NCLEX book CHAPTER 13 - Intravenous Therapy

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first? 1. Slow the IV infusion. 2. Sit the client up in bed. 3. Remove the IV catheter. 4. Call the health care provider (HCP).

1. Slow the IV infusion.

The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement? 1. "I need to wear a MedicAlert tag or bracelet." 2. "I need to restrict my activity while this catheter is in place." 3. "I need to keep the insertion site protected when in the shower or bath." 4. "I need to check the markings on the catheter each time the dressing is changed."

2. "I need to restrict my activity while this catheter is in place."

A client rings the call light and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? Select all that apply. 1. Remove the IV catheter at that site. 2. Apply warm moist packs to the site. 3. Notify the health care provider (HCP). 4. Start a new IV line in a proximal portion of the same vein. 5. Document the occurrence, actions taken, and the client's response.

1. Remove the IV catheter at that site. 2. Apply warm moist packs to the site. 3. Notify the health care provider (HCP). 5. Document the occurrence, actions taken, and the client's response.

The nurse is completing a time tape for a 1000-mL intravenous (IV) bag that is scheduled to infuse over 8 hours. The nurse has just placed the 1100 marking at the 500-mL level. The nurse would place the mark for 1200 at which numerical level (mL) on the time tape? Fill in the blank. Answer: ______ mL

375

The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation? 1. The catheter advances easily. 2. The vein is distended under the needle. 3. The client does not complain of discomfort. 4. Blood return shows in the backflash chamber of the catheter.

4. Blood return shows in the backflash chamber of the catheter.

A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed for this client? 1. 5% dextrose in lactated Ringer's solution 2. 0.33% sodium chloride (1/3 normal saline) 3. 0.45% sodium chloride (1/2 normal saline) 4. 0.225% sodium chloride (1/4 normal saline)

1. 5% dextrose in lactated Ringer's solution

Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 24 hours to increase urine output and maintain the client's blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previously known data? 1. Excessive bleeding 2. Crackles in the lungs 3. Incompatibility of the infusion 4. Chest pain radiating to the left arm

2. Crackles in the lungs

A client has just undergone insertion of a central venous catheter at the bedside under ultrasound. The nurse would be sure to check which results before initiating the flow rate of the client's intravenous (IV) solution at 100 mL/hour? 1. Serum osmolality 2. Serum electrolyte levels 3. Intake and output record 4. Chest radiology results

4. Chest radiology results

A health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter? 1. Elastic wrap 2. Povidone iodine swab 3. Adhesive bandage 4. Sterile 2 × 2 gauze

4. Sterile 2 × 2 gauze

The nurse is assessing a client's peripheral intravenous (IV) site after completion of a vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best? 1. Check for the presence of blood return. 2. Remove the IV site and restart at another site. 3. Document the findings and continue to monitor the IV site. 4. Call the health care provider (HCP) and request that the vancomycin be given orally.

2. Remove the IV site and restart at another site.

The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride. The nurse also needs to hang an IV infusion of piperacillin/tazobactam. The client has one IV site. The nurse should plan to take which action first? 1. Start a second IV site. 2. Check compatibility of the medication and IV fluids. 3. Mix the prepackaged piperacillin/tazobactam per agency policy. 4. Prime the tubing with the IV solution, and back-prime the medication.

2. Check compatibility of the medication and IV fluids.

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action? 1. Obtain a new IV bag. 2. Obtain new IV tubing. 3. Wipe the spike end of the tubing with povidone iodine. 4. Scrub the spike end of the tubing with an alcohol swab.

2. Obtain new IV tubing.

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? Select all that apply. 1. Pain and erythema 2. Pallor and coolness 3. Numbness and pain 4. Edema and blanched skin 5. Formation of a red streak and purulent drainage

2. Pallor and coolness 3. Numbness and pain 4. Edema and blanched skin