IV Therapy

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

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

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 nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to assess the client's: 1. Vital signs 2. Skin color 3. Oxygen saturation 4. Latest Hct level

1.

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.

You are obtaining written consent for a blood transfusion. The patient states, "I am concerned about getting AIDS!" How do you respond?

The blood supply now a days is screened and is very safe.

Infiltration

pain, low temp, damp dressing, slowed rate of infusion, swelling treatment: elevation of extremity apply warm or cold compress

Use infusion pump for

potassium, chloride

gravity flow

rate must be adjusted with roller clamp

Isotonic

same concentration as body fluids

IV bolus

small amount/ short time 1-2min

catheter embolism

small portion of catheter breaks off and enter venous system

16 gauge

trauma clients, rapid fluid volume

Butterfly needle

used in adults with poor veins, less than 24 hrs.

lidocaine for venipuncture pain

vasospasm, allergic reactions, anaphylaxis

Blood, tpn, lipids changed every

24 hrs

Short peripheral cannula changed every

48-72

port

Device surgically implanted

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 nurse is doing a routine assessment of a client's peripheral IV site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which of the following has probably occurred? 1. Phlebitis 2. Infection 3. Infiltration 4. Thrombosis

3.

optimal height for container

30-36 inches above patient

How long do you stay to monitor pt after transfusion starts?

15 minutes to verify no rxn to blood transfusion; document vital signs and pt tolerance to blood Per hospital policy on how often after this; some places are every 15 minutes. Some are before, 15 minutes after start, and 15 minutes after stopping transfusion minimum.

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

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) 24 gauge

discontinuing IV therapy

Clamp IV, remove Iv, stabilize IV , withdraw by pulling it straight back from site, hub parallel to skin

vesicants (use smallest needle)

Drugs capable of causing pain, inflammation and blistering of skin, underlying flesh and structures leading to tissue death & necrosis

Phlebitis/thrombophlebitis

Edema, burning, pain, increased, temp red line up the arm treatment: elevation apply warm compress

TPN (total parenteral nutrition)

Hypertonic Solution Given via PICC line, tunneled catheter Prepared daily by pharmacy Use Sterile Asepsis for dressing change Check blood glucose every 4-6 hours Change bag every 24 superior vena cava when a person cannot receive fluids orally

Fluid bolus

Large amount of fluid in short amount of time (less than an 1 hr) 18' gauge

What is the type of bag solution used with blood transfusions?

Normal saline only! D5W would clot or agglutinate

Your patient needs a unit of blood. His pre-transfusion temp is 100.5. What do you do?

Notify the provider.

continuous infusion

changed 96 hr

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 client is going to be transfused with a unit of packed RBCs. The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started? 1. 5 minutes 2. 15 minutes 3. 30 minutes 4. 45 minutes

2.

IV Intraprocedure

vein below site insertion 10-30 degrees, flashback of blood will confirm placement, lower hub

You are infusing a unit of PRBC's via a peripheral line. It is not on a pump and is infusing via gravity flow. It stops running. How would you troubleshoot?

-Check tubing for occlusion -Raise IV pole -Check clamps

Intermittent IV

8-12hr (checked) changed every 24 hr

A nurse is checking the insertion site of a peripheral IV catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of: 1. Phlebitis of the vein 2. Infiltration of the IV line 3. Hypersensitivity to the IV solution 4. An allergic reaction to the IV catheter material

1

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 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

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

Which of the following clients are most likely to develop circulatory overload? (select all that apply) 1. A premature infant 2. A 101-year-old man 3. The client on renal dialysis 4. The client with diabetes mellitus 5. A 29-year-old woman with pneumonia 6. The client with CHF

1, 2, 3, 6

The nurse assesses the client's peripheral IV site and noes that it is cool, pale, swollen, and not infusing. The nurse should document in the client's record that which of the following has probably occurred? 1) Phlebitis 2) Infection 3) Infiltration 4) Thrombosis

3) Infiltration The infusion stops with the pressure in the tissue exceeds the pressure in the tubing. The pallor, coolness and swelling of the IV site are the result of IV fluid infusing into the subcu tissue.

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 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 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

A nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which of the following? 1. An increased Hct level 2. An increased Hgb level 3. A decline of the temperature to normal 4. A decrease in oozing from puncture sites and gums

4

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

Picc lines changed every

6 weeks

Peripheral and central changed every

72 hrs

occlusive dressing

An airtight dressing that protects a wound from air and bacteria; a commercial vented version allows air to passively escape from the chest, while an unvented dressing may be made of petroleum jelly-based (Vaseline) gauze, aluminum foil, or plastic.

hypertonic

increases blood volume

Your blood has arrived from the blood bank, but your pt's IV just infiltrated. What do you do?

Stop the IV, try to get IV re-done, but only before 30 minutes are up, or the blood goes bad after 30 mins.

18-20 gauge

Surgery

You are transfusing PRBC's. You suspect the IV has infiltrated. What does that look like?

Swelling, purplish like a bruise

You observe a nurse priming tubing for a blood transfusion with D5W. What would you do?

Tell her to stop as D5W can cause clotting along with the transfusion. Normal saline is the only standard.

Is it ok to give blood thru PICC or a central line?

Yes

Can a pt get circulatory overload from a blood transfusion?

Yes, due to volume. osmotic effect and colloids

peripheral sites

changed every 24 hr

22-24 gauge

children, adults

Chlorhexidine

cleansing solution

hypotonic solution

decreases blood volume

fluid excess

dyspnea, shortness of breath, high bp

Extravasation

escape of blood from the blood vessel into the tissue

IV sites must be changed

every 72 hr

Piggy back meds are used with intermittent infusion devices

having meds given at certain times 4-6 hrs

circulatory fluid aka fluid excess

if infusion rate happens fast

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)