Critical Care: Medications and Intravenous Therapy 💊💉

The critical care nurse is caring for a client with a subclavian central line catheter. The nurse knows that a specific central-line bundle was developed to reduce the client's risk for developing a catheter-related bloodstream infection (CLABSI). The interventions include which essential actions? Select all that apply. Strict hand washing Daily dressing change Betadine skin antisepsis Optimal catheter site selection Strict sterile technique with maximal barrier precautions during placement Infection control primary health care provider as a member of the client's health care team

✅Strict hand washing. ✅Optimal catheter site selection. ✅Strict sterile technique with maximal barrier precautions during placement. 📑Rationale: Besides a daily review of line necessity, CLABSI includes strict hand washing, optimal catheter site selection, and strict sterile technique with maximal barrier precautions during treatment. As long as the barrier protection remains intact, the dressing is changed no more often than every 72 to 96 hours. Daily site dressing changes could increase the risk of infection. Chlorhexidine rather than Betadine is usually used for skin antisepsis. An infection control primary health care provider does not need to be a member of the client's health care team.

The nurse is checking the date of an intravenous (IV) insertion in a client. The insertion date on the dressing is 2/9 (February 9). The nurse calculates that the site should be changed on which date? ➖2/12 ➖2/14 ➖2/15 ➖2/16

✅2/12 📑Rationale: The IV site should be changed every 72 to 96 hours based on the Center for Disease Control guidelines. With an insertion date of 2/9, the due date for change should be 2/12. Changing the IV site every 5 to 7 days would place the client at risk for site infection.

The nurse has a prescription to give ear drops to a 2-year-old child. To administer the drops, the nurse should pull the pinna of the ear in which direction? Upward and outward Upward and backward Downward and outward Downward and backward

✅Downward and backward. 📑Rationale: To properly administer ear drops to a child younger than 3 years of age, the pinna of the ear should be pulled downward and backward. When ear drops are given to an adult, the pinna is pulled upward and outward (option 1). The other options are incorrect.

The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. Which is the most appropriate action? ➖Remove the IV. ➖Check for a blood return. ➖Apply a warm compress. ➖Measure the area of infiltration.

✅Remove the IV. 📑Rationale: Blanching, coolness, and edema of the IV site are signs of infiltration. Because infiltration can be damaging to the surrounding tissue, the most appropriate action is to remove the IV to prevent any further damage. The nurse should not depend solely on the blood return for assurance that the cannula is in the vein because a blood return may be present even if the cannula is only partially in the vein. Warm compresses may be applied to the infiltrated area only after the IV is removed and only if the infiltrated solution is not damaging to the surrounding tissues. Measuring the area of infiltration should only be done after the IV has been removed so that further tissue damage is assessed.

The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. Based on these findings, the nurse plans to take which initial nursing action? ➖Remove the IV. ➖Slow the rate of infusion. ➖Call the primary health care provider. ➖Check for loose catheter connections.

✅Remove the IV. 📑Rationale: Phlebitis at an IV site can be determined by client discomfort at the site, as well as by redness, warmth, and swelling proximal to the catheter. The line should be removed, and a new line should be inserted at a different site. Options 2 and 4 are incorrect. The primary health care provider should be notified if phlebitis occurred, but this is not the initial action.

The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item? ➖Band-Aid ➖Alcohol swab ➖Betadine swab ➖Sterile 2 × 2 gauze

✅Sterile 2 × 2 gauze 📑Rationale: A dry, sterile dressing such as sterile 2 × 2 gauze is used to apply pressure to the site while the catheter is discontinued and removed. This material is absorbent, sterile, and nonirritating to the site. A Band-Aid may be used to cover the site after hemostasis has occurred. An alcohol swab or Betadine would irritate the opened puncture site and would not stop the blood flow.

Skin breakdown occurs on a client's hand at the site of an intravenous catheter that had medication infusing. The nurse determines that which adverse effect occurred? Refer to figure. ➖Phlebitis ➖Infiltration ➖Thrombosis ➖Extravasation

✅Extravasation 📑Rationale: Extravasation refers to the tissue injury that occurs from leakage of medication into surrounding skin and subcutaneous tissue; it can also cause tissue necrosis. Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection. Phlebitis can cause the development of a clot (thrombophlebitis). Infiltration is seepage of the intravenous fluid out of the vein and into the surrounding interstitial spaces. It is a form of tissue injury, but the injury is not to the extent that occurs with extravasation.

The nurse is assisting in caring for a client who is receiving morphine sulfate by continuous intravenous infusion. The nurse ensures that which medication is readily available if a morphine overdose occurs? Nalmefene Promethazine Atropine sulfate Protamine sulfate

✅Nalmefene (Revex) 📑Rationale: Nalmefene is a long-acting antagonist that is used to treat opioid overdose. Naloxone is also used to treat opioid overdose. Atropine sulfate is an anticholinergic used in the treatment of cholinergic crisis. Protamine sulfate is the antidote for heparin therapy, and promethazine is an antiemetic.

A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The licensed practical nurse (LPN) inspects the site and determines that the client has developed phlebitis. The LPN should plan to avoid which action in the care of this client? Notify the registered nurse (RN). Prepare to apply warm moist packs to the site. Prepare to discontinue the IV catheter at that site. Prepare to start a new line in a proximal portion of the same vein.

✅Prepare to start a new line in a proximal portion of the same vein. 📑Rationale: As directed, the LPN should discontinue the IV at the phlebitic site and apply warm, moist compresses to the area to speed resolution of the inflammation. Because phlebitis has occurred, the LPN also notifies the RN, who will contact the primary health care provider about the IV complication. The LPN should prepare for restarting the IV in a vein other than the one that has developed phlebitis.

A client rings the call light and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? Select all that apply. Remove the IV catheter at that site. Apply warm moist packs to the site. Notify the primary health care provider (PHCP). Start a new IV line in a proximal portion of the same vein. Document the occurrence, actions taken, and the client's response.

✅Remove the IV catheter at that site. ✅Apply warm moist packs to the site. ✅Notify the primary health care provider (PHCP). ✅Document the occurrence, actions taken, and the client's response. 📑Rationale: Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection and can cause the development of a clot (thrombophlebitis). The nurse should remove the IV at the phlebitic site and apply warm moist compresses to the area to speed resolution of the inflammation. Because phlebitis has occurred, the nurse also notifies the PHCP about the IV complication. The nurse should restart the IV in a vein other than the one that has developed phlebitis. Finally, the nurse documents the occurrence, actions taken, and the client's response.

The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which? ➖Phlebitis of the vein ➖Infiltration of the IV line ➖Hypersensitivity to the IV solution ➖An allergic reaction to the IV catheter material

✅Phlebitis of the vein 📑Rationale: Phlebitis at an IV site results in discomfort at the site and redness, warmth, and swelling proximal to the IV catheter. The IV catheter should be removed, and a new IV line should be inserted at a different site. The remaining options are incorrect; the signs and symptoms in the question are not associated with these conditions.

The nurse is caring for a client who had a small bowel resection the previous day and has continuous gastric suction attached to the nasogastric tube. Which intravenous solution should the nurse anticipate to be prescribed for the client? Normal saline 25% albumin 5% dextrose in water Lactated Ringer's solution

✅Lactated Ringer's Solution. 📑Rationale: Electrolyte solutions such as lactated Ringer's are used to replace fluid from gastrointestinal (GI) tract losses. Albumin is used for shock and protein replacement; 5% dextrose in water contains only glucose and no electrolytes to replace gastrointestinal losses. Normal saline contains no glucose, and glucose is essential for calories when a client takes nothing by mouth (NPO).

A client who is receiving anti-neoplastic medication by the intravenous (IV) route complains of pain at the insertion site of the IV. The nurse inspects the site and finds the area is swollen and reddened. The nurse further observes that the solution is no longer infusing. The nurse immediately takes which priority nursing action? Notifies the registered nurse (RN) Applies ice and elevates the extremity Applies heat to the IV site and slows the infusion Administers a local anesthetic to reduce the discomfort

✅Notifies the registered nurse (RN). 📑Rationale: When anti-neoplastic medications are administered by IV, the nurse vigilantly monitors the infusion to prevent extravasation of the medication. If medication escapes into surrounding tissues, pain, tissue damage, and necrosis can result. The nurse monitors for signs of extravasation such as redness or swelling at the insertion site or a decreased or stopped infusion rate. If extravasation occurs, the nurse should immediately notify the RN, who will then discontinue the infusion, leaving the needle or catheter in place, and call the primary health care provider.

A nursing student is assisting the clinic nurse with the administration of immunizations in the well-baby clinic. The student is asked to administer a measles, mumps, and rubella (MMR) vaccine to a child and prepares to administer the vaccine in which way? Intramuscularly in the thigh Subcutaneously in the upper arm Subcutaneously in the gluteal muscle Intramuscularly in the deltoid muscle

✅Subcutaneously in the upper arm. 📑Rationale: MMR is administered subcutaneously into the outer aspect of the upper arm. Each child should receive two vaccinations, the first between 12 and 15 months of age and the second between 4 and 6 years or 11 and 12 years. Options 1, 3, and 4 are incorrect.

The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred? ➖Phlebitis ➖Infection ➖Infiltration ➖Thrombosis

✅Infiltration 📑Rationale: An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited into the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The other options identify complications that are likely to be accompanied by warmth at the site rather than coolness.

The nurse administering medications to a client notes a prescription to give a subcutaneous dose of heparin sodium. The nurse should perform which action to give this medication safely? Massage the site after injection. Aspirate with the plunger before injecting. Give the injection using a 25- to 27-gauge, ½-inch needle. Withdraw medication using a 1½-inch needle and then change to a 1-inch needle.

✅Give the injection using a 25-27 gauge, ½-inch needle. 📑Rationale: Subcutaneous heparin sodium is given using a 25- to 27-gauge, ½-inch needle to prevent tissue trauma and inadvertent injection into muscle. (A 1-inch needle could inject the heparin sodium into the muscle.) The nurse does not aspirate or massage to prevent tissue trauma and bleeding.

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which is the appropriate action by the nurse? Change the IV tubing. Attach a new needleless device. Wipe the tubing port with povidone-iodine. Scrub the needleless device with an alcohol swab.

✅Change the IV tubing. 📑Rationale: The nurse should change the IV tubing because it has become contaminated and could cause systemic infection in the client. Wiping the port with povidone-iodine is insufficient and would be contraindicated regardless because the catheter will be attached directly to an angiocatheter in the client's vein. The needleless device has not been contaminated and does not need replacement or cleansing.

The nurse checks the peripheral intravenous (IV) site dressing and notes that it is damp and that the tape is loose. Which is the first action by the nurse? Stop the infusion immediately. Check that the tubing is securely attached. Increase the IV flow rate to assess for further leaking. Prepare to restart the IV at a site medial to the original site.

✅Check that the tubing is securely attached. 📑Rationale: If there is leakage at the IV site, the nurse should first locate the source. The nurse should assess the site further to be certain that all connections are secure. The nurse should not increase the IV flow rate. Although it is true that it may leak more, it may also cause more tissue damage if the IV were infiltrating. Information about the IV must first be gathered so that the cause of the leaking can be determined before interventions can be planned.

The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. The nurse planning the work assignment for the shift makes a notation to check the IV sites of these clients at which time interval? Every hour Every 2 hours Every 3 hours Every 4 hours

✅Every hour. 📑Rationale: Safe nursing practice includes monitoring an IV infusion at least once per hour in an adult client. The IV may be checked even more frequently, depending on whether medication also is being infused. Therefore, options 2, 3, and 4 are incorrect.

A client receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On data collection, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which has occurred? ➖Infection ➖Phlebitis ➖Infiltration ➖Thrombosis

✅Infiltration 📑Rationale: An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling at the IV site result when IV fluid is deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of IV solution will slow down or stop. The corrective action is to remove the catheter and start a new IV line at another site. Infection, phlebitis, and thrombosis are likely to be accompanied by warmth at the site, not coolness.

A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed for this client? 5% dextrose in lactated Ringer's solution 0.33% sodium chloride (⅓ normal saline) 0.45% sodium chloride (½ normal saline) 0.225% sodium chloride (¼ normal saline)

✅5% dextrose in lactated Ringer's solution. 📑Rationale: For this client, the goal of therapy is to expand intravascular volume as quickly as possible. In this situation, the client will likely experience a decrease in intravascular volume from blood loss, resulting in decreased blood pressure. Therefore, a solution that increases intravascular volume, replaces immediate blood loss volume, and increases blood pressure is needed. The 5% dextrose in lactated Ringer's (hypertonic) solution would increase intravascular volume and immediately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client's blood pressure. The solutions in the remaining options would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, the solutions would move into the cells via osmosis.

A client with a peripheral intravenous (IV) site calls the nurse to the room and tells the nurse, "The IV is not running right." Which findings would indicate an infiltrated IV? Select all that apply. Cool to touch Vein hard to touch Redness at the site Swelling at the site May not have a blood return

✅Cool to touch ✅Swelling at the site ✅May not have a blood return 📑Rationale: An infiltrated IV is one that has dislodged from the vein, and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line. The other options indicate phlebitis.

An adult client is admitted to the emergency department with acute extensive partial thickness burns to the lower extremities. The nurse anticipates the primary health care provider will initially prescribe which medications and route for pain control? Select all that apply. Oramorph SR orally Ketorolac intramuscularly Hydromorphone intravenously Morphine sulfate intravenously Fentanyl citrate intramuscularly Hydrocodone 5 mg and acetaminophen 500 mg orally

✅Hydromorphone intravenously ✅Morphine sulfate intravenously 📑Rationale: Opioid drugs are only given by the intravenous route for a burn injury because of problems in absorption from the muscle and the stomach. If given by the intramuscular, subcutaneous, or oral route, absorption would be delayed and pain control would be ineffective.

A client uses the call system to notify the nurse to say that "the IV hurts and my left hand is swollen." The nurse assesses the site and determines infiltration has occurred. In order of priority, which actions should the nurse take? Arrange the actions in the order they should be performed. All options must be used.

1. Stop the infusion. 2. Remove the intravenous catheter. 3. Apply a compress to the site. 4. Notify the registered nurse to start a new IV on the right extremity. 📑Rationale: Continuing to infuse the solution will increase the amount of fluid in the tissues, leading to further swelling and pain. Therefore, the first action is to stop the infusion. Since the infiltration has occurred, the nurse would remove the intravenous catheter, apply a compress to the site (the temperature of the compress is determined by the primary health care provider and agency procedure), and notify the registered nurse to start a new IV on the right extremity.

Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 24 hours to increase urine output and maintain the client's blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previously known data? Excessive bleeding Crackles in the lungs Incompatibility of the infusion Chest pain radiating to the left arm

✅Crackles in the lungs. 📑Rationale: Circulatory (fluid) overload is a complication of therapy. Signs include rapid breathing, dyspnea, a moist cough, and crackles. Blood pressure and heart rate also increase if circulatory overload is present. Therefore, since the nurse previously noted rapid breathing and coughing, the nurse should then assess for a moist cough and crackles. Hematoma is another potential complication and is characterized by ecchymosis, swelling, and leakage at the IV insertion site, as well as hard and painful lumps at the site. Allergic reaction is a complication of administration of IV fluids or medication and is characterized by chills, fever, malaise, headache, nausea, vomiting, backache, and tachycardia; this type of reaction could also occur if the IV solutions infused are incompatible; however, there was no indication of multiple solutions being infused simultaneously in this question. Chest pain radiating to the left arm is a classic sign of cardiac compromise and is not specifically related to a complication of IV therapy.

A client is scheduled for insertion of a peripherally inserted central catheter (PICC), and the nurse explains the advantages of this catheter. Which statement by the client indicates a lack of understanding about this type of catheter? It is reasonable in cost. There is less pain and discomfort. This type of catheter is very reliable. It is specifically designed for short-term use.

✅It is specifically designed for short-term use. 📑Rationale: PICC catheters are intended to be used for clients who need long-term catheter placement. It is reasonable in cost because the catheter does not need routine replacement, as do traditional peripheral IV catheters. The catheter is more comfortable for the client because there is no repeated venipuncture with catheter change. The catheter is also very reliable. It is less likely to infiltrate and can be used for administration of a number of different types of medications.

The nurse is caring for a client with liver disease. Laboratory studies are performed, and the client's serum calcium level is 13 mg/dL. The nurse checks to see that which medication is available in the stock medication supply area on the clinical nursing unit that may be needed to treat this calcium imbalance? Calcitonin Vitamin D Calcium chloride Calcium gluconate

✅Calcitonin 📑Rationale: The normal serum calcium level is 8.6 to 10 mg/dL. This client is experiencing hypercalcemia. Calcitonin, a thyroid hormone, decreases the plasma calcium level by increasing the incorporation of calcium into the bones, thus, keeping it out of the serum. Calcium gluconate and calcium chloride are used to treat tetany that results from acute hypocalcemia. In hypercalcemia, large doses of vitamin D should be avoided.