Ig Chapter 13 Study Guide (after the fact)

A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first?

Presence of an ulnar pulse

A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?

Report of headache and stiff neck

A registered nurse (RN) delegates client care to an experienced licensed practical nurse (LPN). Which standards should guide the RN when delegating aspects of IV therapy to the LPN? (Select all that apply.)

State Nurse Practice Act The facility's Policies and Procedures manual

A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?

Stop the infusion of intravenous fluids.

A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?

The client's left lower extremity is cool to the touch.

A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this client's teaching?

"Ask all providers to vigorously clean the connections prior to accessing the device."

A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this client's teaching?

"Avoid carrying your grandchild with the arm that has the central catheter."

While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?

"Grade 3 phlebitis at IV site"

A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene for a client who has a vascular access device?

"Use a plastic bag to cover the extremity with the device."

A client is prescribed 250 mL of normal saline to infuse over 4 hours via gravity. The facility supplies gravity tubing with a drip factor of 15 drops/mL. At what rate (drops/min) should the nurse set the infusion to deliver? (Record your answer using a whole number.) _____ drops/min

4 h x 60 mins = 240 mins 250 mL ÷ 240 mins = 1.04166666667 x 15 drops/mL = 15.6 rounded to 16 drops/min

Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right upper extremity PICC is intact, patent, and has a good blood return. Site clean and free from manifestations of infiltration, irritation, and infection. -Sue Franks, RN January 20: Purulent drainage from sacral wound. Wound cleansed and dressing changed. Dr. Smith notified and updated on client status. New orders received for intravenous antibiotics. -Sue Franks, RN January 13: Client alert and oriented. Sacral wound dressing changed. -Sue Franks, RN January 6: Right upper extremity PICC inserted. No complications. Discharged with home health care. -Dr. Smith Based on the information provided, which action should the nurse take?

Administer the prescribed medication.

A nurse responds to an IV pump alarm related to increased pressure. Which action should the nurse take first?

Check for kinking of the catheter.

A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multi-dose vial of heparin with a concentration of 100 units/mL. Which of the syringes shown below should the nurse use to draw up and administer the heparin?

D. 10 mL syringe

A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next?

Ensure an x-ray is completed to confirm placement.

A nurse assists with the insertion of a central vascular access device. Which actions should the nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.)

Include a review for the need of the device each day in the client's plan of care. Remind the provider to perform hand hygiene prior to starting the procedure. Ask everyone in the room to wear a surgical mask during the procedure.

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 should the nurse assess this client?

Infection

A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications?

Initiate a dedicated team to insert access devices.

A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which complications should the nurse assess? (Select all that apply.)

Phlebitis Thrombophlebitis

A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the client's skin during this procedure?

Place a washcloth between the skin and tourniquet.

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, which action should the nurse take to relieve pain?

Place warm compresses on the site.

A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?

Prepare to assist with chest tube insertion.

A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.)

Unique facility identifier Lot number related to the donor ABO group and Rh type of the donor

A client is prescribed 1000 mL of normal saline to infuse over 24 hours. At what rate should the nurse set the pump (mL/hr) to deliver this infusion? (Record your answer using a whole number.) ____ mL/hr

1000 mL ÷ 24 hours = 41.6 rounded to 42 mL/hr.

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?

Upper extremity swelling is noted.