Invasive I - IV Therapy

An infusion pump is mandatory when patients receive: a - lactated Ringer's. b - chemotherapy drugs. c - proton pump inhibitors (PPIs). d - normal saline IV fluid.

b - chemotherapy drugs. Rational Chemotherapy drugs require critical accuracy and an infusion pump is necessary. Infusion pumps are not mandatory with lactated ringer's, PPIs, or normal saline IV fluid.REF: Page 704

A nurse is preparing to administer ketorolac 0.5 mg/kg IV bolus every 6 hr to a school-age child who weighs 66 lb. The amount available is ketorolac injection 30 mg/mL. How many mL should the nurse administer per dose? Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero

0.5 mL

IV Flow Rates Manual IV tubing - gravity

(gtt/min) Always a whole number (Can't have 1/2 drop)

IV Flow Rates Using Electronic Infusion Pump

(mL/hr) Always a whole number (Can't have 1/2 drop)

A nurse is preparing to administer dextrose 5% in water IV to infuse at 100 mL/60 min. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number. ______________________ gtt/min

100 gtt/min

A nurse is assisting with care of a client who has a prescription for 3,000 mL of intravenous fluids over the next 24 hr. The nurse should set the IV pump to deliver how many mL/hr? Round to the nearest whole number ________________________ mL/hr

125 mL/hr

A nurse is preparing to administer dextrose 5% in water (D5W) 100 mL to infuse over 1 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? Round the answer to the nearest whole number ___________________________ gtt/min

25 gtt/min

A slogan that was developed to emphasize the importance of using a sterile alcohol pad to scrub the injection port with friction for at least 15 seconds when accessing a central line injection port or IV connection. Exceed the standard of care by scrubbing the hub when accessing a peripheral IV line.

"Scrub the hub"

What are the potentially serious complications of IV therapy? Select all that apply. 1 - Infiltration 2 - Infection 3 - Catheter embolus 4 - Site irritation resulting from tape

1 - Infiltration 2 - Infection 3 - Catheter embolus Rational Infiltration, infection, and catheter embolus are potentially serious complications of IV therapy. Site irritation is most likely not a serious, but a localized, reaction caused by tape. REF: Page 709, Table 36 2

Three main functions of IV therapy 1 - Maintenance Therapy 2 - Replacement Therapy 3 - Restorative Therapy

1. Maintenance therapy - meeting the daily needs of fluids and electrolytes 2.Replacement therapy - replaces fluid initially lost from vomiting, diarrhea, trauma, excessive perspiration. 3.Restorative therapy - replaces continuing losses, also medication administration, blood products, total parenteral nutrition. Replace blood lost d/t hemorrhage, pts with anemia

The primary IV tubing set, used in gravity delivery, is sized by the number of drops per milliliter (gtt/mL) to be delivered into the drip chamber. There are three major sizes: 1. Regular drops ________________ gtt/mL 2. Macrodrops _______________ gtt/mL 3. Microdrops __________________ gtt/mL

1. Regular drops (10 to 20 gtt/mL of fluid as specified by the manufacturer), used for administering IV therapy to most adult patients. 2. Macrodrops (10 to 15 gtt/mL), used for viscous (sticky or thick) fluids, such as blood; may be used for regular fluids. 3. Microdrops (60 gtt/mL), used when small amounts of fluid are required or when extreme care must be used to measure the exact amount; most often used for giving IV fluids to infants and children; recommended for older adults with fragile veins.

A nurse is preparing to administer acetaminophen 320 mg PO every 4 hr PRN for pain. The amount available is acetaminophen liquid 160 mg/5mL. How many mL should the nurse administer per dose? Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trialing zero

10 mL

A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride 1,000 mL to infuse at 100 ml/60. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? Round to the nears whole number _________________________ gtt/min

100 gtt/min

Correct size catheter

16 gauge for client who have trauma, rapid fluid volume 18 - 20 gauge for clients who are having surgery, rapid blood administration 22-24 gauge for other clients (children and adults) PowerPoint •16-18 for multiple traumas, surgery, or blood administration •20 gauge is used for adults, minor surgery/trauma and sometimes blood (18 is preferred) •22 gauge is used to peds or adults with small veins •24 peds

A patient is receiving heparin intravenously. What signs and symptoms would alert you to the patient having adverse effects of heparin? Select all 1 - Sleeplessness 2 - Bleeding gums 3 - Blood in urine 4 - Coughing 5 - Bruising

2 - Bleeding gums 4 - Coughing 5 - Bruising Rationale: All are signs of bleeding, which is a complication of heparin.

What is the nurse's primary responsibility in the daily care of a patient with a central line? 1 - Use sterile technique during insertion 2 - Flush the line according to agency policy 3 - Verify catheter placement with an x-ray examination 4 - Rotate the insertion site every 72 hours

2 - Flush the line according to agency policy Rationale: Nurses are responsible for the maintenance of central lines, which would include flushing to ensure patency. (1) Sterile technique is used during the insertion; however, central lines are usually inserted by physicians or advanced practice nurses who have undergone specialized training. (3) The catheter placement should be verified with a radiograph; however, this is the responsibility of the person doing the insertion. The nurse should not use the catheter for infusion until after placement has been verified. (4) The site is not usually changed so frequently. One of the advantages of central line placement over peripheral sites is longevity.

A nurse is preparing to administer metoprolol 200 mg PO daily. The amount available is metoprolol 100 mg/tablet. How many tablets should the nurse administer? Round the answer to the nearest whole number. Do not use a trailing zero

2 tablets

Peripheral venous access device

24 - 20 gauge catheters For continuous and intermittent IV medication admin Short term IV therapy (Can be done at home with assistance of a home health nurse)

A nurse is preparing to administer 0.9% sodium chloride (NS) 100 mL IV to infuse over 4 hr. The drip factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? Round the answer to the nearest whole number _________________________ gtt/min

25 gtt/min

Because of a communication error, the pharmacy says that there is a long delay for a replacement bag of TPN to be mixed and delivered to the unit for the patient. While awaiting the replacement bag of TPN, the nurse recognizes that a medical order is needed for which type of IV fluid? 1 - 0.45% Saline 2 - 5% Dextrose in water 3 - 10% Dextrose in water 4 - Lactated Ringer

3 - 10% Dextrose in water Rationale: If TPN is suddenly discontinued, a patient can experience hypoglycemia. (1) 0.45% saline is a common solution ordered for maintenance replacement of fluids. (2) 5% dextrose is most commonly used as a vehicle for piggyback medications. (4) Lactated Ringer is an isotonic solution that is used for cases of excessive fluid loss, such as trauma or major burns.

In which circumstance would the use of a burette be advised as a safety device 1 - A trauma patient needs several units of packed red blood cells 2 - The patient needs IV fluids, but no infusion pump is available 3 - An infant is at risk for IV fluid overload 4 - A confused patient keeps trying to unplug the infusion pump

3 - An infant is at risk for IV fluid overload Rationale: The burette provides a way to measure the exact amount of IV fluid that could flow into the infant. (1) The burette would not be used in the case of a trauma patient. (2) You could use a burette for a patient who needs IV fluids, but remember that the burette will hold a limited amount of fluid and you will have to refill the burette frequently, so it may cause more work. (4) If a patient unplugs an infusion pump, the pump is likely to continue on a battery. When the battery runs low, an alarm will begin to sound. If the battery depletes, the IV will not infuse. Use of a burette in this case serves no purpose.

A patient returns from physical therapy, and her IV has a very sluggish flow, but it was functioning well before going to physical therapy. What is the priority nursing action? 1 - Call the physical therapist and ask if anything happened to the IV during the treatment session 2 - Discontinue the IV and restart the IV at a new site 3 - Assess the IV insertion site and tubing and try repositioning the extremity 4 - Use a heparin flush to clear the line

3 - Assess the IV insertion site and tubing and try repositioning the extremity Rationale: Assess the site and try to troubleshoot; repositioning the extremity is one solution. Also, try to aspirate for a small blood clot. (See Table 36-3 for other troubleshooting tips.) (1) PT should have called you if something happened to the patient that created a potential danger. It is unlikely that you will gain any useful information by calling, but you could if you suspect an unusual circumstance. (2) Discontinue and restart, if you have tried to reestablish flow without success. (4) Use of a heparin flush requires a medical order.

A nurse is preparing to administer 0.9% sodium chloride 1 L IV to infuse over 8 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero. ________________________ gtts/min

31 gtts/min

At the beginning of the shift, there is 410 mL of fluid in the IV bag. A piggyback medication containing 150 mL is hung at 12:00 noon to run over 30 minutes. You hang a new bag of 1,000 mL at 1:00 p.m. to run at 125 mL/hr. At the end of shift there is 250 mL left in the bag. The count for the total amount of fluid infused during your shift ending at 7:00 p. m. is: 1 - 1260 mL 2 - 1285 mL 3 - 1560 mL 4 - 1310 mL

4 - 1310 mL Intake is 150 mL from the Piggyback medication, 410 mL from the old IV fluid infusion, and 750 mL infused from the bag hung at 1300. 150 + 410 + 750 = 1310 mL.

A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 min. The nurse should set the IV infusion pump to deliver how many mL/hr? Round the answer to the nearest whole number. Do not use a trailing zero.

400 mL/hr

A nurse is preparing to administer dextrose 5% in lactated Ringer's (D5LR) 1,000 mL to infuse over 6 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? Round the answer to the nearest whole number. Do not use a trailing zero.

42 gtt/min

A nurse is preparing to administer 0.9% sodium chloride IV infusion 1000 mL bag at a rate of 200 mL/hr for a client who has rhabdomyolysis. The nurse should expect the IV pump to infuse over how many hr? Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero. _____________________ hr

5 hr

A nurse is preparing to administer 400 mL of 0.9% sodium chloride IV over 8 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero. _____________________ gtt/min

50 gtt/min

A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? Round the answer to the nearest whole number. Do not use a trailing zero

83 gtt/min

A nurse is preparing to administer 0.9% sodium chloride (NaCl) 750 mL to infuse over 8 hr. The nurse should get the IV pump to deliver how many mL/hr? Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ______________________ mL

94 mL

A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include? A - "Avoid driving until the medication's effects are evident." ​B - "Take the medication on an empty stomach." ​C - "Stop taking the medication immediately for headache." ​D - "Diarrhea is an adverse effect of this medication."

A - "Avoid driving until the medication's effects are evident." Rational A -Several CNS-related effects are common, including drowsiness, dizziness, headache, and confusion. Therefore, until the client knows how the medication will affect her, she should not drive a vehicle. B- The medication causes nausea and gastrointestinal distress, so the client should take it with milk or meals. C - Abrupt withdrawal of baclofen, a centrally acting muscle relaxant, might cause seizures, fever, and hypotension. The client should notify the provider if headache persists. D - Constipation is an adverse effect of this medication.

A __________________________ is a long-term peripheral venous access device (VAD), a device that keeps a vein open for long-term intermittent medication administration.

A SALINE LOCK is a long-term peripheral venous access device (VAD), a device that keeps a vein open for long-term intermittent medication administration. ~children are freed from IV tubing, repeated "sticks" ~remains in place and periodically flushed with sterile saline to prevent clotting and documented

Controlled-Volume Intravenous Set

A dose of diluted medication can also be given through a controlled-volume administration set. In most cases, an infusion pump (a machine that delivers IV fluids at a rate that is set by the nurse) is used to administer fluid or medication. However, the controlled-volume system is sometimes used as a safety backup between the primary IV bag and the entry to the infusion pump to prevent free flow of fluid. It can be used for administration of fluids to infants, children, and older adults. Using a controlled-volume set decreases likelihood of fluid overload because only a specified amount of fluid is available to be infused at any one time.

The provider prescribes the type of IV fluid, the volume to infuse, and either the rate at which to infuse the IV fluid or the total amount of time it should take to infuse the fluid. The nurse regulates the IV infusion, either with an IV pump or manually, to be sure to deliver the right amount.

A fluid bolus is a large amount of IV fluid to give in a short time, usually less than 1 hr. A fluid bolus rapidly replaces fluid loss from dehydration, shock, hemorrhage, burns, or trauma. (example pain medication) 18- gauge or larger is essential for maintaining the rapid rate necessary to give medications as an IV bolus. Use extreme caution and observing for adverse reactions or complications such as redness, burning, or increasing pain

Central venous access devices (CVAD)

A peripherally inserted central catheter (PICC) is a type of central venous access device that is inserted for moderate-length therapy. The tip of the catheter usually terminates in the SUPERIOR VENA CAVA. Specially trained RNs may insert the PICC line.

A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down down following a spinal cord injury. Which of the following statements by the adolescent indicates a need for further teaching? A- "I need to catheterize myself twice a day." B - "I carry a water bottle with me because I drink a lot of water." C - "I use a suppository every night to have a bowel movement." D - "I do my wheelchair exercises sitting in my chair."

A- "I need to catheterize myself twice a day." Rational A - In most cases, paralysis from waist down affects bladder and bowel control. Catheterization should be performed every 4 to 6 hr, and as needed. Infrequent emptying of the bladder can result in urinary tract infections. B - A client who is paralyzed from the waist down is at increased risk for urinary tract infections. Therefore, drinking plenty of water is appropriate. C - Using a suppository to stimulate a bowel movement every 1 to 2 days is appropriate. D- Wheelchair exercises are appropriate to prevent skin breakdown and increase upper body strength.

Nursing Intervention - IV therapy

Assess the lungs for signs of crackles indicating fluid overload. Crackles in lungs may indicate fluid overload from IV infusions.

Older adults clients, clients taking anticoagulants, or client's who have fragile veins

Avoid tourniquets Use a blood pressure cuff instead Do not slap the extremity to visualize vein Avoid rigorous friction while cleaning the site

A nurse is reinforcing teaching with a client who is taking benztropine to teat Parkinson's disease. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? A - Excessive salvation B - Difficulty voiding C - Diarrhea D - Slow pulse

B - Difficulty voiding Rational A - The nurse should instruct the client that an adverse effect of the medication is dry mouth, due to the anticholinergic response of the medication, not excessive salvation. B - The nurse should instruct the client to report difficulty voiding as an adverse effect of benztropine, which may indicate urinary retention. Benztropine is an anticholinergic medication that helps decrease the rigidity and tremors of Parkinson's disease. C - The nurse should instruct the client to report constipation, which is due to the anticholinergic response of the medication that slows peristalsis. D - The nurse should instruct the client to report tachycardia not bradycardia, which is due to the anticholinergic response of the medication.

Good Veins to choose from

Back of hand (Dorsal basilic or cephalic) Forearm (Basilic or cephalic) Antecubital - veins are large usually visible palpable and easily accessible. The hard part would be that the arm would have to be immobilized to protect the venipuncture site from dislocation and infiltration. This site is uncomfortable for the patient and is usually reserved for lab

A nurse is caring for an older adult client who has a fractured hip. The client says, "I guess I've lived long enough and my time is up." Which of the following responses should the nurse make? A - "You are in really good shape for your age." B - "This is just a minor setback. You will be back on your feet in no time." C - "You feel as though your life is ending?" D - "The doctors are going to take good care of you. There is nothing to worry about.

C - "You feel as though your life is ending?" Rational A - This response does not address the client's concerns, devalues the client's feelings, and inhibits effective communication. B - This response devalues the client's feelings. It uses a cliché and provides false reassurance, both of which inhibit therapeutic communication. C - This response uses restatement and clarification of the client's feelings to promote therapeutic communication. It addresses the client's immediate concerns. D - This response focuses on the doctors and not on the client. This is inappropriate when promoting therapeutic communication

A nurse is collecting data from a client who has osteomyelitis following a compound fracture of the right lower leg. Which of the following findings should the nurse expect? A - Low erythrocyte sedimentation rate (ESR) B - Pallor of the extremity C - High white blood cell count (WBC) D - Extremity is cool to the touch

C - High white blood cell count (WBC) Rational A - The ESR measures the weight of the erythrocytes circulating within the blood stream. Certain conditions such as infection, inflammation, cancer, or cell death cause an increase in the fibrinogen content of the plasma and, ultimately, cause the RBCs to weigh more and settle faster. The client who has osteomyelitis will have an elevated sedimentation rate. B - The client who has compartment syndrome following a fracture may develop a manifestation of pallor. However, the client who has osteomyelitis would have redness, swelling, and heat at the site. C - Osteomyelitis is an infectious process involving a bacterial infection of the bone. The causative organism is frequently Staphylococcus aureus. The body's response to the bacterial infection is to increase WBCs in order to fight the infection. D - The client who has compartment syndrome following a fracture may develop a manifestation of poikilothermia (taking on the temperature of the environment), or coolness to the touch. However, the client who has osteomyelitis would have redness, swelling, and heat at the site.

The nurse is collecting data on a client who has multiple sclerosis. Which of the following findings should the nurse expect? A - Bulging of the eyeball B - Shuffling gate C - Involuntary movement of the eyes D - Facial grimacing

C - Involuntary movement of the eyes Rational A - Exophthalmos is a manifestation of hyperthyroidism. B - A shuffling gait is a manifestation of Parkinson disease. C - Nystagmus, or involuntary movement of the eyes, is a manifestation of multiple sclerosis. D - Facial grimacing is a manifestation of Huntington's disease.

A nurse is caring for a client who has balanced skeletal traction with a Thomas splint for the treatment of a fracture of the femur. Which of the following actions should the nurse take to prevent skin breakdown? A - Apply lotion to the skin around the edges of the splint. B -Turn the client every 4 hr. C - Pad the top of the splint with protective dressings. D - The nurse should apply a footplate to the bed.

C - Pad the top of the splint with protective dressings. Rational A - The nurse should avoid applying lotion under or around the edges of the splint due to the risk of skin breakdown from moisture. B - The nurse should properly position the client in bed every 2 hr and use a low-air-loss mattress to prevent skin breakdown because the client is unable to turn in bed. C - The nurse should pad the top of the splint with protective dressings or soft cotton padding to prevent skin breakdown at the splint edge. D - The nurse should apply a footplate to the bed if the client is at risk for foot drop.

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia? A - Monitor for elevated blood pressure. B- Provide analgesia for headaches. C- Prevent bladder distention. D - Elevate the client's head.

C- Prevent bladder distention. Rational A - Elevated blood pressure is a serious manifestation of autonomic dysreflexia. However, it is not a causative agent. B- A severe headache is one of the manifestations of autonomic dysreflexia. However, it is not a causative agent. C - Autonomic dysreflexia can occur in clients who have a spinal cord injury at or above the T-6 level. Autonomic dysreflexia can occur as a result of an irritation, or stimulus to the nervous system below the level of injury. Triggers of autonomic dysreflexia include bladder distention, insertion of rectal suppository, enemas, or a sudden change in position D - A sudden change in position can trigger autonomic dysreflexia.

A nurse is caring for a client who has an IV pump that begins to alarm. Which of the following actions should the nurse take? A - Silence the alarm B - Plug the pump into another outlet C - Discontinue the IV infusion D - Tag the pump and notify engineering.

D - Tag the pump and notify engineering. Rational A - Silencing the IV pump alarm does not resolve the malfunction of the IV pump and places the client at risk during the time she is not receiving the IV infusion. B - Plugging the pump into another outlet will not resolve the malfunction of the IV pump and places the client at risk during the time she is not receiving the IV infusion. C - The nurse should continue the IV infusion until the infusion is complete. D - The nurse should find another pump for the client's infusion while tagging the malfunctioning pump so no one else will use it.

A nurse in a community clinic is caring for a 20-month-old toddler who has spiral fractures of the right ulna and radius. Which fo the following findings should the nurse recognize as a potential indication of abuse? A - The child begins to cry when her arm is examined by the provider. B - The child's examination shows a single injury. C - The child was brought to the facility 30 min after the injury occurred. D - The parents report that the child injured herself by falling off the couch.

D - The parents report that the child injured herself by falling off the couch. Rational A - Children who have been abused might not cry when faced with a painful examination or procedure because they are not used to receiving comfort following pain. B - Children who have been abused should be examined carefully for old injuries as well as current ones. The child might have bruises at varying stages of healing or signs of old fractures or burns, indicating an ongoing pattern of abuse. C - An unexplained delay in seeking treatment, such as several hours or days is a warning sign of abuse. Bringing the child to the facility 30 min after the injury occurred is not a warning sign of abuse. D - Spiral fractures occur due to the twisting of a limb; a simple fall from a couch should not cause a spiral fracture to occur. An indication of abuse is present when the parent's report of the injury does not match the type of injury incurred or if the developmental age of a child makes certain types of injury impossible.

Nursing guidelines for Peds Intravenous Lines (Table 22.2) Adolescent (Age 12-18 Years)

IV Placement (Ideal site) - Hand, forearm (less dominant) Preparation of child - Prepare patient several hours to a day before procedure, if possible. Needs time between preparation and insertion to absorb explanations and ask questions. For most adolescents, approach discussion on an adult level. Explain need for IV therapy and expected duration and show equipment. May need much support for acceptance of therapy.

Do's -Use the most distal veins of upper extremity first -Palpate the veins prior to insertion -Use veins appropriate for the infusate -Use veins that will most likely last for 48-72 hours -Use the smallest cannula that will facilitate the infusate

Don'ts •Do not use veins in the lower extremities •Do not use veins that are irritated or sclerosed •Avoid areas of flexion •Avoid veins in the antecubital •Do not use a tourniquet on fragile veins, use a B/P cuff •Do not use the veins on an extremity that -Has had a mastectomy -Has marked edema -Is impaired from a CVA -That is partially amputated -That has burn -That has a AV fistula or graft

Hematoma

Ecchymosis at the site (bruise)

Phlebitis or thrombophlebitis

Edema; throbbing, burning, or pain at the site; increased skin temperature; erythema; a red line up the arm with a palpable band at the vein site; slowed rate of infusion

Filters trap small particles such as undissolved medication or salts that have precipitated from solution

For solutions containing lipids or albumin, a 1.2-micron filter is used. A special filter is needed for blood components.

Isotonic solutions

Have the same concentration, or osmolality, as blood and are used to expand the body's fluid volume. When exposed to isotonic solutions body cells stay approximately the same size. ~ 0.9% Saline - Trauma, diabetic ketoacidosis, blood transfusions, and hyponatremia ~5% Dextrose in water - Vehicle for some IV piggyback medications and hyperkalemia 5% Dextrose in 0.2225% saline - Postoperative, common maintenance fluid Ringer lactate - Trauma, dehydration from severe diarrhea or vomiting

Administering Intravenous Medications The medication is also absorbed more rapidly, which is of value. The nurse monitors the IV site carefully for patency, infiltration, and inflammation. ~Because the medication reaches the heart and brain within seconds, adverse reactions can occur quickly. A rapid rate of flow of IV solution can cause fluid overload (manifested by an increased pulse rate or blood pressure, distended neck veins, and puffy eyes), or a slow rate of infusion can result in clot formation that obstructs the patency of the IV line

IV medications can cause phlebitis, and the nurse must observe the child's IV site hourly for reddened areas or signs of inflammation. Infiltration is a risk for children who are active, and the site should be observed hourly, because infants cannot communicate the burning or pain that may accompany infiltration. Leakage at the IV site, a tense tissue turgor, and cool, blanched skin around the IV site may indicate infiltration; the registered nurse (RN) should be notified. ~A pacifier should be provided for infants who are given nothing by mouth status (NPO) to fulfill their developmental need for sucking.

Check your state's nurse practice act to determine whether an IV certification is necessary to administer IV medications.

In some states, LPN/LVNs are not allowed to perform IV therapy. All nurses must monitor IV therapy.

Parallel, or Y, Intravenous Set

Is used to infuse certain blood product The blood product is placed on one side, and a bag of normal saline is placed on the other side. The saline is started first, and then the blood administration is begun. The saline is stopped while the blood is running. Blood products are never infused into the same IV line as medications or other fluids. When the transfusion (introduction of blood components into the bloodstream) is complete, the tubing is flushed with the normal saline solution.

It is _____________________ to be able to feel or see the vein

It is NECESSARY to be able to feel or see the vein venoscope can be used to illuminate the tissue and outline the vein

Intravenous (IV) therapy involves infusing fluids via an IV catheter to administer ____________

Medications, supplement fluid intake, or provide fluid replacement, electrolytes, or nutrients. Never administer IV medication through tubing that is infusing blood, blood products, or parenteral nutrition solutions. Verify the compatibility of medications with IV solutions before infusing a medication through tubing that is infusing another medication or IV fluid.

catheter embolism

Missing catheter tip on removal, severe pain at the site with migration, absence of findings if no migration. A shaving or piece of catheter breaks off and floats freely in the vessel

IV Therapy in older adults Life span consideration

Monitor electrolyte levels closely; fluid therapy can rapidly change the fluid and electrolyte balance.

When your patient has an IV, you are responsible for ensuring that the correct solution is infusing at the prescribed rate

Movement of the patient can alter the rate. Check the flow rate after the patient has been ambulating, returns from a test or treatment, has been turned in bed, or has been up to the bathroom. Keeping the intravenous solution running ~Each state sets the scope of practice for the LPN/LVN, but each organization can narrow the scope. It is important, therefore, for you to know what your specific organization does and does not allow the LPN/LVN to do.

Infiltration or extravastion

Pallor, local swelling at the site, decreased skin temperature around the site, damp dressing, slowed rate of infusion

Patient-controlled analgesia (PCA) pumps

Patient-controlled analgesia (PCA) pumps are commonly used in both hospitals and home settings. This pump is used for pain control, and it has a remote-control button by which the patient can administer a controlled bolus of pain medication. The pump is programmed to allow a set amount at specified intervals.

Rights of IV Therapy

Right solution Right dose Right route Right time Right patient

The average adult needs 1500 to 2000 mL of fluids in a 24-hour period to replace fluids eliminated by the body.

Some patients have decreased fluid intake. Others experience fluid loss through hemorrhage, severe or prolonged vomiting or diarrhea, profuse perspiration, and moderate to excessive drainage from wounds, especially from burn wounds. Fluid balance is also affected by increased metabolic processes, for example, during a fever. Accurate recording of the patient's intake and output (I & O) is needed to determine the amount of fluids necessary for daily replacement. The primary care provider considers laboratory tests related to electrolytes when ordering replacements such as sodium, potassium, and chloride. Patients who require fluids by the IV method are place on I & O recording to monitor for fluid overload.

Primary IV Set

The primary IV infusion setup consists of a bag of solution, a regular tubing set, a needleless connector, and an IV stand. A filter may be added. The IV tubing set consists of the spike end, which is inserted into the bag; the drip chamber; the tubing; a flow regulator or clamp; and a Luer-Lok connector. The primary IV infusion setup is used for any type of IV therapy except the administration of blood products, which requires a special set with a filter in the drip chamber.

Client who are obese

Use anatomical landmarks to find veins

Difference between Veins and Arteries

Veins - Dark red, unoxygenated blood, NO PULSE. Valves - seen as bulges along the vein. Keep the blood from flowing toward the heart. Superficial veins are found just under the skin. They are the veins normally used for IV access. Tissue supplies - Multiple, and appear in a network formation. An injury to one usually is not serious because another will perform its function. Arteries - Bright red, oxygenated blood. Pulsation with ventricular contraction. Valves do not occur in arteries where blood flows away from the heart. Arteries are found deeper in the skin and surrounded by muscle, which protects them. One in 10 are superficially located and identified as aberrant arteries. Supplies one area. Any injury or occlusion can endanger the tissue supplied.

Table 3 - 5 med surg The Four Acid-Based Imbalances

*Respiratory acidosis - slow, shallow respirations. Respiratory congestion or obstruction. Blood gas values - pH <7.35 & PaCO2 >45 mm Hg *Metabolic acidosis - Shock (poor circulation) Diabetic ketoacidosis, rental failure, diarrhea - Blood gas - pH - <7.35 & HCO3 - <22 mEq/L * Respiratory alkalosis - Hyperventilation -Blood Gas - pH >7.45 & PaCO2 <35 mm Hg * Metabolic alkalosis - vomiting, excessive antacid intake, hypokalemia - Blood Gas - pH > 7.45 & HCO3 - >26 mEq/L

Cellulitis

-Pain; warmth; edema; induration; red streaking; fever, chills, and malaise. treatment, stop IV, elevate the extremity, warm compresses 3-4, culture if drainage is present

Goals of nursing care for a patient receiving an IV infusion are to:

-Prevent infection. -Minimize physical injury to the veins and surrounding tissues. -Administer the correct fluid at the prescribed time and at a safe rate of flow. -Observe the patient's reaction to the fluid and medications being administered. ~ Watch for fluid overload

A nurse is preparing to administer methylprednisolone 10 mg by IV bolus. The amount available is methylprednisolone injection 40 mg/mL. How many mL should the nurse administer? Round the answer to the nearest tenth. Do not use a trailing zero

0.3 mL

Trouble Shooting - Intravenous Flow 1 - Height of infusion container 2 - System Vent 3 - Position of tubing 4 - Position of the extremity where the site is located 5 - Any possible obstruction to the flow 6 - When the filter was changed 7 - Position of the catheter within the vein 8 - If other measures are unsuccessful, try to aspirate blood from the catheter 9 - NEVER FORCE FLUSH AN IV CATHETER

1 - Height of infusion container (infusion pumps may be somewhat less sensitive to the height of the container) - The patient may have changed position. The container should be at least 36 inches above the heart. 2 - System vent - Air vent occlusion will prevent the flow. 3 - Position of tubing - Tubing may be kinked, obstructing the flow. Tubing hanging below the bed interferes with gravity flow. 4 - Position of the extremity where the site is located - Flexion of the extremity may compress the vein, slowing the flow. 5 - Any possible obstruction to the flow - A protective device on the limb may be too tight. Tape may be compressing the extremity. 6 - When the filter was changed - The filter may be occluded. 7 - Position of the catheter within the vein - The catheter may be lying against the vein wall. Turning the catheter slightly may reposition the tip. 8 - If other measures are unsuccessful, try to aspirate blood from the catheter - A small clot may be obstructing the catheter. Aspiration may withdraw the clot. 9 - Never force flush an IV catheter - Forcefully flushing a catheter SEND THE CLOT INTO THE BLOODSTREAM. This creates an embolus that could lodge anywhere, including the brain, heart, or lungs.

The nurse must assess for complications of IV therapy. Signs of common complications include (Select all) 1 - Swelling and coolness at the site 2 - Redness along the vein 3 - Pale skin at the insertion site 4 - Immobility of the extremity 5 - Erythema and tenderness 6 - Vomiting and diarrhea

1 - Swelling and coolness at the site 2 - Redness along the vein 3 - Pale skin at the insertion site 5 - Erythema and tenderness Rationale: Swelling, coolness, or pale skin at the insertion site is a sign of an infiltration of a nonirritating IV fluid. Erythema and tenderness are signs of infiltration of an irritating medication or fluid. Redness along the vein can occur with a very irritating medication. Redness and tenderness could also signal a localized infection. (4) Use of an armboard could decrease the patient's mobility, but armboards are generally not necessary if the IV is properly secured and if the antecubital site is avoided. (6) Vomiting and diarrhea are not usually directly associated with IV fluid therapy or catheter insertion.

Principles that affect the rate of flow for IV infusions NOT administered by a pump are

1 - The higher the container is placed above the level of the patient's heart, the faster the rate of flow 2 - Fuller containers, the faster the rate 3 - The more viscous (thicker) the fluid, the slower the flow - ex - red blood cells will flow more slowly than 5% dextrose in water 4 - The larger the diameter of the needle and tubing the faster the flow 5 - The higher the pressure within the vein, the slower the flow. As an infusion progresses and the veins become fuller, the IV solution may drop more slowly. 6 - Fluid will pass through a straight tube faster than thought one that is coiled or hanging below the level of the cannula. *No attempt should be made to "Catch up" (circulatory overload/volume excess = edema)

Edema in extremities

Apply digital pressure over the selected vein Apply pressure with a swab Cannulate the vein quickly

A nursing is adding a secondary piggyback to the patient's existing IV. To use gravity system, the nurse should hang: 1 - The piggyback bag higher than the maintenance IV bag 2 - The maintenance IV bag at the same height as the piggyback bag 3 - The piggyback bag and the maintenance IV bag using Y tubing 4 - The maintenance IV bag after the piggyback bag is completed.

1 - The piggyback bag higher than the maintenance IV bag Rationale: If the piggyback bag is higher than the maintenance bag, the fluid from the piggyback will flow in first. As soon as the piggyback is empty, fluid from the maintenance bag will begin. Recall that the fluid level in the piggyback bag must be higher throughout the entire infusion. (2) If the maintenance bag and the piggyback bag are at the same height, the fluid from the maintenance bag can flow up into the piggyback (if there is no backflow valve within the tubing). The bag that has the greater volume will flow first. As the volume of the greater bag depletes, the less the bag will begin to flow. Eventually both would infuse, but the two bags of fluid would be competing for flow. (3) Y-tubing is generally reserved for blood product infusion. It would be an inappropriate waste of a more expensive tubing (which has a special filter). (4) You can manually hang or restart the maintenance IV after the piggyback is completed. In fact, if fluid overload is an issue and you do not have an infusion pump, you may choose to do this; however, this completely eliminates the advantage of having a piggyback setup.

A nurse is preparing to administer dextrose 5 % in water (D5W) 1,000 mL IV to infuse over 10 hr. The nurse should set the IV infusion pump to deliver how many mL/hr? Round the answer to the nearest whole number. Do not use a trailing zero

100 mL/hr

A nurse is preparing to administer lactated Ringer's solution IV to infuse at 120 mL/hr for a client who has a respiratory disorder. The drop factor on the manual IV tubing is 60 gtt/mL.. The nurse should set the IV flow rate to deliver how many gtt/min? Round to the nearest whole number ________________________ gtt/min

120 gtt/min

A nurse is preparing to administer lactated Ringer's 1000 mL to infuse over 12 hr. The drop factor on the manual tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? Round the answer to the nearest whole number. Using a leading zero if it applies. Do not use a trailing zero. _____________ gtt/min

14 gtt/min

A nurse is preparing to administer amantadine 150 mg PO for a client who is experiencing Parkinsonism due to an antipsychotic medication. Available is amantadine 50 mg/5mL oral solution. How many mL should the nurse administer? Round the answer to the nearest whole number.

15 mL

You respond to a patient complaining of pain, burning, and wetness over the peripheral IV site. On assessment, you find that the IV insertion site is tender and cool to touch. These are signs and symptoms of 1 - Phlebitis 2 - Infiltration 3 - Infection 4 - Venous spasm

2 - Infiltration Pain, burning, coolness, and wetness over the IV site are signs of infiltration of IV fluid into the tissue. (1) Phlebitis is inflammation of a vein. (3) Infection will cause the area to be hot to the touch. (4) The first sign of a venous spasm is sharp pain extending up the arm.

Which would be the most accurate way to assess for dehydration in an elderly patient? 1 - Skin turgor 2 - Urine output 3 - Respirations 4 - Thirst levels

2 - Urine output Inadequate urine outflow is an indication that dehydration is occurring. A decrease in weight would be a secondary finding and would occur later. (1) Skin turgor is not a good indicator of dehydration in older adults. (3) Respirations are not a good indicator of dehydration in older adults. (4) Dehydration in older adults is often not accompanied by thirst.

The patient is receiving a blood transfusion and develops a fever, shortness of breath, and a diffuse rash within 10 minutes after the start of the transfusion. What is the priority action? 1 - Take vital signs and call the primary care provider 2 - Place the patient in a supine position and start oxygen 3 - Stop the blood and change the IV tubing 4 - Slow the blood and check the vital signs

3 - Stop the blood and change the IV tubing Rationale: First stop the blood and change the IV tubing so that the patient does not receive the blood that is within the tubing. (1, 2, 3) Taking the vital signs, starting oxygen, and calling the primary care provider are appropriate actions. The high Fowler position is better initially for oxygenation; if the patient's vital signs suggest shock, the supine position is used. Slowing the blood is not an adequate measure if a transfusion reaction is in progress.

A nurse is reinforcing teaching for a female client who has multiple sclerosis and a new prescription for dantrolene. Which of the following client statements indicates an understanding of the teaching? A - "I need to notify my provider if I don't get some relief from my muscle spasms within 3 months." B - "I should return to the clinic to have my calcium level checked every 6 weeks." C - "I should take this medication when my spasms are bad." D - "I am glad this medication is safe to take if I get pregnant."

A - "I need to notify my provider if I don't get some relief from my muscle spasms within 3 months." Rational A - Dantrolene is highly hepatotoxic. If the client does not get relief from muscle spasms within 45 days, the provider should discontinue the medication. B - Dantrolene is highly hepatotoxic. The client should have periodic tests for kidney function, liver function, as well as blood cell counts. C - The client should take dantrolene every day as the prescription indicates, not on a PRN basis for spasticity. D - Dantrolene is pregnancy category C. For this category of medications, animal studies might have demonstrated a risk to the fetus, but studies on women are not available. It is used with caution during pregnancy.

A nurse is caring for an older adult client who has a hip fracture and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following statements should the nurse make? A - "Rehabilitation began with the client's admission to the hospital." B - "The focus of rehabilitative care is the client's physical injuries." C - "The client will require long-term rehabilitation services." D - "The client will require inpatient rehabilitation services."

A - "Rehabilitation began with the client's admission to the hospital." Rational A - Rehabilitation is a process that assists a client who has an illness, a disability, or an impairment to achieve the best possible level of functioning. The process of rehabilitation begins with the client's acute care hospital admission. B - The rehabilitation process focuses on the client's physical, mental, social, spiritual, and economic abilities. C - Typically, clients who require long-term rehabilitation have more permanent injuries, such as brain or spinal-cord injuries. D - The client is more likely to receive rehabilitation services on an outpatient basis or in the home environment.

A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? Select all A - "The temperature around the IV site is cooler." B - "The rate of the infusion increases." C - "The skin at the IV site is red." D - "The IV dressing is damp." E - "The tissue around the venipuncture site is swollen."

A - "The temperature around the IV site is cooler." D - "The IV dressing is damp." E - "The tissue around the venipuncture site is swollen." Rational A - A decrease in skin temp around the site is a manifestation of infiltration due to the IV solution entering the subcutaneous tissue around the venipuncture site. B - When infiltration occurs, the rate of infusion can slow or stop, not increase, as the solution is no longer infusing directly into the vein. This occurs due to dislodgment of the catheter or rupture of the vein. C - When infiltration occurs, the skin around the IV site is pale, not red, because the solution is no longer infusing directly into the vein and enters the subcutaneous tissue around the venipuncture site D - A damp IV dressing is a common finding with infiltration due to the IV solution entering the subcutaneous tissue and leaking out through the venipuncture site E - Swollen tissue around the venipuncture site is a manifestation of infiltration due to the IV solution entering the subcutaneous tissue and causing swelling, as the fluid is no longer infusing into the vein.

A nurse is reinforcing teaching about placement of a prosthesis with a client who is having a below the knee amputation. Which of the following information should the nurse include in the teaching? A - "This will improve your ability to ambulate sooner." B - "This will decrease the chance of you experiencing phantom limb pain." C - "This will help to decrease the frequency of dressing changes." D - "Placing this now will improve the fit of the prosthesis."

A - "This will improve your ability to ambulate sooner." Rational A - The nurse should explain that the purpose of a prosthesis immediately following surgery is to promote postoperative ambulation. B - The nurse should teach that phantom limb pain is a neurological disorder for clients who had an amputation; therefore, the placement of a prosthesis immediately following surgery does not decrease the incidence of phantom limb pain. C - The nurse should reinforce in the teaching to check the dressings when obtaining postoperative vitals; however, the placement of a prosthesis immediately following surgery does not decrease the need for or frequency of dressing changes. D - The placement of a prosthesis immediately following surgery does not improve the fit of the prosthesis.

A nurse is caring for a client who has diabetes mellitus and had a below the knee amputation 2 days ago. Which of the following statements by the client should the nurse identify as an indication that the client has a body image disturbance? A - "When I look in the mirror, all I see is a person without a leg." B- "I have not always made good choices in life. I deserve to lose my leg." C - "If my wife had paid more attention to my blood sugar levels I would not have needed an amputation." D - "No matter how hard I work in physical therapy, I can't seem to make any progress."

A - "When I look in the mirror, all I see is a person without a leg." Rational A - A client who has a body image disturbance may not want to look or touch a body part that has been altered by disease or injury. The client may also express feelings of helplessness, hopelessness and powerlessness. B - The client's statement indicates the client feels guilty and blames himself for needing an amputation. However, this does not indicate that the client has a body image disturbance. C- The client is using rationalization to explain the reason for his amputation. This does not indicate that the client has a body image disturbance. D - The client's statement indicates the client is frustrated with his progress towards recovery. However, this does not indicate that the client has a body image disturbance.

A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority? A - Altered level of consciousness B - Oral temperature of 37.7° C (100° C) C - Muscle spasms D - Headache

A - Altered level of consciousness Rational A - When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is for the nurse to monitor the client's altered level of consciousness. A fracture of one of the long bones of the body places the client is at risk for fat embolism, which causes a decrease in oxygenation and alters the client's level of consciousness. B - The nurse should monitor the client's temperature, as this can be a risk for infection or a fat embolism; however, another action is the priority. C - The nurse should observe the client for muscle spasms as a manifestation following this type of procedure; however, another action is the priority. D - The nurse should observe the client for a headache to address his pain; however, another action is the priority.

A nurse is walking down the unit hall and sees a blood spill on the floor. Which of the following agents should the nurse use to sanitize the floor? A - Chlorine B - Triclosan C - Hydrogen peroxide D - Isopropyl alcohol

A - Chlorine Rational A - The nurse should use chlorine, also known as bleach, to clean up the blood spill. Chlorine is an effective agent that destroys the bacteria within blood. B - The nurse should use triclosan on hands, as well as intact skin, to clean off bacteria. C - The nurse should use hydrogen peroxide to sanitize surfaces. D - The nurse should use isopropyl alcohol to sanitize hands and vial stoppers.

A nurse is caring for a client who is postoperative open reduction and internal fixation with placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take? A - Empty the suction device every 4 hr. B - Monitor circulation on the affected extremity every 2 hr for the first 12 hr. C- Position the client's hip so that it is internally rotated. D - Encourage foot exercises every 4 hr.

A - Empty the suction device every 4 hr. Rational A- The nurse should empty the client's wound drain every 4 hr to monitor for bleeding. B - The nurse should monitor neurovascular status of the operative leg every hour for the first 12 to 24 hr to monitor for changes that can indicate impaired circulation. C - The nurse should position the client's hip so that it is abducted to prevent dislocation. D- The nurse should encourage foot and calf exercises every 2 hr to prevent a deep vein thrombosis.

A nurse is preparing to administer heparin intravenously to a client. Which of the following actions should the nurse take? A - Obtain an infusion pump to regulate the continuous flow of the medication B - Verify that a dose of vitamin K is available as an antidote C - Insert an indwelling catheter to monitor closely the client's urine output D - Schedule the client's prothrombin time (PT) to be drawn at regular intervals

A - Obtain an infusion pump to regulate the continuous flow of the medication Rational A - Because of the risk for bleeding, an infusion pump must be used to prevent overdosage and its rate must be checked every 30 to 60 min. B - Protamine zinc is the antidote for heparin, not vitamin K. C - Heparin is an anticoagulant that has no effect on urine output. D - The activated partial thromboplastin time (aPTT), not the PT, is measured to determine the effectiveness of a heparin drip.

A nurse is caring for an adolescent following the application of a plaster cast for a fracture right tibia. Which of the following actions should the nurse take? A - Perform a neurovascular check of the lower extremities. B - Keep the client's leg in a dependent position. C - Discourage the client from ambulating. D - Use a hair dryer on a hot setting to dry the cast.

A - Perform a neurovascular check of the lower extremities. Rational A - The client is at risk for compartment syndrome following the application of a cast because the extremity can continue to swell inside the cast resulting in obstruction to circulation. Therefore, the nurse should perform a neurovascular check following cast application to check circulation, motion, and sensation of the lower extremities. B - The nurse should keep the client's leg elevated to promote venous return and minimize swelling. C - After the cast dries, the nurse should assist the client to ambulate using crutches to promote general circulation and prevent complications of immobility. D - The nurse should not expose the cast to heat, such as from a dryer or a fan, because heat conduction can result in skin burns under the cast.

A nurse is collecting data from a client who is postoperative from a below-the-knee amputation and whose residual limb is wrapped with an elastic bandage to shrink the stump. Which of the following findings should alert the nurse to a possible complication? A - Pitting edema above the bandage B - Looseness of the stump dressing C - The dressing forming a cone shape over the stump D - Figure-eight wrapping around the stump

A - Pitting edema above the bandage Rational A - If the elastic bandage is properly applied, it should prevent edema. The nurse should remove the bandage and rewrap the stump. B - The nurse should expect the bandage to become loose as the limb heals and shrinks, so the nurse should rewrap the stump every 4 to 6 hr. C - If the elastic bandage is properly applied, it should form a cone shape over the stump. D - If the elastic bandage is properly applied, it should form figure-eights around the stump.

A nurse is contributing to the plan of care for a client who has a spinal cord injury resulting in paraplegia. Which of the following interventions should the nurse include? A - Provide a high-protein, high-calorie diet. B - Perform passive range of motion exercises daily. C - Use sequential compression devices for 4 hr three times a day. D - Develop a schedule to restrict fluid intake.

A - Provide a high-protein, high-calorie diet. Rational A - Following injury, the client will have increased caloric needs. The nurse should provide a diet high in protein, carbohydrates, and calories to provide proper nutrition. B - The nurse should plan to perform passive range of motion exercises at least two times a day, using all of the client's extremities. C - The nurse should plan to keep sequential compression devices on the client's lower extremities and remove them each shift for 30 to 60 min. D- The nurse should understand the client is at risk for constipation and urinary tract infection and should promote adequate intake of fluids and fiber.

A nurse is reinforcing teaching to the family of a client who has Parkinson's disease. Which of the following instructions should the nurse include? A - Provide the client a cane. B - Limit the client's physical activity. C - Speak loudly to the client. D- Offer the client 3 large meals a day.

A - Provide the client a cane. Rational A - The nurse's instructions should include providing the client with a cane or walker to increase stability and decrease the risk of falls. B - The nurse's instructions should include providing an exercise program to improve mobility, alternated with periods of rest, not limiting activity. C - The nurse's instructions should include speaking clearly and in a normal tone to the client. There is no reason to speak loudly to a client with Parkinson's disease. D - The nurse's instructions should include offering the client six small meals per day to compensate for the need to eat slowly and take small bites to reduce the risk of aspiration.

A nurse is caring for a client who has a femur fracture and, 8 hr after the injury, reports a sudden onset of dyspnea and a sever headache. Which action should the nurse take first? A - ​Administer oxygen. B - ​Prepare for an ICU transfer. C - ​Increase the IV fluid infusion rate. ​D - Administer pain medication.

A - ​Administer oxygen. Rational A- The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to administer oxygen. In addition to placing the client in high-Fowler's position, the nurse should use a non-rebreather's mask and administer oxygen at a high flow rate. B - The nurse should anticipate that the client will require transfer to ICU; however, there is another action that is the priority. C - The nurse should anticipate that the client will likely require increased hydration; however, there is another action that is the priority. D - The nurse should administer pain medication to the client to treat the headache; however, there is another action that is the priority.

An intravenous (IV) route is the primary method of supplying the patient with fluids and medications via the veins when the patient cannot take them orally. Advantage - Disadvantage -

Advantage of making drugs or fluid instantly available for circulation in to all tissues. Disadvantage - if an error is made adverse effects will occur more rapidly.

Equipment for IV administration 1 - Primary IV set 2 - Seconday, or piggyback 3 - Parallel or Y 4 - Controlled-volume IV set

As long as the patient is not receiving blood, blood products, fat emulsions, or propofol infusion, change IV tubing no more frequently than every 96 hours but at least every 7 days for infection control purposes. Check agency policy for frequency of tubing change ~Check agency policy

A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at 120 mL.hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (Select all) A - "I feel lightheaded." B - "I feel as though my heart is racing." C - "I feel a little short of breath." D - "The nurse technician told me that my blood pressure was 150 over 90." E - "I think my ankles are less swollen."

B - "I feel as though my heart is racing." C - "I feel a little short of breath." D - "The nurse technician told me that my blood pressure was 150 over 90." Rational A - A manifestation of fluid overload is hypertension. lightheadedness is a manifestation of hypotension. B - A manifestation of fluid overload is tachycardia due to the increased blood volume, which causes the heart rate to increase C - A manifestation of fluid overload is shortness of breath or dyspnea due to the increase amount of fluid entering the air spaces in the lungs, which reduces the amount of circulating oxygen. D - A manifestation of fluid overload is hypertension due to the increase blood volume, which causes the blood pressure to increase E - A manifestation of fluid overload is edema. If the client's ankles are less swollen, this is an indication that the edema and the fluid overload are resolving.

A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has a prescription for lorazepam preoperatively. Which of the following statements by the client should indicate to the nurse that the medication has been effective? A - "My mouth is very dry." B - "I feel very sleepy." C - "I am not hungry any longer." D - "My leg feels numb."

B - "I feel very sleepy." Rational A - The nurse should recognize that oral dryness is most likely a result of the client being NPO prior to surgery and not an effect of lorazepam. B - The nurse should recognize that preoperative doses of benzodiazepines such as lorazepam relieve anxiety and promote sedation. C - The nurse should recognize anorexia as an adverse, but unintended, effect of lorazepam. D - The nurse should identify that one of the effects of lorazepam is muscle relaxation, which may decrease the pain experienced with a femur fracture; however, numbness of the extremity is not an effect of lorazepam.

A nurse is reinforcing teaching about legal issues with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? A - "I can inform a client that I will insert a catheter if he does not give me a prescribed urine sample." B - "I will ask permission from the client before observing a procedure the client is having." C - "I should refuse to return car keys to a client who is threatening to leave against medical advice." D - "I can discuss the care of a client with a colleague who works on a different unit."

B - "I will ask permission from the client before observing a procedure the client is having." Rational A - The nurse should reinforce that an attempt or threat to touch a client without consent is assault, and can result in legal charges and punitive action. B - The nurse should reinforce that it is important to obtain permission from a client before working with a client or observing a procedure the client is undergoing. Doing so without permission is an invasion of privacy. C -The nurse should reinforce that although the newly licensed nurse may have the best intentions in trying to keep the client safe, preventing the client from leaving the facility is a form of false imprisonment. This may result in legal charges being brought against the nurse and the facility. D - The nurse should reinforce that confidentiality requirements include only discussing clients with providers who are providing direct care to the client.

A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? A - "I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood? B - "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up." C - "I will apply pressure approximately 1-2 inches below the insertion site prior to removing the needle." D - "I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location."

B - "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up." Rational A - After seeing a flashback of blood, the nurse should lower the hub close to the skin to prepare for threading the needle into the vein, then loosen the needle from the catheter and pull back slightly on the needle so that it no longer extends past the tip of the catheter. The nurse should use the thumb and index finger to advance the catheter into the vein until the hub rests against the insertion site, Inserting the needle all the way into the vein could puncture the vein. B - The nurse should use a smooth, steady motion to insert the catheter through the skin at an angle of 10 to 30 degrees with the bevel up. This is the optimal angle for preventing the puncture of the posterior wall of the vein C - The nurse should apply pressure approximately 3 cm above the insertion site to reduce the backflow of blood into the vein prior to removing the needle. D - The nurse should not use a vein in the antecubital fossa for IV insertion, except for emergency access, because it will limit the mobility of the client's arm.

A nurse is reinforcing teaching with a parent of an 8-year-old child who has a fracture of the epiphyseal plate. Which of the following statements should the nurse include in the teaching? A - "Fractures in a child take longer to heal than fractures in an adult." B - "Normal bone growth can be affected by the fracture." C - "Bone marrow can be lost though the fracture." D - "Your child will need to increase his calcium intake to 3,000 milligrams daily."

B - "Normal bone growth can be affected by the fracture." Rational A - Children heal fractures in less time than adults take to heal because of the generous blood supply to the bone and the epiphyseal plate. B - A fracture of the epiphyseal plate can affect growth in a child. Therefore, it needs to be detected and treated rapidly. C - The epiphyseal plate is the cartilage growth plate. Therefore, bone marrow is not lost through this type of fracture. D - Children who have fractures should be monitored for sufficient calcium intake. However, the recommended daily allowance of calcium for this age group is 1,000 mg. A daily allowance of 3,000 mg is too much for a child and places him at risk for calcium toxicity.

A nurse provides a fracture bedpan for a client who has a femur fracture and needs to defecate. When the client ask why the nurse chose that type of bedpan, which of the following responses should the nurse make? A - "This kind of bedpan will help your fracture heal correctly." B - "This kind of bedpan is easier to place under you." C - "With this bedpan, you can keep lying flat." D - "You'll be able to get on and off this kind of bedpan by yourself."

B - "This kind of bedpan is easier to place under you." Rational A - The type of bedpan does not typically affect the healing of a femur fracture. B - A fracture (or slipper) bedpan is smaller and flatter than a regular bedpan. It is easier to place under a client than a regular bedpan is. A client who has difficulty with raising herself onto a regular bedpan, has femur or lower spine fractures, is immobile, or has limited movement should use a fracture bedpan. C - No matter which type of bedpan the nurse uses, the nurse should elevate the head of the bed at least 30°. D - The nurse should always assist a client who has a femur fracture to get on and off the bedpan.

A nurse notes that a client's IV tubing has disconnected from the IV catheter, resulting in the client's blood spilling onto the sides of the bed and the floor. Which of the following solutions should the nurse use to disinfect the spill. A - Isopropyl alcohol B - Chlorine bleach solution C - Soap and water D - Chlorhexidine

B - Chlorine bleach solution Rational A - Isopropyl alcohol is a skin disinfectant. It is also effective for cleaning vial stoppers, but not blood. B - Chlorine bleach acts as a disinfectant and is recommended for cleaning and disinfecting areas and objects in the hospital setting. It is recommended for blood spills because it is effective in killing the HIV virus. C - Soap and water emulsifies dirt for easy removal from hands; however, soap is not a disinfectant. D - Chlorhexidine disinfects the skin. It is not effective for blood spills.

A nurse is assisting with the care of a client who has femur fracture and is in skeletal traction. Which of the following actions should the nurse take? A - Loosen the knots on the ropes if the client is experiencing pain. B - Ensure the client's weights are hanging freely from the bed. C - Check the client's bony prominences every 12 hr. D - Cleanse the client's pin sites with povidone-iodine.

B - Ensure the client's weights are hanging freely from the bed. Rational A - The knots should never be loosened on the ropes. Doing this will unsecure the traction and possibly injure the client. B - The nurse should ensure that the client's weights are hanging freely from the bed to maintain the client in proper body alignment and should never be removed without a provider prescription or the development of a life-threatening situation that requires removal. C - The client's bony prominences and skin should be checked every 8 hr for skin breakdown, irritation, and inflammation. D - The nurse should cleanse the client's pin sites with chlorhexidine solution to keep the sites clean and free from bacteria.

A nurse is collecting data from a client following the application of a leg cast for the treatment of a fracture. Which of the following findings should the nurse expect to find first if the cast is too tight? A - Toes cool to touch B - Pallor of the toes C - Edema of the toes D - Inability to move toes

B - Pallor of the toes Rational A - The client who has a cast that is too tight may have toes that are cool to the touch, which is called poikilothermia. If a cast is too tight, it will increase pressure on the blood vessels. When this occurs, the temperature of the toes will become cool to the touch; however, there is another manifestation that is the initial finding. B - The client who has a cast that is too tight may have pallor of the toes caused from inflammation and edema that puts pressure on the vascular system, tissues and nerves, which decreases blood flow and can lead to compartment syndrome. When this occurs, pallor of the toes is the initial finding. The nurse should immediately report this finding to the provider. C - The client who has a cast that is too tight may have edema of the toes and should elevate the extremity. If a cast is too tight, it will increase pressure on the blood vessels. When this occurs, edema will become present in the toes; however, there is another manifestation that is the initial finding. D - The client who has a cast that is too tight from inflammation may have an inability to move the toes of the affected extremity. If a cast is too tight, it will increase pressure on the blood vessels. When this occurs, paralysis of the toes and foot will occur; however, there is another manifestation that is the initial finding.

A nurse is collecting data from an older adult client who has a femoral head fracture 24 hr ago and is in a buck's traction. Which of the following findings is an indication of fat embolism syndrome? A - Extremity pain unrelieved by opioid analgesics B - Petechiae on the chest C - Reports of calf pain D- Absent pedal pulse on affected extremity

B - Petechiae on the chest Rational A- Extremity pain unrelieved by opioid analgesics is a manifestation of compartment syndrome. B - A red rash on the client's abdomen, chest, neck or upper arms is a manifestation of fat embolism. C- Reports of calf pain are a manifestation of deep-vein thrombosis. D- Absent pedal pulse is an indication of neurovascular compromise.

A nurse is modifying the diet of a client who has Parkinson's disease and a prescription for selegiline, a monamine oxidase inhibitor (MAOI). Which of the following foods should the nurse eliminate from the client's diet? A - Fresh fish B -Cheddar cheese C - Cherries D - Chicken

B -Cheddar cheese Rational A - The nurse does not need to eliminate fresh fish from the diet of a client who has a prescription for selegiline. Cured meats containing tyramine should be eliminated from the client's diet. B - The nurse should eliminate aged cheeses, such as cheddar cheese, from the diet of a client who has a prescription for selegiline because it contains tyramine, which can cause a hypertensive crisis. C - The nurse does not need to eliminate cherries from the diet of a client who has a prescription for selegiline. Foods containing tyramine should be eliminated from the client's diet. D- The nurse does not need to eliminate chicken from the diet of a client who has a prescription for selegiline. Foods containing tyramine should be eliminated from the client's diet.

A nurse is reinforcing teaching with a client who has Parkinson's disease. The client tells the nurse that he gets nausea when he takes his prescribed levodopa/carbidopa. Which of the following foods should the nurse recommend the client take with this medication? A- 1 cup (8oz) plain low-fat yogurt B - 1 oz of cheddar cheese C - 1 cup (8oz) of applesauce D - 1 cup (8 oz) cooked spinach

C - 1 cup (8oz) of applesauce Rational A - The client should avoid taking levodopa/carbidopa with food that is high in protein because it interferes with absorption and decreases the therapeutic response. 1 cup of plain, low-fat yogurt contains approximately 12 g of protein. B - The client should avoid taking levodopa/carbidopa with food that is high in protein because it interferes with absorption and decreases the therapeutic response. 1 ounce of cheddar cheese contains approximately 7 g of protein. C - The client should take levodopa/carbidopa with food to decrease nausea and vomiting but should avoid food high in protein because it interferes with absorption and decreases the therapeutic response. 1 cup of applesauce contains less than one-half a gram of protein. D - The client should avoid taking levodopa/carbidopa with food that is high because it interferes with absorption and decreases the therapeutic response. 1 cup of cooked spinach contains approximately 5 g of protein.

A nurse is caring for a client who has a fractured tibia as a result of a fall. The x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should recognize this is a finding for which of the following types of fractures? A - Impacted B - Transverse C - Comminuted D - Oblique

C - Comminuted Rational A - An impacted fracture is an injury in which broken ends of bone are forced together, and does not result in bone splintering. B - A transverse fracture is an injury that goes straight across the bone shaft, and does not result in bone splintering. C - A comminuted fracture is an injury in which the bone is broken and splintered into several pieces. D - An oblique fracture is an injury that occurs at an angle across the bone shaft, and does not result in bone splintering.

A nurse is preparing to apply a eutectic mixture of local anesthetics (EMLA) cream prior to inserting an intravenous catheter on a preschool-age child. Which of the following actions should the nurse plan to take Select all A - Spread the cream over the lateral surface of both forearms B - Gently rub the ream into the skin until it disappears C - Cover the treated area with a transparent occlusive dressing D - Apply the medication an hour before the procedure begins E - Use a facial pain rating scale to evaluate effectiveness of the treatment.

C - Cover the treated area with a transparent occlusive dressing D - Apply the medication an hour before the procedure begins E - Use a facial pain rating scale to evaluate effectiveness of the treatment. Rational Spread the cream over the lateral surface of both forearms is incorrect. The nurse should apply the cream to the injection site, or smallest area possible, to prevent systemic effects. Topical anesthetics can cause dysrhythmia, cardiac arrest, and seizures with systemic absorption. Gently rub the cream into the skin until it disappears is incorrect. The nurse should apply the cream to the surface of the skin, avoiding broken, irritated areas. Cover the treated area with a transparent occlusive dressing is correct. The nurse should cover the area with an occlusive dressing to increase the absorption of the medication and prevent the inadvertent transfer of the cream to other areas of the body or to other persons. Apply the medication an hour before the procedure begins is correct. The nurse should apply EMLA cream at least 1 hr before the procedure. Use a facial pain rating scale to evaluate effectiveness of the treatment is correct. Most preschoolers are able to determine degrees of pain based on facial expressions depicted. The nurse can use the FACES or OUCHER scales with the child to evaluate the effectiveness of the treatment and document it in the child's medical record.

A nurse is reinforcing teaching to a client who has a fractured ulna and is to start taking cyclobenzaprine. The nurse should instruct the client to expect which of the following therapeutic effects? A- Increased energy level B - Decreased itching C - Decreased muscle spasms D - Decreased dry mouth

C - Decreased muscle spasms Rational A- Drowsiness weakness and fatigue are adverse effects of cyclobenzaprine. B - Pruritus is an adverse effect of cyclobenzaprine. C - Cyclobenzaprine is a centrally acting muscle relaxant that relieves painful muscle spasms due to acute musculoskeletal injury. D- Dry mouth is an adverse effect of cyclobenzaprine.

A nurse is caring for a client who has Parkinson's disease and is taking selegiline 5 mg by mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for with a client who is taking this medication? A - Improved speech patterns B - Increased bladder function C - Decreased tremors D - Diminished drooling

C - Decreased tremors Rational A - Selegiline preserves dopamine in the brain and is considered a first line medication for the treatment of Parkinson's disease; however, it will not improve speech patterns. B - Selegiline slows the progress of Parkinson's disease; however, it will not increase bladder function. C - Selegiline, an MAO-B inhibitor, improves motor function by decreasing tremors, rigidity and bradykinesia in the client who has Parkinson's disease. D - Selegiline delays the progression of Parkinson's disease by preserving motor function; however, it will not have an effect on drooling.

A nurse is collecting data from a client who has Parkinson's disease and is experiencing bradykinesia. Which of the following findings should the nurse expect? A - Increased blinking B - States of euphoria C - Slurred speech D - Decreased respiratory rate

C - Slurred speech Rational A - The nurse should expect to observe a decrease in blinking in a client who is experiencing bradykinesia. B - The nurse should expect to observe an expressionless, masklike face in a client who is experiencing bradykinesia. C- The nurse should expect to observe slowed, slurred speech in a client who is experiencing bradykinesia. D - A decreased respiratory rate is not an expected finding in a client who is experiencing bradykinesia.

Select the vein by using visualization, gravity, fist clenching, friction with the cleaning solution, or heat

Chose Distal veins on the NONDOMINANT hand A site that is not painful or bruised and will not interfere with activity A vein that is resilient with a soft, bouncy sensation on palpation Avoid Varicose veins Veins in the inner wrist with bifurcations, in flexion areas, near valves (appearing as bumps), in the lower extremities, and in the antecubital fossa (except for emergency access) Veins in the back of the hand Veins that are sclerosed or hard Veins in an extremity with impaired sensitivity Veins that had previous venipuncture

IV Therapy Disadvantages

Circulatory fluid overload Leaves little time to correct errors Can irritate the lining of the vein Failure to maintain surgical asepsis can lead to local and systemic infection

Conditions that can make vein selection difficult

Cold, stress, decreased circulating volume due to dehydration, or the presence of subcutaneous fat in older infants and some toddlers.

Hypotonic solutions

Contain less solute than extravascular fluid and may cause fluid to shift out of the vascular compartment and into the cells. This can cause a dangerous situation, as cells can rupture. Hypotonic solutions are generally considered unsafe to administer to children. ~ 0.45% Saline - Supplies normal daily salt and water requirements

During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventive strategies? A - "I will leave the IV catheter in place after the client completes the course of IV antibiotics." B - "As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt." C - "If my client needs to use the rest room, it would be safer to disconnect his IV infusion as long as I clean the injection port thoroughly with an antiseptic swab." D - "I will replace any IV catheter when I suspect contamination during insertion."

D - "I will replace any IV catheter when I suspect contamination during insertion." Rational A - Nurses should remove catheters as soon as they are no longer clinically necessary to eliminate a portal of entry for pathogens B - Nurses should use a sterile needle or catheter for each insertion attempt for safety and prevention of infection. C - Nurses should not disconnect tubing for convenience, because this increases the risk of bacteria entering the system D - Nurses should replace IV catheters when suspecting any break in surgical aseptic technique, such as in emergency insertions.

A nurse is reinforcing discharge instructions with a client who has multiple sclerosis (MS). Which of the following instructions should the nurse include? A - "Wait to perform difficult tasks until later in the day." B - "Plan to relax in a hot tub spa each day." C - "Limit your intake of dairy products." D - "Implement a schedule to include periods of rest."

D - "Implement a schedule to include periods of rest." Rational A- The nurse should instruct the client to perform difficult tasks early in the day because fatigue worsens in the afternoon. B - The nurse should instruct the client to avoid extreme temperature changes, which may exacerbate the symptoms of MS. C - The nurse should instruct the client to consume dairy products as well as foods containing calcium and vitamin D to help prevent osteoporosis, which can develop as a result of IV steroid treatments. D - The nurse should instruct the client to implement a schedule with periods of exercise followed by periods of rest to maintain muscle strength and coordination.

A nurse is caring for a client who has skeletal traction for treatment of a femur fracture. Which of the following actions should the nurse take? A - Assist the client to shift position every 4 hr. B - Position the weights on the traction so they are touching the head of the client's bed. C - Encourage isometric exercises every 8 hr. D - Administer pain medication to the client before performing pin care.

D - Administer pain medication to the client before performing pin care. Rational ​A - The nurse should assist the client to shift positions every 2 hr to prevent skin breakdown. B - The weights on the traction should hang free to provide balance. C - The nurse should encourage the client to perform isometric exercises every 4 hr to prevent muscle atrophy. D - The nurse should administer pain medications to the client 30 minutes prior to performing pin care to reduce the client's discomfort.

A nurse is preparing a 9-year-old child for an IV catheter insertion. Which of the following cations should the nurse take first? A - Explain to the child's parents what role they will have during the procedure. B - Allow the child to see and touch IV tubing and supplies C - Describe using visual aids D - Ask the child what he knows about the procedure.

D - Ask the child what he knows about the procedure. Rational A - The nurse should explain to the parents what role they will have during the procedure to ensure they comfort the child and do not interfere with the procedure, but there is another action the nurse should take first. B - The nurse should allow the child to see and touch IV tubing and supplies in order to reduce the child's anxiety, but there is another action the nurse should take first. C - The nurse should describe the procedure using visual aids in order to reduce the child's anxiety, but there is another action the nurse should take first. D - The first action the nurse should take when using the nursing process is to collect data. By determining what the child already knows the nurse can determine how to better direct the remaining preparations.

A nurse is reinforcing teaching with a client who has multiple sclerosis and is learning how to use the four-point alternate gait with crutches. Identify the order of the steps the nurse should give to the client. A - Move the right foot forward B - Move the left foot forward to the level of the left crutch C -Move the left crutch forward D - Move the right crutch about 10 to 15 cm (4 to 6 in)

D - B - C - A D - Move the right crutch about 10 to 15 cm (4 to 6 in) B - Move the left foot forward to the level of the left crutch C -Move the left crutch forward A - Move the right foot forward Rational The nurse should reinforce teaching to a client who can bear weight on both legs but requires crutches for balance and support. The nurse should instruct the client to first move the right crutch about 10 to 15 cm (4 to 6 in). Next the nurse should instruct the client to move the left foot forward to the level of the left crutch. Next, the nurse should instruct the client to move the left crutch forward, and lastly to move the right foot forward.

A nurse is inserting an intravenous catheter for a client which results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? A - Ask the client to undergo a blood test B - Wash the gloved hand and then throw the gloves away C - Prepare an incident report D - Carefully remove the gloves and follow with hand hygiene.

D - Carefully remove the gloves and follow with hand hygiene. Rational A - There is no indication the client needs to undergo a blood test. B - Washing the hands while still gloved is not an appropriate action. C - Unless there is a break in the nurse`s skin there is no need for an incident report. D - Standard precautions require the use of gloves and hand hygiene in the care of all clients. The nurse should perform hygiene immediately after removing gloves.

A nurse is collecting data from a client who is receiving IV therapy and reports pain in his arm, chills, and "not feeling well." The nurse notes warmth, edema, induration, and red streaking on the client's arm close to the IV insertion site. Which of the following actions should the nurse plan to take first? A - Obtain a specimen for culture B - Apply a warm compress C- Administer analgesic D - Discontinue the infusion

D - Discontinue the infusion Rational A - The nurse should obtain a specimen for culture to identify pathogens causing infection. However, another action is the priority B - The nurse should apply a warm compress to promote healing and comfort. However, another action is the priority C - The nurse should administer analgesics to promote comfort. However, another action is the priority D - The greatest risk to this client is injury from infection. The first action the nurse should take is to stop the infusion and remove the catheter because the catheter might be the source of infection.

A client is about to undergo a closed reduction of a fracture. In addition to analgesia, the nurse suggests that the client listen to an audiotape of music. Which of the following nonpharmacologic interventions for pain management is the nurse using? A - Meditation B - Guided imagery C - Biofeedback D - Distraction

D - Distraction Rational A - Meditation is the use of focused awareness to quiet the mind. Unless the audiotape is a guided meditation, the nurse is not using this technique. B - Depending on the content of the audiotape, there may be some imagery involved as the client processes the tape's content, but this is not specifically a guided imagery technique. C - Biofeedback uses an electronic monitoring device to facilitate learned self-control of physiological responses. An audiotape cannot accomplish this. D - Distraction is focusing attention on stimuli other than pain. Listening to music or a book on tape is a type of auditory distraction that can effectively reduce the client's perception and awareness of pain.

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following is an appropriate intervention for this client at this time? A - Elevate the foot of the bed. B - Encourage sitting up as much as possible. C - Elevate the stump on a pillow. D - Have the client lie prone several times each day.

D - Have the client lie prone several times each day. Rational A - The nurse should elevate the foot of the bed and keep the knee extended for a client who has had a below-the-knee amputation, not an above-the-knee amputation. B - For an above-the-knee amputation, the client should avoid prolonged sitting. C - The client may have his stump elevated during the initial 24 hr following surgery. However, he should not elevate the stump on a pillow after the initial postoperative period. D - The nurse should encourage the client to lie prone for 20 to 30 min every 3 to 4 hr to help prevent hip flexion contractures.

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following is an appropriate nursing intervention for the client at this time? A - Elevate the foot of the bed. ​B - Encourage sitting up as much as possible. ​C - Elevate the stump on a pillow. D - Have the client lie prone several times each day.

D - Have the client lie prone several times each day. Rational A - The nurse should elevate the foot of the bed and keep the knee extended for a client who has had a below-the-knee amputation, not an above-the-knee amputation. B - The nurse should discourage the client from prolonged sitting to prevent joint deformity. C - After the first 24 hr following an above-the-knee amputation, the client should not elevate the stump on a pillow to prevent joint deformity. D - The nurse should encourage the client to lie prone for 20 to 30 min every 3 to 4 hr to help prevent hip flexion contractures.

A nurse is caring for a child following an open reduction and internal fixation of a fractured femur and application of a cast. The cast has a window cut in it for viewing of the incision. Which of the following actions should the nurse take first? A - Remove the window and view the incision. B - Turn the client so the cast will dry on all sides. C- Medicate the client for pain. D - Perform neurovascular checks of the affected extremity.

D - Perform neurovascular checks of the affected extremity. Rational A - The incision should be viewed regularly for signs of infection; however, this is not the first action the nurse should take. B - The client should be turned regularly to ensure that all sides of the cast are allowed to dry; however, this is not the first action the nurse should take C - Medicating the client for pain is an important nursing action; however, this is not the first action the nurse should take. D - The greatest risk to this client is injury from impaired circulation due to constriction. Therefore, the first action the nurse should take is to perform neurovascular checks.

A nurse is contributing to the plan of care for a client who has spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client's mobility? A - Walk with leg braces and crutches. B - Drive an electric wheelchair with a hand-control device. C - Drive an electric wheelchair equipped with a chin-control device. D - Propel a wheelchair equipped with knobs on the wheels.

D - Propel a wheelchair equipped with knobs on the wheels. Rational A - Crutch walking, even with supportive braces, is an unrealistic goal for this client. A client who has an injury at T1 to T10 may be able to walk with braces. B - A client who has an injury at C5 would require an electric wheelchair with a hand control device. A client who has a C8 spinal cord injury should have a greater degree of mobility. C - A client who has an injury at C1 to C3 would require an electric wheelchair with a chin-control device. A client who has a C8 spinal cord injury should have a greater degree of mobility. D - A client who has an injury at C8 has full use of the shoulders and arms but will likely experience hand weakness. The addition of knobs on the wheels will help the client use the wheelchair more effectively.

A client reports pain above the catheter site during a nurse's attempt to flush the IV saline lock. Which of the following actions should the nurse take? A - Inject the solution more slowly B - Apply a warm compress to the site C - Ask the client to describe the pain D - Remove the IV saline lock

D - Remove the IV saline lock Rational A- There is clear evidence that the lock is not functioning as intended and the IV should be replaced. B - The saline lock should be removed first. After the lock is removed, it would be appropriate to apply a warm saline compress to the site. C - Given that it is difficult to inject the saline and the client has pain, it is clear that the saline lock is not functioning as intended and should be replaced. D - Objective and subjective data indicate the lock is not functioning as intended. It should be removed and replaced in another location.

A nurse is administering meperidine 100 mg IM for a client who is admitted with a pelvic fracture. Following the injection, which of the following data is the priority for the nurse to check? A - Apical pulse rate B - Blood pressure C - Level of consciousness D - Respiratory rate

D - Respiratory rate Rational A - Meperidine might affect the client's apical pulse rate; however, it is not the priority data for the nurse to check. B - Meperidine might lower the client's blood pressure; however, it is not the priority data for the nurse to check. C - Meperidine might affect the client's level of consciousness by causing sedation; however, it is not the priority data for the nurse to check. D- Meperidine, an opioid, can cause respiratory depression. The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning—having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority in the ABC priority setting framework because adequate ventilator effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them.

Postprocedure Maintaining the patency of IV access

Do not stop a continuous infusion or allow blood to back up into the catheter for any length of time Instruct client not to manipulate the flow rate Make sure the IV insertion site's dressing is not too tight Flush intermittent IV catheters after every medication administration or every 8 hr to 12 hr when not in use. Monitor the site and infusion rate at least every hour

Hypertonic solutions

Have a greater tonicity compared with blood. They are used to replace electrolytes and, when given as concentrated dextrose solutions, produce a shift in fluid from the intracellular compartment to the extracellular compartment, causing shrinkage of cells. Concentrated solutions of glucose, mannitol, or sucrose are given to reduce cerebral edema in patients with head injury because the osmotic pressure draws water out of the cells, whereas hypotonic solutions would not be given because the potential fluid shifting could exacerbate cerebral edema ~ 10% Dextrose in water - if TPN is abruptly discontinued ~ 5% Dextrose in 0.9% saline - Early treatment of burns ~ 5% Dextrose in 0.45% saline - Postoperative, common maintenance fluid ~ 5% Dextrose in Ringer lactate - Burns, dehydration from severe diarrhea or vomiting

Nursing guidelines for Peds Intravenous Lines (Table 22.2) Toddler (Age 1-3 Years )

IV Placement (Ideal site) - Hand, arm, foot Preparation of child - Prepare child immediately before procedure (limited attention span), Give very simple explanation, Show equipment, Do not offer choices, Restraining toddler for an IV usually requires more than one person

Nursing guidelines for Peds Intravenous Lines (Table 22.2) School-Age Child (Age 7-11 Years)

IV Placement (Ideal site) - Hand, forearm (less dominant) Preparation of child - Prepare child ahead of time but on same day of insertion. Carefully explain and demonstrate equipment and reasons for IV therapy, letting patient watch or help set up equipment. Ask child if they have any questions, give child choices and let child help in procedure whenever possible. Tell child crying is ok because needles hurt.

Nursing guidelines for Peds Intravenous Lines (Table 22.2) Preschool (Age 4-6 Years)

IV Placement (Ideal site) - Hand, forearm (less dominant) Preparation of child - Prepare child just before procedure. Using small bottle, tubing, and doll or stuffed animal, explain in literal terms the need for IV and insertion procedure. Allow child to see and touch equipment. Explain how child can help with procedure, by cleaning site, opening packages, and tape

Nursing guidelines for Peds Intravenous Lines (Table 22.2) Infant (First year)

IV Placement (Ideal site) - Scalp vein, foot, hand, forearm Preparation of child - It is best not to feed infant immediately before IV insertion (vomiting and aspiration are possible)

Central venous access decives

Non-tunneled catheter or PICC Long term - tunneled catheter or implanted infusion port.

Potassium is always diluted in fluid and given as a carefully controlled infusion. Potassium is ______________ given as a bolus because it can cause cardiac arrest.

Potassium is NEVER given as a bolus because it can cause cardiac arrest.

Intermittent Intravenous Device (Saline or PRN Lock)

Preferred for patients who receive intermittent antibiotics, heparin, corticosteroids, antimetabolites, and other IV push drugs. Advantage - Freedom of movement ~Because no solution is continuously infusing through the lock, saline or dilute heparin is used to flush the device to maintain patency by keeping a clot from forming at the tip of the catheter ~The device is established by applying a Luer-Lok cap or an extension set, which is a short piece of tubing, to the IV cannula. ~Most locks are flushed with saline ~It is critically important to be sure you are using the correct concentration of heparin, because a mistake can result in patient death.

IV Therapy Advantages

Rapid absorption and onset of action Constant therapeutic blood levels Less irritation to subcutaneous and muscle tissue

Whenever a patient who is receiving an IV infusion is out of bed, _____________________ once he is back in bed

Recheck the drop rate. The fluid drop rate often changes when the patient is up and moving around

A nurse is preparing to administer lactated ringer's (LR) 1,500 mL IV infuse over 10 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? Round the answer to the nearest whole number. Using a leading zero if it applies. Do not use a trailing zero.

Step 1 - What is the unit of measurement gtt/mion Step 2 - What is the quantity of the drop factor 15 gtt/mL Step 3 - What is the volume to be infused 1,500 mL Step 4 - What is the total infusion time 10 hr Step 5 - Should the nurse convert the units of measurement? No - (mL = mL) Yes - (hr-min) 1 hr/60 min = 10 hr/X min X = 600 min Step 6 - Set up equation Volume (mL) / Time (min) x Drop factor (gtt/mL) = X 1,500 mL/600 min X 15 gtt / mL = 37.5 = 38 gtt/min

A nurse is preparing to administer dextrose 5% in water (D5W) 500 mL IV to infuse over 4 hr. The nurse should set the IV infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Using a leading zero if applies. Do not use trailing zeros.)

Step 1 - What is the unit of measurement mL/hr Step 2 - What is the volume the nurse should infuse 500 mL Step 3 - What is the total infusion time? 4 hr Step 4 - Should the nurse convert the units of measurement No Step 5 - Set up the equation and solve for X Volume (mL)/Time (hr) = X mL/hr 500 mL/4 hr = X mL/hr 125 = X 125 mL / hr Reassess to determine whether the IV flow rate makes sense.

A nurse is preparing to administer ranitidine 150 mg by intermittent IV bolus. Available is ranitidine 150 mg by intermittent IV bolus. Available is ranitidine 150 mg in 100 mL of 0.9% sodium chloride (0.9% NaCl) to infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.

Step 1 - What is the unit of measurement the nurse should calculate gtt/min Step 2 - Should the nurse convert the units of measurement Yes - (mg - mL) 150 mg/100 mL = 150 mg = X mL X - 100 Step 3 - What is the total infusion time 30 min Step 4 - What is the quantity of the drop factor that is available 10 gtt/mL Step 5 - What is the volume the nurse should infuse? 100 mL Step 6 - Set up an equation Volume (mL) / Time (min) x Drop factor (gtt/mL) = X 100 mL/ 30 min x 10 gtt/mL = 33.33 = 33 gtt/min

A nurse is preparing to administer cefotaxime 1 g intermittent IV bolus over 45 min, Available is cefotaxime 1 g in 100 mL 0.9% sodium chloride (0.9% NaCl). The nurse should set the IV infusion pump to deliver how many mL/hr? Round the answer to the nearest whole number

Step 1 - What is the unit of measurement the nurse should calculate? ml/hr Step 2 - Should the nurse convert the units os measurement Yes (min - hr) & (g = mL) 60 min/45 min = 1 hr/X hr - X=0.75 100 mL/1 g = X mL/1g = X = 100 Step 3 - What is the total infusion time Step 4 - What is the volume the nurse should infuse? 100 mL Step 5 - Set up an equation and solve Volume (mL)/Time (hr) = X mL/hr 100 mL/0.75 hr = 133.333 Step 6 - round - 133 mL/hr Step 7 - reassess to determine whether the IV flow rate makes sense

Solutions that are given intravenously must be ____________________

Sterile Check the expiration date and inspect the container for clarity of solution, the solution should be clear.

Sings of fluid overload

Such as sudden weight gain, crackles in lungs on auscultation, and peripheral edema. The LPN/LVN must accurately record I & O and report changes, observe for subtle changes in urinary patterns, and monitor laboratory results, including: electrolytes, BUN, and serum creatinine. ~Patients who receive IV fluids must be observed

A primary responsibility is to check the IV at least every 60 minutes and observe each of these points

The IV flow—for the gravity method, the solution should drip into the chamber at regular intervals. • The rate of the infusion—count the rate if you are using the gravity method. If it is too fast or too slow, adjust it to the correct infusion rate per minute. • The infusion pump—if a pump is used, check the programmed rate and volume; the dripping in the chamber will occur intermittently. • The insertion site—are there any signs of infiltration, extravasation, or phlebitis? • Patient complaints—an established IV should not cause any pain or discomfort, and there should be no leaking at the site. • The level of the fluid remaining in the bag—when 50 mL are left, a new bag may be added before the current solution is completely infused . Check to see whether the tubing needs to be changed (no more frequently than 96-hour intervals, but at least once every 7 days), and change the tubing when a new bag is hung. Check your facility's policy for frequency of tubing changes.

Legalities - National Organizations

The Joint Commission OSHA FDA CDC DHS ANA INS AABB EPA

Secondary, or Piggyback, Intravenous Set

The primary infusion is interrupted to infuse medications such as antibiotics and antineoplastic drugs at regularly scheduled times The secondary bag containing the medication, also known as the piggyback, is hung higher than the level of fluid in the primary IV so that gravity forces it to empty first. Do not clamp or alter the flow of the primary bag. If the secondary bag is positioned correctly, the primary IV will begin to flow as soon as the secondary bag is finished. ~Use of needleless devices for attaching secondary tubing for the infusion of medication is highly recommended to prevent injury and exposure to these diseases

When Choosing a site, Take into consideration

The purpose of the Therapy - Is it going to be for hydration, and a large amount of fluids are going to be administered. You may want a large needle. Therefore a larger vein. The proposed duration that the IV will be needed - If the therapy is going to be short, a small vein and small needle may be sufficient The condition and location of usable veins - Take the most practical vein. If it doesn't look good, pick a better one. Look for bifurcation, valves and past IV insertion sites. These are all undesirable.

Which route of administration results in a drug instantly being available for circulation to all tissues? a - Intravenous (IV) b - Subcutaneous (SC) c - Intradermal (ID) d - Vaginal application

a - Intravenous (IV) Rational IV route is the main method of supplying the patient with fluids and medications when the patient is unable to take them orally. The IV route has the advantage of making drugs or fluid instantly available for circulation to all tissues. SC injection does not supply substances as rapidly as the IV route. ID injection does not supply substances as rapidly as the IV route. Vaginal application delivers different types of medications and is not as rapid as the IV route.REF: Page 699

Blood should be infused with an IV tubing set selected for: a - regular drops. b - macrodrops. c - microdrops. d - large drops.

b - macrodrops. Rational Macrodrops are used for viscous fluids, such as blood. Regular drops are used to administer IV therapy to most adult patients. Microdrops are most often used for infants and children. a - This is not one of the three major drop sizes.REF: Page 702

A patient requires an intravenous antibiotic for 6 weeks. The appropriate type catheter would be: a - Broviac. b - midline catheter (ML). c - Hickman. d - Groshong.

b - midline catheter (ML) Rational Midline catheter is used in home care for IV therapy of 6 to 8 weeks. Broviac, Hickman, and Groshong are long-term catheters used for more than 6 to 8 weeks.REF: Page 706

Mannitol is given to reduce cerebral edema in patients with a head injury because the osmotic pressure draws water out of the cells. What type of solution is mannitol? a - Isotonic b - Hypotonic c - Hypertonic d - Eutonic

c - Hypertonic Rational Hypertonic solutions have a greater tonicity than blood. They are used to replace electrolytes and, when given as concentrated dextrose solutions, produce a shift in fluid from the intracellular compartment to the extracellular compartment. Isotonic solutions have the same concentration as blood. Hypotonic solutions contain less solute than extravascular fluid. Eutonic does not refer to solutions. REF: Page 699

An appropriate diagnosis for a patient on total parenteral nutrition (TPN) is: a - Deficient fluid volume related to inability to take fluids by mouth. b - Risk for dehydration related to poor fluid intake. c - Imbalanced nutrition, less than body requirements, related to inability to take oral foods or fluids. d - Ineffective tissue perfusion related to loss of red blood cells/fluid volume.

c - Imbalanced nutrition, less than body requirements, related to inability to take oral foods or fluids. Rational Nutritional status of patients who are NPO and on IV therapy must be assessed every day because the amount of calories supplied by the IV solution is below the total daily requirement. Supplemental calories can be provided through TPN; therefore the most appropriate nursing diagnosis would be Imbalanced nutrition, less than body requirements, related to inability to take oral foods or fluids. Deficient fluid volume and Risk for dehydration are nursing diagnoses for fluid replacement. Ineffective tissue perfusion is a nursing diagnosis for blood product transfusion.REF: Page 727

An elderly patient has a rapid pulse, shortness of breath, and distended neck veins. An IV of 0.9 NS at 150 mL/hr is infusing. What should the nurse be concerned about? a - Catheter embolus b - Speed shock c - Septicemia d - Fluid overload

d - Fluid overload Rational Elderly patients who have IV fluid infusing are at risk for potential fluid overload. Rapid pulse, shortness of breath, and distended neck veins are possible signs of fluid overload. Catheter embolus may cause loss of consciousness. Speed shock may result in cardiac arrest. Signs of septicemia are fever, chills, and general malaise.REF: Page 709, Table 36 2

A nurse initiating peripheral IV therapy should use: a - the antecubital site. b - sterile technique. c - three attempts before asking another nurse to perform the venipuncture. d - a catheter stabilization device to secure the catheter.

d - a catheter stabilization device to secure the catheter. Rational The catheter stabilization device is used after insertion of a peripheral IV and has a see-through area to view the IV site. The antecubital site is not used extensively as a result of increased risk of damage to the vein and potential muscle or nerve damage. Asepsis must be maintained when performing a venipuncture. If an IV cannot be initiated in two attempts, another nurse should be asked to complete the task. REF: Page 714

fluid overload

distended neck veins, increased BP, tachycardia, shortness of breath, crackles in the lungs, edema. additional findings varying with the IV solution Treatment: stop IV, raise the head of the bed, assess vital signs and oxygen saturation, adjust the rate as prescribed, administer diuretics if prescribed.

Intravenous setups should be checked once every _________________

hour (must be checked at 30 - 60 minute intervals)

IV and infants Tidbits (infant to first year)

~ Avoid feeding infants immediately before procedure ~Use pacifiers prn ~Family members should not restrain the child or participate directly in the IV process ~Avoid using dominate hand or sucking fingers ~Secure site! ~ Always bring in extra help!

IV Pump Troubleshooting

~ Check the medication, calculate the correct dosage, and determine the pump setting before entering the patient's room ~ For adult usage, most pumps measure delivery rate in milliliters per hour. Set the pump for the correct rate in milliliters per hour. ~ Pumps usually allow you to set a total volume; the machine will alarm when it reaches that volume ~Before you leave the room, check to ensure that the patient is comfortable, there is no swelling at the insertion site, appropriate clamps are open, and intermittent dripping (not continuous) is occurring in the drip chamber. ~ If the IV pump is continually alarming: Check the IV site for infiltration, pain, and other signs of infiltration. Check tubing for kinks or air in the line. Check clamps and flow regulators. Check IV bag to see whether there is fluid for infusion. Make certain the pump is plugged into an electrical source. Recheck settings on the pump. Change the position of the patient's extremity. Try turning the pump off and resetting it. Try another pump.

Determine what size of cannula is needed. As you review the physician orders, evaluate and THINK about the following

~ Information about the patients present illness ~ Medications the patient is receiving ~ The patients ability to take oral fluids or nutrition ~Monitoring of I & O

Using a blood pressure cuff rather than a tourniquet is sometimes better for the fragile veins of older adults. Place the cuff about _______________ above the selected site.

~ Place the cuff about ***** 6 INCHES****** above the selected site. Inflate the cuff to about 10 mm Hg above the diastolic pressure to dilate the vein. If the patient is fluid depleted, inflate to 20 mm Hg over the diastolic pressure. ~For pediatric patients (or confused older adults) who are pulling at the tubing and catheter, a sleeve or roller gauze can be used to cover the site and equipment

IV and Preschool tidbits (Age 4 - 6)

~Able to follow directions ~They receive comfort from having toys accompany them during procedure ~Do not have parents discipline them during procedure ~ If parents gets upset with child, have parents leave the room

Factors that influence the rate of flow of an IV solution

~Are catheter size, height of the solution container, and viscosity of the fluid. Fluids flow less rapidly through a catheter with a small bore (internal diameter) than through a catheter with a larger bore. In the gravity method, the higher the container, the faster the fluid will flow. ~The device may do the math, but you are responsible for correct use of the equipment and correct entry of the required parameters. ~To calculate the flow rate using the gravity method, you must know how many drops are contained in each milliliter (drop factor) as it passes through the drip chamber of the tubing. The standard set produces 10 to 20 gtt/mL, and the pediatric or microdrop chamber produces 60 gtt/mL.

Selection of the intravenous site

~Depends on several factors, including the vein's accessibility and general condition, the type of fluid or medication to be given, and the duration of IV therapy. The veins preferred for infusions and intermittent doses of medications are those distal to the antecubital area; a new site cannot be placed distal to an old site.

IVs are given to supply the body with fluids, electrolytes, nutritional components, or drugs. List Examples

~Fluids & electrolytes that the patient is unable to take orally in sufficient amounts ~Medications that are more effective when given by this route or cannot be given any other way ~Blood, plasma, or other blood components ~ Nutritional formulas containing glucose, amino acids, and lipids.

Disadvantage of pumps

~Include expense and special administration sets. ~ Incidents of pump failure ~ Should purchase infusion pumps that have administration sets with set-based anti-free-flow mechanisms that prevent gravity free flow by closing off the tubing when the administration set is removed from the pump ~Other pumps must have a free-flow safety device attached to the tubing before it enters the pump.

Intravenous in children

~Inspect venipuncture site per facility protocol ~Discuss with the charge nurse the possible need for a peripherally inserted central catheter (PICC) before multiple peripheral attempts ~Use a transilluminator to assist in vein location ~ Avoid terms "bee sting" or "stick" ~Attach an extension tubing to decrease movement of the catheter ~Use play therapy ~Apply EMLA to the site for 60 min prior to attempt ~Keep equipment out of site until procedure beings ~ Preform procedure in a treatment room ~Use nonpharmacologic therapies ~Allow parents to stay ~Use therapeutic holding ~Avoid using dominant hand/Sucking hand ~Cover with colorful wrap ~Swaddle infants ~Off nonnutritive sucking to infants fore, during, and after procedure

Total parenteral nutrition (TPN), also known as hyperalimentation

~Provides the total nutritional needs for infants and children who cannot use the gastrointestinal tract for nourishment for a prolonged period. It allows highly concentrated solutions of proteins, glucose, and other nutrients to infuse directly into a large vessel (e.g., the superior vena cava) via a CVAD. ~Hypoglycemia, hyperglycemia, and electrolyte imbalances can occur. ~The rate is gradually reduced,

IV and Toddler tidbits (Age 1-3)

~Restraining during the insertion will require more of a "mummy" type fo restraint ~Pumps need to be out of reach and out of vision when adjusting any information on it (toddlers will mimic) ~Their biggest fears are injury and separation from caregiver ~Use distraction - toys movies etc ~ Educate the parents ~ Consider topical anesthesia - remember to apply it 30-60 min prior to IV start

Nursing care of a child receiving "parenteral fluids" - given by some route other than the digestive tract

~The IV pump allows the administration of microdrops of IV solution so that a slow rate of infusion can be maintained. ~IV sets administer 15 drops per 1 mL. Pediatric IV sets administer 60 drops per 1 mL. ~The nurse observes the child hourly for: • Low volume in the bag • The rate of flow of the solution • Pain, redness, or swelling at the catheter insertion site • Moisture at or around the catheter insertion site

Many facilities require use of pumps to regulate the flow of routine IV fluids, especially those containing potassium.

~Use of pumps is mandatory when patients are receiving total parenteral nutrition (TPN), or for medications that require critical accuracy, such as heparin, insulin, cardiovascular medications, chemotherapy drugs, or medications that are used to induce labor ~They have alarms that warn when the IV container is empty, when air is present in the tubing, or when there is an occlusion. They also alarm when the site is infiltrated (solution is deposited in tissue outside the vein); however, the infiltration can be extensive before the machine detects an obstruction of flow ~Remember a pump is never a substitute for good nursing observation.

Starting the Primary Intravenous Infusion

~Use strict aseptic technique when handling IV fluids and tubing because an IV site provides access for bacteria to enter the bloodstream. ~Gloves ~Choose the most distal site possible ~Patient education ~6 rights ~Remove cover and check bag ~Open set and clamp, remove tab, maintain sterility ~Contaminated equipment myst be discarded. ~Remove hair by clipping (do not shave) - Hair harbors microorganisms that contribute to infection ~Stabilize the skin below the IV site by placing your thumb about 2 inches directly below the insertion site. ~indirect method, first insert the cannula into the subcutaneous space directly parallel to the side of the vein. Then move the tip toward the vein, and gently ease the cannula into the vein. Using the direct method, hold the cannula with the bevel upright and at a 15- to 25-degree angle to pierce the skin ~Advancing the cannula when it is not in the vein causes pain and tissue damage. If you continue to push the stylet after the flashback, you will go through vein wall, and fluid will infiltrate into the surrounding tissues. Special Considerations • If you cannot initiate a patent IV in two attempts, ask another nurse to perform the task. • A peripheral IV site is changed every 72 to 96 hours or according to agency policy. • Never perform venipuncture in an extremity where there is a hemodialysis access shunt or on the side of a mastectomy or paralysis.

Preventing Infection

~hand hygiene ~standard precautions ~change IV site according to the facility's police (Usually 72 hr ~Replacement of the admin set is dependent upon the tube of infusion. A continuous infusion of fluids with or without secondary fluids should be changed every 96 hr. Intermittent infusion should be changed every 24 hr ~Remove catheters as soon as there is no clinical need ~Replace if suspected break in surgical aseptic ~Use a sterile needle for each insertion attempt ~Avoid writing on bags with pens or markers, because ink can contaminate the solution. ~Do not allow fluids to hand for more than 24 hr unless it is a closed system (Pressure bag for hemodynamic) ~ Wipe all ports with alcohol or an antiseptic swab before connecting IV lines or inserting a syringe ~Never disconnect tubing for convenience or to reposition the client

A nurse is caring for a client who reports shortness of breath and chest pain the first day following multiple long bone fractures. The nurse should consider which of the following client complications first? A - Pneumonia ​B - Fat emboli ​C - Cardiac dysrhythmia ​D - Hypoxic condition

​B - Fat emboli Rational A - The nurse should consider pneumonia as a complication when a client has a compound long bone fracture due to immobility; however, evidence-based practice indicates the nurse should consider another complication first. B - According to evidenced-based practice the nurse should first consider a fat emboli, which can occur from a rupture of small venules allowing fat globules into the circulatory system that occludes a blood vessel. The client who has a compound long bone fracture is at high risk for developing a fat embolus within 24 to 96 hr. C - The nurse should consider cardiac dysrhythmia as a complication, which may indicate a pulmonary emboli from a fat embolism, when a client has a compound long bone fracture; however, evidence-based practice indicates the nurse should consider another complication first. D - The nurse should consider hypoxic condition as a complication, which may indicate a pulmonary emboli from a fat embolism, when a client has a compound long bone fracture; however, evidence-based practice indicates the nurse should consider another complication first.

A nurse is collecting data from a client who has a hip fracture. Which of the following findings should the nurse expect when checking the extremity? A - ​Leg lengthening B - Hip pallor ​C - Muscle spasms ​D - Leg abduction

​C - Muscle spasms Rational A - The nurse should expect leg shortening following a hip fracture. B - The nurse should expect ecchymosis at the fracture site from bleeding into the tissues following a hip fracture. C - The nurse should expect muscle spasms following a hip fracture. D - The nurse should expect internal rotation of the leg following a hip fracture.

A nurse is contributing to the plan of care for a client who has a spinal cord injury and paralysis. Which of the following actions should the nurse include in the plan to decrease the client's risk of skin breakdown? Select all A - Massage erythematous bony prominences. ​B - Implement turning schedule every 4 hr. ​C - Use pillows to keep heels off the bed surface. D- Keep environmental humidity less than 30%. ​E - Minimize skin exposure to moisture.

​C - Use pillows to keep heels off the bed surface. ​E - Minimize skin exposure to moisture Rational Massage erythematous bony prominences is incorrect. The nurse should avoid massaging erythematous bony prominences, which would cause further skin breakdown. Implement turning schedule every 4 hr is incorrect. The nurse should implement a turning schedule to prevent skin breakdown. This includes turning the client every 2 hr while in bed and repositioning hourly if the client is up in a chair. Use pillows to keep heels off the bed surface is correct. The nurse should pad all bony prominences and use devices such as pillows to keep the heels off the bed surface and prevent skin breakdown. Keep environmental humidity less than 30% is incorrect. The nurse should manage humidity in the client's room and keep the humidity above 40%. Humidity less than 40% is drying to the skin and increases the risk of skin breakdown. Minimize skin exposure to moisture is correct. The nurse should include actions to minimize exposure of the skin to moisture from sweating, wound drainage or incontinence as this causes maceration of the skin which leads to skin breakdown.

Intravenous Therapy Guidelines 1 - Keep IV Fluids sterile 2 - Protect the catheter site 3 - Hang fluids at the correct height 4 - Carefully regulate the rate of flow 5 - Monitor I & O when a patient is receiving IV fluids or blood 6 - Hang the solution that should run in first in a higher position 7 - Assess the site frequently for signs of complications Students must have supervision when performing a venipuncture. Whenever an IV site is initiated or changed or an IV solution is hung, document this on the parenteral infusion record

• Keep IV fluid sterile. Everything coming into contact with the solution must be sterile, including the inside surface of the catheter hub and all connecting points between the bag and drip chamber and between the tubing and the needleless connector. • Protect the catheter site from contamination to avoid possible infection. An airtight, transparent dressing is used over the catheter site. Keep tubing free of air. Clear tubing of air before connecting to the catheter. Do not allow the current bag to run dry before changing to the next one. • Hang fluids at the correct height. Keep the bag of fluid sufficiently above the level of the catheter site to maintain flow; avoid having it too high because this significantly increases the effect of gravity. • Carefully regulate the rate of flow. If the IV is behind schedule, do not run in a large amount of fluid to catch up. Rather, recalculate either (1) the span of time for the infusion or (2) the rate of drops per minute for the fluid to run at the ordered rate. (For an infusion pump, access the function of the pump.) • Monitor intake and output when a patient is receiving IV fluids or blood. Keep accurate intake and output records and compare intake with output over 24 hours. • Hang the solution that should run in first in a higher position. Attach the piggyback tubing to a port beneath the roller clamp on the primary tubing. Lower the primary bag without clamping the tubing so it will begin to flow when the piggyback has run in. • Assess the site frequently for signs of complications. Monitor for infiltration, extravasation, swelling at the IV site, irritation of the vein, formation of a clot stopping the flow, or systemic reaction. Take vital signs several times a day to detect early signs of infection or adverse reaction.

Reduce Risk of pump failure • Plan • Label • Check • Use • Report

• Plan: have a backup plan in the event of pump failure; participate in educational opportunities relating to the facility's smart pump; use a secondary device to check the expected volume infused. • Label: clearly label tubing and pump channels with the name of the medication infusing, especially if multiple lines are running. • Check: verify pump settings; have another nurse double-check your settings when infusing high-risk medications. Monitor: carefully watch patients for signs of over infusion or under infusion. • Use: consult with super-users for additional assistance and training, use available resources to prevent and respond to pump problems, and follow the Six Rights for medication administration. • Report: promptly report adverse events to the FDA; remove any equipment that is not working properly.

Guidelines to reduce legal risk

•Applying A&P to appropriate IV sites •Use infusion equipment appropriately •Clarify orders, and refuse to follow orders you know are not within your scope! •Identify adverse actions to medications •Administer IV fluids and meds at correct rates and intervals •Monitor the patient receiving IV fluids for complications •Educate the patient •Document all aspects of IV administration •Use EBP •Abide by your state NPA, and national standards such as given by the INS, CDC, and OSHA

Initiation of the IV

•Be sure to anchor the vein well by pulling the skin taut with non-dominant thumb -If you don't anchor, you won't be able to insert the IV very easily as the skin will roll up -If you contaminate the cannula by brushing the cannula to your gloved hand, this is grossly contaminated ~ 30 degrees is the most (MAX) - start almost parallel •Insert at a 30 degree angle with the bevel up through skin •Once the "pop" sensation is felt you should see a flashback of blood into the cannula and you then need to lower to 10 degree angle or parallel with skin •Advance catheter/needle unit 1/16-1/8 inch further, then thread the catheter into the vein as the needle is slowly withdrawn -Activate safety mechanism -Release the tourniquet -Secure with tape and tegaderm -Apply saline lock

Documentation of IV start

•Date and time •Solution hung •Length and gauge of device •Venipuncture site •NUMBER OF ATTEMPTS •Patient teaching •Name of person initiating the device ~Flow rate ~Complications, patient response and nursing interventions if applicable ~Label the dressing on the insertion site with the date and your initials ~Label the IV fluid container and place a time tape on it ~Don't forget to label the tubing ONGOING DOCUMENTATION ~ Condition of the site ~Site care provided ~Dressing changes ~Site changes ~Tubing and solution changes ~Additional teaching

Nursing care errors that result in negligence

•Failing to gather and chart client information adequately •Failure to recognize the significance of certain information such a lab values and vital signs •Failure to chart each identified problem •Failure to use language in the care plan that other caregivers understand •Failure to ensure continuity of care by ignoring the care plan •Failure to give discharge instructions that the client understands •Failure to administer and document meds correctly •Failure to interpret and carry out doctor's orders •Failure to perform nursing tasks correctly •Failure to pursue the physician if the doctor does not respond to calls

Changes in the older adult in regards to IV therapy

•Skin Changes -There is loss of collagen and subcutaneous fat. -The layers of the skin are thin, becoming more fragile and less elastic, which makes the skin prone to tearing. The loss of SQ tissue makes the veins less stable and this is why they "roll". The number of nerve endings are decreased, so the elderly can not feel pain and pressure, therefore are not able to feel the signs of complications. The vein is weaker and tears more easily by the catheter. This makes the older adult more prone to subcutaneous bleeding. ~Liver, kidney and immune system changes

Discontinuation of IV

•Supplies needed: •Open 2X2 •With gloves, remove the tape and lift up on the tegaderm •Obtain 2X2 in the most aseptic manner possible and hover over the insertion site. •Withdraw the IV cannula and after it is OUT, then apply pressure with the 2X2. •Hold pressure for at least a minute! More if they are on anticoagulants •Double the 2X2 and tape it down in an occlusive manner. •Chart the process and go back to double check that bleeding hasn't occurred!! Documentation ~Time and date ~Reason for D/C ~ Assessmetn of venipucutre site before and after the device is removed ~Patient reaction and complications including any nursing interventions ~Integrity of the venous access device on removal ~Follow up actions (restarting of an IV) ~Don't forget the I&O sheet

Hourly checks consist of checking the following

•The IV flow. Is it flowing easily? •The rate of infusion. Count if gravity. Check time tape. •Check the pump. Check the rate and the volume infused •Check the site for complications •Check for complaints from the patient •Check the level of fluid remaining in the bag. If 50 mls are remaining, change the bag.