Chapter 42 - Fluids_IV Therapy & Maintaining Flow Rate

A nurse is assessing the clinical markers of vascular volume. Which patient may require intravenous (IV) therapy due to extracellular fluid volume deficit?

A dark yellow color indicates concentrated urine that may be caused by a decrease in the extracellular fluid volume; therefore, this patient may require IV therapy. An increase in the pulse rate indicates excess fluid volume. The blood pressure increases with excess extracellular fluid volume. Crackles indicate excess fluid volume.

The primary health care provider suggested intravenous (IV) therapy for a patient with decreased tendon reflexes. Which condition can be observed in this patient?

A decrease in tendon reflexes can be caused by an abnormally high calcium concentration in the blood, known as hypercalcemia; therefore, this patient may require IV therapy. An abnormally low potassium concentration in the blood, known as hypokalemia, may cause muscle weakness. Excessive thirst can be seen in a patient with more salt than water in the body fluids, known as hypernatremia. An abnormally low concentration of magnesium in the blood, known as hypomagnesemia, may cause tremors, muscle cramps, and numbness.

The nurse is assessing the clinical criteria for the infiltration scale. What would the grade be if there is 10.8 cm of edema in the infiltration?

According to the infiltration scale, edema that is 2.54 to 15.2 cm is grade 2. Edema less than 2.54 cm, about an inch, is grade 1. Edema greater than 15.2 cm, or 6 inches, in any direction with mild to moderate pain is grade 3. Edema greater than 15.2 cm with moderate to severe pain is grade 4.

Which clinical criteria of phlebitis should receive a grade of 3?

According to the phlebitis scale, the nurse would give a grade of 3 if there is any streak formation or a palpable venous cord. The nurse would give a grade of 2 if there is only erythema. The nurse would grade give a grade of 4 if there is a palpable venous cord greater than 2.54 cm. Erythema at the access site with or without pain is grade 1.

Which transfusion reaction may include clinical manifestations such as dyspnea?

Anaphylactic reactions may occur due to adverse transfusion reactions, and their clinical manifestations include dyspnea. Mild allergic reactions caused by transfusions may manifest clinically as flushing, itching, and urticaria. Febrile nonhemolytic transfusion reactions manifest clinically as anxiety and muscle pain. Acute intravascular hemolytic transfusion reactions manifest clinically as hemoglobinuria, circulatory shock, cardiac arrest, and death.

While preparing the vein for venipuncture, the nurse applies a blood pressure cuff 10 to 12 cm above the insertion site. What could be the rationale?

Applying the blood pressure cuff 10 to 12 cm above the insertion site dilates and fills the vein. Performing venipuncture stabilizes the vein. Warning the patient before venipuncture avoids movement of the extremity. Inserting the vascular access device at a 10- to 30-degree reduces the risk of puncturing the posterior wall of the vein.

Which complication of intravenous (IV) therapy indicates the need for pressure at the site?

Bleeding may be a complication of IV therapy; applying pressure at the site can reduce bleeding. Phlebitis may indicate that the infusion should be stopped. The primary health care provider should be notified if symptoms of infection occur. Reduction in the IV flow rate may reduce circulatory overload.

Which statement is true regarding vascular access devices (VADs)?

Central catheters are long-term devices. The term "central" applies to the location of the catheter tip, not to the insertion site. Peripheral catheters are for short-term use such as for fluid restoration after surgery and short-term administration of antibiotics. Central catheters are mainly useful for administration of large volumes of fluids and for administration of parenteral nutrition.

Which type of dextrose solution is considered isotonic?

Dextrose 5% in water is an isotonic solution. Dextrose in 10% water is a hypertonic solution. Dextrose 5% in 0.9% sodium chloride and dextrose 5% in 0.45% sodium chloride are also hypertonic solutions.

A patient has a febrile nonhemolytic transfusion reaction after a blood transfusion. Which drugs would be appropriate for this patient?

For the management of febrile nonhemolytic transfusion reactions, the nurse must administer antipyretics to reduce the symptoms of fever. The nurse must administer diuretics when there is evidence of an acute intravascular hemolytic transfusion reaction to induce voiding in the patient. The nurse must administer antihistamines for mild allergic reactions. The nurse must administer glucocorticoids in a patient with sepsis.

The registered nurse is instructing a nursing student about the interventions that must be performed when there is any evidence of complication due to infusion therapy. Which instruction would the nurse follow for a patient with circulatory overload?

If the nurse suspects circulatory overload in a patient, the immediate nursing intervention is to reduce the IV flow rate and notify the health care provider. The nurse must elevate the extremity when there is any evidence of infiltration near the infusion site; this helps the infiltration to subside. The nurse must disconnect IV tubing and discontinue the IV infusion when there is evidence of infiltration.

While caring for a patient who is on intravenous (IV) therapy, the nurse finds that the skin around the catheter site is taut, blanched, cool to the touch, and edematous. Which complication is evident?

Infiltration is a complication that occurs when an IV catheter becomes dislodged and IV fluids inadvertently enter the subcutaneous tissue around the venipuncture site. The assessment findings include taut, blanched, cool, edematous skin. The assessment findings for phlebitis include redness, tenderness, pain, and warmth along the course of the vein starting at the access site. The assessment findings include fresh blood at the venipuncture site. The assessment findings for local infection include redness, heat, and swelling at the catheter entry point.

Which method performed to foster venous distention promotes venous dilation?

Placing the extremity in a dependent position promotes venous dilation. Application of warmth to the extremity for several minutes with a warm washcloth increases blood in the vein by causing dilation. Selecting a larger vein for a vascular access device (VAD) prevents interruption of venous flow while allowing adequate blood flow around the catheter. Palpation of the vein by pressing it downward increases the sensitivity for better assessment of vein location.

Which immediate intervention would be beneficial in a patient who developed redness and pain at the infusion site?

Redness and pain at an infusion site indicate phlebitis; therefore, the nurse should stop the infusion or start a new line if these symptoms occur in the patient. The extremities are elevated if symptoms of infiltration occur. Applying warmth to the site is an intervention for infiltration. The health care provider can be notified, but the immediate action is to stop the infusion.

Which saline solution draws water from cells into the extracellular fluid (ECF) by osmosis?

Saline solution is sodium chloride in water. Sodium chloride 5.0% draws water from the cells into the ECF by osmosis. Sodium chloride 0.9% expands the ECV and does not enter the cells. Sodium chloride 0.45% and 0.225% expand the ECV and rehydrate cells.

The nurse stabilizes the catheter with the nondominant hand and releases the tourniquet while performing a venipuncture. What could be the rationale?

Stabilization of the catheter with the nondominant hand, releasing the tourniquet, and applying gentle but firm pressure with the middle finger of the nondominant hand above the insertion site permits venous flow. If a saline lock is attached, gentle flushing of the catheter with an attached saline syringe to ensure patency provides patient safety. Connecting the distal end of a primed short extension tubing prompts connection of the infusion set, maintains patency of the vein, and prevents exposure to blood. The nurse must attach the distal end of the tubing to a needleless connector on the short extension tubing that is attached to the catheter to initiate the flow of fluid through the catheter and to prevent clotting of the device.

A patient reports swelling at the incision site during administration of intravenous fluids. What should be the immediate nursing intervention?

Swelling at the incision site during administration of intravenous fluids is due to infiltration, so removal of the catheter is indicated. A sterile dressing can be applied after securing the catheter, but the nurse must immediately remove the catheter. The area can be wiped with a skin protectant after the catheter has been removed. Applying tape and gauze may cause compression of the veins.

Which grade on the phlebitis scale is given to a patient with pain at the infusion site and erythema?

The clinical criteria for grade 2 on the phlebitis scale are pain and erythema at the infusion site. The clinical criterion for grade 1 is erythema at the infusion site. The clinical criteria for grade 3 are pain at the site, erythema, and streak formation or a palpable venous cord. The clinical criteria for grade 4 are pain at the site with erythema and streak formation along with purulent discharge.

A patient on intravenous (IV) therapy reports mild pain and numbness at the puncture site. The nurse finds edema 16 cm in size. Which grade according to the infiltration scale is given to the patient?

The clinical criteria for grade 3 are edema greater than 15.2 cm, mild to moderate pain, and numbness. The clinical criteria for grade 1 are edema less than 2.54 cm with or without pain. The clinical criteria for grade 2 are edema 2.54 to 15.2 cm with or without pain. The clinical criteria for grade 4 are a leaky, discolored, swollen appearance of the skin and edema greater than 15.2 cm. Circulatory impairment and pain can occur.

The primary health care provider orders the nurse to culture the drainage from an area on a patient's skin. Which complication of intravenous therapy should the nurse suspect?

The health care provider orders a culture of the drainage on a patient's skin to evaluate the cause of infection. The immediate intervention in a patient with phlebitis is to stop the infusion. The nurse will assess for the intactness of the IV system when there is any evidence of bleeding near the IV site. The nurse will reduce the IV infusion when there is any evidence of circulatory overload.

The nurse curls a loop of intravenous tubing alongside the arm of a patient on intravenous (IV) therapy. Which outcome can be expected with this nursing action?

The nurse curls a loop of the intravenous tubing alongside the arm to reduce the risk of dislodging the catheter during IV therapy. Manipulation of the catheter dressing can cause alteration in the flow rate. The nurse uses a gauze pad over the insertion site to reduce the risk of infection. Applying tape to the gauze pad of the insertion site facilitates access to the tubing junction.

Which location selected for venipuncture would increase the risk of lymphedema?

The nurse must select the area for venipuncture with care. Selecting an extremity affected previously by paralysis would involve a risk of complications such as lymphedema or vessel damage. Selecting a fragile dorsal vein in an older adult would increase the risk of infiltration and hematoma from vessel rupture. Selecting a site distal to a previous venipuncture for IV access can cause infiltration around the newly placed vascular access device. Pain, infection, and tenderness may indicate an inflamed vein or increased risk of infection.

The nurse identifies air bubbles in the single-port intravenous (IV) tubing of a patient who is on intravenous maintenance therapy. Which action should be performed immediately?

The nurse should immediately tap the IV tubing if he or she finds bubbles in the tubing and should also check the entire length of tubing to remove all of the bubbles. The nurse should turn the ports upside down if bubbles are found in multiple-port tubing. The nurse should change the IV tubing if it is found to have leaks. The nurse should change the VAD if it becomes dislodged.

The registered nurse is teaching a nursing student regarding regulation of the intravenous (IV) flow rate. Which statement if made by the nursing student indicates a need for further learning?

The nurse should monitor an IV infusion site every hour to note the IV fluid infusion rate. The nurse should observe for signs of infection and inflammation at the infusion site because it influences infusion rate. The nurse should observe the patient for signs of overhydration to determine the patient's response to therapy. The nurse should also teach the patient to maintain proper arm position because it may cause a difference in the intravenous flow rate.

A patient has acute intravascular hemolysis as an adverse effect of transfusion reaction. Which nursing intervention will be beneficial?

To maintain the urinary flow rate, the nurse must administer diuretics to a patient with acute intravascular hemolysis as an adverse effect of transfusion reaction. Antibiotics are required if the patient develops sepsis. Administration of antihistamines is beneficial if the patient has an allergic reaction. Administration of glucocorticoids would be beneficial if the patient has sepsis.

What would be the immediate nursing intervention when an intravenous (IV) fluid container empties with subsequent loss of vascular access device patency?

When an IV fluid container empties with subsequent loss of patency, the nurse must immediately discontinue the present infusion and start a new IV line in another extremity or proximal to the previous insertion site. The nurse must slow the infusion rate to 10 gtt/minute temporarily and place the patient in a high Fowler's position when there is sudden infusion of large volumes of solution. The nurse must consult the health care provider for new orders to provide necessary fluid volume when the IV fluid infuses slower than prescribed.

Which nursing action is beneficial to deliver a small amount of fluid to a pediatric patient who is on intravenous (IV) therapy?

When delivering a small amount of fluid to a pediatric patient who is on IV therapy, inserting the volume-control device spike into the container promotes the slow infusion of the fluid. The drip rate should be monitored every hour to maintain the flow rate. The patient is placed in Fowler's position if symptoms of overhydration occur. The IV container is placed 36 inches above the IV site in adults to regulate the flow rate