EAQ Week 4 Principles of Venipuncture

Which nursing intervention would the nurse implement for client safety and quality of care when placing a short peripheral venous catheter? - Choose a distal site - Use the wrist of the client - Choose the dominant hand - Do not use the arm on the side of a mastectomy - Choose a vein of appropriate length and width to fit the catheter's size

- Choose a distal site - Do not use the arm on the side of a mastectomy - Choose a vein of appropriate length and width to fit the catheter's size The nurse would choose a distal site to make all subsequent venipunctures proximal to previous sites. The nurse would choose a vein of appropriate length and width to place the short peripheral venous catheter.

Which clinical finding leads the nurse to conclude that an IV has infiltrated rather than cause inflammation? - Pain - Coolness - Localized swelling - Cessation in flow of solution

- Coolness When an IV infiltrates, the IV solution entering the interstitial space is at room temperature (approx 75F while body temp is approx 98.6F; therefore the client's skin will feel cool to the touch at the site of IV infiltration. The site of inflammation will feel warm to the touch bc of vasodilation and hyperemia (an excess of blood in the vessels supplying an organ or other part of body). Pain may occur with both an inflammation and an infiltration. The pain of an inflammation is related to the pressure of edema on nerve endings. The pain of an infiltration is related to the IV solution in the interstitial compartment pressing on the nerve endings. An increase in interstitial fluid occurs with both an inflammation and an infiltration. With an inflammation there is increased vascular permeability at the site; fluid, proteins, and leukocytes then move from the intravascular compartment into the interstitial compartment. With an infiltration the IV solution enters the interstitial compartment rather than the intravascular compartment. A cessation inflow of solution occurs with both an inflammation and an infiltration. An inflammation in the vein at the insertion site may narrow the lumen of the vessel, interfering with the flow of solution. An infiltration will cause excess fluid in the interstitial compartment to the extent that it will not accommodate more solution, interfering with the flow of the solution.

Which factor would the nurse recognize as the cause when a client's IV infusion infiltrates? - Excessive height of the IV bag - Failure to secure the catheter adequately - Contamination during the catheter insertion - Infusion of a chemically irritating medication

- Failure to secure the catheter adequately Infiltration is caused by catheter displacement, which allows fluid to leak into the tissues. Excessive height of the IV bag will affect the flow rate, not cause infiltration. Contamination during the catheter insertion can lead to infection and phlebitis, not infiltration.

The nurse is preparing to insert an IV catheter to a thin, emaciated client who is scheduled to begin IV fluid therapy. Which interventions would the nurse follow to provide high-quality care? - Insert an 18-gauge IV catheter - Change the IV line every 7 days - Flush the IV line with NS - Insert the IV catheter in the client's femur - Stop the insertion procedure when there is a break in technique

- Flush the IV line with NS - Stop the insertion procedure when there is a break in technique

Which clinical indicator would the nurse expect when an IV line has infiltrated? - Heat - Pallor - Edema - Decreased flow rate - Increased blood pressure

- Pallor - Edema - Decreased flow rate

Which cause would a nurse suspect is responsible for warmth, redness, and tenderness identified at a client's IV site? - Rapid fluid delivery - Phlebitis - Allergic response - Infiltration

- Phlebitis Phlebitis is an inflammation that can occur from prolonged IV infusion at a site, undilted irritating medications, and other causes. It manifests as increased warmth, redness, and tenderness. Rapid infusion would not cause the site to become warm, red, and tender. A local allergic reaction is associated with hives or a pruritic rash. Infiltration causes a pale, cool insertion site bc of fluid accumulation in the tissue.

Which action would the nurse taken when a client reports pain and burning at a peripheral IV site after the nurse has flushed the saline lock with normal saline? - Remove the IV catheter and restart the saline lock in another site - Document the findings per protocol and reassess the site in 8 hours - Flush the IV catheter and saline lock again vigorously with NS - Change the dressing and apply a new clean dressing per IV care protocol

- Remove the IV catheter and restart the saline lock in another site

Which action would the nurse perform first when assessing if an IV infusion of a vesicant has extravasated? - Elevate the IV site - Stop the infusion - Contact the prescriber - Aspirate residual medication from the IV catheter

- Stop the infusion

At which time would the nurse release the tourniquet when initiating an IV line? - After cleaning the insertion site - When the needle enters the vein - As soon as the needle pierces the skin - After the device is secured with tape

- When the needle enters the vein