Coursepoint Module 18

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

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

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.

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

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.

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.

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 that all the tubing connections are secure. Check to see if the client is lying on any part of the tubing. Check that the client's arm is being kept straight at the elbow. Check that the roller clamp is open

The nurse is capping a client's IV line for intermittent use in preparation...

Close the clamp on the current administration set

The nurse is initiating a continuous intravenous (IV) infusion. Place in order the steps the nurse will take. Use all options.

Close the roller clamp on the IV tubing. Spike the new bag of IV fluid and hang it on the IV pole. Squeeze the drop chamber and allow it to fill halfway. Open the roller clamp on the IV tubing. Carefully observe IV fluid move through the tubing until no air remains. Replace the end cap on the end of the IV tubing.

When hanging a new bag of IV fluid for a client, which action does the nurse perform first?

Close the roller clamp on the tubing

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.

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

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.

The nurse observes and palpates a client's veins to determine a suitable site for initiating peripheral venous access. If the nurse cannot palpate a vein, which action would be most appropriate?

Massage the client's arm from proximal to distal end.

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

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

The nurse is starting a new IV on the client. The nurse has chosen a distal site of the cephalic vein in the client's left arm, cleaned the site, and applied the tourniquet. What should the nurse do next?

Palpate for the presence of the left radial pulse.

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

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

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.

The 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?

Twisting and pushing motion

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.

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.

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?

SOB

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.

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

The skin around the site is wet

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.

The nurse is caring for a client who had a right mastectomy 2 years ago. In choosing a site to start a peripheral IV, which site would be the best choice by the nurse?

a distal area of the cephalic vein in the client's left upper extremity

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

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

cleaning the end of the cap of the extension tubing with an antimicrobial swab

The nurse has initiated a 20-gauge peripheral IV catheter in the client's left cephalic vein using aseptic technique. The nurse is preparing to hang 1 liter of normal saline with 40 mEq (40 mmol) potassium chloride to infuse at 75 mL/hr beginning at 10:00 a.m. What information will the nurse include on the time strip being attached to the IV fluid container? Select all that apply

client's name normal saline with 40 mEq (40 mmol) potassium chloride initiated at 10:00 a.m. today's date

When caring for a client who requires intravenous (IV) therapy, which actions are within the nurse's scope of practice and can be performed independently? Select all that apply

deciding on the peripheral IV site location determining what gauge IV catheter to use deciding to relocate an IV site that has infiltrated

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