Chapter 15
A nurse prepares to insert a peripheral venous catheter in an older adult. What action will the nurse take to protect the client skin during this procedure?
Place a washcloth between the skin and tourniquet
A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site After removing the device. what action will the nurse take to relieve pain?
Place warm compresses on the site.
A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
Report of headache and stiff neck
A nurse teaches a client who is prescribed a central vascular access device and is transferring to a skilled facility for long-term treatment. Which statement will the nurse include in this client's teaching?
"Ask all providers to vigorously clean the connections prior to accessing the device."
A nurse delegates care to an assistive personnel (AP). Which statement will the nurse include when delegating hygiene for a client who has a vascular access device?
"Use a plastic bag to cover the extremity with the device."
A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication and notes it to have been inserted 4 months ago. The site has no redness, warmth, or swelling and flushes easilv. What action does the nurse take'
Administer the prescribed medication
A nurse leaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement will the nurse include in this client s teaching?
Avoid carrying your Grand child when the arm has the Central catheter
A nurse prepares to insert a short peripheral venous catheter. What action would the nurse take to use best practice? Select all that apply
Choose a distal site on the client non dominant arm Verify that the prescription is appropriate for peripheral infusion Perform hand hygiene before inserting the catheter
A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which common complication will the nurse assess? (Select all that apply.
Phlebitis & Thrombophlebitis
A registered nurse (RN) occasionally delegates client care to licensed practical nurses (LPs) or technicians. What information does the RN consider when delegating components of IV therapy! (Select all that apply).
Each states nurse practice at will regulate who can perform care related to IVs The nurse would check the facilities policies and procedures manual The RN remains accountable for all aspects of IV care and delegated actions The infusion nurse society has guidelines and standards of IV therapy competency
A nurse is caring for a client who has just had a central venous access line inserted. What action will the nurse take next?
Ensure that an x-ray is completed to confirm placement.
While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 1.5 inch inch (4-cm) Venous cord. How will the nurse document this finding?
Grade 3 phlebitis at IV site
A new nurse is caring for a client receiving drug therapy via a smart pump. What statement by the new nurse demonstrates the need for more instructions on this technology?
I don't need to manually calculate IV infusion rates with smart pumps
A nurse assists with the insertion of a central vascular access device. Which actions will the nurse ensure are completed to prevent a catheter-related bloodstream infection? Select all that apply.
Include a review for the need of the device each day in the patient's plan of care. Remind the primary health care provider to perform hand hygiene prior to starting the procedure Ask everyone in the room to wear a surgical mask during the procedure.
A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and "feeling warm". For which complication of this therapy will the nurse assess the client?
Infection
A medical surgical nurse is concerned about the incidence of complications related to IV therapy, Including bloodstream infection. Which intervention with the nurse suggest to the management team to make the biggest impact on decreasing complications?
Initiate a delicate team to insert access devices
A nurse assesses a client who has a radial artery catheter. Which assessment will the nurse complete first?
Skin color and capillary refill
A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. What action will the nurse take next?
Stop the infusion of intravenous fluids.
A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?
The client's left lower extremity is cool to the touch.
A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Iranstusion (ISBI) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply).
Unique facility identifier Lot number related to the donor ABO group and Rh type of donor
A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?
Upper extremity swelling is noted.
