Fluid & Electrolyte (IV Therapy)

Veins.

Contain intraluminal valves

What is the primary danger related to a broken catheter tip?

Embolus

Catheter size

An 18-gauge catheter is used when administration of blood or blood products is possible, such as patients having major surgery or trauma. In a young adult, a 20-gauge catheter is appropriate for fluid maintenance. A 22-gauge catheter may be necessary with the older adult. This is less traumatizing to the vein and allows better blood flow to provide increased hemodilution of the IV fluids or medications. A butterfly needle (scalp-vein needle used with infants) is a specially designed needle for the administration of intravenous fluids.

Hematoma formation

Apply a pressure dressing to the site.

Deep veins.

Are usually accompanied by an artery

A patient has an order for the administration of 1000 mL of 0.9% normal saline at 100 mL/hr. The nurse begins the infusion at 0900. At noon the nurse notices that 500 mL has infused. Of the following options, which should be the nurse's highest priority action?

Assess the patient for symptoms of fluid volume overload.

Which of the following is a correct sequence for administering a medication by IV bolus through a saline lock?

Clean injection port, insert syringe of normal saline, aspirate for blood return, and flush with saline. Remove syringe, clean port, administer medication over recommended period, withdraw syringe, clean port, and flush port with normal saline at same rate as medication administration.

Which of the following is a correct sequence for administering an IV piggyback through a saline lock?

Cleanse the port with alcohol and assess the patency of the IV line by flushing it with 2 to 3 mL of sterile normal saline. Attach IV piggyback tubing to the saline lock, and administer the medication per order. When the infusion is completed, disconnect the tubing, cleanse the port with alcohol, and flush the IV line with 2 to 3 mL sterile normal saline.

A hypertonic solution used carefully in patients at risk for fluid overload because it pulls fluid into the vascular space.

D5LR D51/2 NS

The nurse is preparing an IV infusion before initiating an IV. The nurse removes the protective sheath covering the tubing insertion spike and accidentally touches the spike. What is the nurse's best action at this time?

Discard IV tubing and obtain a new one.

Site is reddened and tender

Discontinue IV site and notify health care provider. May apply warm moist pack.

Right time

Example: administered the medication at the prescribed frequency.

Right route

Example: administered the medication intravenously according to orders.

Right patient

Example: asked the patient to state his name and birthdate and looked at his identification bracelet.

Right dose

Example: calculated and prepared the amount of medication as necessary according to orders.

Right speed

Example: calculated the amount of time necessary to push the medication according to a drug reference.

Right drug

Example: compared the order with the medication label on the vial.

Right monitoring

Example: observed the patient during and after medication administration.

Right documentation

Example: recorded medication administration

Right flush or dilution

Example: verified compatibility with the drug and IV fluids.

The nurse performed hand hygiene and applied clean gloves to perform an intravenous (IV) tubing change. Which step(s) described in the following was missed or performed incorrectly? Remove IV dressing covering catheter hub and slow rate of infusion to keep-vein-open (KVO) by regulating the roller clamp. Fill drip chamber of old tubing, remove IV container from IV pole, and remove old tubing from the solution. Place insertion spike of new tubing into the old fluid container opening and hang it on the IV pole. Fill tubing rapidly with solution, creating air bubbles in the tubing. Turn roller clamp to the "off" position on the new tubing and remove as much air as possible. Turn roller clamp on the old tubing to the "off" position. Stabilize hub of the catheter, disconnect the old tubing from the catheter hub, and quickly insert adapter of new tubing into catheter hub. Open roller clamp on new tubing, and regulate IV drip according to health care provider's orders. Secure tubing with a piece of tape. Place label with date and time on tubing below drip chamber. Discard old tubing and used supplies, remove gloves, and perform hand hygiene.

Failing to close the roller clamp on the new tubing before inserting it into the fluid container.

Which of the following is an acceptable IV site in a child but not a routine site in adults?

Foot Rationale: The use of the foot for an IV site is used with infants and young children but is avoided in the adult because of the danger of thrombophlebitis. The forearm may be used in children and adults. The scalp is used for infants.

Arteries.

Have thicker vessel walls

Assessment Findings: Failure of fluids to infuse; alarming electronic infusion device Indicate: Occlusion

Intervention: Check for kinks in tubing, restrictive dressing, or patient laying on tubing; avoid forceful flushing; this may require site relocation

Assessment Findings: Saturated IV dressing with blood

Intervention: Check source of bleeding, reconnect tubing if disconnected or If bleeding at site, apply a pressure dressing over the site; change dressing

Assessment Findings: Pain, swelling, redness extending up from insertion site Indicate: Phlebitis

Intervention: Determine cause, apply heat, elevate limb, consider IV catheter removal

Assessment Findings: Pain, swelling, pallor, and coolness at IV insertion site Indicate: Infiltration

Intervention: Discontinue IV, insert new line in another extremity, elevate the extremity, wrap in warm moist towel for 20 minutes

Assessment Findings: Fever, chills, purulent drainage at IV site Indicate: Symptomatic of Infection

Intervention: Discontinue IV, retain previous catheter for possible culture, notify the health care provider

Assessment Findings: Shortness of breath, crackles in lungs Indicate: Fluid Volume Excess

Intervention: Slow the rate of infusion, notify the health care provider, raise the head of the bed, monitor vital signs

Catheter tip is broken off

Notify health care provider immediately because this is an emergency situation.

Abnormal serum electrolytes

Notify health care provider; additives in IV or type of IV fluid may be adjusted.

Poor skin turgor, concentrated urine, dry mucous membranes

Notify health care provider; this may require readjustment of infusion rate.

The nurse is changing IV fluids. She has performed hand hygiene and applied clean gloves. The nurse hung the new bag of fluids on the IV pole, removed the protective cover of the tubing port, removed the spike from the old bag, and accidentally touched the spike with her hand. Which action should be taken at this time?

Obtain a new IV tubing set, remove the protective cover of the spike and insert it into the tubing port of the IV bag she just hung. Prime the tubing.

Complication: Occlusion

Preventative measure: Avoid IV "running dry"

Complication: Infection

Preventative measure: Maintain strict asepsis

Complication: Phlebitis

Preventative measure: Rotate IV sites as needed

Complication: Fluid Volume Excess

Preventative measure: Use of volume-controlled devices, such as Volutrol burette

An adult patient developed a complication with his IV and it had to be removed, yet continued IV fluids were needed. Which site would be most appropriate for the nurse to choose?

Proximal to the previous IV site.

Crackles over left mid and lower lobes

Reduce IV flow rate and notify health care provider. These are likely complications from fluid excess.

The nurse is discontinuing peripheral IV access. Which of the following steps, if performed by the nurse, requires correction?

With dry gauze or an alcohol swab held over the site, apply light pressure and withdraw the catheter by using a slow, steady movement with the hub at a 10- to 30-degree angle. Apply pressure to the site for 1 to 2 seconds by using a dry, sterile gauze pad. Rationale: The catheter needle is held at a 10- to 30-degree angle for insertion, but should be removed keeping the hub parallel to the skin. Changing the angle of the catheter inside the vein could cause additional vein irritation, increasing the risk of postinfusion phlebitis. Pressure is applied to the site for 1 to 2 minutes, not seconds, to ensure hemostasis. Pressure will control bleeding and prevent hematoma formation. The gauze should be secured with tape. The patient should be instructed to report any symptoms of phlebitis because postinfusion phlebitis may occur within 48 hours after catheter removal. The nurse should document discontinuation of the IV access device, including the time the peripheral IV was discontinued, site assessment information, gauge and length of catheter removed, and condition of the catheter tip to determine that it is intact.

Volume-control administration (Volutrol, Buretrol) sets

small containers that attach just below the primary infusion bag or bottle.

The student nurse is watching the staff nurse discontinue a peripheral IV. The staff nurse removes the catheter and then looks at it. The student asks the nurse what she is looking for. What would be a correct response?

"I am inspecting the catheter for intactness."

The nursing staff attended an in-service on IV fluid management with discussion on patient safety. Which of the following statements, if made by one of the staff, indicates further instruction is needed?

"It is unnecessary to monitor infusion rates when an electronic infusion device is being used."

The nursing students are studying in a group. Which of the following statements, if made by a nursing student, indicates further instruction is needed?

"The bag of fluids should be changed when there is approximately 100 mL of solution left in the bag to avoid disruption in fluid therapy to the patient."

Advantages of administering medications by intravenous (IV) bolus:

-Ability to maintain a patient on a strict fluid restriction. -Avoids possible discomfort with highly alkaline medications compared with the subcutaneous or intramuscular (IM) route. -Time it takes to achieve constant therapeutic drug levels. -Quick route of administration in an emergency; rapid response.

Disadvantages of administering medications by intravenous (IV) bolus:

-Amount of time allowed for correcting errors. -Possibility of irritation to the lining of blood vessels.

A patient has been receiving intravenous (IV) antibiotics and as a result has had several IV site locations. What action can the nurse take to promote venous distention in the patient? Select all that apply.

-Apply a warm pack to the arm for several minutes. -Rub or stroke the patient's arm.

Which of the following are part of maintenance care of a peripheral intravenous site? Select all that apply.

-Changing IV fluids. -Changing IV tubing. -Regulating the IV flow rate. -Changing the IV dressing. -Ongoing assessment.

Which of the following would be consistent with infiltration? Select all that apply.

-Cool to touch. -Swelling around insertion site. -Pain with increasing infiltration.

An elderly patient is receiving 0.9% normal saline at 125 mL per hour. The nursing assistive personnel (NAP) reports the patient is complaining of feeling short of breath. The nurse determines the patient is experiencing fluid volume excess. What other symptoms would lead the nurse to this conclusion? Select all that apply.

-Crackles in lungs. -Peripheral edema. -Dyspnea.

Identify advantages of administering medication by the IV route. Select all that apply.

-Delivers medication quickly in an emergency. -Establishes therapeutic blood levels. -Causes less discomfort with highly alkaline medications that are irritating to subcutaneous or intramuscular tissue.

The nurse notices failure of flow in the drip chamber with the roller clamp open and an absence of swelling at the insertion site. What should the nurse do? Select all that apply.

-Determine patency by aspirating for a blood return. -Check for kinking of IV tubing.

Which of the following sites should be avoided for intravenous (IV) line insertion? Select all that apply.

-Foot of an adult. -Site distal to a previous venipuncture site. -Ventral surface of wrist (inner wrist). -Areas of venous bifurcation.

The nurse checks the identity of the patient, performs hand hygiene, and applies clean gloves. The nurse removes the old dressing, cleans the site with CHG solution in a back-and-forth motion, and allows the site to dry. The nurse applies a new manufactured catheter stabilization device, applies a transparent dressing, secures the tubing with tape, and labels the dressing with date and time of dressing change. The nurse discards used equipment and performs hand hygiene. The student nurse observing the nurse change the peripheral IV dressing correctly identifies actions the nurse should have performed. The student nurse is correct in identifying which two actions?

-How the dressing was labeled. -To stabilize the catheter when removing the old dressing.

Which of the following indicate that the infusion needs to be temporarily discontinued, the catheter removed, and the IV relocated? Select all that apply.

-Insertion site is pale, cool to touch, and extremity edematous. -Small amount of purulent drainage is at insertion site; redness is noted.

A confused elderly patient has pulled out her IV twice. The health care provider has ordered restraints and that the IV be restarted for the transfusion of packed red blood cells (PRBCs). Which factors in this situation may alter the rate of infusion? Select all that apply.

-Manipulation of the IV catheter by the patient. -Viscosity (thickness) and temperature of the infusion. -Improperly placed restraints.

Identify nursing precautions to ensure safe patient care when administering IV medications. Select all that apply.

-Observing for symptoms of adverse reactions. -Following the six rights of medication administration. -Being knowledgeable of the desired action and side effects of the medication. -Assessing vital signs before, during, and after infusion with potent medications. -Verifying the rate of administration with a drug reference or pharmacist. -Having the antidote available, if the medication has one.

Which of the following would be consistent with phlebitis? Select all that apply.

-Pain. -Redness.

When preparing to administer an IV medication, a nurse checks the health care provider's order with the medication administration record (MAR) and the label on the medication vial. The nurse verifies the IV route for administration. Next the nurse computes the correct dosage and withdraws the medication according to the MAR using the appropriate dilution. The nurse administers the medication intravenously at the time ordered and at the correct rate. Which of the six rights of medication administration did the nurse fail to demonstrate? Select all that apply.

-Right patient -Right documentation

The nurse is assessing the patient for signs and symptoms of fluid volume excess. Which of the following would indicate the patient is experiencing this complication and should be reported? Select all that apply.

-Shortness of breath and crackles in lungs. -Elevated blood pressure and edema.

The nurse is administering vancomycin (Vancocin) 500 mg by IV piggyback over 60 minutes. An hour later the nurse returns to find that approximately half of the infusion has been administered and the IV site appears swollen, pale, and is cool to the touch. What is the appropriate action to be taken for this unexpected outcome? Select all that apply.

-Stop the infusion -Provide extravasation care -Discontinue the IV

Which of the following sites should be avoided when initiating an intravenous infusion?

-The left arm of a patient who has a history of a left-sided mastectomy. -An area of venous bifurcation or palpation of valves. -Side of paralysis.

Which of the following situations indicates discontinuation of peripheral intravenous (IV) access? Select all that apply.

-The patient is being discharged to home on oral (PO) medications. -The electronic infusion pump keeps alarming, indicating "occlusion" on its screen, and the nurse is unable to flush the IV. -The patient's arm is swollen and cool to the touch; the patient complains of pain at the IV site.

If a nurse fails to monitor a patient's intravenous (IV) infusion, what complications could develop? Select all that apply.

-The patient may experience infiltration. -The catheter may clot off. -The patient may receive less than the prescribed amount of IV fluids. -The patient may receive more than the prescribed amount of IV fluids.

Identify the situations in which a peripheral intravenous (IV) line dressing requires changing. Select all that apply.

-The patient's IV dressing got wet during bathing. -There is blood underneath the transparent dressing from movement of the catheter.

The electronic infusion device (EID) is alarming after changing the bag of IV fluids on a continuous infusion. What could be the possible cause(s)? Select all that apply.

-The roller clamp is in the "off" position. -Air is present in the tubing.

A nursing instructor is assisting a student nurse to change the peripheral IV dressing on a patient. Which action, if made by the nursing student, indicates further teaching is necessary? Select all that apply.

-The student nurse applies sterile gloves and removes the old dressing, being careful to avoid dislodging the catheter. -After completing the dressing change, the student nurse documents in the patient's chart the presence of swelling, coolness, blanching, and complaints of pain at the insertion site. -The student nurse cleans the site with a povidone-iodine swab in a concentric circle and immediately applies a new dressing to protect against infection.

Which of the following are advantages of volume-controlled intravenous (IV) infusions? Select all that apply.

-There is less risk of rapid-dose infusion (as compared with IV push) because medications are diluted and infused over longer time intervals (e.g., 30 to 60 minutes). -It allows for administration of medications (e.g., antibiotics) that are stable for a limited time in solution.

The patient has an order to infuse gentamicin (Garamycin) 500 mg IV in 50 mL sodium chloride at a rate of 100 mL/hr every 4 hours. The patient does not have an order for continuous fluids, and therefore the medication is infused with primary tubing and the peripheral access device is saline locked between doses. Which of the following actions could cause contamination or increase the risk of infection? Select all that apply.

-When changing tubing, the nurse disconnects the old tubing and attempts to insert the adapter of the new tubing without removing the protective cap. -The nurse changes the primary intermittent tubing set every 96 hours. -When it is time to hang a new dose of gentamicin (Garamycin), the nurse connects the tubing to the injection port using the same needleless adapter that has been hanging on the IV pole for 4 hours without a protective cover.

The nurse is planning to administer an IV medication with a mini-infusion pump. The nurse has performed hand hygiene; verified the medication, dose, route, and time with the order; and explained the medication therapy to the patient. The nurse uses two patient identifiers to verify the right patient. The nurse connects the prefilled syringe to the mini-infusion tubing and places the syringe into the mini-infuser pump. The nurse connects the mini-infusion tubing to the main IV line and hangs the pump on the IV pole alongside the primary IV. The nurse set the pump to deliver the medication within the recommended time while allowing the primary line to continue to infuse. The nurse observes the patient for any signs of adverse reactions. What steps have not been completed? The nurse needs to: Select all that apply.

-gently push the plunger and fill the tubing with medication. -check that the syringe was secure in the mini-infuser pump. -wipe off the port with an alcohol swab before connecting the mini-infusion tubing to the main IV line. -press the button on the mini-infusion pump to begin the infusion. Rationale: The correct sequence for administering an IV medication with a mini-infusion pump is as follows: Check the patient's identification bracelet and ask the patient to state his or her name and one other identifier (identification of the patient is required before any medication administration); connect the prefilled syringe to mini-infusion tubing (tubing must be attached to syringe for infusion); carefully apply pressure to the syringe plunger, allowing the tubing to fill with medication (infusion tubing should be fluid filled and free of air bubbles to prevent air embolism); place the syringe into the mini-infuser pump and be sure the syringe is secure (to facilitate proper administration); wipe off the port with an alcohol swab (to reduce the transmission of microorganisms); connect the mini-infusion tubing to the main IV line and hang the infusion pump with syringe on the IV pole alongside the main IV bag (prevents delay in flushing after completion of infusion, maintaining patency of device); set the pump to deliver medication within the time recommended (for IV medication to be delivered at recommended rate); press button on the pump to begin the infusion. The main IV infusion normally continues to flow while medication infuses; after the medication has infused, check the flow regulator on the primary infusion, and regulate as needed (prevents infusion of excess fluid); observe the patient for signs of adverse reactions (early identification of a medication reaction or complications enables prompt intervention).

The nurse is preparing to administer a medication by the IV route. Which of the following actions indicates further instruction is needed? The nurse:

-removes the piggyback bag and tubing from the primary line after the piggyback has infused to prevent bacterial growth. -notes the time the piggyback is started on the pump in order to return at time of completion to turn the primary infusion back on. Rationale: The piggyback should be left in place with the tubing for future medication administration unless it is time to change the tubing. Establishment of a secondary line produces a route for microorganisms to enter the main line. Repeated changes in tubing increase the risk of infection transmission. (Check facility policy.) It is unnecessary to turn the primary infusion back on as it will automatically start when the piggyback infusion is completed. The nurse should determine patency and assess the IV site frequently for complications. The Volutrol should be gently rotated to ensure mixing and labeled to identify type and amount of medication added. If the patient is hypotensive, tachycardic, and complaining of itching and difficulty breathing, an allergic reaction should be suspected. The nurse should turn off the IV, follow facility policy for response to an allergic reaction, and notify the health care provider.

A hypotonic solution administered to dilute extracellular fluid and rehydrate cells.

0.45% NaCl

An isotonic solution most commonly used for fluid volume replacement.

0.9% NaCl LR D5W

At what angle should an IV catheter puncture the skin and vein during insertion in a middle-aged adult?

10 - 30 degree angle

Which of the following demonstrates the best documentation of discontinuation of an IV?

1030 20 Gauge 1 inch (2.5 cm) catheter removed from left forearm. Catheter tip intact. Site without redness, swelling, or bleeding. T. Rodriguez, RN.

The nurse is preparing an IV infusion before initiating an IV. Which of the following is a correct action performed by the nurse?

After spiking the bag of IV fluids, the nurse fills the drip chamber 1/3 to 1/2 full and primes the tubing, making sure there are no bubbles.

A nurse working in the emergency room has elected to use macrodrip IV tubing. For which patient would this be most appropriate?

A hypotensive adult trauma victim with cool, clammy skin.

The nurse has received an order to infuse an IV medication. Which of the following would be the safest choice of equipment to use?

A smart pump.

What is the rationale for avoiding taping over the connection of the tubing to the hub?

Access to the catheter hub is needed when changing tubing

When should the tourniquet be released a second time during the procedure for insertion of a peripheral intravenous device?

After a "flashback" of blood is observed and the catheter has been advanced off the stylet.

A patient has received 1000 mL of IV fluid in 2 hours. The patient has dyspnea, tachycardia, crackles in the lungs, and peripheral edema. What is the nurse's priority action at this time?

Slow infusion to keep vein open (KVO) and notify health care provider.

IV site cool to touch with swelling and complaints of tenderness at site

Stop infusion and discontinue IV; elevate affected extremity; restart new IV if continued therapy is necessary.

IV site tender to palpation with area of erythema

Stop infusion and discontinue IV; restart new IV if continued therapy is necessary; place moist, warm compress over area.

The nursing assistive personnel turned and repositioned the patient as requested. However, now the electronic infusion device is alarming. Which of the following situations is most likely to have set off the alarm?

The patient is lying on the tubing.

What additional supplies are required for administering a medication by IV bolus through a saline lock versus an existing infusion of IV fluids?

Two syringes with 2 to 3 mL of normal saline.

Superficial veins.

Typically are used for peripheral IVs

Piggy back

a small IV bag or bottle connected to short tubing lines that connect to the upper Y-port of a primary infusion line. The set is called a piggyback because the small bag or bottle is set higher than the primary infusion bag or bottle. In the piggyback setup, the main line fails to infuse when the piggybacked medication is infusing.

A nurse takes precautions to prevent an undesirable outcome when administering medications by the IV route. Which of the following actions may produce an undesirable outcome? The nurse:

adds piggyback infusion of an antibiotic to main line IV of parenteral nutrition.

Mini-infusion pump

battery operated and allows medications to be given in very small amounts of fluid within controlled infusion times with standard syringes.

A vital factor in the care of a peripheral IV infusion is the prevention of infection. Which of the following, if performed by the nurse, would indicate that the nurse requires further instruction in IV fluid therapy management? The nurse:

palpates the IV insertion site after the site is cleansed to verify vein location before needle insertion.