frame which varies depending on the type of IV line and dressing.
Which site will the nurse choose for a client who is to receive hypodermoclysis treatment for palliative care? A. Anterior forearm B. Lateral aspect of the upper arm C. Area under the clavicle D. Posterior tibial area
C When choosing the infusion site, consider the client's level of activity. The area under the clavicle or the abdomen prevents difficulty with ambulation. In general, extremities are avoided for hypodermoclysis because other sites provide larger surface areas for absorption and the client's use of upper extremities is not restricted.
How often would the nurse routinely change the transparent dressing on a client's central venous IV site? A. Every 24 hours B. Every 48 hours C. Every 3 days D. Every 5 to 7 days
D For central IV lines, when a transparent dressing (e.g., Tegaderm) is used, the dressing is routinely changed every 5 to 7 days. If the dressing does not adhere to the skin or is loose, it may need to be changed sooner.
Where would the nurse insert an IV short peripheral catheter (SPC) in an active client with a prescription for IV therapy? A. Wrist B. Hand C. Antecubital area D. Forearm
D Short peripheral catheters are most often inserted into superficial veins of the forearm. In emergent situations, these catheters can also be used in the external jugular vein of the neck. The areas in options A and C are over joints, which would then have to be immobilized. The back of the hand contains little subcutaneous tissue and is easily damaged. Option B, the hand is not appropriate for older patients with a loss of skin turgor and poor vein condition or for active patients receiving infusion therapy in an ambulatory care clinic or home care. Use of veins on the dorsal surface of the hands should be reserved as a last resort for short-term infusion of nonvesicant and nonirritant solutions in young patients.
Which technique is recommended by the Infusion Nurses Society (INS) for the nurse to maintain a PICC line for a client receiving IV antibiotic therapy every 4 hours? A. Flush the catheter with 10 mL heparinized saline after each dose of antibiotic. B. Flush the catheter every 12 hours using a 5-mL syringe. C. Avoid flushing the catheter with heparinized saline more than twice a week. D. Use 10 mL of sterile saline to flush before and after each dose of antibiotic.
D The INS recommends that PICC lines not actively in use be flushed with 5 mL of heparin (10 units/mL) in a 10-mL syringe at least daily when using a nonvalved catheter and at least weekly with a valved catheter. Use 10 mL of sterile saline to flush before and after medication administration; 20 mL of sterile saline to flush after drawing blood. Always use 10-mL barrel syringes to flush any central line because the pressure exerted by a smaller barrel poses a risk for rupturing the catheter.
What complication does the nurse suspect when a client receiving IV antibiotic therapy over the past 3 days develops chills, headache, and an elevated temperature? A. Fluid volume overload B. Allergic reaction to antibiotics C. Phlebitis with infiltration D. Catheter-related bloodstream infection (CRBSI)
D With catheter-related bloodstream infection (CRBSI), early symptoms include fever, chills, headache, and general malaise. Later symptoms include tachycardia, hypotension, and decreased urinary output.
