N322 Flash cards
Which instruction might the nurse give to nursing assistive personnel (NAP) when caring for a patient whose IV access device is to be removed? A. "Remember to wear gloves to minimize the risk for infection." B. "Be sure to keep pressure on the site for at least 2 to 3 minutes." C. "Let me know if you notice any bleeding on the site dressing." D. "Make sure the patient knows to notify me if the IV site becomes painful."
Answer: "Let me know if you notice any bleeding on the site dressing." Rational: The nurse might offer this instruction because the task of reporting signs of bleeding may be delegated to NAP. The removal of an IV access device cannot be delegated to NAP. The removal of an IV access device cannot be delegated to NAP. Patient education may not be delegated to NAP.
What is the initial infusion rate for a 20% fat emulsion? A. 1 mL/min B. 2 mL/min C. 5 mL/min D. 10 mL/min
Answer: 1 mL/min Rational: In an adult, unless agency policy specifies otherwise, fat emulsions are initially infused at 1 mL/min for the first 15 to 30 minutes.
What will the nurse do after removing the soiled dressing from a patient's CVAD device? A. Cleanse the site with soap and water. B. Use 2% chlorhexidine swabs to cleanse the site. C. Apply a skin protectant. D. Remove the catheter stabilization device, if present.
Answer: Remove the catheter stabilization device, if present. Rational: The nurse would remove the catheter stabilization device, if present, after removing the soiled dressing. Soap and water is not used to cleanse the site of a central venous access device. The site is cleansed after the catheter stabilization device has been removed. Skin protectant is applied after cleansing the site.
Which of the following technique(s) is/are best for minimizing a patient's risk for injury when inserting a venous access device? A. Inserting the needle with the bevel up B. Using a vein on the dorsal surface of the arm C. Holding the skin taut directly below the site D. All of the above
Answer: All of the above Rational: All of these actions will minimize injury to the patient. Inserting the needle bevel-up minimizes vein trauma by the needle itself. Use of adequate veins reduces the chance for rupture. Holding the skin taut directly below the site will decrease drag on insertion.
Which action would the nurse perform to ensure patient safety during PPN and fat emulsion therapy? A. Change the tubing on the fat emulsion every 48 hours. B. Infuse the fat emulsion through a 0.22-µm IV filter. C. Plan to infuse the fat emulsion over 18 hours. D. Allow a refrigerated fat emulsion to sit at room temperature for 1 hour before infusing it.
Answer: Allow a refrigerated fat emulsion to sit at room temperature for 1 hour before infusing it. Rational: The nurse would allow a refrigerated fat emulsion to sit for 1 hour at room temperature before infusing it. The tubing on the fat emulsion must be changed every 24 hours, or immediately if contamination is suspected. Fat emulsions cannot infuse through a 0.22-µm IV filter. Fat emulsions must not be allowed to hang longer than 12 hours as a separate infusion.
Which action would the nurse perform to best ensure effective insertion of a venous access device into a patient's arm? A. Anchor the vein by placing a thumb 1 to 2 inches below the site. B. Insert the device tip at a 45-degree angle distal to the proposed site. C. Place the patient's left arm in a dependent position for 5 minutes before assessment. D. Apply a tourniquet to the left antecubital fossa 8 to 12 inches above the proposed site.
ANSWER: Anchor the vein by placing a thumb 1 to 2 inches below the site. Rational: Anchoring the vein by placing a thumb 1 to 2 inches below the site stabilizes the vein, increasing the possibility of a successful insertion. The angle of insertion should be 10 to 30 degrees. Placing the patient's arm in a dependent position is directed toward improving visualization of the vein. Applying a tourniquet to the left antecubital fossa is directed toward improving visualization of the vein and should be applied 4 to 6 inches above the site.
Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with an intravenous (IV) site dressing? A. "Assess the IV site frequently for signs of inflammation." B. "Be sure not to obscure the insertion site with the dressing." C. "If the gauze dressing looks damp, replace it with a dry 4 × 4 gauze." D. "Be sure to notify me if the patient reports that the IV site is painful or swollen."
Answer: "Be sure to notify me if the patient reports that the IV site is painful or swollen." Rational: The task of reporting a patient's complaint may be delegated to NAP. Assessment may not be delegated to NAP. No aspect of insertion site care or dressing application may be delegated to NAP. The task of changing an IV dressing may not be delegated to NAP.
Which instruction would the nurse give to nursing assistive personnel (NAP) when caring for a patient who is receiving IV fluids? A."If the IV tubing gets disconnected, quickly reconnect it for me and let me know." B. "It's okay for you to turn off the pump alarm when it beeps." C. "Let me know when the IV bag is almost empty." D. "Please check the IV site for me, and let me know if it's tender."
Answer: "Let me know when the IV bag is almost empty." Rational: NAP can and should alert the nurse when the IV fluid bag is getting low. NAP may alert the nurse to disconnected tubing, but the nurse is responsible for changing it in case of contamination. The NAP should not reconnect it. NAP must notify the nurse when a pump alarm sounds. The nurse is responsible for coming in, silencing the alarm, and assessing the integrity and patency of the IV site. The task of assessing an IV site may be done only by the nurse.
While changing a patient's hospital gown, the extension set on the IV infusion becomes disconnected and ends up on the bed linens. What would the nurse do? A. Reconnect the extension set. B. Clean the end with an alcohol swab, and reconnect it. C. Pull the IV from the site, and insert a new catheter. D. Change the extension set tubing.
Answer: Change the extension set tubing. Rational: The nurse would change the contaminated extension set tubing. The extension set must not be reconnected. Cleaning the end of the tubing with alcohol is not an adequate precaution. The IV site need not be changed.
A patient is prescribed to receive an infusion of 20% fat emulsion. The nurse informs the patient that this infusion will last how long? A. 2 hours B. At least 4 hours C. No more than 6 hours D. At least 8 hours
Answer: At least 8 hours Rational: Twenty percent fats are infused over at least 8 hours.
Which instruction might the nurse give to nursing assistive personnel (NAP) caring for a patient receiving a fat emulsion? A. "Check the patient's IV site for any signs of phlebitis." B. "I will need to know the patient's vital signs every 4 hours." C. "Slow down the IV rate if the patient complains of pain at the insertion site." D. "Be sure the patient understands the reason that the infusion has been ordered."
Answer: "I will need to know the patient's vital signs every 4 hours." Rational: The task of measuring and reporting the patient's vital signs to the nurse every 4 hours is within the scope of practice for NAP. Patient assessment or evaluation may not be delegated to NAP. The skill of determining the infusion rate may not be delegated to NAP. Patient education may not be delegated to NAP.
Which statement might a nurse make to nursing assistive personnel (NAP) when caring for a patient prescribed an intravenous (IV) bolus of analgesic medication? A. "Assess the IV site frequently for signs of inflammation." B. "Let me know immediately if the patient complains of pain at the insertion site." C. "Make sure the patient knows what results to expect from the medication." D. "Observe the IV site for sudden swelling when the IV bolus is administered."
Answer: "Let me know immediately if the patient complains of pain at the insertion site." Rational: This is an instruction the nurse might give, because the task of reporting a patient complaint may be delegated to NAP. Patient assessment and education may not be delegated to NAP. No aspect of patient assessment or medication administration may be delegated to NAP.
Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a CVAD? A. "Assess the site frequently for signs of inflammation." B. "Be sure to change the transparent dressing on the site once every 7 days." C. "Let me know immediately if the patient's dressing becomes damp." D. "Make sure the patient knows to notify me if the site is painful or swollen."
Answer: "Let me know immediately if the patient's dressing becomes damp." Rational: The task of reporting the need for a dressing change may be delegated to NAP. Assessment of a CVAD may not be delegated to NAP. No aspect of insertion site care or dressing application may be delegated to NAP. Patient education may not be delegated to NAP.
Which statement might the nurse make to nursing assistive personnel (NAP) when caring for a patient with a dressed central venous access device (CVAD) site? A. "Assess the site frequently for signs of inflammation." B. "Be sure to change the transparent dressing on the site once every 7 days." C. "Let me know immediately if the patient's dressing becomes damp." D. "Make sure the patient knows to notify me if the site becomes painful or swollen."
Answer: "Let me know immediately if the patient's dressing becomes damp." Rational: The task of reporting the need for a dressing change may be delegated to NAP. No aspect of CVAD assessment or patient education may be delegated to NAP. No aspect of CVAD insertion or dressing application may be delegated to NAP.
The nurse is concerned that a confused patient's erratic movements may compromise the intravenous (IV) insertion site. Which action can the nurse take to protect the patient and the site from injury? A. Apply an IV site-protection device over the site, such as House UltraDressing. B. Apply restraints to the patient. C. Check the patient frequently. D. Instruct the patient to avoid dislodging the IV catheter.
Answer: Apply an IV site-protection device over the site, such as House UltraDressing. Rational: This type of site-protection device will help protect the patient and the site from injury. The use of restraints is controversial and would not be the nurse's first choice for protecting the integrity of an IV site. Checking the patient frequently is important but does not guarantee that the patient will not dislodge the IV catheter. The patient is confused and is unlikely to understand the nurse's instructions.
What will the nurse do to prevent possible complications after removing an IV access device in a patient on anticoagulant therapy? A. Instruct the patient to report immediately any sign of bleeding on the site dressing. B. Perform hand hygiene and wear clean gloves while removing the device. C. Encourage the patient to keep a cold compress on the site for 15 minutes. D. Apply firm pressure to the site with sterile gauze for 10 minutes.
Answer: Apply firm pressure to the site with sterile gauze for 10 minutes. Rational: Applying firm pressure will facilitate clotting. Maintaining pressure at the site for 5 to 10 minutes is recommended because the patient is receiving medication that prolongs the amount of time it takes for blood to clot. Instructing the patient to report immediately any sign of bleeding will not prevent complications after the device is removed. Performing hand hygiene and wearing clean gloves will not ensure the patient's safety after the device is removed. Applying a cold compress is not appropriate technique.
Which nursing action is most important to ensure patient safety when infusing a fat emulsion? A. Perform hand hygiene before initiating any contact with the lipid solution. B. Assess the patient every 10 minutes for 30 minutes after starting the infusion. C. Change the infusion tubing with each administration. D. Perform frequent inspection of the patient's access site.
Answer: Assess the patient every 10 minutes for 30 minutes after starting the infusion. Rational: Frequent assessment during the first 30 minutes allows the nurse to monitor the patient's tolerance of the infusion. This is the most important action the nurse can take to ensure patient safety when infusing a fat emulsion. Performing hand hygiene before handling the solution is not the most important action the nurse can take to ensure patient safety when infusing a fat emulsion. Changing the infusion tubing with each administration is not the most important action the nurse can take to ensure patient safety when infusing a fat emulsion. Performing frequent inspection of the patient's access site is not the most important action the nurse can take to ensure patient safety when infusing a fat emulsion.
If the nurse does not see blood return when aspirating the saline lock in preparation for an IV bolus medication, what is the next step? A. Attempt to aspirate the site again. B. Prepare to access another IV site. C. Assess the saline lock site for signs of phlebitis. D. Assess the site for swelling or coolness while flushing the saline lock with normal saline.
Answer: Assess the site for swelling or coolness while flushing the saline lock with normal saline. Rational: Blood return may be absent with a smaller-gauge catheter. Infusing normal saline while checking for infiltration ensures that the catheter tip is both patent and in the vein. There is little chance that a second attempt to aspirate will provide blood return. Finding a new site may not be necessary. Lack of blood return does not indicate phlebitis.
Which action will best minimize a patient's risk for infection while receiving central parenteral nutrition (CPN)? A.Infuse the CPN only with a filter in the line. B. Assess the patient frequently for signs and symptoms of infection. C. Change the CPN infusion tubing at least once every 24 hours. D. Frequently inspect the patient's central venous access site.
Answer: Change the CPN infusion tubing at least once every 24 hours. Rational: Changing the CPN infusion tubing at least once every 24 hours will minimize the patient's risk for infection. Using a filter prevents particulate matter or large droplets of lipid from reaching the patient, but it will not minimize the patient's risk for infection. Assessing the patient frequently for signs and symptoms of infection will not reduce the patient's risk for infection. Frequently inspecting the patient's central venous access site will not minimize the patient's risk for infection.
What is the most important way in which the nurse can reduce the risk for infection in a patient with a CVAD that has a gauze dressing? A. Change the dressing every 48 hours. B. Apply sterile gloves to remove the original dressing. C. Cleanse the catheter and insertion site with sterile saline. D. Label the dressing with the date and time of application and the nurse's initials.
Answer: Change the dressing every 48 hours. Rational: A gauze dressing on a CVAD should be changed every 48 hours and as needed. Doing so will reduce the patient's risk for infection. It is not necessary to wear sterile gloves to remove the soiled dressing. Cleansing the site with sterile saline will not minimize the patient's risk for infection. Labeling the dressing will not minimize the patient's risk for infection.
How would the nurse assess a patient's central venous access device (CVAD) for damage or breakage? A. Assess the patient's neck veins for distention. B. Palpate the patient's arm. C. Check the catheter for pinholes and tears. D. Palpate the area around the insertion site.
Answer: Check the catheter for pinholes and tears. Rational: To assess the CVAD for damage or breakage, the nurse would check the catheter every shift for pinholes, leaks, and tears. Assessing the neck veins for distention would not be an appropriate way to check the catheter for damage or breakage. Palpating the patient's arm would not be an appropriate way to check the catheter for damage or breakage. Palpating the area around the insertion site would not be an appropriate way to check the catheter for damage or breakage.
What would the nurse do to ensure the correct administration of gravity drip intravenous (IV) fluid after changing the tubing on a patient's primary infusion? A. Change the tubing with each new infusion bag. B. Wear clean treatment gloves when changing the tubing. C. Recheck the drip rate by counting the drops for 1 full minute. D. Assess the condition of the patient's insertion site for possible infiltration.
Answer: Recheck the drip rate by counting the drops for 1 full minute. Rational: Counting the drops will ensure that the fluid is being infused at the proper rate. It is unnecessary to change the tubing with each new bag unless it becomes contaminated. Wearing clean treatment gloves would not ensure proper administration of the IV fluid. It is appropriate to assess the insertion site, but doing so will not ensure the correct administration of IV fluid.
After drawing blood from a central venous access device (CVAD), which action would minimize the patient's risk for infection when reconnecting prescribed intravenous fluids? A. Wearing clean gloves B. Changing the IV tubing C. Cleansing the IV needleless connector and the end of the IV tubing with a 2% chlorhexidine swab D. Aspirating for blood return before flushing the catheter
Answer: Cleansing the IV needleless connector and the end of the IV tubing with a 2% chlorhexidine swab Rational: To reduce the patient's risk for infection, the nurse would cleanse the needleless connector and the end of the IV tubing with chlorhexidine swabs before reconnecting the fluids. Wearing clean gloves would not minimize the patient's risk for infection when reconnecting intravenous fluids. The IV tubing does not need to be changed. Doing so may or may not reduce the patient's risk for infection. Aspirating for blood return before flushing the catheter would have no effect on the patient's risk for infection.
After changing the intravenous (IV) tubing on a patient's primary infusion, the nurse notes air bubbles in the tubing. How would the nurse remove them? A. Begin the process again. B. Add more fluid to the drip chamber. C. Inject a syringe of saline into the tubing to vent the air bubbles. D. Close the clamp, stretch the tubing downward, and flick the tubing.
Answer: Close the clamp, stretch the tubing downward, and flick the tubing. Rational: To remove air bubbles from the tubing, the nurse would close the roller clamp, stretch the tubing downward, and flick the tubing, so that the air bubbles will rise into the drip chamber. The nurse need not repeat the entire process. Adding more fluid to the drip chamber will not remove the bubbles. The tubing should not be compromised by inserting a needle through it.
When preparing to infuse a bag of parenteral nutrition through a patient's central line, the nurse notices that the solution has coalesced. What is his or her best response? A. Warm the infusion in the microwave. B. Vigorously shake the bag. C. Contact the pharmacy for a new infusion bag. D. Increase the infusion rate on the pump.
Answer: Contact the pharmacy for a new infusion bag. Rational: A solution that has coalesced cannot be used. A replacement must be requested from the pharmacy. Parenteral infusions are not to be heated in the microwave. Shaking a bag of parenteral solution that has coalesced is not appropriate practice. Increasing the rate on the infusion pump is not an appropriate response, since the solution cannot be infused.
What might the nurse do to improve a patient's cooperation during the removal of an IV access device? A. Describe the entire procedure to the patient. B. Assure the patient that you will remove the IV catheter quickly. C. Assure the patient that the procedure will take only about 5 minutes. D. Tell the patient that the procedure will cause only a slight burning sensation.
Answer: Describe the entire procedure to the patient. Rational: Describing the entire procedure in advance will minimize fear and thus encourage the patient's cooperation. The patient is more likely to be cooperative if he or she understands the entire procedure. The IV device will be removed slowly and steadily. Discussing how long it will take is only one aspect of a complete description of the procedure. Telling the patient that the procedure will cause only a slight burning sensation is only one aspect of a complete description of the procedure.
Which patient safety issue is specific to administration of medication by IV bolus? A. Determining that the medication is compatible with the IV solution B. Checking for patient allergies before giving the medication C. Identifying the patient using two identifiers D. Checking the medication against the medication administration record (MAR) three times
Answer: Determining that the medication is compatible with the IV solution Rational: Medication that is incompatible with the running IV solution could form a precipitate and endanger the patient's health. The necessity of checking for patient allergies is applicable to all routes of medication administration. The necessity of properly identifying the patient before administering a medication is applicable to all routes of administration. The necessity of checking the medication against the MAR three times is applicable to all routes of medication administration.
Which action can the nurse take to ensure a quality blood sample when drawing blood from a patient's central venous access device (CVAD) site? A. Allow fluid infusions to continue to flow right up to the time of the sample. B. Flush the catheter after aspirating for blood return. C. Ensure that the patient has been resting quietly for at least 15 minutes before taking the sample. D. Discard the first 4 to 5 mL of blood drawn.
Answer: Discard the first 4 to 5 mL of blood drawn. Rational: Discarding the first sample reduces the risk of drug concentrations or a diluted specimen. Allowing fluid infusions to continue to flow right up to the time of the sample could alter the sample. Flushing the catheter after aspirating for blood return would have no effect on the quality of the sample. The patient need not be asked to rest before the sample is taken.
Which action would the nurse take if an intravenous (IV) insertion site appeared red, warm, and swollen? A. Assess for blood return. B. Discontinue the infusion. C. Change the existing dressing. D. Secure the tubing with more tape.
Answer: Discontinue the infusion. Rational: An IV site that is red, warm, and swollen suggests phlebitis or infection and the IV catheter must be removed to prevent further damage to the patient's arm. Assessing for blood return would not improve the condition of the IV insertion site. Changing the existing dressing would not improve the condition of the IV insertion site. Securing the tubing would not improve the condition of the IV insertion site.
How can the nurse best minimize the patient's risk for infection when administering an IV bolus of an analgesic? A. Use the injection port closest to the patient. B. Assess the IV insertion site for signs of infiltration. C. Follow aseptic technique during the entire process. D. Instruct the patient to report any adverse medication reactions.
Answer: Follow aseptic technique during the entire process. Rational: Using aseptic technique minimizes the patient's risk for infection. Although the nurse should use the closest injection port, aseptic technique is critical to reducing the risk for infection. It is important to assess the insertion site for infiltration, but aseptic technique is the principal way to prevent infection when administering an IV bolus. Patients should be instructed to report adverse reactions, but doing so will not reduce the risk for infection.
A patient's central parenteral nutrition (CPN) order has been changed to a different solution, and the present solution is to be discontinued immediately. What should the nurse do until the new solution is delivered by the pharmacy? A. Discontinue the present CPN solution, and clamp the catheter hub. B. Continue the present CPN solution, but readjust the flow to a keep-vein-open (KVO) rate. C. Hang an infusion of 0.9% normal saline at the same infusion rate as the CPN. D. Hang an infusion of 10% dextrose in water at the same infusion rate as the CPN.
Answer: Hang an infusion of 10% dextrose in water at the same infusion rate as the CPN. Rational: If CPN must be discontinued suddenly, a solution of 10% dextrose in water can be given at the same infusion rate in order to prevent hypoglycemia. Discontinuing the present CPN solution could cause the patient to develop hypoglycemia. Continuing the present CPN solution at a KVO rate could cause the patient to develop hypoglycemia. Normal saline will not prevent the patient from developing hypoglycemia.
A patient for whom an intravenous antibiotic is prescribed has a multilumen central line in place for central parenteral nutrition (CPN). What should the nurse do? A. Infuse the antibiotic through another lumen of the multilumen central line. B. Interrupt the CPN infusion only long enough to administer the antibiotic. C. Rearrange the antibiotic administration schedule so it does not interfere with the CPN. D. Ask the prescriber if the route of administration for the antibiotic can be changed.
Answer: Infuse the antibiotic through another lumen of the multilumen central line. Rational: IV medications and blood should be infused through a different line or lumen than CPN. The parenteral nutrition must not be interrupted for medication administration. Intravenous medications are to be infused through an alternative line or lumen, not through the same lumen or port being used for parenteral nutrition. It would be inappropriate for the nurse to ask the prescriber to change the route of administration for the antibiotic. Another lumen can be used, or another line can be placed for intravenous medication administration.
What is the most important action the nurse can take to protect the patient when administering a narcotic analgesic by IV bolus? A. Injecting the medication at the prescribed rate B. Observing the insertion site after giving the medication C. Instructing the patient about side effects to report to the nurse D. Using an alcohol swab to wipe the insertion port on the primary tubing
Answer: Injecting the medication at the prescribed rate Rational: Injecting the medication at the prescribed rate is the most important action the nurse can take to protect the patient when administering a narcotic analgesic by IV bolus, since injecting the medication faster than recommended may result in injury or death. Although observing the insertion site after giving the medication is appropriate, injecting the medication at the recommended rate is of greater concern. Although it is important for the patient to understand potential side effects, injecting the medication at the recommended rate is of greater concern. Use of an alcohol swab is important, but it is not the first priority in keeping a patient safe during IV bolus administration. Injecting the medication at the recommended rate is of greater concern.
How might the nurse prepare a patient to anticipate some discomfort when inserting a venous access device? A. Insert the access device as quickly as possible B. Instruct the patient to expect a sharp, quick stick C. Apply a topical anesthetic to the area before inserting the device D. Promise that the procedure will not hurt once the device has been inserted.
Answer: Instruct the patient to expect a sharp, quick stick. Rational: Educating the patient to have reasonable expectations about the possible discomfort will best prepare him or her for it. Inserting the access device as quickly as possible will not prepare the patient regarding what to expect. Applying a topical anesthetic will reduce the likelihood of pain; however, this is not routinely done when inserting a venous access device. It is inappropriate to make such a promise.
Which action will best minimize the patient's risk for vein injury when removing an IV access device from a patient's arm? A. Keep the hub parallel to the skin. B. Cleanse the site with an antibacterial swab. C. Cut the dressing to facilitate its removal. D. Turn the IV tubing roller clamp to the "off" position.
Answer: Keep the hub parallel to the skin. Rational: Keeping the hub parallel to the skin minimizes vein trauma during removal of the device. Cleansing the site with an antibacterial swab is not part of the procedure for removing an IV access device. Cutting the dressing may damage the device. Turning the infusion off prevents fluid from flowing through the catheter as it is removed. It does not, however, protect the patient from vein injury.
The nurse is inserting an over-the-needle catheter into a newly admitted patient. What will the nurse do after confirming blood return? A. Loosen or remove the tourniquet. B. Advance the catheter 1 inch into the vein. C. Lower the catheter until it is flush with the skin. D. Thread the catheter into the vein up to the hub.
Answer: Lower the catheter until it is flush with the skin. Rational: Lowering the catheter until it is flush with the skin minimizes the risk of passing the needle through the opposite vessel wall. The tourniquet is loosened or removed later in the procedure. This is done later in the procedure. Threading the catheter into the vein up to the hub is done later in the procedure.
The nurse is concerned that a patient's central venous access device (CVAD) may have become dislodged. How might the nurse assess for this complication? A. Check for blood return. B. Palpate the skin for coiling. C. Listen for gurgling sounds. D. Assess for pain at the site.
Answer: Palpate the skin for coiling Rational: The nurse would check for coiling, which can occur if the CVAD becomes dislodged. Blood return is checked to assess for an occlusion. Gurgling sounds could indicate catheter migration or pinch-off syndrome. Catheter dislodgement is not associated with pain at the insertion site.
When caring for a patient who has a CVAD, which sign may indicate infection at the insertion site? A. Occlusion alarm sounds on infusion pump B. Patient's oral temperature gradually increases C. Patient's neck veins become distended D. The nurse cannot achieve blood return
Answer: Patient's oral temperature gradually increases Rational: A progressive elevation in the patient's temperature may indicate an infection. The sounding of an occlusion alarm is more likely an indication of an occlusion. Neck vein distention is more likely an indication of catheter migration. Inability to achieve blood return is more likely an indication of an occlusion.
How can the nurse minimize the risk of dislodging the catheter when removing a dressing? A. Lower the patient's head during the dressing change. B. Remove the transparent dressing or tape and gauze in the direction of catheter insertion. C. Apply skin protectant while the stabilization device is off. D. Cleanse the insertion site quickly and gently in concentric circles.
Answer: Remove the transparent dressing or tape and gauze in the direction of catheter insertion. Rational: The old dressing should be removed in the direction of catheter insertion. Positioning the patient with his or her head lower will not reduce the risk of dislodging the catheter during a dressing change. Skin protectant should be applied before placing a new catheter stabilization device. However, doing so will not reduce the risk of dislodging the catheter. The site should be cleansed using a back-and-forth motion vertically and horizontally for at least 30 seconds. However, following this technique will not reduce the risk of dislodging the catheter.
How can the nurse ensure that a patient's IV tubing will not tug on the infusion catheter after a transparent dressing is applied to an infusion site on the arm? A. Encircle the arm with tape. B. Secure the tubing and catheter hub with tape. C. Secure the tubing in two different locations on the arm. D. Label the dressing with the date and time of application.
Answer: Secure the tubing in two different locations on the arm. Rational: Securing the tubing in two different locations will prevent it from tugging on the infusion catheter. The arm should not be encircled with tape, because doing so may compromise circulation. Securing the tubing and catheter hub with tape is inappropriate and makes it difficult to change the tubing as needed. Labeling the dressing will not prevent the IV tubing from tugging on the infusion catheter.
While palpating the skin around a patient's CVAD insertion site, the nurse elicits a crackling sound. What might this finding indicate? A. Catheter occlusion B. Infection C. Skin erosion D. Subcutaneous emphysema
Answer: Subcutaneous emphysema Rational: A crackling sound or sensation probably indicates subcutaneous emphysema as a manifestation of pneumothorax, hemothorax, air embolism, or hydrothorax. A crackling or popping sound does not indicate catheter occlusion and is not associated with infection or with skin erosion.
When drawing blood from a central venous access device (CVAD) in which all ports are patent, it is recommended that the nurse select which lumen? A. The shortest B. The longest C. The proximal port D. The distal port
Answer: The distal port Rational: When drawing blood through a multilumen catheter, the distal lumen is preferred unless the manufacturer has indicated otherwise. This may or may not be the shortest catheter and this may or may not be the longest catheter.
When drawing blood from a patient's central venous access device (CVAD), what can the nurse do to minimize pressure on the device during flushing? A. Clamp the device. B. Use a 3-mL syringe for the flush. C. Use a 10-mL syringe for the flush. D. Cleanse the catheter hub with an alcohol swab.
Answer: Use a 10-mL syringe for the flush Rational: A 10-mL syringe would be used during the flush to minimize pressure on the device. Clamping the device would hinder the nurse's ability to flush the catheter. A 3-mL syringe would not reduce pressure on the device during the flush. Cleansing the catheter hub with alcohol will not affect the amount of pressure being placed on the device.
How will the nurse minimize the risk for infection when changing a patient's IV catheter site dressing? A. Use aseptic technique throughout the process. B. Pull the tape toward the insertion site. C. Remove both the gauze dressing and the tape one layer at a time. D. Explain the process to the patient.
Answer: Use aseptic technique throughout the process. Rational: Following aseptic technique will reduce the patient's risk for infection. Pulling the tape toward the insertion site would not minimize the patient's risk for infection. Removing the gauze one layer at a time would not minimize the patient's risk for infection. Explaining the process of changing the dressing would not minimize the patient's risk for infection.
Which action would the nurse take to minimize the patient's risk for infection when changing the dressing on a CVAD? A. Use sterile technique throughout the process. B. Apply a stabilization device if the initial sutures are no longer intact. C. Apply a mask to the patient during the procedure. D. Change the transparent dressing every 48 hours.
Answer: Use sterile technique throughout the process. Rational: Using sterile technique throughout the dressing application will minimize the patient's risk for infection. Applying a stabilization device will not reduce the patient's risk for infection. A mask need not be applied to the patient when changing a CVAD. Transparent dressings are changed every 5 to 7 days and as needed.
Which action can the nurse take to minimize the patient's risk for infection when applying new tubing to a primary IV infusion? A. Using aseptic technique throughout the process B. Changing the tubing each shift C. Changing the tubing at the same time a new primary fluid bag is hung when possible D. Using aseptic technique and changing the tubing at the same time a new primary fluid bag is hung are both appropriate to minimize the patient's risk for infection
Answer: Using aseptic technique and changing the tubing at the same time a new primary fluid bag is hung are both appropriate to minimize the patient's risk for infection Rational: Both selections A and C are appropriate to minimize the patient's risk for infection. Following aseptic technique throughout the tubing change will minimize the patient's risk for infection. However, this action alone is not the best response. It is unnecessary to change the tubing every shift. Changing the tubing at the same time a new primary fluid bag is hung reduces the number of times the closed IV system is accessed, thereby reducing the patient's risk for infection. However, this action alone is not the best response.
Which nursing action will best ensure the safety of a patient who is about to receive an infusion of parenteral nutrition? A. Assess the patient's blood glucose level by fingerstick. B. Verify the physician's order for central parenteral nutrition (CPN) and the flow rate. C. Confirm that the CPN infusion pump's alarm system is functioning properly. D. Instruct the patient concerning the purpose for administering the CPN solution.
Answer: Verify the physician's order for central parenteral nutrition (CPN) and the flow rate. Rational: Verifying the physician's order for CPN and the flow rate will help ensure that the right solution is administered to the right patient at the right rate. Assessing the patient's blood glucose level is not the best action to ensure patient safety. Confirming that the CPN infusion pump's alarm system is functioning properly is not the best action to ensure patient safety. Providing patient education before starting the infusion is appropriate but will not ensure patient safety.
What would the nurse do to assess a patient's risk for embolus when removing a venous access device? A. Inspect the site for redness. B. Visualize the tip of the IV device. C. Palpate the site for possible edema. D. Ask the patient to rate any pain at the site
Answer: Visualize the tip of the IV device. Rational: Damage to the tip of the device, resulting in a portion of the device remaining in the vessel, may cause an embolus to form. Inspecting the site for redness would identify phlebitis or infection, but doing so would not help assess the patient's risk for embolus. Palpating the site for possible edema would identify infiltration, but doing so would not help assess the patient's risk for embolus. Asking the patient to rate his or her pain would not help assess the patient's risk for embolus.
After drawing blood from a patient's central venous access device (CVAD), what would the nurse do to ensure that the device resumes proper functioning? A. Discard the initial 5 mL of aspirated blood. B. Apply an antiseptic to the injection cap. C. Wear clean treatment gloves during the procedure. D. Flush the catheter with preservative-free 0.9% sodium chloride, per agency policy.
Answer: lush the catheter with preservative-free 0.9% sodium chloride, per agency policy. Rational: Flushing the catheter with preservative-free 0.9% sodium chloride minimizes the risk of clot formation at the catheter tip and ensures continued proper functioning of the device. Discarding the initial 5 mL of aspirated blood would have no effect on the function of the device. Applying an antiseptic to the injection cap would have no effect on the function of the device. Wearing clean treatment gloves would have no effect on the function of the device.
Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with an intravenous access device? A. "Assess the IV site frequently for signs of inflammation." B. "Be sure not to obscure the insertion site with the dressing." C. "Let me know when you notice that the IV bag contains less than 100 milliliters." D. "Explain the symptoms of infection to the patient."
Answer:"Let me know when you notice that the IV bag contains less than 100 milliliters." Rational: The task of reporting when the level of fluid in the IV bag is low may be delegated to NAP. Assessment skills may not be delegated to NAP. The skill of IV dressing application may not be delegated to NAP. Patient education may not be delegated to NAP.
