Chapter 29: Intravenous and Vascular Access Therapy Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition

The nurse is assisting the physician during the insertion of a central line into the subclavian vein. How should the nurse cleanse the area? A. With chlorhexidine in a back and forth scrubbing motion B. With chlorhexidine followed by alcohol in a back and forth scrubbing motion C. With alcohol in a circular motion for 5 minutes D. With antimicrobial solution that must be dabbed dry with a sterile towel

ANS: A Antiseptics such as chlorhexidine remove resident and transient bacteria. Alcohol should not be applied after the application of iodophor solution. Chlorhexidine is scrubbed in a back and forth motion for 30 seconds. Allow the antimicrobial solution to air-dry completely. This ensures maximum antimicrobial effect.

The order is for the patient to receive 500 mL over 4 hours. the nurse has an electronic infusion device (EID) in place that provides for the regulation of hourly infusion. the intravenous (IV) tubing available is 10 gtt/mL. What is the setting for the infusion device? A. 125 mL/hr B. 500 mL/hr C. 21 gtt/min D. 32 gtt/min

ANS: A For use of electronic infusion device (EID) for infusion, turn on the power button, select the required drops per minute or volume per hour, close the door to the control chamber, and press the start button. In this case, 500 mL/4 hr = 125 mL/hr.

What is an appropriate technique for the nurse to implement when changing the dressing at a peripheral intravenous (IV) catheter site? A. Wear sterile gloves to remove the old dressing. B. Keep one finger over the IV catheter until the tape is replaced. C. Cleanse with an antiseptic solution in a circular manner toward the site. D. Tape the connection between the IV catheter port and the tubing.

ANS: B Always keep one finger over catheter until dressing secures catheter hub. If patient is restless or uncooperative, it is helpful to have another staff member help with procedure.

While assessing the patient, the nurse recognizes that special caution should be taken with the intravenous (IV) infusion because of fluid volume excess when the nurse notes the presence of which condition? A. Poor skin turgor B. Crackles in thelungs C. Decreased blood pressure D. Dry skin and mucous membranes

ANS: B Auscultation of crackles or rhonchi in the lungs may signal fluid buildup in the lungs caused by fluid volume excess. Poor skin turgor is common with fluid volume deficit. the pinched skin stays elevated for several seconds (tenting). This may be an indication of the need for IV therapy. Decreased blood pressure may indicate fluid volume deficit caused by a decrease in stroke volume. This may indicate the need for intravenous (IV) therapy. Dry skin and mucous membranes may indicate dehydration.

Which of the following patients would the nurse anticipate requiring the placement of a central venous catheter? A. A patient in same-day surgery who might require blood transfusions B. A patient in the intensive care unit requiring multiple simultaneous intravenous medications C. A patient in the cardiac care unit diagnosed with possible myocardial infarction D. A patient on the surgical unit recovering from hernia repair

ANS: B CVADs have single or multiple lumens. the choice of the number of lumens depends on a patient's condition and prescribed therapy. Patients requiring numerous infusions and blood samplings may have a device placed with more than one lumen, allowing simultaneous administration of solutions and medications. In addition, multiple lumens allow for administration of incompatible solutions or medications at the same time. You access a CVAD through thehub of the device located on the end of each external lumen.

What should be the next action by the nurse once an over-the-needle catheter (ONC) has been inserted through the skin and into the vein? A. Loosen the stylet for removal. B. Check for blood return in the flashback chamber. C. Stabilize the catheter and release the tourniquet. D. Advance the catheter until the hub rests at the insertion site.

ANS: B Observe for blood return in catheter or flashback chamber of catheter, indicating that bevel of needle has entered vein (see illustration. Advance VAD approximately 1/4 inch (0.6 cm) into vein and loosen stylet (needle) of ONC. Continue to hold skin taut while stabilizing VAD and, with index finger on push-off tab of VAD, advance catheter off needle into vein until hub rests at venipuncture site. Do not reinsert stylet into catheter once catheter has been advanced into vein. Advance catheter while safety device automatically retracts stylet (techniques for retracting stylet vary with different VADs). Place stylet directly into sharps container.

The nurse needs to specifically prevent air emboli that may result from intravenous (IV) therapy. What should the nurse make sure to do to prevent air emboli? A. Use a needleless system. B. Prime the tubing completely. C. Check for medication compatibility. D. Select a larger-gauge needle or catheter.

ANS: B Prime the infusion tubing by filling it with intravenous (IV) solution. Be certain that the tubing is clear of air and air bubbles. Large air bubbles can act as emboli. A needleless system does not specifically prevent the introduction of air emboli. Medication incompatibility may lead to crystallization of the medication and may cause emboli to form from precipitate. It will not lead, however, to air embolism. Catheter size does not contribute to emboli formation.

The patient has intravenous (IV) therapy ordered to infuse at 1000 mL over 10 hours. the infusion set has a calibration of 15 gtt/mL. At which rate does the nurse regulate the infusion? A. 20 gtt/min B. 25 gtt/min C. 30 gtt/min D. 32 gtt/min

ANS: B Select one of the following formulas to calculate drop rate based on drops per minute: mL/hr/60 min = mL/min followed by Drop factor mL/min = Drops/min, or mL/hr Drop factor/60 min = Drops/min.

The nurse is caring for a patient receiving antineoplastic medications intravenously. the nurse discovers that the intravenous site is red, edematous, and painful. the nurse knows that antineoplastic medications are vesicant medications and documents that the patient has experienced which of the following events? A. Occlusion B. Extravasation C. Phlebitis D. Thrombophlebitis

ANS: B When a vesicant medication infiltrates the tissue, this is called an extravasation. Occlusion refers to a thrombus or fibrin sheath that impedes the flow of intravenous (IV) fluids. Phlebitis occurs with redness surrounding the vein, and extravasation leads to trauma within the vein. Thrombophlebitis occurs when trauma occurs within a vein due to a thrombus.

What should the nurse do upon noting bleeding around a dressing at an intravenous (IV) catheter insertion site? A. Discontinue the IV. B. Assess the insertion site. C. Leave the dressing intact, but reinforce it. D. Elevate and apply warm compresses to the extremity.

ANS: B When blood appears on the dressing, verify that the system is intact, and change the dressing. the intravenous (IV) catheter should be discontinued in the event of infiltration or phlebitis. If bleeding occurs around the venipuncture site and the catheter is within the vein, gauze dressing may be applied over the site. Be aware that if gauze dressing is used, it must be removed to accurately assess the insertion site. Elevation is used in cases of infiltration to reduce edema. Warm compresses are used in cases of phlebitis.

Which of the following steps is necessary when a patient is prepared for intravenous (IV) catheter insertion? A. Shaving the hair from thesite B. Selecting a proximal site in an extremity C. Applying a tourniquet 4 to 6 inches above the selected site D. Vigorously taping and massaging the selected vein

ANS: C Apply a flat tourniquet around the arm, above the antecubital fossa or 10 to 15 cm (4 to 6 inches) above the proposed insertion site. Do not shave the area. Shaving may cause microabrasions and may predispose to infection. Use the most distal site in the nondominant arm, if possible. Vigorous friction and multiple taping of the veins, especially in older adults, may cause hematoma and/or venous constriction.

The nurse is caring for a patient with a continuous intravenous infusion of 0.9% normal saline with 40 mEq of potassium chloride added to each liter. During a routine hourly check of the infusion, the nurse discovers that 4 hours of fluid has infused in the past 1 hour. the nurse's first action should be to: A. notify the primary care provider. B. assess the patient. C. reduce the infusion rate. D. notify the charge nurse.

ANS: C If the intravenous fluid is infusing 4 times faster than ordered, the first intervention should be to reduce the infusion rate. Notification of the primary care provider and the charge nurse would occur after the flow rate is reduced and an assessment of the patient is performed. Although assessing the patient is vitally important, you do not want to allow the fluid to continue infusing at a rapid rate while you are performing theassessment.

The patient is expected to require intravenous therapy for several years as treatment for a chronic disease process. Which of the following would be the best choice for venous access in this patient? A. Peripherally inserted central catheter (PICC) B. Nontunneled percutaneous central venous catheter C. Subcutaneous implanted port D. Peripheral IV

ANS: C Implanted infusion ports are used for long-term and complex intravenous (IV) infusion therapy. A port may not be used for extended periods (i.e., weeks) between infusions, and it is not necessary that the port remain accessed during these periods. To maintain the patency of a port, it is necessary to flush monthly with heparin solution or 0.9% sodium chloride in accordance with agency policies and procedures and manufacturer directions for use. PICCs provide alternative IV access when the patient requires intermediate-length venous access (greater than 7 days to several months). These catheters are used for shorter placements (e.g., 5 to 10 days). Use of peripheral IV therapy increases the risk for patients to develop infection, vein sclerosis, phlebitis, and infiltration.

The nurse caring for a patient receiving intravenous (IV) fluids knows that the current recommendation for changing the tubing on a continuously running IV is: A. at least every 48 hours. B. every 24 hours. C. no more often than every 96 hours. D. with each IV solution bag change.

ANS: C Intravenous tubing administration sets remain sterile for 96 hours. Thus, the Infusion Nurses Society (INS) recommends changing tubing no more frequently than every 96 hours. When possible, schedule tubing changes when it is time to hang a new IV container.

What should the nurse do to decrease the potential for infection related to intravenous (IV) infusion therapy? A. Use the clean technique for dressing changes. B. Change the IV tubing every 12 hours. C. Palpate the insertion site daily through the intact dressing. D. After cleansing the skin, dab it dry with a sterile gauze pad.

ANS: C Palpate the catheter insertion site for tenderness daily through the intact dressing. Perform hand hygiene before and after palpating, inserting, replacing, or dressing any intravascular device Maintain use of sterile dressings. Replace intravenous (IV) tubing no more frequently than at 72-hour intervals unless clinically indicated. Allow thesite to air-dry before proceeding with the procedure.

What should the nurse do once she recognizes that the patient has phlebitis at his intravenous (IV) catheter site? A. Reduce the IV flow rate. B. Elevate the affected extremity. C. Place a moist warm compress over the site. D. Adjust the additive in the current IV.

ANS: C Phlebitis is indicated by pain, increased skin temperature, and erythema along thepath of the vein. Stop the infusion and discontinue the intravenous (IV) catheter. Start a new IV if continued therapy is necessary. Place a moist warm compress over the area of phlebitis. Document the degree of phlebitis and nursing interventions per agency policy and procedure. the extremity is elevated for an infiltration to reduce edema.

A pediatric patient has an intravenous (IV) catheter with microdrip tubing. the order is for 40 mL/hr to infuse. At what rate does the nurse set the microdrip? A. 10 gtt/min B. 20 gtt/min C. 40 gtt/min D. 80 gtt/min

ANS: C Select one of the following formulas to calculate drop rate based on drops per minute: mL/hr/60 min = mL/min followed by Drop factor mL/min = drops/min, or mL/hr Drop factor/60 min = Drops/min. In this case, 40 mL/hr 60 gtt/mL = 240 gtt/hr 1 hr/60 min = 40 gtt/min. When microdrip is used, mL/hr always equals gtt/min.

Which patient would a nurse anticipate would be a candidate for a peripherally inserted central catheter (PICC)? A. An older adult who is having cataracts removed B. A perinatal patient who is having prolonged labor C. A neonate requiring blood therapy D. An adolescent who is having surgery for reduction of a fracture

ANS: C When a child is critically ill or when long-term intravenous (IV) access is anticipated, a PICC catheter, a Broviac catheter, or an implanted port may be used to access a larger vein. PICCs can be used to infuse IV fluids, parenteral nutrition, blood and blood products, and medications such as antibiotics. Gerontological veins are very fragile, with less subcutaneous support tissue and with thinning of the skin. In older patients, use the smallest gauge possible. For example, a 22-gauge needle is adequate for fluid and medication therapy. PICC lines are not inserted routinely. PICCs are used when long-term IV therapy is needed.

While assessing the patient's intravenous (IV) infusion, the nurse notes that it is infusing more slowly than it should be. What should the nurse do first? A. Discontinue the IV. B. Increase the rate of infusion. C. Observe for fluid overload. D. Check the position of the IV fluid and extremity.

ANS: D Check the patient for positional changes that might affect infusion rate, height of the intravenous (IV) container, and tubing obstruction. Check the condition of the site. the most likely cause of a slow-running IV is positioning. If IV is positional, fluid will run slowly or stop, depending on position of patient's arm; if this continues, you may have to restart IV line. An infiltrated or clotted IV line probably will not be running at all. Discontinue theIV if it is determined that it is infiltrated or clotted off. Position will affect flow even if rate is increased. Fluid overload is not associated with slowing of the infusion rate. Often it occurs when an IV is running too quickly.

Established standards for routine replacement of peripheral IV catheters and intravenous administration sets have recommended a maximum of _____ hours to reduce intravenous (IV) fluid contamination and prevent catheter site complications. A. 24 B. 48 C. 72 D. 96

ANS: D Established standards for routine replacement of peripheral intravenous (IV) catheters and intravenous administration sets have recommended a maximum of 96 hours to reduce IV fluid contamination and prevent catheter site complications.

The nurse assigns nursing assistive personnel (NAP) to care for several patients with continuous IV infusions. Which of the following can NAP assist with? A. Changing empty IV solution containers B. Confirming the correct IV drip rate C. Assessing the patient for response to IV therapy D. Informing the nurse if they notice anything abnormal

ANS: D If nursing assistive personnel (NAP) notice anything they consider abnormal, they should notify the nurse. It is the nurse's responsibility to inform the NAP of specific things to look for. Changing empty intravenous (IV) solution containers cannot be delegated to NAP because the procedure requires knowledge of sterile technique. Confirming the correct IV drip rate is the nurse's responsibility. Assessment is not the responsibility of NAP; it is the responsibility of the nurse.

The nurse is caring for a patient receiving intravenous therapy. the nurse should report which of thefollowing to the primary care provider? A. Completion of each liter of fluid B. Initiation of intravenous (IV) fluids C. Small infiltration D. Extravasation

ANS: D Immediately stop vesicant administration. Administer antidote or therapeutic medications to maintain tissue integrity according to protocol. Apply cold/warm compresses according to specific vesicant protocol. Provide emotional support. Obtain x-ray film if ordered. Use antidotes per protocol. Discontinue IV solution.

What should the nurse do when discontinuing a peripheral intravenous (IV) catheter? A. Withdraw the catheter quickly. B. Keep the hub perpendicular to the skin. C. Apply pressure to the site for 1 minute. D. Inspect the catheter for intactness after removal.

ANS: D Inspect the catheter for intactness after removal, noting tip integrity and length. Place clean sterile gauze above the site, and withdraw the catheter, using a slow, steady motion. Keep the hub parallel to the skin. Do not raise or lift the catheter before it is completely out of the vein, to avoid trauma or hematoma formation. Apply pressure to the site for 2 to 3 minutes, using a dry, sterile gauze pad. Secure with tape. Note: Apply pressure for 5 to 10 minutes if the patient is taking anticoagulants.

The nurse is caring for a patient diagnosed with pneumonia who receives intravenous (IV) antibiotics every 8 hours. How often should the nurse change the primary intermittent IV sets? A. No more often than every 72 hours B. At least every 72 hours C. With each IV bag change D. Every 24 hours

ANS: D The nurse should change primary intermittent sets every 24 hours because the intravenous (IV) system becomes interrupted, which increases the risk for contamination.

The nurse is preparing to draw blood from a central venous access device for blood cultures. Which of the following steps is part of that process? A. Apply sterile gloves. B. Flush the port with 5 to 10 mL of 0.9% sodium chloride. C. Slowly aspirate 5 mL of blood and discard thesyringe. D. Use the distal lumen to draw blood.

ANS: D When drawing through staggered multilumen catheters, draw from distal lumen (or one recommended by manufacturer). Distal lumen typically is largest-gauge lumen.