Module 10: Maintenance of Intravenous Fluid Therapy
The patient has an order to infuse gentamicin (Garamycin) 500 mg IV in 50 mL sodium chloride at a rate of 100 mL/hr every 4 hours. The patient does not have an order for continuous fluids, and therefore the medication is infused with primary tubing and the peripheral access device is saline locked between doses. Which of the following actions could cause contamination or increase the risk of infection? (Select all that apply.) A. When changing tubing, the nurse disconnects the old tubing and attempts to insert the adapter of the new tubing without removing the protective cap. B. The nurse wipes the port on the extension tubing with an alcohol swab and flushes the vascular access device with 3 mL of normal saline when the infusion is complete. C. When it is time to hang a new dose of gentamicin (Garamycin), the nurse connects the tubing to the injection port using the same needleless adapter that has been hanging on the IV pole for 4 hours without a protective cover. D. The nurse attaches the IV bag of gentamicin (Garamycin) to new tubing, primes the tubing, and changes the bag and tubing all at one time when the dose is ordered. E. The nurse changes the primary intermittent tubing set every 96 hours.
a c e 3
1. A confused elderly patient has pulled out her IV twice. The health care provider has ordered restraints and that the IV be restarted for the transfusion of packed red blood cells (PRBCs). Which factors in this situation may alter the rate of infusion? (Select all that apply.) A. Improperly placed restraints. B. The electronic infusion device (EID) being plugged into the wall outlet. C. The patient's age. D. The patient's dehydration and anemia. E. Manipulation of the IV catheter by the patient. F. Viscosity (thickness) and temperature of the infusion.
a e f Factors in this situation that may alter intravenous flow rate include manipulation of the IV catheter by the patient, viscosity and temperature of the blood to be infused because it is thicker than typical IV solutions and is refrigerated, and improperly placed restraints. The patient's age, dehydration, and anemia may make initiating an IV more difficult but are unlikely to alter the rate of infusion once it is begun. The electronic infusion device should remain plugged into the wall outlet to keep the battery from getting low. It may be unplugged when the patient is ambulating or being transported.
The nurse performed hand hygiene and applied clean gloves to perform an intravenous (IV) tubing change. Which step(s) described in the following was missed or performed incorrectly? Remove IV dressing covering catheter hub and slow rate of infusion to keep-vein-open (KVO) by regulating the roller clamp. Fill drip chamber of old tubing, remove IV container from IV pole, and remove old tubing from the solution. Place insertion spike of new tubing into the old fluid container opening and hang it on the IV pole. Fill tubing rapidly with solution, creating air bubbles in the tubing. Turn roller clamp to the "off" position on the new tubing and remove as much air as possible. Turn roller clamp on the old tubing to the "off" position. Stabilize hub of the catheter, disconnect the old tubing from the catheter hub, and quickly insert adapter of new tubing into catheter hub. Open roller clamp on new tubing, and regulate IV drip according to health care provider's orders. Secure tubing with a piece of tape. Place label with date and time on tubing below drip chamber. Discard old tubing and used supplies, remove gloves, and perform hand hygiene. A. Failing to change the IV dressing. B. Failing to close the roller clamp on the new tubing before inserting it into the fluid container. C. Failing to wipe the IV catheter hub with an antiseptic swab before connecting the new tubing. D. Opening the roller clamp on the new tubing after attaching it to the catheter hub.
b L3
A nursing instructor is assisting a student nurse to change the peripheral IV dressing on a patient. Which action, if made by the nursing student, indicates further teaching is necessary? (Select all that apply.) A. The student stabilizes the IV, cleans the insertion site with chlorhexidine gluconate (CHG) solution using friction in a back and forth motion for 30 seconds. B. After completing the dressing change, the student nurse documents in the patient's chart the presence of swelling, coolness, blanching, and complaints of pain at the insertion site. C. The student nurse labels the dressing with date and time of insertion, date and time of dressing change, gauge and length of catheter, and identification of student nurse. D. The student nurse applies sterile gloves and removes the old dressing, being careful to avoid dislodging the catheter. E. The student nurse cleans the site with a povidone-iodine swab in a concentric circle and immediately applies a new dressing to protect against infection.
b d e The student nurse should perform hand hygiene before applying clean gloves. It is unnecessary to wear sterile gloves to remove the old dressing. If signs of symptoms of infiltration are present, the infusion should be temporarily discontinued, the catheter removed, and the IV relocated. The student should do more than simply document the presence of the symptoms, because the infiltration will only worsen. To reduce skin surface bacteria, the student nurse should allow the antiseptic to dry completely before applying the new dressing. The student nurse provided appropriate labeling of the dressing.
The nurse checks the identity of the patient, performs hand hygiene, and applies clean gloves. The nurse removes the old dressing, cleans the site with CHG solution in a back-and-forth motion, and allows the site to dry. The nurse applies a new manufactured catheter stabilization device, applies a transparent dressing, secures the tubing with tape, and labels the dressing with date and time of dressing change. The nurse discards used equipment and performs hand hygiene. The student nurse observing the nurse change the peripheral IV dressing correctly identifies actions the nurse should have performed. The student nurse is correct in identifying which two actions? A. The type of gloves worn by the nurse. B. To stabilize the catheter when removing the old dressing. C. Using a commercial catheter stabilization device. D. That the nurse does not apply the dressing. E. How the dressing was labeled. F. The direction the insertion site was cleaned.
b e The nurse should stabilize the catheter when removing the old dressing to prevent accidental displacement of the vascular access device (pulling tape of old dressing one layer at a time in a direction toward the insertion site). The nurse should label the dressing with date and time of insertion, time of dressing change, gauge and length of catheter, and nurse's initials. Clean gloves may be worn. The site was cleaned in the appropriate direction. A commercial catheter stabilization device, transparent dressing, or sterile gauze dressing may be used.
1. The nursing staff attended an in-service on IV fluid management with discussion on patient safety. Which of the following statements, if made by one of the staff, indicates further instruction is needed? A. "An electronic infusion device may continue to infuse IV fluids after an infiltration has begun." B. "Most electronic infusion devices use microdrip tubing, and therefore the setting on the electronic infusion device in milliliters per hour is the same as the calculated gtt per minute." C. "It is unnecessary to monitor infusion rates when an electronic infusion device is being used." D. "Calculation and regulation of IV flow rates is inappropriate for nursing assistive personnel to perform."
c Correct Infusion controllers or electronic infusion devices are imperfect and do not replace frequent, accurate nursing evaluation. EIDs may continue to infuse IV fluids after an infiltration has begun. Calculation and regulation of IV flow rates is the responsibility of the nurse. Most electronic infusion devices use microdrip tubing that delivers 60 gtt per minute. When calculated, the milliliters per hour will be the same as the number of gtt per minute. For example, it is essential to monitor the infusion site for infiltration because an infiltration may become quite significant before the EID alarm will sound.
A nursing student has initiated and regulated an IV in the skills lab but is now assigned to a patient in a clinical setting. The patient has an IV of 0.9% normal saline infusing at 50 mL/hr. Which of the following indicates correct understanding regarding managing IV fluid administration? A. Nursing assistive personnel are allowed to change the rate on an IV as long as it is on an electronic infusion device. B. Fifty (50) mL/hr is the same as keep-vein-open (KVO) rate. C. When using microdrip tubing, milliliters per hour equals gtt per minute. D. Sterile IV tubing used for a continuous infusion is good for 48 hours.
c Correct Microdrip tubing has a drop factor of 60 gtt per milliliter, and when divided by 60 minutes, this is equivalent to 1; therefore 1 multiplied by the milliliters per hour will have the same product in gtt per minute. Ten milliliters per hour is considered the least amount to keep a vein open; KVO rate is considered to be 25 to 30 mL/hr. The Infusion Nurses Society (INS) recommends 96-hour intervals for continuous tubing changes. The INS also states that tubing used for intermittent infusion through an injection/access port should be changed every 24 hours because both ends of the tubing are manipulated more often than tubing used for continuous infusion. NAP are not allowed to change the rate of an IV infusion but should be instructed to inform the nurse if the EID is alarming, the fluid container is almost empty, or the patient is complaining about the IV site.
A patient has received 1000 mL of IV fluid in 2 hours. The patient has dyspnea, tachycardia, crackles in the lungs, and peripheral edema. What is the nurse's priority action at this time? A. Discontinue present IV. B. Check for positional changes that affect rate, height of IV container, kinking of tubing, or obstruction. C. Slow infusion to KVO and notify health care provider. D. Assess the patient for symptoms of fluid volume overload.
c Correct The nurse should slow the IV infusion to KVO and notify the health care provider so further orders may be received to treat the patient's symptoms of fluid volume overload.
A patient has an order for the administration of 1000 mL of 0.9% normal saline at 100 mL/hr. The nurse begins the infusion at 0900. At noon the nurse notices that 500 mL has infused. Of the following options, which should be the nurse's highest priority action? A. Assess the site for complications such as infiltration, phlebitis, or clotting of the catheter. B. Determine if the electronic infusion device is plugged in or if the "low battery" signal is displayed. C. Assess the patient for symptoms of fluid volume overload. D. Determine if there is a kink in the tubing or if the IV is positional.
c Correct The patient should have received 300 mL of IV fluid in this time but instead received 500 mL. The nurse should first slow the rate to the keep-vein-open (KVO) rate and assess the patient for any adverse effects, primarily symptoms of fluid volume overload.
The nursing assistive personnel turned and repositioned the patient as requested. However, now the electronic infusion device is alarming. Which of the following situations is most likely to have set off the alarm? A. The rate of infusion has increased. B. The patient is probably developing phlebitis. C. The patient is lying on the tubing. D. There is now air in the tubing.
c Correct With the change in patient position, the patient may now be lying on the tubing or there may be a crimp in the tubing causing an occlusion of flow.
The nurse is changing IV fluids. She has performed hand hygiene and applied clean gloves. The nurse hung the new bag of fluids on the IV pole, removed the protective cover of the tubing port, removed the spike from the old bag, and accidentally touched the spike with her hand. Which action should be taken at this time? A. Continue with inserting the spike into the new bag of IV fluids because she was wearing gloves at the time. B. Obtain a new IV tubing set, remove the protective cover of the spike and insert it into the tubing port of the IV bag she just hung. Prime the tubing. C. Obtain a new IV tubing set and a new bag of IV fluids; discard the bag of fluids she just hung and on which she had removed the protective covering of the tubing port. D. Wipe the spike off with an alcohol swab, allow it to dry completely, and insert it into the bag of fluids.
c L3
1. Which of the following indicate that the infusion needs to be temporarily discontinued, the catheter removed, and the IV relocated? (Select all that apply.) A. Patient is afebrile; absence of symptoms of infection at IV insertion site. B. Catheter is leaking at connection of hub. C. Small amount of purulent drainage is at insertion site; redness is noted. Correct D. Dried blood is present on the dressing. E. Insertion site is pale, cool to touch, and extremity edematous.
c e Signs and symptoms of infiltration (i.e., insertion site pale, cool to touch, edema) require the infusion to be temporarily discontinued, the catheter removed, and the IV relocated with a new sterile catheter. Localized infection at the insertion site (redness, purulent drainage) also requires discontinuation of the present IV and relocation. It is unnecessary to relocate the IV site if the patient is afebrile and without symptoms of infection at the IV site. If the catheter is leaking, tightening the tubing and hub connection should be attempted first. Dried blood indicates the need for a dressing change but fails to require IV relocation.
Identify the situations in which a peripheral intravneous (IV) line dressing requires changing. (Select all that apply.) A. The patient's IV dressing got wet during bathing. B. Twenty-four hours have elapsed since the last gauze IV dressing change. C. There has been a change in the health care provider's order for the type of IV fluids. D. It has been 2 days since the last change of a transparent IV dressing. E. There is blood underneath the transparent dressing from movement of the catheter.
a e Peripheral IV dressings must be changed when loose, wet, or soiled. A transparent membrane dressing should be changed with catheter site rotation and immediately if the integrity of the dressing is compromised. Gauze dressing should be changed routinely every 2 days and immediately if integrity is compromised. If blood is present under the dressing, the dressing requires changing, because it may provide a medium for bacterial growth. Furthermore, the presence of blood from catheter movement indicates that the catheter was not well secured and the patient would benefit from an adhering IV dressing. The type of fluids infusing does not affect the frequency of a peripheral IV dressing change.
A nurse working in the emergency room has elected to use macrodrip IV tubing. For which patient would this be most appropriate? A. A child who has experienced nausea and vomiting for the last 24 hours. B. A hypotensive adult trauma victim with cool, clammy skin. C. A young adult being treated for asthma with an order for D5W at 60 mL/hr. D. An older adult who is being treated for congestive heart failure.
b Correct Macrodrip tubing should be used when large quantities or fast intravenous infusion rates are necessary, as in this instance where the patient is demonstrating signs of shock. Hourly rates greater than 100 mL/hr may lend themselves more to macrodrip tubing. Microdrip tubing is preferred for pediatric applications. Microdrip tubing should be used when small or very precise volumes are to be infused. Extra precautions should be made for patients at risk for fluid volume excess, such as elderly cardiac patients or renal patients.
The nurse has received an order to infuse an IV medication. Which of the following would be the safest choice of equipment to use? A. Gravity IV controller. B. A smart pump. C. An electronic infusion device. D. A volume-control device.
b Correct Smart pumps contain computer software to prevent errors that relate directly to administration of IV medications. The pump will sound an alarm if the pump setting does not match the medication administration guidelines, assisting in prevention infusion errors.
The nurse is determining if any of the patients require a peripheral IV dressing change. The date is 2/22 and the time is 0900. The agency uses a commercially engineered catheter stabilization device with its own transparent dressing. Which of the following patients would require a peripheral dressing change? (Select all that apply.) A patient: A. with the peripheral IV dressing dated 2/20, 1400. B. with a wet peripheral IV dressing after bathing. C. whose manufactured stabilization device is loose. D. with the peripheral IV dressing dated 2/17, 1000. E. with the peripheral IV dressing dated 2/21, 0900.
b c d A commercially manufactured catheter stabilization device with transparent semipermeable membrane (TSM) should be changed every 5 to 7 days or immediately if the integrity of the dressing is compromised. Gauze dressings should be changed every 2 days and immediately if integrity is compromised. Dressings should also be changed when wet, soiled, or loosened. Moisture is a medium for bacterial growth and renders the dressing contaminated. A nonadhering dressing increases the risk for bacterial contamination to the venipuncture site or displacement of the IV catheter.
The electronic infusion device (EID) is alarming after changing the bag of IV fluids on a continuous infusion. What could be the possible cause(s)? (Select all that apply.) A. The drip chamber is one-third to one-half full. B. Air is present in the tubing. C. It has been 48 hours since the IV tubing was changed. D. The roller clamp is in the "off" position.
b d L3
Which of the following are part of maintenance care of a peripheral intravenous site? (Select all that apply.) A. Initiating blood therapy. B. Changing IV fluids. C. Inserting a peripherally inserted central catheter. D. Changing IV tubing. E. Ongoing assessment. F. Regulating the IV flow rate. G. Changing the IV dressing.
b d e f g Maintenance of an intravenous site includes continuous assessment, regulation of the rate of flow, changing IV fluid intravenous tubing, and changing the peripheral IV dressing.
1. The nursing students are studying in a group. Which of the following statements, if made by a nursing student, indicates further instruction is needed? A. "Sterile technique is used to change IV tubing." B. "Sterile IV tubing used for a continuous infusion of normal saline may remain sterile for 96 hours." C. "The bag of fluids should be changed when there is approximately 100 mL of solution left in the bag to avoid disruption in fluid therapy to the patient." D. "When a peripheral IV site is being changed, you should change the IV administration set."
c L3
Which of the following is an acceptable IV site in a child but not a routine site in adults? A. Foot. B. Scalp. C. Hand. D. Forearm.
a Correct The use of the foot for an IV site is used with infants and young children but is avoided in the adult because of the danger of thrombophlebitis. The forearm may be used in children and adults. The scalp is used for infants.
A patient has been admitted with heart failure. The health care provider's orders state to administer normal saline at 50 mL per hour. An hour later, the nurse finds that 150 mL have infused. What priority assessments should the nurse make? (Select all that apply.) A. Assess respiratory pattern for evidence of dyspnea. B. Inspect lower extremities for edema. C. Auscultate lungs for crackles. D. Check pulse for tachycardia. E. Check patient's temperature for presence of fever. F. Inspect mucous membranes for dryness.
a b c d The patient should be assessed for symptoms of fluid volume excess. Indications of fluid overload include dyspnea, crackles in the lung, tachycardia, increased urine output, increased weight, and edema. The rate of infusion would slow with an infiltration rather than increase. Dry mucous membranes and a fever may indicate dehydration.
What is the rationale for avoiding taping over the connection of the tubing to the hub? A. Access to the catheter hub is needed when changing tubing. B. It will reduce the transmission of microorganisms Incorrect C. It will help to prevent pressure of the catheter hub against the skin D. It will increase the risk of dislodging the catheter by an accidental pull.
a The nurse should avoid placing tape over the connection between the IV tubing and catheter hub because access to the catheter hub is needed in times of emergency and when changing tubing.
At 0800, a 1000 mL bag of D5 1/2NS is hung. The flow rate is 125 mL per hour and the drop factor is 60 gtt per mL. At 1200 (noon), 550 mL is left. What action should the nurse take to make sure the IV completes on time? A. Increase the rate to 138 mL/hr B. Decrease the rate to 75 mL/hr C. Increase the rate to 175 mL/hr D. None, this IV is on time. E. Decrease the rate to 113 mL/hr
a Correct It should take 8 hours for the infusion to be complete if the IV were on schedule (1000 mL ÷ 125 mL/hr = 8 hr).After 4 hours, 500 mL should have infused.If 550 mL remains, 450 mL has already infused.Therefore, the IV is 50 mL behind schedule.The remaining amount of time is 4 hours. 550 mL ÷ 4 hours = 137.5 = 138 mL/hr
If a nurse fails to monitor a patient's intravenous (IV) infusion, what complications could develop? (Select all that apply.) A. The patient may receive more than the prescribed amount of IV fluids. B. None, because the nursing assistive personnel may regulate the IV in the nurse's absence. C. The patient may receive less than the prescribed amount of IV fluids. D. The patient may experience infiltration. E. The catheter may clot off. F. None, if the patient has a volume-control device. G. None, if the patient has an inline filter.
a c d e If the bag or bottle of IV fluids runs empty, the catheter may become clotted off and patency of the IV will be lost, resulting in the need to restart the IV. A volume-control device helps prevent fluid overload but does not prevent clotting off if the fluids should run dry. If the IV catheter becomes clotted off or the tubing is kinked, the patient may receive less than the prescribed amount of fluids. Without monitoring, the patient may experience undetected infiltration. Electronic infusion devices may continue to infuse IV fluids after an infiltration has begun. If a patient's IV is positional and unmonitored, a patient could accidentally receive more fluids than prescribed, which could result in circulatory overload. If the patient has decreased circulatory blood volume, an IV infusion rate that is too slow can further increase the patient's likelihood of circulatory collapse. An inline filter may prevent particulate matter from entering the patient but does not prevent fluid overload or deficiency. It is inappropriate for assistive personnel to regulate an IV infusion.
The nursing assistive personnel reports to the nurse that the patient appears to be very short of breath. The nurse assesses the patient and determines the patient is experiencing fluid volume excess (FVE). The nurse notes that 500 mL of IV fluids have infused in the last hour, rather than the prescribed 50 mL/hr. What action should the nurse take first? A. Discontinue the IV. B. Notify the health care provider. C. Slow the rate of infusion. D. Administer oxygen at 2 L/min.
c Correct The initial action should be to care for the patient by slowing the rate of infusion to KVO to prevent further volume overload, then notify the health care provider. The peripheral vascular access device should be maintained because the patient may require IV medications to treat the fluid overload. An order would be necessary to administer oxygen.
1. The nurse is changing the IV fluids and tubing. Which of the following are actions the nurse can take to prevent complications and/or keep the electronic infusion device (EID) from alarming? (Select all that apply.) A. Place the roller clamp in the on position after the fluids and primed tubing are connected to the patient and the EID. B. Change the gauze dressing of the IV site whenever the continuous infusion tubing is changed. C. When priming the tubing, have roller clamp in off position, fill drip chamber one-half full and slowly release the roller clamp to prime the tubing. D. Allow the fluid container to run dry before connecting the new IV fluids and primed tubing. E. Change intermittent tubing every 24 hours and change the administration set tubing at same time as fluid container when possible.
a c e Once the primed tubing is connected to the patient and the EID, the roller clamp should be placed in the "on" position to allow the IV fluid to infuse and to prevent the EID alarm from sounding because of an occlusion. Primary intermittent sets should be changed every 24 hours because the IV system becomes interrupted, which increases the risk for contamination. Changing the tubing and the fluid container at the same time decreases the number of times the system is open and maintains sterility, thereby reducing the complication of infection. Changing fluid containers when there is approximately 50 mL left prevents air from entering tubing and vein from clotting from lack of flow. If the IV container runs dry, the EID alarm will sound. Priming the tubing slowly rather than allowing a wide-open flow reduces risk of air entering tubing. A peripheral IV gauze dressing should be changed every 2 days.
A vital factor in the care of a peripheral IV infusion is the prevention of infection. Which of the following, if performed by the nurse, would indicate that the nurse requires further instruction in IV fluid therapy management? The nurse: A. palpates the IV insertion site through the dressing daily. B. allows the IV site to air-dry for 30 seconds after cleaning with chlorhexidine. C. palpates the IV insertion site after the site is cleansed to verify vein location before needle insertion. D. cleans the injection port with an alcohol swab before accessing the system.
c Correct The nurse should not palpate the insertion site after it has been cleansed with a single-use antiseptic solution because this will contaminate the site. The IV site should be allowed to air-dry after a single use antiseptic is applied—30 seconds for chlorhexidine and at least 2 minutes for povidone-iodine solution. The nurse should palpate the IV insertion site daily through the intact dressing to assess for tenderness at the site. The nurse should clean the injection port with a single use antiseptic before accessing the system, whether it be to attach a secondary set or administer an IV push medication.
A student nurse is changing the intravenous (IV) line tubing of a patient's peripheral IV. Which action, if made by the student nurse, indicates that further instruction is needed? The student nurse: (Select all that apply.) A. sets the rate to KVO and fills the drip chamber of the old tubing. B. instructs the patient and family caregiver about the procedure. C. carefully removes the old tubing and quickly inserts the new primed tubing to the catheter hub. D. connects the new tubing to the patient and then removes any air bubbles. E. accidentally contaminates the spike. The student nurse then discards the infusion tubing and obtains a new infusion set. F. opens the clamp so that the flow rate is wide open to reduce the time of priming the tubing.
d f The student nurse requires further instruction regarding two aspects. The student nurse should open the clamp slowly when priming the tubing to avoid the formation of bubbles in the tubing, and the student nurse should remove air from the tubing before connecting it to the patient. All other actions by the student nurse were correct. To reduce the risk of infection, the student nurse should obtain a new infusion set if the spike is contaminated. The patient should be instructed on the procedure to gain patient cooperation, especially to have the patient remain still during the procedure to avoid catheter dislodgement. The drip chamber of the old tubing should kept at a keep-vein-open (KVO) rate and the drip chamber filled to maintain patency of the catheter while priming the new tubing. The student should carefully remove the old tubing so as to not dislodge the IV catheter and quickly insert the new tubing to the IV catheter hub for a smooth transition and to minimize the time the system is open.
