IV Therapy Quiz
In preparing for insertion of a peripheral I.V. catheter, the nurse must select an appropriate site. Which area should the nurse try first if an appropriate vein is found?
Back of the hand. When inserting an I.V. catheter needle, the nurse initially uses veins low on the hand or arm if available, unless contraindicated. Should the I.V. fluid infiltrate or the vein become irritated at this insertion site, veins higher on the arm are still available for use. After a vein higher up on the arm has been damaged, veins below it cannot be used.
A nurse is caring for a client with a history of GI bleeding, sickle cell anemia, and a platelet count of 22,000 mm3. The client, who is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hour, reports having severe bone pain and is scheduled to receive a dose of morphine sulfate. For which administration route should the nurse question an order?
Intramuscular (IM) A client with a platelet count of 22,000 mm3 bleeds easily. The nurse should avoid using the IM route because the area is highly vascular. The client may bleed readily when penetrated by a needle, and it may be difficult for the nurse to stop the bleeding. The client's existing IV access would be the best route, especially because IV morphine is effective almost immediately. Oral and s.q. routes are preferred over IM, but they are less effective for acute pain management than IV.
Type 1 diabetes mellitus
diabetes in which no beta-cell production of insulin occurs and the patient is dependent on insulin for survival
Hyperglycemia
high blood sugar
A nurse is caring for a 22-year-old female client with type 1 diabetes mellitus and toxic shock syndrome (TSS). Which action should the nurse perform first?
Administer 5% dextrose in half-normal saline solution at 150 mL/h IV. Fluid losses can occur from vomiting, diarrhea, and fever and can lead to hypovolemic shock. The first nursing action is to treat the hypovolemic shock that accompanies toxic shock, so the IV fluids must be administered immediately. The fluid replacement is critical to avoid circulatory collapse. Pain medication and teaching can be implemented later. Antibiotics will be given because TSS is caused by a staphylococcal infection; however, fluid replacement is initiated first to treat life-threatening hypovolemic shock.
Cytotoxic agents
damage or destroy cells to treat cancer; often act as immunosuppressants or antineoplastics
Isotonic
when the concentration of two solutions is the same
A physician prescribes penicillin potassium oral suspension 56 mg/kg/day in four divided doses for a client with anorexia nervosa who weighs 25 kg. The medication dispensed by the pharmacy contains a dosage strength of 125 mg/5 mL. How many milliliters of solution should the nurse administer with each dose? Record your answer using a whole number.
14 To determine the total daily dosage, set up this proportion: 25 kg/X = 1 kg/56 mg X = 1,400 mg. Next, divide the daily dosage by four doses to determine the dose to administer every 6 hours: X = 1,400 mg/4 doses X = 350 mg/dose. The adolescent should receive 350 mg every 6 hours. Lastly, calculate the volume to give for each dose by setting up this proportion: X/350 mg = 5 mL/125 mg X = 14 mL.
When making rounds on the pediatric neurology unit, the nurse manager notes that, when giving IV medications, many of the staff nurses are disconnecting the flush syringe first and then clamping the intermittent infusion device. The nurse manager is concerned that the nurses do not understand the benefits of positive pressure technique and turbulence flow flush in preventing clots. After the nurse manager discusses the problem with the staff educator, which intervention would be the most effective way to improve the nursing practice?
Create a poster presentation on the topic with a required posttest. A poster presentation is an eye-catching way to disseminate information that can be used to educate nurses on all shifts. The addition of the posttest will verify that the poster information has been received. Because of the large volume of emails the typical employee receives, information sent this way might be overlooked. If several nurses are observed not using the most current practice, it is quite possible many more do not understand it. Thus, a larger scale plan is needed. Posting an article will not assure that the information is read.
A graduate nurse is reviewing the procedure for removing a peripherally inserted central catheter (PICC) with the preceptor. Which planned action by the graduate nurse should the preceptor correct?
Discarding the catheter in a trash container To prevent injury to others, the graduate nurse should discard the catheter in a sharps-disposal container rather than a trash container. The graduate nurse should measure the length of the catheter to ensure that the entire catheter has been removed. Flushing the line ensures that there are no problems with the line. Applying a dressing and leaving it in place for 24 hours helps ensure hemostasis.
A physician orders an I.V. bolus injection of diltiazem hydrochloride for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus?
Gently aspirate the I.V. catheter to check for a blood return. Before administering an I.V. bolus, the nurse should gently aspirate the I.V. catheter for a small amount of blood to ensure correct placement of the I.V. catheter. Then the nurse may inject the medication over the recommended time interval. The nurse doesn't need to insert another I.V. line unless the ordered medication is incompatible with the medication in the I.V. solution. Warming the medication could alter the drug's action. Placing a tourniquet on the arm would close off the venous system and prevent drug injection.
When caring for a client with a central venous line, which nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply.
Verify patency of the line by the presence of a blood return at regular intervals. Inspect the insertion site for swelling, erythema, or drainage. If unable to aspirate blood, reposition the client and encourage the client to cough. Contact the health care provider about verifying placement if the status is questionable. A major concern with IV administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent reevaluation of blood return when administering vesicant or nonvesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. The nurse should also assess the insertion site for signs of infiltration, such as swelling and redness. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via X-ray study to verify placement if the status is questionable and may require a declotting regimen. The nurse should not administer any drug if the IV line is not open or does not have an adequate blood return.
To determine the I.V. drip rate, a nurse must know the drip factor, which is
the number of drops in one milliliter. The drip factor is the number of drops in one milliliter, not the number of milliliters in one drop. The drip rate refers to the number of drops infused per minute. The flow rate is the number of milliliters, not the number of drops, infused per hour.
central venous catheter
a blood-vessel access device usually inserted into the subclavian or jugular vein with the distal tip resting in the superior vena cava just above the right atrium; used for long-term intravenous therapy or parenteral nutrition
Hyperchloremia
an excess of chloride in the blood plasma
Partial Thromboplastin Time (PTT)
test to determine coagulation defects, such as platelet disorders
Trendelenburg's position
the head of the bed is lowered and the foot of the bed is raised
Hypertonic
when comparing two solutions, the solution with the greater concentration of solutes
total parenteral nutrition (TPN)
nutrient-complete solution given directly into bloodstream when person cannot eat by mouth
Hypoglycemia
low blood sugar
A client who weighs 187 lb (85 kg) has an order to receive enoxaparin 1 mg/kg. This drug is available in a concentration of 30 mg/0.3 mL. What dose would the nurse administer in milliliters? Record your answer using two decimal places.
0.85 The physician's order is for the client to receive enoxaparin 1 mg/kg. Therefore, the client is to receive 85 mg. The desired dose in milliliters then can be calculated by using the formula of desired dose (D) divided by dose or strength of dose on hand (H) times volume (V). 85 (mg) × 0.3 mL = 25.5 mg/mL 25.5 mg divided by 30 = 0.85 mL.
The physician prescribes acetaminophen 650 mg by mouth every 4 hours for a client with a temperature of 102° F (38.8° C) who has a feeding tube in place. The nurse has acetaminophen solution on hand containing 160 mg/5 ml. How many milliliters of solution should the nurse administer? Record your answer using one decimal place.
20.3 This formula is used to calculate drug dosages: dose on hand/quantity on hand = dose desired/X. In this example, the equation is as follows: 160 mg/5 ml = 650 mg/X X = 20.3 ml
A client is to receive 1 unit of packed red blood cells over 2 hours. There are 250 mL in the infusion bag. The IV administration infusion set delivers 10 gtt/mL. At what flow rate (in drops per minute) should the nurse run the infusion? Record your answer using a whole number.
21 One unit of packed red blood cells contains 250 mL, and this is to infuse over 2 hours (120 minutes). First, determine the number of mL/minute by dividing 250 mL by 120 minutes: 250 mL/120 min = 2.1 mL/min. Then multiply by the drop factor of 10 gtt/mL: 2.1 mL/min × 10 gtt/mL = 21 gtt/min.
A client who is experiencing an exacerbation of ulcerative colitis is receiving IV fluids that are to be infused at 125 mL/h. The IV tubing delivers 15 gtt/mL. How quickly should the nurse infuse the fluids in drops per minute to infuse the fluids at the prescribed rate? Record your answer using a whole number.
31 To administer I.V. fluids at 125 mL/h using tubing that has a drip factor of 15 gtt/mL, the nurse should use the following formula:125 mL/60 min × 15 gtt/1 mL = 31 gtt/min.
A client with a deep vein thrombosis has heparin sodium infusing at 1,500 units/hour. The concentration of heparin is 25,000 units/500 mL. If the infusion remains at the same rate for a full 12 hour shift, how many milliliters of fluid will infuse? Record your answer using a whole number.
360 25,000 u/500 ml = 50 units/ml. 1 ml/50 units x 1500 units/hour = 30 ml/hour x 12 hours = 360 ml
A client admitted to the hospital with diabetic ketoacidosis is receiving a continuous infusion of regular insulin. The physician orders an I.V. containing 1 liter of dextrose 5% in water at 150 ml/hour to be started when the client's blood glucose level reaches [250 mg/dl (13.9 mmol/L)]. The drip factor of the I.V. tubing is 15 gtt/ml. What is the drip rate for this I.V. infusion in drops per minute? Record your answer using one decimal place.
37.5 Drip rate = 150 ml ÷ 60 minutes × 15 gtt ÷ 1 ml2,250 gtt ÷ 60 minutes = 37.5 gtt/minute
Deep Vein Thrombosis
blood clot forms in a large vein, usually in a lower limb
peripheral venous catheter
catheter placed in a peripheral vein example cephalic, saphenous, femoral, and auricular vein
type 2 diabetes mellitus
diabetes in which either the body produces insufficient insulin or insulin resistance (a defective use of the insulin that is produced) occurs; the patient usually is not dependent on insulin for survival
ulcerative colitis (UC)
disease characterized by inflammation of the colon with the formation of ulcers, which can cause bloody diarrhea
Hypernatremia
high sodium
The neonate has a prescribed IV rate of 8 mL/h. Fluid totals are recorded every 2 hours on the even hours. There is a new prescription written at 1030 to decrease the IV rate to 6 mL/h. What is the fluid total to be infused and recorded at 1200? Record your answer using a whole number.
13 1000 to 1030 = 4 mL (hourly rate 8), 1030 to 1100 = 3 mL (hourly rate 6 mL), 1100 to 1200 = 6 mL (hourly rate 6 mL). 4 + 3 + 6 = 13.
An infusion of lidocaine hydrochloride is running at 30 mL/hour. The dilution is 1,000 mg/250 mL. What dosage is the client receiving per minute? Record your answer using a whole number.
2 First, calculate the concentration of mg/mL: 1,000 mg divided by 250 mL equals 4mg/mL.Next, multiply the number of milligrams per milliliter by the pump setting in milliliters per hour: 4 mg/mL x 30 mL/h = 120 mg/h.Next, divide the milligrams per hour by 60 to obtain milligrams per minute: 120 mg/h divided by 60 min/h equals 2 mg/min.
A physician prescribes intravenous heparin 25,000 units in 250 ml of normal saline solution to infuse at 600 units/hour for a client who suffered an acute myocardial infarction (MI). After 6 hours of heparin therapy, the client's partial thromboplastin time is subtherapeutic. The healthcare provider orders the infusion to be increased to 800 units/hour. The nurse would set the infusion pump to deliver how many milliliters per hour? Record your answer using a whole number.
8 The nurse would calculate the infusion rate using the formula:Dose on hand/Quantity on hand = Dose desired/X25,000 units/250 ml = 800 units/hour ÷ X25,000 units x X = 250 ml x 800 units/hour25,000 x X = 200,000 ml/hourX = 8 ml/hour
Diabetic Ketoacidosis (DKA)
A form of hyperglycemia in uncontrolled diabetes in which certain acids accumulate when insulin is not available.
Which actions by the nurse will most likely ensure that the correct client receives a medication? Select all that apply.
Check the name on the armband with the name on the medication. Compare the date of birth on the client's medical record to the date of birth on the client's armband. Two sources of identification must be confirmed before administering medication to a client. A source of information can be the client's record number, name, or date of birth, as noted on the client's armband. A client may be confused or hard of hearing and may give a wrong name or answer to a wrong name, thus having the client state his or her name or respond to his or her name is not safe practice. Client recognition is not sufficient identification for administering medication. Clients change rooms frequently, so a room number is not a source of identification for administering medication.
toxic shock syndrome (TSS)
a severe illness characterized by high fever, rash, vomiting, diarrhea, and myalgia, followed by hypotension and, in severe cases, shock and death; usually affects menstruating women using tampons; caused by Staphylococcus aureus and Streptococcus pyogenes
If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first?
Clamp the catheter. If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp. If a clamp isn't available, the nurse may place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension set and restart the infusion. Calling the physician, applying a dry sterile dressing to the site, and telling the client to take a deep breath aren't appropriate interventions at this time.
Total parenteral nutrition (TPN) is prescribed for a client who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN?
Handle TPN using strict aseptic technique. TPN is a hypertonic, high-calorie, high-protein IV fluid that should be provided for clients who do not have functional gastrointestinal track motility, in order to better meet metabolic needs of the client, and to support optimal nutrition and healing. TPN is prescribed once daily, based on the client's current electrolyte and fluid balance, and must be handled with strict aseptic technique (due to the high glucose content, it is a perfect medium for bacterial growth). Also, because of the high tonicity, TPN must be administered through a central venous access, not a peripheral IV line. There is no specific need to auscultate for bowel sounds to determine whether TPN can safely be administered.
Extravasation
escape of blood from the blood vessel into the tissue
The nurse finds an unopened bag of IV 50% dextrose in a sink on the nursing unit. What should the nurse do with the IV bag?
Send it to the pharmacy. The nurse should send the unopened bag of IV 50% dextrose found in the sink to the pharmacy. A concentrated medication such as 50% dextrose could be lethal if inadvertently administered and should not be stored outside the pharmacy. An incident report is not necessary in this situation. The sharps container is not the appropriate method for disposal of this medication.
Subtherapeutic response
Signs and symptoms of infection do not improve
When preparing to insert an IV catheter to administer fluids to a client who is going to surgery, the nurse selects the median cubital vein. Identify the location of the median cubital vein on the accompanying illustration.
The median cubital vein is located in the approximate center of the antecubital space.
Small air bubbles adhering to the interior surface of the syringe might have which effect on parenteral administration?
altered drug dose Although not harmful to the client when injected, small air bubbles can actually change the dose of medication administered; therefore, the nurse should remove the air bubbles. Small air bubbles won't affect the drug's onset of action, duration, or absorption. Air bubbles may be helpful in some situations but should be added only after the dose of the drug has been withdrawn accurately. For example, with iron dextran, an air bubble and the Z-track method of injection help prevent permanent staining of the client's skin if the solution leaks into the subcutaneous tissue.
The health care provider's (HCP's) prescription for an intravenous infusion is 3% normal saline to infuse at 125 mL/h. The client's most recent sodium level is 132 mEq/L (132 mmol/L). The nurse should:
consult the prescriber about the prescription. Three percent saline is a hypertonic solution, which will pull fluid from the interstitial and intracellular spaces into the bloodstream. Its use is usually reserved for severe hyponatremia (sodium less than 115 mEq/L). If this client were experiencing a fluid volume deficit, this IV solution could worsen the condition. The nurse should consult with the HCP about this prescription. The nurse does not have prescribing rights and cannot change the prescription. The IV rate of 62 may still be dangerous for this client, and the rate was prescribed at 125 mL/h.
In a client with a urine specific gravity of 1.040, a subnormal serum osmolality, and a serum sodium level of 128 mEq/L, the nurse should question an order for which I.V. fluid?
dextrose 5% in water (D5W) An elevated urine specific gravity, a subnormal serum osmolality, and a subnormal serum sodium level indicate that the client is excreting too many solutes. Because the client is in a hypotonic state, the nurse shouldn't give a hypotonic I.V. solution. D5W, also referred to as free water, is hypotonic when given I.V. and can further hemodilute the client. Dextrose 5% in half-normal saline solution is hypertonic, normal saline solution is isotonic, and lactated Ringer's solution is isotonic. For this client, each of these three choices are more acceptable than D5W.
A nurse discovers that an I.V. site in a client's hand has infiltrated, causing localized pain and swelling. Which intervention would relieve the client's discomfort most effectively?
elevating the hand and wrapping it in a warm towel Elevating the arm promotes venous drainage and reduces edema; applying warmth increases circulation and eases pain and edema. Ice application would relieve pain but not edema. An analgesic wouldn't correct the primary cause of the discomfort. Wrapping the arm above the hand would slow venous return and is contraindicated.
Which type of solution, when administered I.V., would cause fluid to shift from body tissues to the bloodstream?
hypertonic A hypertonic solution causes the bloodstream to absorb fluids until pressure on both sides of the blood vessel is equal. A hypotonic solution causes fluids to move from the bloodstream into the tissues. An isotonic solution has no effect on the cell. Depending on the concentration of sodium, a sodium chloride solution can be isotonic, hypertonic, or hypotonic.
A nurse may delegate adding medications to I.V. fluid containers to a
pharmacist. A nurse should delegate the task of adding medications to primary fluid containers to a pharmacist. Other assistive personnel aren't qualified to perform this task.
While performing rounds, a nurse finds that a client is receiving the wrong I.V. solution. The nurse's initial response should be to
slow the I.V. flow rate and hang the appropriate solution. When a client is getting the wrong I.V. solution, the nurse should maintain the access and start the proper solution. The nurse doesn't have to remove the catheter. Doing so would subject the client to unnecessary needle sticks. Waiting until the next bottle is due is inappropriate and places the client at risk for problems and the nurse in legal jeopardy. After starting the correct solution, the nurse should complete an incident report describing the specific error.
When positioned properly, the tip of a central venous catheter should lie in the
superior vena cava. When positioned correctly, the tip of a central venous catheter lies in the superior vena cava, inferior vena cava, or right atrium — that is, in the central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilic, jugular, and subclavian veins are common insertion sites for central venous catheters.
Air embolus
A bubble of air in the blood stream.
Hypotonic
Having a lower concentration of solute than another solution
A nurse is administering IV fluids to a dehydrated client. When administering an IV solution of 3% sodium chloride, what should the nurse do? Select all that apply.
Measure the intake and output. Inspect the jugular veins for distention. Evaluate the client for neurologic changes. A 3% sodium chloride solution is hypertonic; it will pull fluid into the intravascular compartment and may increase renal perfusion, so intake and output should be monitored. As fluid is pulled into the vasculature, the client may demonstrate signs of fluid overload such as jugular vein distention. Hypernatremia and hyperchloremia will produce neurologic signs and symptoms. Fluids should not be forced in a client with fluid overload. There is no need for an indwelling urinary catheter.
hypovolemic shock
shock resulting from blood or fluid loss
Which finding is the best indication that fluid replacement for the client in hypovolemic shock is adequate?
urine output greater than 30 ml/hour Urine output provides the most sensitive indication of the client's response to therapy for hypovolemic shock. Urine output should be consistently greater than 35 mL/h. Blood pressure is a more accurate reflection of the adequacy of vasoconstriction than of tissue perfusion. Respiratory rate is not a sensitive indicator of fluid balance in the client recovering from hypovolemic shock.
A client is receiving magnesium sulfate at 3 g/h intravenously. The bag of 1,000 mL normal saline contains 20 g of magnesium sulfate. At what rate (in mL/hour) should the nurse set the IV pump to deliver 3 g/h? Record your answer using a whole number.
150 The rate can be calculated as follows: Rate = (Volume to infuse)/(Time to infuse) Volume to infuse = (Desired dose/Dose on hand) X Supply = (3 g/20 g) X 1000 mL Therefore, Rate = ((3 g/20 g) X 1000 mL)/1 hr = 150 mL/hr.
The health care team has noticed an increase in IV infiltrations on the pediatric floor. As part of a "Plan, Do, Study, Act" quality improvement plan, the team should perform the actions in which order? All options must be used.
Decide to monitor IV gauges. Perform chart audits. Analyze the data. Write a new IV insertion policy. Deciding what to study and how to do it is part of the planning process. Collecting data through chart audits is part of the "do" phase. Once the chart audits are complete the data may be "studied" or analyzed. The final step of the process, or the "act" phase, is to determine what should be done, which may include writing a new policy.
A client is receiving TPN administered through a central line. What should the nurse do to prevent complications associated with this infusion?
Secure all connections of the system. Complications associated with administration of TPN through a central line include infection and air embolism. To prevent these complications, strict aseptic technique is used for all dressing changes, the insertion site is covered with an air-occlusive dressing, and all connections of the system must be secure. Ambulation and activities of daily living are encouraged and not limited during the administration of TPN.
When teaching about prevention of infection to a client with a long-term venous catheter, the nurse determines that the client has understood discharge instructions when the client makes which statement?
"My husband will change the dressing three times per week, using sterile technique. The most important intervention for infection control is to continue meticulous catheter site care. Dressings are to be changed two to three times per week depending on institutional policies. Temperature should be monitored at least once a day in someone with a vascular access device. Hand washing before and after irrigation or any manipulation of the site is a must for infection prevention.
The nurse is to administer chloramphenicol 50 mg IV in 100 mL of dextrose 5% in water over 30 minutes. The infusion set administers 10 gtt/mL. At what flow rate (in drops per minute) should the nurse set the infusion? Round to the nearest whole number.
33 The flow rate is determined by the rate of infusion and the number of drops per milliliter of the fluid being administered: gtt/mL × mL/min = IV flow rate (gtt/minute).Therefore:10 gtt/mL × 100 mL/30 min = 33 gtt/min.
While making rounds, a nurse observes that a client's primary bag of intravenous (IV) solution is light yellow. The label on the IV bag says the solution is D5W. What should the nurse do first?
Hang a new bag of D5W, and complete an incident report. Maintenance of IV sites and systems includes regular assessment and rotation of the site and periodic changes of the dressing, solution, and tubing; these measures help prevent complications. The nurse should also observe the solution for discoloration, turbidity, and particulates. An IV solution is changed every 24 hours or as needed, and because the nurse noted an abnormal color, the nurse should change the bag of D5W and note this on an incident report. It is not necessary to verify this action with another nurse. Paging the HCP is not necessary; maintaining the IV and using the correct solutions is a nursing responsibility. Although the first action is to hang a new bag, hospital policy should be followed if there is a question as to whether there could have been an unknown substance in the bag that caused it to change color.
A nurse fails to give the evening dose of an IV antibiotic that is to be administered every 12 hours. The evening dose was scheduled for 1800; it is now 2200. The nurse should next:
report the incident to the health care provider. The error must be reported to the health care provider to obtain a new scheduling prescription. An incident report should be completed, and the agency policy for medication errors should be followed.Assessing for signs of infection is not the nurse's first action and should be completed routinely for clients receiving antibiotics.The dose should not be administered 4 hours late unless prescribed by the health care provider; a new medication schedule will be arranged.The pharmacist is not responsible for giving directions for medication omissions; this is the responsibility of the health care provider.
A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, the phyician connects a 10-ml syringe to the catheter and withdraws a sample of blood. The phyisician then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. The nurse should
turn the client on the left side and place the bed in Trendelenburg's position. A nurse who suspects an air embolism should place the client on their left side and in Trendelenburg's position. Doing so allows the air to collect in the right atrium rather than enter the pulmonary system. The supine position, high-Fowler's position, and the shock position are therapeutic for other situations but not for air embolism.
