Chapter 18: Intravenous Therapy

2. As part of a written standard protocol for the unit, a nurse adds that irrigation of an occluded cannula is not recommended. What is the rationale against performing this procedure? a. It may damage a venous valve. b. It may introduce an air embolus into the line. c. It may cause the patient pain. d. It may force blood clots into the main bloodstream.

ANS: D A cannula may be occluded because a clot has formed against the end of the shaft. By irrigating it, the clot is forced into the bloodstream. DIF: Cognitive Level: Comprehension REF: p. 298 OBJ: 5 TOP: Occluded Cannula KEY: Nursing Process Step: Implementation

21. A patient with a subclavian line complains of shortness of breath after an infusion. The patient is diaphoretic, and the blood pressure is 168/100 mm Hg, higher than a previous reading of 140/86 mm Hg. What should the nurse assess these symptoms as indicating? a. Fluid overload from too rapid an infusion b. Incorrect dilution of the infused drug c. Infection from faulty aseptic technique d. Embolus from introduced air or blood clot

ANS: D Air can be introduced into the subclavian line from any of the ports that are left unclamped. The symptoms have occurred too quickly for an overload or infection. DIF: Cognitive Level: Analysis REF: p. 298 OBJ: 6 TOP: Embolus KEY: Nursing Process Step: Assessment

12. A nurse has a patient with a tunneled central line with a triple-lumen catheter. The insertion site is covered by an occlusive dressing with yesterday's date. The nurse is to give an intravenous drug through the central line. What should be the initial action of the nurse? a. Use any of the three ports for delivery. b. Change the occlusive dressing. c. Affirm catheter placement by withdrawing 10 mL of blood. d. Check dilution of the drug.

ANS: D Checking the drug for the proper dilution is essential. The dressing is not due to be changed. Drawing 10 mL of blood for site placement is excessive. Only two of the ports, which are color coded, are to be used for drug, fluid, or blood administration. DIF: Cognitive Level: Application REF: p. 298 OBJ: 3 TOP: IV Medication through Central Line KEY: Nursing Process Step: Implementation

7. A physician prescribes a hypertonic intravenous line for an extremely edematous patient. What solution should the nurse anticipate to be prescribed? a. D5W in NS b. Lactated Ringer solution c. D5W in 0.25 NS d. 10% glucose in water

ANS: D D5W in 0.25 NS is hypotonic. D5W in NA and lactated Ringer solution is isotonic; 10% glucose is hypertonic. DIF: Cognitive Level: Comprehension REF: p. 288 OBJ: 2 TOP: IV Tonicity KEY: Nursing Process Step: Planning

18. Where should a nurse inject medication when administering an intravenous (IV) push medication to a patient who is receiving a continuous infusion? a. Into the hanging IV bag b. Directly into the insertion cannula after temporarily disconnecting the IV bag c. Into the port nearest to the insertion site to ensure quick delivery d. Into the port nearest to the IV bag for less painful administration

ANS: C An IV push is to be administered through the port closest to the patient. DIF: Cognitive Level: Knowledge REF: p. 291 OBJ: 6 TOP: IV Push KEY: Nursing Process Step: Implementation

16. An older adult patient is assessed by a nurse as showing signs of fluid volume excess. What signs should the nurse assess? a. Redness, warmth, and drainage of fluid at the IV site b. Redness, warmth, and tenderness at the IV site c. Complaints of shortness of breath and pounding pulse d. Puffiness of face, dyspnea, and pain at the IV site

ANS: C Fluid volume excess in the circulating volume can overload the heart's ability to handle the excess blood. The excess fluid can leak into the pulmonary tree, causing shortness of breath and rales. DIF: Cognitive Level: Comprehension REF: p. 295 OBJ: 5 TOP: Fluid Volume Excess KEY: Nursing Process Step: Assessment

4. How often should intravenous (IV) rounds be performed during a nursing shift? a. Every 15 minutes b. Every 30 minutes c. Every 60 minutes d. Twice per shift

ANS: C IV checks every hour, made by a nurse, ensure maintenance of a proper rate, infusion condition, and complication detection. DIF: Cognitive Level: Application REF: p. 293 OBJ: 6 TOP: Time Checks for IV Infusions KEY: Nursing Process Step: Implementation

27. A nurse explains to a patient that the peripheral intravenous (IV) tubing administration set and dressing should be changed every _____ hours.

ANS: 72 To prevent infection, the IV tubing administration set and dressing should be changed every 72 hours. DIF: Cognitive Level: Knowledge REF: p. 294 OBJ: 6 TOP: IV Administration Sets Change KEY: Nursing Process Step: Implementation

29. What actions should a nurse implement when assessing a peripheral intravenous (IV) line for an infiltration? (Separate the letters with a comma and space: A, B, C, D.) A. Elevate the arm. B. Apply warm compresses to the area. C. Restart the infusion at a different site. D. Stop the infusion. E. Notify the charge nurse.

ANS: D, C, A, B, E The infusion must be stopped to reduce the risk of further infiltration and then restarted to ensure that the adequate dose is received. The affected arm is elevated, warm compresses are applied, and the charge nurse is notified. DIF: Cognitive Level: Application REF: p. 297 OBJ: 5 | 6 TOP: Infiltration KEY: Nursing Process Step: Implementation

28. What steps should a nurse take when administering an intravenous (IV) push drug through a peripheral intermittent device? (Separate the letters with a comma and space: A, B, C, D.) A. Clear the device with NS. B. Flush the device with NS only or a combination of NS and heparin. C. Check placement of the device. D. Slowly administer the drug through the device. E. Check the concentration of the drug.

ANS: E, C, A, D, B IV push medication requires careful checking of the appropriate dilution, checking the placement of the device, flushing the device with NS to clear it, slowly injecting the drug, and flushing the device with NS or a combination of NS and heparin. DIF: Cognitive Level: Application REF: p. 291 OBJ: 3 | 6 TOP: Peripheral Intermittent Device KEY: Nursing Process Step: Implementation

19. An intravenous (IV) administration of doxycycline (Vibramycin) has extravasated. What nursing action should be implemented after stopping the IV line? a. Notify the physician, and restart the IV line in another site. b. Restart the IV line at another site and document the extravasation. c. Flush NS through cannula at the insertion site. d. Discard the IV tubing and the IV bag.

ANS: A Because doxycycline is a vesicant, the physician should be notified. The IV line should be restarted to maintain the drug at a therapeutic level. DIF: Cognitive Level: Application REF: p. 297 OBJ: 7 TOP: Extravagation KEY: Nursing Process Step: Implementation

23. An older adult patient is quite ill and confused and begins to cry pitifully when a nurse approaches the bed to start an intravenous (IV) line. What is the best action for the nurse at this time? a. Keep the infusion equipment out of sight as much as possible, talk slowly, and divert the attention of the patient. b. Inform the patient that the physician has ordered the IV and calmly continue to prepare the site and start the IV. c. Give an analgesic as ordered, wait a few minutes, and then proceed. d. Restrain the patient's arm to a padded armboard and proceed as directed.

ANS: A Confusion during a bout of illness in older adults is common. Distraction and reassurance usually gain compliance. Medication and restraints are not indicated. DIF: Cognitive Level: Application REF: p. 295 OBJ: 6 TOP: IVs and Older Adult Patients KEY: Nursing Process Step: Implementation

9. What signs of infiltration should be assessed by a nurse? a. Burning sensation, pain, and puffy b. Pain, heat, and puffy c. Burning sensation and no feeling at the site d. Red streak up the arm

ANS: A Intravenous fluid in the immediate tissues causes pain and swelling of the adjacent tissues. DIF: Cognitive Level: Knowledge REF: p. 297 OBJ: 5 TOP: IV Infiltration KEY: Nursing Process Step: Assessment

22. A patient has had an air embolus. What should be the immediate action of the quick-thinking nurse? a. Turns the patient to the left side and lowers the head of the bed b. Calls the "code team" c. Gives oxygen at 100% in a nonrebreathing mask d. Notifies the charge nurse

ANS: A Lowering the head of the bed and turning the patient to the left side traps the air in the left atrium, where it can be more readily reabsorbed. DIF: Cognitive Level: Application REF: p. 298 OBJ: 6 TOP: Air Embolus KEY: Nursing Process Step: Implementation

3. What is a major advantage when medication is administered intravenously? a. Better maintained at a therapeutic blood level b. Less expensive than oral route c. Safer than administering by oral or intramuscular route d. Lower incidence of allergy than other routes

ANS: A Patients who receive intravenous medications can be better ensured of a more constant therapeutic blood level. DIF: Cognitive Level: Comprehension REF: p. 287 OBJ: 5 TOP: IV Care Plan KEY: Nursing Process Step: Implementation

10. A physician orders an infusion of 1000 mL of 5% dextrose in 0.45% NS to be completed in 8 hours. The IV delivery system's drop factor is 20 gtt. How many mL/hr should the nurse set the electronic infusion pump to deliver the infusion? a. 125 mL/hr b. 100 mL/hr c. 85 mL/hr d. 42 mL/hr

ANS: A Whole volume (1000 mL) divided by number of hours (8) = 125 mL/hr. Volume per hour (125 mL) 8 hr = 1000 mL. DIF: Cognitive Level: Analysis REF: p. 293-294 OBJ: 4 TOP: IV Calculations KEY: Nursing Process Step: Implementation

26. A nurse explains to a patient that, in the event of an accidental needle stick, the nurse should adhere to hospital policy. What directives should the nurse follow? (Select all that apply.) a. Antibiotics are taken if infection is present. b. Blood is drawn from both the nurse and the patient. c. Repeat blood draws are performed 4 weeks after the stick. d. Obtain the physician's permission to return to work. e. An incident report is initiated.

ANS: A, B, E Most policies follow the general guidelines of making an incident report in case of time lost from the injury, drawing blood from both the nurse and the patient to determine whether an infection might be present and what type it is, and giving the antibiotic protocol to the nurse in the event of an infection in the patient. As a rule, permission from a physician to return to duty or a blood draw in 4 weeks is not necessary. DIF: Cognitive Level: Comprehension REF: p. 294 OBJ: 6 TOP: Needle Stick KEY: Nursing Process Step: Implementation

6. Using an IV infusion system that delivers 60 drops/mL, a nurse hangs a 500-mL bag of normal saline (NS) at 0800. The physician has ordered a rate of 20 mL/hr. What should the nurse set the roller clamp to deliver? a. 10 gtt/min b. 20 gtt/min c. 25 gtt/min d. 30 gtt/min

ANS: B 20 mL (amount to be infused in 1 hr) 60 gtt = 1200 gtt/hr. 1200 gtt 60 min in 1 hr = 20 gtt/min. This roller clamp is an old method to determine rates, but in the case of a nonavailability of electronic delivery devices, it is a good thing to know. DIF: Cognitive Level: Analysis REF: p. 293-294 OBJ: 4 TOP: IV Calculations KEY: Nursing Process Step: Implementation

8. What is the source of calories in IV solutions? a. Electrolytes b. Dextrose c. Vitamins d. Water

ANS: B Dextrose is sugar and the source of calories. DIF: Cognitive Level: Comprehension REF: p. 288 OBJ: 2 TOP: Calories in IVs KEY: Nursing Process Step: Implementation

1. In an assessment of a patient who has been receiving intravenous (IV) fluids for the past 6 hours, a nurse finds that the pulse is now bounding, the blood pressure is more than 15 mm Hg higher than the last reading, and pedal edema has developed. What should the nurse suspect? a. Infiltration of the IV site b. Vascular fluid volume excess c. Pulmonary air embolism d. Phlebitis of the leg veins

ANS: B Excess fluid volume accounts for the changes in the vital signs. DIF: Cognitive Level: Comprehension REF: p. 298 OBJ: 5 TOP: Increased Vascular Fluid Volume KEY: Nursing Process Step: Assessment

11. A nurse assesses an area where an intravenous (IV) line had been recently removed. The area has redness, swelling, and warmth. What should the nurse suspect as the cause? a. Infiltration and air embolus b. Inflammation and possible phlebitis c. Blood loss and hemorrhage d. Embolus from the former catheter

ANS: B IV sites may show signs of inflammation or infection or both after an IV line has been removed. DIF: Cognitive Level: Comprehension REF: p. 297 OBJ: 5 TOP: Infection and Inflammation in Previous IV Site KEY: Nursing Process Step: Assessment

25. Which order should be clarified by a nurse when transcribing orders? a. Potassium chloride, 80 mEq in 1000 mL D5W in 24 hours b. Potassium chloride, 40 mEq IV in 10 mL D5W IV push c. Potassium chloride, 50 mEq in 500 mL D5W in 4 hours d. Potassium chloride, 80 mEq in 1000 mL D5W in 12 hours

ANS: B Potassium chloride is never given by intravenous push in such a small amount of diluent. Potassium chloride is always dissolved in D5W and should be infused at no more than 10 mEq/hr. DIF: Cognitive Level: Analysis REF: p. 297 OBJ: 6 TOP: IV Potassium KEY: Nursing Process Step: Implementation

15. What instruction should a nurse provide to a patient when removing a central catheter? a. Lean forward and cough. b. Take a deep breath and bear down. c. Breathe deeply through the mouth. d. Lie on the right side.

ANS: B The patient is instructed to take a breath and bear down to prevent air from entering the bloodstream as the catheter is removed. DIF: Cognitive Level: Comprehension REF: p. 298 OBJ: 6 TOP: Removal of Central Line KEY: Nursing Process Step: Implementation

24. What action should the nurse implement when discontinuing an intravenous (IV) line? a. Remove the dressing, remove the catheter, dispose of the used equipment in the sharps container, and chart observations and actions. b. Observe the site for redness, swelling, and pain, and put on sterile gloves. Remove the dressing catheter and chart the findings and action. c. Observe the site for redness, swelling, and pain, and put on clean gloves. Remove the dressing and catheter, place a 2 2 dressing over the site, and chart the findings and action. d. Observe the site for redness, swelling, and pain and put on clean gloves. Remove the dressing and catheter; chart the findings and action.

ANS: C This procedure is not sterile. Clean gloves protect the nurse from the body fluids. Placement of a small 2 2 dressing keeps the area clean until the insertion site closes. DIF: Cognitive Level: Application REF: p. 294 OBJ: 6 TOP: Discontinuing an IV KEY: Nursing Process Step: Implementation

17. Where is the best place to begin to select a vein for an initial intravenous (IV) site in a left-handed patient? a. Antecubital vein of the right arm b. Antecubital vein of the left arm c. Right forearm d. Left forearm

ANS: C Unless other reasons are identified, IV sites should be started in the most distal portion of the nondominant arm or hand. DIF: Cognitive Level: Knowledge REF: p. 291-292 OBJ: 6 TOP: Beginning an IV KEY: Nursing Process Step: Implementation

5. Using an intravenous (IV) infusion system that delivers 60 drops/L, a nurse hangs a 1000-mL bag of 5% dextrose in water (D5W), which the physician has ordered to infuse at 80 mL/hr. It is now 1000. What time should the nurse anticipate the IV will need to be changed? a. 1800 b. 2000 c. 2030 d. 2230

ANS: D 1000 mL (whole volume) 80 mL (volume infused per hour) = 12.5 hours. 1000 + 12.5 hours = 2230. Military times should be used. DIF: Cognitive Level: Analysis REF: p. 293-294 OBJ: 6 TOP: IV Rate and Times KEY: Nursing Process Step: Planning

20. A patient is to receive ampicillin (Unasyn) IV piggyback in 100 mL of fluid every 8 hours. The main intravenous (IV) line of D5W is running at 80 mL/hr and is on time. A nurse's responsibility is to calculate the total 24-hour intake. At the end of the 24-hour shift, how much IV intake should the nurse document that the patient has received? a. 300 mL b. 800 mL c. 1920 mL d. 2220 mL

ANS: D 80 mL/hr 24 hr = 1920 mL; 100 mL 3 = 300 mL. Therefore, 1920 mL + 300 mL = 2220 mL in 24 hours. DIF: Cognitive Level: Analysis REF: p. 293-294 OBJ: 4 | 6 TOP: IV Calculation for 24 Hours KEY: Nursing Process Step: Implementation

14. A nurse assesses for signs of infected phlebitis. How should the nurse most accurately describe this complication when documenting? a. Rupture of the cannula with a lump under the skin b. Pale, cool skin with swelling at the puncture site c. Firm, cool, raised, painful area at the puncture site; oozing and purulent drainage d. Puncture site red, warm, with an oozing drainage

ANS: D Infection causes redness, warmth, and drainage from the intravenous site. Red streaks following the path of the vein may be visible. DIF: Cognitive Level: Comprehension REF: p. 297 OBJ: 5 TOP: Phlebitis Signs KEY: Nursing Process Step: Evaluation

13. A nurse is choosing an intravenous cannula for an older adult patient and will choose the smallest size that will deliver the appropriate fluid. What size cannula is the most appropriate choice? a. 12 gauge b. 14 gauge c. 18 gauge d. 22 gauge

ANS: D The inside diameter, called the gauge, is expressed in reverse numerical order. DIF: Cognitive Level: Comprehension REF: p. 288 OBJ: 6 TOP: IV Needle Sizes KEY: Nursing Process Step: Planning