Block 2 Taylor's Skills Quizzes: Peripheral Venous Access, IV, and PICC

Which client would be at highest risk for experiencing fluid overload as a complication of IV therapy?

An older adult client receiving an IV infusion for pneumonia. Although any client receiving IV therapy could develop fluid overload, older adult clients are more at risk for fluid overload due to the possible decrease in cardiac and/or renal functions.

The nurse is flushing a client's peripherally inserted central catheter (PICC). What action should the nurse perform first?

Cap the infusion line. Rationale:The order in which the nurse should flush a PICC is (1) cap the infusion line, (2) swab the access cap with an alcohol wipe, (3) insert the saline syringe into the catheter port, and (4) flush the catheter using steady pressure.

Which is a normal finding upon assessment of a client's peripherally inserted central catheter (PICC)?

an insertion site free of blood and intravenous (IV) solution Rationale:The transparent dressing should allow the nurse to visualize that the catheter inserted into the arm is free of blood or IV solution. A small amount of blood or a crusted appearance at the insertion site would indicate the need for a dressing change. IV solution surrounding the catheter may indicate infiltration and would require further assessment.

The nurse is capping an existing IV line for intermittent use. Which action by the nurse follows correct procedure?

cleaning the end cap of the extension tubing with an antimicrobial swab Rationale:The student nurse demonstrates understanding of the steps required for this procedure in cleansing the end cap of the extension tubing with an antimicrobial swab. Normal saline is used to flush the tubing, not a heparin solution, to maintain patency. The student nurse should have attempted to aspirate for a blood return before flushing the extension tubing. The extension tubing should be looped next to the insertion site, not wrapped over and taped on top of the insertion site.

A nurse must administer an isotonic intravenous solution to a client who has lost fluid. Which fluids are isotonic? Select all that apply.

0.9% NaCl (normal saline), Lactated Ringer's solution Rationale:The following IV fluids are isotonic: 0.9% NaCl (normal saline) and lactated Ringer's solution (LR). The IV fluids 0.45% NaCl (½ strength saline) 0.33% NaCl (1/3-strength normal saline) are hypotonic. The IV fluids 5% dextrose in 0.45% NaCl and 5% dextrose in lactated Ringer's solution are hypertonic.

The nurse is capping an intravenous (IV) line for intermittent use. Place in order how the nurse will perform these actions. Use all options.

1)Scrub the needleless connector or end cap on the extension tubing with an antimicrobial swab. 2)Insert the saline flush syringe into the needleless connector or end cap on the extension tubing. 3)Aspirate the catheter for positive blood return by gently pulling back on the syringe. 4)Flush the tubing slowly, over one minute, with a sterile saline filled syringe. 5)Reclamp the extension tubing and loop it near the entry site, securing it with tape. Rationale:When capping an IV line, the nurse begins by disinfecting the needleless connector or end cap on the extension tubing, vigorously scrubbing it with an antimicrobial swab, and then allowing it to dry. Next, the nurse should insert the saline flush syringe into the end cap and aspirate for a blood return to confirm patency before administering fluids or medications. After getting a blood return, the nurse should slowly flush the line with sterile saline over one minute, and then reclamp the extension tubing to prevent air from entering. Lastly, the nurse should loop the line near the entry site to prevent the weight of the tubing from dislodging the catheter and secure it with tape.

A nurse would perform additional monitoring of the IV site and infusion according to facility policy for which client?

A client who is receiving IV medications. Rationale:The nurse should monitor the IV infusion every hour or per agency policy, but more additional monitoring is necessary if the client is receiving IV medications. This promotes the safe administration of IV fluids and medications.

While removing a client's peripherally inserted central catheter (PICC), part of the catheter breaks off. What action is the nurse's priority?

Apply a tourniquet to the client's upper arm. Rationale:In the event that a portion of the catheter breaks off during removal of a PICC, the nurse should immediately apply a tourniquet to the upper arm, close to the axilla, to prevent advancement of the piece of catheter into the right atrium. The other actions should be performed during a routine PICC removal. Use of the Valsalva maneuver by the client during expiration reduces the risk for air embolism. Measurement and inspection of the PICC following removal ensures that the entire catheter was removed. Application of adequate pressure with sterile gauze following PICC removal prevents hematoma formation.

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client?

Apply pressure to insertion site for at least 3 minutes. Rationale:The nurse recognizes the client prescribed warfarin is at risk for bleeding and individualizes care by applying pressure to the insertion site for longer than the minimum recommended 1 minute. The remaining interventions are appropriate for all clients when discontinuing a PICC line; they do not individualize care for the client prescribed warfarin.

The nurse knows that monitoring the infusion rate and IV site is a nursing responsibility. When does the nurse routinely monitor client IVs?

Beginning of the work shift. Rationale:The nurse is responsible for monitoring the infusion rate and the IV site. This is routinely done as part of the initial client assessment and at the beginning of a work shift. In addition, IV sites would be checked at specific intervals and each time an IV medication is given, per the institution's policies.

A client has a peripheral access IV infusion running via an electronic infusion device. While monitoring the infusion, the nurse notices that the electronic infusion device is not running. What should the nurse do?

Check the electronic device for proper functioning. Rationale:If the electronic infusion is not running, the nurse would check the electronic device for proper functioning, make sure the flow clamp is open and that the drip chamber is approximately half full, and check the IV site for problems with the catheter. If the IV is free flowing, the nurse would raise the height of the IV pole. The nurse could also attempt to flush the IV with 1 to 3 mL of saline in a syringe.

Which hospitalized clients are good candidates for capping of an existing intravenous line for intermittent use? Select all that apply.

Client who needs infusions of an antibiotic only every 12 hours., Client who is only receiving fluids at a keep-vein-open rate., Client who no longer requires intravenous infusions. Rationale:The client who needs infusion of an antibiotic only every 12 hours is a good candidate for capping of an existing intravenous line for intermittent use, because the client now requires only twice daily infusions, not continuous infusions. The client who no longer requires IV infusions is a good candidate, because capping the line maintains IV access in case of an emergency; it is a typical hospital policy to do so. The client who is solely receiving fluids at a keep-vein-open rate is a good candidate for capping of an existing intravenous line, because continuous fluids are not needed to keep the vein open and the line patent. The client receiving a continuous infusion of normal saline at 60 mL/hour is not a good candidate, because the client still need continuous infusions. The client who is tolerating clear liquids is not a good candidate. The most common reasons for a client to be on a clear liquid diet is because the client recently had surgery, is experiencing nausea/vomiting, or has a bowel obstruction; in any of these cases, the client would need continuous infusions.

The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply.

Client's reaction to the procedure, Rate of the IV solution, Type of IV solution, Gauge and length of the IV catheter, Location of the IV catheter access Rationale:The nurse should document the location where the IV access was placed, as well as the size of the IV catheter or needle, the type of IV solution, the rate of the IV infusion, and the use of a securing or stabilization device. Additionally, document the condition of the site. Record the client's reaction to the procedure and pertinent client teaching, such as asking the client to alert the nurse if the client experiences any pain from the IV or notices any swelling at the site. Document the IV fluid solution on the intake and output record.

The nurse is capping a client's IV line for intermittent use in preparation for the administration of an antibiotic. After inspecting the site, what will the nurse do next?

Close the clamp on the current administration set. Rationale:After inspecting the site, the nurse should close off the clamp on the current administration set to prevent leaking of fluid when the set is removed. Following closure of the current administration set, the nurse should open the short extension tubing and close the clamp on that tubing to ensure air does not enter when priming, then remove the current tubing and cleanse the end cap or access cap before attaching the primed extension tubing.

The nurse is changing the IV solution container and administration set for a client receiving a peripheral IV infusion for dehydration via an electronic infusion device. After inserting the new administration set spike into the entry port of the new IV container, the nurse primes the tubing and closes the clamp. What would the nurse do with the electronic infusion device at this point?

Count the drops, adjusting until correct rate is achieved. Rationale:If the client is using an electronic infusion device, the nurse would open the slide clamp, check the drip chamber of the administration set, verify the flow rate programmed in the infusion device, and turn the device to "run" or "infuse."

When changing the IV solution container and administration set for a client's IV, the nurse accidentally touches the opened entry site on the IV container. Which action would be appropriate?

Discard the container. Rationale:Touching the opened entry site on the IV container results in contamination, so the container must be discarded. The site is considered sterile; it cannot be decontaminated with antimicrobial wipes or soap and water.

While assessing the IV site of a client who has had abdominal surgery, the nurse suspects infiltration. Which finding would help support the nurse's suspicions?

Pallor Rationale:The nurse inspects the site for swelling, leakage, and coolness or pallor, which may indicate infiltration. When this happens, the catheter may become dislodged from the vein, and IV solution may flow into subcutaneous tissue. Heat, redness, and slight edema may indicate sepsis, phlebitis, or thrombus.

A nurse is assessing a client's intravenous (IV) site while changing the dressing. Which signs would indicate fluid infiltration into the tissue around the IV catheter? Select all that apply.

Pallor, Coolness, Swelling Rationale:The nurse should inspect the tissue around the IV entry site for swelling, coolness, or pallor. These are signs of fluid infiltration into the tissue around the IV catheter. The nurse should also inspect the site for redness, swelling, and warmth. These signs might indicate the development of phlebitis or an inflammation of the blood vessel at the site.

The nurse is changing the IV solution container for a client with an electronic infusion device. The nurse removes the administration set from the package and applies the label to the tubing. What would the nurse do next?

Pause the device or put it on "hold." Rationale:When using an electronic infusion device, the nurse would pause the device or put it on "hold." The action of the infusion device needs to be paused while the solution container is changed. Then the nurse would close the clamp on the administration set, invert the IV solution container and remove the cap on the entry site. Next, the nurse would remove the cap from the spike on the administration set and insert the administration set spike into the entry site of the IV container using a twisting and pushing motion. Lastly, the nurse would hang the container on the IV pole.

The nurse changes a client's peripheral venous access dressing. Which nursing action is correct?

Press the chlorhexidine applicator against the skin using a back-and-forth motion. Rationale:The nurse is correct in pressing the chlorhexidine applicator against the skin and applying it using a back-and-forth motion. The label should include the date and time the dressing was changed and the nurse's initials, not the client's name or date of birth. The nurse is correct in applying skin protectant to all the skin that would be covered by the dressing, but an antibacterial ointment is not used. Looping the IV tubing near the entry site and taping it in place is correct, but securing it under the access dressing can lead to increased infection or accidental removal of the IV catheter.

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the siderail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate?

Remove the IV catheter and reinsert another in a different location. Rationale:An IV catheter should not be reinserted. Whether the IV is salvageable depends on how much of the catheter remains in the vein. Because this catheter has been almost completely pulled out of the insertion site, it should be discarded and a new one inserted at a different location. It is not acceptable simply to apply a new dressing and leave the catheter sticking out of the site.

The nurse is monitoring a client receiving an IV infusion to replace fluids lost during surgery and notices air bubbles in the tubing above the roller clamp. Which action would be most appropriate?

Remove the bubbles by closing the roller clamp, stretching the tubing downward and tapping the tubing with a finger. Rationale:If the bubbles are above the roller clamp, the nurse can easily remove them by closing the roller clamp, stretching the tubing downward, and tapping the tubing with a finger so the bubbles rise to the drip chamber. Ensuring that the flow clamp is open and that the drip chamber is half full helps to promote fluid flow. It would not be necessary to change the administration set to troubleshoot this problem. Disconnecting the tubing from the client would be inappropriate and disrupt the integrity of the sterile IV administration system.

While assessing a client receiving peripheral IV therapy as part of the treatment plan for hypovolemia, the nurse suspects that the client is experiencing fluid overload based on which finding?

Shortness of breath. Rationale:Fluid overload is caused when too large a volume of fluid infuses into the circulatory system. This complication manifests as engorged neck veins, shortness of breath and abnormal breath sounds (suggesting respiratory failure), increased blood pressure, and difficulty breathing. A pounding headache is a sign of speed shock and the change in level of consciousness is related to the existence of an air embolus.

The nurse is changing the IV solution container and administration set for a client with an electronic infusion device. Which part of the set-up must be removed prior to inserting new tubing into the device?

The administration set. Rationale:When changing the IV solution container and administration set of an electronic infusion device, the nurse must remove the current administration set from the device first. Following the manufacturer's directions, the nurse would then insert a new administration set into the infusion device. The slide clamp and drip chamber are part of the administration set and cannot be removed separately. Once the new administration set is inserted, the access cap of the short extension tubing is removed to attach the new administration set.

Which situation would warrant the need for the nurse to change a client's venous access dressing?

The skin around the site is wet. Rationale:Dressing changes are completed according to facility policy and as necessary, based on nursing judgment and assessments findings that the site dressing is damp, loosened, or soiled. The wet skin around the site suggests that the dressing is damp and needs to be changed. A slowed infusion rate or pain at the insertion site would require further assessment to identify the source of the problems; furthermore, pain at the site would likely require changing the site. Typically, tubing is looped near the site of entry to prevent pulling on the IV device.

The nurse, who is monitoring the IV site of a client receiving peripheral venous fluid therapy, checks for bleeding at the site. The nurse understands that bleeding at an IV site is most likely to occur at which time?

When the IV is discontinued. Rationale:Bleeding at an IV site may be caused by anticoagulant medication and is most likely to occur when the IV is discontinued.

When completing a routine assessment of a client's peripherally inserted central catheter (PICC), the nurse finds no redness, swelling or drainage at the insertion site. The transparent dressing is dry and intact and adheres to the skin around all edges. What is the most appropriate intervention at this time?

Your Response:Ask the client about any pain or discomfort at the insertion site. Rationale:Assessing for pain and discomfort is part of a routine assessment of the PICC, as these may indicate infection or infiltration. The assessment should be complete before documenting. The dressing is intact and assessment findings do not warrant a dressing change at this time. Flushing the PICC is not part of the routine assessment.

he nurse is inserting the administration set spike into the entry port of the new IV container as it hangs on the IV pole. Which type of motion should the nurse use?

Your Response:Twisting and pushing motion. Rationale:The nurse would use a twisting and pushing motion to insert the administration set spike into the entry site of the IV container. Inserting the spike with a twisting and pushing motion punctures the seal in the IV container and allows access to contents.

Assessing the insertion site of a client's peripherally inserted central catheter (PICC), the nurse notes redness, swelling, and odor at the site. Which complication does the nurse suspect?

infection Rationale:Redness, swelling, odor, drainage, and discomfort signify an infection at the insertion site. Swelling, pallor, coldness, or pain around the site are symptoms of infiltration. A rash would appear as red, itching bumps. Speed shock is the body's reaction to a substance injected into the circulatory system too rapidly; it manifests as a pounding headache, rapid pulse rate, apprehension, chills, back pains, and dyspnea.

The nurse is caring for a client receiving an antibiotic via a peripherally inserted central catheter (PICC). What two solutions should the nurse use to flush the line and keep it patent?

normal saline and heparin Rationale:When a PICC is being used intermittently, the nurse should flush the PICC after each use with normal saline and heparin to maintain patency. Sterile water is not used for flushing a PICC line. Heparin maintains patency.

Which action by the nurse is most important to ensure the client's safety when changing a peripheral venous access device dressing?

placing the bed in the lowest position before leaving the room Rationale:While all actions are correct, the one that is most important to ensure the client's safety is to place the bed back into the lowest position before leaving the room. This action helps to prevent falls or injuries when the client is getting out of the bed. Using a semi-permeable dressing allows moisture to evaporate. Gathering all equipment before entering the client's room helps the nurse be prepared and organized. Inspecting the site allows the nurse to recognize complications early and address them as needed.

The nurse is monitoring an IV site for a client who reports that the needle feels "funny." What should the nurse do first?

Check the integrity of the IV system, IV solution and tubing, and flow rate. Rationale:The nurse would first check the integrity of the IV system, IV solution and tubing, and validate the correct drip rate. Next, the nurse would assess the venous access for redness, edema, warmth, coolness, pallor, and pain. If any of these are present, the nurse would discontinue the IV, initiate a new venous access in a different site, and notify the health care provider.

On assessment of a client's antecubital IV site, the nurse observes that the client's IV fluids are not infusing. The IV fluids are to infuse via gravity. What action(s) can the nurse implement to troubleshoot and identify the cause? Select all that apply.

Check to see if the client is lying on any part of the tubing., Check to see that all the tubing connections are secure., Check that the client's arm is being kept straight at the elbow., Check that the roller clamp is open. Rationale:To trouble-shoot an IV infusion via gravity that is not infusing, the nurse should check to see that all the tubing connections are secure and ensure that the client is not lying on any part of the tubing. If the IV site is in the client's antecubital area or wrist, the nurse should ensure that the area is being kept straight so as not to kink the tubing and explain the need for this to the client. The nurse should also check to ensure that the roller clamp is open. A closed roller clamp will not allow the fluids to infuse. The IV fluid should be hanging above the client's heart level, not below.

The nurse determines that the client's intravenous gravity infusion is not flowing. What action does the nurse take next?

Ensure the tubing is straight and fluid can flow freely. Rationale:The nurse first checks that the tubing is without kinks, is not clamped, and that all connections are correct. If it is determined that the client's positioning caused the lack of flow, the nurse teaches the client how to position him- or herself to keep the infusion flowing. For example, if the client has an antecubital IV, the nurse might teach the client to straighten the arm. If the infusion still will not flow, the nurse flushes the IV catheter to ensure it is not clotted. If everything seems correct, the nurse considers there may be an unknowable tubing malfunction and changes the set.

Inspection of a client's peripheral venous access site reveals signs of phlebitis. Which action by the nurse would be most appropriate?

Notify the health care provider, discontinue the IV, and start it at another site. Rationale:When the nurse suspects phlebitis due to the findings of redness, swelling, and heat, the health care provider should be notified. The IV will need to be discontinued and restarted at another site. The health care provider should be notified immediately, not just if the phlebitis worsens.

When monitoring the peripheral access IV sites of various clients receiving IV therapy, the nurse would assess closely for which finding as the most common complication related to IV therapy?

Phlebitis Rationale:The most common complication related to IV therapy is phlebitis. Chemical irritation or mechanical trauma can cause injury to the vein and lead to phlebitis. Infection, thrombus, and sepsis manifest as redness, pus, warmth, induration, and pain similar to phlebitis and may be caused by poor aseptic technique.

The nurse has just flushed a peripheral venous access site and notices fluid leaking from the insertion site. Which action is most appropriate?

Remove the IV catheter and restart the venous access site in a new location. Rationale:Fluid leaking from the insertion site indicates that the catheter is not fully within the vein or that the catheter is cracked. The nurse should remove the catheter and restart the venous access site in a new location. Replacing or reinforcing the dressing will not stop the leaking, nor will flushing the catheter again.

The nurse is assessing the insertion site of a client's peripherally inserted central catheter (PICC). What is a normal finding?

a transparent dressing covering the site Rationale:A PICC is held in place with a transparent dressing. The nurse should assess whether the dressing is intact and adheres to the skin around all the edges. Tape, gauze, or a sterile bandage covering the site should all be unexpected findings. If a gauze pad is used as a dressing on a PICC, it must be changed within 48 hours.

The nurse is assessing a client's peripheral venous access site and notes redness and inflammation at the site. What is the best action by the nurse at this time?

Discontinue current IV and relocate to new site. Rationale:Redness and inflammation indicate a complication such as infection or phlebitis. Once noted, the nurse should discontinue the current IV, then locate and initiate a new IV site. Changing the dressing will not address the complications found. The nurse would document the findings and the actions taken, but should also discontinue and relocate the IV, not simply continue monitoring. Monitoring the site without taking action to discontinue and relocate the site will not address the current complication and puts the client at risk of a worsening infection. The health care provider can be notified after the IV is discontinued and relocated.

The nurse is preparing to change the IV tubing of a client receiving a peripheral venous IV infusion 5% dextrose and water based on the understanding that IV tubing is generally changed at which interval?

Every 96 hours. Rationale:Generally, IV tubing is changed every 72 to 96 hours. Changing the tubing helps to prevent contamination and bacterial growth.

The nurse is flushing a client's peripherally inserted central catheter (PICC) to maintain patency, because it is being used intermittently. After flushing with normal saline, which action should the nurse perform next?

Flush the line with heparin. Rationale:After flushing the PICC with saline, the nurse should flush the line with heparin to maintain patency. Because the PICC is being used intermittently, the infusion is not restarted. The nurse attempts a blood return prior to flushing the PICC. Documentation should occur following the procedure.

A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client?

Gauze dressing Rationale:A gauze dressing is recommended if the client is diaphoretic or if the site is bleeding or oozing. However, the gauze dressing should be replaced with a transparent semipermeable membrane once this is resolved. Transparent semipermeable membranes are a type of sealed IV dressing. Occlusive dressings would not be appropriate.

The nurse is caring for a client who has a continuous intravenous (IV) infusion. The nurse has just changed the IV solution container and notices several large air bubbles below the roller clamp. Which action is appropriate?

Swab the medication port on the tubing below the air bubbles; attach a syringe and aspirate the air. Rationale:If there is a large amount of air in the tubing (below the roller clamp), swab the medication port on the tubing below the air with an antimicrobial solution and attach a syringe to the port below the air. Clamp the tubing below the access port and aspirate the air from the tubing via the syringe. If the bubbles were above the roller clamp, the nurse could remove them by closing the roller clamp, stretching the tubing downward, and tapping the tubing with the finger so the bubbles rise to the drip chamber. If not removed from the tubing, large amounts of air can act as an embolus and be a significant risk to the client; thus, the bubbles must be removed.

The nurse is caring for a client who has been diaphoretic and observes that the dressing on the peripheral venous access site has become loose and needs changing. Which type of dressing would be best for this client?

a sterile gauze dressing Rationale:A sterile gauze dressing is the best choice for this client, as it will absorb the extra moisture caused by the diaphoresis. Once the diaphoresis is resolved, the dressing should be changed to a transparent semi-permeable membrane dressing (TSM). TSM dressings allow easy inspection of the IV site and, because they are semi-permeable, permit evaporation of moisture that accumulates under the dressing normally. Non-permeable dressings are not recommended, because they do not allow evaporation of moisture. A dressing with foam tape is not recommended, because it does not allow visualization of the site.

The nurse is assessing a client's peripherally inserted central catheter (PICC) insertion site. The nurse measures the length of the catheter that extends out from the insertion site to:

assess if the catheter has migrated inward or moved outward. Rationale:The nurse measures the length of the catheter extending out from the insertion site to compare it to the documented length at time of insertion. This assesses whether the catheter has migrated inward or moved outward. The measurement should not be used to determine the size of the replacement tubing, to ensure patency, or to determine time for catheter removal. Flushing will assist in determining patency. Removal and replacement are dependent on the individual client treatment plan.