Competency 3: Infusion Therapy Test Bank, Study Guide, and Review Questions

Which instruction will the nurse be sure to give the assistive personnel (AP) when checking the blood pressure of a client receiving IV therapy? A. "Avoid taking blood pressure in an extremity with any type of IV catheter in place." B. "Put the pump on hold while you take the client's blood pressure, then restart it." C. "Remind the phlebotomist to draw blood from the extremity without an IV catheter." D. "You can check blood pressure with a short peripheral catheter, but not with a midline catheter."

A Remind assistive personnel (AP) to avoid taking blood pressures in an extremity with any type of catheter in place. If a short peripheral catheter is being used for continuous infusion, the compression while taking the blood pressure can increase venous pressure, causing fluid to overflow from the puncture site and infiltration. When a midline catheter or PICC is being used, compression from the blood pressure cuff could increase vein irritation and lead to phlebitis.

What is the nurse's first action(s) when a client who is receiving IV chemotherapy through a PICC line develops infiltration into the tissue and redness is observed? A. Stop the infusion and disconnect the IV line from the administration set. B. Apply pressure and elevate the site of swelling and redness. C. Aspirate the drug from the intravenous access device. D. Check vital signs, monitor the client, and document the incident.

A The IV insertion site should be assessed carefully for early signs of infiltration, including swelling, coolness, tingling, or redness. If any of these symptoms are present, discontinue the drug immediately and notify the infusion therapy team and/or primary health care provider per agency policy when complications like this occur.

What would the nurse do when caring for an older adult client receiving IV fluids through a central line at 150 mL/hr, who becomes short of breath, develops puffiness around the eyes, and now has a cough? A. Place the client in an upright position, administer oxygen, slow the IV fluids, and notify the health care provider. B. Notify the health care provider, place the client in Trendelenburg position, and administer urokinase to unclot the catheter. C. Assess for patency of the central line catheter, change the tubing, and resume the IV fluids. D. Remove the central line, apply pressure, notify the health care provider, and place the client in a semi-Fowler's position.

A The client's symptoms point to circulatory over-load, not a clot or other obstruction within the catheter. Key interventions at this time would include: slow the IV rate and notify the health care provider; raise client to an upright position; monitor vital signs and administer oxygen as prescribed; administer diuretics as pre-scribed. When breathing difficulties are present, lying flat or in Trendelenburg position makes breathing harder.

Which priority concept concerns the nurse when performing infusion therapy for any client? A. Fluid and electrolyte balance B. Tissue integrity C. Acid-base imbalance D. Perfusion

A The priority concept for when a nurse is providing infusion therapy for any client is fluid and electrolyte balance. The interrelated concept for infusion therapy is tissue integrity.

What is the priority nursing responsibility when a client is receiving IV therapy through an infusion pump? A. Monitor the client's infusion site and rate. B. Program the correct amount of fluid into the pump. C. Position the container for gravity flow. D. Check the equipment at the end of the infusion.

A The use of pumps does not decrease the nurse's responsibility to carefully monitor the client's infusion site and the infusion rate. Smart pumps (infusion pumps with dosage calculation soft-ware) have been promoted to reduce adverse drug events (ADEs). Incorrect programming of pumps without this feature is one of the most common types of drug errors, especially in hospitals.

Which teaching would the nurse provide for the client and family on prevention of catheter-related bloodstream infection (CRBSI) before the IV catheter was inserted? Select all that apply. A. The type of catheter to be inserted B. Hand hygiene C. Aseptic technique for care of the catheter D. Activity limitations E. Signs and symptoms of complications F. Alternatives to catheter and therapy

A, B, C, D, E, F All options are correct responses to essential teaching that the nurse should provide for the client and family before an IV catheter is inserted for therapy.

Which specific actions will the nurse take when assessing a client's IV site? Select all that apply. A. Look for redness, swelling, hardness, or drainage. B. Check integrity of the dressing to make sure it is clean, dry, and adherent to the skin on all sides. C. Ensure that all connections are taped to prevent disconnection and leaking of fluids. D. Check the rate and amount of fluid that has infused. E. Be sure that the correct type of fluid is being infused. F. Check the skin around the dressing for medical adhesive-related skin injury (MARSI).

A, B, D, E Options A, B, D, and E are appropriate to assessing a client's IV site. Connections should not be taped. The skin under the dressing (not around) should be checked for medical adhesive-related skin injury (MARSI).

What information must the nurse know before giving any IV drug to a client? Select all that apply. A. Indications and proper dosage B. Contraindications and precautions C. Percentage of adverse events for the drug D. Compatibility with other IV medications E. Rate of infusion and osmolarity F. Potential for irritant and vesicant effects

A, B, D, E, F For all drug administration, nurses must be knowledgeable about drug indications, proper dosage, contraindications, and precautions. IV administration also requires knowledge of appropriate dilution, rate of infusion, pH and osmolarity, compatibility with other IV medications, appropriate infusion site (peripheral versus central circulation), potential for vesicant/ irritant effects, and specific aspects of client monitoring because of its immediate effect.

Which major components and precautions of the catheter-related bloodstream infection (CRBSI) prevention bundle must the specially trained nurse follow when inserting a PICC line into a client? Select all that apply. A. Measuring upper arm circumference as a baseline before insertion B. Betadine skin antisepsis C. Proper aseptic hand hygiene D. Maximal barrier precautions on insertion E. Optimal catheter site selection F. Daily review of line necessity with prompt removal of unnecessary lines

A, C, D, E, F All options are appropriate and part of the catheter-related bloodstream infection (CRBSI) prevention bundle, except option B which should be chlorhexidine skin antisepsis (not betadine).

What information must be included with each prescription for IV therapy for the nurse to administer it safely to a client? Select all that apply. A. Frequency of drug administration B. Specific type of administration equipment C. Rate of administration D. Specific type of solution E. Method for diluting drugs for the solution F. Specific drug to be added to the solution

A, C, D, F A drug prescription should include: drug name, preferably by generic name; specific dose and route; frequency of administration; time(s) of administration; length of time for infusion (number of doses/days); purpose (required in some health care agencies, especially nursing homes). The specific type of equipment to be used is not a requirement for a valid prescription. The pharmacy determines the correct diluent based on manufacturer's recommendations or requirements.

A new nurse is caring for a client receiving drug therapy via a smart pump. What statement by the new nurse demonstrates the need for more instruction on this technology? a. "I don't need to manually calculate IV infusion rates with smart pumps." b. "Responding to IV pump alarms is a high priority for client safety." c. "The hospital can preprogram the pumps for high-alert drug limits." d. "These pumps have a system to prevent fluids from free-flowing into the client."

ANS: A The "smarter" the pump is the more programming needs to occur and errors can happen and systems can fail. Using a programmable pump does not relieve the nurse of his or her responsibility to monitor the infusion site and rates and ensure the client is receiving the fluids or medications as prescribed. The Joint Commission continues to include responding to alarms as a National Patient Safety Goal. Pumps can be preprogrammed so that upper limits exist for high-alert drugs. All electronic infusion devices have some mechanism for preventing free flow of fluids if the cassette or tubing is removed from the pump.

A nurse assists with the insertion of a central vascular access device. Which actions will the nurse ensure are completed to prevent a catheter-related bloodstream infection? Select all that apply. a. Include a review for the need of the device each day in the client's plan of care. b. Remind the primary health care provider to perform hand hygiene prior to insertion if he or she forgets. c. Cleanse the preferred site with alcohol and let it dry completely before insertion. d. Ask everyone in the room to wear a surgical mask during the procedure. e. Plan to complete a sterile dressing change on the device every day. f. Minimal client draping and barrier precautions as blood loss are minimal.

ANS: A, B, D The central vascular access device bundle to prevent catheter-related bloodstream infections includes using a checklist during insertion, performing hand hygiene before inserting the catheter and anytime someone touches the catheter, using chlorhexidine to disinfect the skin at the site of insertion, using preferred sites, and reviewing the need for the catheter every day. The practitioner who inserts the device would wear sterile gloves, gown, and mask, and anyone in the room would wear a mask. Maximal barrier precautions are used which requires the client to be draped sterilely from head to toe. The initial dressing on a central vascular access device is changed in 24 hours. Gauze and tape dressings are changed every 48 hours and transparent membrane dressings are changed every 5 to 7 days.

A nurse prepares to insert a short peripheral venous catheter. What actions will the nurse take to use best practices? Select all that apply. a. Choose a distal site on the client's nondominant arm. b. Verify that the prescription is appropriate for peripheral infusion. c. Place the venous catheter near an area of joint flexion. d. Wear a surgical mask during the catheter insertion procedure. e. Perform hand hygiene before inserting the catheter. f. Limit unsuccessful attempts by up to three clinicians to one attempt each.

ANS: A, B, E Best practices for the insertion of a short peripheral venous catheter include hand hygiene prior to the procedure, verification of the prescription for intravenous therapy and its appropriateness for infusion through a short peripheral catheter, and placement of the catheter in a distal site, away from an area of joint flexion and when possible in the client's nondominant arm. Surgical masks are needed for central venous catheter placement but not for short peripheral venous catheter placement. Unsuccessful attempts to insert the catheter should be limited to two per person and no more than four total.

A registered nurse (RN) occasionally delegates client care to licensed practical nurses (LPNs) or technicians. What information does the RN consider when delegating components of IV therapy? Select all that apply. a. Each state's Nurse Practice Act will regulate who can perform care related to IVs. b. The nurse would check the facility's Policies and Procedures manual. c. The LPN's level of experience primarily guides the decision. d. Technicians cannot participate in any part of caring for IV infusions. e. The RN remains accountable for all aspects of IV care and delegated actions. f. The Infusion Nurses Society has guidelines and standards of IV therapy competency.

ANS: A, B, E, F The state Nurse Practice Act will have the information the RN needs to determine scope of practice, and in some states, LPNs and technicians are able to perform specific aspects of IV therapy. The nurse would also be familiar with facility policies and procedures regarding delegation of IV therapy. Amount of experience is not a criterion as LPNs and technicians can have their knowledge and skills verified. The nurse remains accountable for all aspects of IV therapy include what has been delegated. The Infusion Nurses Society has published guidelines and standards related to competency for IV therapy.

A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which common complications will the nurse assess? Select all that apply. a. Phlebitis b. Pneumothorax c. Thrombophlebitis d. Excessive bleeding e. Extravasation f. Pneumothorax g. Infiltration

ANS: A, C Although the complication rate with PICCs is fairly low, the most common complications are phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Excessive bleeding, infiltration, and extravasation are not common complications. Pneumothorax does not occur.

A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the client's chart prior to administering the medication and notes it to have been inserted 4 months ago. The site has no redness, warmth, or swelling and flushes easily. What action does the nurse take? a. Notify the primary health care provider. b. Administer the prescribed medication. c. Discontinue the PICC. d. Switch the medication to the oral route.

ANS: B A PICC that is functioning well without inflammation or infection may remain in place for months. Because the line shows no signs of complications, it is permissible to administer the IV antibiotic. There is no need to call the primary health care provider or to have the IV medication changed to an oral route.

A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, what action will the nurse take to relieve pain? a. Administer topical lidocaine to the site. b. Place warm compresses on the site. c. Administer prescribed oral pain medication. d. Massage the site with scented oils.

ANS: B At the first sign of phlebitis, the catheter will be removed and warm compresses used to relieve pain. The other options are not appropriate for this type of pain.

A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and "feeling warm." For which complication of this therapy will the nurse assess the client? a. Allergic reaction b. Bowel obstruction c. Catheter lumen occlusion d. Infection

ANS: D Fever, abdominal pain, abdominal rigidity, and rebound tenderness may be present in the client who has peritonitis related to intraperitoneal therapy. Peritonitis is preventable by using strict aseptic technique in handling all equipment and infusion supplies. An allergic reaction would show other signs and symptoms. Bowel obstruction and catheter lumen occlusion can occur but would present clinically in different ways.

A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. What action will the nurse take next? a. Apply cold compresses to the IV site. b. Elevate the extremity on a pillow. c. Flush the catheter with normal saline. d. Stop the infusion of intravenous fluids.

ANS: D Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of infiltration include edema and tenderness above the site. The nurse would stop the infusion and remove the catheter. Cold compresses and elevation of the extremity can be done after the catheter is discontinued to increase client comfort. Alternatively, warm compresses may be prescribed per institutional policy and may help speed circulation to the area.

A nurse delegates care to an assistive personnel (AP). Which statement will the nurse include when delegating hygiene for a client who has a vascular access device? a. "Provide a bed bath instead of letting the client take a shower." b. "Use sterile technique when changing the dressing." c. "Disconnect the intravenous fluid tubing prior to the client's bath." d. "Use a plastic bag to cover the extremity with the device."

ANS: D The nurse will ask the AP to cover the extremity with the vascular access device with a plastic bag or wrap to keep the dressing and site dry. The client may take a shower or bath with a vascular device. The nurse will disconnect IV fluid tubing prior to the bath and change the dressing using sterile technique if necessary. These options are not appropriate to delegate to the AP.

A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention? a. The initial site dressing is 3 days old. b. The PICC was inserted 4 weeks ago. c. A securement device is absent. d. Upper extremity swelling is noted.

ANS: D Upper extremity swelling could indicate infiltration, and the PICC will need to be removed. The initial dressing over the PICC site would be changed within 24 hours. This does not require immediate attention, but the swelling does. The dwell time for PICCs can be months or even years. Securement devices are being used more often now to secure the catheter in place and prevent complications such as phlebitis and infiltration. The IV lacking one does not take priority over the client whose arm is swollen.

At what rate would the nurse set the infusion when a client is to receive 0.45% normal saline, 1000 mL over 15 hours? A. 50 mL/hr B. 67 mL/hr C. 75 mL/hr D. 83 mL/hr

B 1000mL / 15 hr 5 66.6 rounded up to 67 mL/hr

Which intravenous (IV) fluid would the nurse infuse for a client when the health care provider prescribes a hypotonic solution? A. 0.9% NaCl B. 0.45% NaCl C. Lactated Ringer's solution D. 5% dextrose with 0.9% saline

B A hypotonic solution has a lower than normal blood plasma osmolarity (fluids less than 270 mOsm/L). An example of a hypotonic solution is half-strength saline (0.45% NaCl).

Which factor increases the likelihood that a client who comes into the emergency department (ED) after a serious motor crash is a candidate for intraosseous (IO) therapy? A. Endotracheal intubation is difficult to accomplish. B. IV access cannot be established within a few minutes. C. Client is an older adult and very thin. D. Client has a history of chronic renal failure.

B Adult victims of trauma benefit from IO therapy because health care providers often cannot access these clients' vascular systems for traditional IV therapy.

Which intervention would the nurse use to reduce the risk of infection when a client is receiving IV drugs by way of a needleless system? A. Always use a hand scrub when entering a client's room. B. Clean all needleless system connections with an antimicrobial agent for 10-15 seconds before connecting infusion sets. C. Use tape to assure that secondary IV sets remain attached to primary IV sets. D. Disconnect secondary IV sets after each dose of IV drug is completed.

B Clean all needleless system connections vigorously with an antimicrobial agent (usually 70% alcohol or alcohol and 2% chlorhexidine swabs) for 10-15 seconds before connecting infusion sets or syringes, paying special attention to the small ridges in the Luer-Lok device. The "scrub the hub" technique suggests generating friction by scrubbing the connection hubs in a twisting motion.

What is the nurse's priority action when attempting to insert a short peripheral catheter (SPC) and the client reports a feeling of "pins and needles"? A. Ask the client to wiggle the fingers to stimulate circulation. B. Stop immediately, remove the catheter, and choose a new site. C. Change to a short-winged butterfly needle. D. Pause the procedure and gently massage the fingers.

B Reports of tingling, feeling "pins and needles" in the extremity, or numbness during the venipuncture procedure can indicate nerve puncture. If any of these symptoms occur, stop the IV insertion procedure immediately, remove the catheter, and choose a new site.

Which actions must the nurse follow to remove a short peripheral catheter (SPC) when a client is ready for discharge to home? Select all that apply. A. Flush the SPC before removal. B. Remove the SPC dressing. C. Explain the procedure to the client. D. Rapidly withdraw the catheter from the skin. E. Immediately cover the puncture site with dry gauze. F. Hold pressure until hemostasis is achieved. G. Assess the catheter tip to ensure it is intact and completely removed. H. Document catheter removal and appearance of the site.

B, C, E, F, G, H All options are appropriate actions for removal of an SPC, except A and D. It is not necessary to flush the catheter before removing it. The catheter should be slowly (not rapidly) with-drawn from the skin.

The primary healthcare provider has prescribed 1 liter of D5NS to infuse at a rate of 125 ml/hour. The nurse begins the infusion at 0700 (7am). When will the nurse anticipate completion of the infusion? A. 1300 hours (1pm) B. 1500 hours (3pm) C. 1900 hours (7pm) D. 2100 hours (9pm)

B. 1500 hours (3pm)

What would the nurse's first action(s) be when a client's IV site demonstrates slowed flow rate, skin tightness, discomfort at the site (e.g., burning, tenderness), and leakage around the site? A. Apply a cold pack and elevate the extremity. B. Place a sterile dressing over the site if weeping from the tissue occurs. C. Stop the solution and remove the intravenous access. D. Insert a new IV catheter above the site of the old one.

C First, stop infusion and remove short peripheral catheter immediately. After this, a sterile dressing can be applied if there is weeping from the tissue. Next, the extremity can be elevated and cold or warm compresses applied. A new catheter should be inserted in the opposite (not the same) extremity. Finally, the nurse would rate the infiltration using the INS Infiltration Scale and document the event.

What solution and volume does the nurse typically use to flush a client's short peripheral catheter IV saline lock? A. 3 mL heparinized saline B. 5 mL bacteriostatic saline C. 3 mL normal saline D. 5 mL heparin solution

C For short peripheral catheters, usually 3 mL nor-mal saline is adequate to flush the catheter. For all other catheters, 5 to 10 mL of preservative-free normal saline is needed. Flush catheters immediately after each use. A saline lock should be flushed at least once each shift. Research has shown that for SPCs, 3 mL of saline is just as effective at maintaining patency of the catheter without the risks associated with the use of heparin flushes.

For which potential problem does the nurse assess the client after receiving epidural therapy when symptoms of headache, stiff neck, or temperature higher than 101°F (38.3°C) develop? A. Allergic reaction B. Leakage of cerebrospinal fluid C. Meningitis D. Catheter migration

C The client may also exhibit neurologic and systemic signs of infection (e.g., meningitis) such as headache, stiff neck, or temperature higher than 101°F (38.3°C). Report any neurologic change to the primary health care provider immediately!

What is the RN generalist's role for a client in need of infusion therapy? A. Placement of a peripherally inserted central catheters (PICC) B. Changing dressing on all intravenous sites every 48 hours C. Insertion of short peripheral catheters (SPC) D. Providing services such as hypodermoclysis and intraosseous infusions

C The registered nurse (RN) generalist is taught to insert peripheral IV lines; most institutions have a process for demonstrating competency for this skill (e.g., demonstrate successful placement a specified number of times on clients with a preceptor watching). Options A and D are specialty actions not usually performed by a generalist nurse. Option B is wrong because of the time frame which varies depending on the type of IV line and dressing.

A client had a 20-gauge short peripheral catheter (SPC) inserted for antibiotic administration 48 hours ago. Which nursing intervention is appropriate? A. Discontinue the SPC. B. Relocate the SPC for infection control. C. Assess the SPC for redness, swelling, or pain. D. Change the occlusive dressing covering the SPC.

C. Assess the SPC for redness, swelling, or pain.

An older adult client receiving an infusion of 5% dextrose in 0.9% normal saline at 150 mL/hour has developed shortness of breath with a decrease in oxygen saturation to 86%. What is the priority nursing intervention? A. Notify the health care provider B. Place the client on oxygen C. Sit the client upright in bed D. Assess the client's lung sounds

C. Sit the client upright in bed

Where would the nurse insert an IV short peripheral catheter (SPC) in an active client with a prescription for IV therapy? A. Wrist B. Hand C. Antecubital area D. Forearm

D Short peripheral catheters are most often inserted into superficial veins of the forearm. In emergent situations, these catheters can also be used in the external jugular vein of the neck. The areas in options A and C are over joints, which would then have to be immobilized. The back of the hand contains little subcutaneous tissue and is easily damaged. Option B, the hand is not appropriate for older patients with a loss of skin turgor and poor vein condition or for active patients receiving infusion therapy in an ambulatory care clinic or home care. Use of veins on the dorsal surface of the hands should be reserved as a last resort for short-term infusion of nonvesicant and nonirritant solutions in young patients.

Which technique is recommended by the Infusion Nurses Society (INS) for the nurse to maintain a PICC line for a client receiving IV antibiotic therapy every 4 hours? A. Flush the catheter with 10 mL heparinized saline after each dose of antibiotic. B. Flush the catheter every 12 hours using a 5-mL syringe. C. Avoid flushing the catheter with heparinized saline more than twice a week. D. Use 10 mL of sterile saline to flush before and after each dose of antibiotic.

D The INS recommends that PICC lines not actively in use be flushed with 5 mL of heparin (10 units/mL) in a 10-mL syringe at least daily when using a nonvalved catheter and at least weekly with a valved catheter. Use 10 mL of sterile saline to flush before and after medication administration; 20 mL of sterile saline to flush after drawing blood. Always use 10-mL barrel syringes to flush any central line because the pressure exerted by a smaller barrel poses a risk for rupturing the catheter.

What complication does the nurse suspect when a client receiving IV antibiotic therapy over the past 3 days develops chills, headache, and an elevated temperature? A. Fluid volume overload B. Allergic reaction to antibiotics C. Phlebitis with infiltration D. Catheter-related bloodstream infection (CRBSI)

D With catheter-related bloodstream infection (CRBSI), early symptoms include fever, chills, headache, and general malaise. Later symptoms include tachycardia, hypotension, and decreased urinary output.

A client receiving gentamycin intravenously reports that the peripheral IV insertion site has become painful and reddened. What is the priority nursing action? A. Contact the primary health care provider. B. Document findings in the electronic health record. C. Change the IV site to a new location. D. Stop the infusion of the drug.

D. Stop the infusion of the drug.

Which client does the charge nurse on a medical-surgical unit assign to the LPN/LVN? a. An older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours. b. A client receiving blood products after excessive blood loss during surgery. c. A client admitted for hyperglycemia who has an IV insulin drip and needs frequent glucose checks. d. A client who has a diltiazem IV infusion being titrated to maintain a heart rate between 60 and 80 beats/min.

a. An older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours.

The nurse is starting a peripheral IV catheter on a client who was recently admitted. What actions does the nurse perform before insertion of the line? Select all that apply. a. Apply povidone-iodine to clean skin, dry for 2 minutes. b. Prepare the skin with 70% alcohol or chlorhexidine. c. Clean the skin around the site. d. Wear clean gloves and touch the site only with fingertips after applying antiseptics. e. Shave the hair around the area of insertion.

a. Apply povidone-iodine to clean skin, dry for 2 minutes. b. Prepare the skin with 70% alcohol or chlorhexidine. c. Clean the skin around the site.

The nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters will the nurse choose most often? a. Cephalic vein of the forearm b. Palmer side of the wrist c. Back of the hand d. Subclavian vein

a. Cephalic vein of the forearm

The nurse is administering a drug to a client through an implanted port. Before giving the medication, what will the nurse do to ensure safety? a. Check for blood return. b. Administer 5 mL of a heparinized solution. c. Flush the port with 10 mL of normal saline. d. Palpate the port for stability.

a. Check for blood return.

The nurse is documenting peripheral venous catheter insertion for a client. What will the nurse include in the note? Select all that apply. a. Vein used for insertion b. Client's response to the insertion c. Date and time inserted d. Client's name and hospital number e. Type of dressing applied f. Type and size of device

a. Vein used for insertion b. Client's response to the insertion c. Date and time inserted e. Type of dressing applied f. Type and size of device

The nurse is inserting a peripheral intravenous (IV) catheter. Which client statement is of greatest concern during this procedure? a. "It hurts when you are inserting the line." b. "My hand tingles when you poke me." c. "My IV lines never last very long." d. "I hate having IVs started."

b. "My hand tingles when you poke me."

The nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What will the nurse do first? a. Check connections. b. Check the infusion rate. c. Assess the insertion site. d. Discontinue the IV and start another.

c. Assess the insertion site.

The nurse is revising an agency's recommended central line-associated bloodstream infection (CLABSI) bundle. Which actions decrease the client's risk for this complication? Select all that apply. a. During insertion, draping just the area around the site with a sterile barrier b. Making certain that observers of the insertion are instructed to look away during the procedure c. Using chlorhexidine for skin disinfection d. Thorough hand hygiene before insertion e. Removing the client's venous access device (VAD) when it is no longer needed

c. Using chlorhexidine for skin disinfection d. Thorough hand hygiene before insertion e. Removing the client's venous access device (VAD) when it is no longer needed

The nurse is checking an IV fluid order and questions accuracy. What nursing action is appropriate? a. Ask the charge nurse about the order. b. Start the fluid as ordered. c. Contact the pharmacy for clarification. d. Contact the prescribing health care provider.

d. Contact the prescribing health care provider.

The nurse is teaching a course about the special needs of older adults receiving IV therapy. What teaching will the nurse include? a. To avoid rolling the veins, a greater angle of 25 degrees between the skin and the catheter improves success with venipuncture. b. Placement of the catheter on the back of the client's dominant hand is preferred. c. When the catheter is inserted into the forearm, excess hair should be shaved before insertion. d. Skin integrity can be compromised easily by the application of tape or dressings.

d. Skin integrity can be compromised easily by the application of tape or dressings.

When flushing a client's central line with normal saline, the nurse feels resistance. Which action will the nurse take first? a. Decrease the pressure being used to flush the line. b. Use "push-pull" pressure applied to the syringe while flushing the line. c. Obtain a 10-mL syringe and reattempt flushing the line. d. Stop flushing and try to aspirate blood from the line.

d. Stop flushing and try to aspirate blood from the line.

Which nursing assessment data indicate the need for immediate nursing intervention? a. Client states, "It really hurt when the nurse put the IV in." b. Transparent dressing was changed 5 days ago. c. Tubing for the IV was last changed 72 hours ago. d. The vein feels hard and cordlike above the insertion site.

d. The vein feels hard and cordlike above the insertion site.