Ch, 13 Review questions

The nurse is teaching a hospitalized client who is being discharged about how to care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education? A. "I can continue my 20-mile (32-km) running schedule as I have for the past 10 years." B. "I can still go about my normal activities of daily living." C. "I have less chance of getting an infection because the line is not in my hand." D. "The PICC line can stay in for months."

"I can continue my 20-mile (32-km) running schedule as I have for the past 10 years." The statement by the client stating that his or her normal running schedule can continue indicates a need for further education. Excessive physical activity can dislodge the PICC and should be avoided.Clients with PICCs should be able to perform normal activities of daily living. PICCs have low complication rates because the insertion site is in the upper extremity. The dry skin of the arm has fewer types and numbers of microorganisms, leading to lower rates of infection. PICC lines can be used long term (months).

The nurse is inserting a peripheral intravenous (IV) catheter. Which client statement is of greatest concern during this procedure? A. "I hate having IVs started." B. "It hurts when you are inserting the line." C. "My hand tingles when you poke me." D. "My IV lines never last very long."

"My hand tingles when you poke me." The client's statement about a tingling feeling indicates possible nerve puncture and is of greatest concern to the nurse. To avoid further nerve damage, the nurse should stop immediately, remove the IV catheter, and choose a new site.Statements such as, "I hate having IVs started," "It hurts when you are inserting the line," and "My IVs never last very long," are addressed with teaching about the importance of proper protection of the site.

A client who used to work as a nurse asks, "Why is the hospital using a 'fancy new IV' without a needle? That seems expensive." How does the nurse respond? A. "OSHA, a government agency, requires us to use this new type of IV." B. "These systems are designed to save time, not money." C. "They minimize health care workers' exposure to contaminated needles." D. "They minimize clients' exposure to contaminated needles."

"They minimize health care workers' exposure to contaminated needles." The nurse informs the client that needleless IVs were designed to protect health care personnel from exposure to contaminated needles.The Occupational Safety and Health Administration (OSHA) requires the use of devices with engineered safety mechanisms only. It does not mandate that they be needleless. Saving time and money is not the purpose of the needleless IV, and it was not designed to protect clients from exposure to contaminated needles.

A 22-year-old client is seen in the emergency department (ED) with acute right lower quadrant abdominal pain, nausea, and rebound tenderness. It appears that surgery is imminent. What gauge catheter does the ED nurse choose when starting this client's intravenous solution? A. 24 B. 22 C. 18 D. 14

18 An 18-gauge catheter is the size of choice for clients who will undergo surgery. If they need to receive fluids rapidly, or if they need to receive more viscous fluids (such as blood or blood products), a lumen of this size would accommodate those needs.Neither a 24-gauge nor a 22-gauge catheter is an appropriate size (too small) for clients who will undergo surgery. If it becomes necessary to administer fluids to the client rapidly, another IV would be needed with a larger needle—18, for example. Administering through the smallest gauge necessary is usually best practice, unless the client may be going into hypovolemic status (shock). A 14-gauge catheter is an extremely large-gauge needle that is very damaging to the vein.

The nurse is starting a peripheral IV catheter on a recently admitted client. What actions does the nurse perform before insertion of the line? Select all that apply. A. Apply povidone-iodine to clean skin, dry for 2 minutes. B. Clean the skin around the site. C. Prepare the skin with 70% alcohol or chlorhexidine. D. Shave the hair around the area of insertion. E. Wear clean gloves and touch the site only with fingertips after applying antiseptics.

A. Apply povidone-iodine to clean skin, dry for 2 minutes. B. Clean the skin around the site. C. Prepare the skin with 70% alcohol or chlorhexidine.

A client is being admitted to the burn unit from another hospital. The client has an intraosseous IV that was started 2 days ago, according to the client's medical record. What does the admitting nurse do first? A. Anticipate an order to discontinue the intraosseous IV and start an epidural IV. B. Call the previous hospital to verify the date. C. Immediately discontinue the intraosseous IV. D. Nothing; this is a long-term treatment.

Anticipate an order to discontinue the intraosseous IV and start an epidural IV. The admitting nurse would first anticipate an order to discontinue the intraosseous IV and start an epidural IV. The intraosseous route should be used only during the immediate period of resuscitation and should not be used for longer than 24 hours. Alternative IV routes, such as epidural access, should then be considered for pain management.The nurse should know what to do in this client's situation without contacting the previous hospital. Other client data, such as the date and time that the burn occurred, should validate the date and time of insertion of the IV. Discontinuing the IV is not the priority in this situation—the client is in a precarious fluid balance situation. One IV access should not be stopped until another is established. This type of IV is not used for long-term therapy; an action must be taken.

The nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What does the nurse do initially? A. Assess the insertion site. B. Check connections. C. Check the infusion rate. D. Discontinue the IV and start another.

Assess the insertion site. The initial response by the nurse is to assess the insertion site. The purpose of this action is to check for patency, which is the priority. IV assessments typically begin at the insertion site and move "up" the line from the insertion site to the tubing, to the tubing's connection to the bag.Checking the IV connection is important, but is not the priority in this situation. Checking the infusion rate is not the priority. Discontinuing the IV to start another may be required, but it may be possible to "save" the IV, and the problem may be positional or involve a loose connection.

A client is admitted to the cardiothoracic surgical intensive care unit after cardiac bypass surgery. The client is still sedated on a ventilator and has an arterial catheter in the right wrist. What assessment does the nurse make to determine patency of the client's arterial line? A. Blood pressure B. Capillary refill and pulse C. Neurologic function D. Questioning the client about the pain level at the site

Capillary refill and pulse Capillary refill and pulse should be assessed to ensure that the arterial line is not occluding the artery.Blood pressure and neurologic function are not pertinent to the client's arterial line. Although the client's comfort level is important with an arterial line, it is not a determinant of patency of the line.

The nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters does the nurse choose most often? A. Back of the hand for an older adult B. Cephalic vein of the forearm C. Lower arm on the side of a radical mastectomy D. Subclavian vein

Cephalic vein of the forearm The cephalic vein of the forearm is the insertion site chosen most often. For same-day surgery, the cephalic or basilic vein allows insertion of a larger IV catheter while allowing movement of the arm without impairing intravenous flow.Peripheral venous catheters should never be inserted into the back of the hand in an older adult because the veins are brittle. Peripheral venous catheters should never be inserted into the lower arm on the same side as a radical mastectomy because they interfere with limited circulation. Catheters are typically inserted into the subclavian vein by the health care provider, not by the nurse.

A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened and begun 20 hours ago. What action does the nurse take? A. Change the set immediately. B. Change the set in about 4 hours. C. Change the set in the next 12 to 24 hours. D. Nothing; the set is for long-term use.

Change the set in about 4 hours. Because both ends of the set are being manipulated with each dose, standards of practice dictate that the set should be changed every 24 hours, so the set should be changed in about 4 hours.It is not necessary to change out the set immediately, but it must be changed before the next 12 to 24 hours.

The nurse is administering a drug to a client through an implanted port. Before giving the medication, what does the nurse do to ensure safety? A. Administer 5 mL of a heparinized solution. B. Check for blood return. C. Flush the port with 10 mL of normal saline. D. Palpate the port for stability.

Check for blood return. To ensure safety, before a drug is given through an implanted port, the nurse must first check for blood return. If no blood return is observed, the drug should be held until patency is reestablished.If no blood return is observed, the drug should be held until patency is reestablished. Ports are flushed with heparin or saline after, rather than before, use. The port is palpated for stability, but this action alone does not ensure the client's safety.

The nurse is documenting peripheral venous catheter insertion for a client. What does the nurse include in the note? Select all that apply. Client's name and hospital number Client's response to the insertion Date and time inserted Type and size of device Type of dressing applied Vein used for insertion

Client's response to the insertion, Date and time inserted, Type and size of device, Type of dressing applied, Vein used for insertion

The nurse checking an IV fluid order questions its accuracy. What does the nurse do first? A. Asks the charge nurse about the order B. Contacts the health care provider who ordered it C. Contacts the pharmacy for clarification D. Starts the fluid as ordered, with plans to check it later

Contacts the health care provider who ordered it First, the nurse contacts the health care provider who ordered it. The nurse is legally and professionally responsible for accuracy and has the duty to verify the order with the health care provider who ordered it.The nurse can consult the charge nurse, but this is not the definitive action that the nurse should take. Contacting the pharmacy is not the best action that the nurse should take. Giving (or starting) the fluid when the order is questionable is not appropriate and could possibly harm the client.

The nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion? A. Asks the client to both say and spell his or her full name before starting the blood transfusion B. Ensures that another qualified health care professional checks the unit before administering C. Checks the blood identification numbers with the laboratory technician at the blood bank at the time it is dispensed D. Makes certain that an IV solution of 0.9% normal saline is infusing into the client before starting the unit

Ensures that another qualified health care professional checks the unit before administering To ensure safety, blood must be checked by two qualified health care professionals, usually two registered nurses.Administering an incorrectly matched unit of blood creates great consequences for the client and is considered to be a sentinel event. It requires a great amount of follow-up and often changing of policies to improve safety. The Joint Commission requires that the client provide two identifiers, but they are the name and date of birth or some other identifying data, depending on the facility; saying and spelling the name is only one identifier. Although a check is provided at the blood bank, this is not the one that is done before administration to the client. Clients do need to have normal saline running with blood, but this is not considered to be part of the safety check before administration of blood and blood products.

A client is seen in the emergency department (ED) with pain, redness, and warmth of the right lower arm. The client was in the ED last week after an accident at work. On the day of the injury, the client was in the ED for 12 hours receiving IV fluids. On close examination, the nurse notes the presence of a palpable cord 1 inch (2.5 cm) in length and streak formation. How does the nurse classify this client's phlebitis? A. Grade 1 B. Grade 2 C. Grade 3 D. Grade 4

Grade 3 Grade 3 indicates pain at the access site with erythema and/or edema and streak formation with a 1' palpable cord.Grade 1 indicates only erythema with or without pain; the client has additional symptoms. Grade 2 indicates only pain at the access site with erythema and/or edema; the client has additional symptoms. Grade 4 indicates pain at the access site with erythema and/or edema, streak formation, a palpable venous cord longer than 1 inch (2.5 cm), and purulent drainage. No purulent drainage is present in this client, and the palpable cord is 1 inch (2.5 cm) in length.

The nurse is revising an agency's recommended central line catheter-related bloodstream infection prevention (CR-BSI) bundle. Which actions decrease the client's risk for this complication? Select all that apply. A. During insertion, draping the area around the site with a sterile barrier B. Immediately removing the client's venous access device (VAD) when it is no longer needed C. Making certain that observers of the insertion are instructed to look away during the procedure D. Thorough hand hygiene (i.e., no quick scrub) before insertion E. Using chlorhexidine for skin disinfection

Immediately removing the client's venous access device (VAD) when it is no longer needed, Thorough hand hygiene (i.e., no quick scrub) before insertion, Using chlorhexidine for skin disinfection

A client is to receive an IV solution of 5% dextrose and 0.45% normal saline at 125 mL/hr. Which system provides the safest method for the nurse to accurately administer this solution? A. Controller B. Glass container C. Infusion pump D. Syringe pump

Infusion pump The safest method is to administer the solution with an infusion pump. Infusion pumps are used for drugs or fluids under pressure. They accurately measure the volume of fluid being infused.A controller is a stationary, pole-mounted electronic device that uses a sensor to monitor fluid flow and detect when flow has been interrupted. Because controllers rely completely on gravity to create fluid flow and do not create pressure, they do not ensure infusion but only control the drip rate. A glass container is necessary to use only with IV solutions that may cling to the plastic bag. This IV solution does not cling to plastic bags. A syringe pump does not hold sufficient volume to be practical in this situation.

A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does the nurse teach the new graduate nurse to use for this client? A. Midline catheter B. Tunneled percutaneous central catheter C. Peripherally inserted central catheter D. Short peripheral catheter

Midline catheter For a client with fragile veins (which occur with long-term corticosteroid use) and the need for a catheter for 5 days, the midline catheter is the best choice.Tunneled central catheters usually are used for clients who require IV access for longer periods. Peripherally inserted central catheters usually are used for clients who require IV access for longer periods. A short peripheral catheter is likely to infiltrate before 5 days in a client with fragile veins, requiring reinsertion.

A client admitted to the intensive care unit is expected to remain for 3 weeks. The nurse has orders to start an IV. Which vascular access device is best for this client? A. Midline catheter B. Peripherally inserted central catheter (PICC) C. Short peripheral catheter D. Tunneled central catheter

Midline catheter Midline catheters are the best device for this client. These catheters are used for therapies lasting from 1 to 4 weeks.PICCs are typically used when IV therapy is expected to last for months. Short peripheral catheters are allowed to dwell (stay in) for 72 to 96 hours, but they then require removal and insertion at another venous site. Tunneled central catheters must be inserted by a health care provider. Nurses are typically not qualified to start tunneled central catheters.

Which client does the charge nurse on a medical-surgical unit assign to the LPN/LVN? A. Cardiac client who has a diltiazem (Cardizem) IV infusion being titrated to maintain a heart rate between 60 and 80 beats/min B. Diabetic client admitted for hyperglycemia who is on an IV insulin drip and needs frequent glucose checks C. Older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours D. Postoperative client receiving blood products after excessive blood loss during surgery

Older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours The older client admitted for confusion with a heparin lock is the most stable and requires basic monitoring of the IV site for common complications such as phlebitis and local infection, which would be familiar to an LPN/LVN.The cardiac client with a diltiazem (Cardizem) IV infusion, the diabetic client on an IV insulin drip, and the postoperative client receiving blood products all are not stable and will require ongoing assessments and adjustments in IV therapy that should be performed by an RN.

A severely dehydrated client requires a rapid infusion of normal saline and needs a midline IV placed. Which staff member does the emergency department (ED) charge nurse assign to complete this task? A. RN who is certified in the administration of oral and infused chemotherapy medications B. RN with 2 years of experience in the ED who is skilled at insertion of short peripheral catheters C. RN with 10 years of experience on a medical-surgical unit who has cared for many clients requiring IV infusions D. RN with certified registered nurse infusion (CRNI) certification who is assigned to the ED for the day

RN with certified registered nurse infusion (CRNI) certification who is assigned to the ED for the day The nurse with CRNI certification is most likely to be able to quickly insert a midline catheter for a client who is dehydrated.The chemotherapy nurse and the ED nurse have the appropriate scope of practice, but will not be as skilled in inserting a midline IV catheter. The medical-surgical nurse may be skilled at inserting short peripheral catheters, but will not be skilled in inserting midline IV catheters.

Which statement is true about the special needs of older adults receiving IV therapy? A. Placement of the catheter on the back of the client's dominant hand is preferred. B. Skin integrity can be compromised easily by the application of tape or dressings. C. To avoid rolling the veins, a greater angle of 25 degrees between the skin and the catheter will improve success with venipuncture. D. When the catheter is inserted into the forearm, excess hair should be shaved before insertion.

Skin integrity can be compromised easily by the application of tape or dressings. Skin in older adults tends to be thin. Tape or dressings used with IV therapy can compromise skin integrity.Placement on the back of the dominant hand is contraindicated because hand movement can increase the risk of catheter dislodgement. An angle smaller than 25 degrees is required for venipuncture success in older adults. This technique is less likely to puncture through the older adult client's vein. Clipping, and not shaving, the hair around the insertion site typically is necessary only for younger men.

A 70-year-old client with severe dehydration is ordered an infusion of an isotonic solution at 250 mL/hr through a midline IV catheter. After 2 hours, the nurse notes that the client has crackles throughout all lung fields. Which action does the nurse take first? A. Assess the midline IV insertion site. B. Have the client cough and deep-breathe. C. Notify the health care provider about the crackles. D. Slow the rate of the IV infusion.

Slow the rate of the IV infusion. The presence of crackles throughout the lungs is a sign of possible fluid overload. The nurse should slow the rate of infusion and further assess for indicators of volume overload and/or respiratory distress.The presence of crackles throughout the lungs is a sign of possible fluid overload. The nurse should slow the rate of infusion and further assess for indicators of volume overload and/or respiratory distress. Assessing the site and having the client cough and deep-breathe are not appropriate. Crackles do not disappear with coughing. Notifying the provider may be appropriate, but is not the initial actions for this client.

When flushing a client's central line with normal saline, the nurse feels resistance. Which action does the nurse take first? A. Decrease the pressure being used to flush the line. B. Obtain a 10-mL syringe and reattempt flushing the line. C. Stop flushing and try to aspirate blood from the line. D. Use "push-pull" pressure applied to the syringe while flushing the line.

Stop flushing and try to aspirate blood from the line. The nurse's first step is to stop flushing and try to aspirate blood from the line. If resistance is felt when flushing any IV line, the nurse should stop and further assess the line. Aspiration of blood would indicate that the central line is intact and is not obstructed by thrombus.Decreasing the pressure to flush the line is not appropriate. Continuing or reattempting to flush the line, or using a push-pull action on the syringe, might result in thrombus or injection of particulate matter into the client's circulation.

The nurse assessing a client's peripheral IV site obtains and documents information about it. Which assessment data indicate the need for immediate nursing intervention? A. Client states, "It really hurt when the nurse put the IV in." B. The vein feels hard and cordlike above the insertion site. C. Transparent dressing was changed 5 days ago. D. Tubing for the IV was last changed 72 hours ago.

The vein feels hard and cordlike above the insertion site. A hard, cordlike vein suggests phlebitis at the IV site and indicates an immediate need for nursing intervention. The IV should be discontinued and restarted at another site.It is common for IVs to cause pain during insertion. An intact transparent dressing requires changing only every 7 days. Tubing for peripheral IVs should be changed every 72 to 96 hours.