Initiating a Peripheral Venous Access IV Infusion & Monitoring an IV Site and Infusion

The nurse is preparing to insert an intravenous catheter into an adult client. Place the following steps in the correct order. Use all options.

1)Apply a tourniquet 3 to 4 in (7.5 to 10 cm) above the site. 2)Cleanse the site with chlorhexidine. 3)Place nondominant hand 1 to 2 in (2.5 to 5 cm) below the site and pull the skin taut. 4)Insert the needle gently. 5)Release the tourniquet. 6)Stabilize the catheter or needle.

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

1)Close the roller clamp on the IV tubing. 2)Spike the new bag of IV fluid and hang it on the IV pole. 3)Squeeze the drop chamber and allow it to fill halfway. 4)Open the roller clamp on the IV tubing. 5)Carefully observe IV fluid move through the tubing until no air remains. 6)Replace the end cap on the end of the IV tubing.

A nurse is preparing to insert an intravenous (IV) catheter into a client's arm. At which angle relative to the client's skin should the catheter be inserted?

10- to 15-degree angle

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

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

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

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

A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply.

Deciding the size of the IV catheter., Deciding the location of the IV catheter., Administering the IV solution

A nurse is caring for four different pediatric clients, all of whom require insertion of an intravenous (IV) catheter. For which of these clients would it be appropriate to insert the IV into the foot?

Infant

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

1The 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 administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect

Phlebitis

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 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.

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?

Shortness of breath

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

Type of IV solution, Rate of the IV solution, Client's reaction to the procedure, Gauge and length of the IV catheter, Location of the IV catheter access

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

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

1The 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.

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