Chapter 7 Med Surg IV

28. The nurse is preparing to start a peripheral IV infusion. Which technique should the nurse use to help ensure success with the venipuncture? (Select all that apply.) a. Use a tourniquet to dilate the vein. b. Elevate the extremity to promote venous return. c. Apply a warm compress prior to site preparation. d. Lower the head of the bed to reduce cardiac output. e. Encourage the patient to open the hand and lay it flat on the bed. f. Push the skin toward the intended puncture site to prevent rolling.

A, C A. Use a tourniquet to dilate the vein C. Apply a warm compress prior to site preparation

29. The nurse is planning to insert an IV catheter into a patient with severe upper extremity edema. Which actions should the nurse take to ensure the catheter is placed appropriately? (Select all that apply.) a. Select a catheter that is 2 inches in length. b. Use alcohol to cleanse the site before insertion. c. Bring three tourniquets to the patients bedside. d. Displace edema to visualize the patients veins. e. Apply sterile gloves before beginning the procedure.

A, C, D A. Select a catheter that is 2 inches in length C. Bring three tourniquets to the patients bedside D. Displace edema to visualize the patients veins When needing to insert an IV catheter into an edematous limb, the nurse should use a catheter that is 2 inches in length; the nurse should use the multiple tourniquet technique, which employs 3 tourniquets, and press down on the tissue to displace the edema and visualize the patients veins. B. Alcohol is not used to cleanse the insertion site. E. Sterile gloves are not needed to insert the catheter.

23. A patient is prescribed to receive two units of packed red blood cells. When preparing for this patients infusion of blood, which type of IV solution should the licensed practical nurse/licensed vocational nurse LPN/LVN select? a. 0.9% Normal Saline b. 0.45% Normal Saline c. Dextrose 5% and water d. Dextrose 5% and 0.9% Normal Saline

A. 0.9% Normal Saline Blood component administration sets can be primed ONLY with 0.9% sodium chloride solution

5. The nurse notes that a patients central venous access device (CVAD) infusion site gauze dressing is saturated with blood. What should the nurse do? a. Change the dressing. b. Reinforce the dressing with a gauze pad. c. Notify the physician to change the dressing. d. Apply a transparent dressing over the gauze.

A. Change the dressing. If saturated with blood, the gauze dressing over a CVAD infusion site should be changed. B. Reinforcing the dressing with a gauze pad is not sufficient for this access site. C. The nurse can change the dressing. D. A transparent dressing should not be placed over a soiled gauze dressing.

11. A patient is in the intensive care unit with acute renal failure secondary to septic shock and is receiving IV fluids of 0.9% NaCl at 125 mL/hr. The patient develops crackles in the lungs, distended neck veins, 1+ pitting edema in the feet, and a 4-pound weight gain from the previous day. What nursing diagnosis is most appropriate for this situation? a. Excess fluid volume b. Decreased cardiac output c. Ineffective tissue perfusion: peripheral d. Imbalanced nutrition: greater than body requirements

A. Excess fluid volume

2. The nurse is preparing to insert an intravenous (IV) catheter in a newly admitted patient. Which area should the nurse use first for this catheter? a. Hand b. Forearm c. Upper arm d. Antecubital space

A. Hand

10. An IV infusion is not running. The insertion site looks normal. Which action should the nurse take to try to get it to run again? a. Reposition the extremity. b. Place gentle pressure on the bag of solution. c. Flush the catheter with 1 to 2 mL of heparin flush solution. d. Flush the catheter with 1 to 2 mL of normal saline solution.

A. Reposition the extremity. B,C,D: these actions could cause a clot to be dislodged into the general circulation and should not be taken.

14. Upon entering a patients room, the licensed practical nurse (LPN) notes a white precipitate forming in the IV tubing at the site of a piggybacked antibiotic. What should the nurse do first? a. Stop the infusion. b. Notify the physician. c. Call the pharmacy to see whether this is an expected reaction. d. When the infusion is complete, remove the tubing, and send it to the laboratory for analysis.

A. Stop the infusion

17. The nurse suspects a patient receiving IV therapy is experiencing fluid overload. Which assessment should the nurse perform first? a. Check the patients weight. b. Assess lung sounds for crackles. c. Observe the patients feet for edema. d. Inspect the insertion site for infiltration

B. Assess lung sounds for crackles Breathing is a priority

3. The IV infusion pump for a patient receiving an IV therapy begins to alarm and displays occlusion. When the silence button is pushed, the alarm quickly resumes. Which action should the nurse take first? a. Notify the physician. b. Check for kinking of the tubing or a closed clamp. c. Decrease the rate to 10 mL/hr, and flush the line with 1 mL of heparin solution. d. Turn off the IV solution, and gently flush the line with 3 mL of saline flush solution.

B. Check for kinking of the tubing or a closed clamp.

20. At a monthly staff meeting, the nurse manager announces that all central line insertion and dressing kits will now come bundled with 2% chlorhexidine gluconate for site preparation and cleansing. Which evidence best supports this decision? a. The use of 2% chlorhexidine gluconate reduces hospital costs by 7%. b. Chlorhexidine gluconate (CHG) is the preferred prep solution of choice based on scientific evidence. c. The company that supplies IV and central line catheter equipment has recently changed the product bundling to include 2% chlorhexidine gluconate. d. The chief of surgery is interested in performing a direct comparison study examining infection rates associated with long-term access devices as they are related to length of time the catheters are in place.

B. Chlorhexidine gluconate (CHG) is the preferred prep solution choice based on scientific evidence.

6. An angiocatheter site in a patients left forearm has become red and tender. What should the nurse do first? a. Check for a blood return. b. Remove the angiocatheter. c. Apply a warm compress over the insertion site. d. Run the IV solution at a slightly faster rate to encourage sluggish circulation.

B. Remove the angiocatheter. Redness and tenderness indicate infection. Must be removed and a new one placed.

7. As soon as the nurse begins to insert an IV catheter in the patients antecubital space, a hematoma forms at the site. What should the nurse do first? a. Remove the catheter and call for help. b. Remove the catheter and apply pressure to the site. c. Remove the catheter and insert a new one in the same site. d. Finish threading the catheter quickly and apply a pressure dressing and tape.

B. Remove the catheter and apply pressure to the site. The situation is not dire and calling for help is not necessary.

26. The nurse analyzes the fluid volume status of assigned patients. Which patients are most likely to need continuous IV therapy? (Select all that apply.) a. A 45-year-old woman with a broken humerus b. A patient with pitting edema and lung crackles c. A 16-year-old girl with anorexia who has been repeatedly purging d. A 3-year-old who has had frequent diarrhea and vomiting for 3 days e. An 85-year-old man with Alzheimers disease who refuses to eat or drink

C, D, E c. A 16-year-old girl with anorexia who has been repeatedly purging d. A 3-year-old who has had frequent diarrhea and vomiting for 3 days e. An 85-year-old man with Alzheimers disease who refuses to eat or drink

27. The nurse is concerned that a patient is developing complications from peripheral IV therapy. For which systemic complication should the nurse assess the patient? (Select all that apply.) a. Phlebitis b. Infiltration c. Septicemia d. Air embolism e. Extravasation f. Fluid overload

C, D, F C. Septicemia D. Air embolism F. Fluid overload C, D, and F are systemic complications, because they involve many body systems. A. B. E. These are local complications, limited to the IV site and surrounding area.

25. After preparing the skin for IV catheter placement, the nurse decides that the vein needs to be palpated before introducing the catheter. How should the nurse perform this action? a. Palpate the vein with the clean gloved hand. b. Palpate the vein and then cleanse the skin again. c. Apply sterile gloves before palpating the cleansed skin site. d. Apply skin cleanser to the gloved fingertip before palpating the vein.

C. Apply sterile gloves before palpating the cleansed skin site. The nurse should not repalpate the site after prepping it. If the site needs to be repalpated after cleaning, sterile gloves must be worn to perform this step. A. This could cause an infection. B. This could cause excessive skin irritation. D. This is incorrect technique and should not be done.

8. The nurse is preparing heparin to use as a flush for a patients IV infusion site. For which type of site is the nurse providing care? a. Peripheral access device b. Intermittent access device c. CVAD d. Intermittent piggyback device

C. CVAD Heparin is an anticoagulant and is recommended for flushing CVADs. Heparin is a medication and may be incompatible with other medications.

22. The nurse is preparing to administer a bolus IV medication through a patients saline lock. Which action should the nurse take immediately before providing the patient with this medication? a. Calculate the drip rate. b. Prepare the saline flush. c. Cleanse the hub for 15 seconds. d. Check the order for the medication.

C. Cleanse the hub for 15 seconds. This is to prevent infection

16. A patient is prescribed an IV infusion of a hypertonic solution. Which fluid shift should the nurse expect to occur with this type of infusion? a. Fluid moves from the plasma into the cells. b. Fluid moves from the venous circulation into the interstitial space. c. Fluid moves from the interstitial space into the venous circulation. d. Fluid moves from the arterial circulation into the venous circulation.

C. Fluid moves from the interstitial space into the venous circulation Hypertonic solutions pull water into the venous circulation through osmosis. A. B. These describe actions of hypotonic solutions. D. Fluid does not move directly from arterial to venous circulation.

19. When assessing a patient with an IV line in the right arm, the LPN notices that the skin near the infusion site is taut and cool, and when the arm is lowered, it appears to swell. What should the nurse consider is occurring with this patients IV access site? a. Infection b. Embolism c. Infiltration d. Venous spasm

C. Infiltration

4. Assessment of blood glucose levels is prescribed every 6 hours for a patient who is receiving parenteral nutrition (PN). The patient asks why this is necessary. Which response by the nurse is most appropriate? a. We have to monitor your glucose because the physician prescribed it. b. When people receive PN, they develop mild diabetes, which needs to be well regulated. c. PN contains a lot of sugar. We monitor blood glucose to be sure it doesnt get too high. d. There is a lot of sugar in the solution, which can increase the risk for rebound hypoglycemia.

C. PN contains a lot of sugar. We monitor blood glucose to be sure it doesn't get too high.

12. An IV insertion site begins to leak, and the tape over the site is wet. What should the nurse do first? a. Reduce the IV flow rate. b. Call the physician to report the problem. c. Remove the dressing from the IV site, and observe the insertion site. d. Slowly increase the speed of the IV drip, and watch the site carefully for increased leaking of IV solution.

C. Remove the dressing from the IV site, and observe the insertion site.

9. A patient in an outpatient oncology clinic is going to have a peripherally inserted central catheter (PICC) line placed and wants to know what that means. What is the best response by the nurse? a. A PICC line is a percutaneous IV core catheter. b. A PICC line is just a regular IV, but an extra-small catheter is used to prevent vein irritation. c. A PICC line is a catheter that is inserted into your jugular vein and ends in the central circulation. d. A PICC line is an IV device that is inserted into your arm and ends in the circulation near your heart.

D. A PICC line is an IV device that is inserted into your arm and ends in the circulation near your heart

13. The nurse needs to dilate a patients vein prior to inserting an IV catheter. Which technique should the nurse use to dilate the patients vein? a. Elevate the extremity for 5 minutes. b. Apply an alcohol swab for 60 seconds. c. Apply a cool compress for 15 minutes. d. Apply a tourniquet for up to 3 minutes.

D. Apply a tourniquet for up to 3 minutes.

24. A patient is prescribed to receive a continuous infusion of IV fluids. When preparing to place the catheter, the nurse notes that the client has a dialysis fistula in the right arm and had a left breast mastectomy three years prior. What should the nurse do? a. Place the catheter in the left hand. b. Place the catheter in the right foot. c. Place the catheter in the right hand. d. Ask the physician where to place the catheter.

D. Ask the physician where to place the catheter. The patient has contraindications for placement of the catheter in either arm.

15. A patients IV fluids are infusing too quickly despite adjustments made to the flow rate. Which approach should the nurse consider to slow the flow rate of a gravity solution? a. Opening the roller clamp b. Flushing the cannula with saline solution c. Raising the level of the solution container d. Flexing the extremity above the insertion site

D. Flexing the extremity above the insertion site. Flexing the extremity may compress the vessel and slow the rate. A. B. C. Raising the level of the solution, opening the clamp, and flushing a cannula may speed flow rate.

18. A patient is prescribed IV fluid to replace electrolytes and expand plasma volume. Which type of fluid will the nurse provide to the patient? a. Isotonic solution b. Dextrose solution c. Hypotonic solution d. Hypertonic solution

D. Hypertonic solution Hypertonic fluids pull fluid from the interstitial space into the venous circulation, expanding plasma volume. Lactated Ringers solution is a hypertonic solution that also replaces electrolytes

1. The health care provider is planning to discontinue total parenteral nutrition for a patient who has been receiving it for 3 weeks after an episode of severe gastrointestinal (GI) bleeding. What patient care order should the nurse anticipate? a. Place the patient on clear liquids for 1 week. b. Start tube feedings tid via nasogastric tube. c. Sodium-restricted diet with high-protein snacks bid. d. Taper PN rate and introduce regular feedings slowly.

D. Taper PN rate and introduce regular feedings slowly. When PN therapy is started, the rate is increased gradually to the prescribed rate to help prevent hyperglycemia. When it ends, the rate is gradually decreased to prevent hypoglycemia. A. Clear liquids do not provide enough protein. B. Tube feedings use the GI system the same as oral feedings. C. A sodium-restricted diet with high-protein snacks is not indicated.

21. The nurse is preparing to flush a patients intermittent IV catheter. Why is the nurse flushing this catheter? a. To open an occluded catheter b. To provide electrolyte replacement c. To prevent the formation of emboli d. To ensure the patency of the catheter

D. To ensure the patency of the catheter